Faculty Bibliography

OBJECTIVE:The objective of this study was to assess the clinical utility of a pretreatment barium enema in women with endometrial cancer. METHODS:The medical records of 249 patients with endometrial cancer who underwent a pretreatment barium enema were retrospectively reviewed. The patients' charts were abstracted for demographic information, stage, grade, histology, current disease status, and barium enema results. RESULTS:The pretreatment barium enema was normal in 122 (49%) patients. Diverticulosis was the most common abnormality, reported in 112 (45%) patients. Apparent intraluminal abnormalities were found in 15 (6.0%) patients. Each of these patients underwent colonoscopy prior to treatment for endometrial carcinoma. During colonoscopy, benign colonic polyps were removed from 11 (4.4%) patients. Primary colonic adenocarcinoma was discovered in polypoid lesions removed from 2 (0.8%) patients. Significant luminal narrowing from extrinsic lesions was noted in 2 (0.8%) patients, one at the rectosigmoid and the other at the cecum. No patient was found to have colonic mucosal involvement by endometrial cancer. CONCLUSION/CONCLUSIONS:The results of this study do not justify routine pretreatment barium enema to assess the colonic mucosa for metastatic involvement by endometrial cancer or as a screening tool for colorectal cancer in women with endometrial cancer.

Uterine papillary serous carcinoma (UPSC) is a highly aggressive type of endometrial cancer that occurs in the absence of hyperestrogenism and endometrial hyperplasia. Biologically, UPSC belongs to a distinct group of aggressive neoplasms of the extended Müllerian epithelium that are characterized by hypoestrogenism, advanced disease at diagnosis, a serous papillary histotype, and a dismal prognosis. There is mounting evidence that loss of p53 function is critical for the molecular genetic cause of all tumors in this group. To further assess the role of p53 alterations in UPSC, we studied 40 patients using immunohistochemical expression analysis. Thirty-four tumors (85%) showed intense nuclear overexpression of p53, whereas six tumors (15%) were p53 negative. Thirteen p53-positive tumors had multiple samplings from distinct anatomic sites, and all showed complete concordance in p53 staining, suggesting that p53 alterations occur early in UPSC carcinogenesis. p53 positivity was associated with loss of hormone receptors. Thirty-nine cases were concomitantly analyzed for estrogen or progesterone receptor expression. Among those, 31 tumors were p53 positive but hormone receptor negative throughout, in contrast to only two tumors that were diffusely p53 positive and focally hormone receptor positive. Patients whose tumors overexpressed p53 had a statistically significant shorter survival than those whose tumors did not at 24 and 48 months (P = .03). This study represents one of the two largest analyses published to date that confirm the strong association between UPSC and p53 overexpression. Furthermore, we suggest that the concept of UPSC be broadened: UPSC is a p53-driven neoplasm that biologically is a kin to other serous papillary malignancies of the ovaries and peritoneum. This group of tumors bypasses the slow hormone-dependent pathway of tumorigenesis but instead undergoes early p53 alterations that lead to rapid tumor development.

OBJECTIVE:To evaluate the effect of nasogastric decompression after extensive intra-abdominal surgery in gynecologic oncology patients. METHODS:Over a 1-year period, 110 gynecologic oncology patients undergoing extensive intra-abdominal surgery were enrolled in a randomized controlled trial of postoperative nasogastric tube versus intra-operative orogastric tube decompression. RESULTS:The nasogastric and orogastric groups were similar in age, case distribution, surgery length, and blood loss. The nasogastric group had significantly longer times to first passage of flatus and tolerance of a clear liquid diet than did the orogastric group. However, both groups were similar in time to tolerance of a regular diet and hospital stay. On average, the nasogastric tube was maintained for 3.2 +/- 2.1 days (range 1-8) after surgery. The average daily nasogastric output was 440 +/- 283 mL (range 68-1565). No patient in the orogastric group required a nasogastric tube postoperatively, but one patient in the nasogastric group had a nasogastric tube reinserted for recurrent nausea and vomiting. Use of a nasogastric tube led to significantly more subjective complaints, eg, ear pain, painful swallowing, and nasal soreness, but did not significantly reduce the incidence of abdominal distention or nausea and vomiting. Major complications, eg, pneumonia, atelectasis, gastrointestinal bleeding, and wound breakdown or infection, occurred equally in both groups. However, the incidence of febrile morbidity was significantly greater in the nasogastric group. There were no known anastamotic complications or aspirations in either group. Postoperative changes in hematological indices and electrolytes were comparable in both groups. CONCLUSION/CONCLUSIONS:Postoperative nasogastric tube decompression in gynecologic oncology patients undergoing extensive intra-abdominal surgery does not appear to provide any substantial benefit but significantly increases patient discomfort. As a result of this study, we have eliminated postoperative nasogastric decompression except in highly selected circumstances, such as extensive bowel surgery in patients with prior irradiation or substantial edema from bowel obstruction.

