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An interstitial pregnancy complicated by rectal bleeding is described. Despite modern imaging modalities, confounding features made preoperative diagnosis difficult. The pregnancy ruptured into the ileum. Ossified fetal skull bones and degenerated placental tissue were the only remains from the pregnancy. [ABSTRACT FROM AUTHOR]

Pregnancy luteomas are rare, nonmalignant lesions thought to be caused by hormonal changes during pregnancy. Granulosa cell tumor is a rare type of ovarian cancer; 10% occur during pregnancy and typically present with elevated inhibin levels. Herein, we present a case of a pregnant female with a pelvic mass and elevated inhibin B suggestive of a granulosa cell tumor, yet with final pathology consistent with a pregnancy luteoma., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: RM receives research grants under Angle Inc and consulting/speaker fees from Fujirebio Diagnostics Inc. No disclosures from other authors. All fees are outside of submitted work and the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Author(s).)

Pelvic metastasis of melanoma is extremely rare and may pose a diagnostic challenge. We present a case report of a female with a history of colon cancer who underwent exploratory surgery for a pelvic mass that was suspicious for ovarian malignancy. Pathology was consistent with both recurrent colon cancer as well as synchronous newly diagnosed metastatic melanoma., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors. Published by Elsevier Inc.)

Objective: To evaluate the detection of malignancy in women with a pelvic mass by using multiplexed gene expression analysis of cells captured from peripheral blood., Methods: This was an IRB-approved, prospective clinical study. Eligible patients had a pelvic mass and were scheduled for surgery or biopsy. Rare cells were captured from peripheral blood obtained preoperatively by using a microfluidic cell capture device. Isolated mRNA from the captured cells was analyzed for expression of 72 different gene transcripts. Serum levels for several commonly assayed biomarkers were measured. All patients had a tissue diagnosis. Univariate and multivariate logistic regression analyses for the prediction of malignancy using gene expression and serum biomarker levels were performed, and receiver operating characteristic curves were constructed and compared., Results: A total of 183 evaluable patients were enrolled (average age 56 years, range 19-91 years). There were 104 benign tumors, 17 low malignant potential tumors, and 62 malignant tumors. Comparison of the area under the receiver operating characteristic curve for individual genes and various combinations of genes with or without serum biomarkers to differentiate between benign conditions (excluding low malignant potential tumors) and malignant tumors showed that a multivariate model combining the expression levels of eight genes and four serum biomarkers achieved the highest area under the curve (AUC) (95.1%, 95% CI 92.0-98.2%). The MAGIC (Malignancy Assessment using Gene Identification in Captured Cells) algorithm significantly outperformed all individual genes (AUC 50.2-65.2%; all P <.001) and a multivariate model combining 14 different genes (AUC 88.0%, 95% CI 82.9-93.0%; P =.005). Further, the MAGIC algorithm achieved an AUC of 89.5% (95% CI 81.3-97.8%) for stage I-II and 98.9% (95% CI 96.7-100%) for stage III-IV patients with epithelial ovarian cancer., Conclusion: Multiplexed gene expression evaluation of cells captured from blood, with or without serum biomarker levels, accurately detects malignancy in women with a pelvic mass., Clinical Trial Registration: ClinicalTrials.gov, NCT02781272., Funding Source: This study was funded by ANGLE Europe Limited (Surrey Research Park, Guildford, Surrey, United Kingdom)., Competing Interests: Financial Disclosure Richard G. Moore disclosed receiving consulting payments from Fujirebio Diagnostic Inc. and Abcodia Inc. He receives research funding from ANGLE Europe Limited. Michael C. Miller is a full-time employee of ANGLE North America, while Kelly Seto and David Englert are full-time employees of ANGLE Biosciences, Inc. Brent DuBeshter disclosed that money was paid to his institution from Angle PLC. The other authors did not report any potential conflicts of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

