Gestational trophoblastic disease.

Gestational trophoblastic disease consists of a broad spectrum of conditions ranging from an uncomplicated partial hydatidiform molar pregnancy to stage IV choriocarcinoma with cerebral metastases. Fortunately, with the advent of combination chemotherapy, the patient with advanced-stage disease has a significant chance of achieving complete remission. In addition, several studies have demonstrated that patients with a history of gestational trophoblastic neoplasia do not experience an increased risk of complications with future pregnancies. Patients who have undergone chemotherapy do not seem to experience an increase in the risk for congenital anomalies in their offspring. Patients with a history of hydatidiform molar pregnancy should be advised that they are at increased risk of future molar pregnancies, with a risk of 1% in subsequent gestations after one molar pregnancy and a risk as high as 23% after two molar gestations. Although patients should be reassured regarding their reproductive future, they should be advised to seek prompt medical attention once gestation is suspected so that an early work-up can be initiated if pregnancy is confirmed.

Somatic mutation of PTEN in vulvar cancer.

PTEN, a candidate tumor suppressor gene located at chromosome 10q23.3, has been shown to be mutated in approximately 40% of endometrial cancers. Such mutations have also been identified in endometrial hyperplasia, indicating that inactivation of the PTEN tumor suppressor gene is an early event in the genesis of some endometrial cancers. In this study, we have extended the analysis of PTEN in gynecological cancer to include adenocarcinoma of the cervix and vulvar carcinomas. Microdissected tissue (including normal tissues), preneoplastic, and neoplastic lesions were analyzed from 9 patients with cervical cancer and 10 patients with vulvar cancer. Only 1 cervical adenocarcinoma displayed a PTEN mutation. In contrast, five of eight vulvar carcinomas studied harbored PTEN mutations. Alterations were identified in carcinoma in situ as well as squamous cell carcinoma of the vulva. In two patients, PTEN mutations were identified in mucosal regions with mild or focal dysplasia. These results suggest that PTEN is frequently altered in vulvar carcinomas and can be found associated with early dysplastic changes in vulvar mucosa.

Ultrasonic surgical aspiration for gynecologic disease.

Ultrasonic Surgical Aspiration (USA) is a technique which employs a hand-held instrument that selectively fragments and aspirates tissues of high-water content. The selectivity of the device permits preservation of underlying vital structures while the aspiration provides a tissue specimen for histologic analysis. Application of this device to neoplastic disease of the lower genital tract has been reported to provide durable success rates of 78% for conyloma acuminata and vulvar intraepithelial neoplasia (VIN) and 81% for vaginal intraepithelial neoplasia (VAIN).Employment of USA in patients with advanced ovarian cancer has been shown to improve surgical cytoreduction without increasing blood loss or complication rates.

Dysgerminoma: the role of conservative surgery.

Twenty-five cases of pure ovarian dysgerminoma treated at UCLA Medical Center between 1958 and 1992 were reviewed retrospectively. Patterns of recurrence and overall survival were analyzed with regard to primary surgery (conservative versus nonconservative), use of adjuvant therapy, and stage of disease. Fourteen patients (56%) underwent conservative surgical therapy defined as preservation of the contralateral ovary, 10 patients (40%) had nonconservative primary surgery, and one patient (4%) had chemotherapy as primary treatment. Three patients (12%) received adjuvant chemotherapy and nine patients (36%) received postoperative radiation therapy. Fifteen patients (60%) had stage I disease, four (16%) stage II, and three each (12%) had stage III and IV disease. Nine patients (36%) experienced recurrence of disease. Seven of these nine patients (78%) had stage I disease and all seven had undergone conservative primary surgery with preservation of the contralateral ovary. Six of the seven had received no adjuvant therapy. Only one of these seven patients experienced recurrence in the preserved ovary. She was found to have a dysgenetic ovary and an XY karyotype. Three patients with recurrent disease had received radiation therapy after primary surgery. Twenty patients (80%) were alive without disease at follow-up, two patients (8%) were alive with disease, and three (12%) had died of disease. There was no statistically significant difference in recurrence rates between those patients treated with conservative surgery and those treated with nonconservative surgery, although the total number of patients with recurrences was greater in the former group. Our data suggest that a conservative surgical approach is the preferred treatment in patients with pure dysgerminoma of the ovary who desire future fertility. Lack of adjuvant chemotherapy or radiation therapy, rather than type of initial surgery, may be associated with a higher risk of recurrence.

The importance of communication between the pathologist and the clinician in caring for patients receiving gynecologic treatment.

These cases clearly illustrate the importance of communication between the pathologist and gynecologist or gynecologic oncologist to deliver optimal patient care. It is not only important for the pathologist and gynecologist to review the pathologic diagnosis before implementing treatment plans, it is also imperative that the gynecologist provide the pathologist with a thorough history. As part of this communication process, the pathologist conveys abnormalities of histology as well as uncertainties, such as that which occurred in the mucinous cystadenocarcinoma case. By maintaining open communication, the patient receiving gynecologic treatment will receive the best possible care.

Two-year follow-up of 263 patients with post/perimenopausal vaginal bleeding and negative initial biopsy.

Patients with post- or perimenopausal bleeding (PMB) whose initial endometrial biopsy or dilation and curettage (D&C) reveals benign or insufficient tissue may eventually be diagnosed with endometrial cancer or complex endometrial hyperplasia. We studied 286 consecutive patients with PMB who had either an endometrial biopsy or D&C at Brigham and Women's Hospital during November 1990 to April 1991 and reviewed their subsequent specimens after a minimum of 23 months of follow-up. Of the initial 286 patients with PMB, 6 (2%) had endometrial cancer on their index biopsy, 17 (6%) had complex hyperplasia, and 201 (70%) had other benign findings. Sixty-two (22%) had "tissue insufficient for diagnosis." Excluding the 23 with cancer/complex hyperplasia, there were 263 patients in the cohort, 86 of whom (33%) had further endometrial sampling during the follow-up period. Of these, four (2%) were subsequently found to have a uterine malignancy (2 of the benigns, 2 of the insufficients) and five (2%) were subsequently found to have complex hyperplasia. Of the four patients subsequently found to have cancer, two had stage I adenocarcinoma, one had stage IV adenocarcinoma, and one had stage I high-grade stromal sarcoma.