Ectopic ACTH syndrome due to bilateral ovarian androblastoma with double, gynandroblastic differentiation in one ovary.

A case of fulminant Cushing's syndrome due to an ectopic ACTH secretion in a patient with bilateral ovarian sex-cord stromal tumour is reported. Surgical resection of the ovaries as well as the inhibitors of steroid synthesis and cytostatics caused only transient improvement because the widespread neoplastic dissemination progressed very quickly.

Clinical value of transvaginal, sonographically guided fine needle aspiration biopsy of parametria in recurrent cervical carcinoma.

Forty four patients with a clinically suspected relapse of cervical carcinoma were evaluated with transvaginal sonographically guided fine-needle aspiration biopsy (FNAB) of parametria in the Gynaecological Department of the Institute of Oncology, Warsaw, Poland. Sonographical scans and FNAB results were compared with subsequent clinical course (41 cases) and surgery (3 cases). Of the total of 56 aspiration biopsies 50 specimens were of cytological value. Overall diagnostic accuracy of FNAB was 82%, specificity and positive predictive value 100%, sensitivity 61% and negative predictive value 75%. As regards sonography the accuracy rate was 77%, the sensitivity as well as negative predictive value were 100%, specificity was 62% with false positive rate 23%. The definitive diagnosis of recurrence was obtained by FNAB in 13 out of 18 cases and in 8 of these radiotherapy was instituted. The negative FNAB correctly rules out the recurrent disease in 22 of 26 cases. In all cases with relapse parametrial lesions were detected on ultrasound scans. The Authors have found that sonographically guided FNAB of parametria is a useful diagnostic tool in imaging and biopsying of parametrial masses. As the conjunction of two complementary diagnostic methods this technique is an excellent tool for obtaining the cytologic verification of recurrence, especially in doubtful cases, when post-therapeutic pelvic fibrosis is present. It is also a quick, safe technique, well accepted by the patient.

Induced soft tissue sarcomas following radiation treatment for uterine carcinomas.

Twenty-two cases of sarcomas arising from irradiated soft tissues were observed in 531 patients operated on for soft tissue sarcomas over 38 years in our Department. Eleven women were initially irradiated for cervical cancer (ce-ca), two for endometrial cancers. The remaining nine patients were irradiated for other lesions, malignant or benign. The median interval between the radiation for uterine cancer and the outcome of clinical symptoms of a sarcoma was 18 years. Sarcomas more frequently arose in the posterior fields (buttock or sacral region in nine patients) than in the anterior (pubis, hypogastrium-four patients). The infiltration of skin was almost always present (10/13), in seven cases with an ulceration (7/13). Histologically, four hemangiosarcomas, four fibrosarcomas, three malignant fibrous histiocytomas and two neurofibrosarcomas were found. The irradiation administered to ce-ca patients consisted of radium (22.0 mcd to 58.0 mcd) and an external radiation from X-ray units (except in one case) from two pairs of two anterior and posterior fields, with skin doses of 3200 cGy to 4200 cGy directly on one field plus several hundreds cGy from the opposite field. Three-year overall survival rate was low (30%) similar to that observed in patients with primary high-grade (G-3) sarcomas. We observed more cases subjected to radiotherapy for cervical cancer than might be expected.

Gestational trophoblastic diseases: the ratio of choriogonadotropin to specific pregnancy protein, hCG/SP1, provides useful diagnostic and prognostic evidence.

Serum levels of human chorionic gonadotropin (hCG), specific pregnancy protein (SP1), and hPL were measured in 675 samples from women with uneventful pregnancy, and serially from the time of presentation in 125 patients with hydatidiform mole (HM), 43 with invasive mole (IM), and 34 with choriocarcinoma (CC). In HM serum levels of hCG and SP1 declined steadily from presentation to remission; when gestational age at the time of molar evacuation was shorter than 11 weeks, hCG declined to the normal range later than SP1 (57% patients), and when the age was longer--at the same rate as SP1 (26% patients) or earlier (17% patients). Serum levels of either marker were higher in IM than in HM and tended to increase, and in CC were either lower or higher than in IM. Treatment was followed by parallel decline of either marker, although SP1 declined to the normal range later than hCG in 12% of patients with IM and in 10% with CC. The hCG/SP1 ratios in normal pregnancy declined exponentially between the beginning and 23rd week of gestation and stayed level thereafter. The ratios calculated for the gestational age at the time of initial evacuation of the uterus or delivery were close to those of normal pregnancy in 80%, slightly increased in 20% of patients with spontaneously regressing HM, and markedly increased in 70% of patients with IM and in 74% of patients with CC. The ratios tended to increase during chemotherapy. An increase in the hCG/SP1 ratio seemed to be a characteristic sign of malignant change when compared with this ratio in normal pregnancy and hydatidiform mole. Determination of SP1 for monitoring therapy seemed redundant, and hPL assay was useful for discrimination between relapse and pregnancy.

Clinical usefulness of serum ferritin measurements in patients with testicular germ cell tumors.