The objective of this study is to review our experience with robotic interval cytoreduction following neoadjuvant chemotherapy for advanced ovarian cancer. We retrospectively reviewed patients with advanced ovarian cancer treated with neoadjuvant chemotherapy (NAC) and interval robotic cytoreduction (IRC) between 2011 and 2016 at the University of Rochester Medical Center. Demographic information, chemotherapy treatment, operative results, and follow-up were extracted from medical records. Twenty-nine patients underwent IRC after a mean of 3.9 cycles of NAC. The mean operative time was 165 min with a mean EBL of 107 cc. The mean length of stay was 2.0 days. One case (3.3%) was converted to an open procedure because of extensive tumor not amenable to robotic cytoreduction. Overall, 19 (66%) patients underwent an R0 cytoreduction, 8 (28%) an optimal (<1 cm) cytoreduction, and 2 (7%) a suboptimal cytoreduction. The median overall survival was 39.7 months and median progression-free survival was 21.2 months. Interval robotic cytoreduction following NAC is feasible and may be preferable to open interval cytoreductive surgery, in specific patients, to minimize morbidity and length of hospital stay.

Background: While robotic surgery for gynecologic indications received U.S. government approval in 2005, and has been rapidly and widely adopted, it is currently unclear how often this approach to hysterectomy is utilized. Objective: The aim of this research was to assess length of stay (LOS), mortality, indications, and current use of robotic hysterectomy, compared to other types of hysterectomy. Methods: A retrospective study of hysterectomies performed in New York State (NYS) in 2011 was performed. Data, including indication for surgery, age, procedure, LOS, and discharge status were obtained from the NYS Department of Health Statewide Planning and Research Cooperative System (SPARCS). Outcome Measures: LOS and mortality rate, were calculated according to institution, procedure, and indication for surgery. Results: For 22073 hysterectomies performed in NYS, the mean LOS was 2.9 days, and there were 29 (0.13%) deaths. The mean LOS for abdominal (12774 cases, 3.9 days) hysterectomies was longer than for laparoscopic (3927 cases, 1.6 days), robotic (2814 cases, 1.6 days), or vaginal (2558 cases, 1.7 days) hysterectomies ( p <0.05). The adjusted mortality rates for abdominal (0.20%), laparoscopic (0.03%), robotic (0.07%), and vaginal (0.04%) hysterectomies were not significantly different. Overall, robotic surgery was performed in 29% of hospitals, by 11% of physicians and in 13% of cases. A robotic approach was utilized in 35% of patients with uterine cancer, 13% with endometriosis, 11% with excessive bleeding, 8% with leiomyomata, and 8% with pelvic relaxation. Conclusions: Despite the advantages in reduced LOS for robotic and other minimally invasive types of hysterectomies, the abdominal route is still predominant in most institutions. (J GYNECOL SURG XX:1).

Purpose: Doxorubicin and cisplatin have activity in endometrial carcinoma and at initiation of this study ranked as the most active agents. This trial of stage III, IV, or recurrent disease evaluated whether combining these agents increases response rate (RR) and prolongs progression-free survival (PFS) and overall survival (OS) over doxorubicin alone., Patients and Methods: Of 299 patients registered, 281 (94%) were eligible. Regimens were doxorubicin 60 mg/m(2) intravenously or doxorubicin 60 mg/m(2) plus cisplatin 50 mg/m(2) every 3 weeks until disease progression, unacceptable toxicity, or a total of 500 mg/m(2) doxorubicin., Results: There were 12 (8%) complete (CR) and 26 (17%) partial responses (PR) among 150 patients receiving doxorubicin versus 25 (19%) CRs and 30 (23%) PRs among patients receiving the combination. The overall response rate was higher among patients receiving the combination (42%) compared with patients receiving doxorubicin (25%; P =.004). Median PFS was 5.7 and 3.8 months, respectively, for the combination and single agent. The PFS hazard ratio was 0.736 (95% CI, 0.577 to 0.939; P =.014). Median OS was 9.0 and 9.2 months, respectively, for the combination and single agent. Overall death rates were similar in the two groups (hazard ratio, 0.928; 95% CI, 0.727 to 1.185). Nausea, vomiting, and hematologic toxicities were common. The combination produced more grade 3 to 4 leukopenia (62% v 40%), thrombocytopenia (14% v 2%), anemia (22% v 4%), and nausea/vomiting (13% v 3%)., Conclusion: Adding cisplatin to doxorubicin in advanced endometrial carcinoma improves RR and PFS with a negligible impact on OS and produces increased toxicity. These results have served as a building block for subsequent phase III trials in patients with disseminated and high-risk limited endometrial carcinoma.

