August 1983, Volume 33, Issue 8

Case Reports

Selected Abstracts

Malignant Melanoma of the Female GenitalSystem; a Report of 48 Patients and Review of the Literature. Irving M. Ariel. J. Surg. Oncol., 1981, 16:371-383.
THIS IS a report of 48 female patients with melanoma of the genital area. Such patients comprise 3 per cent of all melanomas. Since the female genital area represents only 1 to 2 per cent of the total skin area, it was concluded that the incidence rate of melanoma of the genital area is no more than that of any other area of the skin.
The mean age of the patients was 56 years with a range from 15 to 84 years. Forty-five of the patients had melanoma on the vulva, the majority, 80 per cent, on the labia niinora and three in the vagina. The most common sythptoms were bleeding or puritis, or both. All of the patients were white. The five year survival rate was 3 1.6 per cent. The treatment of choice was radical vulvectomy or radical dissection of the groin, or both.
-Kofi S. Amankwah.

Risks of Cervical Intraepithelial Neoplasia Among DES-Exposed Women. Wesley C. Fowler, Jr., Grant Schmid, David A Edelman and others. Obstet. GynecoL, 1981, 58:720-724.
IT WAS FOUND that 14.9 per cent of 335 women who had proved exposure to diethyistilbestrol had one cytologic smear interpreted as cervical intraepithelial neoplasia, and 16.2 per cent of the women had one biopsy interpreted as cervical intraepithelial neoplasia. No invasive lesions were noted. The authors conclude that the lesions found in women exposed to diethyistilbestrol should be treated conservatively, but it is imperative that follow-up examinations should be done at least every six months with Pap tests, colposcopy and, if indicated, biopsies.
-William E. C)isp.

Carcinoma of the Cervix: An Attempt to Individualize Treatment; Results of a 20-Year Cooperative Study. J. Zander, J. Baltzer, K. J. Lohe and others. Am. J. Obstet. Gynecol., 1981, 139 :752-759.
THIS ARTICLE is a tantalizing summary of the results of a 20 year German co-operative study involving four universities and over 1,000 patients with carcinoma of the uterine cervix who were studied in detail. Since the article is essentially a summary, it lacks some details, but it makes up for this in the numbers and care taken with the evaluation of the histopathologic study.
The beauty of this co-operative study is the standardization of the operative procedure and the histologic examination of the surgical specimen. The procedure was the Mackinroth-LatzkoMeigs radical abdominal hysterectomy with obligatory pelvic and periaortic lymphadenectomy. The main data regard 980 instances of squamous cell carcinoma, of which 757 were Stage IB, 129 were Stage Ha, 82 were stage IIB, nine were classified as IIA/IIB, and three were Stage III. Most of the data relate to the complication, metastasis to the lymph nodes, and the length of survival of the patients with Stage I and II squamous cell carcinoma.
The detailed pathologic evaluation is unique in that the entire uterine cervix and vagina were blocked and sections made so that the actual tumor volume could be calculated and related to the dimensions of the uterine cervix itself. The lymph nodes were similarly serially blocked. These statistics were calculated by means of detailed computer program. Metastases to the lymph nodes were classified with regard to the finding of tumor cell emboli, that is, tumor cells free in the lymphatic spaces, versus micrometastases and macrometastases in which actual nests of tumor cells were noted in the stroma of the lymph node. In regard to clinical versus histologic staging, the surgical staging correlated reasonably well in Stage I disease, with 68 per cent being correct- This correlation gradually decreased to 47 per cent for Stage IIA disease and 24 per cent for Stage IIB. In general, the failure was a tendency to overestimate the extent of tumor in Stage II disease. Interestingly, the rate of micrometastases and macrometastases to the lymph nodes increased with stage, 19 per cent in Stage lB disease and 41 per cent in Stage IIB, whereas the rate of tumor cell emboli remained about 4 per cent in all stages.
As expected, the number of patients with micrometastases or macrometastases increased with tumor volume, and the five year survival rate decreased with tumor volume. The relationship between the cervical size and tumor size also correlated with the five year survival rate. Lymphatic versus blood vessel invasion,was also examined, and as one would suspect, the five-year survival rate was poorest among those with invasion of blood vessels. Those with more poorly differentiated disease showed the highest incidence of lymphatic and blood vessel invasion.
One of the most interesting findings was that, in both Stage I and II, there was a slight increase in the survival rate among those patients who had operation alone versus those who had operation and radiation. This was not statistically significant for patients with Stage II disease but was for those with Stage I. Unfortunately, we do not know how the patients were selected for radiation therapy, and the details of radiation therapy are not given in this article. There was no difference in those patients who had ovaries retained and those who had ovaries removed, with over 50 per cent of patients having an ovary retained.
Certainly these data are important and show what most gynecologic oncologists believe: that those patients with larger amount of tumor and with tumor involving vascular spaces have a poorer prognosis. The patients with more poorly differentiated lesions also seemed to have a poorer prognosis. The finding of a particularly poor prognosis for those patients with blood vessel invasion, if collaborated by results of other studies, might .indicate those patients at particular high risk who would benefit from systemic chemotherapy. It does not seem that, from the data presented, one can completely rely on the finding of no improvement with radiation, since the method of selecting the patients for this treatment is not given.
-George D. Wilbanks.

