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ABSTRACT: The purpose of this study is to detect differences in overall survival between the 1988 FIGO staging and current staging of uterine carcinosarcomas to determine if revised 2009 staging accurately predicts actual patient survival.
From 1988 until 2010, patients with uterine carcinosarcoma were retrospectively identified from tumor registry records. Patients were grouped in both broad stages (1-4) and all FIGO substages in order to detect differences. Time-dependent receiver operating characteristic curves (ROC) were generated to predict death before the end of the second year post-diagnosis for both the new and revised system. Kaplan Meier estimated median survival time was utilized to compare actual patient survival.
Of 112 patients with carcinosarcoma, 37 patients (33%) had FIGO Stage I disease, 15 patients (13.4%) had Stage II disease, 36 patients (32%) were diagnosed as Stage III, and 24 patients (21.4%) had Stage IV disease. 106 of 112 (94.6%) patients underwent lymphadenectomy (pelvic +/- para-aortic). Four patients (3.6%) were downstaged when utilizing broad staging criteria: 2 patients were downstaged from Stage II to I, and 2 patients were downstaged from Stage III to Stage I and II respectively. When looking at substage, the area under the ROC was 0.67 for the former staging system, and 0.65 for the revised staging. Kaplan-Meier estimated median survival time post-diagnosis was 610 days (95% CI [478,930]).
Based upon our reclassification of 112 patients with uterine carcinosarcoma, the revised FIGO staging system does not predict survival more accurately than former staging. Carcinosarcoma has an overall poor prognosis and better indicators of survival are needed.
Gynecologic Oncology 08/2011; 123(2):221-4. · 3.89 Impact Factor
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ABSTRACT: To determine whether hydronephrosis is an independent prognostic indicator of survival among patients with advanced cervical carcinoma. Moreover, we wanted to demonstrate the relationship between unilateral and bilateral hydronephrosis and overall survival.
Retrospective analysis of 197 patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIIB cervical carcinoma or higher treated between 1990 and 2007 was conducted. Inclusion criteria were clinical staging according to FIGO criteria, standardized radiation treatment and cisplatin-based chemosensitization regimens. Associations between hydronephrosis and covariates-age, race, histopathologic diagnosis, pelvic sidewall involvement, stage, nodal involvement, and Gynecologic Oncology Group/Eastern Cooperative Oncology Group performance status (PS)-were determined. Statistical analysis including Kaplan-Meier, log-rank test, proportional hazards regression, Fisher exact test, and Mann-Whitney test were used where appropriate, with P < 0.05 considered significant.
Of 143 included patients, 73 patients had no hydronephrosis (HN), 39 patients had unilateral HN, and 31 patients had bilateral HN. Twenty-nine patients (40%) with no HN died compared to 24 patients (61.5%) with unilateral HN and 21 patients (67.7%) with bilateral HN. Median time to death was significantly shorter for patients with unilateral HN (27 months; 95% confidence interval [CI], 10-48) and bilateral HN (12 months; 95% CI, 6-23) versus patients without HN (68 months; 95% CI, 39-∞; P < 0.001). Unadjusted hazard ratio (HR) for HN (both unilateral and bilateral) was 2.4 (95% CI, 1.5-3.8); P < 0.001. Of potential covariates evaluated, PS and sidewall involvement were significantly associated with HN (P = 0.021 and P = 0.014, respectively). Proportional hazards regression revealed that controlling for use of radiation, chemotherapy, and for PS, HN was still significantly associated with poor prognosis (HR unilateral HN = 2.0, 95% CI, 1.2-3.5; HR bilateral HN = 3.2, 95% CI, 1.7-6.0); P ≤ 0.001.
Hydronephrosis is an independent poor prognostic indicator of survival in patients with advanced cervical cancer. Bilateral hydronephrosis compared to unilateral involvement confers a worse overall prognosis. Additional studies are needed to determine if FIGO staging should be amended.
International Journal of Gynecological Cancer 08/2011; 21(6):1091-6. · 1.65 Impact Factor
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ABSTRACT: Acute hematometra, also termed the postabortal syndrome or redo syndrome, is a rare immediate complication of suction curettage characterized by severe lower abdominal cramping in association with an enlarged and markedly tender uterus. We describe the transvaginal sonographic features of this syndrome.
Journal of Clinical Ultrasound 02/2011; 39(3):155-6. · 0.81 Impact Factor
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ABSTRACT: To evaluate the activity and toxicity of fulvestrant in advanced, recurrent, or persistent endometrial carcinoma.