Objective: To determine the efficacy of high-dose rate brachytherapy as adjuvant treatment for Stage I/II papillary serous or clear cell endometrial cancer., Methods: A retrospective study of all patients with Stage I/II papillary serous or clear cell endometrial cancer treated with high-dose rate brachytherapy between 1995 and 2001 was performed. Following surgical staging, which included hysterectomy with pelvic and aortic lymphadenectomy, all patients without extrauterine disease were treated with high-dose rate brachytherapy and followed for recurrence. The locations of recurrences were noted and were classified as local or distant., Results: Three (13%) recurrences occurred among 24 patients with Stage I/II papillary serous or clear cell carcinoma. The risk of recurrence was similar for papillary serous and clear cell cancer (12% vs. 12%). Local control was achieved in 96%. The risk of recurrence for those with no myometrial invasion, less than 1/2, or more than 1/2 myometrial invasion was 0%, 10%, and 50%, respectively (P < 0.04). Two of the three recurrences were distant and all patients with recurrence died despite additional treatment., Conclusions: High-dose rate brachytherapy (HDR) as the sole adjuvant treatment of Stage I/II papillary serous or clear cell carcinoma is associated with a 13% risk of recurrence. Although local control with HDR is excellent, the risk of distant recurrence is increased with deep myometrial invasion. High-dose rate brachytherapy is adequate for Stage IA cases, but more aggressive treatment combining chemotherapy with HDR should be evaluated for more advanced Stage I/II cases.

Effective management of a vulvar wound resulting from oncological ablative surgery poses a formidable task for the reconstructive surgeon. During the past two decades, numerous procedures have been described in an effort to provide stable, sensate coverage that minimizes deformity and preserves function, often in the setting of concomitant radiation. At the authors' institution, a fasciocutaneous V-Y advancement flap based on the gluteus maximus has been adopted as a common approach to this problem. They present their institutional experience with this procedure. A 10-year chart review (1991-2001) yielded a series of 20 vulvectomy patients, all of whom were reconstructed by the same surgeon using ischial fasciocutaneous V-Y flaps based on perforators from the inferior border of the gluteus maximus muscle. Patients underwent vulvectomy for recurrent or advance-stage vulvar cancer, or extensive carcinoma in situ. Squamous cell carcinoma was the most common pathology (N = 13). Fifteen patients had bilateral V-Y flaps; the remainder had unilateral procedures. Six patients underwent prior radiation therapy. Two patients had delayed reconstruction for vaginal stenosis. Flap survival was 100%. There were no major complications, early or late. Minor complications were limited to localized areas of delayed healing, all of which responded to conservative measures. Functional outcome was excellent in all patients. At an average follow-up of 44 months, there were five episodes of recurrent disease necessitating surgical intervention. Based on this series, the gluteus maximus V-Y advancement flap provides a straightforward and reliable method to recruit local tissue for stable coverage of these often difficult-to-manage wounds.

Individual cancer patients differ in their nausea/vomiting response to chemotherapy. It is not known why patients receiving the same chemotherapy have different severity of side effects. Several lines of research implicate the autonomic nervous system (ANS) in the development of chemotherapy-induced nausea. We examined the association between autonomic reactivity and the level of nausea experienced following chemotherapy in 20 patients with ovarian cancer treated with cisplatin or carboplatin who received the same antiemetic. We applied eight common non-invasive clinical tests of autonomic function prior to inpatient chemotherapy treatment, 2 h after treatment and again 24 h following treatment. Two hours after chemotherapy and before any nausea was reported by the patients, the nine patients who subsequently experienced high levels of nausea had a greater overall percentage of abnormal clinical ANS tests than the 11 patients who subsequently developed low levels of nausea (P < 0.01). Twenty-four hours after treatment, the overall number of abnormal autonomic tests remained non-significantly higher than at the pretreatment baseline for the high nausea group. Demographic and clinical characteristics were not related to chemotherapy-induced nausea in this sample. Autonomic reactivity appears to be related to the development of nausea following chemotherapy. Further investigation of ANS involvement in chemotherapy-induced nausea could increase understanding of nausea etiology and potentially lead to the prediction of susceptible patients.

