Fatal recurrent reexpansion pulmonary edema

A case is reported of fatal recurrent unilateral reexpansion pulmonary edema following thoracentesis in a woman with stage IV ovarian adenocarcinoma. Reexpansion pulmonary edema is a rare complication resulting from reexpansion of a collapsed lung after treatment of pleural effusion, pneumothorax, or atelectasis. The etiology is unknown, and there are no guaranteed measures of prevention. The clinical presentation varies from asymptomatic to rapidly progressive fatal pulmonary edema. The diagnosis is established by chest x-ray. Depending on the severity of the clinical symptoms, treatment varies from monitoring with serial chest x-rays to mechanical ventilation. Reexpansion pulmonary edema is fatal in 20% of cases. Gynecologists should be aware of this rare entity because it may require immediate diagnosis and aggressive treatment.

Photodynamic therapy in gynecologic malignancies

Twenty-one patients with recurrent gynecologic malignancies were treated with photodynamic therapy using Photofrin II and argon dye laser. Seven of twenty-one patients with cutaneous lesions treated palliatively had a complete response and four of eleven patients with cervical and vaginal recurrences had an objective response to phototherapy. Two of the patients with complete response continued to be free of disease after 28 and 36 months of follow-up.

Patient-controlled analgesia in gynecologic oncology. A comparative analysis

Patient-controlled analgesia (PCA) allows postoperative gynecologic oncology patients to self-administer intravenous analgesia but has not been well compared to standard intramuscular analgesia. Seventy patients undergoing laparotomy were treated with meperidine via PCA or intramuscular administration and evaluated 24 and 48 hours postoperatively. The 35 patients receiving PCA used statistically significantly less meperidine than did the controls at 24 and 48 hours postoperatively. The pharmacy's cost of the drug was statistically significantly less for PCA patients. PCA meperidine was well tolerated, with minimal alterations in consciousness and infrequent nausea.

Alternating methotrexate and dactinomycin in nonmetastatic gestational trophoblastic disease

Alternating 5-day chemotherapy with methotrexate and dactinomycin as primary therapy for nonmetastatic gestational trophoblastic disease was studied in nine patients. The complete response rate was 100% with follow-up of a median of 80 months. Stomatitis was universal but rarely prevented oral alimentation or delayed therapy. Overall, 94% of toxicity was mild or moderate in severity and all toxicity was reversible. This alternating non-cross resistant regimen, reported in a total of 40 patients in the literature, is the only regimen to result in a 100% response rate. This response rate is statistically improved when compared to historical controls receiving methotrexate/folinic acid or pulse dactinomycin. No patients required hysterectomy for disease control. Cooperative prospective phase III studies are needed to determine the efficacy and toxicity of current regimens.

Weekly cisplatin induction chemotherapy in the treatment of recurrent cervical carcinoma

Sixty-nine patients with recurrent cervical carcinoma were treated with weekly cisplatin induction chemotherapy. A 27% objective response was obtained in 67 evaluable patients. The highest responses were seen in liver (33%), supraclavicular nodes (40%), and lung (48%), whereas only one out of 24 (4.2%) patients with central recurrence responded. Consolidation therapy with cisplatin combinations administered on a monthly basis did not enhance response to cisplatin. Cisplatin induction therapy was well tolerated with minimal toxicity.

Patterns of metastasis in uterine sarcoma. An autopsy study

The autopsy findings of 73 patients with uterine sarcoma were studied to determine the sites and possible modes of metastasis. Homologous mixed mesodermal tumors were the most frequent (41%) followed by leiomyosarcoma (26%), heterologous mixed mesodermal tumor (18.3%), stromal sarcoma (12%), and endolymphatic stromal myosis (3%). The peritoneal cavity and omentum were the most frequently involved sites (59%), followed by the lung (52%), pelvic lymph nodes (41%), paraaortic lymph nodes (38%), and liver parenchyma (34%). The presence of lung metastasis was not associated with pelvic or paraaortic node metastasis or intraperitoneal disease. Metastasis to other distant sites including the brain, heart, kidney, and bone were independent of pelvic and paraaortic nodal metastasis or intraperitoneal disease. Metastatic sites were not different among various histologic types. Distant metastatic sites were statistically associated with lung metastasis. Hematogenous metastasis best explains this metastatic pattern and adjuvant systemic therapy seems indicated.

