The effect of sartorius transposition on wound morbidity following inguinal-femoral lymphadenectomy.

In spite of efforts to reduce complications associated with inguinal-femoral lymphadenectomy (IFL), morbidity continues to be substantial. We sought to assess the efficacy of sartorius transposition (ST) in reducing groin wound complications following IFL, in patients with vulvar malignancy. The records of 101 patients with vulvar cancer undergoing IFL through separate incisions between March 1975 and December 1994 were examined. Sixty-two patients undergoing ST (group 1) were compared to 38 who did not (group 2). The groups were similar with respect to age, weight, tobacco/alcohol use, prior abdominal/vulvar surgery, prevalence of diabetes, hypertension, or peripheral vascular disease, and previous exposure to irradiation or chemotherapy. Additionally, there was no significant difference with respect to extent of disease, incidence of macro-/microscopic groin metastases, use of groin drains, and use of perioperative antibiotics or deep venous thrombosis prophylaxis. Groin wound complications were less frequent in patients undergoing ST (group 1). The incidence of groin cellulitis was 30% in group 1 compared with an incidence of 58% in group 2 (P = 0.011). Significant groin wound morbidity, defined as either wound breakdown or cellulitis, was seen less frequently in group 1 (41% vs 66%; P = 0.029). Employing a multivariate analysis, only patient weight < 150 lbs and performance of ST were established as independently associated with a reduction in groin morbidity following IFL (P = 0.0281 and P = 0.0075, respectively). In conclusion, despite waning enthusiasm for its performance, ST appeared to significantly reduce the incidence of wound morbidity after IFL. Our data confirmed that separate incisions, and improved perioperative antibiotics, have not eliminated the value inherent in this surgical modification. We suggest a prospective trial to further establish the benefit of sartorius transposition during IFL.

A pure brain metastasis of choriocarcinoma from a mixed germ cell tumor of the ovary.

We report a pure brain metastasis of choriocarcinoma from a mixed germ cell tumor of the ovary in a 19-year-old patient. This condition is extremely rare. Following abdominal operative procedures, multiple courses of combination chemotherapy, and resection of chemotherapy-resistant pulmonary metastases, a brain metastasis developed during chemotherapy. Craniotomy with resection of the neoplasm, brain radiation, and further chemotherapy was followed by disappearance of a pulmonary metastasis and long-term survival of the patient.

Management of pelvic venous stenosis with intravascular stainless steel stents.

Patients with gynecologic malignancies may develop stenosis of the large pelvic veins as a result of their disease or its treatment. The percutaneous insertion of a stainless steel vascular stent is a novel approach to the management of an extrinsically compressed vein. The objective of this study was to review the results of treating lower extremity edema secondary to a pelvic venous stenosis through the percutaneous insertion of a stainless steel vascular stent. A retrospective review was performed on gynecologic oncology patients who presented with an edematous lower extremity and underwent an evaluation to diagnose proximal venous stenosis. The evaluation included sonography, venography, and balloon angioplasty prior to the percutaneous insertion of a stainless steel vascular stent. If a venous thrombosis was documented, thrombolysis with urokinase was performed prior to evaluation for venous stenosis. Records were reviewed for the etiology of the venous stenosis, the location and type of stent inserted, and the ability of the stent to maintain patency and provide symptomatic relief. Patency was evaluated at 1-week and then at 1-, 3-, and 6-month intervals. The probability of vascular stent patency was calculated using life table analysis. Ten patients with cervical (n = 4), corpus (n = 3), ovarian (n = 1), vulvar (n = 1), and vaginal (n = 1) cancer had one or more vascular stents inserted for the treatment of a stenosed pelvic vein. The etiologies of venous stenosis were radiation fibrosis and surgery (n = 5), postoperative fibrosis (n = 3), and metastatic tumor (n = 2). The stented vessels were the left common (n = 5) or left external (n = 4) iliac veins, the right common (n = 1) or right external (n = 3) iliac veins, and the right common femoral vein (n = 1). The median follow-up was 21 months. All patients had subjective resolution of their edematous extremity while the stents were patent. The interval probability of patency of stented veins was greater than 85% at each evaluation interval. Patency was 100% for patients beyond 6 months of follow-up. There were no major complications. The percutaneous intravascular insertion of a stainless steel stent was safe and subjectively effective in the management of venous stenosis associated with a gynecologic cancer. A prospective trial with objective endpoints may be warranted.