Background: Intravenous platinum-based chemotherapy is the standard primary therapy for advanced ovarian cancer. We conducted a phase 3 trial to compare the effects of intraperitoneal and intravenous cisplatin on the survival of women with previously untreated, stage III, epithelial ovarian cancer., Methods: The patients underwent an initial exploratory laparotomy and resection of all tumor masses larger than 2 cm. Within four weeks after surgery, six courses of intravenous cyclophosphamide (600 mg per square meter of body-surface area per course) plus either intraperitoneal cisplatin (100 mg per square meter) or intravenous cisplatin (100 mg per square meter) were administered at three-week intervals., Results: Of 654 randomized patients, 546 were eligible for the study. The estimated median survival was significantly longer in the group receiving intraperitoneal cisplatin (49 months; 95 percent confidence interval, 42 to 56) than in the group receiving intravenous cisplatin (41 months; 95 percent confidence interval, 34 to 47). The risk of death was lower in the intraperitoneal group than in the intravenous group (hazard ratio, 0.76; 95 percent confidence interval, 0.61 to 0.96; P = 0.02). Moderate-to-severe tinnitus, clinical hearing loss, and neuromuscular toxic effects were significantly more frequent in the intravenous group., Conclusions: As compared with intravenous cisplatin, intraperitoneal cisplatin significantly improves survival and has significantly fewer toxic effects in patients with stage III ovarian cancer and residual tumor masses of 2 cm or less.

The purpose of this short communication is to report our clinical findings regarding the use of the low frequency (LF, 0.02-0.15 Hz) and high frequency (HF, > 0.15 Hz) components of the spectral decomposition of heart-rate as indices of sympathetic (SNS) and parasympathetic nervous system (PNS) activity, respectively. Thirty-two females with histologically confirmed ovarian cancer, ranging in age from 46-72 years, participated in an autonomic assessment protocol consisting of a resting heart rate recording and several ANS function tests. The LF, HF and total power measures from the spectral decomposition were highly correlated with one another. In addition, the spectral components were most highly correlated with measures of PNS activity, i.e. standard deviation of heart rate at rest and the ratio of the six longest to the six shortest R-R intervals during deep breathing (E:I ratio). It is concluded, as other researchers have stated, that the use of the HF component of the HR spectrum as a measure of PNS activity is warranted, but caution must be used when interpreting the LF component.

There is a critical need to find additional effective therapies in the management of ovarian cancer. A previously reported Gynecologic Oncology Group trial demonstrated that tamoxifen is an active drug when used in the salvage setting in this malignancy. Unfortunately, this original report did not specifically examine the utility of tamoxifen in patients with clinically defined platinum-refractory disease. In this reanalysis of the results of treatment of 102 evaluable patients entered into this multi-institutional trial, an objective response rate of 13% (95% confidence interval, 6.4-22.6%) was observed in patients with cisplatin-refractory ovarian cancer. The median response duration in this patient population was 4.4 months (range 1.2-9.2 months). Although the response rate is modest, this well-tolerated hormonal agent is a reasonable therapeutic option in selected patients with ovarian cancer when salvage therapy is to be considered. A possible role for this hormonal agent in other clinical settings in ovarian cancer will need to be defined through the conduct of carefully designed randomized clinical trials.

Thin-layer (TL) technology can improve the detection rate for squamous lesions of the uterine cervix. Studies to date have under-represented high grade lesions and malignancies. The present study utilized a patient population at high risk for such lesions in order to analyze the performance of TL procedures in this group, and in addition, to assess the similarities and differences in morphologic appearances of specimens prepared by the two methods. Conventional (CS) and thin-layer smears (TLS) were made in parallel from the same specimen. Each slide was examined in a blinded fashion. Diagnoses were compared and morphologic observations made. Two hundred fifty-nine cases were included, of which 32 (12%) were high grade dysplasias (11) or carcinomas (21). Thirty five (14%) were atypical or low grade dysplasias. There was exact correlation between Bethesda classification in 231 cases (89%). Of the 21 carcinomas identified, 19 (91%) were present on each preparation. Two cases of endometrial adenocarcinoma were missed on unsatisfactory or negative TLS. One case of squamous cell carcinoma was called high grade squamous intraepithelial lesion (HGSIL) on TLS while the CS was unsatisfactory. Three cases called atypical glandular cells (AGCUS) on TLS, and negative on CS, showed HGSIL (1) or no lesion (2) on follow-up. Morphologic features of low grade lesions were virtually identical on both preparations. Distinct features were noted on TLS in the high grade lesions. These included smaller appearing nuclear areas, less distinct nuclear chromatin, thicker three-dimensional groupings, and more isolated cells. Such findings were most pronounced in the glandular lesions. With training and experience, these features were easily identified in TL preparations, further documenting the utility of this procedure for use in routine practice.

