Clinicopathologic Review of Metastatic Breast Cancer to the Gynecologic Tract

Metastatic spread is the single most significant predictor of poor survival in breast cancer. Some of the most common metastatic sites are the bones, lungs, liver, brain, and peritoneal cavity. Clinically metastatic breast cancer to the gynecologic tract is usually asymptomatic and diagnosed as an incidental finding during a histologic examination of gynecologic specimens resected for other reasons. Cases of metastatic breast cancer to gynecologic organs diagnosed from August 1995 to January 2021 were retrieved from our institution's pathology databases, and their clinicopathologic features were reviewed. The most common site of metastasis was the ovary which was involved in about 79% (22 of 28 cases) of metastases to the gynecologic tract. Clinically, only 8 cases (36%) presented with ovarian mass detected in imaging studies and the rest of the cases were all incidental findings. Among ovarian metastasis, 59% of cases were invasive lobular carcinoma and 41% were invasive ductal carcinoma. In 5 cases, metastatic breast cancer was found in the endometrium, including 2 cases with endometrial metastasis only and 3 cases with multiple gynecologic organs involved. Metastatic breast cancer rarely involved the lower gynecologic tract, with only 7% vaginal metastasis and 4% found in the vulva. The absolute majority of metastatic breast cancer outside of the ovaries were lobular carcinoma (88%). Most of the metastatic breast carcinomas were positive for estrogen receptor on immunohistochemistry (27 of 28 cases, 96%). Her-2/neu immunostaining was positive in 4 cases only (14%). Metastatic breast cancer needs to be distinguished from gynecologic primary neoplasms and metastatic tumors from adjacent urinary and GI tracts. A careful review of the patient's history and adequate immunohistochemistry panel are helpful to render the diagnosis.

Origin, Incidence, and Management of Nongynecologic Pelvic Masses Seen on Cross-sectional Imaging

OBJECTIVE

To characterize the origin of nongynecologic pelvic masses.

STUDY DESIGN

Using a radiology database, women who underwent transvaginal ultrasound, CT scan, or MRI for the indication of pelvic mass or pelvic fullness were identified. Demographic information, radiologic data, and outcomes were reviewed.

RESULTS

A total of 450 women underwent imaging for the above indications been 2002 and 2012. Of those women, 347 had at least 1 pelvic mass; 3 women had both gynecologic and nongynecologic masses, and 13 women had 2 gynecologic masses. Forty women (12%) had nongynecologic pathology. Of the nongynecologic masses 13 were gastrointestinal in origin, 9 were urologic, and 9 were neuromuscular. Other etiologies included metastatic cancers, iatrogenic masses, and hematologic masses. Seventy-four women had malignant pathology (21%): 17/40 (43%) of nongynecologic pelvic masses and 57/320 (18%) of gynecologic masses (p < 0.05).

CONCLUSION

Compared to pelvic masses of gynecologic origin, nongynecologic pelvic masses are more likely to be malignant.

Ulcerated plaques in the pelvic region of an adult female

Cutaneous metastatic mammary carcinoma may occur in patients with a history of breast carcinoma. Cutaneous metastases typically present as firm papulonodules on the chest. We describe a rare case of cutaneous metastatic mammary carcinoma arising in a 45-year-old woman presenting as painful, indurated plaques with ulceration in the pelvic region.

[Secondary malignant tumors of the female genital tract]

OBJECTIVE

Information sheet about metastatic tumors of the female genital tract.

DESIGN

Literature review with case reports.

SETTING

Department of Gynaecology and Obstetrics, Faculty of Medicine, Masaryk's University and Fakulty Hospital, Brno.

METHODS

Literature review about metastatic tumors of the female genital tract with illustrative case reports.

CONCLUSIONS

Secondary gynecological malignant tumors are much less common than primary tumors of the female genital tract with the exception cancer of the fallopian tube and the vagina. Primary malignant tumors of the fallopian tube and the vagina are rare, the primary location of the tumor usually is in other areas of the female genital tract and the tumor grows directly into the above-mentioned organs secondarily. There is talking about metastatic malignant tumors of the female genital tract in the strict sense in the case of extragenital primary origin the cancer. Metastases can be caused by direct penetration of the tumor from anatomically adjacent organs, particularly from the bladder and the rectum, or are going through the lymph or the blood vessels. The most common primary location of the tumor are the breast, the stomach and the bowel in this case. Secondary laesions of the female genital tract can be sometimes the first clinical manifestation of the primary extragenital malignant tumor, simultaneously represent clearly negative prognostic factor for the disease. Differential diagnostic algorithm for solving the secondary laesions of the female genital tract requires a multidisciplinary approach and cooperation with the pathologist and the clinical oncologist. Surgical treatment, the indication and extent based on adequately performed staging, is essential for the diagnosis of the primary tumor and is necessary as the palliative treatment for the elimination event, clinical symptoms and for the improving quality of the life.

Diagnostic accuracy of FDG PET imaging for the detection of recurrent or metastatic gynecologic cancer

PURPOSE

This study evaluated the diagnostic role and accuracy of positron emission tomography (PET) using 2-[F-18]fluoro-2-deoxy-D-glucose (FDG) for the detection of tumor foci in patients with suspected recurrent or metastatic lesions of gynecologic cancers.

MATERIALS AND METHODS

FDG PET imaging was performed on 51 patients with a previous history of gynecologic cancer who were referred for a clinical suspicion of recurrent disease. PET acquisition was started 50-60 min after the intravenous injection of 5-6 MBq/kg FDG in all patients. The PET images were interpreted visually, and tracer uptake was quantitated as the standardized uptake value adjusted to body weight (SUV) in the lesions showing FDG uptake. The accuracy of the PET results was assessed by a consensual verdict based on histology, cytology, other imaging and clinical follow-up.

