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ABSTRACT: To assess the diagnostic accuracy of cervical conization in women with adenocarcinoma in situ and to determine whether a select group of women could be managed by conization alone without hysterectomy.
We retrospectively reviewed 40 cases of cervical adenocarcinoma in situ diagnosed on cervical conization.
Cervical conization revealed adenocarcinoma in situ alone in 15 women. Twenty-five women had adenocarcinoma in situ coexisting with squamous dysplasia (23) or microinvasive squamous cell carcinoma (two). Twenty-two women underwent hysterectomy after cone biopsy. Adenocarcinoma in situ was detected in the hysterectomy specimen in one of 12 women with uninvolved cone margins, versus seven of ten women with involved margins (P = .006); two of these seven women also had foci of invasive adenocarcinoma in the hysterectomy specimen. Conization was the only treatment for 18 selected women with adenocarcinoma in situ and uninvolved margins; all were relapse-free after a median interval of 3 years (range 1.5-5).
Women with cervical adenocarcinoma in situ diagnosed by conization who have positive margins are at high risk of residual adenocarcinoma in situ and moderate risk of occult invasive adenocarcinoma; expectant management is not warranted. However, a cone biopsy with uninvolved margins can reliably guide subsequent therapy. Selected young women who desire preservation of fertility and have uninvolved margins probably can be managed by conization alone, but further study is required to establish the safety of this approach.
Obstetrics and Gynecology 01/1993; 80(6):935-9. · 4.73 Impact Factor
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ABSTRACT: A 49-year-old woman presented with a profuse watery vaginal discharge 16 years after a vaginal hysterectomy. Pelvic examination revealed clear fluid leaking from the vaginal apex. Cytologic evaluation of the draining fluid was normal, as was a biopsy of the vaginal apex. A vesicovaginal fistula was suspected. Intravenous pyelogram and cystogram did not reveal communication of the urinary tract with the fistula. Injection of radiopaque dye through the fistula tract demonstrated a 5-7-cm enclosed cystic space with a 4-cm pedunculated mass within the cyst lumen. Exploratory surgery revealed fallopian tube carcinoma involving the right tube. The tumor mass was completely excised, and there was no evidence of spread beyond the encapsulated cystic fallopian tube. The woman was treated with six cycles of cisplatin combination chemotherapy, and after 5 years remains free of disease.
Obstetrics and Gynecology 06/1992; 79(5 ( Pt 2)):853-6. · 4.73 Impact Factor
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ABSTRACT: Refractory lactic acidosis and hypoglycemia characterize a paraneoplastic syndrome observed in advanced gynecologic cancer, as illustrated by a patient with a large malignant mixed Mullerian tumor. Massive infusions of sodium bicarbonate and glucose failed to reverse her metabolic abnormalities, and the patient suffered a rapidly fatal course. The biochemical basis for this metabolic complication is reviewed, including how medical intervention can lead to iatrogenic exacerbation of the metabolic imbalance.
International Journal of Gynecological Cancer 06/1992; 2(3):163-167. · 1.65 Impact Factor
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ABSTRACT: Dysgerminoma is the most common malignant germ cell tumor in young women. The management of advanced-stage dysgerminoma challenges the gynecologic oncologist to achieve maximal survival, while maintaining childbearing potential. Radiation therapy has been extremely successful in curing dysgerminoma, but ovarian conservation is usually not possible. In contrast, various chemotherapeutic regimens have achieved high cure rates with continued ovarian function. Diagnosing recurrent dysgerminoma promptly so that salvage therapy can be initiated is important when conservative management has been employed. While alpha-fetoprotein and human chorionic gonadotropin have proven useful as tumor markers in some types of germ cell tumors, they have not been useful in patients with dysgerminoma. Serum lactic dehydrogenase (LDH) levels are known to be elevated in some patients with dysgerminoma. We treated a patient with Stage IIIC dysgerminoma whose initial serum LDH level was markedly elevated. After unilateral salpingo-oophorectomy with pelvic and paraaortic lymphadenectomy, followed by four cycles of VAC chemotherapy, her LDH level returned to normal. Her LDH level rose with disease recurrence and returned to normal again with salvage BEP chemotherapy. This is the first report to document the utility of serial LDH measurements in detecting disease recurrence in patients with ovarian dysgerminoma.
