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Objective To assess the feasibility and surgical outcome of laparoscopic surgery among women with large benign ovarian cysts. Methods We conducted a prospective study applying laparoscopic surgery among women with ovarian cysts whose maximum diameter was ≥10 cm and radiologic and laboratory features suggestive of benign disease. Patients' demographics, clinical and ultrasound features, CA-125 values, surgical procedures, operative and post-operative complications, estimated amount of blood loss (EBL), operative time, conversion to laparotomy and the pathologic findings were recorded. Results Thirty-three consecutive patients underwent laparoscopic surgery over 7 years. The mean (range) age and body mass index were 45.2 (17–73 years) and 30 (21–42), respectively. Laparoscopic surgery was successful in 31 (93.9%) patients. The procedure was converted to laparotomy in 2 patients secondary to adhesions. There were no operative or post-operative complications. The mean (range) operative time, EBL and hospital stay were 82 (45–125 min), 89 (20–250 mL) and 0.94 (0–4 days), respectively. Twenty-three (70%) patients were discharged home the day of the surgery. The surgical procedures performed were: unilateral salpingo-oophorectomy (SO) ( n =16), bilateral SO ( n =4), ovarian cystectomy ( n =2) and laparoscopically assisted vaginal hysterectomy and bilateral SO ( n =9). The cysts were extracted after aspiration through the vagina ( n =11), lower quadrant incision ( n =5) or the umbilical incision ( n =15). Pathologic findings included serous cystadenoma ( n =11), mucinous cystadenoma ( n =6), dermoid ( n =6), endometriosis ( n =5), benign epithelial-lined cyst ( n =3) and borderline ovarian tumors ( n =2). Conclusion Laparoscopy is feasible and safe for women with large ovarian cysts with benign features and results in a short hospital stay.

The purpose of our study was to find if uterine manipulation at the time of laparoscopic hysterectomy among women with endometrial carcinoma increases the incidence of malignant cells in the peritoneal washings.We conducted a prospective study including women with clinical stage I endometrioid endometrial carcinoma undergoing laparoscopic surgery between 07/01/2000 and 07/01/2004. Surgery on all patients was conducted by the same surgeon using the same technique and instruments. Two sets of peritoneal washings were obtained, one before and one after the insertion of the Pelosi uterine manipulator. The two sets of washings were blindly reviewed by the same cytopathologist for the presence of malignant cells. Correlation was made between the two sets of washings.Forty-two consecutive women (age 46-90, median: 58) were enrolled in the study. The procedure was converted to laparotomy in 3 (7.6%) patients after obtaining the two sets of washings. The preoperative tumor grades were: G1: 22 (52.4%), G2: 12 (28.6%), and G3: 8 (19.0). The incidence of positive peritoneal washings was 14.3%. All patients underwent laparoscopically assisted vaginal hysterectomy with bilateral salpingo-oophorectomy, 30 patients had bilateral pelvic lymphadenectomy, and 5 patients had bilateral pelvic and para-aortic lymphadenectomy. There was perfect agreement between the two sets of washings in all patients (100%, P.001). No patients had positive washings after the insertion of the uterine manipulator if the washings were negative before the insertion. The surgical stages were: IA: 14 (33.3%), IB: 12 (28.6%), IC: 7 (16.7%), IIA: 1 (2.4%), IIB: 1 (2.4%), IIIA: 4 (9.5%), IIIB: 1 (2.4%), IIIC: 1 (2.4%), and IV: 1 (2.4%). Twenty-nine patients received no postoperative treatment, 2 received chemotherapy, 3 received Megace, and 9 received radiation therapy. Patients were followed-up for 7-56 months (median: 28). Two patients had tumor recurrence, and one patient died secondary to her disease. Two other patients died secondary to other causes.We conclude that uterine manipulation at the time of laparoscopic hysterectomy does not increase the incidence of positive peritoneal cytology among women with endometrial carcinoma.

