Biomedical subjects
Publications and source records attributed to J A Carlson.
A 20-year-old female with a primary melanoma of the ovary arising from a mature cystic teratoma presented with bulky peritoneal metastases. Following aggressive surgical resection and platinum-based chemotherapy the patient remains disease-free 5 years following diagnosis.
Measurement of the relative contributions of morphology alone; minimal essential clinical data; immunohistologic reactivity of a prototypic tumor marker, carcinoembryonic antigen (CEA); and the process by which a pathologist can identify the origin of a metastatic adenocarcinoma of unknown primary site is the subject of this report. To standardize the case material, we used an image digitizing and archival system to present 100 metastatic adenocarcinomas of known primary site as unknowns to two pathologists. The images were selected to show only gland-forming areas of the carcinomas and excluded all normal tissue elements. They were viewed, initially without, and then with, identification of gender and metastatic site. Subsequently, the results of immunoperoxidase staining for CEA, assessed independently by a third pathologist, were provided. Our analysis showed that, overall, the correct primary site was chosen as choice 1, 2, or 3 in 72% and 76%, and as choice 1 in 49% and 47% of cases, respectively. Accuracy was highest for prostatic, ovarian, and breast carcinomas, and lowest for upper-gastrointestinal tract, biliary tract, and pancreatic adenocarcinoma. Statistical analysis showed the largest increments in accuracy in the choice 1 prediction in each tumor category were achieved by provision of minimal essential clinical data. Knowledge of CEA status did not affect overall accuracy; however, it increased the odds of making the correct diagnosis for ovarian, colorectal, and endometrial (both pathologists) carcinomas, and for prostatic, pulmonary and esophago-gastric adenocarcinomas (one pathologist). The study exemplifies a model for the objective measurement of the contribution of ancillary studies, such as immunoperoxidase markers, to the accuracy of pathologic diagnosis.
A case of spontaneous internal jugular vein thrombosis associated with distant malignancy is presented. This unusual manifestation of a hypercoagulable state was associated with a low-grade epithelioid leiomyosarcoma of the omentum. It was discovered on a gynecologic oncology service in a patient explored for a pelvic abdominal mass.
Primary vaginal adenocarcinoma unrelated to intrauterine hormone exposure is very uncommon. We report a case of a 52-year-old woman who presented with primary vaginal adenocarcinoma that showed intestinal differentiation with prominent papillary formations and numerous papillary and villous features with prominent goblet cells. There was vaginal adenosis in the immediate vicinity of the tumor. To our knowledge, this is the first reported case of a primary vaginal adenocarcinoma of the intestinal type associated with adenosis in a patient unexposed to prenatal diethylstilbesterol.
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Twenty-five patients with recurrent or advanced-stage endometrial cancer were treated with cisplatin, doxorubicin, and cyclophosphamide (PAC) from May 1982 to November 1987. A retrospective chart analysis was performed to evaluate the effect of treatment on survival and progression-free interval. Toxicity was moderate. Neutropenia was the most common side effect. Age, performance status, and tumor cytoreduction were statistically significant predictors of survival time (P less than 0.03). In the 17 evaluable patients, the response rate was 47%. PAC is an active regimen in the treatment of endometrial cancer. Larger prospective studies are needed to evaluate whether tumor cytoreduction is important in the treatment of this disease.
A registry of ultrasound procedures spanning nearly 5 years was searched retrospectively to discover cases of endometrial cavity fluid collections in postmenopausal women. Twenty cases were identified; all medical records were available for review. One patient was lost to follow-up. Seventeen patients had surgical procedures: 11 had only a D&C, and six had a primary evaluation of laparotomy with removal of the uterus and adnexa. Five women had cancer (two ovarian, one tubal, one endometrial, and one cervical); eight women had benign gynecologic conditions, including uterine fibroids (five), ovarian serous cystadenoma (two), and cervical dysplasia (one). There were two cases of apparent subclinical pyometra. Five women had endometrial pathology consistent with prescribed hormone therapy for breast cancer (four) or endometrial hyperplasia (one).
