Rare occurrence of pseudomyxoma peritonei (PMP) syndrome arising from a malignant transformed ovarian primary mature cystic teratoma treated by cytoreductive surgery and HIPEC: a case report

Background

Pseudomyxoma peritonei (PMP) syndrome is a disease process that typically occurs from ruptured appendiceal mucocele neoplasms. PMP syndrome arising from malignant transformation of an ovarian primary mature cystic teratoma (MCT) is a pathogenesis rarely encountered.

Case Presentation

Herein, we report a 28-year-old patient evaluated and treated for a right ovarian mass and large volume symptomatic abdominopelvic mucinous ascites. Molecular profiling and genetic analysis revealed mutations in ATM, GNAS, and KRAS proteins while IHC demonstrated gastrointestinal-specific staining for CK20, CDX2, CK7, and SATB2. Peritoneal cytology showed paucicellular mucin. Diffuse peritoneal adenomucinosis (DPAM) variant of PMP arising from a ruptured ovarian primary MCT after malignant transformation to a low-grade appendiceal-like mucinous neoplasm was ultimately confirmed. Treatment included staged therapeutic tumor debulking and right salpingo-oophorectomy followed by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC).

Conclusions

Our report builds upon the existing literature supporting this aggressive treatment option reserved for advanced abdominal malignancies utilized in this patient with a rare clinical entity.

An assessment of oncofertility content on reproductive endocrinology and infertility clinic websites

PURPOSE

To assess oncofertility content on fertility clinic websites as indicated by eight relevant keywords. Additionally, we sought to describe the relationship between oncofertility content and five predetermined clinic characteristics.

METHODS

We examined 381 fertility clinic websites that are members of the Society for Associated Reproductive Technology (SART). Extracted data included clinic location, practice type (private vs academic), size (cycles/year), type of NCI designated center (cancer center vs comprehensive cancer center), and distance from the nearest NCI center. Additionally, we documented whether the clinic was located in a state mandating reproductive and infertility services and/or included fertility preservation for "iatrogenic infertility" as reported by the American Society for Reproductive Medicine (ASRM). Data were summarized using descriptive statistics and compared using chi-squared or t-test as appropriate.

RESULTS

Of the 381 fertility clinic websites analyzed, 322 (85%) contained at least one oncofertility-related keyword. Most frequently used terms included cancer (79%) and fertility preservation (78%), while less frequently used terms included suppression (9.4%) and shielding (5.0%). Practices that initiated ≥ 501 cycles per year were more likely to mention one of the oncofertility keywords (OR 1.2; 95% CI 1.1-1.3). The associations of oncofertility website content with practice type, state-mandated fertility insurance coverage, and distance from an NCI-designated cancer center were not statistically significant. Large clinic size was the only predictive factor for inclusion of oncofertility website content. Further studies are required to evaluate whether inclusion of oncofertility content on clinic websites impacts the use of these services by patients with cancer.

CONCLUSION

This is the first study correlating availability of oncofertility content on SART fertility clinic websites with consideration of geographic proximity to NCI designated cancer centers. Large clinic size was the only predictive factor for inclusion of oncofertility website content.

Isolated Ovarian Metastasis from Pancreatic Cancer Mimicking Primary Ovarian Neoplasia: Role of Molecular Analysis in Determining Diagnosis

Background and Presentation: In this study, we present the case of a 64-year-old female with a chief complaint of abdominal pain and bloating, which had been persistent over a period of 4 months. Imaging revealed a 6.1-cm left-sided pancreatic mass as well as a 19.1-cm multiloculated cystic lesion in the pelvis, later revealed to be replacing the left ovary. The pancreatic mass was biopsied through endoscopic ultrasound-guided fine needle aspiration, and diagnosed as adenocarcinoma by cytology. The patient was treated with neoadjuvant chemotherapy and radiation before laparotomy for resection of the pancreas and left adnexal mass. Her response to treatment was followed radiologically and biochemically with cancer antigen (CA) 19-9 (114–35 U/mL), carcinoembryonic antigen (12–4.8 ng/mL), and CA-125 (119–15.3 U/mL) levels. She subsequently underwent an Appleby procedure, and resection of left pelvic mass and bilateral oophorectomy. Permanent sections revealed residual pancreatic ductal carcinoma with treatment effect, and a multicystic epithelial neoplasia of the left ovary for which the differential was primary ovarian carcinoma versus metastatic disease.

