Laparoscopy. A clinical sign for intraperitoneal needle placement.

Experience with a new clinical sign for proper Verres needle placement is reported. Although the use of one or more tests to confirm accurate needle position have become standard, most complications associated with laparoscopy still result from inaccurate or extraperitoneal needle placement. This new sign, when present, has proven completely reliable and should aid laparoscopists in reducing the incidence of needle complications.

Clostridium perfringens infection complicating chemotherapy for choriocarcinoma.

A case of Clostridium perfringens sepsis and gas gangrene complicating chemotherapy for gestational choriocarcinoma is reported. The infection was eradicated using antibiotics, surgery, and hyperbaric oxygen therapy. The pathophysiology, diagnosis, and treatment of this unusual but often lethal complication are reviewed.

Management of incurable urinary fistulas by percutaneous ureteral occlusion.

Women with large urinary tract fistulas in the presence of advanced incurable gynecologic cancer are a difficult problem. In the past, treatment has usually been either inadequate or highly morbid. We have palliated three women with large incurable urinary tract fistulas by occluding the distal ureters with isobutyl-2-cyanoacrylate (Bucrylate) and implanting permanent bilateral percutaneous nephrostomies. This technique is easily performed and effective, and has few complications.

Irradiation of liver metastases due to gestational choriocarcinoma.

One of the major unresolved problems in high-risk choriocarcinoma is the prevention of hemorrhage from tumor necrosis during chemotherapy. The authors report a successfully treated patient who developed intrahepatic bleeding while receiving systemic chemotherapy and concomitant whole liver irradiation. Patients with trophoblastic liver metastases are at risk for bleeding from tumor necrosis during chemotherapy but, because there are few reported cases, the degree of risk cannot be predicted. Radiation therapy for the prevention of this complication may not be as successful for liver metastases as it is for brain metastases; reports are too scarce to evaluate its efficacy. As demonstrated in the present patient, radiation therapy does not completely eliminate the risk of hemorrhage from chemotherapy. The hypothesis that patients with liver metastases from gestational choriocarcinoma are more susceptible to treatment failure and life-threatening complications than other members of the high-risk category needs support. Other investigators are encouraged to report their results with trophoblastic liver metastases to clarify the type and degree of risk, to determine the role of adjuvant radiation therapy, and to establish optimum treatment protocols.

Laparoscopy in the evaluation of gynecologic cancer.

Laparoscopy was used to evaluate 60 patients with a variety of known or suspected gynecologic neoplasms. Diagnostic laparoscopy was performed on 18 patients to confirm benign or malignant pelvic masses or to confirm peritoneal carcinomatosis. Ten of these 18 patients (56%) were found to have unresectable carcinomatosis or benign disease which did not require further surgery. Staging laparoscopy was performed on 13 patients of which 3 had clinically unsuspected intraperitoneal spread of their disease. Surveillance laparoscopy was performed on 29 patients to determine the remission, regression, or progression of their disease following treatment; 8 (27%) had progressive or unresectable persistent disease. Despite the fact that the study comprised a high-risk group of previously operated on or irradiated patients, there was only one major complication. There was, however, a 10% incidence of laparoscopic failure from inadequate visualization. Twenty-one of the study patients (35%) were spared a laparotomy by the use of laparoscopy. The findings of this investigation help to identify those gynecologic oncology patients who should benefit most from the use of laparoscopy as an adjunct to the diagnosis, staging, or surveillance of intraabdominal malignant tumors.

Merkel cell carcinoma of the vulva.

The authors describe the clinical and histologic findings in a case of Merkel cell carcinoma of the vulva, which was associated with squamous cell carcinoma in situ and lichen sclerosus. Electron microscopy of the tumor revealed membrane-bound granules. At postmortem examination, metastases from this primary skin tumor were found in the pelvic lymph nodes, in paraortic lymph nodes, in the liver, and in vertebral bodies. The case is unusual because Merkel cell tumors are usually found on the face or the extremities and seldom metastasize widely.

Ultrasound and the pelvic mass.

