Subclavian artery puncture repair with Angio-Seal deployment

BACKGROUND

Inadvertent placement of a port-a-catheter in an artery during central venous cannulation is rare and can result in devastating complications. Although traditional closure devices have been employed as prompt and adequate treatment, more innovative devices such as collagen plugs are being studied for their efficacy.

CASE

We report a case involving a 63-year-old woman who was treated with chemotherapy for recurrent metastatic uterine leiomyosarcoma. During port-a-catheter placement, puncture of the subclavian artery occurred. Vascular surgery and interventional radiology consultation was obtained, wherein an Angio-Seal device was used to seal the exit from the subclavian artery. Angio-Seal placement was successful and the patient has since become clinically stable and was then discharged.

CONCLUSION

Subclavian artery puncture is rare but can occur due to the close proximity between the subclavian artery and vein. Prompt vascular surgery and radiology consultation is necessary. Although traditional manual compression and closure devices have been effective at restoring hemostasis, collagen seals or plugs may be more viable to treat this precarious situation.

Tuberculosis mimicking cervical carcinoma--case report

Tuberculosis is a chronic bacterial infection that primarily results in pulmonary disease. Although there are several reported cases of extra-pulmonary tuberculosis, very few reports have described this disease in the female genital tract. We present a case involving a 67-year-old woman who presented with vaginal discharge, abdominal discomfort, and a pelvic mass in 2006. Clinically, cervical carcinoma was suspected, but pathologic diagnosis eventually revealed tuberculosis of the cervix. Tuberculosis is associated with a significant inflammatory reaction, which may mimic a gynecologic malignancy on exam or with diagnostic imaging. Despite the rare incidence, tuberculosis of the cervix should be considered in the differential diagnosis when cervical carcinoma is initially suspected.

Spontaneous bacterial peritonitis following treatment for cervical carcinoma

Spontaneous bacterial peritonitis (SBP) is an acute bacterial infection usually associated with ascites and cirrhosis or is a complication of peritoneal dialysis. There are very few case reports of cancer patients who developed this disease. Furthermore, there have been no published case reports of successfully treated gynecological cancer patients who later developed SBP. We present a case involving a 41-year-old woman who was treated for cervical carcinoma in 1992. She underwent radical surgery and adjuvant chemoradiation therapy. Two years later, the patient presented with streptococcal group B cellulitis associated with left leg lymphedema. She recovered following antibiotic treatment but had recurrent episodes of streptococcal cellulitis in her leg over the past 10 years. In 2003, the patient was admitted to the hospital because of sepsis, acute renal failure, and SBP. She was treated and recovered following treatment. SBP is usually associated with cirrhosis. Although SBP is rarely seen in successfully treated gynecological cancer patients, oncologists should be aware of this clinical entity. Timely treatment is essential to maximize chances of survival.

Ovarian cancer metastatic to the breast

BACKGROUND

Metastatic ovarian cancer to the breast should be considered in the differential diagnosis for gynecologic cancer patients with a breast tumor. Despite early detection and treatment, the long-term prognosis for these patients is poor.

CASES

We present three ovarian cancer patients who developed metastatic ovarian cancer to the breast. All patients were heavily pre-treated prior to the development of metastatic disease. Currently, one patient is alive at 64 months following initial detection of her metastatic disease to the breast. The second and third patients are also alive for 30 and 3 months subsequent to their diagnosis of metastatic disease.

CONCLUSION

Although metastatic ovarian cancer to the breast following treatment for ovarian cancer is rare and associated with a poor prognosis, oncology physicians should be prepared to contend with disease metastatic to the breast. Additional investigation into the efficacy of surgery and novel chemotherapy agents is warranted.

Surgery alone or surgery with a combination radiation or chemoradiation for management of patients with bulky-stage IB2 cervical carcinoma

The management of stage IB2 cervical carcinoma remains controversial. This retrospective review evaluates 47 IB2 cervical carcinoma patients treated with surgery alone (S), surgery plus postoperative radiotherapy (SR), or surgery plus postoperative chemoradiation (SRC). Median progression-free interval (PFI) was 70.3 months for the SR group (n= 21), 73.3 months for the SRC group (n= 15), and 33.5 months for the S group (n= 11). The survival rate was 76% for the SR group, 87% for the SRC group, and 55% for the S group. Overall 5-year survival rate for the three groups was 75%. Median follow-up for the patient population was 61.3 months. The number of the patient and the nonrandomized nature of this study preclude any definitive conclusions, but interestingly, the SRC and SR groups exhibited a substantially better PFI and overall survival compared to the S group. Selection bias does not appear to be a factor since patients in SR or SRC group were at greater risk for recurrence (eg, higher incidence of deep stromal invasion, parametrial involvement) than patients in the S group; yet, they still experienced superior PFI and overall survival. Further studies comparing postoperative irradiation and chemoradiation with these patients in a randomized phase 3 trial may be warranted.

Pelvic radiation necrosis and osteomyelitis following chemoradiation for advanced stage vulvar and cervical carcinoma

BACKGROUND

The treatment regimen indicated for most advanced stage vulvar, vaginal, and cervical cancer usually involves adjuvant chemoradiation therapy. Although the risk of complications is low, there have been reported cases of radiation necrosis and osteomyelitis following treatment for vulvar, vaginal, and cervical cancer.

CASES

We present a vulvar cancer patient and a cervical cancer patient, both of whom were treated with radical surgery and postoperative chemoradiation. Following therapy, they were afflicted with pelvic radiation necrosis and osteomyelitis. The patients underwent surgery to resect the necrotic bone tissue and long-term antibiotic therapy to treat their osteomyelitis. They have since recovered and are followed closely by their gynecologic oncology and infectious disease physicians.