RESULTS

FDG PET correctly diagnosed 33 of 36 patients with recurrent disease and 12 of 15 patients without recurrence. On patient-based analysis, the sensitivity, specificity and accuracy of FDG PET were 91.7%, 80.0% and 88.2%, respectively, depending on the selected scheme for visual scoring of the lesions. The area index in receiver-operating characteristic analysis was 0.95 for patient detection. Malignant lesions accumulated significantly more FDG than the benign ones (the mean SUVs were 3.7 +/- 1.9 and 1.6 +/- 1.1, respectively, p = 0.004). The sensitivity and specificity in correct identification of tumor recurrence or metastases using a threshold SUV 1.9 were 88.8% and 66.7% in contrast to the visual analysis (sensitivity 96.4%, specificity 50%) on a lesion-based analysis. The partial volume effect of SUV in a few small lesions and the presence of bone lesions in which FDG uptake was relatively low might be the reason for the lower sensitivity in SUV analysis. FDG PET was valuable when CT/MRI was negative or inconclusive, and in patients with elevated tumor marker levels as well as with normal tumor marker levels when recurrence was suspected clinically. However, PET failed to visualize some small metastatic lesions in lung and bone, and showed falsely high FDG uptake in some benign lesions.

CONCLUSION

The results indicated that FDG PET is a reliable and accurate diagnostic method for detecting recurrent or metastatic gynecologic cancer particularly lymph node metastases. Although the sensitivity of PET for detecting small metastases was relatively limited, the overall sensitivity of FDG PET was significantly higher than morphologic imaging.

A critical appraisal: providing care for patients with solid tumors metastases--challenges across academic and community practice

Emerging therapies and the growing number of therapeutic options available for some of the solid cancers have led to a large number of patients eligible for metastasectomy and cytoreductive surgery. It is likely that within the current health care structure, academic tertiary referral centers alone are not going to be able to accommodate the growing number of patients that are potential beneficiaries. Community-based practices will have to develop strategies to meet the demand for appropriate multimodality treatment teams to address the needs of these patients.

[Recurrence risk analysis in patients treated for I clinical stage of endometrial cancer]

INTRODUCTION

The risk of endometrial cancer recurrence is estimated to be about 20%. In most cases, such situations are recognized in the first 3 years after the primary treatment. Early detection of such episodes leads to effective treatment. The aim of this study was to evaluate some histoclinical factors in the risk of recurrence.

MATERIAL AND METHODS

Between the year 2001 and 2003, 203 from 243 patients with endometrial cancer underwent surgery. All procedures were performed in accordance with surgical-pathological staging system. The following histoclinical factors were taken into account: age, number of deliveries, BMI, use of estrogens, co-morbidity, histoclinical type, grading and the spread of cancer inside the uterus, pelvis and retroperitoneal space.

RESULTS

29 recurrences (14.3%) were found in all analyzed groups. The mean time of follow-up was 43 months. The mean time of recurrences was 16 months (9-51 months). Lymph node metastases were recognized in 28 patients (13.7%). The most important factors in the multivariate analysis were: type of histology (serous or clear cell cancer) and lymph node involvement. Recognizing 2 or more metastatic lymph nodes significantly increased the risk of recurrences.

CONCLUSION

In patients with endometrial cancer the risk of recurrences increases when lymph node metastases are recognized. This risk is 5 times higher when 2 or more lymph nodes are involved, comparing with patients with one node metastasis. Four times higher recurrence risk is observed in serous or clear cell cancer, comparing with other histological types.

Clinical applications of immunohistochemistry in gynecological malignancies

Over the past two decades, immunohistochemical techniques have improved to such a degree that it is now a common adjuvant test to the traditional hematoxylin and eosin-stained histologic sections. It is used in most realms of surgical pathology and can often aid in final diagnosis and, in some cases, prognosis. However, immunohistochemistry (IHC) is not always helpful and many pitfalls to its use exist. Understanding the basics of IHC, its utility and difficulties will aid clinicians in better understanding how diagnoses are rendered. This study reviews the general principles of IHC and demonstrates its utility with several commonly encountered problematic areas in gynecological pathology.

A pilot phase 2 study of oregovomab murine monoclonal antibody to CA125 as an immunotherapeutic agent for recurrent ovarian cancer

This prospective, open-label, pilot phase 2 study examined the clinical and immunologic effects of oregovomab (OvaRex) in heavily pretreated patients with recurrent ovarian cancer (OC). Thirteen women were administered intravenous oregovomab (2 mg) at weeks 0, 2, 4, 8, and 12, followed by quarterly doses for up to 2 years or disease progression. Concomitant chemotherapy was not permitted. Eligibility criteria included recurrence after one or more platinum-based chemotherapy regimens, CA125 >35 U/mL, evaluable or measurable disease. Tumor burden was evaluated by physical or radiologic methods pretreatment, weeks 12, 24, and every 24 weeks thereafter. Immune responses, including antibodies and T cells to oregovomab and CA125, were demonstrated in over half the patients. Stabilization of disease and survival >2 years was observed in 3 of 13 patients and coincided with robust immune responses. Shrinkage of marker lesions was not observed; however, four patients showed decreases in CA125 levels. Treatment was well tolerated without serious adverse events or discontinuations due to therapy. This pilot study supports immunologic activity and safety of oregovomab in recurrent OC. Further study of this agent in the consolidation and adjuvant setting is ongoing to establish its clinical utility.

Current application of sentinel lymph node lymphoscintigraphy to detect various cancer metastases

In this review article, the application of sentinel lymph node (SLN) lymphoscintigraphy not only in breast cancer and melanoma but also in cancers of the genital organs and the lungs is described. After a brief historical background, including Virchow and Cabanas' views, a description of the basic technique and the sensitivity and specificity of this technique in identifying SLN in breast cancer and melanoma are presented. In cervical and vulvar cancer and also in lung cancer, special techniques are applied before and during surgery and evaluated after surgical operation. The advantages and disadvantages of using SLN lymphoscintigraphy are described. Finally, our experience from using SLN lymphoscintigraphy, especially in cervical cancer, is presented. The technique for SLN mapping may save the patient from extended surgical procedures, indicate the pathways of lymph drainage and identify skip metastases. Nevertheless, the sensitivity of this technique should improve more in order to provide information concerning the extent of surgical treatment.