Danazol; Endocrine Consequences in Healthy Women. Anthony A. Luciano, Katherine S. Hauser, Frederick K. Chapler and Barry M. ShermanAm. J. Obstet. Gynecol., 1981, 141: 723.
THIS STUDY was undertaken to evaluate the effects of danazol on the function of the pituitary gland and the overies in normal women of reproductive age who are free of known endocrine diseases. Seven women were studied during a normal cycle and two subsequent cycles while receiving 400 mgm. of danazol orally twice a day. During the first two months of study, a blood sample was drawn every other day between 8 and 10 a.m. for determination of levels of leuteinizing hormone, fofficle stimulating hormone, prolactin, estradiol, estrone, testosterone, androstenedione and dehydrocpiandrosterone sulfate. During the second month of treatment, blood samples were obtained twice weekly.
It was concluded that danazol induces an anovulatory state and is associated with normal basal levels of gonadotropin, estrogens and prolactin, increased levels of serum androgens and intact pituitary function as assessed by perturbation tests with gonadotropin releasing hormone, thyrotrophin releasing hormone and estradiol. These results suggested that danazol may have a primary action at the ovary to suppress the normal orderly process of maturation of the fofficles and to enhance atresia, thus resulting in chronic anovulation.
-David L. Barclay.

Surgical Ovarian Lesions in Children. Richard J.Bower and John G. Adkinsh4m. Surg., 1981, 47: 474-478.
THE EXPERIENCE of the authors with the management of 87 patients who had acoplasms of the ovary from 1958 to 1979 is reported upon. The patients ranged from less than one to 16 years of age. The most frequent presenting symptom in this series was abdominal pain in 55 per cent, which led to emergency exploratory laparotomy in 30 per cent of the patient population. Twelve of 87 patients, 14 per cent, were incorrectly diagnosed as having acute appendicitis. Vomiting and vague symptoms suggestive of an infection of the urinary tract were present in a small percentage of patients. A palpable mass was present in 1947 patients, 54 per cent. Evidence of isosexual precocious puberty was present in seven patients, 8 per cent, and all had either granulosa cell or theca cell tumors.
Twenty-four lesions in this series, 28 per cent, were malignant. No malignant lesions occurred in the 16 patients who were less than one year of age. Among the one to five year old patients, five of the 15 tumors, 33 per cent, were malignant, and three of these were granulosa cell tumors associated with precocious puberty. Among the six to ten year old patients, ten of the 28 tumors, 36 per cent, were malignant, with the majority being germ cell tumors. Nine of 29 tumors in the 11 to 16 year old group, 31 per cent, were malignant, again with the majority being germ cell tumors. There was only one instance of bilaterality in this series. This occurred in a 15 year old who underwent bilateral partial oophorectomy for dermoids. It was emphasized that this is much less than the reported incidence rate of 5 to 10 per cent in other series.