CONCLUSION

The radiotherapy utilized to treat advanced stage gynecologic cancer can cause intestinal, vaginal, and urologic complications from micro-vascular damage to the organs. Pelvic bone osteonecrosis is a rare but disabling complication of pelvic radiation. Fortunately, with aggressive therapy, these patients may do well clinically.

Vaginal reconstruction following supra-levator total pelvic exenteration

BACKGROUND

There are several available techniques for neovaginal reconstruction following exenterative gynecologic surgery. However, all methods are associated with prolonged operative time and increased morbidity. The Apogee and Perigee vaginal vault and prolapse repair systems are innovative and minimally invasive procedures that may prove to be effective in controlling the levator defect and reconstructing the vagina in patients undergoing supra-levator pelvic exenteration.

CASE

We present a patient who underwent supra-levator total pelvic exenteration for treatment of recurrent squamous cell carcinoma of the cervix. Vaginal reconstruction was performed with the Apogee and Perigee systems utilizing the porcine mesh (InteXen) from American Medical Systems. The patient did well without any postoperative vaginal or small bowel complications.

CONCLUSION

The Apogee and Perigee systems comprise an innovative technique for vaginal vault reconstruction and prolapse repair. These systems may prove useful in reconstruction of the pelvis following ultra-radical pelvic procedures for recurrent gynecologic malignancies.

A Rare Case of Precoccygeal Endometriosis

BACKGROUND

Endometriosis is commonly identified in the abdomen, specifically the ovaries, adnexa, and fallopian tubes, and sometimes in more distant areas; precoccygeal endometriosis is an extremely rare phenomenon.

CASE

We present a case involving a 44-year-old woman diagnosed and treated for precoccygeal endometriosis. She underwent laparotomy, extensive lysis of pelvic adhesions, and resection of a 2.5-cm midline precoccygeal mass. After surgical excision of the precoccygeal endometriosis, the patient recovered without incident.

CONCLUSION

Precoccygeal endometriosis is a very rare diagnosis.

Abraxane in the treatment of ovarian cancer: The absence of hypersensitivity reactions

BACKGROUND

Paclitaxel is one of the most active agents in the treatment of ovarian carcinoma. However, paclitaxel is solubilized in cremophor, a polyoxyethylated castor oil. Cremophor is allegedly responsible for many paclitaxel-associated hypersensitivity reactions (HSR). Novel agents such as abraxane are solvent free and currently being evaluated to potentially avoid certain patient side effects.

CASE

We present a case involving a 60-year-old ovarian cancer patient with a significant history of chemotherapy induced HSR. She underwent optimal cytoreductive surgery and began adjuvant chemotherapy in 2000 until she suffered a severe HSR to paclitaxel. In 2002, she was diagnosed with recurrent disease and underwent subsequent treatment with carboplatin, cisplatin, and doxorubicin, all of which resulted in severe HSR. The patient began abraxane therapy in 2005 and has shown no signs of HSR.

CONCLUSION

Abraxane is a solvent free taxane, which can be administered without the pre-medications routinely used to prevent HSR. Abraxane may offer paclitaxel HSR patients the benefit of continued taxane treatment. Although the clinical activity of abraxane has not been extensively investigated in ovarian carcinoma, the distinct activity of paclitaxel and good results with recurrent metastatic breast cancer patients suggest additional evaluation with this drug is important.

Pilot study assessing robotic laparoscopic hysterectomy and patient outcomes

STUDY OBJECTIVE

To examine the operative variables and complications associated with robotic-assisted total laparoscopic hysterectomy.

DESIGN

Canadian Task Force classification II-1.

SETTING

Gynecology service affiliated with a major cancer center in Southern California.

PATIENTS

Twenty women with a benign gynecologic condition.

INTERVENTION

Robotic-assisted total laparoscopic hysterectomy. Patient status was evaluated in terms of operative morbidity, length of surgery, anesthesia time, estimated blood loss, and hospital stay.

MEASUREMENTS AND MAIN RESULTS

Mean operative time was 3.2 hours, and anesthesia time was 4 hours. Mean estimated blood loss was 81 mL, and patient postoperative hospital stay was 2 days. The complication rate in this study was low. The surgical procedure was converted to a laparotomy and abdominal hysterectomy in two patients because of poor visualization during robotic-assisted surgery.

CONCLUSIONS

While the number of patients and nonrandomized nature of this single-institution experience are insufficient to draw any definitive conclusions regarding potential treatment efficacy, the patient postoperative stay and low complication rates suggest that this procedure is feasible and promising. Additional study comparing the efficacy and cost of robotic laparoscopic hysterectomy with standard laparoscopic hysterectomy with a larger patient population is warranted.

Gamma-knife radiosurgery for the treatment of ovarian cancer metastatic to the brain

BACKGROUND

Central nervous system (CNS) metastases from an ovarian malignancy are uncommon. The long-term prognosis for these patients is poor, with studies reporting a mean survival of less than 12 months.

CASES

We present three ovarian cancer patients who developed metastatic disease to the brain. All patients were heavily pre-treated prior to the development of CNS disease. Following detection of CNS disease, they all were treated with multi-modality therapy including gamma-knife radiosurgery (GKRS). At this time, one patient is alive at 26 months following treatment with GKRS. The second and third patients survived for 88 and 22 months respectively, before succumbing to their disease.

CONCLUSION

Local control of ovarian cancer metastatic to the brain can be achieved in some patients with GKRS. Additional investigation into GKRS is warranted.