Lymphatic mapping and sentinel node detection in gynecologic malignancies of the lower genital tract

The utility of lymphatic mapping and sentinel lymph node biopsy in malignancies of the female lower genital tract-- vulvar, vaginal, and cervical cancers--is being explored in multiple centers internationally. For patients with these tumors, lymphatic mapping with sentinel lymph node biopsy holds the promise of increasing the identification of microscopically metastatic disease while decreasing the morbidity of complete lymphadenectomy. In this review article we present the published data on mapping techniques and discuss the advantages and pitfalls of these procedures.

[Multiple organ resections for the surgical treatment of locally advanced colorectal cancer infiltrating the urinary tract]

The authors present data on 13 patients operated on for the treatment of locally advanced colorectal cancer infiltrating the adjacent parts of the urinary tract. Based on prior diagnostic evidences, every surgical intervention has been indicated as an expected curative resection. All patients of this study underwent a curative resection. The origin of the advanced cancer was in 9 cases the sigmoid colon, in 3 cases the rectum and in 1 case the ascending colon. Beside the resection of the tumorous colon or rectum, a resection of the urinary bladder has been performed in 9, a nephrectomy in 3 and the resection of the ureter in 2 cases. An additional gynecological resection was made in 4 cases for tumors infiltrating the female internal genitals. No mortality and no serious complication needing reoperation occurred in these series. Based on their experiences of a series of 13 radically operated cases, the authors suggest extended multiple organ resection for the treatment of advanced colorectal cancer infiltrating the urinary tract.

Prospective evaluation of contrast-enhanced MRI in the depiction of peritoneal spread in primary or recurrent ovarian cancer

The purpose of this study was to assess the accuracy of MRI in the staging of intra-abdominal tumor seeding of ovarian carcinoma. Fifty-seven patients with suspected primary or recurrent ovarian carcinoma were included in this study. All patients received laparotomy within 8 weeks after MRI. The MRI protocol included fat-saturated T1-weighted spin-echo (SE) sequences pre- and post i.v. application of gadopentetate dimeglumine. The criteria for tumor manifestation was contrast enhancement of intra-abdominal soft tissue lesions or peritoneum. The image review was performed by a blinded radiologist, a specialist in gynecological and abdominal MR imaging. Results were compared with findings during laparotomy. Sensitivity, specificity, positive and negative predictive values, and corresponding 95% confidence intervals were calculated for single intra-abdominal locations and for groups of locations defined according to surgical strategies for intra-abdominal cytoreduction. Laparotomy and histopathology confirmed 251 abdominal tumor locations. Sensitivity was high in lower pelvis locations (73-83%) except for ureter or bladder infiltration (40%). Bowel or mesentery locations displayed sensitivity values from 73 to 77%. Sensitivity was very low for pelvic lymph nodes (28%), greater omentum (38%), and lesser sac (43%). Magnetic resonance imaging based on contrast-enhanced fat-saturated T1 SE sequences improves planning of cytoreduction preceding chemotherapy in advanced primary or relapsed ovarian carcinoma.

Pathological findings of gynecologic organs obtained at female radical cystectomy

PURPOSE

Historically anterior pelvic exenteration has been the recommended treatment for invasive urothelial carcinoma in women undergoing radical cystectomy. We evaluated the pathological features of reproductive organs removed during exenteration to determine the incidence of malignant pathology in these organs and the need for removal.

MATERIALS AND METHODS

We reviewed the records of all patients who underwent radical cystectomy between January 1994 and December 2000. Of these 382 patients, we identified 68 females who underwent radical cystectomy for urothelial carcinoma. We reviewed preoperative, operative and pathological findings, including bladder, lymph nodes, uterine and adnexal pathology, in these female patients.

RESULTS

Median patient age was 64 years (range 35 to 86). Gynecologic organs were present in 40 of the 68 surgical specimens (59%). The reasons for absent gynecologic pathology were previous hysterectomy in 26 cases and the preservation of organs during orthotopic urinary diversion creation in 2. Malignancy was identified in 3 specimens, including invasive urothelial carcinoma in 2 (5%). In these 2 cases invasion was clearly identified intraoperatively. Low grade stromal sarcoma of the uterus was present in 1 specimen (2%).

CONCLUSIONS

In the absence of clinical suspicion radical hysterectomy at cystectomy rarely improves cancer control. Furthermore, secondary malignancies are rare. The functional impact of preserving gynecologic organs is a subject of ongoing study.

Usefulness of imaging-guided catheter drainage and talc sclerotherapy in patients with metastatic gynecologic malignancies and symptomatic pleural effusions

OBJECTIVE

The purpose of our study was to assess the usefulness of imaging-guided catheter drainage and talc sclerotherapy in patients with metastatic gynecologic malignancies and symptomatic pleural effusions and to assess the affect of ascites on the success rate of this treatment.

MATERIALS AND METHODS

Twenty-five patients (mean age, 63 years) with metastatic gynecologic malignancies who had 26 symptomatic effusions treated at our institution over a 4-year period with imaging-guided catheter drainage and talc sclerotherapy were included in this study. Response to treatment was assessed by comparing pre-, immediate post-, and 30-day postsclerotherapy chest radiographs. Response to the treatment was graded as complete (no reaccumulation), partial (accumulation above immediate post- but below presclerotherapy level), or no response (reaccumulation to or above the presclerotherapy level). The presence of ascites on CT (n = 23), sonography (n = 1), direct intraoperative visualization (n = 1), or at physical examination (n = 1) was also noted.

RESULTS

Of the 25 patients, 13 patients with 14 treated malignant effusions survived at least 30 days after sclerotherapy and formed the final study group. The remaining patients either died (n = 11) or were lost to follow-up (n = 1). At 30 days, 12 of the 14 treated effusions showed complete responses and one showed a partial response. The overall response rate was 86%. Abdominal ascites was present at the time of treatment in 11 patients (79%) and did not affect the success rate (p > 0.999).

CONCLUSION

Imaging-guided catheter drainage and talc sclerotherapy are an effective treatment for symptomatic pleural effusions in patients with metastatic gynecologic malignancies. Ascites does not adversely affect the response to pleurodesis.