Conclusions: Molecular mutational analysis was performed on sections of both the ovarian tumor and the pancreatic tumor to aid in diagnosis. The ovarian tumor in this case showed exactly the same mutations, KRAS G12R and TP53 G245S, as in the treated pancreatic cancer. This raised the high probability that these tumors originated from the same clonal event. The findings suggested that the ovarian tumor was an isolated metastasis of the pancreatic primary, despite the morphologic ambiguity between the two sites of neoplasia.

Surgical and Radiological Management of Complicated Uterine Leiomyoma Aided by 3D Models in a Patient with Fibrodysplasia Ossificans Progressiva

Patient: Female, 27-year-old

Final Diagnosis: Fibrodysplasia ossificans progressiva

Symptoms: Fever

Medication: —

Clinical Procedure: —

Specialty: Endocrinology and Metabolic • Obstetrics and Gynecology

Diaphragm hernia after debulking surgery in patients with ovarian cancer

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Left-sided diaphragm hernias are rare after extensive upper abdominal debulking surgery in advanced stage ovarian cancer.

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A left-sided diaphragm hernia can easily be misdiagnosed because patients may present with a variety of different symptoms.

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After peritonectomy of the diaphragm, the diaphragm should be carefully checked for defects; any defect must be repaired.

Over 80% of patients with epithelial ovarian cancer present with advanced disease, FIGO stage III or IV at the time of diagnosis. The majority require extensive upper abdominal surgery to obtain complete gross resection. This may include splenectomy, distal pancreatectomy, partial hepatectomy, cholecystectomy, and usually diaphragmatic peritonectomy or resection. Following surgery, diaphragmatic hernia—a very rare but serious complication—may occur.

We describe four cases of left-sided diaphragmatic hernia resulting after debulking surgery, which included left diaphragm peritonectomy and splenectomy, in patients with advanced ovarian cancer. In association with the current shift towards more extensive debulking surgery for ovarian cancer, more patients may present with postoperative left-sided diaphragm hernia, making the prevention, diagnosis, and management of this complication important to practicing gynecologic oncologists. Intraoperatively the diaphragm should be checked thoroughly to rule out any defects, which should be closed. A diaphragmatic hernia may be easily misdiagnosed because the patient can present with various symptoms. While rare, these hernias require prompt identification, intervention and surgical correction to avoid serious complications.

Stereotactic body radiation therapy for oligometastatic gynecologic malignancies: A systematic review

OBJECTIVE

To assess the efficacy and safety of stereotactic body radiation therapy (SBRT) for oligometastatic gynecologic malignancies.

METHOD

A comprehensive search of the PubMed, Medline, and EMBASE databases was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. "Oligometastatic" was defined as a limited number of uncontrolled/untreated metastatic lesions (typically ≤ 5), including regional nodal metastases. Primary outcomes were response rate (complete response or partial response), local control of oligometastatic lesions, and toxicity.

RESULTS

Of 716 screened records, 17 studies (13 full length articles, 4 conference abstracts) were selected and analyzed as 16 unique studies. A total of 667 patients were treated with ~1071 metastatic lesions identified. Primary sites included ovarian (57.6%), cervical (27.1%), uterine (11.1%), vaginal (0.4%), vulvar (0.3%), and other/unspecified (3.4%). Most patients (65.4%) presented with a single metastatic lesion. Metastatic lesion sites included the abdomen (44.2%), pelvis (18.8%), thorax (15.5%), neck (4.6%), central nervous system (4.3%), bone (1.6%), and other/unspecified (11%). Of the lesions, 64% were nodal. Response rate (among 8 studies) ranged from 49% to 97%, with 7/8 studies reporting > 75% response rate. Local control ranged from 71% to 100%, with 14/16 studies reporting ≥ 80% local control. No grade ≥ 3 toxicities were observed in 9/16 (56%) studies. Median progression-free survival (PFS) (among 10 studies) ranged from 3.3 months to 21.7 months. Disease progression most commonly occurred outside of the SBRT radiation field (79% to 100% of failures).

CONCLUSIONS

SBRT for oligometastatic gynecologic malignancies is associated with favorable response and local control rates but a high rate of out-of-field progression and heterogeneous PFS. Additional study into rational combinations of SBRT and systemic therapy appears warranted to further improve patient outcomes.