Serous psammocarcinoma of the ovary: an unusual finding

BACKGROUND

Serous psammocarcinoma of the ovary is a rare and infrequently described variant of ovarian cancer, characterized histologically by the pervasive presence of psammoma bodies. The risk of recurrent disease following surgical resection is low.

CASE HISTORY

A 70-year-old patient was admitted to the emergency room after falling at home. CT evaluation revealed a pelvic mass and free fluid in the abdomen and pelvis. Her serum CA-125 level was greatly elevated. The patient underwent an abdominal hysterectomy with bilateral salpingo-oophorectomy. Histologic examination revealed serous psammocarcinoma of the ovary.

CONCLUSION

Psammocarcinoma is a rare form of ovarian cancer associated with a favorable prognosis. However, the rare incidence of this disease and inconsistent biological behavior can confound the diagnosis for the treating physician.

Laser ablation of surgical margins after excisional partial vulvectomy for VIN: Effect on recurrence

OBJECTIVE

To determine the recurrence rates in patients who underwent different surgical treatments for vulvar intraepithelial neoplasia (VIN) 2 and 3.

STUDY DESIGN

Data on every patient who underwent surgical treatment for VIN 2 or 3 between January 1994 and December 2002 by a single gynecologic oncologist were retrospectively reviewed. The recurrence rates for 3 different surgical therapies were analyzed using Fischer's exact test.

RESULTS

Thirty-three patients, who had a median age of 46 years (range, 31-80), were identified. The preoperative biopsy demonstrated VIN 2 or 3 in 9.1% and 90.9% of the patients, respectively. The following primary surgical procedures were employed: 16 patients (48.4%) underwent excisional partial vulvectomy with CO2 laser ablation of the margins, 10 patients (30.3%) had CO2 laser ablation alone, 6 patients (18.2%) had an excisional partial vulvectomy, and 1 patient (3.0%) was. treated with the ultrasonic surgical aspirator. No patient had invasive disease. Recurrent disease was seen in 7 patients (70.0%) treated by laser alone, 3 patients (50.0%) who had an excisional partial vulvectomy and 1 patient (6.25%) who underwent a combined laser and excisional partial vulvectomy (p = 0.0016).

CONCLUSION

The results of this small study suggest that laser and excisional partial vulvectomy for the treatment of VIN 2 and 3 may be associated with a lower recurrence rate than either modality alone. A larger study will be needed to confirm these results.

Experience with single-agent paclitaxel consolidation following primary chemotherapy with carboplatin, paclitaxel, and gemcitabine in advanced ovarian cancer

OBJECTIVE

Twelve cycles of single-agent paclitaxel have been demonstrated to prolong progression-free survival in women with advanced ovarian cancer whom achieved a clinical complete response to a primary platinum/paclitaxel chemotherapy regimen. This trial was conducted to compare the toxicity and disease-free interval of 3 cycles vs. 12 cycles of paclitaxel consolidation in patients treated with an intensive three-drug front-line regimen of carboplatin, paclitaxel, and gemcitabine.

METHODS

Following cytoreductive surgery, 26 ovarian cancer patients received primary chemotherapy with carboplatin (AUC = 5, day 1), paclitaxel (175 mg/m(2) over 1 h, day 1), and gemcitabine (800 mg/m(2), day 1 day 8), with treatment repeated every 21 days x 6 cycles. The first 13 patients (group A) received three additional cycles of paclitaxel (175 mg/m(2) over 1 h every 21 days). The second set of 13 patients (group B) also received three cycles of paclitaxel (175 mg/m(2) over 1 h every 21 days) and then received nine additional cycles of paclitaxel (135 mg/m(2) over 1 h every 21 days) consolidation therapy. The change from 3 cycles to 12 cycles of consolidation therapy for group B was made following the published results of GOG 178.

RESULTS

In group A, all 13 patients completed three courses of consolidation therapy. One patient experienced grade 3 neutropenia and two patients exhibited both grade 4 neutropenia and thrombocytopenia. Grade > or = 2 neuropathy developed in 3 patients (23%). In group B, 9 of the 13 patients whom were intended to receive 12 total cycles of paclitaxel consolidation were able to complete the program. There was no grade 3-4 neutropenia or anemia in this population, although 1 patient developed grade 3 thrombocytopenia. Grade > or = 2 neuropathy developed in 7 patients (54%). Although not a randomized experience, median progression-free interval was 76 weeks for group B, and 47 weeks for group A.

CONCLUSION

Single-agent paclitaxel consolidation therapy can be administered for 12 cycles following first-line carboplatin, paclitaxel, and gemcitabine induction therapy, but there is considerable risk for development of a moderately severe peripheral neuropathy.

Abdominal/pelvic Coccidioidomycosis

BACKGROUND

Coccidioidomycosis is the second most common endemic fungal infection in the southwestern United States. Rarely, this fungal infection exhibits symptoms suggestive of peritoneal malignancy, such as ascites and abdominal pelvic masses.

CASE

We present a case involving a 51-year-old woman who presented with abdominal pain, ascites, and elevated serum CA-125 levels in 1995. She underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Final pathology revealed Coccidioidomycosis. Following prolonged treatment with fluconazole, her fungal symptoms resolved completely.

CONCLUSION

Patients with Coccidioidomycosis have a good prognosis if they are optimally diagnosed and treated. Ascites and elevated serum CA-125 levels associated with Coccidioidomycosis are not documented in the literature. Although extremely rare, abdominal Coccidioidomycosis could be considered in the differential diagnosis in patients who present with ascites or elevated serum CA-125 levels.

