Clear cell carcinoma of the ovary: a clinicopathologic analysis of 34 cases

The clinical and pathologic aspects of 34 cases of pure clear cell carcinoma of the ovary are discussed. These tumors represented 12.1% (34/280) of all ovarian cancers. The ages of the patients ranged from 34 to 78 years (mean 51.6 years) and 59% were postmenopausal. The clinical stages (FIGO) of these patients were as follows; I 22, II 5, III 6, and IV 1. Thirty-nine percent of the patients were nulligravidas. The diameters of the tumor varied from 6 to 31 cm (mean 16 cm), and 47% of the patients had endometriosis. Thirteen tumors were directly connected with endometriosis and this suggests that some ovarian clear cell carcinoma arose from the epithelium of an endometriotic cyst. Three architectural patterns (solid, papillary, and tubulocystic) were recognized. Forty-seven percent of the tumors were predominantly papillary and 24% contained mixtures of these three patterns. Four cell types such as clear, hobnail, eosinophilic, and flattened were also seen. Thirty-eight percent of the tumors had psammoma bodies. Histological patterns and cell types were not prognostic factors, and the stage at presentation was the most important prognostic factor. The 5-year survival rate was 54% (7/13) which was better than that in patients with serous adenocarcinoma of the ovary. The estimated survivals in patients with clear cell carcinoma however, were worse than those in patients with serous adenocarcinoma when compared stage for stage.

Malignant hemangiopericytoma of the omentum presenting as an ovarian tumor

Malignant hemangiopericytomas are usually found in the musculature of the extremities, the retroperitoneum, and the pelvis. Malignant hemangiopericytoma arising in the omentum is extremely rare. We recently experienced such a case, in which a malignant ovarian tumor was suspected preoperatively on the basis of the sonogram, CT scan, magnetic resonance image, and increased CA-125 value. Microscopically, the tumor showed many mitoses, increased cellularity, and cytologic atypia. The patient was treated with CAP combination therapy following resection of the tumor; however, an intraperitoneal recurrence probably due to implantation was recognized 11 months later.

Squamous cell carcinoma arising in a cystic teratoma presenting as a vulvar mass

A case of squamous cell carcinoma arising in a cystic teratoma presenting as a vulvar mass is reported. This appears to be the first report of such a case.

[Pseudomyxoma peritonei with myxoglobulosis--a case report and the pathogenesis of the myxoglobules]

A case of pseudomyxoma peritonei with myxoglobulosis is described. The myxoglobulosis was characterized by globules consisting of firm opaque whitish-gray nodule that measured up to 1.0 cm in diameter. Many globules in the abdominal cavity were filled with mucinous material. Electron microscopically, these globules were found to be covered by mesothelial cells with microvilli and contained mucous material, fibrous tissue, and a few myofibroblasts.

Pulmonary metastasis from carcinoma of the uterine cervix

Of 817 patients with carcinoma of the uterine cervix that were treated and followed-up, 50 (6.1%) developed pulmonary metastases. The incidence of pulmonary metastasis was 3.2% in stage I, 5.0% in stage II, 9.4% in stage III, and 20.9% in stage IV disease. The incidence of pulmonary metastasis in patients with adenocarcinoma and undifferentiated carcinoma was higher. Of the patients in whom lung metastases were detected, 41.7% had no symptoms; 96% was diagnosed within 2 years from the initiation of treatment. All patients had abnormal shadows in chest X rays. We recommend that chest X rays be obtained every 2 months within the 8 months after treatment and every 6 months thereafter. Eighty-one percent of the patients had local recurrence or other distant metastatic lesions. The main treatment for these patients was chemotherapy, and CAP was effective for the patients with adenocarcinoma. Surgical resection of the pulmonary lesion may be an effective treatment for the patients who have no lesions in other sites.

