Surgical stapling technique for radical hysterectomy

We developed a new technique for performing radical hysterectomy using surgical staplers. An endoscopic stapler was used to transect the uterosacral and cardinal ligaments and a roticulating stapler with absorbable staples was used to transect the vaginal cuff. Fifteen consecutive patients with primary stage IA2 or IB cervical carcinoma underwent class III radical hysterectomy using the new stapling technique and were compared to the previous 15 consecutive similarly staged patients who underwent class III radical hysterectomy by the traditional clamp, cut, and suture ligation technique. Median operative time for the stapler group was 3 hr (1.3-4 hr) versus 4.3 hr (2.5-5.8 hr) for the traditional technique (P = 0.0002). Estimated blood loss for the stapler technique was 650 ml (200-1200 ml) versus 1100 ml (450-2600 ml) for the traditional technique (P = 0.009). Three patients (20%) received transfusions in the stapler group versus 10 (67%) in the traditional group (P = 0.05). There was no difference in the rate of infections, venous thrombosis, lymphocysts, fistuli, bladder atony, or obstipation between the two groups. At a median follow up of 22 months, only one patient has recurred (from the traditional group). In conclusion, the surgical stapling technique of radical hysterectomy does not appear to adversely affect survival or increase complications while operative blood loss and operative time are significantly reduced.

Postthaw viability of frozen human ovarian cancer tumor specimens

Thirty-five human ovarian cancer tumor specimens were frozen by both rapid freeze and slow freeze with dimethyl sulfoxide (DMSO) to determine which method results in optimal postthaw viability. Median viability following a rapid freeze was 8% as compared to 90% with slow freeze with DMSO (P = .0001). Eighty-seven percent of tumors had a viability of > 80% following slow freeze with DMSO. When experimentation on human ovarian cancer tumor cells requires postthaw viability, we recommend slow freeze with DMSO.

Carbon dioxide laser vaporization of intestinal metastases of epithelial ovarian cancer

Purpose To determine the efficacy and morbidity of carbon dioxide laser vaporization of intestinal metastases of epithelial ovarian cancer. Patients and methods Following maximum surgical cytoreduction, 20 patients were treated with laser vaporization of serosal and mesenteric metastases with a carbon dioxide hand-held laser at a median wattage of 25 watts using a super-pulse mode. The maximum diameter of intestinal metastases ranged from 1 mm to 2 cm and the number ranged from 1 to> 100 implants. These patients were compared with 20 matched controls. Results Median laser time was 7 min and no patient experienced bleeding> 15 ml. Eighteen patients (90%) had no gross residual disease following laser vaporization compared to five (25%) of the controls (P = 0.0001). Nineteen patients (95%) had no gross intestinal residual disease following laser vaporization compared to eight (40%) of the controls (P = 0.01). There was no difference in the incidence of postoperative ileus, wound infection or febrile morbidity between the groups. No patient in either group developed bowel obstruction, perforation, fistula, peritonitis or abscess. Conclusion Carbon dioxide laser vaporization of intestinal metastases of epithelial ovarian cancer represents intensive cytoreduction which results in superior debulking and does not appear to increase postoperative morbidity.

Carboplatin, etoposide, and ifosfamide as second-line treatment for ovarian cancer

A total of 25 patients with epithelial ovarian cancer were treated with second-line carboplatin, etoposide, and ifosfamide (ICE) following failure of first-line cisplatin-based combination chemotherapy. The combination carboplatin 35 mg/m2, etoposide 50 mg/m2, and ifosfamide 1,200 mg/m2 was administered intravenously daily for 3 consecutive days. Response was seen in 13 patients (52%) with 7 complete responses (28%) and 6 partial responses (24%). Median duration of response was 9+ months (range: 4-17+ months). Response rate to second-line ICE relates directly to prior response to first-line cisplatin-based chemotherapy: 12 patients (67%) responded to second-line ICE who responded to first-line cisplatin-based chemotherapy, while only 1 patient (14%) responded who progressed on first-line cisplatin-based chemotherapy. Median survival was 18+ months (range: 2-31+ months). There were six episodes (4%) of grade 4 neutropenia, seven episodes (4%) of grade 4 thrombocytopenia and no grade 3 or 4 nonhematologic toxicity. ICE has moderate activity with minimal toxicity as second-line treatment of advanced epithelial ovarian cancer.