Objective. The purpose of our study was to assess the surgical stage, final grade, and survival of women with endometrial carcinoma whose preoperative endometrial biopsy showed well-differentiated (FIGO grade 1) carcinoma. Materials and methods. A retrospective study was conducted including all women treated at the University of Vermont between 1992 and 2004 whose preoperative endometrial biopsy was reviewed by the staff at the Pathology Department and diagnosed as FIGO grade 1 adenocarcinoma and who received peritoneal washings, total abdominal (or laparoscopic) hysterectomy, bilateral salpingo-oophorectomy, and pelvic ± para-aortic lymphadenectomy as part of their surgery. Results. One hundred eighty-two patients (age: 32–91, median: 60) were enrolled. All patients had total hysterectomy, bilateral salpingo-oophorectomy, peritoneal washings, and bilateral pelvic lymphadenectomy. Fifteen (8.2%) patients had para-aortic lymphadenectomy. There were no operative mortalities. Fourteen patients (7.7%) had major operative or postoperative complications. There was disagreement between the pre- and postoperative grade in 30% of the study group. The surgical stages were: IA: 55 (30.2%), IB: 61 (33.5%), IC: 26 (14.3%), IIA: 9 (4.9%), IIB: 8 (4.4%), IIIA: 10 (5.5%), IIIB: 2 (1.1%), IIIC: 8 (4.4%), and IV: 3 (1.6%). Postoperatively, 131 (72%) patients received no additional treatment, 47 (25.8%) received radiation therapy, 3 (1.6%) received chemotherapy, and 1 (0.5%) received Megace. During a median follow-up period of 6 years, 8 (4.4%) patients had recurrence and 6 (3.2%) died from their disease. The 5-year disease-free and overall survival was 95.2% and 96.4%, respectively. Conclusions. Approximately 30% of women with endometrial carcinoma whose preoperative endometrial biopsy shows grade 1 tumors have grade 2 or 3 in the hysterectomy specimen and 12.6% have advanced surgical stage (stage III and IV) disease. Women with preoperative endometrial biopsy showing grade 1 tumors who undergo surgical staging have excellent survival and acceptable operative morbidity.

The aim of the current study is to investigate the clinical and molecular factors associated with cytoreduction among women with advanced stage epithelial ovarian carcinoma EOC.Seventy-two women with FIGO stage III and IV EOC or primary peritoneal carcinoma (PPC) underwent similar attempt at surgical cytoreduction, mostly by the same surgeon. The histologic material of these patients was reviewed and the histologic subtype and grade were assigned. Immunohistochemical tests were performed for expression of molecular regulators of apoptosis (p53, p21, Bcl(2), Bcl(x), Bax) and chemoresistance (PGP, MRP, LRP, GST). The following factors were assessed for their association with complete (no residual tumor) and optimal (residual tumor1 cm) cytoreduction: type of carcinoma (EOC versus PPC), stage, CA-125 values, ascites, histology, tumor grade, and p53, p21, Bcl(2), Bcl(x), Bax, PGP, MRP, LRP, GST expression using the odds ratio and associated 95% confidence intervals. Significant univariate odds ratios were assessed jointly in a multivariate logistic regression model. Receiver operating characteristic curve analysis was performed to determine the CA-125 level with the maximal cytoreduction prognostic power.Twenty-three (31.9%) women had no residual tumor, 35 (48.6%) hador=1 cm residual tumor and 14 (19.4%) had residual tumor1 cm. Factors with significant univariate associations with complete cytoreduction included stage, CA-125 level, ascites, histology, and p53. p53 expression was the only factor which remained significant in the multivariate analysis (odds ratio 7.2, 95% CI 1.5, 34.9). A preoperative CA-125 value ofor=500 IU/ml best determined complete cytoreducibility.Innate tumor characteristics determine cytoreducibility of women with ovarian carcinoma. Pre-operative evaluation of p53 expression may be of value in predicting the outcome of cytoreductive surgery in women with advanced stage EOC.

Objectives The predictive value of cervical Papanicolaou (Pap) smears reported as "positive for malignancy," especially those obtained by the liquid-based method, has not been adequately assessed. The objectives of this study are to determine the positive predictive value of Papanicolaou smears with features of malignancy, to compare the accuracy of Papanicolaou smears obtained by the liquid-based method to those obtained by the conventional technique in this setting, and to study the factors influencing a false-positive cytologic diagnosis of malignancy. Materials and methods Pap smears significant for malignant cytology were identified at Fletcher Allen Health Care Hospital in Burlington, VT, from May 1, 1995, to April 30, 2001. A retrospective review of the hospital records and pathology reports was performed documenting patient characteristics, the collection technique, and the final histology. An independent review of the cytology and histology was performed. The positive predictive value and false-positive rate of malignant cytology were calculated for the liquid-based and conventional Pap smear techniques. Results A total of 472,743 Pap smears were performed during the period specified. One hundred four Pap smears were reported as positive for malignancy, yielding a prevalence rate of 0.02%. A total of 68 patients had paired cytology and histology specimens. Malignant cytology was identified in 36 smears obtained by the liquid-based technique and 32 smears obtained by the conventional technique. A true-positive result, meaning malignant cytology confirmed by the presence of invasive carcinoma on histology, was obtained in 61 of 68 (89.7%) patients. A false-positive result, meaning malignant cytology not confirmed by histology, was obtained in 7 of the 68 (10.3%) patients. The false-positive rate of malignant cytology was 8.4% for the liquid-based technique and 12.5% for the conventional technique. All 7 false-positive smears were diagnosed with high-grade dysplasia by histology. Three of the 7 patients with high-grade dysplasia had previous treatment for dysplasia, one of whom was also pregnant at the time of the smear. Conclusions Malignant cervical Papanicolaou smear cytology has a high positive predictive value in the setting of gynecologic and nongynecologic malignancies. Previous treatment for cervical dysplasia or pregnancy may influence the false-positive rate of malignant cytology.