We compared the findings from pelvic examination, preoperative ultrasound and surgery on 50 patients who underwent exploratory laparotomy for a pelvic mass at Tulane University Medical Center. Of the 50 cases, 34 (68%) were correctly diagnosed as a pelvic mass by both pelvic examination and ultrasonography. Ultrasound had nine false negatives (21%) and only one false positive (2%). Pelvic examination had 7 false positives (16%). There was no statistical difference by chi-square analysis in the accuracy between ultrasonography and pelvic examination in the detection or diagnosis of the masses. Ultrasound indicated pathology not associated with the suspected mass in ten patients; surgery confirmed pathology in five of them. More errors occurred on both pelvic examination and ultrasonography in obese patients than in nonobese ones: seven of the ten ultrasound errors occurred in obese patients, and five of the seven pelvic exam errors also occurred in obese patients. In the nine cases of false-negative ultrasound findings surgery was postponed, but all of them eventually underwent surgery because of a deteriorating clinical course. In our study pelvic ultrasonography was not beneficial in the management of patients with a known or suspected pelvic mass, but it was very accurate for confirmation of a mass.

Vulvovaginal reconstruction following radical surgery.

An important aspect of the care of women with a gynaecological malignancy is not only improved survival, but complete rehabilitation. There are a number of reconstructive techniques available which can be used at the time of radical surgery, or at some later date, to correct the untoward effects of therapy. Whenever possible, the least morbid, yet most reliable reconstructive procedure should be performed at the initial surgery to decrease postoperative morbidity and wound infection and improve rehabilitation and body image. For many situations there is no single ideal procedure, therefore one should be familiar with several techniques in order to select or adapt the procedure best suited to the circumstances. The split thickness skin graft (STSG) is used primarily to cover skin defects where there has been little or no loss of subcutaneous tissue, such as after skinning vulvectomy for carcinoma in situ. It is also the procedure of choice for vaginal reconstruction after simple vaginectomy for extensive in situ carcinoma and for congenital absence of the vagina. It may also be useful in the management of vaginal distortion, secondary to previous surgery or radiation therapy. In gynaecology, full thickness skin flaps are used when there has been major loss of skin and subcutaneous tissue of the vulva, groin or vagina. Defined arterial and fasciocutaneous flaps are more reliable than random cutaneous flaps, but they are not mutually exclusive in their application. Thus, one or the other may be used for the same defect in differing patients, depending on the situation. Circumstances that dictate which flap is preferable include size, contour, depth of the deformity, proximity of the deformity to the potential donor site, presence of necrosis and infection, and the requirement for new blood supply, as in an irradiated wound. In appropriately selected patients the myocutaneous flap will provide the most reliable source of a new blood supply. If the requirement for a new blood supply is of paramount importance, and the myocutaneous flap is too thick, the skin and subcutaneous tissue may be sacrificed to reduce the size of the flap. A STSG can then be applied at a later time to achieve the desired result. There are many other situations when several reconstructive procedures used simultaneously, or serially, may be required to achieve a balance between anatomy and function. However, ultimate success will depend largely on patient selection, familiarity with the procedures, and exacting surgical technique.

Adenocarcinoma of Skene's duct associated with a systemic coagulopathy.

Adenocarcinoma of the urethra is a rare neoplasm which is believed to arise from the periurethral ducts. Four such cases have been diagnosed at our institution during the past 25 years and their clinical courses are summarized in this report. In one patient, a disseminated coagulopathy with a predominantly fibrinolytic component developed. The pathologic mechanism of fibrinolysis is addressed and a successful approach to the medical management of this confusing coagulopathy is outlined.

Atypical melanocytic hyperplasia of the vagina.

A case of extensive pigmentation of the vagina is reported. Microscopic sections showed a resemblance to atypical melanocytic hyperplasia, which has been described as a possible precursor of malignant melanoma of the skin including the acral lentiginous form.

Verrucous carcinoma of the cervix: a report of two cases and literature review.