Chemoprophylaxis with oral ciprofloxacin in ovarian cancer patients receiving taxol.

The purpose of this study was to review the clinical outcomes and cost of administration of a prophylactic antibiotic compared to G-CSF for the prevention of neutropenic morbidity associated with taxol. The study group was composed of 62 patients with ovarian cancer who received a 24-h infusion of a taxol-based regimen at doses less than or equal to 175 mg/m2 between June 1992 and April 1994. The records were retrospectively reviewed and the patients were grouped and analyzed according to the management of their myelosuppression. Group I patients (n = 29) were observed until their absolute neutrophil count (ANC) was less than 500/microliters and then were placed on ciprofloxacin 500 mg orally twice a day until their ANC was 1,000/microliters. Group II patients (n = 15) received G-CSF from Day 2 until the ANC was greater than 10,000/microliters beginning with their first cycle. Group III patients (n = 18) received their taxol regimen without either ciprofloxacin or G-CSF. Two hundred eighty-two taxol-based chemotherapy cycles were administered to these 62 patients. There was no statistically significant difference between the groups concerning disease status as measured by age, stage, performance status, dose intensity, or number of previous regimens. There were two episodes of febrile neutropenia in Group I and three episodes in Group II. Group III had 15 episodes of febrile neutropenia. The estimated cost of the different prophylactic regimens was $5,215.00 for Group I versus $104,000.00 for G-CSF in Group II. Within the three groups, there were 27 patients with an episode of febrile neutropenia (n = 20) or prolonged myelosuppression (n = 7) that were followed for an additional 104 taxol cycles. Twenty-four of these patients received G-CSF prophylaxis with intermittent ciprofloxacin and three received only ciprofloxacin. There were eight more episodes of febrile neutropenia in the patients receiving G-CSF. There were no additional febrile episodes on cycles prophylaxed with ciprofloxacin. There was no septic mortality. For patients receiving a 24 h infusion of taxol at doses less than 175 mg/m2, ciprofloxacin given through the ANC nadir may be effective in preventing febrile morbidity. A prospective randomized trial is underway to evaluate this approach.

Radical vulvectomy with postoperative irradiation for vulvar cancer: therapeutic implications of a central block.