Recently developed immunohistochemical antibodies developed for non-gynaecological lesions may be of use in diagnostic ovarian pathology. These antibodies include markers of epithelial surface tumours such as E and N cadherin, Wilms' tumour gene product and uroplakin III, as well as markers of both sex cord stromal tumours (CD99, melan-A, calretinin) and germ cell tumours (CD117 and CD30).

Objective. The best treatment modality and factors affecting recurrence among women with vaginal intraepithelial neoplasia (VAIN) are yet to be determined. The aims of the current study were to describe the clinical features, results of treatment, and factors affecting recurrence among patients with VAIN. Methods. We conducted a retrospective review of 121 women with VAIN after confirming the histologic diagnosis. Patient demographics, clinical features, and results of therapy were recorded. Factors affecting recurrence were assessed using the odds ratio and the 95% confidence intervals among patients who were followed up for 7 months or more and had at least one posttreatment Papanicolaou smear. Significant univariate odds ratios were assessed jointly in a multivariate model with a stratified analysis. Results. The mean age of the patients was 35.0 (±17), 41% of the patients smoked, 39% had a history of human papillomavirus infection, 27% had history of sexually transmitted diseases, 22% had history of surgery for cervical intraepithelial neoplasia (CIN), and 23% had total hysterectomy. The upper third of the vagina was the most common site of VAIN and 61% of the lesions were multifocal. Associated cervical and vulvar intraepithelial neoplasia (VIN) were present in 65 and 10%, respectively. Recurrences of VAIN and progression to invasive vaginal cancer occurred in 33 and 2%, respectively. Recurrences following partial vaginectomy, laser, and 5-fluorouracil were 0, 38, and 59%, respectively ( P = 0.0001). Multifocality and method of treatment were significant independent predictors of VAIN recurrences (odds ratio 3.3, 95% CI 1.2, 9.2, P = 0.02, and 22.4, 95% CI 1.3, 393.6, P = 0.001, respectively), with no interaction, based on a stratified analysis. Conclusions. VAIN occurs most often among women with CIN or VIN, commonly involves the upper third of the vagina, and is often multifocal. Partial vaginectomy provides the highest cure rate and multifocality is a risk factor for recurrence.

Objective. The best technique for obtaining cytologic specimens necessary for evaluation of diaphragmatic spread among women undergoing surgical staging for ovarian cancer has yet to be determined. The aim of the current study was to compare two methods for obtaining diaphragmatic cytology—wash and scrape—in accuracy, correlation to clinical findings, and smear quality. Methods. We conducted a prospective study among women undergoing surgical staging for ovarian cancer. In each patient diaphragmatic scrape and wash specimens were obtained, then the undersurface of the diaphragm was inspected and palpated. The smears were examined for presence of cancer cells, correlated to clinical findings, and scored for quality (cellularity, preservation, and background). Results. In 46 consecutive patients with stage I–III ovarian cancer, the diaphragm was clinically involved in 12 (26.1%). Malignant cells were demonstrated in 21 (45.7%) of wash and scrape specimens. There was perfect agreement between washes and scrapes and good agreement between clinical evaluation and scrapes or washes (κ = 1.0 and 0.592, respectively). Wash specimens had significantly higher overall smear quality and cellularity scores (6.26 ± 1.26 vs 6.11 ± 1.06, P < 0.02, and 2.20 ± 0.81 vs 1.85 ± 0.76, P < 0.05, respectively). Conclusion. Although diaphragmatic wash specimens provide better-quality smears than scrape specimens, both techniques are equally diagnostic of diaphragmatic involvement in women undergoing surgical staging for ovarian cancer.