Eligible patients with advanced, recurrent or persistent endometrial carcinoma not amenable to curative therapy were treated with fulvestrant at a dose of 250 mg by IM injection every 4 weeks for at least 8 weeks. Therapy was continued until evidence of progressive disease, or adverse effects prohibited further therapy. Response was assessed in patients with at least one target lesion as defined by Response Evaluation Criteria in Solid Tumors (RECIST) v1.0. Immunohistochemical analysis of tumor tissue (histology or cytology) for estrogen and progesterone receptors was required from the metastatic or recurrent site.
Sixty-seven patients were enrolled in this study. Upon review, 14 patients were excluded. In the 22 estrogen receptor (ER) negative patients, no patients demonstrated either a complete or partial response, and 4 (18%) demonstrated stable disease (as best response). In the 31 ER positive patients, 1 (3%), 4 (13%) and 9 (29%) patients demonstrated a complete, partial response, and stable disease (as best response), respectively. The median progression free survival and overall survival in the ER negative patients were 2 and 3 months and in the ER positive patients 10 and 26 months. Treatment was well tolerated, and no patient discontinued therapy due to toxicity.
Fulvestrant has minimal activity in advanced, recurrent, or persistent endometrial carcinoma.
Gynecologic Oncology 11/2010; 120(2):185-8. · 3.89 Impact Factor
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European journal of obstetrics, gynecology, and reproductive biology 04/2010; 149(2):230-1. · 1.97 Impact Factor
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ABSTRACT: Thrombocytosis is present in a wide range of malignancies, with a reported incidence of 10% to 57%. Several reports have documented thrombocytosis at the time of diagnosis as a poor prognostic indicator. Our study is the first report evaluating the role of preoperative thrombocytosis and its association with survival in a predominantly African American and Caribbean American urban population.
We retrospectively reviewed the charts of 99 consecutive patients treated for endometrial carcinoma at SUNY Downstate Medical Center. Seventy-seven patients were deemed eligible for the study, and the following clinicopathologic characteristics were recorded from their medical records: age, stage, grade, histological subtype, presence of lymphovascular space invasion, depth of myometrial invasion, intrauterine tumor volume, preoperative prothrombin time, activated partial thromboplastin time, platelet count, progression-free survival (PFS), and overall survival (OS). The data were analyzed using Spearman and Pearson correlations, Student t test, chi(2) test, and Fisher exact test. Survival analysis was performed using Kaplan-Meier tables, log-rank test, and Cox proportional hazard model. The 2-tailed value of P < 0.05 was considered significant.
Fourteen (18.2%) of 77 patients exhibited thrombocytosis (platelet count, >400 x 10(9)/L). Patients with advanced disease (stages III-IV) had a significantly higher mean preoperative platelet count (359 +/- 23.8 x 10(9)/L) in comparison with patients with localized disease (stages I-II, 283 +/- 14.3 x 10(9)/L, P = 0.005). The median PFS among patients with stages III and IV without preoperative thrombocytosis was 15.0 +/- 4.8 months (n = 21) and with thrombocytosis was 3.0 +/- 1.4 months (n = 8, P = 0.032). The median OS in patients without thrombocytosis was 24.0 +/- 4.5 months (n = 21) and in patients with thrombocytosis was 7.0 +/- 3.8 months (n = 8, P = 0.015). Multivariate analysis was performed using log-rank test and Cox proportional hazard model. The only variables that retained independent prognostic significance were stage (hazards ratio, 3.268; P = 0.040) and preoperative thrombocytosis (hazards ratio, 1.714 per 100 platelets; P = 0.030). Among patients with localized disease, preoperative thrombocytosis was not associated with worsened OS or PFS.
Our data indicate that preoperative thrombocytosis among high-risk inner-city patients with stages III to IV endometrial cancer is an independent prognostic indicator. This is the first such report in a predominantly African American and Caribbean American population. Further research is needed to elucidate the mechanisms of thrombocytosis in malignancy. Association of thrombocytosis and aggressive tumor behavior warrants investigation of antiplatelet therapy and its effect on outcome.
International Journal of Gynecological Cancer 11/2009; 19(8):1384-9. · 1.65 Impact Factor
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ABSTRACT: Bilateral uterine artery embolization has become an accepted therapeutic modality in the management of patients with symptomatic uterine leiomyomata. Complications of bilateral uterine artery embolization, including rare cases of malignancies, have been reported following this procedure.
