Second-look laparotomy in the management of gynecologic malignancy

Eighty-four second-look laparotomies performed between June 1972 and March 1981 were reviewed. Sixty-three patients had epithelial carcinoma of the ovary. The other malignancies represented include nonepithelial cancer of the ovary, cancer of the uterine fundus, and adenocarcinoma of the fallopian tube. All patients were without objective evidence of intraperitoneal disease just prior to the laparotomy. In the epithelial ovarian carcinoma group, the outcome of the laparotomy was affected by stage, histologic type, histologic grade, and presence of residual disease after initial tumor-reductive surgery. The type of treatment didn't seem to affect laparotomy outcome. Recurrence after a negative second-look laparotomy was affected by stage and presence of residual disease after initial tumor reduction. The second-look laparotomy remains the most sensitive indicator of persistent disease in epithelial carcinoma of the ovary. Experience with second-look laparotomies in other gynecologic malignancies is increasing.     

Intrauterine growth of chronically instrumented rhesus monkey fetuses

The effect of surgical and experimental manipulations on intrauterine growth of the fetus was investigated in 61 rhesus monkey fetuses in which chronic preparations were attempted. The surgical procedure consisted of hysterotomy and insertion of vascular catheters and included unilateral ligation of the fetal carotid artery. The mother was kept in a restraining chair after the operation for the duration of the preparation (0 to 39 days). Thirty-four fetuses who died within 48 hours after operation served as the control group for the growth parameters. The remaining fetuses that survived 7 days or more after the operation were included in the experimental group. Body weight, crown-rump length, crown-heel length, and foot length of the fetus and placental weight were measured at the termination of the preparation. There were significant linear correlations between all parameters and gestational age. Comparison between the control and experimental groups revealed that none of the parameters from the experimental group differed significantly from those of the control group. No relationships were found between the duration of the preparation and any of the parameters. Total brain weights from 19 fetuses exhibited a significant increase with gestational age and these values were within the normal range reported previously. There were no significant differences in weight between right and left cerebral hemispheres. No evidence of unequal blood flow to the cerebral hemispheres was found with the radioactive microsphere technique. The data suggest that the surgery performed on both the mother and the fetus and prolonged maternal restraint did not alter intrauterine fetal development.     

Pharmacokinetic study of moxalactam in patients undergoing gynecologic operations

Moxalactam was administered prior to operation to patients undergoing operation for a known or suspected gynecologic malignancy. Subsequent plasma and tissue levels demonstrated a prolonged duration of action and rapid concentration in pelvic organs after infusion.     

Effect of antepartum glucocorticoid administration upon neonatal respiratory distress syndrome and perinatal infection

A double-blind, randomized study comparing the antepartum use of betamethasone (12 mg), methylprednisolone (125 mg), and hydrocortisone (250 mg) was performed to evaluate effect on neonatal respiratory distress syndrome and perinatal infection. Of 144 mothers and 149 infants entered, 92 mothers and 97 infants were available for analysis. The betamethasone-treated group had a significantly reduced incidence of severe respiratory distress syndrome (4%) compared with the control group (26%; p = 0.038); this effect was confined to patients who received at least two doses. No similar effect was found in the methylprednisolone or hydrocortisone groups. Neonatal infection and neonatal mortality rate were not affected by glucocorticoid use. Maternal infection was significantly increased in hydrocortisone-treated patients who were delivered vaginally compared with control patients (all patients: 50% versus 9.5%, p less than 0.05; with ruptured membranes: 63% versus 15%, p = 0.04). No similar increase in maternal infection was found with betamethasone or methylprednisolone use.     

Arterio-enteric fistula following pelvic radiation: a case report.

Two cases of arterial perforation into the small bowel are reported. Etiology was not determined in one case, but surgical trauma leading to localized infection in the irradiated tissue seemed responsible in the other. After the initial episode of hemorrhage, there was a symptom-free interval before its reappearance and vascular collapse. This is believed to be due to the distensibility of the large bowel. The site of arterial perforation was determined pre-operatively in one case by selective arteriography. Review of the recent literature relevant to transcatheter arterial embolization suggests that it may have potential in management of the arterio-enteric fistula as an alternative to or an aid in surgical correction by stabilizing the patient in a favorable condition.     

The prognostic significance of tumor emboli in lymphatic or vascular spaces of the cervical stroma in Stage IB squamous cell carcinoma of the cervix

The presence of tumor emboli in lymphatic or vascular spaces within the cervical stroma in squamous cell carcinoma of the cervix has been reported by several authors to be associated with a decrease in 5-year survival. In a 10-year review of 124 radical hysterectomies for Stage IB squamous cell carcinoma of the cervix at the University of Michigan from 1970 to 1980 the presence of tumor emboli in the cervical stroma without other known risk factors did not significantly alter the 3- and 5-year survival. With the potential risks and lack of proved benefit the use of adjuvant radiotherapy or chemotherapy in this setting is not recommended.     

