Synchronous and metachronous endocervical and ovarian neoplasms: evidence supporting interpretation of the ovarian neoplasms as metastatic endocervical adenocarcinomas simulating primary ovarian surface epithelial neoplasms

The vast majority of endocervical adenocarcinomas are high-risk human papillomavirus (HPV)-related neoplasms, characterized by p16 expression and frequent loss of hormone receptor expression, which infrequently metastasize to the ovaries. We report 10 cases of endocervical adenocarcinomas with ovarian metastases in which the ovarian tumors simulated primary ovarian surface epithelial neoplasms. The presence of HPV DNA was assessed to determine whether the ovarian neoplasms were metastases or independent neoplasms. Immunohistochemistry for hormone receptors and p16 was also performed. The ovarian metastases presented concurrently with the primary endocervical tumors in 5 cases, subsequent to the endocervical tumors in 3 cases, and prior to diagnosis of the endocervical tumors in 2 cases. The ovarian tumors ranged in size from 2 to 30 cm, with tumors in 7 cases measuring 10 cm or greater. The ovarian tumors were unilateral in 8 cases and bilateral in 2. In all cases, the ovarian tumors were initially diagnosed as or thought to represent independent primary ovarian surface epithelial tumors (atypical proliferative [borderline] tumors or well-differentiated carcinomas of endometrioid or mucinous type). The endocervical tumors ranged in size from microscopic foci to 3 cm, with depth of invasion ranging from 0.2 to 1.5 cm; in 2 cases, the invasive foci qualified as microinvasive according to Federation Internationale de Gynecologie et d'Obstetrique staging criteria for cervical carcinoma. Adenocarcinoma in situ was identified in all tumors. In all cases, the paired endocervical and ovarian tumors contained identical HPV types. All evaluable tumors were diffusely positive for p16; and in 8 cases, there was absent or only limited expression of hormone receptors. Two of the minimally invasive endocervical tumors were initially interpreted as adenocarcinoma in situ and not recognized as unequivocally invasive even when evaluated in conjunction with the histologically identical ovarian tumors. HPV DNA detection in the ovarian tumors of 2 patients without known cervical disease led to discovery of occult cervical adenocarcinomas in those patients. Endocervical adenocarcinomas, including some qualifying as microinvasive, can metastasize to the ovaries and simulate primary ovarian surface epithelial neoplasms. The presence of HPV DNA in these ovarian tumors confirms that they are metastatic endocervical adenocarcinomas.     

Aberrant peripancreatic arterial anatomy. Considerations in performing pancreatectomy for malignant neoplasms

One-hundred twenty patients with malignant neoplasms of the pancreas referred to the Surgery Branch of the National Cancer Institute over a 5-year period were prospectively examined with selective celiac and superior mesenteric angiography. Forty-one patients (34%) showed various arterial anomalies in the peripancreatic and hepatic areas. The most common anomalies included the right hepatic artery arising from the superior mesenteric artery (16%) and the left hepatic artery arising from the left gastric (11%). Thirty-two of the 120 patients eventually underwent pancreatic resection, and ten of the 32 resected patients (31%) had aberrant arterial anatomy. Recognition of the arterial anomalies permitted resection with no arterial reconstruction in nine of the patients. One patient required sacrifice of an aberrant right hepatic artery that was reconstructed with an anastomosis to the gastroduodenal artery remnant. Selective angiography should be done routinely before any potential radical resection for malignant neoplasms of the pancreas. Recognition of arterial anomalies generally permits satisfactory resection. Even if arterial segments require sacrifice, reconstruction can generally be accomplished with regional vessels, avoiding major arterial grafts.     

Outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface dissemination from ovarian neoplasms

Background

Few data exist on the treatment of peritoneal surface dissemination (PSD) from ovarian cancer (OC) with hyperthermic intraperitoneal chemotherapy (HIPEC). This work represents a review of the authors' institution's experience with HIPEC for PSD from OC.

Methods

Fifty-one patients with OC treated with HIPEC between 1996 and 2009 were identified in a prospectively managed database. All patients underwent maximal tumor debulking followed by HIPEC with mitomycin C, carboplatin, or paclitaxel.

