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The aim of this study was to evaluate the survival of gynecologic cancer patients diagnosed with deep vein thrombosis.We retrospectively reviewed the charts of patients admitted to our institution with gynecologic malignancy who were diagnosed with deep vein thrombosis (DVT) between 1984 and 1995. Data were collected regarding site, stage, histology, treatment, and proximity of DVT to treatment with surgery, chemotherapy, and radiotherapy. This study was limited to cases of ovarian, uterine, and cervical cancer. Descriptive statistics were generated and the survival of patients from the time of DVT was calculated using the Kaplan and Meier method. Cases were then matched by site, stage, histology, and age to controls without DVT to evaluate the effect of DVT on survival. A Cox regression model was used to assess the effect of multiple variables on survival.A total of 74 cases were identified. Ovarian, uterine, and cervical cancer accounted for 45, 27, and 28% of cases, respectively. Approximately 64% of patients had stage III or greater disease. The median survival of all patients from the time of DVT diagnosis was 7.8 months, with only about 20% of patients surviving at 5 years. Patients with cervical cancer or patients who had radiation therapy within 3 months of DVT diagnosis had significantly lessened survival (P0.01) than other patients with DVT. The survival of patients from the time of cancer diagnosis with venous thrombosis was significantly worse than a matched control group without DVT (P0.001). On multivariate analysis, there was a twofold greater risk of dying in those patients with gynecologic cancer and DVT.The development of DVT in conjunction with a gynecologic malignancy connotes a poor prognosis, especially in patients with cervical cancer. It is possible that this poor prognosis is related to the pathophysiology that results in venous thrombosis and not just the presence of cancer. more...

INTRODUCTION significant amount of exposure to general surgical techniques both during internship at the University of Pennsylvania Nineteen-hundred ninety-five is an important anniversary Hospital, then in the armed forces, and again during my year. It marks the centennial year since the performance of residency at Penn, where I spent a 4-month rotation on genthe first radical hysterectomy by John Goodrich Clark on eral surgery. In my case, I was very fortunate in that I spent April 26, 1895, at Johns Hopkins Hospital. A second imall of the time during my second year of residency on two portant event in 1895 was the discovery of X rays by Wilgynecologic services where we operated 6 days a week for helm Konrad Roentgen. Three years later Marie Sklodowska the entire year. Curie discovered radium. Thus, the constellation of events Despite the fact that Clark had been Professor of Gynecolnecessary for the successful management of cervical cancer ogy at the University of Pennsylvania from 1899 until his was made available. death in 1927, there never developed a strong tradition or The history of the development of the radical hysterecprogram in the use of radical pelvic surgery for gynecologic tomy is beautifully elucidated by Clark in a chapter from a cancer. After World War II there were a few feeble attempts 1907 textbook edited by Howard A. Kelly entitled ‘‘Gyneat establishing such a program that were soon abandoned cology and Abdominal Surgery.’’ In it, Clark reviewed the for what then was a safer and more effective treatment by historic events leading up to the first abdominal radical hysradiation therapy. terectomy, the technical problems associated with many of In 1954, the late Dr. Michael Newton who was a resident the early cases, and the factors involved in ensuring the with me in Obstetrics and Gynecology and was trained also complete removal of the cancer with maximum safety to the in general surgery was asked to develop a program of radical patient. Various issues were discussed such as pelvic node gynecologic surgery. Unfortunately, after about 6 months in involvement, the need for node removal, and the extent of this position he was offered the post as Chairman of the dissection, and later whether it was reasonable to continue newly developed Department of Obstetrics and Gynecology doing radical hysterectomy in view of the high morbidity at the University of Mississippi and left the University of and mortality observed in some of the early series of cases. In Pennsylvania. In the Spring of 1955 my chief, Dr. Franklin Chapter 16 of Hoskins and Rubin’s recent textbook entitled L. Payne, asked me if I would be willing to undertake the ‘‘Cervical Cancer and Preinvasive Neoplasia,’’ I outlined vacant position. With much trepidation I agreed. Two days the history of the development of radical hysterectomy later, I took the overnight train from Philadelphia to Boston throughout the latter part of the nineteenth century as well to the Pondville State Hospital where I met Dr. Langdon as the early part of the twentieth century. Parsons, whom Dr. Payne had contacted and made arrangements for my arrival. That day was a turning point in my thinking about how radical pelvic surgery should be done. PROLOGUE Dr. Parsons, a superb general and gynecologic surgeon, carI thought it would be helpful to describe the type of experiried out an anterior pelvic exenteration with urinary diverence and training which was available to many of us not sion to an isolated segment of ileum. Just roughly 6 or 7 long after World War II, when upon completion of a year’s hours of observation of this master surgical craftsman taught rotating internship most of us returned to military service me more than I had learned in all the years before. I shall before beginning our residencies in obstetrics and gynecolbe forever grateful to Dr. Parsons for the opportunity he ogy since residency positions were very limited by returning afforded me and for all that I learned on that day. This was essentially my fellowship. veterans who preceded us. This schedule provided me with a more...