Verrucous carcinoma of the cervix, like verrucous carcinoma of the vulva, is commonly misinterpreted as condyloma accuminata, resulting in a protracted delay of appropriate treatment. Since the correct diagnosis depends upon histological criterion which frequently belies the malignant nature of this lesion, conveyance to the pathologist of the history, physical findings, and clinical behavior of the lesion may facilitate early recognition. Aggressive surgical procedures including exenteration should be considered as primary treatment for large lesions and recurrent lesions when local excision fails. Radiotherapy is not usually an effective treatment for verrucous carcinoma and may induce malignant transformation. To date, 27 cases of verrucous carcinoma of the cervix have been reported. Two additional cases managed in recent years by the authors and a review of the world's literature about this uncommon lesion form the basis of this report.

Vagina: evaluation with MR imaging. Part II. Neoplasms.

The potential of magnetic resonance (MR) imaging in the detection of vaginal tumors and the assessment of their extent was evaluated retrospectively in 87 patients in whom primary, metastatic, or recurrent vaginal cancer was clinically suspected. MR findings were compared with the results of surgery and/or biopsy. Results of histopathologic study verified a normal vagina in 51 patients, benign cysts in two, primary tumor in four, metastatic cancer in 22, and recurrent tumor in eight. MR imaging demonstrated the two benign cysts, correctly depicting their size and location, and demonstrated and enabled correct staging of the four primary tumors. MR accuracy for demonstrating metastatic cancer was 92%, sensitivity was 95%, and specificity was 90%. Tumor extension to the vagina was reliably excluded (negative predictive value = 97%), but false-positive interpretations occurred (positive predictive value = 84%) primarily because inflammation (n = 2) and congestion (n = 2) could not be distinguished from tumor invasion. An additional role of MR imaging was the ability to differentiate tumor from fibrotic tissue in patients with suspected recurrent vaginal carcinoma. The overall accuracy of MR imaging for recurrent vaginal cancer was 82% (14 of 17).

Vaginal reconstruction after exenteration with use of gracilis myocutaneous flaps: the University of California, San Francisco experience.

At the University of California, San Francisco Medical Center we have performed 18 vaginal reconstructive procedures with gracilis flaps at the time of anterior, posterior, or total pelvic exenteration. We have compared these patients with 13 other patients undergoing exenteration during the same interval who chose not to have vaginal reconstruction. There was no significant difference between the two groups with respect to age, weight, operating time, blood loss, or duration of postoperative hospitalization, but there were significantly fewer serious complications in the patients receiving gracilis flaps. The results of a questionnaire indicated that the perineal cosmetic results are highly acceptable, although residual scarring on the legs is a common source of minor complaint. Sexual adjustment can be complete or nearly complete in surviving patients. Given the major contribution to wound healing, reduced postoperative morbidity, excellent cosmetic results, and the opportunity for complete sexual rehabilitation, we believe the gracilis myocutaneous flap neovagina remains the procedure of choice for most women undergoing major exenterative procedures.

Fine-needle aspiration biopsy in the management of cervical carcinoma following primary therapy.

Thirty-five fine-needle aspiration biopsies (FNAB) in 30 patients who had previously received primary therapy for cervical carcinoma are reported. There were 22 positive FNABs, and in 11 cases the positive FNAB definitely changed the patient's planned therapy. There were no complications due to FNAB in these 30 patients. FNAB has an important role in follow-up and management of patients with cervical carcinoma.

Endometrial carcinoma staging by MR imaging.

The potential of magnetic resonance (MR) imaging in the detection of endometrial carcinoma and in the assessment of its extent was evaluated prospectively in 51 patients clinically suspected of having the disease. MR imaging findings were compared with the results of surgical-pathologic staging and lymph node sampling following hysterectomy. Histologic findings showed 45 patients to have endometrial carcinoma, three to have no residual tumor after dilatation and curettage, and three to have adenomatous hyperplasia of the endometrium. MR imaging demonstrated an endometrial abnormality in 43 of the 51 patients (84%). Endometrial carcinoma could not be differentiated from adenomatous hyperplasia or blood clots. Therefore, MR imaging was not specific for tumor detection, and histologic diagnosis remains essential. The overall accuracy of MR imaging in staging endometrial carcinoma was 92%; its overall accuracy in demonstrating the depth of myometrial invasion was 82%. Demonstration of lymphadenopathy and adnexal or peritoneal metastases by MR imaging was suboptimal.