Malignant potential of positive peritoneal cytology in endometrial cancer

OBJECTIVE

To investigate the malignant potential of positive peritoneal cytology in endometrial cancer.

METHODS

Fifty patients with clinical stage I-II endometrial cancer in whom the disease was completely surgically resected and positive peritoneal smears were found at surgery formed the study population. In these patients, a tube for cytologic analyses was inserted into the peritoneal cavity when closing the abdomen. The peritoneal cavity was irrigated with physiologic saline, and washings were obtained through the tube 7 and 14 days after the operation.

RESULTS

Persistence of positive peritoneal cytology was observed in four of seven patients with adnexal metastasis, zero of nine patients with nodal disease, and one of 34 patients with disease confined to the uterus, for a total of 10% (5 of 50). In the remaining 45 (90%) patients, no malignant cells were found in any of the washings.

CONCLUSION

The current series suggests that endometrial cancer cells found in the peritoneal cavity usually disappear within a short time and seem to have a low malignant potential. It also seems that only malignant cells from special cases, such as adnexal metastasis, may be capable of independent growth, and are possibly associated with intraperitoneal recurrence.

[Role of lymphadenectomy in the surgery of gynecologic cancer]

BACKGROUND

Complete surgical removal of cancer tissue is a goal in modern cancer treatment, and this is one of the arguments for total lymphadenectomy in gynaecologic cancer surgery.

MATERIAL AND METHODS

Review of the literature identified through limited searches on Medline, Cochrane, Bibsys and the Internet.

RESULTS

Lymphadenectomy improves the staging and represent advanced surgical treatment with considerable complication rates, related to the surgeon's experience. It is likely that lymphadenectomy directly influences survival for vulva and cervical cancer. The effect on survival among endometrial and ovarian cancer patients is unsettled, but prospective randomized trials are ongoing.

INTERPRETATION

Correct staging is especially important in randomized trials of treatment alternatives, and it is the basis for individualised treatment. However, the effect of available treatment is not always well documented, hence the mortality and complication rates related to the procedure should be considered in relation to the potential benefit from the relevant treatment in each patient. Special training in the surgical technique is necessary. For rare conditions, this implies centralization. There are promising new approaches like the sentinel node and laparoscopic techniques, and studies of prognostic tumour markers, that may partially replace total lymphadenectomy in the future.

Cancer and laparoscopy, experimental studies: a review

OBJECTIVE

To review the experimental studies on laparoscopy and cancer and to propose guidelines for the clinical management of gynecologic cancer.

METHODS

The literature in MEDLINE was searched from January 1992 to December 1998 using the terms 'cancer', 'laparoscopy' and 'experimental or animal study'. Cross-referencing identified additional publications. Abstracts and letters to the editor were excluded. All the relevant papers were reviewed.

RESULTS

Depending on the model used, controversial results have been reported on the incidence of trocar site metastasis when comparing CO(2) laparoscopy and laparotomy. In contrast, the following conclusions can be proposed: (i) tumour growth after laparotomy is greater than after endoscopy; (ii) tumour dissemination is worse after CO(2) laparoscopy than after laparotomy; (iii) some of the disadvantages of CO(2) laparoscopy may be treated using local or intravenous treatments or avoided using other endoscopic exposure methods, such as gasless laparoscopy.

CONCLUSIONS

The laparoscopic treatment of gynecologic cancer has potential advantages and disadvantages, and may only be performed in prospective clinical trials. The risk of dissemination appears high when a large number of malignant cells are present. Adnexal tumours with external vegetations, and bulky lymph nodes should be considered as contra-indications to CO(2) laparoscopy.

The accuracy of frozen-section diagnosis in metastatic breast and colorectal carcinoma to the adnexa

OBJECTIVE

The objective of our study was to describe the accuracy of intraoperative frozen-section diagnosis of carcinoma metastatic to the adnexa in women with a history of breast or colorectal carcinoma.

METHODS

We conducted a retrospective chart review of all patients with a history of breast or colorectal carcinoma who developed histologically proven pelvic or abdominal metastases between 1988 and 1995. In those patients whose final histologic review revealed carcinoma metastatic to the adnexa, the accuracy of the intraoperative frozen-section diagnosis of the adnexal tumor was compared to the final diagnosis.

RESULTS

Forty-three patients were identified and in 36 patients the frozen section was obtained from the adnexa. Twenty-one patients (58.3%) had metastatic breast carcinoma and 15 (41.7%) had metastatic colorectal carcinoma to the adnexa. Carcinoma in the adnexa was correctly diagnosed by frozen section in 35 of 36 patients (97.2%). Metastatic carcinoma was identified at frozen section in 17 of 21 patients (81%) with metastatic breast cancer and 13 of 15 patients (86.7%) with metastatic colorectal cancer. In 3 of 21 patients (14.3%) with metastatic breast cancer and in 2 of 15 patients (13.3%) with metastatic colorectal cancer, the frozen-section diagnosis was carcinoma of uncertain origin. One patient had a false-negative frozen section because the small focus of metastatic breast cancer was not sampled at the time of frozen section.

CONCLUSION

Intraoperative frozen-section evaluation correctly diagnosed carcinoma in the adnexa in 97% of patients, and in over 80% of cases, the carcinoma was diagnosed as being metastatic in origin.

Primary surgical cure of stage III-B cervical carcinoma with adnexal metastasis

Management of patients with advanced stage cervical carcinoma remains suboptimal. Primary radiation therapy has been the standard treatment for years. Despite some changes in radiation technique, cure rates for advanced stage cervical cancer remain disappointing. Radiation complications in those patients can also be severe. We report here a case of a patient who presented with renal failure from bilateral ureteral obstruction from stage III-B cervical squamous carcinoma. The patient underwent a primary total pelvic exenteration with low rectosigmoid reanastomosis, urinary conduit construction, and cecal neovagina construction as definitive treatment. She was found to have metastasis to the broad ligament, ovary, and fallopian tube. Surgical margins and lymph nodes were negative. The patient did not receive any radiation therapy or chemotherapy. The patient is alive, healthy, and without evidence of disease 8 years following treatment.