We present a 46-year-old woman, gravida 3, para 1, who was treated with bilateral uterine artery embolization for symptomatic uterine leiomyomata following pelvic sonography and magnetic resonance imaging, which depicted bilateral normal adnexa. Nine months after the procedure she was diagnosed with stage III ovarian carcinoma.
Patients undergoing bilateral uterine artery embolization should be informed of the possibility of preexisting or potential subsequent development of ovarian carcinoma, reflecting the lack of an effective screening method for this disease.
The Journal of reproductive medicine 06/2009; 54(5):325-6. · 0.87 Impact Factor
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ABSTRACT: Dehydroepiandrosterone sulfate (DHEAS) is metabolized to active androgens and estrogens, which may have a role in the development of endometrial cancer.
We studied DHEAS conversion to dehydroepiandrosterone (DHEA) in normal and neoplastic endometrium utilizing gas chromatography-mass spectral (GC-MS) analysis. Endometrial homogenate was incubated with known amounts of DHEAS for 4 h at 37 degrees C. Methanol extract was separated from debris by centrifugation, concentrated to 200 microl and 1 microl injected into the GC-MS instrument, equipped with a CP-Sil 8 column. DHEAS and DHEA areas were calculated by autoquantization and DHEA/DHEAS ratio was used for comparing sulfatase activity among normal endometrium (n = 6), Stage I endometrioid carcinoma (EC) (n = 15), Stage I mixed mesodermal Mullerian tumor (MMMT) (n = 6) and Stage I uterine papillary serous carcinoma (UPSC) (n = 7).
DHEA/DHEAS ratios in normal endometrium, EC, MMMT and UPSC were 1.45 +/- 1.10, 5.63 +/- 3.27, 2.88 +/- 0.99, and 3.04 +/- 1.76, respectively. Sulfatase activity was significantly higher in EC when compared with normal endometrium (p < 0.001), MMMT (p < 0.05), and UPSC (p < 0.05). The enzyme activity did not differ significantly between low-grade and high-grade EC tumors (5.8 +/- 2.77 and 5.49 +/- 3.84, respectively, p > 0.05).
Stage I EC have higher sulfatase activity than normal endometrium, and Stage I MMMT and UPSC tumors.
Gynecologic and Obstetric Investigation 10/2008; 67(1):57-60. · 1.28 Impact Factor
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Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 11/2007; 26(10):1453-6. · 1.25 Impact Factor
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Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 06/2007; 26(5):667-70. · 1.25 Impact Factor
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ABSTRACT: To identify parameters associated with the presence or development of invasive cervical cancer among patients who underwent cold knife conization (CKC) following loop electrocautery excision procedure (LEEP) revealing positive endocervical curettings for stage 3 cervical intraepithelial neoplasia (CIN III).
Patients who underwent CKC following LEEP with endocervical curettings indicating CIN III were observed retrospectively.
Of 146 patients identified, 133 (91.1%) had residual CIN on their cone biopsy; 23 (15.8%) had invasive cervical carcinoma. Patients with residual CIN III, ectocervical and endocervical margins with CIN, and positive endocervical curettings on cone biopsy were more likely to harbor or develop invasive cervical carcinoma.
Patients with CIN III on endocervical curettage at the time of LEEP procedure are at high risk for harboring residual cervical dysplasia or micros-invasive carcinoma, or developing carcinoma in the future. Residual CIN III, ectocervical or endocervical margins positive for CIN, and/or positive endocervical curettings on CKC subsequent to LEEP with positive endocervical curettings for CIN III all indicate a higher likelihood of harboring or developing cervical carcinoma.
American journal of obstetrics and gynecology 06/2007; 196(5):469.e1-4. · 3.28 Impact Factor
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ABSTRACT: Malignant neoplasms of the vagina are rare gynecologic tumors. Primary vaginal sarcomas are even more unusual lesions, representing fewer than 2% of malignant vaginal lesions.
We present a case of a primary vaginal spindle cell sarcoma, treated with neoadjuvant radiation followed by total pelvic exenteration. The patient remains without evidence of disease 2 years after surgery.
The mainstay of treatment of vaginal sarcomas is surgical. Neoadjuvant radiation treatment may decrease surgical morbidity and lead to long-term cure.