Gynecologic Oncology 04/1992; 44(3):281-3. · 3.89 Impact Factor
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New England Journal of Medicine 03/1992; 326(7):466-71. · 53.30 Impact Factor
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ABSTRACT: The importance of endocervical glandular atypia in a cervicovaginal Papanicolaou smear has not been fully investigated. Between July 1988 and June 1989, 21,930 cervicovaginal smears were reviewed by the Massachusetts General Hospital Cytopathology Laboratory. One hundred smears with endocervical atypia were identified, an incidence of 0.46%. Follow-up was available on 63 cases: Seven had negative follow-up smears for at least 2 years, 15 had negative biopsies, seven had endocervical polyps, two had endometrial hyperplasia, eight had mild dysplasia, five had moderate dysplasia, six had severe dysplasia, six had squamous carcinoma in situ, five had adenocarcinoma in situ, and two had invasive adenocarcinoma. Twelve women's smears showed endocervical atypia with features suggestive of reactive atypia; three of these had dysplasia. Twenty-six (41%) of the Papanicolaou smears with endocervical atypia had coexisting squamous atypia or dysplasia. We conclude that endocervical atypia may be associated with substantial cervical disease in as many as half of cases.
Obstetrics and Gynecology 02/1992; 79(1):101-4. · 4.73 Impact Factor
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ABSTRACT: The experience of the authors with primary non-Hodgkin's lymphoma of the uterine cervix from 1980 to 1986 included five Ann Arbor Stage IE cases successfully managed by meticulous staging and radiation therapy. The clinicopathologic features of the patients are described and compared with 38 previously reported Stage IE cases. When all 43 patients were evaluated, the median age was 40 years of age (range, 20 to 80 years of age) and 77% were premenopausal. Most patients (74%) reported abnormal vaginal bleeding, although approximately 20% were asymptomatic. The primary cervical tumors were typically of large size, with half exceeding 4 cm in diameter. Using the International Federation of Gynecology and Obstetrics (FIGO) system for staging cervical cancer, stage distribution was 44% Stage I, 42% Stage II, 12% Stage III, and 2% Stage IV. Histologically, approximately 70% were of the diffuse, large cell type (Working Formulation). External beam radiation therapy supplemented by brachytherapy or hysterectomy was used for 76% of the patients reviewed. There was only one treatment failure among the 28 patients whose treatment included radiation and whose cases were followed for at least 2 years. This experience and a review of the literature indicate that most cases of primary lymphoma of the uterine cervix are Ann Arbor Stage IE, and can be cured with traditional combinations of surgery and radiation therapy after careful evaluation.
Cancer 12/1991; 68(9):2023-32. · 4.77 Impact Factor
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ABSTRACT: Genital tuberculosis presented as postmenopausal bleeding in a woman with third-degree procidentia. After two months of combination antimycobacterial treatment, she underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy followed by nine months of postoperative drug therapy.
The Journal of reproductive medicine 09/1991; 36(8):616-8. · 0.87 Impact Factor
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ABSTRACT: Advanced adenocarcinoma of the fallopian tube has a poor prognosis, with 5-year survival rates commonly less than 20%. Since 1980, we have managed 12 patients with disseminated tumor with combination chemotherapy following surgical cytoreduction. Analogous to the International Federation of Gynecology and Obstetrics staging of ovarian carcinoma, 3 patients were classified in Stage II, 8 in Stage III, and 1 in Stage IV. Ten patients received cisplatin-containing regimens. The 3 Stage II patients, without measurable disease after primary surgery, had an indeterminate response to chemotherapy. In Stages III-IV there were 4 complete responses (3 confirmed by second-look laparotomy) and 2 partial responses, for an overall response rate of 67%. Disease progressed in 2 patients and was stable in 1 patient. After median follow-up of 3.5 years, 4 of the Stage III-IV patients have no evidence of disease, 1 is alive with disease, and 4 are dead.
Gynecologic Oncology 04/1991; 40(3):268-73. · 3.89 Impact Factor
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ABSTRACT: A pregnant woman sustained an abdominal gunshot wound during the second trimester; the bullet injured multiple loops of bowel and passed through the uterus, placenta and fetus. Although the stillborn fetus was delivered by cesarean section, a review of the literature indicated that operative delivery is not indicated when the fetus has died already. Labor and delivery are well tolerated, and an unnecessary hysterotomy is thus avoided. If labor does not ensue spontaneously, it can be induced. Approximately 40% of fetuses will survive the initial injury. In past reviews the risk of prematurity often outweighed the benefits of delivery of those infants. Advances in neonatology now make survival routine after 28 weeks' gestation, and viable fetuses should be delivered promptly by cesarean section to decrease the risk of delayed death from fetal or placental injury.