A case of primary retroperitoneal mucinous cystadenocarcinoma of low malignant potential in the presence of normal ovaries is reported. The precise etiology of these neoplasms has not been defined; however, they may arise from heterotopic ovarian tissue, monodermal teratomas, embryonal urogenital remnants, intestinal duplication, or coelomic metaplasia. Although minimal data exist to define the appropriate management, it seems reasonable to extrapolate from the treatment of analogous ovarian neoplasms.

PURPOSE/OBJECTIVE:To determine outcomes and treatment toxicities in patients with optimal (< or = 1 cm residual) Stage III ovarian carcinoma treated with three courses of cisplatin-cyclophosphamide, surgical reassessment (SRA), and hyperfractionated whole abdominal irradiation (WAI). METHODS AND MATERIALS/METHODS:Forty-two eligible patients entered this prospective Phase II study conducted by the Gynecologic Oncology Group (GOG). Disease characteristics were as follows: age range, 32-76 years (median 58); Stage IIIA (n = 1, 2%), IIIB (n = 2, 5%), IIIC (n = 39, 93%); histology-serous papillary (n = 21, 50%); other (n = 21, 50%); Grade 1 (n = 1, 2%); 2 (n = 14, 33%); 3 (n = 27, 54%); residual disease after initial surgery (present: n = 23, 55%; absent: n = 19, 45%). Five patients progressed while on chemotherapy, could not be effectively cytoreduced, and were not eligible for WAI. Of the remaining 37 patients, 35 received WAI. Surgical reassessment was not performed in five patients. RESULTS:Of 37 patients with known SRA status after chemotherapy, 21 (57%) were grossly positive, 4 (11%) were microscopically positive, and 12 (32%) were negative. Based on measurements recorded following initial laparotomy and surgical reassessment, progression during chemotherapy was noted in 40%, stage disease in 37%, and objective response in 23%. Toxicity during hyperfractionated WAI was limited and reversible. No patient beginning WAI failed to complete or required a significant treatment break. Following WAI, six patients underwent laparotomies for abdominal symptoms; five had recurrent disease. Five additional patients were managed conservatively for small bowel obstruction (SBO) or malabsorption, of whom three subsequently developed recurrence. Twenty-two patients having pelvic boosts were significantly more likely to require management for gastrointestinal morbidity (p = 0.0021). Considering all eligible patients, median disease-free and overall survivals were 18.5 and 39 months, respectively. Considering patients completing chemotherapy and WAI, median disease-free and overall survivals were 24 and 46 months, respectively. CONCLUSIONS:(a) Disease progression occurred within three cycles of cisplatin and cyclophosphamide chemotherapy in 40% of patients with optimal (< or = 1 cm residual) Stage III ovarian carcinoma. (b) Following limited chemotherapy, hyper-fractionated WAI was acutely well tolerated. (c) Late radiation-related toxicity was observed in only three patients (8.6%) in the absence of recurrent disease. Late gastrointestinal morbidity was significantly associated with the administration of a pelvic radiotherapy (RT) boost. (d) Short duration chemotherapy followed by SRA and hyperfractionated WAI without a pelvic boost is a promising management option for patients with optimal Stage III ovarian cancer. A Phase III trial will be necessary to determine how this treatment strategy compares with chemotherapy or RT alone in this patient population.