Pilot study of outpatient paclitaxel, carboplatin and gemcitabine for advanced stage epithelial ovarian, peritoneal, and fallopian tube cancer

OBJECTIVE

The purpose of this study was to determine the feasibility, response rate, and toxicity of paclitaxel, carboplatin, and gemcitabine as an outpatient regimen in the treatment of ovarian/non-ovarian and tubal adenocarcinoma. This is the largest completed study using this regimen as first-line treatment of these patients.

METHODS

Following cytoreductive surgery, eligible patients were initially treated with paclitaxel (175 mg/m(2) via 1 h infusion), carboplatin (AUC = 5), and gemcitabine (800 mg/m(2)) as an outpatient every 21 days. Gemcitabine (800 mg/m(2)) was repeated on day 8. After six cycles of treatment, responders were eligible for an additional three cycles of paclitaxel and gemcitabine. Colony-stimulating factors were used at the discretion of the treating physician.

RESULTS

Fifty-seven patients (median age = 58; range 41-81) with stage III/IV epithelial carcinoma of the ovary, fallopian tube, and peritoneum received a total of 476 cycles of chemotherapy. Grades 3 and 4 neutropenia developed in 19.7% and 9% of cycles while grades 3 and 4 thrombocytopenia developed in 4.2% and 1.3% of the cycles. One hundred thirty-seven (28.8%) cycles of a possible 476 cycles of gemcitabine were delayed primarily due to grades 3 and 4 neutropenia. Forty-five (84.9%) patients exhibited a complete response and three (5.7%) patients demonstrated a partial response, for a total response rate of 90.4%. Twenty-two patients developed some degree of neuropathy, although there was no reported interference with activities of daily living. The patients' median progression-free interval and median overall survival was 15.5 and 40.8 months, respectively. Forty-one of the original 57 patients were alive at the conclusion of data collection.

CONCLUSIONS

This report represents the largest completed study in the world employing this triplet regimen in the first-line treatment of advanced stage epithelial ovarian, fallopian tube, or peritoneal cancer patients. Although the study exhibited a high response rate, the neuropathy encountered in the study, and the need to eliminate gemcitabine in 54% of the patients due to bone marrow suppression merits further investigation of the dosing schedule. More recent gemcitabine data suggest that lower doses and a 2-week regimen may be as effective with less toxicity. A comparison of our results with the GOG-0182 study, that utilizes the same regimen, should be informative.

Cecal pelvic transposition following total pelvic exenteration

BACKGROUND

Multiple techniques have been utilized in an attempt to prevent small bowel obstructions following total pelvic exenteration. Pelvic transposition of the cecum may be an effective way to reduce the incidence of this serious complication.

CASES

We present three women who underwent total pelvic exenteration and cecal pelvic transposition to exclude the small bowel from the "empty pelvis". All three patients did well without any postoperative small bowel complications.

CONCLUSION

Cecal pelvic transposition precludes the small bowel from entering the pelvis. This procedure can be performed relatively easily by a gynecologic oncologist experienced with bowel surgery. A larger patient series is needed to assess the efficacy of this previously unpublished procedure.

Long-term survival in an ovarian cancer patient with brain metastases

BACKGROUND

Central nervous system (CNS) metastases from ovarian adenocarcinoma are uncommon. The long-term prognosis for these patients is poor, with studies reporting a mean survival of less than 12 months.

CASE

We present a case involving a 57-year-old woman diagnosed and treated for primary ovarian cancer in 1994. She underwent optimal cytoreductive surgery and received adjuvant chemotherapy. In 1996, she was diagnosed with a right cerebellar metastatic lesion, and treated with surgery and whole-brain radiotherapy. She is currently 7 years post-treatment of her brain metastasis without evidence of recurrent disease.

CONCLUSION

Brain metastases from primary ovarian cancer are a relatively rare finding. These patients have a poor prognosis, with studies reporting a mean survival of 12 months. However, the patient in this report remains disease-free since her treatment for metastatic disease. Aggressive surgical and radiation treatment for patients with isolated CNS metastases is reasonable.

Three-consecutive-day topotecan is an active regimen for recurrent epithelial ovarian cancer

OBJECTIVE

The aim was to determine the response rate and toxicity of topotecan administered Days 1-3 every 21 days for recurrent epithelial cancers of the ovary, peritoneum, or fallopian tube. A 3-day regimen may be more convenient and less expensive than a 5-day schedule.

METHODS

Patients with recurrent epithelial cancer of the ovary, peritoneum, or fallopian tube who had adequate hepatic, renal, and hematologic function were eligible for participation. Topotecan (2 mg/m(2)) was administered for 3 consecutive days every 21 days. Response was measured clinically and serologically. Granulocyte colony stimulating factors (GCSF) were not utilized prophylactically, but could be added under specific conditions.

RESULTS

Thirty-one patients with recurrent ovarian cancer whose median age was 63 (range 32-84) received 165 cycles of topotecan (median = 6; range 2-8) and are evaluable for toxicity. The median number of prior regimens was 1. Topotecan was administered on schedule in 96.6% of cycles. Grade 3/4 neutropenia was seen in 29.1 and 23.6% of courses, respectively; but only 3.4% of cycles required GCSF support (6 cycles for 2 patients). Grade 4 thrombocytopenia was rare (1% of cycles). Nonhematologic toxicity was mild. The response rate for 28 evaluable patients was 32.1% (10.7% complete response (CR) and 21.4% partial response (PR)); stable disease was seen in 17.9% of patients. The median progression-free interval (PFI) for all patients was 15.5 weeks (range 5-40). Eighteen platinum-sensitive patients demonstrated a 43.4% response rate (12.5% CR and 31.3% PR); stable disease was documented in 18.8%. The median PFI for platinum-sensitive patients was 18.5 weeks (range 5-40).