Patterns of metastasis in uterine sarcoma. An autopsy study

The autopsy findings of 73 patients with uterine sarcoma were studied to determine the sites and possible modes of metastasis. Homologous mixed mesodermal tumors were the most frequent (41%) followed by leiomyosarcoma (26%), heterologous mixed mesodermal tumor (18.3%), stromal sarcoma (12%), and endolymphatic stromal myosis (3%). The peritoneal cavity and omentum were the most frequently involved sites (59%), followed by the lung (52%), pelvic lymph nodes (41%), paraaortic lymph nodes (38%), and liver parenchyma (34%). The presence of lung metastasis was not associated with pelvic or paraaortic node metastasis or intraperitoneal disease. Metastasis to other distant sites including the brain, heart, kidney, and bone were independent of pelvic and paraaortic nodal metastasis or intraperitoneal disease. Metastatic sites were not different among various histologic types. Distant metastatic sites were statistically associated with lung metastasis. Hematogenous metastasis best explains this metastatic pattern and adjuvant systemic therapy seems indicated.

Synthesis and release of glycoconjugates bearing N-linked oligosaccharides by ovarian carcinoma cells isolated from effusions

Ovarian carcinoma cell clusters were isolated from patient effusions. The cell isolates were incubated in vitro with radioactive glycoconjugate precursors. Radiolabelled glycoconjugates released to culture media were analyzed for molecular mass heterogeneity and lectin binding activity. From 10 to 50% of the released glycoconjugates were present as a heterogeneous array of glycoconjugates of molecular mass greater than 250 kilodaltons. The remaining glycoconjugates were dispersed in a molecular mass range extending down to approximately 15 kilodaltons. Concanavalin A-Sepharose affinity chromatography revealed the presence of N-linked oligosaccharides. Interaction of glycoconjugates with lentil and pea lectins indicated the presence of L-fucose residues linked to asparagine-bound N-acetylglucosamine. Precipitation of glycoconjugates with ricinus communis agglutinin I showed the presence of nonreducing terminal N-acetyllactosamine residues. Collectively, the data indicate that ovarian carcinoma cells release to culture medium fucosylated glycoconjugates bearing complex-type oligosaccharides. The synthesis and release of these glycoconjugates showed no significant differences among different histologic types of ovarian carcinoma; however, modulation as a function of tumor progression may occur.

Surgically documented response to intraperitoneal cisplatin, cytarabine, and bleomycin after intravenous cisplatin-based chemotherapy in advanced ovarian adenocarcinoma

Thirty-one evaluable patients with stages III and IV invasive ovarian adenocarcinoma were treated on a phase II protocol of second-line intraperitoneal cisplatin, cytarabine, and bleomycin. All 31 patients received first-line intravenous (IV) cisplatin-based chemotherapy; the size of the residual cancer was documented surgically before intraperitoneal chemotherapy in all patients. Response to intraperitoneal chemotherapy was documented by a third-look laparotomy in all patients not evidencing progression of disease clinically. There were eight responses (26%): five surgical complete responses and three surgical partial responses. Responders were patients with stage III ovarian cancer, small residual disease of less than or equal to 1 cm (primarily less than or equal to 5 mm), and patients who previously had responded to cisplatin-based IV chemotherapy. Of the 15 patients with stage III ovarian cancer, residual disease less than or equal to 1 cm, and those who had responded to first-line IV cisplatin-based chemotherapy, 53% (eight) responded to second-line intraperitoneal chemotherapy. Intraperitoneal chemotherapy as used in this phase II protocol would appear to be an effective second-line treatment in advanced ovarian cancer in this specific subset of patients.

Peritoneal papillary carcinoma

Between 1977 and 1986, 325 patients with a diagnosis of ovarian carcinoma, peritoneal cancer, or malignant mesothelioma were reviewed with identification of 23 patients (7%) having peritoneal papillary cancer. Only 2 patients had disease confined to the pelvis and the rest had widespread abdominal disease. Various combination chemotherapeutic agents were used with over a 65% response rate to first-line chemotherapy. Twenty of the 23 patients received cisplatin combination chemotherapy with an overall response rate of 65%.