Patients with a palpable mass often benefit most from aspiration. As the clinician tries to aspirate, fluid may be obtained if the lesion is cystic. A solid lesion can be assessed with FNA biopsy with a very high degree of accuracy. Excisional biopsy should be used when a cystic lesion recurs, the mass does not disappear after the cyst is aspirated, or if the fluid obtained is bloody. A solid lesion may need to be excised if the aspirate is negative. The overall detection rate of breast cancer is approximately 20% for excisional biopsies. Mammographically detected lesions can be evaluated with needle-localization biopsies and stereotactic biopsies. The detection rates for breast carcinoma averages approximately 30%, with at least 20% of these lesions being noninvasive. The role of core needle biopsy of palpable lesions is limited; however, histologic confirmation of positive cytologic results from aspirate is possible with this approach. Stereotactic needle biopsy appears to correlate well with the specimen obtained at incisional biopsy and may decrease the need for needle-localized excisional biopsy.

Percutaneous nephrostomy (PN) will rapidly correct renal failure due to ureteral obstruction. Complications of the procedure are few and the procedure can be quickly accomplished on an outpatient basis using local anesthesia. A retrospective review of fifty patients who underwent PN led to derivation of a formula which predicts the expected degree of correction of renal function. Measurement of renal intracalyceal pressures at the time of PN was not helpful in predicting-outcome.

A descriptive study of 67 patients with uterine sarcoma reveals the patients to be elderly (mean age 73 years) with significant co-existent medical problems. Despite this, primary surgical therapy is associated with minimal morbidity. Overall, survival is 63% for disease confined to the uterine corpus, and considerably less for more extensive disease. Nodal status, depth of myometrial invasion, peritoneal washings, cervical involvement, histologic type of sarcoma and treatment do not accurately predict survival. Patients alive 26 months after treatment are likely to survive their disease.

Continued emphasis on treating endometrial cancer primarily as a surgical disease has led to the institution, in 1988, of a new staging system based on operative findings. Since the system is new, limited experience has been published confirming its theoretical advantage in predicting clinical outcome. In a four year period, 117 patients with newly diagnosed endometrial cancer were referred for adjuvant radiation therapy to the Department of Radiation Oncology. All patients were restaged based on surgical findings according to the revised 1988 FIGO Staging System. This requires an assessment of peritoneal washings, myometrial invasion, cervical involvement, adnexal and pelvic/para-aortic lymph node metastasis. 39 patients were excluded, leaving 78 patients who were distributed in each stage as follows: Stage I-39 pts (IA 2 pts, IB 24 pts, IC 13 pts), Stage II-10 pts (IIA 5 pts, IIB 5 pts), Stage III-21 pts (IIIA 6 pts, IIIB 1 pt, IIIC 14 pts). and Stage IV-8 pts (IVA 1 pt, IVB 7 pts). The median follow-up time was 40 months, ranging from 3-82 months. The three year absolute and disease-free survival in each stage were: Stage I-97% and 97%, Stage II-79% and 80%, Stage III-37% and 24%, and Stage IV-13% and 0%, respectively. The locoregional and distant failure rates were: Stage I-3% and 5%, Stage II-20% and 0%, Stage III-10% and 76%, respectively. This retrospective analysis suggests that the survival and distant failure are well predicted by the revised FIGO Staging System, which relies completely on findings at surgical staging.

BACKGROUND:This study reviewed all patients managed by the Gynecologic Oncology service of a tertiary care facility (n = 468) whose deaths occurred between 1980 and 1990 to ascertain the site of death and potential factors affecting whether patients died at home or in a hospital. METHODS:Gynecologic Oncology Tumor Registry data were analyzed for patient diagnosis, age at diagnosis, age at death, marital status, insurance coverage, and year of death in relation to location of death. RESULTS:This study found that 78% of patients died in the hospital, and 22% died at home. The mean terminal hospital stay was 15 days. The variables examined in this study could only accurately predict location of death in 59% of the cases. Examination of the variable year of death, however, demonstrated that the likelihood of death in the hospital generally increased from 1980 to 1990, despite introduction of diagnosis related groups and aggressive efforts by caregivers to facilitate and encourage death at home. CONCLUSIONS:Philosophical and economic considerations to the contrary, a significant majority of terminal patients with gynecologic cancers will die in a hospital, thus extensively utilizing our limited health resources.