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Primary vulvar malignant melanoma: Review and evaluation of surgical management
192
SOCIETY OF GYNECOLOGISTS
adenocarcinoma of the ovary, it has been suggested that UPSC might be responsive to platinum-based cytotoxic therapy. Twenty patients with UPSC were treated with PAC chemotherapy between Jan 1982 and Dee 1989. They included 11 patients with advanced primary disease, 5 with recurrence, and 4 treated in an adjuvant setting. Patients received a median of five cycles of PAC. Only 2 of 10 patients with measureable disease achieved complete clinical responses of 12 and 23 months duration; there were no partial responses. Actuarial 5-year survival for all patients was 25%. The mean progression-free interval was 9 months. A higher survival rate was seen in clinical stages I and II compared to III and IV (P = 0.003). We were unable to correlate survival with depth of myometrial invasion (P = 0.81) or size of residual tumor following initial surgery (P = 0.16). Estrogen receptors were detected in 9 of 11 tumors tested, while progesterone receptors were found in 7 of 8 cases. Seven of 9 patients tested had elevated serum levels of CA-125. Correlation between CA-125 value and clinical course was demonstrated in 3 of 5 patients who had serial measurements. Only 4 patients are currently alive; one has documented disease. Moderate to severe toxicity was seen in 17 patients (85%) and included: neutropenia (13), emesis (9), and anemia (7). There was one possible treatmentrelated death from cardiomyopathy. Despite its similarites to ovarian cancer, UPSC is relatively resistant to PAC chemotherapy. 104. Primary Vulvar Malignant Melanoma: Review and Evaluation of Surgical Management. S. C. P. BRYSON,B. A. JOHNSTON,AND
G. M. LICKRISH,Toronto General Hospital, Toronto, Ontario, Canada, M5G 2C4. Twenty-two previously unreported cases of primary malignant melanoma are retrospectively analyzed for clinical and pathological features, management, and outcome. Also, an English language literature review is summarized. Results show clinical parameters corresponding to previous reports: mean age is 58 years, % of lesions involve the vulvar mucosa, most are pigmented lesions, overall actuarial 5-year survival is 40%. Parity, pregnancy, oral contraception, or postmenopausal hormone therapy are not associated factors. Similar to cutaneous melanomas, the Breslow classification of tumor thickness is a more significant prognosticator in vulvar melanoma than Stage or Clark’s level of invasion. Histologically positive inguinal nodes are found in 33% (versus average of 25%) with a clinical false positive rate of 4% and a clinical false negative rate of 6%. Primary spread is to the inguinal nodes even with central lesions. Although statistical analysis is precluded by the retrospective review, management by radical surgery versus wide local excision neither decreases local, regional, or distant metastases nor improves overall survival. Also, prophylactic inguinal and pelvic node dissection are of no proven benefit. This data is supported by analysis of previous reports. 105. “P-Treatment Carcinoma.
in the Management of Poor Prognosis Endometrial C. E. RAMIREZ,J. CARRODEGUAS, T. MANGUAL,R. C.
WALLACH,AND K. ADAMSONS. Endometrial carcinoma carries a poor prognosis when there is deep myometrial invasion, peritoneal cytologic spread, adnexal metastases, distant metastases, or papillary serous histology. In an attempt to improve control in these cases, we have employed intraperitoneal radioactive phosphorus “P. Seventeen patients had endometrioid adenocarcinema with deep myometrial invasion and of these, 4 had positive peritoneal cytology, 2 had adnexal metastases, and one had omental implants. Nine patients had cancer of the papillary serous type. Postoperatively 15 MC of 32Pdiluted in 2000 ml saline were instilled into the peritoneal cavity. Twenty-six patients have been followed for at least 24 months, and 19 for at least 36 months. After 24 months, 25 were clinically free of disease. None of the patients demonstrated additional morbidity to pelvic irradiation because of ‘*P therapy. We conclude that the addition of 3ZPto the treatment of poor prognosis en-
ONCOLOGISTS-ABSTRACTS dometrial cancer increases the disease free survival, and appears to provide higher cure rates than conventional treatment. 106. Acceleration of Fetal Maturation with Intraamniotic Thyroxine in G. REYES, the Presence of Maternal Malignancy. J. ROMAGUERA,
D.