Metformin as a Therapeutic Target in Endometrial Cancers

Endometrial cancer is the most common gynecologic malignancy in developed countries. Its increasing incidence is thought to be related in part to the rise of metabolic syndrome, which has been shown to be a risk factor for the development of hyperestrogenic and hyperinsulinemic states. This has consequently lead to an increase in other hormone-responsive cancers as well e.g., breast and ovarian cancer. The correlation between obesity, hyperglycemia, and endometrial cancer has highlighted the important role of metabolism in cancer establishment and persistence. Tumor-mediated reprogramming of the microenvironment and macroenvironment can range from induction of cytokines and growth factors to stimulation of surrounding stromal cells to produce energy-rich catabolites, fueling the growth, and survival of cancer cells. Such mechanisms raise the prospect of the metabolic microenvironment itself as a viable target for treatment of malignancies. Metformin is a biguanide drug that is a first-line treatment for type 2 diabetes that has beneficial effects on various markers of the metabolic syndrome. Many studies suggest that metformin shows potential as an adjuvant treatment for uterine and other cancers. Here, we review the evidence for metformin as a treatment for cancers of the endometrium. We discuss the available clinical data and the molecular mechanisms by which it may exert its effects, with a focus on how it may alter the tumor microenvironment. The pleiotropic effects of metformin on cellular energy production and usage as well as intercellular and hormone-based interactions make it a promising candidate for reprogramming of the cancer ecosystem. This, along with other treatments aimed at targeting tumor metabolic pathways, may lead to novel treatment strategies for endometrial cancer.

Group-based trajectory modeling of fear of disease recurrence among women recently diagnosed with gynecological cancers

OBJECTIVE

Fear of cancer recurrence is an important clinical phenomenon and is associated with decrements in life domains. The study goals were to characterize patterns of global fear of recurrence (FOR) and 4 domains of fear (health, role, womanhood, and death worry) over time in women who were diagnosed with gynecological cancer and to identify demographic, medical, and psychological predictors of FOR.

METHOD

One hundred eighteen women participating in the usual care arm of a randomized trial completed the Concerns about Recurrence scale as well as measures of depressive symptoms, cancer-specific distress, coping, coping efficacy, and social network responses at 4 time points. The majority of the sample was diagnosed with stage 3 ovarian cancer.

RESULTS

Group-based trajectory modeling identified subgroups of women with high-stable (49.1%), high-decreasing (25.3%), and low-stable (25.5%) trajectories for global FOR. For role worries, 3 similar group trajectories were identified. For health worries, modeling identified subgroups with high-decreasing (19.1%) and low-increasing (80.9%) trajectories. For womanhood worries, modeling identified subgroups with high-increasing (15.7%) and low-decreasing (84.2%) trajectories. Young age, metastatic cancer, depression, cancer distress, holding back, and lower coping efficacy were associated with the high-stable global FOR and at least 1 domain of FOR.

CONCLUSION

Almost half of the women recently diagnosed with gynecological cancer evidence persistently elevated FOR over the 6-month period postdiagnosis. Psychological interventions to reduce FOR may be more effective if they focus on teaching patients coping skills, as well as greater comfort expressing cancer-specific concerns to others.

Influence of bevacizumab on vaginal cuff evisceration eight months after ovarian cancer cytoreduction surgery: A case report

•44 year old woman treated with bevacizumab for metastatic epithelial ovarian cancer•The patient experienced vaginal cuff dehiscence and evisceration at 8 months post-operatively.•Metastasis at the surgical site and chronic inflammation implicated.

Colposcopic and cytologic detection of chronic lymphocytic leukemia in the vagina: a case report

BACKGROUND

Chronic lymphocytic leukemia (CLL) is one of the chronic lymphoproliferative disorders. CLL has a wide range of physical findings at the time of initial discovery, with lymphadenopathy being the most common. We report the first case of primary presentation of CLL of the vaginal cuff in an asymptomatic patient.

CASE

A 68-year-old, white woman status post-total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis 25 years earlier, was referred for colposcopic evaluation of low-grade squamous intraepithelial lesion of the vagina. Pathologic examination, immunohistochemical studies, and immunoglobulin gene rearrangement studies of the biopsy specimens were performed. All of these findings were supportive of a diagnosis of CLL.

CONCLUSION

CLL in the vagina may present as an asymptomatic lesion. Hematologic malignancies should be considered in the differential diagnosis during workup of abnormal vaginal cytology.