CONCLUSION

Topotecan is an effective regimen with acceptable toxicity for recurrent ovarian cancer when administered for 3 consecutive days (2 mg/m(2)) every 21 days. It can be delivered on schedule without GCSF support in the vast majority of patients.

A phase I trial of a 3-day topotecan Q 21 days for recurrent epithelial cancers of the ovary, fallopian tube, and peritoneum

OBJECTIVE

This trial was undertaken to determine the dose limiting toxicity (DLT) and maximum tolerated dose (MTD) of topotecan that can be administered for 3 days q 21 days. A 3-day schedule is more convenient and less expensive than standard 5-day dosing.

METHODS

Patients with recurrent epithelial ovary, tubal, or peritoneal carcinoma were treated with escalating doses of topotecan beginning at 2.50 mg/m(2) as an outpatient days 1-3 q 21 days. Colony stimulating factors were not employed prophylactically, but could be added for grade 4 marrow toxicity.

RESULTS

Twenty patients with a median age of 61 (range 46-80) and performance status of 0 or 1 were entered. All patients had received at least one prior paclitaxel/platinum regimen; 6 had received two. Ninety-one cycles were delivered (median = 6) and 98.9% were on schedule. Grade 4 neutropenia was seen in 17 of 20 patients (85%) in cycle 1 and in 38 of 91 (41.8%) total cycles. Sixteen of 20 patients (80%) started G-CSF on cycle 2. Two of 91 (2.2%) cycles had grade 4 thrombocytopenia. Four cycles (4.4%) were associated with febrile neutropenia. Two patients experienced grade 4 neurotoxicity (DLT) at 4.25 mg/m(2). Other nonhematologic toxicity was mild.

CONCLUSIONS

Topotecan can be safely administered on schedule as an outpatient days 1-3 q 21 days. Neurotoxicity was the DLT when G-CSF was added; the MTD was 3.75 mg/m(2). There was minimal other nonhematologic toxicity. Neutropenia was predictable and easily managed with G-CSF. Febrile neutropenia was uncommon and thrombocytopenia was rare at the doses evaluated.

"Medically necessary" panniculectomy to facilitate gynecologic cancer surgery in morbidly obese patients

A retrospective review of patients in our practice who underwent abdominal panniculectomy to facilitate gynecologic cancer surgery was performed. The objective of the study was to determine if panniculectomy was a safe and useful procedure in the morbidly obese gynecologic cancer patient. A total of 12 patients underwent the procedure between 1992 and 1996. Optimal pelvic oncologic surgery was accomplished in all 12 patients. All aspects of those procedures were performed by gynecologic oncologists. The Buchwalter retractor was used in all cases. The patients' weights ranged from 170 to 429 pounds, with a mean of 275 pounds. The mean body mass index was 48, with a range from 37 to 67. Four patients had a history of diabetes mellitus. Nine patients healed without wound complications. Three patients developed superficial subcutaneous wound infections/necrosis that were successfully managed with office debridement. Abdominal panniculectomy is a reasonably safe procedure that makes radical pelvic surgery possible regardless of the patient's weight. Prolonged wound bulb suction drainage may decrease the incidence of wound necrosis/infection in these high-risk patients.

Single-dose dexamethasone paclitaxel premedication

Paclitaxel is one of the most active chemotherapy agents for the treatment of ovarian and other gynecologic cancers. Hypersensitivity reactions (HSR) remain one of the major clinical concerns in the use of paclitaxel. This report deals with 183 consecutive patients treated with paclitaxel chemotherapy. A total of 1010 cycles were administered. Premedication consisted of single-dose intravenous decadron, benadryl, and cimetidine administered immediately prior to chemotherapy. Four hypersensitivity reactions occurred. All patients recovered uneventfully from these reactions. Two of these patients received additional oral decadron followed by the standard premedication and were successfully retreated with multiple courses of paclitaxel therapy without reaction. Our findings confirm other reports that paclitaxel chemotherapy hypersensitivity reactions can be decreased with a single-dose intravenous decadron premedication regimen and that patients who do have paclitaxel HSRs may be safely retreated with paclitaxel.

Three-hour paclitaxel infusion and carboplatin is an effective outpatient treatment for stage III epithelial ovarian cancer

OBJECTIVE

The aim of this study was to determine the response rate and toxicity of a 3-h paclitaxel infusion and carboplatin delivered as outpatient therapy for the treatment of stage III/IV epithelial ovarian cancer.

METHODS

Thirty patients with stage III/IV epithelial ovarian cancer underwent cytoreductive surgery. The first 10 patients received adjuvant paclitaxel 150 mg/m2 via 3-h infusion on day 1 and carboplatin 5 times area under the curve on day 2 (group 1) every 28 days. The paclitaxel dose was escalated to 175 mg/m2 for the next 20 patients (group 2). chi 2 and Kaplan-Meier procedures were used for statistical analysis.

RESULTS

Nine of 51 cycles in group 1 (17.6%) and 19 of 116 cycles (16.4%) in group 2 were associated with grade 4 neutropenia (P = 0.96), but only 2 of the 161 total cycles (0.01%) had fever and neutropenia. One patient in group 1 experienced grade 3 thrombocytopenia. Two patients in the entire group (7.4%) required colony-stimulating factors. One patient in group 2 (3.7%) had grade 3 neurotoxicity. With a median follow-up of 29 months for the entire group, 5 of 8 patients (62.5%) in group 1 and 14 of 19 patients (73.7%) in group 2 are alive. Median progression-free survival for group 1 and 2 is 13 and 14 months, respectively. Median overall survival has not been reached.