Twenty-five patients with recurrent or advanced-stage endometrial cancer were treated with cisplatin, doxorubicin, and cyclophosphamide (PAC) from May 1982 to November 1987. A retrospective chart analysis was performed to evaluate the effect of treatment on survival and progression-free interval. Toxicity was moderate. Neutropenia was the most common side effect. Age, performance status, and tumor cytoreduction were statistically significant predictors of survival time (P less than 0.03). In the 17 evaluable patients, the response rate was 47%. PAC is an active regimen in the treatment of endometrial cancer. Larger prospective studies are needed to evaluate whether tumor cytoreduction is important in the treatment of this disease. more...

With the ready availability of powerful desktop computers, the ability to manage large clinical databases has become practical. A computer can enhance the capability of a gynecologic oncology service to catalog, recall, and analyze data about patients, tumors, and therapies. While commercially available database packages can be used for this purpose, we have developed a custom database for tracking the clinical activity of a busy gynecologic oncology service. The system catalogs data about patients, admissions, tumors, and therapeutic modalities and uses this information to generate several useful reports. The reports are used for daily patient care, fellow and resident case statistics, and clinical research. What is unique about the system is that it is optimized for ease of use. The development of this tumor registry, its user friendliness, and advantages over a manual recordkeeping system are described. Unlike other tumor registries, our system is utilized on a daily basis for patient care. Therefore, the data being entered have an immediate usefulness in addition to being simultaneously added to the tumor register for retrospective clinical research. One may hypothesize that it would be useful if all gynecologic oncology services used a common computerized tumor registry that could allow for the sharing of information on a national or global Scale. more...

In order to determine whether optimal surgical debulking in Stage IV epithelial ovarian cancer impacts survival, a retrospective review of patients treated at the University of Pennsylvania Cancer Center (UPCC) from 1984 to 1995 diagnosed with Stage IV epithelial ovarian cancer was performed. Data were collected regarding grade, histology, reason for allocation to Stage IV, extent of surgery performed and residual disease at initial staging procedure, major perioperative complications, first-line chemotherapy regimen, length of inpatient hospital stay, outcome at second-look laparotomy, follow-up, and survival. For the purposes of this study, optimal cytoreduction was defined as a residual disease of 2 cm or less. Forty-seven patients with Stage IV epithelial ovarian cancer identified in the Society of Gynecologic Oncologists (SGO) Database at UPCC are included. Fourteen of 47 (30%) were optimally cytoreduced at the time of their staging procedure. Twenty-six of 47 (55%) were deemed Stage IV by virtue of positive pleural effusion cytology only. Twenty-one of 47 (45%) had intraparenchymal liver involvement or metastatic disease outside of the abdomen. The median survival of the suboptimally debulked group was 17 months, while median survival in the optimal group was 37 months (P = 0.0295). These data suggest that Stage IV epithelial ovarian cancer patients with less than 2 cm residual disease have a survival advantage over patients with greater than 2 cm residual. more...

The Center for Disease Control (CDC) recently added invasive cervical cancer to its list of surveillance case-defining diseases, and also included cervical dysplasia, carcinoma in situ , and pelvic inflammatory disease (PID) in the classification system. There are several reported cases of cervical cancer in AIDS patients that behaved in an unusually aggressive fashion and responded poorly to therapy. In light of the above-reported cases, it may be expected that cervical cancer may manifest itself in unusual ways in HIV-positive women. A case of aggressive cervical cancer in an AIDS patient with PID is reported. She was admitted with PID and newly diagnosed cervical cancer with recurrent fever spikes despite adequate antibiotic coverage. An aspiration of a presumed psoas abscess revealed metastatic squamous call carcinoma. These data suggest that not only are HIV-infected women at risk for aggressive and unusual presentations of cervical cancer, but also that coexistent pelvic infection may contribute to development and spread of the disease. Immunosuppression from the virus may increase the incidence and severity of neoplasia. Data suggest that cervical cancer in HIV-infected women is often of advanced stage and responds poorly to treatment. Unique treatment approaches may need to be developed as conventional strategies do not seem to be adequate. More research is required to determine what these strategies should be. Lastly, universal HIV screening of women with either PID or cervical cancer seems prudent. more...