The Journal of reproductive medicine 05/1990; 35(4):436-8. · 0.87 Impact Factor
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ABSTRACT: We report a patient who, at age 43, underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy for an unrupted 10 cm granulosa cell tumor. A recurrence was subtotally totally resected 2.5 years later, followed by six cycles of cyclophosphamide, doxorubicin, and cis-platin (CAP) chemotherapy. She had no evidence of disease at second-look laparotomy. Serum estradiol (E2) levels paralleled her clinical course, becoming elevated at the time of her recurrence, and returning to postmenopausal levels during her chemotherapy. Four years later, further elevation in E2 heralded a second recurrence of tumor. The patient underwent a cytoreductive procedure and has resumed chemotherapy. Reports of the few other patients treated with multiagent chemotherapy are reviewed. Several combinations appear active, with the CAP regimen having possibly less toxicity. Compared with radiotherapy, chemotherapy may yield longer survival in patients with recurrent granulosa cell tumor, but actual cure remains elusive.
European journal of gynaecological oncology 02/1990; 11(4):263-8. · 0.47 Impact Factor
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ABSTRACT: Four cases of carcinosarcoma and mixed müllerian tumors of the fallopian tube are presented. Each patient presented with abnormal bleeding and a pelvic mass. All underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, staging, and cytoreduction. Disease was limited to the pelvis in two patients, analogous to FIGO stage IIB ovarian carcinoma; the other two patients had upper abdominal disease, analogous to FIGO stage III. The primary tumors were intraluminal and papillary. There were equal amounts of carcinoma and sarcoma in three tumors; in one, sarcoma constituted only a small intraluminal focus. The sarcoma was predominantly homologous, with foci of heterologous elements present in three tumors. Adjuvant therapy consisted of pelvic radiation in two patients. One patient died of inanition within one year of diagnosis. The other patient, who had the small focus of sarcoma within a stage IIB carcinoma, had an 11-year disease-free interval before retroperitoneal recurrence of carcinoma. Two patients received chemotherapy. A stage IIB patient, after pelvic radiation, received Cytoxan and Adriamycin; she is clinically free of disease after 6 years. A stage III patient lived over 3 years after treatment with multiple agents; she responded to Cytoxan and cis-platinum before suffering a systemic relapse and death.
Gynecologic Oncology 08/1989; 34(1):109-15. · 3.89 Impact Factor
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ABSTRACT: Nineteen women with a mean age of 62 were treated for primary adenocarcinoma of the fallopian tube from 1960 to 1980. Common presentations were bleeding or discharge, pelvic mass, and pain. Cervical cytology was positive in five of eleven cases; endometrial curettings revealed adenocarcinoma in three of nine cases. Staging was by a system analogous to the International Federation of Gynecology and Obstetrics (FIGO) classification of ovarian carcinoma: 11% stage I, 44% stage II, 28% stage III, and 17% stage IV. Bleeding and abnormal cervical cytology were associated with earlier stage lesions and better prognosis. The most common treatment was excision of the primary tumor and gross intraperitoneal metastases. Total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed in 14 cases. Thirteen patients received 40-50 Gray of 2 MeV external beam pelvic radiation. Stages I and II had five-year survival of 100% and 63%. However, 38% of stage II patients had late extrapelvic relapses, and two early stage patients suffered serious complications of radiation therapy. All stage III and IV patients died of disease, 63% within the first 3 years. Based upon these results and review of other modern series, the importance of early diagnosis and complete surgical staging is emphasized, and stage-specific adjuvant therapy recommended.
European journal of gynaecological oncology 02/1989; 10(4):239-49. · 0.47 Impact Factor
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ABSTRACT: Two patients were treated for fallopian tube prolapse after abdominal hysterectomy. This rare complication is usually seen after vaginal hysterectomy. Our patients presented with a profuse, blood-tinged vaginal discharge and lower abdominal pain two and three months after hysterectomy. The tender, fimbriated end of the fallopian tube must be distinguished from common cuff granulation tissue, one patient underwent painful cautery treatments for over a year before the correct diagnosis was made. Biopsy of the prolapsed tissue in both cases failed to provide the correct diagnosis. In cases reported on previously, repair of the prolapsed tube usually was accomplished transvaginally, but in one of our patients laparotomy was required to control bleeding from the retracted proximal tube. The other patient had her prolapsed tube diagnosed and resected laparoscopically. This technique, described in detail, has the advantage of avoiding more-extensive surgery in selected cases.
The Journal of reproductive medicine 06/1988; 33(5):467-9. · 0.87 Impact Factor
