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The use of laparoscopy in the management of gynecologic malignancies has significantly increased over the last 5 years. The safety and adequacy of pelvic and para-aortic lymphadenectomy has been established by several investigators. Patients with early carcinoma of the cervix are now undergoing Schauta (radical vaginal) hysterectomy after laparoscopic lymphadenectomy. Patients with carcinoma of the endometrium are treated by laparoscopically assisted vaginal hysterectomy in conjunction with laparoscopic pelvic and para-aortic lymphadenectomy. Staging and second-look procedures are now being performed laparoscopically in patients with carcinoma of the ovary. The Gynecologic Oncology Group is currently investigating the role of laparoscopic surgery for patients with carcinoma of the cervix, endometrium, and ovary in four Phase II trials. A randomized Phase III trial comparing laparoscopy to laparotomy for patients with carcinoma of the endometrium will begin soon.

Objective: To determine the feasibility, safety, limiting factors, and advantages of laparoscopic para-aortic lymphadenectomy in a series of patients with gynecologic malignancies., Methods: During a 2-year period, 61 women underwent laparoscopic para-aortic lymph node dissection as part of their management for invasive gynecologic malignancies. A transperitoneal incision directly over the aorta was used. Initially, only the right-side infra-inferior mesenteric artery nodes were removed. The technique of removal of left-side low para-aortic nodes was then developed, followed by the technique for removal of right- and left-side nodes above the transverse duodenum. A total of 52 right para-aortic lymphadenectomies were performed, 12 of which were combined with left-side lymphadenectomies. A total of 17 left-side lymphadenectomies were performed, 12 of which were bilateral. Four patients had nodes removed above the inferior mesenteric artery., Results: The procedure could not be performed in four instances because of obesity or adhesions. Twenty-four patients had their laparoscopic surgery combined with another procedure, which increased their hospital stays: radical hysterectomy (five), laparoscopy-assisted vaginal hysterectomy (17), transperineal interstitial irradiation (one), and anterior-posterior colporrhaphy (one). The remaining 33 patients had laparoscopic surgical staging only. One patient required laparotomy to control bleeding from the vena cava; however, the others had no short- or long-term complications, and the average hospital stay was 1.3 days., Conclusion: Laparoscopic para-aortic lymphadenectomy is a safe, effective procedure that allows a shorter hospitalization than traditional laparotomy.

Objective: To assess the validity of Doppler flow sonography for the prediction of malignancy in adnexal masses and to compare the results with two-dimensional ultrasonographic examination and CA 125 levels., Methods: In a cross-sectional study, 55 patients with adnexal masses were examined using Doppler sonography to measure the resistance index of tumor-associated blood flow profiles. In addition, abdominal and transvaginal ultrasound examinations were performed and preoperative CA 125 serum levels were assessed., Results: Sixteen patients had malignant tumors and 39 had benign tumors. A resistance index cutoff of less than or equal to 0.8 showed the highest sensitivity (93.8%), with a specificity of 56.4%, a positive predictive value of 46.8%, and a negative predictive value of 95.7%. Compared with two-dimensional sonographic evaluation using either a scoring system or subjective assessment, and with CA 125 levels, the resistance index showed higher sensitivity and negative predictive value but lower specificity and positive predictive value. False-positive resistance index values were prevalent with endometriosis, leiomyomata, and mucinous cystadenoma. The combination of the resistance index with either the sonographic features or CA 125 increased the sensitivity and negative predictive value to 100%, with only a slight decrease in specificity and positive predictive value, but was not superior to the combination of two-dimensional sonography and CA 125., Conclusion: Doppler sonographic evaluation of resistance indexes in the vessels of adnexal masses increased the sensitivity of two-dimensional sonography and CA 125. However, 46% of positive Doppler results were false and 37.5% of the benign tumors had low resistance indexes, thus limiting the validity of this technique for screening programs.

Formation of a neovagina is an important step in restoring a normal self-image for the woman who has had treatment for gynecologic cancer. There are several techniques that the surgeon may select based on the amount of tissue removed or damaged, the surrounding anatomy, and the condition of the patient. The indications, techniques, and results of these procedures will be described in this article.

Review of the admissions to the Gynecologic Oncology Service at the University of Alabama Medical Center over a 12-year period reveals that 1% of all referrals had nongynecologic malignancies. Duration of symptoms was short; of 40 patients with adequate follow-up, 31 (77%) were dead from their cancer, with a median survival of eight months. The value of diagnostic radiologic procedures was assessed and, while these procedures proved helpful, most patients required a surgical procedure (often a reoperation) to establish the diagnosis.

The contribution of abdominal-pelvic computed tomography (CT) and ultrasound scanning to the management of gynecologic malignancy patients was assessed retrospectively in 62 scans that were performed immediately preceding laparotomy. A total of 55.5% CT and 71.4% ultrasound scans were found to be helpful. Diagnostic problem areas included the detection of lymph node metastases, peritoneal implants, omental metastases, and parametrial extension. An additional 75 scans performed in patients not undergoing laparotomy were received to assess any alteration in management resulting from the scans. It is concluded that clinicians should be more discriminating in their requests for scanning procedures and that appropriate communication between the clinician and the radiologist may avoid unproductive scans.

Small condylomata acuminata are easily diagnosed clinically and are not often difficult to treat. Giant condylomata, however, can pose real problems in diagnosis and treatment. They must be distinguished from verrucous carcinomas or giant condylomata with squamous malignant change. Large biopsy specimens that include the stroma are necessary in order to make the correct diagnosis, since these entities have somewhat similar histologic features. Treatment should be surgical because radiation and podopyhyllum have both proved to be of little benefit. Surgical removal also allows excellent pathologic study to determine the presence of squamous malignant change or verrucous carcinoma.

Verrucous carcinoma is a variant of squamous cell carcinoma that often presents as a large cauliflower-like lesion with locally destructive growth. A high index of suspicion on the part of the clinician and pathologist is needed for an accurate diagnosis since the pathologic findings may be benign on an individual cell basis or may even resemble those of a condyloma. Deep biopsy that includes the base of the lesion is needed for accurate histologic diagnosis, and the pathologist should be aware of the aggressive nature of the lesion. The treatment of choice is surgical, with wide local excision being sufficient in most cases. Radiotherapy often fails to eradicate the lesion and may even cause it to become more anaplastic.