Five and ten year estimated survival and disease-free rates after intraperitoneal chromic phosphate; stage I ovarian adenocarcinoma

From 1975 to 1982, 25 evaluable patients with FIGO Stage I ovarian cancer were treated with intraperitoneal chromic phosphate (32P). All patients underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy with (28%) or without (72%) omentectomy, with no other surgical staging procedures prior to referral. Patients were restaged by laparoscopy (inspection of diaphragms, abdomen, and pelvis), biopsy of suspicious lesions, and peritoneal cytologic washings prior to intraperitoneal chromic phosphate therapy. For the 25 patients, the estimated 5- and 10-year recurrence-free rates and the 5- and 10-year survival rates are 84% and 75%, respectively. Excellent 10-year recurrence-free rates were achieved for Stages IA and IC, nonruptured cysts, and Grade I and II tumors. In contrast, very low 10-year survival rates were achieved for patients with Stage IB, ruptured cysts, or Grade III tumors.

Effect of adjuvant chemotherapy on time to recurrence and survival of stage I uterine sarcomas

We have evaluated the effect of adjuvant chemotherapy on time to recurrence and survival in two prospective trials of women with stage I uterine sarcomas. The first trial compared surgery only to surgery plus Adriamycin. The 5-year estimated survival rate was 36% for surgery alone and 63% for surgery plus Adriamycin. The 5-year recurrence free rate for surgery alone was 46% as compared to 75% for surgery plus Adriamycin. The second trial, without a concurrent control group, included patients with stage I uterine sarcoma and adjuvant cyclaphosphamide, vincristine, Adriamycin, and dacarbazine (CYVADIC) chemotherapy. The 5-year survival rate was 89% and the recurrence-free rate was 80%. In all of these trials, as well as in the report of Van Nagell et al (Cancer 57:1451-1454, 1986) of adjuvant vincristine, actinomycin-D, and cyclophosphamide (VAC) chemotherapy, there are too few patients to make any formal statistical comparison of the groups, although the surgery plus CYVADIC group appears to be the most promising.

Conservative therapy for melanoma of the vulva

Recent cooperative studies have demonstrated that less radical local resection of cutaneous melanomas is equally effective as a traditional radical approach. A retrospective review of vulvar melanoma was undertaken to determine if mode of therapy affected recurrence. Survival correlated independently with depth of invasion and age (p = 0.05 and p less than 0.02, respectively). In the comparison of radical vulvectomy with local excision, no patient differences in age or histopathologic variables were determined (nodal disease status, histology, mitotic count, lymphocytic infiltration, or ulceration). Radical vulvectomy did not improve survival over local therapy (p greater than 0.2). Six of eight patients whose melanoma had less than 2 mm of invasion treated with local therapy are disease free after a median of 127 months (range 6 to 300 months). For local excision, recurrences were more frequent when margins were less than 2 cm, but this was not statistically significant in this small sample. Although the current series is small and retrospective, its findings suggest that treatment recommendations of large cutaneous nonvulvar melanoma studies are applicable to vulvar melanoma. A prospective randomized study of radical versus conservative surgery for vulvar melanoma will be necessary to confirm these treatment recommendations.

The impact of aggressive debulking surgery and cisplatin-based chemotherapy on progression-free survival in stage III and IV ovarian carcinoma

Forty consecutive patients with stage III and IV invasive ovarian carcinoma were treated on a phase II protocol consisting of optimal debulking surgery, induction cisplatin, cisplatin, doxorubicin, and cyclophosphamide (PAC) chemotherapy, 6-month interval laparoscopy, reinduction cisplatin, PAC chemotherapy, and second-look procedure. All 40 patients have either disease progression or have completed the 12-month protocol. Eighty-seven percent of the patients (35) underwent optimal (less than or equal to 2 cm residual) debulking surgery before chemotherapy, in spite of the fact that 50% (20) were referred to Roswell Park Memorial Institute (RPMI) as inoperable after initial surgery elsewhere. There were no postoperative deaths and chemotherapy was started in less than or equal to 14 days in 97% of the patients. Of the 40 patients, 30% (12) achieved a pathologic complete remission (11) or a clinical complete remission (one patient refused second-look surgery). The estimated 3-year survival rate was 62%, but the 3-year progression-free survival rate was only 29%. The median survival time was 48 months. The estimated 3-year progression-free survival rate was 31% for residual disease less than or equal to 2 cm. For the five patients with residual disease greater than 2 cm, four died within 3 years. The median survival time of patients with less than or equal to 2 cm residual disease was 48 months, as compared with 21 months for those with greater than 2 cm residual disease. Although the estimated 3-year survival rate of 62% is noteworthy, the 3-year progression-free survival rate of only 29% is probably indicative that in spite of extensive debulking surgery and cisplatin-based chemotherapy as used in this protocol, the long range proportion of patients "cured" will remain small.