CAISEDA,
R. C.
WALLACH,
AND
K.
ADAMSONS.
Acceleration of fetal maturation with intraamniotic administration of thyroxine was employed in eight patients in whom preterm delivery was necessary because of malignant disease of the mother. Thyroxine (200 mcg to 500 mcg) was given at weekly intervals starting at the 27th to 32nd week of gestation until the L-S ratio exceeded 2.0. The fetuses were delivered between Weeks 29.4 and 34.0. None of the newborns suffered from respiratory distress syndrome, and three newborns were cared for in the regular nursery. Thyroxine-induced acceleration of fetal maturation and preterm delivery permits earlier initiation of antineoplastic and radiation therapy without exposing the fetus to the hazards of maternal therapy and those of prematurity. 107. cis-Platinum Chemotherapy as Radiation Sensitizer for Radioactive “P in Ovarian Cancer. ROLANDA. PATTILLO,HUSSEINM. ABDEL-
DAYEM, ANNA C. RUCKERT,KUTLAN OZKER, CHARLESWILSON, KAREN HAMILTON, AND B. DAVID COLLIER, Obstetrics & Gynecology and Nuclear Medicine, Medical College of Wisconsin, 8700 W. Wisconsin Avenue, Milwaukee, Wisconsin 53226. No previous study of radiation sensitizing potential of cis-platinum for p irradiation of radioactive “P has been reported. The present study employed ovarian cancer in vitro and asks the following questions: What is the effect of cis-platinum alone, what is the effect of “P alone, what is the effect of cis-platinum plus ‘*P? The LD,,, (lethal dose), as determined by Trypan dye exclusion, was determined on doses of chemotherapy and radiochemical comparable to those used in vivo. The log of survival fractions of cells was calculated and thermal luminescence dose (TLD) was used to measure absorbed radiation dose. The results show that there was a linear cell killing response between the doses of chemotherapy and “P with the TLD reading. The survival fraction at 14 days was 0.10 for cis-platinum alone, 0.06 for ‘*P alone, and 0.02 for the combination. It was concluded that the results of this study support a radiation sensitizing effect of cis-platinum and establish the basis for clinical trials of IV cis-platinum and intraperitoneal ‘*P for all stages of ovarian cancer. With the establishment of the scientific basis for sequential combined therapy a clinical trial has been initiated. The purpose of this presentation is therefore to enlist collaboration in a prospective study of the radiation sensitizing effect of cis-platinum chemotherapy on “P and to determine its impact on all stages of ovarian cancer. 108. Relative Prevalence of 14 Major Anogenital HPVs in Health and Disease. A. T. LORINCZ,R. REID, A. B. JENSON,R. J. KURMAN, ANDY. DAOUD, Bethesda, Maryland; Washington, D.C.; Detroit, Michigan. A large cross-sectional study was undertaken to clarify confusion about the true prevalence of anogenital HPV infection, to evaluate the contribution of the more recently cloned types, and to derive relative risk estimates quantifying differences for HPVs 6, 11, 16, 18, 31, 33, 35, 42, 43, 44, 45, 51, 52, and 56. Subject material came from two sources: exfoliated cervical cells collected during cytologic and colposcopic screening of 1924 women and colposcopic biopsies from 703 women with abnormal Pap smears or known cancers. Specimens from these 2627 women were screened by low stringency Southern blot, and positives were then verified at high stringency, using a panel of 14 probes. HPV DNA was identified in 165 (9.02%) of 1829 normals, 261 (67.97%) of 384 condy/CIN Is, 228 (87.36%) of 261 CIN 2-3s, and 136 (88.89%) of 153 invasive cancers (133 squamous; 16 adeno). Our
SOCIETY OF GYNECOLOGISTS