Particle concentration fluorescence immunoassay chemosensitivity assay for human epithelial ovarian cancer

We adapted particle concentration fluorescence immunoassay technology to develop a new chemosensitivity assay. Six human epithelial ovarian cancer cell lines were incubated with cisplatin for 24 hours. Cells were then labeled with a fluorophore for 30 minutes. Removal of supernatant, washing of tumor cells, and reading of epifluorescence was performed automatically. Percent cell lysis was calculated simultaneously by chromium release assay. The particle concentration fluorescence chemosensitivity assay detected cell lysis in all six cell lines. The chemosensitivity assay detected a larger percent lysis than the chromium release assay in each of the cell lines. The advantages of our chemosensitivity assay are plating efficacy, speed, efficiency, safety, and accuracy.

Ondansetron and metoclopramide fail to prevent vomiting secondary to ultra-high-dose cisplatin-carboplatin chemotherapy

OBJECTIVE

To determine the severity of emesis caused by ultra-high-dose cisplatin-carboplatin chemotherapy and to compare the antiemetic efficacy of an ondansetron regimen and a metoclopramide regimen.

METHODS

Forty consecutive patients with stage III or IV epithelial ovarian cancer or advanced or recurrent endometrial cancer were treated with ultra-high-dose cisplatin-carboplatin chemotherapy. No patient had received prior chemotherapy. Chemotherapy consisted of intravenous (IV) cisplatin 70 mg/m2 and IV carboplatin 100 mg/m2 administered on days 1 and 8 every 28 days for five cycles, representing a total monthly organoplatin dose of 207 mg/m2. Patients were randomized to receive metoclopramide, diphenhydramine, prochlorperazine, and lorazepam; or ondansetron, dexamethasone, prochlorperazine, and lorazepam. Patients were blinded and there was no crossover. The metoclopramide dose was 2 mg/kg IV every 2 hours x 3, and the ondansetron dose was 0.15 mg/kg IV every 4 hours x 3.

RESULTS

All 40 patients developed vomiting; 21 (52%) developed severe vomiting and seven (17%) required home IV therapy (grade 4). Eight patients (40%) receiving the metoclopramide regimen developed severe vomiting, compared to 13 (65%) in the ondansetron group (P = .50). Two patients (10%) in the metoclopramide group developed grade 4 vomiting, compared to five (25%) in the ondansetron group (P = .45). Except for sedation and amnesia, there were no significant side effects associated with either regimen.

CONCLUSION

Neither regimen was effective in preventing high-dose cisplatin-carboplatin-induced emesis, and the ondansetron regimen did not appear to be superior.

False-positive malignant peritoneal cytology associated with pelvic endometriosis

The peritoneal washings obtained at diagnostic laparoscopy of two women with suspected endometriosis contained cells with cytologic features of adenocarcinoma. Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and pelvic washings confirmed endometriosis with no evidence of cancer. At 1.5-year and 4.0-year follow-up, respectively, cancer had not developed in either patient. The authors report what they were able to find in the literature regarding false-positive assessments of malignancy obtained by cytologic examination. They also outline steps to be taken should a diagnosis of malignancy arise in a woman with endometriosis who desires pregnancy.

False-positive malignant peritoneal cytology associated with pelvic endometriosis

The peritoneal washings obtained at diagnostic laparoscopy of two women with suspected endometriosis contained cells with cytologic features of adenocarcinoma. Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and pelvic washings confirmed endometriosis with no evidence of cancer. At 1.5-year and 4.0-year follow-up, respectively, cancer had not developed in either patient. The authors report what they were able to find in the literature regarding false-positive assessments of malignancy obtained by cytologic examination. They also outline steps to be taken should a diagnosis of malignancy arise in a woman with endometriosis who desires pregnancy.

Multiple spontaneous coronary artery dissections in a middle aged woman: support for an underlying eosinophilic arteritis predisposing to intimal disruption

A 43-year-old female received tissue plasminogen activator for an acute antero-apical myocardial infarction. Cardiac catheterization demonstrated three focal dissections involving the left anterior descending and circumflex arteries. She expired unexpectantly after undergoing emergency coronary artery bypass grafting for therapy of an extension of her infarct. To our knowledge, this is the fourth report of multiple spontaneous coronary artery dissections and the second in which tissue plasminogen activator was administered. The histologic findings and their implications are reviewed.