Postoperative external pelvic irradiation in carcinoma of the corpus stage I: A controlled clinical trial

During the years 1968–1972, 386 patients entered a controlled clinical trial with the aim of assessing the value of external high voltage irradiation in carcinoma of the corpus Stage I. After primary surgery, all patients received intravaginal radium application delivering 6000 rads to the vaginal wall. They were then allocated to one of two groups by random numbers. Group A received no further treatment, while Group B was given 4000 rads of high voltage irradiation to a pelvic field. During a follow-up period of between 2.5 and 7 years no difference was found in the number of deaths and recurrences between the two treatment groups. The frequency of local recurrences in the vagina and the pelvis was higher in Group A. This was outweighed by a higher number of distant metastases in Group B. It is concluded that possibly only those cases with anaplastic tumours infiltrating deep in the myometrium may benefit from additional external radiotherapy.     

Peritoneal fluid prostaglandins and prostanoids in women with endometriosis, chronic pelvic inflammatory disease, and pelvic pain

Peritoneal fluid obtained at laparoscopy from 49 women was measured for its content of prostaglandin E2 (PGE2), prostaglandin F2 alpha (PGF2 alpha), 6-keto-prostaglandin F1 alpha (6-KF), and thromboxane B2 (TxB2) by specific radioimmunoassays. In normal women (n = 10), the concentrations of prostaglandins in peritoneal fluid were (mean +/- SE): PGE2 = 0.79 +/- 0.26, PGF2 alpha = 0.60 +/- 0.18, 6-KF = 0.48 +/- 0.19, and TxB2 = 0.23 +/- 0.09 ng/ml; in women with endometriosis (n = 16): PGE2 = 1.43 +/- 0.72, PGF2 alpha = 1.52 +/- 0.59, 6-KF = 3.32 +/- 0.71, and TxB2 = 1.14 +/- 0.69 ng/ml; in women with chronic pelvic inflammatory disease and/or obstructed tubes (n = 19): PGE2 = 1.94 +/- 1.04, PGF2 alpha = 1.20 +/- 0.61, 6-KF = 1.55 +/- 0.40, and TxB2 = 0.64 +/- 0.24 ng/ml; in women with pelvic pain without any visible pathologic condition (n = 4): PGE2 = 1.11 +/- 0.66, PGF2 alpha = 0.73 +/- 0.55, 6-KF = 1.35 +/- 0.35, and TxB2 = 0.39 +/- 0.17. The mean volumes of peritoneal fluid recovered were 10 to 16 ml and were not significantly different between the groups. Except for a significantly elevated concentration of 6-KF in the peritoneal fluid of women with endometriosis compared to normal women (p = less than 0.02), the prostaglandins measured did not differ significantly between the groups of women studied. The possible significance of elevated 6-KF in the peritoneal fluid of women with endometriosis is discussed.     

Psychosocial adjustment to pelvic exenteration

A structured interview was used in 16 patients who underwent pelvic exenteration for gynecologic cancer to determine the factors that influenced patients' acceptance of the procedure and their physical, mental, and social recovery. Patients were interviewed pre- and postoperatively, with the longest follow-up being 44 months. Not only does the surgery offer a significantly improved prognosis, but the quality of this life is very satisfactory, with only sexual function compromised.     

Free serum amino acids in patients with advanced cervical carcinoma

Free serum amino acids were measured in patients with untreated advanced cervical carcinoma and compared to amino acid concentrations in normal patients. Of the 20 amino acids measured, 11 were significantly elevated in the patients with carcinoma.     

Subcutaneous emphysema secondary to perforated radiation proctosigmoiditis

An apparently unique case history of subcutaneous emphysema presenting in the head and neck arising from perforated radiation proctosigmoiditis is reported.     

Hemodynamic parameters following pelvic exenteration

Hemodynamic parameters were prospectively studied in 31 patients who underwent pelvic exenteration. With the use of a thermistor-tipped pulmonary artery catheter, hemodynamic parameters were calculated during the intraoperative and acute (less than 48 hours) postoperative interval. The mean operative time was 5.5 +/- 0.8 hours, and volume replacement (mean, 21.6 ml/kg/hr) consisted of crystalloid, colloid, and blood. Postoperative urine production (mean, 1.9 ml/kg/hr) was maintained with crystalloid (mean, 2.5 ml/kg/hr), colloid (0.2 ml/kg/hr), and blood (0.4 ml/kg/hr). Despite individual variations, the important parameters of cardiovascular function were maintained in the physiologic range. No patient developed cardiovascular or respiratory failure. We believe that the lack of perioperative morbidity and mortality was related, in substantial part, to this type of cardiovascular monitoring, which allows for the prompt diagnosis of potential problems and enables the physician to make appropriate interventions to correct these problems.     

