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Objective: The objective of this study was to determine whether hormone production by postmenopausal ovaries containing benign ovarian tumors differed from that of normal postmenopausal ovaries., Study Design: The sera of 32 postmenopausal patients were assayed before and after bilateral oophorectomy for estrone, 17 beta-estradiol, androstenedione, testosterone, and dehydroepiandrosterone sulfate. The data from all patients as a group were analyzed, followed by analysis of the data from 15 patients with normal ovaries separately from the remaining 17 patients who had nonfunctioning, benign ovarian tumors., Results: For patients with benign ovarian tumors there was a statistically significant drop in estrone (from a presurgical level of 55.8 +/- 46.3 pg/ml to a postoperative level of 29.9 +/- 10.2 pg/ml, p < 0.03) and 17 beta-estradiol (from 18.6 +/- 14.1 pg/ml preoperatively to 9.8 +/- 3.8 pg/ml postoperatively, p < 0.02). For postmenopausal woman with normal ovaries there was no significant drop in estrone or 17 beta-estradiol after bilateral oophorectomy. There was a statistically significant drop in testosterone and androstenedione after bilateral oophorectomy both for women with normal ovaries and for those with benign tumors. No significant differences in dehydroepiandrosterone sulfate were noted in either group., Conclusions: These data suggest that, although normal postmenopausal ovaries have not been demonstrated to secrete clinically significant amounts of estrogen, those that contain benign ovarian tumors do secrete small but significant amounts of estrone and 17 beta-estradiol. Both tumor-containing and normal ovaries secrete the androgens androstenedione and testosterone, this secretion not being significantly influenced by the presence of a tumor.

Laparoscopic surgery for ovarian lesions has the potential for an enormous positive impact on the care that we are able to provide for our patients. Technologic advances and the proliferation of new equipment have occurred at a rapid rate. However, the criteria for the safe and appropriate use of endoscopic surgery have not been developed fully or followed by all surgeons, and there is some evidence that a lack of adherence to carefully considered protocols has the potential to have an adverse impact on women with ovarian lesions. McDonough made a thoughtful presentation on the need for technology assessment in the reproductive sciences, focusing on the fact that there has been a rapid diffusion of technology without prior broad-based critical peer review and stressing the need to have scientific technology assessment. Pitkin, in his editorial on operative laparoscopy, questioned whether we are evaluating therapeutic appropriateness properly as a separate and independent issue from technical feasibility. Obviously, it would be preferable to have had more controlled prospective data on the relative merits and risks of the use of the laparoscope for resection of ovarian cysts before the widespread use of this technology. However, there are several situations in which it currently appears to have important clinical utility for the patient. In addition, it already is being used widely, and it would be inappropriate to withhold this method from our patients. However, it should be urged that careful prospective evaluation be undertaken so that both the scientific community and the public are able to have an accurate understanding of the risks, benefits, indications, and contraindications of this technology. In addition, when a surgeon is considering pelviscopic surgery for an ovarian mass, it is essential that this be done with strict adherence to carefully constructed preoperative criteria and intraoperative protocols.

One hundred fifty-six members and candidate members of the Society of Gynecologic Oncologists responded to a survey concerning the "laparoscopic management of ovarian neoplasms subsequently found to be malignant." Twenty-nine responders (19%) reported a total of 42 cases of ovarian malignancy. The laparoscopic procedure was aborted or the cyst was aspirated in 38% of the cases, and partial or complete excisions were attempted in 33 and 29%, respectively. The characteristics of the masses were as follows: less than 8 cm 67%, cystic 62%, unilocular 48%, and unilateral 81%. All four "benign" characteristics were present in 31% of the cases found to be malignant, and three of four characteristics were present in 24%. Laparotomy was performed at the time of laparoscopy in 17% of cases, after laparoscopy in 71% with an average interval of 4.8 weeks, and not at all in 12%. Fifty-seven percent of the cases were invasive epithelial malignancies, whereas 29% were tumors of low malignant potential. At least 50% of the patients had stages II-IV. We conclude that attempted laparoscopic excisions of adnexal masses that are subsequently found to be malignant are not uncommon, and that the presence of so-called "benign" characteristics does not preclude malignancy. Attempts at partial or complete excision are common, as are delays in subsequent definitive surgery. The stage of disease is often advanced, and all histologic types of malignancy are encountered. We advocate careful evaluation of this practice, with development of strict guidelines to ensure optimal patient care.

Seven cases of patients with gynecologic cancer and Sister Joseph's nodule, umbilical metastases from intraabdominal malignancy, are presented, making a total of 44 such cases in the literature. One such case, uterine leiomyosarcoma with umbilical metastases, is the first such lesion reported. Although the prognosis is generally poor, a few long-term survivors have been reported, and aggressive therapy may be warranted, particularly in patients with ovarian malignancy.

Eleven women with advanced ovarian cancer treated postoperatively with combination chemotherapy (cytoxan, hexamethylmelamine, Adriamycin, and cis-platinum) had disease-free intervals of 5 to 46 months (mean: 22 months) and subsequently developed recurrent carcinoma. Each patient was then retreated with combination chemotherapy which included cis-platinum. There was a 72% response rate to retreatment (36% complete, 36% partial). These overall and complete remission rates are comparable to those of platinum-based combination chemotherapy in patients without prior treatment. Those patients who responded to retreatment had a significantly longer mean survival rate than those who did not.

Three hundred twenty-seven patients with ovarian carcinoma were compared with matched controls to determine the association of parity and marital status with the development of ovarian cancer. Nulliparous women were found to have 2.31 times the risk of developing ovarian cancer as parous women. Unmarried women had 3 times the risk of developing ovarian cancer, but marital status was not established as a variable independent of parity. Almost 8% of patients with ovarian carcinoma had had hysterectomies when they were over 40 years of age. This study indicates that parity is an important consideration when determining whether a patient is at high risk for the development of ovarian carcinoma. Other epidemiologic variables are discussed in an effort to facilitate the judicious selection of patients for elective oophorectomy at the time of hysterectomy.

Eighteen women with bulky ovarian cancer at the start of chemotherapy were brought to second laparotomy after 6 months of combination chemotherapy in an effort to resect previously unresectable tumor masses. Only one of 18 had significant resection of bulk tumor such that no gross tumor was remaining, although 8 of 15 had the residual uterus removed and 6 of 10 had resection of residual ovary or ovaries. Failure to resect tumor was due to absence of any gross tumor (33%), presence of myriad small seedlings not amenable to resection (22%), or massive residual tumor (18%). Partial resection was accomplished in 22%, but all relapsed promptly in spite of continued aggressive therapy with drugs and whole abdominal irradiation. It is concluded that 6-month "second-effort" surgical resection is unlikely to benefit many women with bulky ovarian cancer, and that surgical resection must be attempted early in the course of the disease if it is to be effective.