Perceived stress is associated with impaired T-cell response to HPV16 in women with cervical dysplasia

BACKGROUND

Infection with high-risk subtypes of human papillomavirus (HPV) is a central factor in the development of cervical neoplasia. Cell-mediated immunity against HPV16 plays an important role in the resolution of HPV infection and in controlling cervical disease progression. Research suggests that stress is associated with cervical disease progression, but few studies have examined the biological mechanisms that may be driving this association.

PURPOSE

This study examines whether stress is associated with immune response to HPV16 among women with cervical dysplasia.

METHODS

Seventy-four women presenting for colposcopy completed measures of health behaviors, stressful life events and perceived stress. A blood sample was obtained to evaluate proliferative T-cell response to HPV16, and a cervical sample was obtained during gynecologic exam for HPV-typing.

RESULTS

More than 55% tested positive for one or more HPV subtypes. Women who did not show proliferative responses to HPV (i.e. non-responders) were more likely to be HPV(+) compared to women who had a response (i.e. responders). Consistent with study hypotheses, logistic regression revealed that higher levels of perceived stress were associated with a non-response to HPV16, controlling for relevant covariates. Stressful life events were not associated with T-cell response to HPV.

CONCLUSIONS

Higher levels of perceived stress are associated with impaired HPV-specific immune response in women with cervical dysplasia, suggesting a potential mechanism by which stress may influence cervical disease progression.

Oncoprotein profiles of primary peritoneal malignant mixed mullerian tumors

Primary peritoneal malignant mixed müllerian tumors (MMMTs) are extremely rare and highly aggressive malignancies associated with poor clinical prognoses. We present a clinicopathologic review of three cases of this rare tumor by examining expression of selected oncoproteins by immunohistochemistry. Three consecutive cases of primary peritoneal MMMT were examined by paraffin immunohistochemistry for expression of p53, p16, BCL2, CerbB2, and classical cadherins E-cadherin, P-cadherin, and N-cadherin. All three cases expressed p16, but showed less consistent expression of other markers, with one case expressing p53 and one expressing BCL2. All cases were negative for membrane expression of Cerb-B2. The three classical cadherins were expressed in two cases with one case showing only weak N- and P-cadherin expression. No difference in antigen expression was seen in the epithelial compared to sarcomatous components. We conclude that p16 may be a common tumor suppressor gene expressed in peritoneal MMMT. P53 overexpression may be of lesser frequency in peritoneal MMMT compared to MMMT from the ovary and the uterus. We did not observe any difference in antigen expression between areas of epithelial or sarcomatous differentiation, which would support a single pluripotential malignant clone in the histogenesis of these tumors.

Primary small cell carcinoma of the vagina

BACKGROUND

Primary vaginal small cell carcinoma is extremely rare, with a total number reported in English-language journals to date of 23. Most patients die of the disease within 2 years of diagnosis from metastatic disease.

CASE

A 69-year-old woman presented with vaginal spotting while on Premarin. She was subsequently diagnosed with Stage I (T1N0M0) small cell carcinoma of the vagina. She underwent concurrent chemoradiation and then brachytherapy for persistent disease. Due to residual disease after the brachytherapy, surgical resection was planned but aborted because of metastatic disease.

CONCLUSIONS

Of the three reported cases treated with concurrent chemoradiation, ours is the first case reported with persistent local disease after therapy. Extrapolating from the available clinical trials from lung carcinoma, concurrent chemoradiation as a primary treatment approach should still be considered.

Expression of cadherins, p53, and BCL2 in small cell carcinomas of the cervix: potential tumor suppressor role for N-cadherin