Four hundred fifteen patients with early-stage cervical carcinoma were explored via a transperitoneal approach for radical hysterectomy at the Hospital of the University of Pennsylvania between January 1, 1960, and December 31, 1985. Twenty-four of these patients were found to have histologic documentation of para-aortic lymph node metastases. Twenty-one patients (88%) were treated primarily with extended-field radiotherapy. Forty-eight percent of these patients have survived greater than 5 years from diagnosis. Six patients have been followed more than 10 years after initial treatment. All six are alive although one patient has recurrent disease that was diagnosed at 164 months. Patients with adenocarcinoma or adenosquamous carcinoma had a survival significantly lower than that of those with squamous cell cancers (p = 0.022). Complications included one treatment-related death from multiple fistulas and sepsis, one vesicovaginal fistula, two enteric fistulas, and two small bowel obstructions. The major morbidity rate was 19%. Extended-field radiation is effective therapy for para-aortic nodal metastasis associated with early-stage squamous cell carcinomas of the cervix but carries a considerable morbidity rate. Other modalities such as combined chemotherapy and radiation may be necessary for adenocarcinoma. more...

The optimal management of stage II carcinoma of the endometrium remains to be established. We reviewed our experience in treating 42 patients with stage II endometrial cancer by surgery, radiation, or combined radiation and surgery at the Hospital of the University of Pennsylvania. The overall 5-year survival was 47.6%. The 5-year survivals of patients treated by surgery only, radiation only, or combination radiation and surgery were 68.5, 36.5, and 46.1%, respectively, which were not significantly different. Histologic grade was found a significant prognostic factor but type of cervical involvement was not. Major complication rates were similar in each treatment group. We conclude that the majority of patients with stage II endometrial carcinoma are best treated by combination radiation and surgery, but in a select subset of patients, radical hysterectomy and lymphadenectomy constitute a reasonable treatment option. more...

Malignant struma ovarii is a very rare tumor, with considerable disagreement concerning the necessary histologic features for malignancy. The prognosis with patients with a malignant struma ovarii is difficult to make because of inadequate follow-up of the reported cases and long clinical courses. In most cases the patients responded well to surgical treatment but sometimes patients have died from malignant struma ovarii, in particular, if there is metastasis. There is evidence that radioactive iodine is effective in treating metastatic struma. The present case reports the use of intraperitoneal chromic phosphate for metastatic intraperitoneal disease, with thyroid suppression. Long-term follow-up will be necessary to properly evaluate this therapy. Prophylactic administration of thyroid hormone should be considered in cases of malignant struma ovarii. more...

Eighty-five patients underwent a surgical staging procedure during a 2-year period. Fifty-eight of these patients were evaluated in relation to the histologic grade of their squamous carcinoma of the cervix. An increased incidence of extrapelvic lymph node metastasis is associated with poorly differentiated tumors and with parametrial extension of the primary tumor regardless of histologic grade. Surgical staging is suggested for patients with parametrial extension of their tumor or for patients with poorly differentiated tumors. more...

Seventy-five cases of primary squamous cell carcinoma of the vagina treated at the University of Pennsylvania are reviewed with long-term follow-up presented. These comprised 2.5% of all female genital malignancies treated during 1958 to 1980 inclusive. Patients treated during that time with non-squamous cell cancers have been excluded. Patients are analyzed with regard to stage, therapy, complications, and survival. Sixty-five percent of patients were stage I or II. Five-year survival for the entire group was 45%. Patients treated with radical surgery other than exenteration did well, with 7 of 8 surviving 5 years. Serious treatment complications were mostly related to radiation therapy and primarily involved the bowel and bladder. Three patients died of complications. Recurrence carried a grave prognosis as 30 of 33 patients with recurrence died of disease. Most recurrences were diagnosed within the first year following treatment. Patients with advanced disease were more likely to have distant recurrences. Although radiation therapy is generally the treatment of choice, radical surgery can yield excellent results when used in carefully selected patients. With meticulous attention to radiation dosage and technique it is hoped that treatment morbidity can be reduced. Optimal treatment of advanced disease may require some form of adjuvant systemic therapy. more...