PURPOSE/OBJECTIVE: To report the long-term results of vulvectomy, node dissection, and postoperative nodal irradiation using a midline vulvar block in patients with node positive vulvar cancer. METHODS AND MATERIALS: From 1971 through 1992, 27 patients with carcinoma of the vulva and histologically involved inguinal lymph nodes were treated postoperatively with radiation therapy after radical vulvectomy and bilateral lymphadenectomy (n = 25), radical vulvectomy and unilateral lymphadenectomy (n = 1), or hemivulvectomy and bilateral lymphadenectomy (n = 1). Federation Internationale de Gynecologic et d'Obstetrique stages were III (n = 14), IVA (n = 8), and IVB (n = 5) squamous cell carcinoma. Inguinal lymph nodes were involved with tumor in all patients (average number positive = 4, range 1-15). Postoperative irradiation was directed at the bilateral groin and pelvic nodes (n = 19), unilateral groin and pelvic nodes (n = 6), or unilateral groin only (n = 1). These 26 patients had the midline blocked. In addition, one patient received irradiation to the entire pelvis and perineum. Doses ranged from 10.8 to 50.7 Gy (median 45.5) with all patients except 1 receiving > or = 42.0 Gy. RESULTS: Actuarial 5-year overall survival and disease-free survival estimates were 40% and 35%, respectively. Recurrences developed in 63% (17/27) of the patients at a median of 9 months from surgery (range 3 months to 6 years) and 15 of these have died; two patients with recurrences are surviving at 24 and 96 months after further surgery and radiation therapy. Central recurrences (under the midline block) were present in 13 of these 17 patients (76%), either as central only (n = 8), central and regional (n = 4), or central and distant (n = 1). Additionally, three patients developed regional recurrences and one patient developed a concurrent regional and distant relapse. One patient developed a squamous cell cancer of the anus under the midline block 54 months after the initial vulvar cancer and an additional patient developed transitional cell carcinoma of the ureter (outside the radiation field) 12 months after diagnosis. Factors associated with a decreased relapse-free survival included increasing Federation Internationale de Gynecologic et d'Obstetrique stage (p = 0.01) and invasion of the tumor into the subcutaneous (SC) fat or deep soft tissue (p = 0.05). Chronic lower extremity edema developed in four patients, but there have been no other complications. CONCLUSIONS: Radical vulvectomy has often been considered sufficient central treatment for vulvar carcinoma, with postoperative irradiation directed only to the nodes. Although designed to protect the radiosensitive vulva, use of a midline block in this series resulted in a 48% (13/27) central recurrence rate, much higher than the 8.5% rate previously reported with this technique. Routine use of the midline block should be abandoned and, instead, postoperative irradiation volumes should be tailored to the individual patient.

Outcome assessment of home parenteral nutrition in patients with gynecologic malignancies: what have we learned in a decade of experience?

Recent improvements in parenteral nutrition and home care delivery systems have made home parenteral nutrition (HPN) a reality for patients with gynecologic malignancies. The records of 61 patients with gynecologic cancers who received HPN between 1981 and 1990 were retrospectively reviewed for outcome, complications, survival, and quality of life. Indications for HPN included mechanical bowel obstruction, short bowel syndrome, malnutrition during cancer therapy, or complications of cancer therapy. Ninety-two percent of patients had disease present at initiation of HPN. Fifty-six percent of patients had ovarian cancer; the remainder had other gynecologic malignancies. The vast majority of patients had prior surgery, radiotherapy, or chemotherapy before receiving HPN. Sixty-four percent of patients underwent cancer treatment (chemotherapy, surgery, or radiation) during HPN. Median survival for ovarian cancer patients on HPN was 72 days and 52.5 days for nonovarian patients (not statistically significant, P = 0.95). Minimal complications were noted from HPN with 9% of hospitalizations due to HPN. Nutritional parameters initially improved in most patients on HPN but then decreased prior to death. Quality of life parameters improved significantly in patients on HPN as compared to pre-HPN status (P < 0.05). In conclusion, HPN is a viable option in gynecologic cancer patients and offers improved quality of life even during the terminal phase of their illness.

Prediction of malignancy using transvaginal color flow Doppler in patients with gynecologic tumors.

Eighty-five patients referred to the Women's Cancer Center, University of Minnesota had transvaginal color flow Doppler performed to determine if pelvic malignancy could be predicted by blood flow assessment. Their mean age was 49 years (range 21-86 years). Thirty-five patients were subsequently found to have malignant tumors of the cervix, uterus or ovary. The presence of increased intratumoral blood flow as depicted by color flow Doppler had a sensitivity of 83%, specificity of 100%, positive predictive value (PPV) of 100% and negative predictive value (NPV) of 89% for malignancy. The mean intratumoral Pulsatility Index (PI) of the patients with malignant tumors was 0.81 (SD 0.24; range 0.3-1.2), which was significantly lower than for the benign group (P = 0.001). A PI of

Serum levels of macrophage colony-stimulating factor in patients with ovarian cancer undergoing second-look laparotomy.