CONCLUSIONS

Paclitaxel via 3-h infusion and carboplatin is an effective outpatient treatment for epithelial ovarian cancer that can be safely administered on schedule in the majority of patients.

Carbon dioxide laser ablation combined with doxorubicin hydrochloride treatment for vaginal fibrosarcoma in a dog

The combined use of CO2 laser ablation and doxorubicin hydrochloride (30 mg/m2) administered twice, 4 weeks apart, resulted in complete remission of vaginal fibrosarcoma in a 10-year-old Miniature Poodle. The tumor had redeveloped when only CO2 ablation was used for treatment and doxorubicin hydrochloride alone has had marginal influence on fibrosarcomas; however, use of both treatments in this dog resulted in a 20-month, disease-free period. This treatment combination was minimally traumatic to the dog, easily accomplished, and effective, and it allowed retention of the normal anatomy and function of the urogenital tract.

Whole-abdominal radiotherapy for patients with minimal residual epithelial ovarian cancer

Sixteen patients with advanced epithelial ovarian cancer who were treated with cytoreductive surgery followed by multiagent chemotherapy were found to have residual tumor masses less than 2 cm in greatest diameter at reexploration and were treated with whole-abdominal radiation (19-31 Gy). Thirteen patients also received pelvic boosts to a total pelvic dose of 41-53.7 Gy. Radiotherapy was completed in all but 2 patients after treatment delays in 7 patients. Early treatment complications included myelosuppression in 11 patients, diarrhea in 3, and a self-limited small bowel obstruction in one. Delayed complications were severe and included 9 patients with radiation enterocolitis, 8 of whom required intestinal resection or diversion. One additional patient with radiation cystitis required instillation of formalin to control bleeding. Two patients are without evidence of disease 28 and 30 months following radiotherapy, while the remaining 14 patients have recurred after a median progression-free interval of 9 months (range 1-30 months). All patients who recurred failed within the treatment field and died of cancer after a median interval of 19 months following radiotherapy and 9 months after documentation of progression. These data suggest that few patients with persistent ovarian cancer following surgery and chemotherapy will be salvaged with radiotherapy.

Ovarian epithelial tumors of low malignant potential

Forty-one patients with epithelial ovarian tumors of low malignant potential are discussed. Twenty-three patients presented with Stage I, four with Stage II and 14 with Stage III disease. All patients with Stage I disease were solely treated surgically. Twelve patients with Stage II and III disease also received postoperative chemotherapy. Four of ten patients had persistent disease at second look laparotomy. Chemotherapy was not used in six patients with Stage II and III disease when the tumor was considered to have been removed completely. Forty of the 41 patients are currently alive and free of disease at two to nine years of follow-up study. Vigorous and, at times, multiple surgical procedures remain the primary treatment of ovarian tumors of low malignant potential.

Intraperitoneal cisplatin: comparison of antitumor activity and toxicity as a function of solvent saline concentration

The use of increasing concentrations of NaCl in the solvent during administration of cisplatin is known to decrease nephrotoxicity, but its effect on antitumor activity is less certain. A murine tumor model employing the subrenal capsule assay was used to test the toxicity and antitumor activity of intraperitoneal cisplatin at different doses of the drug using varying concentrations of NaCl in the vehicle of administration. Toxicity (measured by LD50, weight loss, and nephrotoxicity) was significantly lower in mice treated with cisplatin prepared in 4.5% NaCl as compared to cisplatin prepared in distilled water (DW) or 0.9% NaCl. Administration of 4.5% NaCl subcutaneously along with intraperitoneal cisplatin prepared in DW failed to decrease toxicity. Despite lower toxicity, no decrease in antitumor activity could be demonstrated based on increasing concentrations of NaCl in the solvent during intraperitoneal therapy.

Radical hysterectomy and tailored postoperative radiation therapy in the management of bulky stage 1B cervical cancer

Ninety-two patients with Stage IB cervical cancers having a diameter equal to or greater than 4.0 cm were treated with radical surgery. Thirty-two patients received postoperative radiotherapy because of operative findings suggestive of high risk of pelvic recurrence. All 32 irradiated patients were treated with a standard pelvic field. Four patients also received paraaortic radiotherapy, and ten received intravaginal brachytherapy. Postoperative complications were seen in five patients (two nonirradiated, three irradiated). Projected 5-year survival is 79% (71% 5-year survival in irradiated patients, and 83% 5-year survival in nonirradiated patients). Preoperative evaluation of tumor volume was not found to reliably predict histologic high risk factors such as depth of stromal invasion, risk of lymph node metastases, or presence of extracervical/uterine involvement. A primary surgical approach in this group of patients with large-diameter Stage IB cervical cancers allows definition of those patients who might benefit from a combined surgical and radiotherapeutic approach to treatment based on findings at operation.

Treatment of advanced and recurrent endometrial carcinoma: correlation of patient response to hormonal and cytotoxic chemotherapy and the response predicted by the subrenal capsule chemosensitivity assay

The tumors from 38 patients with advanced or recurrent endometrial carcinoma were assayed by the subrenal capsule xenograft assay (SRCA) for sensitivity to hormonal and cytotoxic chemotherapy. Three patients initially received radiation therapy. All other patients received maximal surgical debulking followed by treatment with radiation therapy (5), and/or hormonal (19), and cytotoxic (30) chemotherapy. All the patients who received hormonal chemotherapy had progression of disease. There were 2 complete responses, 5 partial responses, and 26 disease progressions with cytotoxic chemotherapy; and 2 complete responses, 2 partial responses, and 5 disease progressions with radiation therapy. The SRCA was 100% predictive of the response of the tumors to hormonal therapy and had 75% sensitivity, 65% specificity, and 66% efficiency of the response of the tumors to cytotoxic chemotherapy. Laboratory assays of tumor response to radiation therapy were not measured. Those patients with early stage, well-differentiated tumors with no residual disease had the longest survival times. Absence of residual disease after the first surgery was the most important delineator of survival for all categories of patients.