Cadherins are tissue-specific cell adhesion molecules that function as tumor suppressors. Analysis of cadherin expression is useful for differentiation of tumor histogenesis, and because they serve as markers of tumor behavior and prognosis. Since the pattern of cadherin expression is not well characterized for small cell carcinoma of the cervix, we examined cases of these tumors for expression of cadherins, and two other oncoproteins p53 and BCL2. Four cases of small cell neuroendocrine carcinomas were identified from the Gynecologic Oncology Service with diagnoses confirmed by immunohistochemistry for neuroendocrine markers. Archival paraffin blocks were studied by heat-enhanced immunohistochemistry using commercially available antibodies specific for E-cadherin, P-cadherin, and N-cadherin, p53, and BCL2. Sections were examined for specific membrane staining of cadherins, nuclear staining of p53, and cytoplasmic staining of BCL2. E-cadherin was expressed in three of four cases, P-cadherin in one of four, and N-cadherin in none of four cases. P53 was expressed in one of four cases and BCL2 in one of four cases. The four cases showed three different patterns of immunohistochemical staining for the five oncoproteins. Specifically, two cases expressed E-cadherin only; one case lacked all three cadherins, was negative for BCL2, and was only positive for p53; and one case expressed E- and P-cadherin and BCL2. Prior studies of other neuroendocrine and small cell tumors of other organs showed E-cadherin expressed in 98% (42 /43), N-cadherin in 65% (28/43), and P-cadherin in 40% (17/43) of cases. Additionally, one case of vaginal small cell carcinoma showed expression of all three cadherins. The only significant difference between cervical primaries and other primary sites is that N-cadherin was not detected in our four cases vs. 65% expression in other sites (P < 0.001). We conclude that cadherin and oncoprotein profiles in small cell carcinoma of the cervix are different in the four cases analyzed. Additional cases need to be studied to determine the specificity and frequency of these oncoprotein profiles for small cell carcinoma of the cervix. These may possibly represent different oncogenic pathways in development of small cell cancer of the cervix. Also, our results suggest that N-cadherin may be a tumor suppressor gene in these tumors.

p16 Expression in Squamous Lesions of the Female Genital Tract

The aim of this study was to examine the role of p16 in the pathogenesis of squamous carcinoma of the gynecologic tract. Squamous carcinoma and carcinoma in situ from the female genital tract were examined for the expression of p16 by paraffin immunohistochemistry. About 74% (40/54) of cases showed p16 expression. By primary site, 77% (23/30) of cervical, 67% (6/9) of vaginal and 85% (11/13) of vulvar primaries expressed p16, but two endometrial primary squamous carcinomas were negative (0/2). In addition, p16 was not identified in non-dysplastic tissue and low grade dysplasia. In cases where there were matched vaginal or vulvar and cervical primaries in a given patient, there was concordant positive p16 expression. It is concluded that p16 is frequently expressed in squamous carcinoma of the cervix, vagina and vulva, but not seen in cases of benign and low grade lesions. It may be a marker of transformation from a low to a high grade lesion. More cases of endometrial primaries need to be studied to see if these evolve by a p16-independent pathway.

Immunohistochemical confirmation of pulmonary papillary adenocarcinoma metastatic to ovaries

Metastatic papillary adenocarcinomas of the ovary are rare compared to primary ovarian papillary serous carcinomas. We report a case of pulmonary papillary adenocarcinoma metastatic to the ovary and show how this tumor can be differentiated immunohistochemically from an ovarian primary. Paraffin blocks of the ovarian tumor were analyzed for carcinoembryonic antigen, CA 125, surfactant, E-cadherin, N-cadherin, and vimentin. These markers are useful in differentiating epithelial tumors of lung versus ovarian origin. The papillary tumor showed expression of carcinoembryonic antigen, surfactant, and E-cadherin, but was negative for CA 125, N-cadherin, and vimentin. These findings support a lung carcinoma metastatic to the ovary.

Uterine papillary serous carcinoma presenting as distant lymph node metastasis

BACKGROUND

Uterine papillary serous carcinomas are highly aggressive malignancies that often present with high-stage disease. We report two cases that presented initially as distant metastatic disease. One case was found incidentally at the time of axillary dissection for breast cancer and the second case in the workup of a neck mass.

CASES

Clinicopathologic review of the patient material including review of routine H&E pathology and immunohistochemical studies of the patients tumors was performed. Both cases showed high-grade papillary carcinomas with psammoma bodies metastatic to lymph nodes in the axilla or neck. Sampling of the endometrium in these patients confirmed primary uterine papillary serous carcinoma. Patients were treated with adjuvant chemotherapy.

CONCLUSIONS

Metastatic uterine papillary serous carcinoma presenting initially in distant sites is an unusual manisfestation of this highly aggressive tumor. This tumor should be considered in the differential diagnosis when patients present with metastatic high-grade papillary serous carcinomas and the primary site is unknown.

Cadherin expression in glandular tumors of the cervix

BACKGROUND

The cadherins are homotypic adhesion proteins that are important in cell sorting during organogenesis. Classic cadherins include several different types that show tissue specific expression. Specific tissue expression of cadherins often is preserved in neoplastic transformation, and cadherin phenotype can be used to differentiate morphologically similar but histogenetically distinct tumors.