OBJECTIVE: The purpose of this study was to evaluate the prognostic significance of macrophage colony-stimulating factor serum levels in patients with ovarian cancer undergoing second-look laparotomy. STUDY DESIGN: The presurgical serum levels of macrophage colony-stimulating factor from 33 consecutive patients with ovarian cancer undergoing second-look laparotomy were determined and compared with those of 50 healthy control subjects. Mean differences in groups were evaluated with the Student t test. RESULTS: Sixteen of 33 patients had a positive result at second look and a mean serum macrophage colony-stimulating factor level of 2.31 +/- 1.45 ng/ml. Seventeen of 33 patients had a negative result at second look and a mean macrophage colony-stimulating factor level of 1.90 +/- 0.86 ng/ml (p greater than 0.05). The mean macrophage colony-stimulating factor level in the control group was 1.20 +/- 0.51 ng/ml. This was statistically lower than the mean level found in patients with a negative second-look result (p less than 0.05). CONCLUSION: Regardless of tumor status, serum macrophage colony-stimulating factor levels tend to be elevated at the time of second-look laparotomy.

The integration of whole abdominal radiotherapy and intraperitoneal cisplatin into the primary management of advanced ovarian carcinoma.

Eleven women with Stages III and IV epithelial ovarian carcinomas were entered into a protocol consisting of concurrent whole abdominal radiotherapy and intraperitoneal cisplatin followed by additional intraperitoneal cisplatin. The entire abdomen received 20 Gy in 20 fractions with no renal or hepatic shielding. Intraperitoneal cisplatin dosage was 20 mg/m2 weekly during radiation and 90 mg/m2 monthly thereafter for an additional three courses. Patients with Stages IIIC and IV had a median survival of 18 months and a two-year actuarial survival of 32%. Primary failure sites were the abdomen, pleura, and lymph nodes. Acute toxicity during radiotherapy was comparable to patients treated with radiation alone. No chronic renal, hepatic, or enteric complications were observed. Although the protocol did not have substantial efficacy in advanced disease, its toxicity was moderate enough to consider its use in less advanced cancers with peritoneal metastases. In particular, the protocol can be considered for women with ovarian cancer with no gross residuum and for women with papillary serous carcinoma of the uterine corpus.

Intraperitoneal contrast material improves the CT detection of peritoneal metastases.

The preoperative detection of peritoneal metastases from gynecologic malignancies is difficult; in particular, CT often fails to detect peritoneal implants. This study was designed to determine if the administration of intraperitoneal iodinated contrast media would increase the CT detection of such peritoneal metastases. Prospectively, both standard and intraperitoneal contrast-enhanced CT studies of the abdomen and pelvis were performed in 16 patients with suspected gynecologic tumors. All patients then underwent operative staging, with the location and number of metastases documented. The intraperitoneal enhanced CT studies were more sensitive in the detection of peritoneal metastases than standard CT examinations. Whereas routine CT detected peritoneal metastases in seven (64%) of 11 patients with surgically proved implants, the intraperitoneal enhanced CT studies detected peritoneal metastases in all 11 patients. Depending on the specific intraperitoneal compartments involved, the sensitivity of intraperitoneal enhanced CT in the detection of peritoneal metastases was two- to fourfold greater than that of standard CT examinations. Our results suggest that intraperitoneal enhanced CT is superior to standard CT in the detection of peritoneal metastases.

Concomitant whole-abdominal radiation and intraperitoneal chemotherapy in advanced ovarian carcinoma. A pilot study.

Because the use of cisplatin-based chemotherapy for ovarian carcinoma has not significantly improved 5-year survival rates compared with either whole-abdominal radiation (WAR) or single-agent chemotherapy, a pilot study was begun to assess the feasibility of concomitant radiation and chemotherapy. Eleven previously untreated patients with Stages III and IV ovarian carcinoma were treated concomitantly with 2000 cGy of WAR and intraperitoneal (IP) cisplatin followed by additional IP cisplatin after debulking surgery. Toxicity was moderate to severe. Sixty-four percent of patients had Grades 3 to 4 hematologic toxicity, and 36% required hospitalization for sepsis during WAR/IP cisplatin. Hematologic toxicity was less pronounced during IP cisplatin alone. All patients experienced moderate gastrointestinal toxicity. The average percentage of total body weight lost was 13.5%. Fifty-five percent of all patients demonstrated a complete clinical response to therapy, and patients with minimal postoperative residual disease fared better. One patient with persistent disease had acute nonlymphocytic leukemia (ANLL) 24 months after initial diagnosis. No patients with residual disease greater than 20 mm survived, while 50% of patients with less than 20 mm are clinically free of disease. Toxicity appears to be additive with the combination of WAR and IP cisplatin. Therapeutic efficacy was comparable with standard chemotherapy regimens, but no therapeutic or survival advantages were demonstrated with the use of this treatment protocol.