Purpose: Steroid doses similar to those used to prevent paclitaxel-associated hypersensitivity reactions and cisplatin-induced nausea have been associated with hypothalamic-pituitary-adrenal (HPA) axis suppression. We assessed HPA function in patients receiving high-dose steroids as part of their chemotherapy regimen for epithelial ovarian cancer., Patients and Methods: From January to July 1994, a cross-sectional study of HPA function was performed on patients receiving dexamethasone (DEX) as part of their paclitaxel and cisplatin chemotherapy regimen (n = 9). Patients received 20 mg of DEX orally, 6 and 12 hr prior to paclitaxel (135 mg/m2) and 10-20 mg intravenously before cisplatin (50-100 mg/m2). In addition, patients received approximately 12 mg/day of DEX orally for 4 days after their chemotherapy as an antiemetic. HPA integrity was evaluated by the administration of synthetic adrenocorticotropic hormone (ACTH). The ACTH stimulation test was performed 11-19 days after the completion of the course of DEX. Patients had fasting baseline cortisol levels drawn at approximately 0800 followed by a 25-unit intravenous injection of ACTH. Post-ACTH cortisol levels were repeated at 30 and 60 min., Results: The mean (+/- SEM) fasting baseline level of cortisol was 12.4 +/- 2.3 micrograms/dl (normal, 7-23 micrograms/dl). At 30 min following ACTH administration, the mean cortisol level rose 17.1 micrograms to 29.5 +/- 1.8 micrograms/dl; at 60 min it rose 21.4 micrograms to 33.8 +/- 2.5 micrograms/dl [P < 0.001] (normal increase 9-39 micrograms). All patients demonstrated a sufficient increase in their plasma cortisol after ACTH stimulation, indicating normal HPA function on the days tested. However, there was a significant trend toward lower increases in plasma cortisol at 30 and 60 min as the interval from ACTH stimulation testing to the DEX regimen decreased (r = 0.986; P < 0.0001). The chemotherapy cycle number had no impact on cortisol response in the multivariate analysis. Based on multiple linear regression, HPA function may be suppressed for approximately 8 days, but up to 14 days from the start of this DEX regimen., Conclusion: Current steroid regimens prescribed with chemotherapy transiently decrease HPA function, but do not appear to inhibit the HPA axis long term. HPA function may be suppressed for approximately 8 days from the commencement of chemotherapy cycles involving DEX. Patients presenting within the first 8 days of a chemotherapy cycle using steroids with symptoms attributable to HPA suppression may benefit from HPA axis testing.

The development of paclitaxel-containing chemotherapeutic regimens has been hindered by the frequent occurrence of allergic-type reactions to the drug or its diluent. Fortunately, current pretreatment regimens are associated with a reduced risk of major hypersensitivity reactions. However, there is still a group of patients that may experience these reactions from Taxol despite the use of prechemotherapy steroids and antihistamines. In a recent report, patients with prior reactions to Taxol were successfully retreated utilizing 24 hr of high-dose steroids and a very prolonged infusion regimen. We now report on two patients with major hypersensitivity reactions despite the use of this regimen. We conclude that not all Taxol-associated hypersensitivity reactions are preventable with current drug regimens. In addition, there is little evidence to support continued or exclusive use of the suggested rechallenge premedication schedule or the prolonged infusion rate.