METHODS

The authors examined by using immunohistochemistry in paraffin sections the expression of E- (epithelial) and P- (placental) cadherin in 39 patients with glandular tumors of the cervix, including invasive adenocarcinoma, villoglandular adenocarcinoma, adenocarcinoma in situ (AIS), and adenoma malignum.

RESULTS

In all cases, E-cadherin was expressed in both normal and malignant glands without appreciable differences. P-cadherin, normally confined to basal epithelial cells and not observed in benign glands, was aberrantly expressed in neoplastic glands in 27 cases, including 96%(23 of 24 cases) of invasive cancers, 40% (2 of 5) of villoglandular carcinomas, 25% (2 of 8) of AIS, and 0% (0 of 2) of adenoma malignum.

CONCLUSIONS

The authors' results show that E-cadherin is uniformly expressed in glandular tumors of the cervix with no evidence of decreased expression in these tumors. In addition, P-cadherin is aberrantly expressed in most adenocarcinomas and appears to be preferentially expressed in invasive rather than in situ lesions. Thus, aberrant expression of P-cadherin may be a useful marker of invasive or aggressive clinical behavior in glandular lesions of the cervix.

Primary, localized vulvar B-cell lymphoma expressing CD44 variant 6 but not cadherins. A case report

BACKGROUND

Primary extranodal lymphoma of the vulva is rare, with only 17 prior cases reported. Its immunohistochemical profile has not been characterized beyond B- or T-cell phenotype.

CASE

A 64-year-old, white woman presented with a nontender enlargement of the right labium minus and labium majus. Bilateral vulvar punch biopsies revealed an infiltrate of neoplastic lymphocytes that filled the reticular dermis and extended down to the subcutaneous fat. Lymphoma cells were positive for CD20 and expressed CD43 in an aberrant manner. The tumor was examined for adhesion protein expression. There was expression of CD44 standard and variant 6 but not of E-, N- or P-cadherin. No systemic spread of this rare lymphoma was evident after one year.

CONCLUSION

Adhesion protein expression in primary vulvar lymphoma may have prognostic implications.

Adenocarcinoma arising in extragonadal endometriosis: an immunohistochemical study

BACKGROUND

Malignant transformation is an infrequent but reported complication of endometriosis. Previous reports of these cases have been limited to clinicopathologic studies based on routine histologic examination of these tumors, whereas, to the authors' knowledge, characterization of these lesions based on immunophenotype and hormone receptor and oncoprotein expression has not been described.

METHODS

Using commercially available monoclonal antibodies, the authors studied three recent cases of adenocarcinoma arising in extragonadal endometriosis using paraffin immunohistochemistry. Proteins examined included different cytokeratin (CK) subtypes, as well as hormone receptor status, proliferation rate, and oncoprotein expression.

RESULTS

All three cases presented clinically and macroscopically as colonic masses, and the tumors expressed an endometrial CK phenotype (CK7+, CK20-). In contrast, the adjacent benign colonic epithelium expressed the expected opposite phenotype (CK7-, CK20+). Estrogen receptor (ER) and progesterone receptor (PR) were expressed in one of the three tumors. Interestingly, in the ER/PR negative tumors, receptor expression was present in areas of benign endometriosis adjacent to malignancy, suggesting a loss of receptor expression with malignant transformation. The tumors also were examined for proliferation by Ki-67, and the expression of oncoproteins c-erb B-2, p53, cyclin D1, and bcl-2. All cases of malignancy had a high proliferation rate as measured by Ki-67, which was in contrast to areas of benign endometriosis which had a low proliferation rate. Of the other oncoproteins only p53 protein was detected at a significant level in all three cases. Cyclin D1 was overexpressed in two of the three cases. c-erb B2 and bcl-2 overexpression was not detected.

CONCLUSIONS

The results of the current study 1) show the utility of CK subtypes in confirming endometrioid phenotype in tumors arising in extragonadal endometriosis with colonic involvement and 2) suggest that loss of hormone receptor expression and p53 oncoprotein abnormalities may be involved as mechanisms in malignant transformation in extragonadal endometriosis.