Treatment of recurrent pelvic and selected primary gynecologic malignancies with 241Am

The purpose of this study was to update the experience and demonstrate the effectiveness and limitations of 241Am applicators for previously irradiated patients and for selected patients with primary gynecologic malignancies. Between October 1986 and May 1994, 30 patients were treated with 241Am. The median patient age was 68 years, ranging from 41 to 91 years. Patients were retrospectively categorized by treatment intent, i.e., palliative vs. curative. Patients undergoing curative therapy were further classified as to whether 241Am brachytherapy was directed at microscopic residua after surgery or to gross primary tumor. Of the 30 patients, 18 had recurrent pelvic malignancies from various primary sites and were reirradiated with 241Am for palliation. Six patients had microscopic disease after surgical resection and were managed with postoperative radiotherapy (RT) that included 241Am. Six patients had gynecologic cancers managed with primary RT that included treatment with 241Am. Overall, 50% (9/18) of the patients with recurrent pelvic malignancies were locally controlled after reirradiation with 241Am. Including surgical salvage, the ultimate local control rate was 61% (11/18). Postoperative 241Am with or without external beam radiation therapy (XRT) was effective in 83% (5/6) of the patients with microscopic disease. Including surgical salvage, 100% (6/6) of the patients were ultimately free of disease. Fifty percent (3/6) of the patients treated with primary RT that included 241Am brachytherapy experienced local control. Including surgical salvage, 67% (4/6) of the patients were ultimately controlled with 241Am. In conclusion, reirradiation utilizing 241Am was effective in palliating patients with recurrent pelvic malignancies. 241Am was effective in 83% (5/6) of the patients with microscopic disease managed with postoperative RT. 241Am was of marginal benefit in patients with gynecologic tumors managed with primary RT.

Clear cell tumors of the female genital tract

Clear cell adenocarcinomas of the vagina, cervix, endometrium, and ovaries show very similar histological features. Several other tumors and tumor-like lesions of the female genital tract may also contain clear cells and may occasionally be misinterpreted as clear cell adenocarcinomas. These conditions include microglandular hyperplasia, mesonephric hyperplasia, Arias-Stella change, smooth muscle tumors containing clear cells, dysgerminoma, yolk sac tumor, metastatic renal cell carcinoma, steroid cell tumors, hepatoid carcinomas, signet-ring-cell stromal tumors, and trophoblastic tumors. This review discusses the histological features of all of these lesions, emphasizing the morphological aspects that are essential to accurate differential diagnosis.

Expression of CD44 alternative splicing variants in primary and lymph node metastatic lesions of gynecological cancer

CD44 is known as an adhesion molecule which is involved in lymphocyte activation and lymphocyte homing. In recent years, its role in the invasion and metastasis of malignant tumors has attracted the attention of investigators. In this study, the expression of CD44 variants was investigated in primary lesions and metastasis into the lymph node in 53 patients with gynecological cancer. The following patients with various types of gynecological carcinoma, established by operation and pre-treatment biopsy, were included in this study: 19 patients with cancer of the uterine cervix, 23 with cancer of the uterine endometrium, and 11 with ovarian cancer. Tissue samples were obtained from a primary lesion and a nodal metastasis of each patient, and immunohistochemical staining was performed by the ABC method through the use of monoclonal antibodies against CD44v1-10. Specimens proving CD44v1-10 positive were then submitted to immunohistochemical staining through the use of monoclonal antibodies against CD44v6 and CD44v9. Expression of CD44v was judged positive when DAB revealed color development, irrespective of the degree of staining intensity. CD44v were all expressed in the cancer cell membrane. In normal endometrium, expression of CD44v1-10 and v9 was observed in the endometrial gland cell membrane. In normal ovarian tissues, CD44v6 and v9 were not detected. The expression of CD44v6 in patients with endometrial cancer was noted in 13 (72.2%) of 18 patients with vascular invasion and in one (20.0%) of 5 patients without it, indicating a significant relation to vascular invasion. It was also remarkably higher in those for whom the invasion exceeded 1/2 of the myometrium than in those for whom the invasion did not exceed 1/2 of the myometrium, and was higher too in advanced stages and in node-positive patients. In one patient, CD44v6 was detected not in the primary lesion but in the nodal metastasis. The expression of CD44v6 in patients with ovarian cancer occurred more frequently in node-positive patients. Our study results suggest that the expression of CD44v6 in endometrial adenocarcinoma cells is involved in the progression of the carcinoma, nodal metastasis, myometrial invasion, and vascular invasion, and that in ovarian cancer, the expression of CD44v6 is involved in nodal metastasis.

Prognostic significance of gross myometrial invasion with endometrial cancer

OBJECTIVE

To determine if intraoperative estimation of gross myometrial invasion is sufficiently precise to guide surgical aggressiveness in staging patients with endometrial cancer.

METHODS

Between September 1987 and September 1995, 236 women with endometrial cancer had visual estimation of gross myometrial invasion during surgical staging which included pelvic and para-aortic lymphadenectomy.

RESULTS

In 213 patients (90.3%), the depth of gross myometrial invasion correctly predicted the microscopic depth of invasion on permanent histopathologic sections. Statistically significant associations were found between gross depth of myometrial invasion and tumor grade (P < .001), histopathology (P = .014), cervical metastases (P < .001), adnexal metastases (P < .001), omental metastases (P < .001), malignant pelvic cytology (P < .001), pelvic lymph node metastases (P < .001), para-aortic lymph node metastases (P = .001), and surgical stage (P < .001). Patients with more than 50% gross myometrial invasion were more likely to have poorly differentiated malignancies; nonendometrial histologies; malignant pelvic cytology; higher surgical stage; and cervical, adnexal, omental, pelvic lymph node, and para-aortic lymph node metastases. Patients with more than 50% gross myometrial invasion had a 6.4-fold higher prevalence of pelvic lymph node metastases, a 6.9-fold higher prevalence of para-aortic lymph node metastases, and a 6.7-fold higher prevalence of advanced surgical stage than patients with less than 50% myometrial invasion.