Advances in antiemetic therapy for cancer patients have been hindered by a lack of understanding of the physiological mechanisms associated with nausea and their corresponding measurement techniques. Here we review conceptual and methodological issues involved in developing an autonomic frame of reference for nausea and outline two strategies for assessing autonomic function. A primarily research-oriented strategy uses heart rate, blood volume pulse, pallor, and skin temperature to assess autonomic activity and reactivity over 24 hr. Peak values of these measures relative to time of emesis, heart rate spectral analyses of autonomic activity, and analyses of the standard deviation of successive differences of beat-to-beat intervals were all associated with subsequent nausea. A primarily clinically oriented strategy assesses normal and abnormal results on eight common bedside clinical tests of autonomic function. The total number of abnormal tests was associated with subsequent nausea. A better understanding of chemotherapy side effect mechanisms is likely to result in less polypharmacy and more effective individualized treatment for cancer patients.

Placenta percreta is a severe condition associated with maternal morbidity and mortality even when surgery is performed electively. Methotrexate has been suggested as a possible treatment modality for adherent placenta to avoid catastrophic surgery. The purpose of this report is to present a case where the placenta was left in situ to avoid cystectomy at the time of cesarean section, with subsequent failure of treatment with methotrexate.

Twenty-one evaluable patients with recurrent or metastatic endometrial carcinoma were treated with 1,500 micrograms/m2 of echinomycin every 3 weeks. All patients had received prior chemotherapy. There was one complete response (5%), 95% confidence interval for response is 0.9-22.7%. The major toxicity was nausea and vomiting which was moderate to severe in 42% of patients. Myelosuppression was minimal. Echinomycin, in this dose and schedule, displays minimal activity in patients with advanced endometrial carcinoma who have had prior chemotherapy.

Cytomegalovirus is present in the female lower genital tract with an incidence of 4% to 12%. Intracellular inclusion bodies, which constitute evidence of the presence of this organism, are noted on Papanicolaou smears or at direct biopsy. All previous reports regarding tissue diagnosis have involved the uterine cervix. We report an unusual case of a postmenopausal woman who was found to have recurrent symptomatic vaginal lesions; repeated biopsies of the lesion disclosed the presence of cytomegalovirus inclusion bodies.

Invasive hemodynamic monitoring has become an integral part of intensive care management. Whereas the pulmonary artery catheter is the mainstay for determination of the hemodynamic profile and differentiation between cardiogenic and noncardiogenic forms of pulmonary edema, immediate central venous access in itself is of importance in rapid volume replacement in cases complicated by severe hypovolemia. Central venous catheters are also the preferred route of administration of total parenteral nutrition to patients with cancer. We present our experience with real-time ultrasonographic guidance during subclavian vein catheterization in critical care obstetrics and gynecologic oncology.

Malignant transformation of leiomyomatosis peritonealis disseminata is a very rare occurrence, reported twice previously. We report the third case and present the computed tomography findings associated with the development of this unusual pathologic condition.

The management and outcome of 80 women with an undiagnosed pelvic mass who were referred to the Gynecologic Oncology Division at the University of Rochester during a one year period were reviewed. All patients underwent an exploratory laparotomy for definitive diagnosis. We correlated the final diagnosis with the results of preoperative evaluation and intraoperative assessment. Of the 80 patients, 48 were diagnosed with malignant disease. Of patients with carcinoma, 32 had carcinoma of the ovaries, two had other gynecologic malignancies, ten had nongynecologic malignancies and four had synchronous gynecologic and nongynecologic carcinomas. Carcinoma of the colon and rectum was the most common nongynecologic carcinoma; other malignant diseases were found in the endometrium, vagina, colon and rectum and the breast as well as lymphoma. Preoperative roentgenographic examinations and colonoscopy only had a sensitivity of 38 percent in detecting primary carcinoma of the colon and rectum. Ultrasound of the pelvic region and computed tomographic scan of the abdomen did not improve prediction of malignant disease in the patient population. Serum CA 125 was elevated in 26 of 37 patients with a carcinoma; however, it was elevated with relatively equal frequency in carcinomas of the ovaries and colon and rectum. Intraoperative frozen section accurately identified the primary site of the disease in 90 percent of the patients. However, in the presence of a tumor in the ovaries, carcinomatosis and a tumor in the colon, the results of frozen section were erroneous in four of six patients. Because preoperative assessment seems to be of limited value in excluding nongynecologic lesions, we recommend that pelvic surgeons be prepared to manage operatively a variety of malignant disease or have appropriate consultation available at laparotomy.