Use of a murine model for comparison of intravenous and intraperitoneal cisplatin in the treatment of microscopic ovarian cancer

The most effective method for the delivery of cisplatin chemotherapy in the treatment of epithelial ovarian cancer limited to the presence of microscopic intraperitoneal disease is a controversial issue. The use of intravenous (iv) versus intraperitoneal (ip) cisplatin was evaluated in a murine tumor model of human epithelial ovarian cancer. Using single dose cisplatin therapy for microscopic disease limited to positive cytology of abdominal disease and microscopic peritoneal involvement, ip therapy had significantly greater (P less than 0.001) survival time than iv therapy (28 +/- 1.6 days vs. 23 +/- 1.6 days, respectively). Once ascites and macroscopically evident intraperitoneal tumor became apparent, no difference could be found in survival time based on iv versus ip therapy (16 +/- 3 days for both groups); though both forms of therapy significantly (P less than 0.05) prolonged survival in mice with macroscopic disease when compared to control animals (13 +/- 1.2 days). The evidence presented implies that ip cisplatin therapy is significantly more effective than iv therapy when dealing with microscopic intraperitoneal disease.

Concordance of combination and single agent chemosensitivity prediction in ovarian carcinoma using the subrenal capsule xenograft assay (SRCA)

The tumors from 62 patients with advanced ovarian adenocarcinoma were assayed by the subrenal capsule xenograft assay (SRCA) for sensitivity to doxorubicin (A), cis-platinum (P), and cyclophosphamide (C), individually and in combination. In some instances only one or two of the individual drugs were assayed; however, the combination, CAP, was always tested. All patients received an optimal surgical debulking (absence of any residual tumor masses greater than or equal to 2 cm) followed by chemotherapy with CAP. Forty-two tumors were predicted to be sensitive to CAP by the SRCA; 51 of 71 (72%) individually tested drugs agreed with this determination. Twenty-one tumors were predicted to be resistant to CAP and 32 of 36 (89%) individually tested drugs agreed with this determination. In this preliminary study, 11 patients had surgically documented partial responses to CAP chemotherapy. All of these patients had tumors which prospectively tested as sensitive to CAP in the SRCA: 13 of 18 (72%) of separately tested drugs were in concordance with this sensitivity. Fourteen patients failed CAP therapy and three of these failures were predicted prospectively by the SRCA: 9 of 9 (100%) of separately tested drugs were in concordance. Thus, there is an overall concordance of 82% (22/27) between the individual components of a combination chemotherapy and the combination therapy itself. It would seem that extrapolations of sensitivity or resistance can be made from the individual components.

Treatment of advanced and recurrent squamous carcinoma of the uterine cervix with constant intraarterial infusion of cisplatin

Twelve patients with primary or locally recurrent squamous carcinoma of the cervix were treated with constant internal iliac artery infusion of cisplatin (CDDP) via a totally implantable chemotherapy pump. Seven previously untreated patients received standard external and interstitial radiotherapy (RT) in conjunction with CDDP infusion. Five patients with isolated pelvic recurrences received CDDP therapy only. The chemotherapy pump was refilled weekly on an outpatient basis. All nine evaluable patients developed unilateral or bilateral lower extremity pain which responded to dosage reduction. No renal or marrow toxicity was seen. Both of the evaluable patients treated for recurrent tumor died 32 and 60 weeks after initiation of treatment. The seven patients treated primarily with RT + CDDP infusion include one who expired with persistent tumor and one with no evidence of disease (NED) after exenteration for a pelvic recurrence at 48 and 85 weeks respectively. The five remaining patients are NED at 12 to 60 weeks. Constant internal iliac artery infusion of CDDP via an implantable chemotherapy pump can be performed with acceptable toxicity. The preliminary results suggest that further study in previously untreated undergoing concurrent radiotherapy is warranted.

Relationship of serum CA125 and lipid-associated sialic acid tumor-associated antigen levels to the disease status of patients with gynecologic malignancies

Serum samples obtained from 133 patients with gynecologic malignancies were assayed for two tumor-associated antigen markers: CA125, an ovarian marker, and lipid-associated sialic acid, a nonspecific marker. In the patient population, there were 77 papillary serous and 19 unspecified ovarian adenocarcinomas, and 24 miscellaneous ovarian carcinomas. Thirteen patients had nonovarian malignancies. Sixty-nine percent (74 of 108) of the patients with known disease had abnormal CA125 levels, whereas only 32% (20 of 63) had abnormal lipid-associated sialic acid levels. Changes in CA125 serum levels reflected the disease status of the patients for whom there were serial serum samples. Normal levels of CA125 corresponded to no evidence of disease in 100% (six of six) surgically evaluated patients and 75% (30 of 40) of clinically evaluated patients. Changes in CA125 levels from normal to abnormal corresponded to disease progression in 80% (12 of 15) of the patients. Decreases in CA125 levels from abnormal to normal corresponded to complete clinical response in 55% (11 of 20), and partial clinical response in 45% (nine of 20). No such correlations were available for lipid-associated sialic acid antigen levels. For tumors that express CA125 antigen, serum levels appear to be a good marker for the extent of malignant gynecologic disease. Levels of CA125 that rose from normal to abnormal were usually associated with recurrent disease.