CONCLUSION

Patients with endometrial cancer and more than 50% myometrial invasion on gross visual intraoperative estimation are at marked risk for extrauterine metastases, including pelvic and para-aortic lymph node metastases. Such patients should be considered for more aggressive surgical staging, including pelvic and para-aortic lymphadenectomy.

Primary and recurrent colorectal cancer masquerading as gynaecological malignancy

To make clinicians more aware of the phenomenon of primary and recurrent colorectal and anal carcinoma masquerading as primary gynaecological malignancy, we reviewed the records of 8 women referred to our gynaecological oncology unit with primary colorectal cancer (1), recurrent colorectal cancer (6) and primary anal cancer (1). Seven of these patients presented with abnormal vaginal bleeding or discharge. All patients had Papanicolaou smears performed; 7 were abnormal and 1 unsuitable for cytological assessment. None of the 6 patients with recurrent carcinoma had been previously treated with more than standard anterior or abdominoperineal resection; no radiotherapy had been given, and only 1 patient had received chemotherapy. These patients were treated in our gynaecological oncology unit for their recurrence by surgery and/or chemotherapy and/or irradiation. All 6 had further recurrences in the pelvis despite this aggressive therapy. Follow-up of colorectal cancer in women should involve gynaecological history, pelvirectal examination and Pap smear at each visit. Correct diagnosis of the colorectal origin of a genital tract tumour is made on careful history, examination and biopsy. An abnormal Pap smear may be the first indication of recurrent colorectal cancer in the cervix and vagina, although most patients ultimately present with abnormal vaginal bleeding. The presence of a tumour invading both cervix and posterior vaginal wall is suggestive of spread from a colorectal tumour compared to the more common lateral spread of a cervical primary.

Carcinosarcomas of the female genital tract. A pathologic study of 29 metastatic tumors: further evidence for the dominant role of the epithelial component and the conversion theory of histogenesis

Carcinosarcomas of the female genital tract have generally been regarded as a type of sarcoma. Recent evidence suggests, however, that they may be more closely related to carcinoma. The histologic features of 29 carcinosarcomas with documented metastases were analyzed to study the relative importance of the carcinomatous and sarcomatous components and attempt to provide further evidence on the histogenesis of these neoplasms. Patients' ages ranged from 33 to 81 years (mean, 68). The primary tumor originated in the uterus in 17 cases, the ovary in 11, and the fallopian tube in one. Heterologous sarcoma was present in 21 of the primary tumors (72%). Myometrial invasion was present in all 15 of the uterine tumors treated with hysterectomy and consisted only of the carcinomatous component in 12 cases (80%). In two cases, which possibly developed as "collision"-type carcinosarcomas, the myometrium was separately invaded by carcinoma and sarcoma. Myoinvasive tumor consisted solely of sarcoma in one case. Lymphatic-vascular invasion was found in 10 of the primary tumors (eight uterine, two extrauterine) and consisted of pure carcinoma in all instances. The cellular composition of 62 metastases was evaluated. Of these, 51 metastases were diagnosed concurrently with the primary tumor in 21 patients (73%). Eleven metastases were diagnosed from 2 to 26 months after initial treatment. Carcinoma only was found in 43 metastases (70%), both carcinoma and sarcoma in 15 (24%), and sarcoma alone in four (6%). A total of 35 lymph node metastases occurred in 10 cases, consisting of carcinoma alone at 34 sites. The sole example of a purely sarcomatous lymph node metastasis occurred in one of the possible uterine "collision"-type tumors. Intraperitoneal metastases to serosal surfaces or the omentum occurred in 19 cases and consisted of both carcinoma and sarcoma in 14 and carcinoma only in five. Vaginal metastases occurred in four cases and consisted of only carcinoma in two, carcinoma and sarcoma in one and only sarcoma in one. Four patients had distant organ metastases, including one each to the liver (carcinoma only), breast (carcinoma only), bone marrow (sarcoma only), and brain (sarcoma only). Of the 51 concurrent metastases, only carcinoma was present in 37 (73%), both carcinoma and sarcoma in 13 (26%), and sarcoma alone in one. Of the 11 subsequent metastases, carcinoma alone was found in six (55%), sarcoma alone in three (27%), and both carcinoma and sarcoma in two (18%).(ABSTRACT TRUNCATED AT 400 WORDS)

Steroid receptor concentrations in endometrial carcinoma: effect on survival in surgically staged patients

Estrogen and progesterone receptor concentrations were measured in the primary tumors of 137 surgically staged women with clinical stages I and II endometrial carcinoma. For each steroid, increasing receptor concentrations were associated with a decrease in hazard (increase in survival) and the effect was linear for each receptor. When expressed dichotomously, steroid receptor status was also significantly associated with a number of known risk factors, and the significance of the association was influenced by the receptor concentration used as the criterion for receptor positivity. In a multivariate analysis, only progesterone receptor concentration affected survival independently, but the effect disappeared when the analysis was restricted to women with disease confined to the uterus. We conclude that the estrogen and progesterone receptor status of the primary tumor is of limited prognostic significance in endometrial carcinoma unless extrauterine disease is present.

Gynecologic Oncology Group studies with ifosfamide

The Gynecologic Oncology Group has conducted a series of phase II studies with ifosfamide and mesna since 1985. Previously untreated patients received ifosfamide 1.5 g/m2 intravenously daily for 5 days. Mesna was given intravenously every 4 hours three times daily at 20% of the daily ifosfamide dose. Because of the toxic effects observed in previously treated patients with ovarian cancer, the ifosfamide dose was reduced to 1.2 g/m2/d in patients with prior chemotherapy or radiotherapy. In epithelial ovarian cancer, responses were observed in eight (20%) of 41 evaluable patients, with three (7%) complete responses. In patients with squamous carcinoma of the cervix, an 11.1% response rate (three of 27 patients) was observed in those who had received prior platinum therapy. In 51 previously untreated patients, the response rate was 15.7%. In nonsquamous cervical carcinomas, there were three partial responses among 25 patients (12%). An 8.6% response rate was observed among 23 patients with previously treated endometrial adenocarcinomas. In uterine sarcomas, response rates were 30.7% in mixed müllerian tumors, 17.2% in leiomyosarcomas, and 27.3% in endometrial stromal sarcomas. Patients with ovarian sarcomas responded in 27.8% of cases. Studies with ifosfamide combinations are currently under way by the Gynecologic Oncology Group.