Recurrent endometrial carcinoma, even when clinically confined to the vagina or pelvis, is associated with poor survival. Pelvic radiotherapy for patients with localized recurrences who have not been previously irradiated has not been highly effective. Our hypothesis was that local salvage therapy fails because a significant number of patients have occult, subclinical distant metastases at the time of relapse. In order to accurately assess disease status at the time of the recurrence, we prospectively evaluated eight patients with recurrent disease limited to the vagina/pelvis by physical examination, routine laboratory tests, and radiologic imaging. All patients underwent a "staging" procedure which included laparotomy, selective pelvic/periaortic lymphadenectomy, peritoneal biopsies, and washings. Three (37.5%) of eight patients had upper abdominal disease found at laparotomy (95% confidence interval 0.11 to 0.71). Presence of subclinical metastases was associated with larger tumor size (> or = 2 cm) and elevated serum CA 125 antigen levels. Treatment was modified in three patients according to the results of surgical staging. One patient was treated with chemotherapy while two patients received whole-abdominal radiation in addition to pelvic fields. Seven of eight patients are alive 21 to 61 months following salvage therapy. Three (43%) of seven patients treated with radiotherapy suffered nonneoplastic bowel obstruction requiring laparotomy at 3, 6, and 15 weeks following completion of radiation therapy. Since 37.5% of patients with recurrent endometrial carcinoma clinically confined to the pelvis had occult upper abdominal disease, surgical reassessment may be warranted, especially in those with elevated serum CA 125 levels or large tumors. Our limited sample size precludes any definitive conclusions regarding our data. Further research will determine the frequency of subclinical metastases and the value of serum CA 125 levels in assessing disease status.

Certain autonomic variables have been shown to be responsive to motion induced nausea and vomiting. Here we report preliminary data on changes in heart rate, blood volume pulse, pallor and skin temperature assessed during a one hour period at baseline, a one hour period of peak nausea, and a one hour period of emesis in five female patients receiving identical cancer chemotherapy and antiemetic drugs according to a common protocol. Examination of coefficients of variation showed that heart rate and face temperature were more stable measures across each of the three time periods than blood volume pulse and pallor. Furthermore, the four measures were found to be more variable during times of emesis than times of nausea. The four measures were shown to be responsive to patient reported nausea and vomiting. Temperature and pallor showed a linear change from baseline to nausea to vomiting. Heart rate and blood volume pulse significantly decreased from baseline time during nausea and then significantly increased from a time of nausea to during emesis. Variations in the time course of each variable change during nausea supported a view that nausea may be more related to a rebound of parasympathetic activity than a slow decrease of sympathetic activity. Replication with larger samples is needed. Examination of the nausea and vomiting of pregnancy, general anaesthesia or different chemotherapeutic agents could help explore whether results reported here are singular or representative of a more generalisable autonomic response associated with patient reported nausea.

Vulvar carcinoma has been managed in recent years with modifications of radical vulvectomy and groin dissection. Separate groin incisions, superficial inguinal lymphadenectomy, unilateral groin dissection, and wide excision have been utilized to reduce the morbidity of treatment. In this study, the surgical management of 82 patients with vulvar squamous cell carcinoma was reviewed in order to assess morbidity and risk of recurrence. A modification of radical vulvectomy and groin dissection was employed in 67 patients, while 15 patients underwent classical en-bloc vulvar and groin dissection. Wound complications of the vulva occurred in 1 of 12 patients undergoing hemivulvectomy, in 8 of 55 undergoing radical vulvectomy, and in 7 of 15 who had en-bloc vulvar resection and groin dissection (P = 0.01). Among the 46 patients undergoing bilateral groin dissection through separate incisions, groin breakdown, lymphocyst, and lymphedema occurred in 10 (22%), 7 (15%), and 7 (15%), versus 0, 1 (7%), and 2 (13%) of the 15 who had unilateral groin dissection. Modification of vulvar resection did not increase the risk of local recurrence. Groin recurrence developed in 2 of 15 patients who underwent en-bloc groin dissection and in 1 of 46 who underwent bilateral groin dissection through separate incisions. Two of 15 who had a unilateral groin dissection recurred in the contralateral groin. The risk of recurrence as well as morbidity following modifications of radical vulvectomy with groin dissection should be considered when planning treatment.

