Massive delayed vaginal hemorrhage after laparoscopic supracervical hysterectomy.

Background. A known complication of supracervical hysterectomy is cyclical bleeding from the retained cervix when functioning endometrial tissue is not totally removed. We present a rare case of delayed postoperative vaginal hemorrhage after supracervical hysterectomy. Case. A 44-year-old woman presented on postoperative day 15 after laparoscopic supracervical hysterectomy with massive vaginal hemorrhage requiring emergent re-operation. Her bleeding was controlled with vaginally placed sutures. Ultrasound confirmed no intraperitoneal free fluid. The etiology was thought to be induced by postoperative tissue necrosis from cautery applied to the endocervical canal during the original surgery. Conclusion. Delayed vaginal hemorrhage from a retained cervix is a rare complication of laparoscopic supracervical hysterectomy. Caution should be exercised when cauterizing the endocervical canal as induced tissue necrosis may increase the risk of postoperative bleeding.

Incidental placental choriocarcinoma in a term pregnancy: a case report.

INTRODUCTION: Gestational choriocarcinoma occurs in 1 in 40,000 pregnancies. Of all forms of gestational choriocarcinoma, placental choriocarcinoma is the most rare. Maternal choriocarcinoma is usually diagnosed in symptomatic patients with metastases. The incidental finding of a choriocarcinoma confined to the placenta with no evidence of dissemination to the mother, or infant is the least common scenario. CASE PRESENTATION: The patient is an 18 year-old Gravida 1 Para 1 African American female who delivered a viable 3641 g female infant at 39 weeks gestation. Her pregnancy course was complicated by gestational hypertension during the third trimester. Her placenta revealed intraplacental choriocarcinoma. She was then followed closely by the Gynecologic Oncology service with a weekly serum beta human chorionic gonadotropin value. Beta human chorionic gonadotropin values dropped from 3070 mIU/ml to less than 2 mIU/ml two months post partum. No chemotherapy was initiated. Metastasis was ruled out by chest x-ray and whole body computed tomography scan. To date, both mother and baby are well. CONCLUSION: Due to the potential fatal outcome of placental choriocarcinoma, careful evaluation of both mother and infant after the diagnosis is made is important. The incidence of placental choriocarcinoma may actually be higher than expected since it is not routine practice to send placentas for pathological evaluation after a normal spontaneous delivery. The obstetrician, pathologist, and pediatrician should have an increased awareness of placental choriocarcinoma and its manifestations.

The treatment of early stage cervical cancer: an assessment of pre-operative factors.

OBJECTIVE: To assess the pre-operative clinical factors of a group of early stage cervical cancer patients and correlate them to the risk for adjuvant radiotherapy using GOG 92 and 109 criteria. METHOD: A retrospective chart review of cervical cancer patients treated at the Saint Louis University Division of Gynecologic Oncology between the years 1989 and 2004 was performed. The results were compared with chi-squared testing and multivariable regression analysis. A p-value of 0.05 was considered significant. RESULTS: One hundred and thirty-one cervical cancer patients underwent exploration for radical hysterectomy during the study time period. Five patients had stage IA1 disease, 6 patients had stage IA2 disease, 98 patients had stage IB1 disease, 20 patients had stage IB2 disease and one patient had stage IIA disease. No patient with stage IA1 or IA2 disease met criteria for adjuvant radiotherapy. The patients with stage IB1 tumors who were 45 years of age or younger and had tumors up to 2 cm in diameter had a low (14%) likelihood for treatment with adjuvant radiotherapy. The patients with stage IB1 tumors who were older than 45 years of age with tumors larger than 2 cm in diameter and the patients with stage IB2 tumors both had a high likelihood for adjuvant radiotherapy (77% and 90% respectively). CONCLUSION: In our study group, the stage of cervical cancer and a combination of tumor diameter and patient age was found to stratify early stage cervical cancer patients by likelihood for adjuvant radiotherapy.

Management of recurrent endometrial carcinoma.