Neovaginal reconstruction after exenteration using an omental flap and split-thickness skin graft

The earliest efforts at neovaginal reconstruction used split-thickness skin grafts when bladder and rectum remained in place. In patients undergoing total pelvic exenteration, the pelvic organs are not available to accept the skin graft. By modifying the omental flap normally used to close off the pelvic inlet after total pelvic exenteration with or without lower coloproctostomy, a cylinder can be created that provides anterior, posterior, and lateral walls for the neovagina. When this omental cylinder is lined with a split-thickness skin graft and secured in the postoperative period using a soft vaginal form, a satisfactory neovagina can be created. This article presents the authors' experience with 20 patients who underwent radical pelvic exenteration for gynecological malignancy and neovaginal reconstruction using an omental cylinder flap lined with a split-thickness skin graft. In this series, all flaps and skin grafts have remained soft and completely viable with no pelvic infections, perineal fistulae, or hernias, and they offer the potential for sexual function in approximately 80 percent of patients. Average reconstruction operating time is less than 2 hours. In the properly selected patient, this method provides distinct advantages over reconstruction with myocutaneous flaps, which may be too bulky, too difficult to pass into the pelvis, and require additional donor-site incision with prolonged operative time. Myocutaneous flaps may have greater potential for partial or complete tissue loss. Neovaginal reconstruction using an omental cylinder flap lined with a split-thickness skin graft compares favorably with previously described methods by providing support for the pelvic floor with primary healing while restoring the potential for sexual function with minimal overall morbidity.

Morbidity after intraperitoneal insertion of saline-filled tissue expanders for small bowel exclusion from radiotherapy treatment fields: a prospective four year experience with 34 patients

When prolonged small bowel exclusion (SBE) from external radiotherapy (RT) fields or immediate exclusion of bowel from brachytherapy sources is required for a patient without adequate omentum, there are no simple proven methods available for accomplishing these goals. We report a prospective study of SBE by intraperitoneal, saline-filled tissue expanders (TE). Thirty-four patients had exclusion of small bowel from either external radiotherapy (RT) ports (20), afterloading catheter treatment fields (5), both (5), or from intracavitary implants (4). Twenty-seven TEs were placed in the pelvis and 7 in the iliolumbar fossa. TE volume ranged from 400-1500 cc (median 550 cc). Patients had rectal (n = 15), colon (6), endometrial (4), anal (3), and vaginal (1) cancers and sarcomas (5). Fifteen patients had recurrent neoplasms, 13 of which were in previously irradiated fields. Nine patients had colorectostomies directly behind the TE, and 12 had other bowel (6) or ureteral (3) anastomoses or bladder repairs (3) adjacent to the TE.

RESULTS

TEs remained in the patients from 6 to 173 days (median 95). Morbidity included three early TE withdrawals before RT was begun, one for a prolonged ileus, one for a perineal wound dehiscence, and one for an unrelated small bowel obstruction. Two patients (5.9%) early in the series had post-withdrawal complications (non-lethal small bowel fistulas requiring reoperation), although in a recent cohort of patients no post-withdrawal complications occurred using a different placement technique (0/17 vs. 2/14, P = 0.2). The patient injury complication rate was 4/34 (11.8%). None of these limited or delayed RT, but RT was limited to less than that planned in one other by TE deflation (total complication rate 14.7%). There were no clinical infections involving the prostheses, even though one patient had an abdominal wound dehiscence, 3 had pelvic abscesses, and 2 had exposure of the TE through the vagina (1 planned, 1 at dehisced vaginal cuff) after TE placement. We noted no acute and one possible late RT complication in these patients (18 months median follow-up, range 3-43 months). Small bowel was displaced from > 95 per cent of the RT treatment volume in 70 per cent and from > 75 per cent of the treatment volume in 89 per cent of 27 evaluable patients treated with external RT.

CONCLUSION

Intraperitoneal placement of a saline-filled tissue expander is a simple, safe and effective means of small bowel exclusion from RT portals.

Phase II trial of thio-TEPA in relapsed and refractory ovarian carcinoma

On the basis of a Phase I reevaluation of thio-TEPA in which 3 of 9 patients with ovarian carcinoma responded, we instituted a Phase II study at high doses. Fourteen patients with a histologic diagnosis of epithelial carcinoma of the ovary, who had received at least one prior cisplatin-based regimen, were entered. Thio-TEPA was initially administered intravenously at a dose of 65 mg/m2 every 4 weeks, but was reduced to 50 mg/m2 after severe myelotoxicity developed in the first 5 patients. In 4 patients stable disease lasted 3, 4, 5, and 9 months; 10 patients progressed. There were no objective responses. At this dose and schedule, thio-TEPA has a response rate less than 20% in ovarian cancer patients previously treated with cisplatin.