Objective: This study was undertaken to determine the accuracy of systematic intraoperative clinical evaluation of lymph nodes in women with gynecologic cancers and to examine the factors affecting such accuracy. Study Design: The characteristics and overall intraoperative clinical impression of lymph node metastases were prospectively recorded for 178 consecutive women undergoing lymphadenectomy. The overall clinical impression and lymph node characteristics (enlargement, firmness, and adherence) were correlated with the final histopathologic diagnosis. Results: The overall clinical impression showed excellent agreement with the final histopathologic diagnosis (κ = 0.753) but had a high false-negative rate (25.8%). The combination of enlargement and firmness had the highest overall accuracy (93.3%). Accuracy of clinical evaluation varied significantly according to the type of cancer, node positivity, and the proportion of positive nodes with respect to the total number of nodes. Conclusion: Although systematic intraoperative clinical evaluation of lymph nodes by a trained surgeon has high overall accuracy and correlates well with the final histopathologic diagnosis, it has a high false-negative rate and cannot substitute for histopathologic examination. (Am J Obstet Gynecol 2001;184:1177-81.)

The aim of this study was to investigate the feasibility and safety of laparoscopic management of obese women with early stage endometrial cancer and to compare the surgical outcome, cost, hospital stay, recall of postoperative pain control, time to return to full activity and to work, and overall satisfaction among these women and those managed by laparotomy.We conducted a prospective study over 2 years applying laparoscopic surgery to all women with clinical stage I endometrial cancer and body mass indices (BMIs) between 28.0 and 60.0 who can tolerate such surgery. As a control, we used women with clinical stage I endometrial cancer and similar BMIs who underwent laparotomy in the previous 2 years. Both groups were compared in their characteristics, surgical outcome, cost, and hospital stay, and interviewed regarding time to recovery, recall of postoperative pain control, and overall satisfaction with their management.Forty of 42 obese women who presented with clinical stage I endometrial cancer during the study period were offered laparoscopic surgery. The procedure was converted to laparotomy in 3 (7.5%) patients. Laparoscopic surgery was thus successful in 88.1% of all obese women. There was no significant difference between women who underwent laparoscopy and those who underwent laparotomy in patient characteristics, proportion of women who underwent lymphadenectomy, complications, total cost, patients' recall of postoperative pain, and patients' satisfaction with management. Women who underwent laparoscopy had a significantly longer operative time, more pelvic lymph nodes removed, a smaller drop in postoperative hematocrit, less pain medication, and a shorter hospital stay (194.8 versus 137.7 min, P0.001; 11.3 versus 5.3, P0.001; 3.9 versus 5.4, P = 0.029; 32.3 versus 124.1 mg, P0.001; and 2.5 versus 5.6 days, P0.001, respectively). There was a trend toward earlier resumption of full activity and return to work among women who underwent laparoscopy (23.2 versus 45.0 days, P = 0.073, and 35.3 versus 67.0 days, P = 0.055, respectively).Most obese women with early stage endometrial cancer can be safely managed through laparoscopy with excellent surgical outcome, shorter hospitalization, and less postoperative pain than those managed through laparotomy.

Objective. The aim of this study was to assess the role of first-line chemotherapy with paclitaxel and platinum in the treatment of advanced or recurrent cervix cancer. Methods. Twenty patients with advanced or recurrent cancer of the cervix with no prior chemotherapy and measurable disease were entered in a phase II trial from September 1995 to September 1998. Seventeen patients were treated with paclitaxel at 135 mg/m 2 over 24 h followed by cisplatin at 75 mg/m 2 every 4 weeks. Three patients with impaired renal function were treated with paclitaxel at 135 mg/m 2 over 3 h with carboplatin at 300 mg/m 2 . Results. A clinical response rate of 45% was noted (two complete responses and seven partial responses) with a median duration of 6 months (range: 1.5–9). The median progression-free interval and overall survival in patients with a clinical response was 10.5 and 13 months, respectively, compared to 4 ( P = 0.015) and 6 months in the nonresponders ( P = 0.14). Seven of nine patients (77.8%) with a clinical response are alive. Patients with recurrences outside the radiation field had twice the response rate (60%) than that of those within the radiated field. The chemotherapy was well tolerated; the most significant toxicity was grade 3/4 neutropenia (55%). No patient had discontinuation of chemotherapy due to toxicity. Conclusions. First-line chemotherapy with paclitaxel and platinum for advanced and recurrent cervix cancer is promising and deserves consideration for large phase III trials.