Fatal Yersinia enterocolitica (serotype 0:5,27) sepsis after blood transfusion.

Septicemia is a rare complication of blood transfusion. This is probably primarily due to the use of sealed disposable containers for blood collection and the storage of red cell-containing components at 4 degrees C. However, despite these measures, septicemia due to blood transfusion continues to occur. We report here a fatal case of Yersinia enterocolitica septicemia due to a contaminated unit of red cells which was collected from an apparently healthy, asymptomatic blood donor. The organism grows at cold temperature and multiplies during storage of red blood cell-containing components. Contaminated components do not show any visible abnormalities. The possibility of transfusion-transmitted Y. enterocolitica should be considered in patients who have symptoms of sepsis or shock following transfusion.

Multimodality therapy for advanced and recurrent vulvar squamous cell carcinoma. A pilot project.

From 1985 to 1989 eight women with advanced or recurrent vulvar carcinoma were treated at the Women's Cancer Center of the University of Minnesota Hospital and Clinic. Each received a combination of 5-fluorouracil, mitomycin C and cisplatin during radiotherapy. Five of the eight women who underwent posttreatment radical vulvectomy had acceptable operative morbidity. Six patients experienced a complete clinical response. Of them, one had microscopic residual disease in the surgical specimen. One patient with recurrent vulvar carcinoma experienced progression of disease on therapy. One death was attributable to chemotherapy toxicity, and two patients died of intercurrent disease. The overall survival rate at 27 months was 33%. This multimodality approach to the treatment of advanced vulvar carcinoma should be considered when designing a therapeutic approach to treating extensive or resistant vulvar carcinoma.

Surgical intervention following multimodality therapy for advanced cervical cancer.

From 1978 through 1986, 183 women with cervical carcinomas underwent pretreatment extraperitoneal surgical staging followed by definitive radiation therapy. Overall 10-year actuarial relapse-free and survival rates were both 64%. There were a 20.2% overall incidence and 31.6% actuarial incidence of patients with subsequent abdominal surgery. Of the 47 total surgical procedures, most frequent were 15 repairs of radiation-related bowel injury (11 patients), 11 colostomies for tumor-related obstruction or fistula and 10 explorations for possible exenteration. Only one exenteration could be performed. Other operations consisted of 5 hysterectomies, 3 negative explorations for suspected recurrence, 1 cholecystectomy, 1 small bowel obstruction following surgical staging, and 1 sigmoid resection for colon cancer. Seven patients had multiple operations. Logistic analysis revealed cervix size, pelvic node status, periaortic lymph node status, and thin physique to be significant predictors of overall recurrence, while cervix size was the only significant predictor of exploration for exenteration. Tumor-related colostomies and radiation complications tended to occur in lower and higher clinical stages, respectively. There was a trend toward greater survival in patients with surgery for radiation complications.

Primary malignant melanoma of the vagina: a clinicopathological analysis of 10 cases.