Journal of Lower Genital Tract Disease 05/2007; 11(2):105-7. · 1.07 Impact Factor
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ABSTRACT: OBJECTIVE: Endometrial cancer generally carries a good prognosis. However, 10% to 15% of patients will manifest recurrent disease. One half of these recurrences are confined to the vagina. Whereas pelvic recurrence is most common in patients who do not receive postoperative adjuvant radiation therapy, distant metastases predominate among patients who received postoperative radiation therapy. Surgical resection of disease may be possible, therapeutic and even curative, in select patients with isolated cancer recurrence. CASE 1: A 63-year-old patient presented 7 years after treatment of endometrial cancer with a vulvar lesion and groin mass. The lesions were successfully resected and confirmed to be recurrent endometrial cancer. Adjuvant radiation and chemotherapy were prescribed leading to a complete clinical response. This patient survived without evidence of disease for 1 year. However, she eventually died 8 months later because of a disease recurrence. CASE 2: An 83-year-old patient with a history of a hysterectomy for endometrial cancer and radiation therapy for a vaginal vault recurrence presented with an exophytic labial mass. After radical wide excision of her vulvar mass and bilateral groin dissection, final pathology revealed that the mass was consistent with recurrent endometrial cancer. This patient remains without evidence of disease 18 months after treatment of disease recurrence. CONCLUSIONS: Uncommon sites of recurrence of endometrial cancer may include the vulva. These rare metastases may be amenable to surgical resection with adjuvant therapy as indicated.
Journal of Lower Genital Tract Disease 05/2007; 11(2):118-21. · 1.07 Impact Factor
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ABSTRACT: To evaluate whether body mass index (BMI) is an independent risk factor for survival in patients with endometrial adenocarcinoma.
Women treated for endometrial cancer at the State University of New York (SUNY), Downstate and Kings County Hospital between January 1982 and September 2003 were eligible. Patients were divided into groups based upon their histology at the time of diagnosis. The first included patients with low-grade endometrioid adenocarcinoma (FIGO grades 1 and 2); the second included grade 3 endometrioid adenocarcinoma; and the third contained papillary serous and clear cell carcinomas. Data regarding BMI, patient age, race, grade, and stage of disease and overall survival, were assessed by survival analysis, with P < 0.05 considered significant throughout.
The analysis included 442 patients. Mean BMI was 32.6 +/- 8.2. There were 312 patients (70%) treated for low-grade endometrial adenocarcinoma; 64 patients (14%) for grade 3 endometrioid adenocarcinoma; and 71 patients (16%) for papillary serous and clear cell adenocarcinoma. Increased BMI was associated with improved overall survival (P = 0.003). BMI was also correlated to tumor grade, stage at diagnosis, age, and race. Tumor grade, stage, age, and race were correlated to survival. Statistical analyses revealed the majority of the association between BMI and survival can be attributed to the association between BMI and these other risk factors for survival in endometrial cancer.
Increased BMI is associated with survival advantage among patients with endometrial cancer. Because of the relationship between obesity and other confounding variables obesity alone is not an independent predictor of survival.
American journal of clinical oncology 02/2007; 30(1):8-14. · 2.21 Impact Factor
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ABSTRACT: In the ovary cortisol-cortisone inter-conversion is catalyzed by the enzyme 11beta-hydroxysteroid dehydrogenase (11beta-HSD). Its role in carcinomas of human ovary is unknown. The majority of ovarian cancers are derived from ovarian surface epithelium and the inflammation caused by successive ovulation seems to a play a role in the development of cancer. Cortisol is known to act as anti-inflammatory agent and its metabolism by type 1 and type 11beta-HSD may control the inflammatory action by cortisol in ovary. We undertook this study to investigate type 2 11beta-HSD activity which functions exclusively oxidative direction, in normal ovarian tissue compared to ovarian epithelial cancer. Ovarian tissue was obtained from patients undergoing hysterectomy for both benign and malignant disease. Tissue was placed immediately on dry ice and subsequently transferred to a freezer where they were maintained at -70 degrees C. NAD dependent 11beta-HSD activity was then determined in this tissue. T-test was performed to determine statistical significance. Mean type 2 enzyme activity was 0.87 +/- 1.65 pmol/min g tissue in normal ovarian tissue versus a mean enzyme activity of 2.96 +/- 1.37 pmol/mim g tissue in from cancer specimens. This difference was statistically significant with a p-value of 0.03. Type 2 1beta-HSD activity in ovarian cancer specimens was significantly higher than enzyme activity measured in normal post-menopausal ovarian tissue. Decreased cortisol levels due type 2 1beta-HSD activity may play a role neoplastic transformation as well as tumor proliferation in ovarian cancer by eliminating anti-inflammatory action of cortisol.