Phase I pharmacokinetic study of intraperitoneal etoposide

The synergistic interaction of etoposide with cisplatin in certain tumors prompted an evaluation of its potential role in the i.p. treatment of ovarian cancer and other intraabdominal malignancies. We conducted a Phase I evaluation of etoposide as a single agent to determine the maximum tolerated dose i.p., to describe dose-limiting and other toxic effects, and to examine the pharmacokinetics of etoposide in this setting. Etoposide was diluted in 2 liters of normal saline, and instilled i.p. over 10 to 25 min following maximal drainage of ascites. The dwelling time was 4 h, followed by peritoneal drainage. Twenty-two patients received 56 courses at doses which ranged from 100 to 800 mg/m2. The median age was 49, the median performance status was 1, and 18 patients had received prior chemotherapy, with or without radiation. The principal acute toxicity was abdominal pain in 10 patients; this was usually accompanied by signs of peritoneal irritation and was always responsive to nonsteroidal antiinflammatory medications. The major toxicity was dose-related neutropenia; Grade 3 or 4 toxicity affected five of six patients at 800 mg/m2. Thrombocytopenia, nausea and vomiting, and alopecia were also observed. The recommended dose for further study is 700 mg/m2. The pharmacokinetics of etoposide in plasma and peritoneal fluid was measured in 19 patients. Peritoneal levels over the 4-h dwelling time declined monoexponentially with a harmonic mean half-life of 3.5 h (range, 1.9 to 7.8). Plasma levels rose to a peak at 2.9 +/- 1.7 (SD) h and then declined exponentially with a harmonic mean terminal half-life of 7.7 h (range, 4.2 to 15.6). The plasma area under the concentration-time curve increased linearly with respect to dose. The relative pharmacological advantage (ratio of peritoneal to plasma area under concentration-time curve) for i.p. administration was measured as 2.8 and was independent of dose. Based on the high plasma protein binding of etoposide (94%) and the minimal protein binding in the fluid instilled i.p., the ratio of the areas under the concentration-time curves of free drug is estimated to be 4%. These results illustrate that tumor confined to the peritoneal cavity would be exposed to substantially higher free (diffusible) drug concentrations following i.p. than following i.v. administration and support the further evaluation of etoposide by this route.

Malignant struma ovarii

Malignant struma ovarii is a very rare tumor, with considerable disagreement concerning the necessary histologic features for malignancy. The prognosis with patients with a malignant struma ovarii is difficult to make because of inadequate follow-up of the reported cases and long clinical courses. In most cases the patients responded well to surgical treatment but sometimes patients have died from malignant struma ovarii, in particular, if there is metastasis. There is evidence that radioactive iodine is effective in treating metastatic struma. The present case reports the use of intraperitoneal chronic phosphate for metastatic intraperitoneal disease, with thyroid suppression. Long-term follow-up will be necessary to properly evaluate this therapy. Prophylactic administration of thyroid hormone should be considered in cases of malignant struma ovarii.

Gonadotropin-releasing hormone radioimmunoassay and its measurement in normal human plasma, secondary amenorrhea, and postmenopausal syndrome

A sensitive and specific double antibody radioimmunoassay for gonadotropin-releasing hormone (GnRH) has been developed for measurement in ethanol extracts of human plasma. Iodinated hormone was prepared with the use of the chloramine-T method, and antibodies were developed in rabbits over a six-month period with a GnRH synthetic copolymer immunogen. A Scatchard plot revealed at least three species of antibody. The assay can measure conservatively at the 5 pg. per milliliter level and shows no cross-reactivity with other available hypothalamic and pituitary hormones. The releasing hormone was quantitatively recovered from human plasma with immunologic identity to native hormone. Unextracted plasma could not be used because of nonspecific displacement. The measurement of GnRH in individuals receiving 100 mug of intravenous bolus infusions of the synthetic decapeptide show extremely elevated values with two half-lives: one of two to four minutes and another of 35 to 40 minutes. In our experiments, we have found measurable GnRH in patients with secondary amenorrhea and at the midcycle in normal women. In the normal cycling woman during the follicular and luteal phases, GnRH was undetectable. In postmenopausal women with extreme hypoestrogenism and markedly elevated luteinizing hormone values, GnRH was also undetectable. No bursts of GnRH could be detected in normal men when sampled every ten minutes over a two-hour period and every two hours throughout the day.