High-dose cisplatin carboplatin chemotherapy in primary advanced epithelial ovarian cancer

The purpose of the study was to maximize platinum dose intensity in women with ovarian cancer by combining cisplatin and carboplatin and using Day 1 and 8 scheduling. Thirty-two consecutive patients with primary stage 3 or 4 epithelial ovarian cancer underwent radical cytoreductive surgery followed by high-dose cisplatin carboplatin chemotherapy. Twenty-eight tumors (88%) were stage 3C or 4 and 20 (62%) were grade 3. Following radical cytoreductive surgery, 21 patients (66%) had less than 5 mm of residual disease. The first 2 patients treated with 75 mg/m2 cisplatin and 150 mg/m2 carboplatin on Days 1 and 8 every 28 days for 5 cycles developed severe and prolonged thrombocytopenia. As a result, the dose was reduced to 70 mg/m2 cisplatin and 100 mg/m2 carboplatin for the remaining 30 patients, representing a monthly platinum dose of 207 mg/m2. Projected platinum dose intensity was 700 mg/m2 cisplatin and 1000 mg/m2 carboplatin delivered over 16 weeks. Eleven patients (44%) received 100% and 27 patients (84%) received > 90% projected platinum dose intensity. Median projected platinum dose intensity received was 97%. Grade 4 thrombocytopenia occurred in 43 cycles (28%) and grade 3 peripheral neuropathy occurred in 15 patients (47%). Central nervous system toxicity occurred frequently: ototoxicity, 66%; decreased taste, 50%; optic toxicity, 41%; memory loss, 34%. Twenty-seven patients (84%) had a clinical complete response and 7 patients (44%) undergoing second-look laparotomy had a pathologic complete response. The majority of clinical responses were based on CA-125. Median survival has not been reached at 2.1 years. Median progression-free survival is 1.4 years. Combining cisplatin and carboplatin using Day 1 and 8 scheduling allows maximum hematologic platinum dose intensity; however, peripheral neuropathy is prohibitive. Day 1 and 8 scheduling does not appear to prevent peripheral neuropathy when delivering dose-intense platinum chemotherapy. Central nervous system toxicity of high-dose platinum is more common than previously reported.

High-dose-rate brachytherapy in primary stage I and II vaginal cancer

Thirteen patients with primary vaginal cancer were treated with external beam irradiation and high-dose-rate brachytherapy. Median age was 65 years old. Five tumors were stage I, 4 stage IIA, and 4 stage IIB. Twelve tumors were squamous and 11 were moderately or poorly differentiated. Median tumor diameter was 4 cm. Patients were treated with external beam irradiation (4500 cGy) and high-dose-rate brachytherapy (2000-2800 cGy in three to four fractions). All 13 patients had a complete response. Local control was achieved in 12 patients (92%) at a median follow-up of 2.6 years. No acute or chronic intestinal or bladder grade 3 or 4 toxicity was observed. Moderate to severe vaginal stenosis occurred in 6 patients (46%). Treatment of stage I and II primary vaginal cancer with external beam irradiation and high-dose-rate brachytherapy appears to produce a high response rate, local control, and survival with minimal complications.

In-111 CYT-103 immunoscintigraphy in the imaging of ovarian carcinoma

Fifteen presurgical patients with a history of ovarian carcinoma were evaluated with immunoscintigraphy using the In-111-labeled monoclonal antibody conjugate CYT-103. Twelve of these patients had residual neoplasia at time of laparotomy. A single intravenous dose of the radiolabeled monoclonal antibody was given to these patients before restaging laparotomy. All patients also underwent CT scanning of the abdomen and pelvis before laparotomy. Immunoscintigraphy detected the presence of disease in 10 of 12 patients before surgery, whereas CT scanning detected disease in only 6 of these 12 women. The results of this study indicate that immunoscintigraphy using In-111 CYT-103 is more sensitive than CT and may add useful information to the preoperative evaluation of women with ovarian carcinoma.