Results

The median survival in this cohort was 29 months. When stratified by resection status, patients undergoing R0 and R1 resections experienced longer median survival than those who underwent R2 resections (47 vs 12 months, P = .0002). Intraoperative blood loss ≤ 400 mL resulted in greater 5-year survival than blood loss > 400 mL (60% vs 15%, P = .025).

Conclusions

This experience demonstrates that long-term survival is anticipated in patients who undergo complete cytoreduction followed by HIPEC for PSD from OC. These findings not only highlight the potential utility of HIPEC in the treatment of OC but also underscore the importance of maximal cytoreduction followed by HIPEC in this cohort of patients.     

Endoscopic laser therapy for gastrointestinal neoplasms

Neoplasms of the esophagus, stomach, duodenum, ampulla, colon, and rectum have been treated with endoscopic laser therapy. For the most part, the therapy has been palliative, although curative treatment has sometimes been achieved. Considerations involved in management of cancers of the GI tract by the laser are discussed and future options envisioned.     

Photodynamic therapy for cutaneous and subcutaneous malignant neoplasms

Twenty-seven patients with cutaneous and subcutaneous malignant neoplasms were treated with photodynamic therapy. Therapy was administered to 248 areas during a total of 72 separate treatment sessions after patients received a total of 45 injections of sensitizer. Seven patients had basal cell carcinoma, three had squamous cell carcinoma, three had malignant melanoma, one had liposarcoma, and 12 had breast cancers. One patient had Bowen's disease. Treatment was given either by surface radiation or interstitially. One month after treatment, 48 (67%) of the treatment sessions resulted in a complete response (no clinical evidence of tumor), and 19 (26%) resulted in a partial response (greater than 50% reduction in the number or size of tumors). Fifteen patients were examinable 12 months after treatment, and in this group, 31 treatment sessions were evaluated as a complete response one month after therapy, 15 (48%) of which retained this status at one year after treatment. By comparing the ability of different light-delivery instrumentation, it was concluded that the Yellow Springs radiometer (Yellow Springs Instruments, model 65A, Yellow Springs, Ohio) provided the most reliable spot power density readings. Straight-tipped fibers are nonhomogeneous and can result in overtreatment of the central area with necrosis and pain and in undertreatment of the periphery.     

Clinical diagnosis of polycystic ovarian syndrome and response to metformin therapy

Objective: To determine the accuracy of diagnosing polycystic ovarian syndrome (PCOS) predominantly on clinical features and the response to metformin therapy. Study Design: Quasi experimental study. Place and Duration of Study: Shifa College of medicine and Shifa International Hospital, Islamabad from January 2003 to July 2006. Patients and Methods: Women fulfilling the inclusion criteria (oligo/hypomenorrhea, infertility, weight gain, hyperandrogenism) were enrolled. Ultrasound pelvis was obtained in all women. Presence of eight or more multiple follicles in both or one ovary without presence of mature follicle was the cutoff number for positive ultrasound. Thyroid stimulating hormone levels were performed in all patients, and patients with abnormal levels were excluded from the study. Metformin was adjusted to 500 mg thrice daily. Six months later patients were again evaluated for response to metformin therapy and those who failed to conceive were given clomiphene citrate along with metformin. Fertility was re-evaluated at the end of one year. Results: At the start of the study, 81% women had menstrual irregularity and 84% had infertility. Hirsutism was seen in 72% while history of weight gain was present in 62% of patients. Ultrasound evidence of polycystic ovaries was seen in 93% of women. After 6 months of metformin therapy, 80% patients had achieved correction in their menstrual irregularity. After 6 months on metformin alone, 51% patients conceived while an additional 20% conceived on both metformin and clomiphene citrate during next 6 months. Overall fertility rate was 71% at the end of one year. There was statistically significant change in pre-treatment and posttreatment BMI. Conclusion: Combination of three or more of the clinical features (irregular cycles, history of weight gain, infertility and hirsutism) provide an appropriate basis for the diagnosis of PCOS. Metformin alone was an effective treatment for PCOS in this series.     