Cytoplasmic estrogen receptor levels (ER) were measured in ovarian epithelial malignancies from 44 patients using a dextran-coated charcoal assay with analysis of the data by Scatchard plots. In 31 cases, progesterone receptor levels (PR) were also determined. In untreated patients, 68.8% of malignancies were ER-positive (greater than or equal to 10 fmole receptor/mg protein) and 35.0% were PR-positive (greater than or equal to 50 fmole/mg protein). Receptor levels in ovarian epithelial malignancies were not dependent on patient age, menopausal status, tumor stage, or histologic grade. However, ovarian endometrioid carcinomas contained significantly more PR than other histologic variants (P less than 0.02). Excluding endometrioid carcinoma, tissues from patients treated with chemotherapy contained less ER and PR than tissues from untreated patients. ER-positive tumors from three patients assayed before cyclophosphamide or combination chemotherapy became ER-negative after therapy. In addition, tamoxifen increased cytoplasmic PR (124 to 333 fmol/mg) and decreased cytoplasmic ER (65 to 4 fmol/mg) in a single patient with endometrioid carcinoma. more...

Thirty-six patients with primary ovarian carcinoma who had 42 second-look procedures performed are reported. Twenty-three patients had no tumor found at the second-look celiotomy and were given no further treatment. Thirteen patients had tumor at the second-look procedure and were continued on therapy. Six patients have died with disease and all had a positive second-look celiotomy. Two patients have died with leukemia but with no evidence of ovarian cancer, one after a negative second-look and the other a negative third-look. No patient with a negative second-look celiotomy has died with disease. A correlation with respect to the findings at the second-look was found with respect to the stage of disease and the amount of residual tumor at the initial surgery. The use of the second-look celiotomy in patients with disease in the early stages and in patients treated with irradiation is discussed, along with the utilization of the laparoscopy. more...

Malignant gestational trophoblastic disease arising after term pregnancy is associated with a poorer prognosis than postmolar trophoblastic disease [1]. Choriocarcinoma coexistent with intrauterine pregnancy has also been reported [2]. The case described herein represents the rare occurrence of a term pregnancy in a patient with preexisting metastatic choriocarcinoma and serves to underscore the need for adequate contraception in the follow-up of patients treated for malignant gestational trophoblastic disease. more...

The nomenclature of the lymph node groups draining the pelvic organs has been poorly standardized. This has impaired understanding of the natural history of gynecologic malignancies and led to difficulties in communication among specialists treating those diseases. In order to assess the extent of this problem, members of the Society of Gynecologic Oncologists and other physicians treating pelvic malignancy were asked to label a diagram of the pelvic lymph nodes. The lack of uniformity in the answers confirms the need for a simple, clinically relevant system of nomenclature. Such a system is proposed. more...

From 1960 to 1979 there were a total of 14 patients followed at the University of Pennsylvania with early cervical carcinoma who had histologically documented metastases to the para-aortic nodes and who were treated with extended-field radiotherapy. Thirteen of these patients were stage IB and one was stage IIA. All patients underwent exploratory laparotomy and lymph node dissection, followed by extended-field radiotherapy. Six patients are alive with NED for greater than 5 years; one patient is alive with NED at 3 years. An additional patient is now alive and well almost 3 years from a biopsy documented recurrence treated with chemotherapy, and 6 years from initial diagnosis. Thus 8 of 14 patients have enjoyed a long-term survival. Five patients experienced severe treatment-related morbidity. Two had long-term survival, two died of disease, and one died of radiation complications with NED on autopsy. Each of the six patients that died of disease had recurrences at distant sites. One also had a pelvic recurrence. These patients appear to have a prognosis quite different from that of patients with locally advanced cervical cancer metastatic to the para-aortic nodes and deserve aggressive treatment. The need for adjuvant systemic therapy is stressed. more...

The average postoperative stay for 45 patients undergoing radical vulvectomy with femoral and inguinal lymphadenectomy was 37 days. Five patients were treated with oral zinc sulfate for at least 7 days prior to surgery. The incidence of wound infection was decreased, and the average postoperative stay was reduced to 18 days. more...