Monoclonal antibodies in ovarian and prostate cancer

Radioimmunoscintigraphy (RIS)--using radiolabeled monoclonal antibodies (MoAbs) to image disease--is a growing subspecialty of nuclear medicine. RIS of the reproductive tracts of men and women has shown encouraging results in imaging both primary lesions and metastases of these cancers. Ovarian cancer is the most fatal gynecologic cancer in the United States, and prostate cancer is the most prevalent form of cancer in men. Several MoAbs against reproductive tumor antigens were used with limited success in clinical trials before 1989. Most recently, MoAbs CYT-103 (satumomab pendetide) and OV-TL 3 have shown promise as safe, sensitive imaging tools for ovarian cancer. Although to date more agents have been used to image ovarian carcinoma than prostate cancer, research has been restimulated in prostate carcinoma imaging because of development of a promising MoAb conjugate, CYT-356. Radionuclide indium-111 appears to be the most promising radiolabeled to date for ovarian and prostate carcinoma RIS performed in the United States. In future clinical trials, consideration of safety issues and a standardization of methods among institutions using RIS are needed before the use of MoAb technology in cancer imaging will become routine. Comparative studies with more traditional methods like computed tomography are needed, as well as more trials comparing radioimmunoscintigraphic findings with pathological evidence.

Meta-analysis of cisplatin, doxorubicin, and cyclophosphamide versus cisplatin and cyclophosphamide chemotherapy of ovarian carcinoma

OBJECTIVE

To compare the survival with cisplatin, doxorubicin (Adriamycin), and cyclophosphamide versus that of cisplatin and cyclophosphamide in women with advanced epithelial ovarian cancer, to evaluate the effect of dose intensity, and to evaluate meta-analysis methodology.

METHODS

Meta-analysis was done on 30 studies of 2060 women with stages III and IV epithelial ovarian cancer. All had 3-year survival data, adequate follow-up, no other chemotherapy, no radiation therapy, and had information for various prognostic variables (age, stage, grade, and residual disease). We used four different methods of meta-analysis: pooled published data and modified effect-size analyses of the entire group (30 studies), and pooled published data and effect-size analyses of the subset of five prospective randomized studies.

RESULTS

Three-year survival for the entire group was 43% for cisplatin, doxorubicin, and cyclophosphamide versus 36% for cisplatin and cyclophosphamide; for the five prospective randomized studies, the rates were 46 and 35%, respectively. The survival advantage of cisplatin, doxorubicin, and cyclophosphamide was statistically significant when analyzed by the pooled published data and modified effect-size meta-analysis of the entire group and the pooled published data meta-analysis of the five prospective randomized studies. The effect-size meta-analysis of the five prospective studies did not reach statistical significance. Total dose intensity and doxorubicin dose intensity were not significantly associated with survival advantage in cisplatin, doxorubicin, and cyclophosphamide use.

CONCLUSIONS

There seems to be a survival advantage to treatment with cisplatin, doxorubicin, and cyclophosphamide versus treatment with cisplatin and cyclophosphamide. We believe this to be due to the properties of multiagent chemotherapy (the addition of doxorubicin) rather than to increased dose intensity. In addition, we believe that physicians need to familiarize themselves with meta-analysis methodology.

Laser vaporization conization

Laser vaporization conization is a modified technique for the diagnosis and treatment of cervical intraepithelial neoplasia. Two circles are marked on the cervix with the laser; the inner circle outlines the circumference of the conization specimen, while the outer one outlines an area 3 mm peripheral to all colposcopically abnormal tissue. The area between the circles is vaporized to 7 mm. This initial vaporization allows easier manipulation of the conization specimen. Laser conization is then performed. This technique is significantly easier to perform than laser excisional conization or combination excisional-vaporization conization and thus is ideal for teaching residents laser conization. Besides ease of performance, laser vaporization conization retains the advantages of laser vaporization and provides a specimen for pathologic review. In this study the median laser time was 14 minutes. There was minimal operative hemorrhaging, and only one patient (2%) developed a secondary cervical hemorrhage. A significant laser artifact was present in one case (2%). One case of invasive squamous cell cancer was diagnosed.