Treatment of a syngeneic rat tumor with magnetically responsive albumin microspheres labeled with doxorubicin or protein A

The tumoricidal activity of magnetically responsive albumin microspheres tagged with either doxorubicin or Staphylococcal protein A was tested against an induced mammary adenocarcinoma, 13762, implanted subcutaneously in the tail of female Fischer-344 rats. Magnetically responsive albumin microspheres containing Fe3O4 particles were prepared by an emulsion polymerization method incorporating either doxorubicin or protein A into the albumin matrix. Microspheres were produced with an average diameter of 1 micron (0.2 to 1.5 micron) in a concentration of 10(9) microspheres/mg. Microspheres were injected either directly into the tail artery and localized to the implanted tumor using a permanent bipolar adjustable gap magnet with a field strength of 8000 Oe, or directly into the femoral vein with no magnetic localization. Control groups consisted of animals treated with intravenously or intraarterially administered microspheres containing no active agent, and a no-treatment group. Survival was significantly greater in both the doxorubicin- and protein A-treated animals than in the control groups. First appearance of local metastases was prolonged in only the intraarterial magnetically localized doxorubicin-treated group of animals. Tumor growth rate was significantly depressed in both intraarterially magnetically localized treatment groups when compared to intravenously administered nonlocalized treatment groups. Magnetically responsive albumin microspheres appear to be an effective delivery system for cytotoxic agents and biologic response modifiers. Significant tumoricidal activity can be produced with a one-time administration of these agents utilizing this drug delivery system.

Skinning vulvectomy for the treatment of multifocal vulvar intraepithelial neoplasia

Of 108 women treated for vulvar intraepithelial neoplasia between 1977 and 1984 at the Irvine Medical Center, University of California, and the Memorial Medical Center of Long Beach, Women's Hospital, 48 with multifocal and/or widespread lesions underwent skinning vulvectomy and split thickness skin graft reconstruction. Six women in the skinning vulvectomy sample had early stromal invasion in the vulvectomy specimen. Recurrences at intervals of four to 87 months occurred in 13 patients undergoing this procedure. The risk of recurrence did not appear to be related to the status of the surgical margins because seven of 22 patients with involved margins experienced recurrence compared with six of 26 with uninvolved margins.

Accurate laboratory predictions of the clinical response of patients with advanced ovarian cancer to treatment with cyclophosphamide, doxorubicin, and cisplatin

Seventy-six patients with advanced ovarian cancer treated with cyclophosphamide, doxorubicin, and cisplatin (CAP) at 3-week intervals were tested for the response of their tumors to treatment with CAP in the subrenal capsule tumor implant assay. Thirty-four of the patients' tumors were assayed prospectively before clinical treatment and 33 were assayed retrospectively, after clinical treatment with CAP. Nine of the patients' tumors were assayed both prospectively and retrospectively. All of the patients underwent a tumor debulking laparotomy. Of the patients with clinically measurable residual disease, 17 had a partial response of at least 50% regression of disease, and 11 had a progression of disease. Of the patients with known residual but nonmeasureable disease, 7 had surgically verified complete responses, 8 at least 50% regression, and 23 had progression of disease: 10 had no evidence of disease clinically but had not had surgical confirmation. Twenty-six of the tumors were adenocarcinomas not otherwise specified (2 grade I, 2 grade II, and 22 grade III), 39 were serous adenocarcinomas (7 grade I, 9 grade II, and 23 grade III), 7 were endometrioid adenocarcinoma (all grade III), 3 were mucinous adenocarcinomas (1 each of grade I, II, and III) and 1 was an adenosquamous carcinoma (grade III). Thirty-four of the patients failed the therapy. The subrenal capsule (SRC) assay predicted 21 of these failures (4 prospective and 17 retrospective). Thirty-two of the patients responded to CAP chemotherapy. The SRC assay accurately predicted the clinical regression of the tumors of 22 of the patients (15 prospective and 7 retrospective). Second-look laparotomy confirmed 7 patients with no evidence of disease, 5 patients with minimal disease, and 5 patients with a greater than 50% reduction of their disease. The SRC assay predicted the response of all these patients except 2 with partial responses to chemotherapy. Thus, while the overall positive predictive value of the SRC assay in this study is 65%, it is 100% for those patients whose tumors respond completely and for those who have minimal residual disease after CAP chemotherapy.

Treatment of advanced ovarian cancer with polyinosinic-polycytidylic lysine carboxymethylcellulose (poly(ICLC))

Eight patients with advanced ovarian cancer were treated with polyinosinic-polycytidylic lysine carboxymethylcellulose (poly(ICLC]. Toxicity was substantial. No responses were seen in this small group of patients. Further clinical trials utilizing poly(ICLC) at the doses described in patients with advanced ovarian cancer do not appear to be warranted.

Semipermanent right atrial catheter in gynecologic cancer patients

The indications for insertion of semipermanent right atrial silicone catheters and immediate and long-term complications in patients admitted to a gynecologic oncology service, are described. Eight-five catheters were inserted in 79 patients for a variety of indications. Most catheters were placed under local anesthesia, in the patient's hospital room. Immediate morbidity caused by damage to the pleura was limited to three patients (3.5%). Infectious morbidity related to catheter use was seen in five patients (5.9%). Two patients were unable to administer daily heparin boluses through the catheter, and in both of these patients catheter thrombosis was seen (2.4%). A right atrial catheter can easily be inserted at the patient's bedside or in an outpatient setting. This device should be offered to any patient in whom intermediate or long-term vascular access is desired for nutritional support, chemotherapy, pain control, or similar indications.