The aim of this study was to study the relationship between borderline ovarian tumors (BLOT) and epithelial ovarian cancer (EOC) by comparing the epidemiologic features of women with BLOT with those of women with EOC of similar histology.The epidemiologic features of 32 women with serous and mucinous BLOT were compared with those of 273 women with primary serous or mucinous EOC. We included all women with the documented respective histologic diagnoses admitted to Roswell Park Cancer Institute between 1982 and 1996 who returned a self-administered epidemiologic questionnaire which contained 44 items pertaining to reproductive, contraceptive, medical, social, dietary, occupational, and family histories of cancer. Individual variables between both groups were compared using the Student t test, chi2 analysis, the Mantel-Haenszel test, and the Wilcoxon nonparametric test. Two-tailed P0.05 was considered significant.The response rate to the questionnaire was 63% in the BLOT group and 60% in the EOC group. There was no significant difference between the two groups in geographic location, race, education, income, smoking, marital status, age at first pregnancy, age at first birth, history of hysterectomy, history of infertility, history of tubal surgery, use of hormone replacement therapy, or history of diaphragm or intrauterine contraceptive device use. There were no significant differences in family history of malignancy between women with BLOT and those with EOC. Women with BLOT were significantly younger than those with EOC (mean age 47 +/- 14.0 versus 56 +/- 13.7, P0.01). There was an apparent difference in oral contraceptive pill use between both groups. However, when we adjusted for age by stratification this difference was not significant (P = 0.089).The epidemiologic features of women with BLOT are similar to those of women with EOC with the exception of an earlier age of onset. These findings might be consistent with one etiology for both conditions.

Despite intensive investigation, the nature of epithelial ovarian cancer precursors remains controversial. Because women with a strong family history of ovarian cancer have a high probability of developing ovarian cancer themselves, ovaries removed prophylactically from such patients provide an opportunity to identify early neoplastic changes. Ovaries removed from 64 consecutive patients undergoing prophylactic oophorectomy and from 30 women with normal ovaries and no known family history of ovarian cancer were examined by light microscopy for a number of histopathologic features and by image cytometry for abnormalities of the cyst and surface epithelium. All analyses were performed without knowledge of the family history. Seven benign, but no tumors of low malignant potential or malignant epithelial tumors were found in the prophylactic oophorectomy group. There were more cortical inclusion cysts in the prophylactically removed than controls ovaries (P = .016), but no other architectural features differed between the two groups. No abnormalities were found in the surface or cyst epithelium in either group by light microscopy. In contrast, image analysis identified differences in the nuclei between the two groups, indicating that those from the surface epithelium of prophylactically removed ovaries were larger and contained more heterogeneously dense chromatin than those of controls, and that nuclei of the cyst epithelium had more irregular outlines. Ovarian epithelium from prophylactically removed ovaries exhibit abnormalities that are only identified by image analysis, and which might represent early preneoplastic changes. Such ovaries may be useful for identifying early molecular changes in ovarian cancer.

To determine the pathological, clinical, and therapeutic factors which had prognostic significance in women with extraovarian primary peritoneal carcinoma (EOPPC).A retrospective, clinicopathologic study was conducted of 75 women diagnosed with EOPPC. Diagnosis and assessment of prognostic pathological factors were based on the Gynecologic Oncology Group (GOG) criteria. Univariate and multivariate analyses were used to assess the following factors for their effect on overall survival: age, parity, presenting symptoms and signs, ascites, CA 125 level, history of oophorectomy, maximum ovarian dimension, histologic type, architectural and nuclear grades, number of mitosis and psammoma bodies, depth of ovarian invasion, estrogen and progesterone receptors (positive, negative), p53 overexpression (present, absent), performance status (GOG criteria), stage (FIGO criteria for ovarian cancer), debulking surgery (optimal versus suboptimal), first-line chemotherapy (platin-based without paclitaxel versus platin/paclitaxel), secondary cytoreduction, and second-line chemotherapy (paclitaxel-based versus no paclitaxel).The median overall survival of all patients was 23.5 months (95% CI 18.6, 39.8 months). The 5-year survival was 26.5% (SE 6.7%). p53 overexpression and estrogen and progesterone receptor positivity were demonstrated in 42.4, 50.0, and 6.3%, respectively. In univariate analysis, performance status, primary debulking surgery, stage, and age were significant on overall survival (P0.001,0. 001, 0.004, and 0.012, respectively). In multivariate analysis, only performance status (P0.001) and primary debulking surgery (P = 0. 03) were independent prognostic factors. Conclusions. Overall survival in women with EOPPC is affected significantly by performance status and primary debulking surgery as independent variables. To improve survival, efforts should be made to achieve optimal tumor cytoreduction at primary surgery.