Management of recurrent endometrial carcinoma has traditionally focused on providing targeted adjuvant therapy in select groups of patients based on their risk factors. Major progress has been made over the last two decades in identifying these clinical-pathological risk factors, which has led to the classification of patients into different risk groups. Patients with high-risk factors are generally treated with adjunctive radiation therapy immediately following surgery to minimize the incidence of recurrence. Those patients identified as low-risk generally receive no further treatment. Patients with intermediate-risk factors are individualized either to receive adjunctive therapy or not to receive further therapy based on institutional bias. Review of the literature suggests this traditional treatment strategy may reduce local recurrence, but fails to improve overall survival. Further studies to identify molecular based biomarkers may improve current classification of risk factors and the selection of patients for adjunctive therapy. Once the recurrence takes place, loco-regional disease can be treated with radiation therapy with reasonable success. Targeted radiotherapy and several cytotoxic chemotherapeutic agents are effective in the treatment of systemic recurrent disease. Hormonal therapy has also been demonstrated to be useful in selected group of patients for palliative purpose. The current areas of controversy and debate include the efficacy of adjunctive therapy, mode of therapy, timing of therapy, and issues related to surgical staging of patients as required by the current FIGO staging system.

Invasion of interstitial matrix by a novel cell line from primary peritoneal carcinosarcoma, and by established ovarian carcinoma cell lines: role of cell-matrix adhesion molecules, proteinases, and E-cadherin expression.

OBJECTIVE: Primary peritoneal carcinosarcomas are similar to ovarian carcinomas in that they can metastasize by intraperitoneal dissemination; therefore, invasion of the submesothelial interstitial (stromal) matrix is an integral part of the pathology. Our objective was to study cell-matrix interactions that may influence invasive behavior of a novel, primary peritoneal carcinosarcoma cell line (PC880), and to assess how these cell-matrix interactions are different from frequently studied cultured ovarian carcinoma cells NIH:OVCAR-3, SKOV-3, and ES-2. We also wanted to determine how the expression of the cell-cell adhesion molecule E-cadherin is related to invasive behavior. METHODS: The PC880 cell line was established from ascites fluid of a patient diagnosed with primary peritoneal carcinosarcoma. Adhesion assays were done in titer plates coated with individual matrix components. Cell migration in monolayer cultures was assessed by the scratch wound assay method. Invasion assays were done using a three-dimensional type I collagen gel. Cytokeratin, vimentin, and E-cadherin were detected by Western blotting. E-cadherin mRNA was detected by RT-PCR. RESULTS: PC880 cells adhered well to fibronectin, laminin, and vitronectin in an integrin-dependent manner. The cells also adhered to type I collagen and invaded a three-dimensional type I collagen matrix. The invasiveness of the PC880 cells was moderated by pretreatment of the collagen matrix with heparin or chondroitin sulfate (82 and 63% of control invasiveness, respectively), indicating a role of cell surface proteoglycans in promoting invasive phenotype. Treatment of PC880 cells with sodium chlorate also decreased invasiveness (80% of control), further confirming the role of cell surface proteoglycans. Treatment of PC880 cells with function-blocking antibody to alpha2 integrin decreased invasiveness (57% of control), indicating the role of integrins in promoting the invasive phenotype. The protease inhibitors GM6001, E-64, and AEBSF decreased invasiveness (35, 57, and 37% of control, respectively) of PC880 cells. The ES-2 cells also adhered to type I collagen, and invaded the three-dimensional type I collagen matrix; however, inhibitors such as heparin, chondroitin sulfate, function-blocking antibody to alpha2 integrin, E-64, and AEBSF were less effective in moderating the invasiveness. Inhibition of invasiveness with sodium chlorate was the same as in PC880 cell, while GM6001 did not inhibit invasiveness at all. The NIH:OVCAR-3 and SK-OV-3 cells were previously found to adhere to type I collagen, but these cells did not invade the three-dimensional type I collagen matrix. In a monolayer culture PC880 and ES-2 cells had significantly higher motility than NIH:OVCAR-3 and SK-OV-3 cells. Only these noninvasive cell lines expressed E-cadherin protein or mRNA. CONCLUSIONS: PC880 is the first cell line established from primary peritoneal carcinosarcoma, and the cytoskeletal composition indicated that these cells represent the sarcomatous elements of the tumor. PC880 cells, similar to ES-2 cells, adhered to type I collagen, and invaded a three-dimensional collagen matrix. The invasion of the interstitial matrix by both the peritoneal carcinosarcoma and the ovarian carcinoma cell line was mediated by cell surface proteoglycans, alpha2 integrin, and proteases. The invasive cell behavior of PC880 and ES-2 cells correlated with a high degree of motility, and with the lack of expression of the cell-cell adhesion molecule E-cadherin.