adenocarcinoma of the ovary, it has been suggested that UPSC might be responsive to platinum-based cytotoxic therapy. Twenty patients with UPSC were treated with PAC chemotherapy between Jan 1982 and Dee 1989. They included 11 patients with advanced primary disease, 5 with recurrence, and 4 treated in an adjuvant setting. Patients received a median of five cycles of PAC. Only 2 of 10 patients with measureable disease achieved complete clinical responses of 12 and 23 months duration; there were no partial responses. Actuarial 5-year survival for all patients was 25%. The mean progression-free interval was 9 months. A higher survival rate was seen in clinical stages I and II compared to III and IV (P = 0.003). We were unable to correlate survival with depth of myometrial invasion (P = 0.81) or size of residual tumor following initial surgery (P = 0.16). Estrogen receptors were detected in 9 of 11 tumors tested, while progesterone receptors were found in 7 of 8 cases. Seven of 9 patients tested had elevated serum levels of CA-125. Correlation between CA-125 value and clinical course was demonstrated in 3 of 5 patients who had serial measurements. Only 4 patients are currently alive; one has documented disease. Moderate to severe toxicity was seen in 17 patients (85%) and included: neutropenia (13), emesis (9), and anemia (7). There was one possible treatmentrelated death from cardiomyopathy. Despite its similarites to ovarian cancer, UPSC is relatively resistant to PAC chemotherapy. 104. Primary Vulvar Malignant Melanoma: Review and Evaluation of Surgical Management. S. C. P. BRYSON,B. A. JOHNSTON,AND
G. M. LICKRISH,Toronto General Hospital, Toronto, Ontario, Canada, M5G 2C4. Twenty-two previously unreported cases of primary malignant melanoma are retrospectively analyzed for clinical and pathological features, management, and outcome. Also, an English language literature review is summarized. Results show clinical parameters corresponding to previous reports: mean age is 58 years, % of lesions involve the vulvar mucosa, most are pigmented lesions, overall actuarial 5-year survival is 40%. Parity, pregnancy, oral contraception, or postmenopausal hormone therapy are not associated factors. Similar to cutaneous melanomas, the Breslow classification of tumor thickness is a more significant prognosticator in vulvar melanoma than Stage or Clark’s level of invasion. Histologically positive inguinal nodes are found in 33% (versus average of 25%) with a clinical false positive rate of 4% and a clinical false negative rate of 6%. Primary spread is to the inguinal nodes even with central lesions. Although statistical analysis is precluded by the retrospective review, management by radical surgery versus wide local excision neither decreases local, regional, or distant metastases nor improves overall survival. Also, prophylactic inguinal and pelvic node dissection are of no proven benefit. This data is supported by analysis of previous reports. 105. “P-Treatment Carcinoma.
in the Management of Poor Prognosis Endometrial C. E. RAMIREZ,J. CARRODEGUAS, T. MANGUAL,R. C.
WALLACH,AND K. ADAMSONS. Endometrial carcinoma carries a poor prognosis when there is deep myometrial invasion, peritoneal cytologic spread, adnexal metastases, distant metastases, or papillary serous histology. In an attempt to improve control in these cases, we have employed intraperitoneal radioactive phosphorus “P. Seventeen patients had endometrioid adenocarcinema with deep myometrial invasion and of these, 4 had positive peritoneal cytology, 2 had adnexal metastases, and one had omental implants. Nine patients had cancer of the papillary serous type. Postoperatively 15 MC of 32Pdiluted in 2000 ml saline were instilled into the peritoneal cavity. Twenty-six patients have been followed for at least 24 months, and 19 for at least 36 months. After 24 months, 25 were clinically free of disease. None of the patients demonstrated additional morbidity to pelvic irradiation because of ‘*P therapy. We conclude that the addition of 3ZPto the treatment of poor prognosis en-
ONCOLOGISTS-ABSTRACTS dometrial cancer increases the disease free survival, and appears to provide higher cure rates than conventional treatment. 106. Acceleration of Fetal Maturation with Intraamniotic Thyroxine in G. REYES, the Presence of Maternal Malignancy. J. ROMAGUERA,
D.