[An evaluation of scalene lymph node metastasis in patients with gynecologic malignancies]

From 1981, through 1985, 90 patients with primary or recurrent gynecologic malignancies underwent a scalene lymph nodes (SLN) biopsy. Pelvic lymph nodes (PN) and paraaortic lymph nodes (PAN) also were examined for metastasis with CT, lymphography, and palpation or were biopsied after a laparotomy. Twenty-three of these 90 patients (25.6%) were found to have positive SLN. In 5 of these 23 (21.7%), their SLN had not been palpable on physical examination. All signs of PN, PAN and SLN were examined in 42 patients. Twenty-one of these 42 (50%) had positive PN, 14 (66.7%) had positive PAN, and 4 (28.6%) had positive SLN. Seven patients with negative PAN had no SLN metastasis. Of twenty-one patients with negative PN, 2 had positive PAN and none had an SLN metastasis. Thus, it has been concluded that an evaluation of SLN is important for the management of a gynecologic malignancy in patients with positive PAN.

Bone metastasis from cervix cancer

Among 713 patients followed after treatment for cancer of the uterine cervix, 48 (6.6%) had a metastasis to the bone. The rates of metastasis in each of the four clinical stages were 11/273 (4.0%) in stage I, 16/243 (6.6%) in stage II, 13/162 (8.0%) in stage III, and 8/35 (22.9%) in stage IV, respectively. The most frequent site of metastasis was the vertebral column, particularly the lumbar spine (23 cases, 48%) followed by the pelvic bones. Pulmonary metastasis also frequently occurred. For 32 (67%), lesions of the bone were detected within 1 year after completion of the initial treatment, and 36 (75%) died within 1 year after detection of the metastasis. Those patients who survived over 2 years were those for whom the lesions of the bone had been treated by radiotherapy followed by chemotherapy.

Peritoneal cytology in patients with endometrial carcinoma

Peritoneal cytology was obtained in 61 patients with carcinoma of the endometrium at the time of laparotomy. The incidence of positive peritoneal cytology was 23.0%. It increased as the clinical stage advanced. The incidence of positive peritoneal cytology in patients with well-differentiated carcinoma or superficial myometrial invasion was low. The rate of paraaortic lymph node metastasis was higher in patients with positive peritoneal cytology than in patients with negative peritoneal cytology. However, this trend was not recognized in pelvic lymph node metastasis. In the positive peritoneal cytology group, 64.3% had disease outside of the uterus, while in the negative group only 12.8%. The 2-year survival rate in patients with positive peritoneal cytology was 57.1% and it was 86.4% in patients with negative peritoneal cytology. It is concluded that the findings of positive peritoneal cytology is an important prognostic factor and routine peritoneal cytology should be obtained at the time of laparotomy in patients with carcinoma of the endometrium.

[Superior vena cava syndrome associated with carcinoma of the uterine cervix--report of two cases]

Superior vena cava syndrome (SVCS) is a very rare complication in patients with a gynecologic malignancy. Only 4 cases have been reported in the English literature thus far and, to our knowledge, no such case has been reported in the Japanese literature. We have encountered two cases of SVCS in patients with cervical cancer. In case 1, the SVCS developed secondarily to a metastasis of the cervical cancer to the lungs and mediastinum. In case 2, the cause of the SVCS had been presumed to be due to metastatic cervical cancer, however on autopsy, it turned out to be due to a coexistent malignant lymphoma.

Peritoneal cytology in patients with carcinoma of the uterine cervix

Peritoneal cytology was obtained in 125 patients with carcinoma of the uterine cervix at the time of laparotomy. The incidence of positive peritoneal cytology was 11.2%. Positive peritoneal cytology was found four times more frequently in adenocarcinoma than in squamous cell carcinoma. The incidence of pelvic lymph node and paraaortic lymph node metastasis was higher in patients with positive peritoneal cytology than in patients with negative peritoneal cytology. The 2-year survival rate in patients with positive peritoneal cytology was 30.0% and it was 82.7% in patients with negative peritoneal cytology. Some patients (28.6%) with positive peritoneal cytology developed peritonitis carcinomatosa. It was concluded that it is very important to obtain peritoneal cytology routinely at the time of laparotomy in patients with carcinoma of the cervix.