Objective. The aim of this study was to determine the potential benefit and complications of prolonged salvage and maintenance chemotherapy among patients with recurrent epithelial ovarian cancer who achieve response to salvage chemotherapy. Methods. Patients with recurrent platinum-sensitive epithelial ovarian cancer who were treated between 1982 and 1996 and achieved complete response to platinum-based salvage chemotherapy were offered prolonged (1 year) monthly salvage followed by maintenance (every 8 weeks) chemotherapy. Patients who accepted such treatment ( n = 16) were compared to those who refused and discontinued therapy ( n = 11) with regard to overall survival from time of initial diagnosis and overall and disease-free survival from time of recurrence. Chemotherapy-related toxicity in the study group was recorded. Survival curves were constructed according to the Kaplan and Meier method and survival curves were compared using the log-rank test. Results. Patients in the study and control groups were similar with regard to age, stage, histology, grade, performance status, primary cytoreductive surgery, type of primary and salvage chemotherapy, and method of assessment of tumor response. The study group had a significantly longer disease-free interval from date of recurrence than the control group (median: 35.0 versus 6.0 months, respectively, P = 0.001). The study group had longer overall survival from date of recurrence than the control group. However, the difference did not achieve statistical significance (median: 119 versus 90 months, respectively, P = 0.056). There was no significant difference between the study group and the control group as to survival from date of initial diagnosis (median: 157 versus 124 months, respectively, P = 0.28). Chemotherapy-related toxicity was minimal. Conclusions. Prolonged salvage and maintenance chemotherapy is a safe method of treatment that may extend disease-free interval among patients with platinum-sensitive recurrent epithelial ovarian cancer who achieve response to salvage chemotherapy. These preliminary results need to be confirmed by a larger prospective randomized trial.

To assess the rate of complications of indwelling caval catheter (ICC) use on a gynecologic oncology service and to compare complication rates between subcutaneous ports and external catheters.A retrospective analysis of 185 patients who underwent 216 ICC placements between April 1, 1987 and April 1, 1997, was performed. Patient and catheter characteristics were analyzed as they related to the rate of pneumothorax, bacteremia, and deep neck and thoracic vein thrombosis (DNVT).A total of 216 ICCs were placed including 152 implanted ports and 64 external catheters. Pneumothorax occurred in 2% of ICC insertions. Bacteremia complicated 16% of ICCs. Multivariate analysis demonstrated that external catheters (P0.01) and neutropenia (P0.01) were independent risk factors for bacteremia. DNVT complicated 6% of ICCs and was observed significantly (P0.02) more frequently among 11 catheters placed in patients with clear cell malignancies of the female reproductive tract. Unplanned catheter removal occurred significantly (P0.01) more frequently among patients with external catheters compared to implanted devices.Implantable ICCs appear to offer a significant advantage compared to external devices with regard to the development of bacteremia and unplanned catheter removal. Though catheter type, neutropenia, and TPN are associated with an increased incidence of bacteremia, multivariate analysis does not include TPN as an independent risk factor for ICC-related bacteremia. A significant increase in the rate of DNVT among a small number of patients with clear cell gynecologic malignancies warrants further study.

Objective. The extreme drug resistance (EDR) assay has been correlated with failure of response to chemotherapy in greater than 99% of patients. The goal of this study is to correlate the results of the EDR assay to response to first-line paclitaxel/cisplatin among patients with epithelial ovarian cancer. Methods. Seventy-five of 100 patients with epithelial ovarian cancer for whom EDR assay was performed were treated with weekly induction cisplatin (1 mg/kg body wt) × 4, followed by monthly paclitaxel (135 mg/m 2 ) and cisplatin (75 mg/m 2 ) × 6 and were evaluable for correlation of response to chemotherapy and EDR assay. Specimens for EDR assay were obtained at primary surgery and the EDR assay was performed by Oncotech, Inc. Response to chemotherapy was correlated to EDR assay results regarding paclitaxel and cisplatin. Results. Among 75 evaluable patients, the prevalence of EDR to paclitaxel was 20.0% ( n = 15) and to cisplatin it was 2.7% ( n = 2). Only 1 patient (1.3%) exhibited EDR to both paclitaxel and cisplatin. Surgical assessment of response was performed in 42 patients; 33 patients were clinically evaluable. The overall response rate was 85.3%. The overall response rate for patients whose tumors demonstrated no EDR to either paclitaxel or cisplatin did not differ significantly from that for patients whose tumors demonstrated EDR to at least one of these two drugs (86.4% versus 81.3%, respectively, P = 0.692). Similarly, the complete surgical response rate for both groups did not differ significantly (25.4% versus 12.5%, respectively, P = 0.34). A single patient whose tumor exhibited EDR to both paclitaxel and cisplatin had tumor progression. The sensitivity, specificity, positive predictive value, and negative predictive value of the EDR assay were 79.6, 27.0, 86.0, and 19.0%, respectively. Conclusions. EDR to paclitaxel does not preclude response to the combination of paclitaxel and cisplatin as primary therapy for patients with epithelial ovarian cancer. The role of the EDR assay in the primary management of patients with epithelial ovarian cancer remains to be determined.