Complete details of the histopathologic characteristics and the clinical follow-ui study are given in the article. Twelve of 24 patients with malignant lesions, 50 per cent, are alive at various stages of the follow-up period. The most common malignant tumor in this series was dysgerminoma. There were six instances, five of which were treated with salpingo-oophorectomy and one with bilateral salpingo-oophorectomy. Five patients were diagnosed as having embryonal cell carcinoma and were treated with salpingo­oophorectomy. Four died of the disease, and one patient survived five years only to die of lym­phoma. Three patients had teratomas and were treated with either oophorectomy or salpingo­oophorectomy. Two are alive at five and nine years, and the third has survived with adjuvant therapy despite recurrences in the peritoneum. The most common benign lesions were torsion with hemorrhagic necrosis in 22 of 64 patients, 34 per cent, and benign lesions and dermoid cysts in 17 of 64, 27 per cent. None of the 87 patients died intraoperatively or postoperatively, and no wound infections were reported.
It was emphasized that the tendency to preserve tissue of the ovary is the surgical approach of choice in the pediatric population. Differentiation between benign and malignant lesions cannot be done on the basis of size. If the mass is solid or if the mass is cystic with papillary projections, then it is presumed to be malignant. Totally cystic lesions should be treated as benign with enucleation or conservative ex­cision. If a malignant condition is suspected in the opposite ovary, biopsy is recommended. It was concluded that improvement in survival will depend upon the institution of effective multimodal adjuvant therapy. Because of the rarity of these lesions, this will only be achieved through the enrollment of all patients into protocols which are developed by national co-operative groups.
-Scott Norwood.

Early Invasive Carcinoma of the Vulva. Joseph Buscema, Jeffrey L. Stern and J. Donald Woodruff. Am. J Obstet. Gynecol., 1981, 140:563-569.
IN THIS RETROSPECTIVE. STUDY, 58 patients with early invasive carcinoma or microinvasive carcinoma, or both, of the vulva were reviewed in an effort to correlate the depth of invasion with the results of various surgical therapies. Six patients, 8.6 per cent, had abnormal inguinal lymph nodes. These patients had lesions which invaded the stroma by 3 mm. or more. Recurrence was demonstrated in 11 patients, 19 per cent, with the depth of invasion being 0.8 mm. or more. Importantly, there was no metastasis to the lymph nodes or recurrences in patients with microinvasive carcinoma regardless of the type of surgical therapy used. These results suggest that lesions with nests of invading cells between, but not beyond, the tips of the papillary ridges- that is, microinvasive lesions-are amenable to conservative surgical therapy such as wide local excision.
-Eluis S. Donaldson.

Incidence of Premature Delivery Following the Oxytocin Challenge Test. Patricia S. Braly,Roger K. Freeman, Thomas J. Gante and others. Am. J. Obstet. Gynecol., 1981, 141: 5-8.
A PROSPECTIVE STUDY was undertaken in an effort to delineate the actual incidence of spon­taneous premature labor in patients who have had oxytocin challenge tests at various times during their pregnancies. Twenty-six of 389 patients who had at least one oxytocin challenge test prior to 38 weeks gestation, 6.7 per cent, underwent delivery within five days of an oxytocin challenge test. This compares to an inciclence rate or premature spontaneous ueiivery of 7.5 per cent prior to 38 weeks of gestation with no intervention and a rate to 7.6 per cent among those with nonstress test only. It is concluded that no increased risk of premature labor was observed in patients observed by oxytocin challenge tests.
-Morteza Dim.

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