Single-fraction palliative pelvic radiation therapy in gynecologic oncology: 1,000 rads

The management of the patient with advanced gynecologic malignancies presents multiple problems for the gynecologic and radiation oncologists involved in their care. When palliative management only is indicated, conventional treatment protocols occupy a significant portion of the patient's remaining life span, oftentimes with associated morbidity. Single-fraction external radiation therapy, consisting of 1,000 rads to the whole pelvis, was used in 30 patients with advanced gynecologic malignancies to palliate locally advanced pelvic disease. Alleviation of symptoms and maintenance of a reasonable quality of life were obtained in all patients. No untoward acute side effects were observed. Thirteen patients are alive from 2 to 19 months after treatment, with a mean overall survival after treatment of 8.4 months. It is concluded that this regimen should be considered as the palliative therapy of choice for certain patients with advanced gynecologic malignancies.     

False-negative Pap smear in uterine malignancy

For the period 1964 to 1976, Papanicolaou smears of 384 patients with uterine malignancies admitted to Cook County Hospital were studied. There were 36 negative Pap smears in a group of 307 patients with invasive cervical carcinoma (11.7% false-negative rate), and three negative Pap smears in a group of 45 patients with in situ squamous cell carcinoma of the cervix (6.6% false-negative rate). Forty-seven of 77 patients with endometrial carcinoma had negative cytologic examinations (51.9% false-negative rate). Because routine cervicovaginal cytology is not as satisfactory for the detection of endometrial carcinoma as it is for squamous cell carcinoma of the cervix, the importance of other screening techniques for endometrial carcinoma is discussed.     

Infectious morbidity associated with pelvic exenteration

Forty-six consecutive cases of pelvic exenteration were retrospectively reviewed to identify the infectious morbidity incurred with this procedure in the absence of prophylactic antibiotic administration. Thirty (65%) of these patients required antibiotics (other than urinary tract suppressants) during their hospitalizations. Twenty-one patients (46%) had serious infections. Asymptomatic bacteruria (72%), pelvic cellulitis (70%), abdominal wound infections (28%), pyelonephritis (15%), and septicemia (15%) were the most common infections encountered. Analysis of the data identified several areas in which infectious morbidity could be circumvented without antibiotic therapy.     

Cryosurgical treatment of cervical intraepithelial neoplasia: Analysis of failures

Cryosurgery is rapidly becoming the treatment of choice for cervical intraepithelial neoplasia (dysplasia and carcinoma in situ) in the young woman desirous of retaining her reproductive capacity. This report analyzes 87 cases of cervical intraepithelial neoplasia treated with cryosurgery on one municipal hospital service. Twenty-seven patients (31.0%) were lost to follow-up. Of the 60 patients on whom follow-up from 6 months to 3 years is available, 28 (46.6%) are documented treatment failures. The causes of failure are analyzed and comparisons from the current literature are made.     

The use of para-aortic radiation therapy based on lymphangiogram interpretation in uterine cervical carcinoma

From January, 1965, to June, 1979, 79 nonrandomized patients with carcinoma of the uterine cervix had a bipedal lymphangiogram (LAG) prior to radiotherapy at the Stanford University Medical Center. In 32 patients the LAGs were interpreted as normal. Of the remaining 47 patients, 28 had LAGs interpreted as positive for metastatic involvement of pelvic nodes alone, 11 as positive for pelvic and para-aortic (PA) metastasis, and 8 as positive in PA nodes alone. Five-year survival and freedom from relapse (FFR) were found to be similar for patients with LAGs interpreted as normal or positive in pelvic nodes only (all stages combined). The addition of elective PA irradiation in those patients with positive pelvic nodes alone (median 5000 rad/5 weeks) did not enhance either survival or FFR in this group. The 19 patients with positive PA nodes had significantly worse survival and FFR when compared with the other groups. Survival was not enhanced by the addition of therapeutic PA irradiation (median 5000 rad/5 weeks) and the 7 patients in this group so treated appeared to have a reduced FFR when compared to the 12 untreated patients. Irrespective of the location of nodal abnormality on LAG and regardless of stage, the majority of relapses ( ) occurred either centrally or at the pelvic sidewalls. It is concluded that the LAG is a good predictor of subsequent relapse and survival, but that the addition of either elective or therapeutic PA radiotherapy based on LAG interpretation does not affect survival of FFR and should, therefore, be considered for investigational or palliative use only.