Purpose: To assess the efficacy of diagnostic laparoscopy at the time of interstitial brachytherapy in patients with FIGO Stages IIB-IVA cervical carcinoma, who were not candidates for conventional brachytherapy after completion of whole pelvic radiation. Materials and Methods: Six patients with FIGO Stages IIB-IVA cervical carcinoma completed whole pelvic radiation (WPR) and were assessed for the placement of conventional intracavitary brachytherapy. Three patients (Stage IIB) received 50.40 Gy WPR and three (Stage IIIA-VA) received 61.20 Gy WPR. Because distorted vaginal anatomy precluded the placement of standard intracavitary brachytherapy equipment, interstitial therapy was selected. To minimize the risk of source misplacement, needles were placed with laparoscopic guidance. 192 Iridium was utilized as a source of radiation. Results: A total of 98 needles were placed under direct laparoscopic guidance. The median interstitial brachytherapy tumor dose was 20.00 Gy (range 19.00-41.20 Gy). Eleven perforations in the pelvic peritoneum and/or bladder were identified intraoperatively in 5 of the 6 patients, leading to immediate repositioning of needles. No acute or short-term morbidity related to the procedure was appreciated. Conclusion: Interstitial brachytherapy offers an alternative for intracavitary radiation therapy for selected patients, in whom adequate placement of intracavitary afterloading equipment is precluded by abnormal pelvic geometry. Historically, the placement of interstitial sources has been a procedure that was performed without visualization of the pelvic cavity. A major concern is direct injury to pelvic viscera and intestine. The use of diagnostic laparoscopy at the time of placement of interstitial brachytherapy may avert potential complications from misapplication of interstitial sources. Longer follow-up is required to substantiate these results.

Objective. The objective was to study the feasibility and complications of the use of the inferior gluteal flap in the difficult vaginal, perineal, and vulvar reconstruction among women treated for gynecologic cancers. Methods. A prospective pilot study is reported. Between October 1994 and May 1996, seven patients underwent either unilateral ( n = 3) or bilateral ( n = 4) inferior gluteal flaps for primary reconstruction of extensive vulvar, perineal, and vaginal defects. Results. The median age of the patients was 59 years (range, 40–70). The indications for the construction of the flaps were radical resection of recurrent vulvar cancer ( n = 2), radical resection of stage IV vulvar cancer ( n = 2), resection of recurrent Paget's disease of the vulva ( n = 1), resection of perineal recurrence of cancer of the cervix ( n = 1), and resection of enteroperineal fistula following total pelvic exenteration ( n = 1). The median surface area of the vulvar and perineal defect was 113 cm 2 (range, 10.5–448 cm 2 ). The median operative time for both the extirpative and the reconstructive procedures was 270 min (95–685 min) and the median estimated blood loss was 200 mL (50–950 mL). The median postoperative hospital stay was 15 days (9–29). None of the patients experienced complete graft loss. Two patients suffered necrosis of the tip of the flap that resulted in minimal wound dehiscence which healed by secondary intention, and one patient suffered graft separation which required graft revision and reconstruction. The patients were followed for a median of 11 months (3–26 months). No late complications of the reconstructive surgery were recorded. Conclusions. The inferior gluteal flap can be safely used for the reconstruction of the difficult and extensive vulvar, perineal, and vaginal defects with excellent results.