Cervical implantation metastasis by endometrial adenocarcinoma

A distinct type of cervical involvement by endometrial cancer is reported and termed cervical implantation metastasis. It is believed to result from implantation of endometrial cancer on the denuded endocervix after fractional dilatation and curettage (D & C). The histologic criteria for diagnosis are: (1) the cervical implantation metastasis must be imbedded in the endocervical epithelium or superficial stroma surrounded by an implantation site of inflammatory cells and granulation tissue (free-floating cancer cells above the cervical mucosa are not acceptable as implantation tissue), (2) the histologic findings of the cervical implantation metastasis must be similar to those of the endometrial adenocarcinoma in the uterine corpus, (3) the cervical implantation metastasis must be separate from the primary tumor with no evidence of direct extension, and (4) the cervical implantation metastasis should be surrounded by nonneoplastic endocervical glands with no transition between the two. Of the 176 patients who underwent fractional D & C before hysterectomy, nine (5%) were found to have cervical implantation metastasis. No patients had cervical implantation metastasis who did not undergo fractional D & C before hysterectomy. When stratified according to stage, grade, and myometrial invasion, there was no statistically significant difference in the recurrence rate between patients with or without cervical implantation metastasis. It appears that cervical implantation metastasis does not alter prognosis or require specific treatment.

Five-year survival for cisplatin-based chemotherapy versus single-agent melphalan in patients with advanced ovarian cancer and optimal debulking surgery

The purpose of this study was to evaluate 5-year survival and 5-year progression-free survival in previously untreated patients with advanced ovarian cancer treated with single-agent melphalan in which very few patients underwent optimal debulking surgery (less than 2 cm residual) as compared with the patients treated with Cisplatin-based chemotherapy in which most patients underwent optimal debulking surgery. Significant increases in 5-year survival and 5-year progression-free survival were noted as we changed from the melphalan trial, in which only 14% underwent optimal debulking surgery, to PAC-H, in which 57% and the PAC trial in which 90%, respectively, underwent optimal debulking surgery. However, for those patients whose tumors were optimally debulked in the three trials, there were no statistically significant differences in median survival, median progression-free survival, 5-year survival, or 5-year progression-free survival in those patients treated with melphalan, PAC-H, or PAC. Without optimal debulking surgery, Cisplatin-based multiagent chemotherapy offered a small survival advantage. These results are similar to that reported by Gruppo Interregionale Cooperativo Oncologico Ginecologia, in which survival curves were identical for all the subgroups of chemotherapy regimens for those patients with residual disease less than 2 cm at the onset of chemotherapy whether they received (1) cyclophosphamide; (2) cyclophosphamide and Adriamycin; (3) cyclophosphamide, Adriamycin, and Cisplatin; (4) cyclophosphamide, Adriamycin, and hexamethylmelamine; (5) Cisplatin and cyclophosphamide; (6) low-dose Cisplatin; (7) high-dose Cisplatin; or (8) carboplatin.

Phase II trial of cisplatin, adriamycin, and etoposide for metastatic endometrial adenocarcinoma

Twenty patients with metastatic or recurrent endometrial adenocarcinoma not amenable to surgery or radiation were treated with monthly cisplatin (20 mg/m2 x 3), etoposide (75 mg/m2 x 3), Adriamycin (40 mg/m2) (PAV) and Megace. Patient characteristics were as follows: grade 3 differentiation, 55%; papillary subtype, 15%; prior radiotherapy, 70%; prior chemotherapy, 10%; and prior hormonal therapy, 20%. Hematologic toxicity was significant but acceptable: WBC nadirs, 50%; platelet nadirs, 40%. There was no hematologic mortality. There was a 75% objective response rate and a 55% complete response rate with PAV. The median survival was 15+ months, the 2-year survival was 42%, and the 2-year progression-free survival was 20%. PAV appears to be an active combination with acceptable toxicity in the treatment of metastatic or recurrent endometrial cancer, and we believe that phase III evaluation is indicated.

Development of lung metastases after curative intraperitoneal chemotherapy in a rat colon cancer model

A model of colon peritoneal carcinomatosis was developed by injecting 5 x 10(7) viable tumor cells intraperitoneally into Fisher 344 rats. All 40 control rats developed bulky abdominal tumor with ascites and died of peritoneal carcinomatosis and bowel obstruction (median survival 5 weeks). One day after tumor implantation, treatment group rats received a single intraperitoneal injection of single agent or combination chemotherapy. The most active intraperitoneal single agents were 5-fluorouracil, cisplatin, and etoposide. The most active combination was 5-fluorouracil and cisplatin. Combination chemotherapy produced a significant increase in median, 10-week, and 20-week survival (vs control and single agent). Six of 11 (55%) rats treated with intraperitoneal combination chemotherapy dying between 10-20 weeks died of lung metastasis with cure of intraperitoneal tumor. The increased ability of intraperitoneal combination chemotherapy to cure intraperitoneal disease was offset by the development of lung metastasis.