Steroids 12/2006; 71(11-12):1019-23. · 2.83 Impact Factor
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Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 08/2006; 25(7):917-20. · 1.25 Impact Factor
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Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 05/2006; 25(4):515-7. · 1.25 Impact Factor
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ABSTRACT: The isoforms of 11beta-hydroxysteroid dehydrogenase (11beta-HSD) types 1 and 2, regulated by ovarian steroids, catalyze the interconversion of glucocorticoids and their 11-keto metabolites. The role of these enzymes in malignancies of human endometrium is unknown. We compare NAD dependent 11beta-HSD (type 2) activity levels among normal human endometrium and endometrial carcinomas of differing grades and histologies.
NAD dependent 11beta-HSD activity was determined in endometrial tissue obtained from patients undergoing hysterectomy for benign or malignant disease (endometroid, serous and carcinosarcomas). Student's t test was utilized with p < 0.05 considered significant. Data are presented as mean +/- SD.
NAD dependent 11beta-HSD activity was present in all endometrial samples. The activities were 0.61+/- 0.27 in normal (n = 9), 0.43 +/- 0.29 in endometrioid endometrial carcinoma (n = 14), 0.50 +/- 0.26 in uterine serous carcinoma (n = 6) and 0.25 +/- 0.37 in carcinosarcomas (n = 9). NAD dependent 11beta-HSD activity was lower in the carcinosarcoma group as compared to normal endometrial tissue (p = 0.03).
NAD dependent type 2 11beta-HSD activity was demonstrated in all normal and endometrial tumors. Enzyme activity in endometroid and uterine serious carcinoma tumors was similar to enzyme activity in normal endometrium. In contrast, carcinosarcomas show significantly lower enzyme activity compared to normal tissue.
Gynecologic and Obstetric Investigation 02/2006; 62(2):103-7. · 1.28 Impact Factor
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ABSTRACT: Thymoma is the most common tumor of the anterior mediastinum. Due to its relative rarity, its inconsistent clinical course and its frequent proximity to vital thoracic structures, management of this generally indolent tumor varies considerably. We present an unusual case of recurrent thymoma metastatic to the pelvis and review treatment experience employing surgical, radiotherapeutic and medical modalities.
The present case is that of a 46-year-old woman with recurrent thymoma metastatic to a distal pelvic lymph node. Resection of the pelvic recurrence followed many years of local and systemic treatment for her thoracic primary tumor. Her case is unique for its involvement of pelvic anatomy and her clinical course marked by treatment-related congestive heart failure.
While the indolent clinical course of thyomoma frequently necessitates re-treatment and multi-modality therapy in patients suffering recurrences, treatment selection must take into account potential long-term morbidity and attendant quality of life. When anatomically and technically feasible, resection of recurrent disease should be considered in attempts to avoid potential cumulative and long-term toxicity resultant from radiotherapy and chemotherapy.
Gynecologic Oncology 11/2005; 99(1):228-31. · 3.89 Impact Factor
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ABSTRACT: To estimate the antitumor activity of topotecan in patients with persistent or recurrent carcinosarcoma (malignant mixed mullerian tumors) of the uterus and to determine the nature and degree of toxicity of topotecan in this cohort of patients.
Eligible patients had measurable advanced or recurrent carcinosarcoma of the uterus. Topotecan at a target dose of 1.5 mg/m(2) was administered IV daily for 5 days, every 3 weeks, until progression of disease or adverse affects prohibited further therapy.
Twenty-seven member institutions entered 51 patients. Of the patients entered, 48 were eligible. Patient characteristics included a median age of 65, with 33% having prior radiation and 92% having prior chemotherapy. Twenty-six patients (54%) had a performance status (PS) of 0, 18 (38%) had a PS of 1, and four (8%) had a PS of 2. Patients received from 1 to 21 (with a median of 2) courses of treatment. The most frequently observed grade 4 toxicities were neutropenia seen in 35 (73%) patients, leukopenia in 14 (29%), and thrombocytopenia in 10 (21%). Three (6%) patients developed neutropenic sepsis and died shortly after their first treatment cycle. There were five (10%) complete responses; 13 (27%) patients maintained stable disease, 26 (54%) experienced increasing disease, and reassessment did not occur in four (8%).
Topotecan at this dose and schedule does not appear to have major activity in patients with advanced or recurrent uterine carcinosarcoma previously treated with chemotherapy.
Gynecologic Oncology 09/2005; 98(2):217-21. · 3.89 Impact Factor