[Cutaneous and gynecologic metastases disclosing renal-cell carcinoma: the diagnostic and therapeutic implications]

The spread of is uncommon renal cell carcinoma to the female genital system it is even more uncommon to observe metastasis or its symptoms or signs, masking or preceding the clinical manifestations of the primary lesion. In the course of nephrectomy due to renal tumor, the early ligation of the gonadal vein during the control maneuvers of the vascular pedicle can reduce the risk of posterior genital metastasis. Similarly, the skin is an uncommon site of metastasis. The appearance of cutaneous metastasis from renal cell carcinoma may precede the detection of the underlying tumor, although most of the cutaneous metastases are observed after the primary lesion has been detected. In patients with solitary skin metastasis and no evidence of spread to other organ systems, nephrectomy and excision of the metastatic lesion have permitted a survival of 35% at 5 years.

Solitary cerebral metastases from gynaecological malignancy: the case for radical therapy

Three cases of solitary cerebral metastases from gynaecological malignancy are reported. Each was treated with surgical resection followed by radical radiotherapy resulting in prolonged disease-free survival. The reasons for the increasing incidence of cerebral metastases in these malignancies is discussed, the case for radical treatment made and the literature reviewed.

Comparison of smears and cell blocks in the fine needle aspiration diagnosis of recurrent gynecologic malignancies

A retrospective, seven-year study was conducted to evaluate the value of cell blocks as an adjunct to smears in the fine needle aspiration (FNA) diagnosis of recurrent gynecologic malignancies. Eighty-four FNAs were performed on patients with previously diagnosed malignancies of the cervix (39 cases), ovary (27), uterus (14), vulva (2) and vagina (2). Material for the preparation of cell blocks was available in all cases. Smears and cell blocks were reviewed separately, and the findings were categorized as positive, negative, suspicious or unsatisfactory. Identical smear and cell block results were reported in 71 (84.5%) of the 84 cases (45 positive, 20 negative, 1 suspicious and 5 unsatisfactory). In 12 cases (14.3%) the smear was superior to the cell block in detecting malignant cells; while all 12 smears were positive, 8 cell blocks were negative, and 4 were suspicious. In no case was the cell block positive with a negative smear; in one (1.2%) the cell block was positive and the smear suspicious. The results of this study indicate that the additional study of cell blocks is of little benefit in the FNA cytodiagnosis of recurrent disease in patients with documented gynecologic malignancies.

[Value of colposcopy in diagnosing recurrent gynecologic malignancies]

From 1983 to 1988, colposcopic follow-up examination was done in 82 treated gynecologic tumor patients (68 cervical cancer, 7 vulval cancer and 7 other cancers) comprising 10% of all examined by colposcopy during the same period. Twenty-one cases were found to have recurrence or metastasis in the cervix, vagina or vulva proven by pathology. Ten of these 21 cases were initially diagnosed by colposcopy. The conformation rate between colposcopic examination and pathology was 85.7%. An accuracy of 86.7% was achieved by combination of cytology and colposcopy for recurrent tumors. The results suggest that tumor recurrence can be detected earlier by colposcopy than by clinical examination. Colposcopy combined with cytology as follow-up examination can improve the clinical diagnosis and treatment of treated patients.

[Clinical aspects and morphology of extra-ovarian serous cancer of the pelvis]

An extraovarian peritoneal serous carcinoma is characterised macroscopically by ovaries without pathology, histologically, however, by a serous carcinomatous structure in the pelvis, in an advanced tumour stage of usually marked peritoneal carcinomatosis. Extraovarian pelvic serous carcinomas are rarely described in literature. In our study on five patients with such carcinomas, laparotomy findings revealed peritoneal carcinomatosis as in advanced ovarian carcinomas, but without ovarian involvement. Histogenesis does not reveal any difference between the extraovarian mesothel, which is of Mullerian origin and the serous ovarian carcinoma. Therapy of extraovarian peritoneal carcinoma is similar to that of ovarian cancer with maximal tumour reduction and cisplatinum or carboplatinum containing chemotherapy. The prognosis is extremely unfavourable with little expectation of lengthy remission and survival rates are short. Extraovarian serous carcinomas deserve better recognition because they are underreported. They must be differentiated from malignant mesotheliomas, which are not of Mullerian origin.

[Radical and palliative combined surgery in the surgical treatment of cancer of the rectum]

Analysis of 186 combined resections and extirpations of the rectum for primary carcinoma, among which 31 were palliative operations, showed that the indications for them are limited with age from 21.7% in the young to 12.8% in patients over 60 years of age. Combined interventions were carried out irrespective of the site of the tumor in the rectum. Morphological verification of growth of the tumor into other organs in 32.3% of patients who had been operated on merely points to the expediency of a combined operation excluding ungrounded refusal of treatment. Combined operations failed to lead to an increase in postoperative mortality, which was 5.4%, and produce favourable late-term results--54.5 +/- 4.3% of patients have a survival period of 5 years.

Metastatic adnexal trophoblastic neoplasm: contribution of MR imaging

We report a case of pathologically proven metastatic trophoblastic neoplasm involving the adnexa which occurred after dilatation and curettage and chemotherapy. Duplex doppler ultrasound demonstrated increased vascularity in the adnexa. Angiography was sensitive but did not decisively distinguish between tumor in the adnexa and arteriovenous fistula in the uterus. In addition to abnormal vascularity, magnetic resonance also showed foci of abnormal signal in the adnexa not seen in the uterus and correctly suggested the presence of tumor.