Long-term follow-up and complications of infants with vulvovaginal embryonal rhabdomyosarcoma treated with surgery, radiation therapy, and chemotherapy

The long-term follow-up is presented of three infants with vulvovaginal rhabdomyosarcoma treated at 10, 11, and 15 months of age by radical surgery, pelvic radiation therapy, and chemotherapy. Two patients developed colonic stricture requiring operative repair. One of these two patients also has urinary incontinence secondary to severe bladder contraction. Pelvic radiation did not significantly affect stature. Lateral transposition of the ovaries at the time of surgery preserved endocrine function in one patient with a normal puberty. The other two patients developed normal secondary sexual characteristics with hormonal replacement therapy. These patients perform well academically and socially. They have adapted 14, 14, and 16.5 years after their therapy.

Serum alpha 1-acid glycoprotein in epithelial ovarian cancer

Fifty-six patients with ovarian adenocarcinoma receiving chemotherapy were monitored with serum alpha 1-acid glycoprotein (AGP) levels. The mean and standard deviation of serum AGP levels for 63 healthy controls were 0.88 +/- 0.469 mg/ml. A serum level above 1.80 mg/ml was considered as above normal level. Five patients had evidence of persistent ovarian carcinoma and had elevated AGP levels. Sixteen patients had normal serum AGP levels and had no evidence of persistent ovarian cancer at second-look laparotomy. However, 35 patients had false-negative AGP levels at the time they had persistent tumor. Although the specificity of the AGP level was 100%, the sensitivity was only 12.5% and the overall accuracy 37%. Therefore, it would appear that serum AGP levels are not of value in monitoring patients with ovarian adenocarcinoma.

Stage I uterine adenosarcoma: a report of six cases

Six cases of Stage I adenosarcoma of the uterus are reported. Although these neoplasms have generally been regarded as being of low malignant potential with little propensity for distant metastasis, our experience reveals some of them to be aggressive tumors with rapid clinical demise. Five (83%) patients demonstrated recurrence after initial surgery, three despite postoperative vaginal radium or external pelvic radiation. Four of the recurrences occurred in the pelvis and abdomen; the fifth was limited to the vagina. Three patients were dead of disease within three years of diagnosis, two of whom achieved clinical remission for at least one year to combination chemotherapy. One of the remaining three patients died from intercurrent disease without recurrence, and two are alive without disease after treatment for recurrence. Based on this limited experience, we believe these neoplasms should be regarded as potentially as malignant as their mixed Müllerian counterpart.

Radical hysterectomy and pelvic lymphadenectomy versus radiation therapy for small (less than or equal to 3 cm) stage IB cervical carcinoma

One hundred and three women with FIGO stage IB cervical carcinoma were treated either by radical hysterectomy and bilateral pelvic lymphadenectomy, or external pelvic radiation and intracavitary brachytherapy to deliver greater than or equal to 6000 rads to point A. Surgical therapy was to be limited to stage IB tumors measuring less than or equal to 3 cm in greatest diameter, Patients with lesions greater than 3 cm, medical contraindications to surgery, or advanced age were to be treated by radiation therapy. Of the 55 women treated surgically, 3 (5.6%) were found on final histologic evaluation to have tumors greater than 3 cm. The 5-year estimated disease-free interval was 92.3% for patients treated by surgery and 91.1% for patients treated by radiation therapy. Similar rates were achieved for the 5-year disease-free interval for lesions greater than 1 cm, 1-3 cm, and less than 3 cm in diameter by either surgery or radiation. It is tentatively concluded that radical hysterectomy and pelvic lymphadenectomy or radiation therapy as outlined above provide equally good disease-free intervals for stage IB cervical tumors measuring less than or equal to 3 cm in diameter. Because of a bias against patients treated with radiation, it is possible that radiation could lead to better results than surgery in comparable (younger, healthier, thinner) population. The advantage of surgical treatment in the younger patient is preservation of ovarian function.