Salvage whole-abdominal irradiation following chemotherapy failure in epithelial ovarian carcinoma.

During the period 1977 to 1985, 12 patients with FIGO stage II and III epithelial ovarian carcinoma failed to achieve a pathologic complete response with chemotherapy and underwent salvage whole-abdominal irradiation (WAXRT). Six of these patients had gross residual disease present at the time of irradiation, and three (50%) were unable to complete the planned radiotherapy. All eventually failed in the treatment field; their 5-year actuarial survival and local control rates were zero. The other six were irradiated without residual macroscopic disease. Five of the six (83%) were able to complete WAXRT as planned without prolonged delays. The 5-year actuarial survival and local control rates for this group were 21 and 25%, respectively. The actuarial laparotomy rate to relieve bowel obstruction following WAXRT was 40% at 2 years. The results from this and other series indicate that salvage WAXRT is not effective for patients irradiated with macroscopic tumor. However, WAXRT appears to be potentially curative for a small but significant percentage of patients irradiated without gross disease, although the risk of significant complications is high.

Invasive cervical carcinoma: comparison of MR imaging and surgical findings.

The accuracy of magnetic resonance (MR) imaging in staging invasive carcinoma of the cervix was determined retrospectively in 57 consecutive patients in whom the extent of disease was surgically confirmed. MR images were analyzed for (a) location and size of the primary tumor; (b) tumor extension to the uterine corpus, vagina, parametria, pelvic sidewall, bladder, or rectum; and (c) pelvic lymphadenopathy. The accuracy of MR imaging in determination of tumor location was 91% and for determination of tumor size within 0.5 cm, 70%. Its accuracy was 93% for vaginal extension and 88% for parametrial extension. Pelvic sidewall, bladder, and rectal involvement were accurately excluded in all patients, but the positive predictive values were 75%, 67%, and 100%, respectively. Overall, the accuracy of MR imaging in staging was 81%. MR imaging is valuable because it can accurately demonstrate tumor location, tumor size, degree of stromal penetration, and lower uterine segment involvement. It is also valuable for ruling out parametrial, pelvic sidewall, bladder, and rectal involvement.

Treated ovarian cancer: comparison of MR imaging with serum CA-125 level and physical examination--a longitudinal study.

PURPOSE: To evaluate whether gadolinium-enhanced magnetic resonance (MR) imaging can demonstrate clinically occult tumors in women with treated ovarian cancer and to compare the diagnostic accuracy of MR imaging, serum CA-125 (ovarian cancer antigen) level, and physical examination. MATERIALS AND METHODS: From 1992 to 1997, a longitudinal study comparing MR imaging findings, CA-125 values, and physical examination results with eventual clinical outcome in 69 women with treated ovarian cancer was performed. Tumor presence was determined with surgery, by an elevated CA-125 value, or with follow-up of patients longitudinally to assess for tumor recurrence. Absence of tumor was accepted with a disease-free interval of at least 2 years. RESULTS: Twenty-three of 39 patients in clinical remission with a normal CA-125 level and physical examination result had subclinical tumor proved at laparotomy or clinical follow-up. Gadolinium-enhanced MR imaging correctly demonstrated residual tumor in 20 of 23 patients. In all 69 patients, MR images had a 91% sensitivity, 87% specificity, 90% accuracy, and 72% negative predictive value and were superior to serum CA-125 level (53%, 94%, 63%, and 38%, respectively) (P < .001) and physical examination (26%, 94%, 43%, and 29%, respectively) (P < .001) in the depiction of residual tumor. CONCLUSION: Gadolinium-enhanced MR imaging is a valuable clinical tool in patients with ovarian cancer. An abnormal MR examination with a normal CA-125 value is a strong indication of residual or recurrent tumor.