In 50 patients with seminoma and in 50 with nonseminomatous germ cell tumors of the testis, serum levels of conventional markers (CEA, AFP, hCG) and ferritin were measured at the time of admission and during management. The conventional markers behaved as reported previously. After orchiectomy, elevated levels of ferritin were found in the presence as well as in the absence of tumor; the extent of these elevations was highly variable. Serial determinations of serum ferritin showed two patterns of variation. First, in patients treated with retroperitoneal lymph node dissection, irradiation, and chemotherapy regimens without platinum, decreasing levels of the conventional markers and serum ferritin were associated with response to therapy and increasing levels with relapse of tumor. Second, in patients treated with chemotherapy regimens containing cis-diamminedichloroplatinum, the conventional markers returned to normal values while the ferritin level doubled or tripled and returned to pretreatment or normal values only several weeks after therapy. Thus, it appears that hyperferritinemia was a sensitive index of platinum toxicity. We conclude that the serum ferritin level has no value in staging after orchiectomy but is a useful index of response to therapy during treatment with retroperitoneal lymph node dissection, irradiation or chemotherapy without platinum or relapse of tumor. During treatment with platinum, elevated levels might be explained as a possible toxic side effect of this drug.

Evaluation of five tumor markers (AFP, CEA, hCG, hPL and SP1) in monitoring therapy and follow-up of patients with testicular germ cell tumors.

61 patients with seminoma and 113 with nonseminomatous germ cell tumors of the testis were treated according to the histology, stage of disease, and serum levels of tumor markers (CEA, AFP, hCG, hPL and SP1). 33 were stage I, 63 stage II, and 78 stage III patients. Most patients with seminoma, mature teratoma, immature teratoma, and 'pure type' embryonal carcinoma, as well as the latter three types with seminomatous admixture, had normal serum levels of the markers. Sometimes, slightly elevated levels of hCG suggested the presence of metastases. But, serial measurements of the markers were seldom useful in monitoring therapy. The 5-year tumor-free survival rates were favorable: 100% for stage I and II disease; and 57 or 44% for, respectively, stage III seminoma or the other tumors amounting to 10% of the nonseminomatous group. The role of the five markers was significant in patients with teratoma with malignant transformation, choriocarcinoma, endodermal sinus tumor (EST), and embryonal carcinoma or teratocarcinoma with an admixture of EST or choriocarcinoma or both. Elevation of a marker was a grave prognostic sign. The 5-year survival rates were 100, 16, and 4% for stages I, II and III disease, respectively. An elevated level of one or more of the markers assayed was always useful for monitoring therapy. Decreasing level indicated regression. However, return of an elevated level to normal did not indicate eradication of all tumor and called for diagnosis by imaging modalities. Constantly elevated or increasing marker levels during treatment indicated resistance to therapy. An increasing level from any nadir during remission indicated recurrence. Elevated levels of any of the five markers tested were as important as imaging modalities, and often more sensitive.

Value of five tumor markers (AFP, CEA, hCG, hPL and SP1) in diagnosis and staging of testicular germ cell tumors.

Serum levels of AFP, CEA, hCG, hPL and SP1 were measured by specific radioimmunoassays in 111 patients with testicular germ cell tumors. Seminomas, mature teratomas and "pure type" embryonal carcinomas, as well as the latter two types of tumor with seminomatous admixture, do not produce markers unless in advanced stages when they may do so (small amounts of hCP, hPL and SP1). Tumors composed of yolk-sac elements alone or mixed with embryonal carcinoma produce AFP: of syncytiotrophoblastic elements - hCG, hPL or SP1; and teratomas with differentiated structures - CEA. Compound tumors can produce any of the five markers. When present in serum after orchiectomy or lymphadenectomy, the markers are useful both in diagnosis of the tumor elements that metastasized and in staging; whereas their absence does not exclude regional or distant metastases which may contain only marker-negative elements, e.g., due to changes in tumor histology. Measurement of the serum levels of the markers informs about the remaining regional tumor elements or latent metastases and therefore is more useful than immunoperoxidase staining which provides information on the already dissected structures only.

On cytologic vagaries in the diagnosis of breast tumors.

The article describes the difficulties, the errors and limitations of the fine needle aspiration biopsy technique in the diagnosis of the breast tumors encountered during a 2.5 year period of activity. The question of false-negative and false-positive results and the way these problems were partly overcome in the Institute of Oncology in Warsaw are discussed in detail.

Endodermal sinus tumor of the ovary. Clinicopathologic study of 6 cases.

6 cases of endodermal sinus tumor of the ovary are presented. In 4 patients pure endodermal sinus tumor was found microscopically. 1 patient had endodermal sinus tumor in one ovary and gonadoblastoma in the contralateral one. In another case endodermal sinus tumor was accompanied by an embryonal teratoma. Histologically, the tumor had characteristic features with meshwork of spaces and channels lined by embryonal cells, glomerulus-like structures known as Schiller-Duval bodies, solid aggregates of epithelial cells, hyaline basement membranes and round, PAS-positive small globules found both intra- and extracellulary. In 1 patient the elevated serum alpha-fetoprotein was stated. All patients were treated surgically with adjunctive radiation and/or with chemical agents. None of them were cured. The median duration of survival amounted to 8.5 months. Discussing the value of the more recent approach to diagnostic and therapeutic methods found in the literature, it must be emphasized that the demonstration of elevated serum alpha-fetoprotein in patient with that tumor lend not only further support to its yolk sac origin but also might be useful to monitor response to the therapy applied. It is also of prognostic significance by indicating the presence of residual or recurrent disease, even in its subclinical stage. Combined postoperative irradiation and triple chemotherapy according to the VAC regimen of patients can prevent recurrence and in some cases even may cause permanent remission of the neoplasm.