Serum beta-(1----4)-galactosyltransferase activity with synthetic low molecular weight acceptor in human ovarian cancer

A modified procedure was developed for the determination of UDP-galactose: 2-acetamido-2-deoxy-glucopyranoside beta-(1----4)-galactosyltransferase (GT) in human serum which employed the synthetic substrates p-nitrophenyl 6-0-(2-acetamido-2-deoxy-beta-D-glucopyranosyl)-beta-D-galactopyranoside and p-nitrophenyl 6-0-(2-acetamido-2-deoxy-beta-D-glucopyranosyl)-alpha-D- mannopyranoside as acceptors. The enzyme products were identified by thin layer chromatography with authentic reference compounds, and the galactosyl linkage was characterized by hydrolysis with beta-D-galactosidase from jack beans. The diagnostic value of this GT for ovarian cancer was tested by measuring the serum enzyme activity in 28 ovarian cancer patients with disease, 20 ovarian cancer patients with no clinical evidence of disease, and 22 healthy females. Although the level of the enzyme activity was significantly higher (P less than 0.002) in the serum of patients with active disease when compared to healthy controls, an appreciable overlap of enzyme activity was found between them. Also, no correlation was found between enzyme activity and tumor size. Differences in methodology and selection of patients makes it difficult to compare results from other reports. However, based on our improved assay procedure, we suggest caution should be exercised in evaluating the merits of GT as a diagnostic marker for ovarian cancer.

Hydroxyurea plus pelvic radiation versus placebo plus pelvic radiation in surgically staged stage IIIB cervical cancer

Forty-five evaluable patients with stage IIIB carcinoma of the uterine cervix were entered into a prospective, double-blind, randomized study to evaluate the possible radiation-potentiating properties of hydroxyurea. All patients were documented to be without para-aortic lymph node metastasis by pretherapy staging para-aortic lymphadenectomy. The original plan of therapy was for continuous therapy (200 rads/day) of 6,000 rads of pelvic radiation for 6 weeks plus intrauterine radium. However, 16 patients received 6,000 rads in 8 weeks by split-course therapy (2-week rest after 3,000 rads) plus radium. Twenty-nine patients received the planned continuous therapy. The median dose of pelvic radiation for patients who received continuous therapy or split-course radiation was 6,000 rads. Leukopenia (WBC less than 2,500/mm3) was significantly increased in the patients given hydroxyurea as compared to those given placebo (P less than .001). There was no statistically significant difference relative to anemia, thrombocytopenia, radiation skin reaction, diarrhea, or radiation-induced complications requiring surgical correction. The estimated 5-year progression-free survival rate for the combined, continuous, and split-course radiation therapy hydroxyurea patients was 60%, and its was 52% for the corresponding placebo patients (P = .49). However, the estimated 5-year progression free survival rate for the correctly treated patients (continuous therapy) was 91% for the hydroxyurea group and 60% for the placebo group (P less than .06).

1.5-5 years of uninterrupted cis-diamminedichloroplatinum II chemotherapy for metastatic cervical cancer

In an attempt to prolong remission duration in patients with metastatic cervical cancer to cis-platinum based chemotherapy, patients were treated on an every other month basis after a minimum of 1 year of cis-platinum based chemotherapy. To date, five patients have received 5, 4.5, 2.3, 2.3, and 1.5 years, respectively, of uninterrupted cis-platinum based chemotherapy. All remain in complete remission after receiving a total dose of cis-platinum of 2523 mg (1530 mg/m2), 2.408 mg (1655 mg/m2), 1496 mg (880 mg/m2), 1325 mg (970 mg/m2), and 1640 mg (950 mg/m2), respectively. The only apparent toxicity has been asymptomatic hypomagnesemia. In contrast, three other patients in complete remission on cis-platinum based chemotherapy voluntarily discontinued such therapy and have subsequently developed uncontrolled recurrent cervical cancer. It is concluded that patients in complete remission from cis-platinum chemotherapy for metastatic cervical cancer can receive long-term cis-platinum based chemotherapy and that such therapy appears to be without significant toxicity.