In this study, we review the clinical presentation, treatment, and prognosis of 89 patients with stage I cervical adenocarcinoma treated at Strong Memorial Hospital over the past 25 years. In the past decade, the mean age of patients with stage I cervical adenocarcinoma was 44 years, in contrast to a mean of 58 years in the prior interval (P less than 0.001). Prior to 1980 only 4% of patients were of childbearing age, whereas in the past decade 27% were under 35 years old (P = 0.02). The difference in age at presentation cannot be explained by earlier detection, as the fraction of stage I patients, the mean tumor size, and the percentage of clinically occult tumors have not changed. There were no ovarian metastases in 41 patients who underwent oophorectomy. Adenosquamous tumours did not differ in prognosis from pure adenocarcinoma. Grade and lymph node status were significant predictors of outcome. Treatment results have not improved over the past 25 years, and combined therapy with radiation and surgery offered no advantage over radiation alone. Because this tumor is more frequently seen in younger patients, the management of occult adenocarcinoma with early stromal invasion has become problematic. Ovarian conservation has been questioned, and the lack of generally accepted criteria for microinvasive adenocarcinoma has led to radical therapy in patients who might have been adequately treated with local excision. Further study is necessary to guide our recommendations regarding preservation of ovarian function or even childbearing potential in young women.

In patients with endometrial carcinoma, preoperative identification of poor prognostic factors is helpful in planning therapy. Extended surgical staging, including pelvic and periaortic node dissection, is indicated in patients with deep myometrial invasion or high-grade tumor, or when other risk factors for extrauterine spread are present. In this study, cervical cytology was reviewed in 86 patients with endometrial carcinoma, all of whom underwent surgical staging, to correlate the cytologic results with surgical and pathologic findings. Cervical cytology was normal in 20 patients (23%), whereas suspicious or malignant endometrial cells were present in 23 and 43 cases (27 and 50%), respectively. Suspicious or malignant cervical cytology was associated with deeper myometrial invasion (P = .011), higher postoperative tumor grade (P = .006), positive peritoneal washings (P = .012), and more advanced stage by International Federation of Gynecology and Obstetrics criteria (P = .024). When compared with patients with normal cervical cytology, those who had malignant endometrial cells had over twice the risk of deep myometrial invasion (67 versus 30%), twice the risk of grade 2 or 3 tumor (60 versus 30%), and three times the risk of positive peritoneal washings (33 versus 10%). Seventy-four percent of patients with malignant cervical cytology were stage IC or more. In contrast, 70% of patients with normal cervical cytology were stage IA or IB. Patients with endometrial carcinoma who have malignant endometrial cells detected by cervical cytology are at increased risk of having a deeply invasive, high-grade, advanced-stage tumor, and therefore are more likely to require extended surgical staging.

The clinical course of 48 patients with low-risk metastatic gestational trophoblastic tumors (GTTs) treated with primary single-agent chemotherapy was reviewed. All patients achieved sustained remission, although 25 (51%) required a second single-agent regimen, and 7 (14%) needed combination chemotherapy to achieve it. An average of 3.4 courses of chemotherapy were necessary to achieve remission, and 6 patients (12%) underwent resection of resistant tumor foci. Primary single-agent chemotherapy is a reasonable treatment option in patients with low-risk metastatic GTT.

The patient with gestational trophoblastic neoplasia faces a number of risks; the greatest is the failure of current treatment to bring about remission. Based on a review of past experience, a number of risk factors associated with failure of single-agent chemotherapy were identified, and the subsequent utilization of combination chemotherapy led to an improved outcome. An analysis of more recent experience has identified factors associated with the failure of standard combination chemotherapy, and it is hoped that the development of new treatments will again improve the outcome. This review provides a perspective on known high-risk factors in light of contemporary treatment.

This review of the current management of complete molar pregnancy is based upon the clinical experience at the New England Trophoblastic Disease Center. Suction curettage is the preferred method of molar evacuation regardless of uterine size in patients who desire to preserve fertility. Prophylactic chemotherapy may be useful in the management of high-risk molar pregnancy, especially when hormonal follow-up is either unavailable or unreliable. All patients must be followed with serial human chorionic gonadotropin levels to ensure that remission has occurred.