Compliance with estrogen replacement therapy (ERT) following surgical menopause is poor. In women who have a family history of ovarian cancer, fear of the oncogenic potential of estrogen might affect compliance with ERT following oophorectomy. Compliance with ERT in such a select group of women has not been previously reported. The aim of the present study was to report on compliance with and side effects of ERT in women with a family history of ovarian cancer who underwent oophorectomy either prophylactically or for benign disease. Eighty women with a family history of ovarian cancer who underwent oophorectomy at Roswell Park Cancer Institute were followed for a median duration of 4.2 years (range, 5 months to 14 years). Of the 76 women who were given prescriptions for ERT, the rates of commencement and maintenance of ERT at 1, 2, and 5 years were calculated. Side effects related to the different modalities of ERT were recorded. Seventy-one of 76 women (93.4%) who were given prescriptions for ERT initiated treatment. The rate of commencement of ERT was higher in premenopausal than in postmenopausal women (98.3% versus 75%, respectively, P = 0.003). Except for one patient who developed breast cancer after the oophorectomy and was advised to stop estrogen, all patients said they continued to use ERT. The maintenance rates at 1, 2, and 5 years were 100% as per patients' history. The pharmacy records for ERT prescription refills were reviewed for 52 patients who were on ERT for more than 1 year. ERT compliance was confirmed in 42 patients (80.7%). Seven of 30 patients (23.3%) who retained their uterus developed irregular uterine bleeding and 4 underwent endometrial biopsies. The incidence of irregular uterine bleeding was significantly higher after continuous compared to cyclic estrogen and progestogen (37.6 and 7% respectively, P = 0.049). Four patients (5.6%) complained of hot flashes and were managed by changing the dose or formula of estrogen. Compliance with ERT among patients with a family history of ovarian cancer who underwent oophorectomy either prophylactically or for benign disease was excellent. The presence of the uterus and the incidence of irregular uterine bleeding did not affect patients' compliance with ERT.

Primary peritoneal adenocarcinoma is a relatively newly identified disease entity whose clinical behavior is not fully recognized. We report a case of a patient with progressive primary peritoneal adenocarcinoma who developed brain metastases and died shortly afterward. The incidence of central nervous system metastases in 72 patients with documented primary peritoneal adenocarcinoma was 1.4%. The risk factors, clinical behavior, and prognosis of patients with primary peritoneal adenocarcinoma metastatic to the central nervous system seem to be similar to those of patients with epithelial ovarian cancer metastatic to the central nervous system.

We present the first reported case of cancer-associated retinopathy with uterine sarcoma. A 65-year-old woman presented in August 1990 with loss of vision, photophobia, and visual field restriction. Antiretinal antibodies were elevated. A diagnosis of cancer-associated retinopathy was made, the patient was started on prednisone, and a workup for malignancy was initiated. The patient was found to have uterine sarcoma. She underwent an extrafascial hysterectomy with bilateral salpingo-oophorectomy followed by eight courses of chemotherapy (carboplatin and cyclophosphamide). After that, the patient's vision improved, her visual field stabilized. She was doing well when last seen, in July 1994. The literature regarding cancer-associated retinopathy and paraneoplastic syndromes associated with gynecologic malignancies is reviewed.

Background. Synchronicity of renal cell carcinoma and gynecologic malignancies is a rare condition and standardized treatment does not exist. Cases. Three cases of synchronous renal cell carcinoma and gynecologic malignancies are described. All three cases underwent optimal cytoreductive surgery for the gynecologic malignancy and a radical nephrectomy for the renal cell carcinoma. Adjuvant treatment, after surgery, was individualized in each case. Estrogen and progesterone receptors were positive in all the gynecologic tumors but negative in the renal cell tumors. Conclusions. This is apparently the largest report of synchronous renal cell carcinoma and gynecologic malignancies. Despite this rare condition, surgery should still be considered as primary treatment for these patients.

Beta-endorphin ( β -EP) immunostainable cells were demonstrated in human ovarian tissue using a non-cross-reacting anti- β -EP serum and the avidin-biotin-peroxidase detection technique. In ovaries from ovulating and premenopausal women, β -EP immunoreactivity was localized in the luteinized cells of theca interna of maturing follicles with almost negligible staining in granulosa cells; cells of primary follicles did not stain. In corpora lutea, luteinized cells in both theca interna and granulosa, layers were equally positive. In postmenopausal ovaries, staining was detectable only in scattered luteinized stromal cells. This is the first report on the presence of immunoreactive β -EP in human ovaries, in which β -EP seems to be produced by the same sex cord cells engaged in active steroidogenesis and may be under gonadotropin central regulation. The significance of this finding is discussed.