The importance of peritoneal cytology in endometrial carcinoma

From 1971-1986, peritoneal washings were obtained for cytologic examination at the time of primary exploratory laparotomy in 340 patients with endometrial adenocarcinoma. Seventy-two samples (21.2%) contained malignant cells. The finding of malignant cytology increased with stage of disease: stage I, 17%; stage II, 19.5%; stage III, 68.7%; and stage IV, 85.7% (P less than .001). In 248 patients with clinical stage I disease for whom uterine evaluation was complete, there was an increasing incidence of malignant cytology with increasing grade (P = .002), depth of myometrial invasion (P = .003), and adnexal spread (P less than .001). Twelve of 41 patients (29.3%) with clinical stage I and positive cytology developed recurrent disease, compared with six of 207 (2.9%) with negative cytology (P less than .001). Survival for all stages together was poorer in patients with positive washings than in those with negative washings (P less than .001). This difference in survival was also observed in patients with clinical stage I disease (P less than .001). Among patients with surgical stage I disease, disease-free survival was also superior in the group with negative cytology. In both clinical and surgical stage I, intra-abdominal recurrences were more common among patients with malignant peritoneal cytology.

Influence of age on the metastatic behavior of breast carcinoma

The effects of aging on the biologic behavior of malignant neoplasms are poorly understood. To examine the question of a possible age effect on the metastatic behavior of tumors, we reviewed the clinical histories, autopsy protocols, and histologic slides of 187 patients with metastatic breast carcinoma who were subjected to complete autopsy at The Johns Hopkins Hospital. Patients were categorized in four groups according to the age of onset of breast carcinoma: group I had 12 young patients (less than 40 years old); group II had 41 patients, 40 to 46 years old, considered to be premenopausal; group II had 89 patients, 47 to 60 years old, considered to be early postmenopausal; and group IV had 45 patients over 60 years old, considered to be late postmenopausal. Group II patients survived about 50% longer than group III or IV patients (p less than 0.05), and groups I, II, and III patients had significantly greater numbers of metastases than group IV patients (p less than 0.05). There was a progressive decline in the frequencies of metastases in several locations as a function of age, such that group I and II patients had significantly more frequent metastases to the central nervous system (p less than 0.05), endocrine organs (p less than 0.01), ovary (p less than 0.05), pancreas (p less than 0.01), and gastrointestinal tract (p less than 0.05) than patients in group III or IV. These differences in number and distribution of metastases were not explainable on the basis of survival, therapy, or initial stage of disease. The results suggest that the process of aging may influence the metastatic behavior of breast carcinoma; hormonal and metabolic factors may be implicated.

Unusual behavior of low-grade, low-stage transitional cell carcinoma of bladder

A case report of low-grade, low-stage transitional cell cancer of the bladder with isolated metastases to the uterus, fallopian tube, and ovary is presented. The pathogenesis of such unusual behavior for a local bladder malignancy is discussed along with a review of similar cases from the literature.

Metastases to the female genital tract. Analysis of 325 cases

In order to better define the frequency and patterns of metastasis to the female genital tract, all cases of nonhematopoietic metastases to the adnexa, uterus, vagina, and vulva encountered in patients treated at Barnes Hospital between 1950 and 1981 were reviewed. Three hundred twenty-five metastatic cancers from 269 patients were recovered. One hundred forty-nine cases were from extragenital primaries; the remaining tumors were intragenital metastases. Ovary and vagina were the most frequent metastatic sites for both extragenital and genital primaries. The majority of the extragenital metastases were adenocarcinomas from the gastrointestinal tract, but a variety of other primaries did spread, on occasion, to the genital tract. Twenty-seven percent of the metastases presented as possible primary gynecologic lesions, and 75% of these tumors had an extragenital origin. It is shown that despite certain trends in the distribution of metastases, all sites in the female genital tract are at risk for the occurrence of metastases.

Metastases to the female genital tract. Analysis of 325 cases

In order to better define the frequency and patterns of metastasis to the female genital tract, all cases of nonhematopoietic metastases to the adnexa, uterus, vagina, and vulva encountered in patients treated at Barnes Hospital between 1950 and 1981 were reviewed. Three hundred twenty-five metastatic cancers from 269 patients were recovered. One hundred forty-nine cases were from extragenital primaries; the remaining tumors were intragenital metastases. Ovary and vagina were the most frequent metastatic sites for both extragenital and genital primaries. The majority of the extragenital metastases were adenocarcinomas from the gastrointestinal tract, but a variety of other primaries did spread, on occasion, to the genital tract. Twenty-seven percent of the metastases presented as possible primary gynecologic lesions, and 75% of these tumors had an extragenital origin. It is shown that despite certain trends in the distribution of metastases, all sites in the female genital tract are at risk for the occurrence of metastases.

Fibrosarcoma of ovary. A new component in the nevoid basal-cell carcinoma syndrome

An 8-year-old child with nevoid basal-cell carcinoma syndrome who developed abdominal pain underwent exploratory laparotomy. Both ovaries were enlarged and replaced by fibroblastic proliferations having cellular foci with high mitotic indices (greater than 4 mitoses/10 high-power fields) diagnostic of fibrosarcoma. Two years following salpingo-oophorectomy, a metastasis was excised from one adnexa. Further recurrence or distant metastasis was not evident after 6 more years of follow-up. The association of fibrosarcoma of the ovary in a patient with nevoid basal-cell carcinoma further expands the multifarious nature of this syndrome.

The neodymium:YAG laser in the treatment of gynecologic malignancies

The Nd:YAG laser has been used for tumor volume reduction of recurrent gynecologic malignant tumors after previous radiation therapy. The localization of the tumor did not allow conventional surgical resection or surgery was contraindicated because of severe medical problems. Hemorrhage caused by recurrent tumor was controlled by tissue coagulation. The laser beam was delivered by means of a handpiece using the Model 8000 of the Molectron Medical Corporation. A power of 40 to 100 W was used with the maximal pulse duration of 9.9 sec and multiple pulse irradiation. The total energy ranged between 620 and 13.105 Ws. Good palliation was achieved in patients with hemorrhaging tumors of the cervix and ovary metastatic to the vagina.