Anabolic therapy for osteoporosis: Parathyroid hormone

Recombinant human parathyroid hormone (PTH 1–34) is the only anabolic agent currently approved for the treatment of osteoporosis. The term anabolic is based on mechanism of action. PTH stimulates bone formation, in contrast to antiresorptive agents, which reduce bone resorption and formation. Recent investigations involving the PTH(1-34) and PTH(1-84) peptides, alone and in combination or sequential regimens with antiresorptive agents, have provided a greater understanding of the place of PTH in the armamentarium against osteoporosis. These studies indicate that adding a bisphosphonate to PTH in previously untreated individuals does not produce additional bone benefit; however, sequential use of PTH followed-up by an antiresorptive agent is highly effective at increasing BMD. Adding PTH after an antiresorptive agent also produces substantial bone density increments, though the magnitude of bone density increase may differ for different antiresorptive agents. PTH can repair underlying micro-architectural defects in bone, improve bone mass substantially, and perhaps change macro-architecture and geometry of bone. There are still many unanswered questions regarding PTH treatment of osteoporosis, including the optimal duration of treatment, optimal dosing regimen, mechanism of resistance to its effect after 18–24 months, and the effect of subsequent rechallenge.     

Strategies for transfusion therapy

Transfusion of allogeneic red blood cells (RBCs), fresh frozen plasma (FFP) and platelets is associated with risks, and outcome studies comparing liberal and restrictive transfusion regimens are lacking in surgical patients. Therefore, guidelines have been established. They recommend first maintaining normovolaemia by the use of crystalloids and colloids. RBC transfusions are recommended for haemoglobin levels <6 g/dl and for physiological signs of inadequate oxygenation such as haemodynamic instability, oxygen extraction>50% and myocardial ischaemia (new ST-segment depressions >0.1 mV, new ST-segment elevations >0.2 mV or new wall motion abnormalities in transoesophageal echocardiography). FFP transfusions are recommended for urgent reversal of anticoagulation, known coagulation factor deficiencies, microvascular bleeding in the presence of elevated (>1.5 times normal) prothrombin time (PT) or partial thromboplastin time (PTT) and microvascular bleeding after the replacement of more than one blood volume when PT or PTT cannot be obtained. Platelet transfusions are recommended prior to major operations in patients with platelet counts <50 000/μl, intraoperatively with microvascular bleeding at platelet counts <50 000/μl and in the range of 50 000–100 000/μl following cardiopulmonary bypass and in patients undergoing surgery where already minimal bleeding may cause major damage such as in neurosurgery.     

Superselective parathyroid hormone determination--a reliable diagnosis of the location of endocrinological active parathyroid neoplasms]

The importance of superselective catheterization of the small jugular veins for PTH-radioimmunoassay is shown as an improvement of the preoperative localization technique. Since May 1976 in 20 patients the diagnosis of pHPT could be established. Our own experiences with the method of small vein sampling combined with the radioimmunoassay demonstrate that a reliable localization of overactive parathyroid tumours is possible.     

Perspectives on pure ovarian stromal neoplasms and tumor-like proliferations of the ovarian stroma

In this study, we discuss the advances in our knowledge of the pathology of pure ovarian stromal neoplasms and discuss tumor-like conditions of ovarian stroma that can mimic ovarian stromal neoplasms clinically, macroscopically, or histologically. This review emphasizes recent studies and those that have significantly advanced our knowledge in the past. The neoplasms in this group occur over a wide age range and are often unilateral. In difficult cases, immunocytochemistry provides improved diagnostic accuracy. The most useful antibodies in this regard are inhibin and calretinin that are positive in most tumors and tumor-like proliferations in the ovarian stromal category. Steroidogenic factor 1 is a promising new marker that has not yet been completely validated. Recent studies of tumors in the fibroma-thecoma group suggest that nuclear atypia is more significant than mitotic activity in the assessment of the biological behavior of these neoplasms. Wherever applicable, we discuss molecular techniques that are currently diagnostically useful.