CAISEDA,
R. C.
WALLACH,
AND
K.
ADAMSONS.
Acceleration of fetal maturation with intraamniotic administration of thyroxine was employed in eight patients in whom preterm delivery was necessary because of malignant disease of the mother. Thyroxine (200 mcg to 500 mcg) was given at weekly intervals starting at the 27th to 32nd week of gestation until the L-S ratio exceeded 2.0. The fetuses were delivered between Weeks 29.4 and 34.0. None of the newborns suffered from respiratory distress syndrome, and three newborns were cared for in the regular nursery. Thyroxine-induced acceleration of fetal maturation and preterm delivery permits earlier initiation of antineoplastic and radiation therapy without exposing the fetus to the hazards of maternal therapy and those of prematurity. 107. cis-Platinum Chemotherapy as Radiation Sensitizer for Radioactive “P in Ovarian Cancer. ROLANDA. PATTILLO,HUSSEINM. ABDEL-
DAYEM, ANNA C. RUCKERT,KUTLAN OZKER, CHARLESWILSON, KAREN HAMILTON, AND B. DAVID COLLIER, Obstetrics & Gynecology and Nuclear Medicine, Medical College of Wisconsin, 8700 W. Wisconsin Avenue, Milwaukee, Wisconsin 53226. No previous study of radiation sensitizing potential of cis-platinum for p irradiation of radioactive “P has been reported. The present study employed ovarian cancer in vitro and asks the following questions: What is the effect of cis-platinum alone, what is the effect of “P alone, what is the effect of cis-platinum plus ‘*P? The LD,,, (lethal dose), as determined by Trypan dye exclusion, was determined on doses of chemotherapy and radiochemical comparable to those used in vivo. The log of survival fractions of cells was calculated and thermal luminescence dose (TLD) was used to measure absorbed radiation dose. The results show that there was a linear cell killing response between the doses of chemotherapy and “P with the TLD reading. The survival fraction at 14 days was 0.10 for cis-platinum alone, 0.06 for ‘*P alone, and 0.02 for the combination. It was concluded that the results of this study support a radiation sensitizing effect of cis-platinum and establish the basis for clinical trials of IV cis-platinum and intraperitoneal ‘*P for all stages of ovarian cancer. With the establishment of the scientific basis for sequential combined therapy a clinical trial has been initiated. The purpose of this presentation is therefore to enlist collaboration in a prospective study of the radiation sensitizing effect of cis-platinum chemotherapy on “P and to determine its impact on all stages of ovarian cancer. 108. Relative Prevalence of 14 Major Anogenital HPVs in Health and Disease. A. T. LORINCZ,R. REID, A. B. JENSON,R. J. KURMAN, ANDY. DAOUD, Bethesda, Maryland; Washington, D.C.; Detroit, Michigan. A large cross-sectional study was undertaken to clarify confusion about the true prevalence of anogenital HPV infection, to evaluate the contribution of the more recently cloned types, and to derive relative risk estimates quantifying differences for HPVs 6, 11, 16, 18, 31, 33, 35, 42, 43, 44, 45, 51, 52, and 56. Subject material came from two sources: exfoliated cervical cells collected during cytologic and colposcopic screening of 1924 women and colposcopic biopsies from 703 women with abnormal Pap smears or known cancers. Specimens from these 2627 women were screened by low stringency Southern blot, and positives were then verified at high stringency, using a panel of 14 probes. HPV DNA was identified in 165 (9.02%) of 1829 normals, 261 (67.97%) of 384 condy/CIN Is, 228 (87.36%) of 261 CIN 2-3s, and 136 (88.89%) of 153 invasive cancers (133 squamous; 16 adeno). Our