[Gliomatosis peritonei]

Gliomatosis peritonei, the miliary implants of mature glial tissues on the peritoneum or omentum, is a rare complication of solid ovarian teratoma. Our case is reported and 38 previously reported cases are reviewed. The grade of the primary tumors varied from grade 0 to grade 3. Only five cases were composed entirely of mature tissues. Five of the 39 patients died. Despite of varied therapy, the rest of the patients were alive from 3 months to 38 years later. Inspite of intraperitoneal implants, the prognosis in patients with these tumors is good, irrespective of the mode of therapy. On the basis of this study, we recommended a conservative therapy for the primary tumor and therapy for the implants is not required.

[Treatment of epithelial ovarian carcinoma with cisplatin and adriamycin: analysis of factors influencing prognosis in advanced cases]

Thirty previously untreated patients with epithelial ovarian carcinoma were treated with cisplatin and adriamycin (PA). Of eight evaluable patients, six were responders (two CRs and four PRs). The three-year survival rates were 83% for stage I, 67% for stage II, 50% for stage III, and none for stage IV. Toxicities included moderate myelo-suppression, mild nephrotoxicity, alopecia, and severe vomiting in almost all patients. Patients with residual lesions smaller than 2 cm had excellent prognosis when PA was given for more than five courses. Patients with residual lesions larger than 2 cm, however, had poor prognosis irrespective of the number of courses. No specific relation between histological grade and prognosis could be found. From the present data, aggressive cytoreductive surgery followed by PA therapy repeated more than five times is recommended for achieving a good outcome in the treatment of epithelial ovarian carcinoma.

Modified VAB-3 combination chemotherapy of advanced and recurrent endodermal sinus tumors of the ovary

Three patients with advanced and recurrent endodermal sinus tumor (EST) of the ovary were treated with modified vinblastine, actinomycin-D, and bleomycin (VAB-3) regimen. Serum alpha-fetoprotein (AFP) levels were monitored for all patients during and after therapy. In all patients a clinical response was achieved. In one stage IV patient with huge multiple liver metastases complete response was attained and she is free of disease following secondlook larparotomy. In other two patients, one stage IV and another recurrent, with large liver metastases, partial responses were achieved with normalization of serum AFP. Serum AFP monitoring is valuable for the management of EST, but a negative AFP titer does not eliminate the possibility of persistent or recurrent disease. The VAB-3 combination, previously found effective in metastatic nonseminomatous testicular cancer, is also effective in advanced and recurrent EST of the ovary.

Endolymphatic stromal myosis: a case with positive estrogen and progesterone receptors and good response to progestins

This report describes a case of recurrent and metastatic endolymphatic stromal myosis (ESM), which showed good response to progestin therapy. Metastatic lung nodules regressed after medroxyprogesterone acetate (MPA) treatment, recurred while MPA was stopped, and disappeared again when MPA was restarted. The levels of estrogen and progesterone receptors measured in the resected tumor amounted to 79.5 and 310 fmole/mg protein, respectively. Sex steroid hormone dependency of ESM was reviewed in the literature.

[Modified VAB-3 combination chemotherapy of stage IV endodermal sinus tumor of the ovary]

A case of pure endodermal sinus tumor (EST) of the ovary with huge multiple liver metastases was treated with modified VAB-3 protocol. Serum alpha-fetoprotein (AFP) before treatment was 137,775 ng/ml. A complete clinical response was achieved with rapid shrinkage of liver metastases and normalization of serum AFP. Second-look laparotomy preformed 17 months after the start of chemotherapy revealed no evidence of disease. VAB-3 combination chemotherapy, which was proved to be very effective in the treatment of metastatic testicular cancer, also seems to be effective in the treatment of advanced EST of the ovary. This is believed to be the first detailed report of the successful management of advanced EST of the ovary.

Cyclophosphamide-induced interstitial pneumonitis in a patient with ovarian carcinoma

A 40-year-old female with ovarian cancer being treated with daily oral cyclophosphamide developed fatal interstitial pneumonitis. Autopsy did not show any evidence of ovarian cancer. The review of the literature revealed eight reported cases of cyclophosphamide-induced interstitial pneumonitis and fibrosis. The case is reported to alert gynecologists to this rare but lethal complication of cyclophosphamide.