We retrospectively analyzed clinicopathological findings in 10 cases of primary malignant melanoma of the vagina. The main presenting symptoms were vaginal bleeding, vaginal discharge, and feeling of a mass. The tumors were predominantly located in the lowest one-third and in the anterolateral aspect of the vagina. Patients underwent various surgical procedures, radiation therapy, and chemotherapeutic modalities. The mean survival time and the recurrence time from the time of diagnosis were 15 and 8 months, respectively. The tumors were examined for histological characteristics of cell type, presence of melanin pigment, depth of invasion, vascular invasion, intraepithelial spread, junctional activity, and mitotic count. Of all these histological variables, the mean survival time had a significant correlation to mitotic count (P less than 0.04). We concluded that patients with lower mitotic counts (less than 6 per 10 HPF) had better survival (21 months) compared to patients with mitotic counts greater than 6 per 10 HPF who had a mean survival of only 7 months.

Symptomatic central venous thrombosis and long-term right atrial catheters.

The use of long-term right atrial access catheters is increasing due to their value as aids in the administration of chemotherapy and hyperalimentation. A rare complication of catheter use is subclavian vein thrombosis. Suspicion of subclavian venous thrombosis based on clinical findings should be confirmed by venography. Therapy should be individualized, but may include antibiotics, catheter removal, thrombolytics, and anticoagulants. Resolution of symptoms is the usual outcome, but this may be influenced by other compounding factors.

The role of surgical debulking in cancer of the uterine cervix.

From 1978 to 1985, 159 women with advanced cervical cancer received definitive radiation therapy following extraperitoneal surgical staging including pelvic lymph node dissection and periaortic lymph node sampling. Relapse-free survival was a strong function of peritoneal and nodal metastases but was independent of clinical stage. The 5-year relapse-free rate fell from 86% in women without pelvic node metastases to 0% in those with unresectable pelvic node metastases. Women with microscopically positive pelvic node metastases had virtually the same (56%) relapse-free rate as those with grossly positive but completely resected metastases (57%). The overall pelvic failure rate was 16.4% and was significantly higher in women with unresectable pelvic node metastases. Periaortic and peritoneal metastases substantially increased the probability of recurrence. Although histologic grade was prognostically significant, histopathologic category was not. Severe enteric morbidity occurred in 3.6% of patients treated solely to the pelvis and in 7.9% of patients treated to the pelvis and periaortics. Therapeutic implications of debulking pelvic node metastases are discussed.

Prognostic significance of steroid receptors measured in primary metastatic and recurrent endometrial carcinoma.

Forty-two cases of recurrent and 14 cases of advanced clinical stage (III and IV) endometrial carcinoma are presented, in which progesterone and estrogen receptors from the metastatic sites were measured. Mean survival time (time from recurrence or, in advanced stages, from the time of diagnosis to death or last follow-up), mean total survival time (time from diagnosis to death or last follow-up), and mean time to recurrence (time from diagnosis of primary tumor to the time of recurrence) were positively correlated with positive progesterone and estrogen receptor status and with histologic grade of tumor. No correlation was found with age, clinical stage, depth of myometrial invasion, or site of metastasis. However, when multiple variables were considered with the Cox regression model, the combination most highly correlated with survival included progesterone receptor, grade of tumor, and site of metastasis (pelvis vs. other sites). All differences were statistically significant (p less than 0.05). We conclude that measurement of progesterone and estrogen receptors in metastatic or recurrent endometrial tumors may be used as an additional prognostic variable.

Fibromatosis of the female pelvis.

Fibromatosis is a benign, infiltrating, nonmetastasizing neoplasm which is rarely completely resected. Therefore, the incidence of recurrence is high. Fibromatosis is more common in females and is frequently diagnosed during pregnancy. Inasmuch as fibromatosis of the female pelvis appears to be a discrete entity, management poses significant problems for the gynecologist. Radiation therapy, frequently used following incomplete resection or for recurrence, is undesirable due to the loss of ovarian function and fertility. Hormonal manipulation and combination chemotherapy are alternatives which have been effective in some reports. Three patients with pelvic fibromatosis, referred within 1 year, are reported. The various aspects of this neoplasm and the diagnostic procedures are discussed. Treatment modalities whose effects are reversible are recommended for recurrent fibromatosis. Radiation therapy can be reserved for patients in the older age groups or for those with progressive disease not responding to other therapy.