Group Health Cooperative of Puget Sound is a consumer-governed health maintenance organization with approximately 380,000 enrollees. The enrollees are provided pharmacy services at 3 hospital locations, 28 primary care clinics, and 4 specialty care clinics. A Pharmacy and Therapeutics Committee (P&T) oversees cooperative-wide formulary management of all medications used for inpatients and outpatients, thus decreasing the stock of medications in all the pharmacy locations while providing representative drugs from all therapeutic classes. A subcommittee of the P&T committee, the Antibiotic Usage Review Group, manages the antimicrobial formulary. It consists of staff members from infectious disease, nursing, pulmonary medicine, family practice medicine, and pharmacy departments. The group provides recommendations based on seven specific areas; reviewing requests from prescribers for the addition of new antimicrobial agents to the formulary; evaluating antimicrobial agents by drug class; reviewing potential drugs for therapeutic interchange; developing use criteria for specific antimicrobial agents or classes; developing treatment algorithms for specific infectious diseases; performing drug use evaluations for antimicrobial agents; and approving the use of nonformulary antimicrobial agents. This approach has limited the inappropriate prescribing of antimicrobials and has increased the medical staff's knowledge on appropriate use of these agents.
With the ready availability of powerful desktop computers, the ability to manage large clinical databases has become practical. A computer can enhance the capability of a gynecologic oncology service to catalog, recall, and analyze data about patients, tumors, and therapies. While commercially available database packages can be used for this purpose, we have developed a custom database for tracking the clinical activity of a busy gynecologic oncology service. The system catalogs data about patients, admissions, tumors, and therapeutic modalities and uses this information to generate several useful reports. The reports are used for daily patient care, fellow and resident case statistics, and clinical research. What is unique about the system is that it is optimized for ease of use. The development of this tumor registry, its user friendliness, and advantages over a manual recordkeeping system are described. Unlike other tumor registries, our system is utilized on a daily basis for patient care. Therefore, the data being entered have an immediate usefulness in addition to being simultaneously added to the tumor register for retrospective clinical research. One may hypothesize that it would be useful if all gynecologic oncology services used a common computerized tumor registry that could allow for the sharing of information on a national or global scale.
DNA flow cytometry (FCM) data and estrogen receptor (ER) and progesterone receptor (PR) status were studied in three cases of low-grade stromal sarcoma (LGSS). One case was a primary presentation and the remaining two were recurrent tumors. DNA FCM showed a DNA index (DI) equal to 1.00, consistent with a diploid cell population, for four of the six specimens studied. The other two showed near-diploid populations. Proliferation indices (PI) were low in two of the patients' tumors (8.0 and 12.7%). These findings are consistent with the clinical history of LGSS and its propensity for indolent growth, long intervals between recurrences, and generally favorable prognosis. In case 2, a patient with several recurrences, the PI was increased to 20.3% in a specimen from the first recurrence. She subsequently recurred within 1 year with a more aggressive tumor, characterized by a mitotic index of greater than 10 mitoses/10 high-power fields (HPF), absence of ER and PR, and an aneuploid population (DI = 1.19). Receptor data, obtained by dextran-coated charcoal assay, showed that all tumors except the aggressive recurrence in case 2 had high ER (average 316 fmole/mg protein) and high PR (average 753 fmole/mg protein) levels. These ER and PR data are similar to the two other reports in the literature and the usual clinical response to progestational therapy was demonstrated. Further studies will help define the possible role of FCM and ER and PR determinations in patients with LGSS. These preliminary data suggest that they may be of prognostic significance.
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Treatment of human papillomavirus (HPV) infection of the lower genital tract with trichloroacetic acid was evaluated in a randomized, double-blind fashion at the Hospital of the University of Pennsylvania. Thirty-four patients who had colposcopic and histologic evidence of HPV without dysplasia were entered into the study and randomly placed into either a treatment or placebo group. The treatment group received a single topical application of 50% trichloroacetic acid to the vagina and cervix on day 1. The placebo group was treated in the same manner using saline. The patients were evaluated at 4 and 16 weeks post-treatment for cytologic and histologic evidence of HPV. No differences between the treatment and placebo groups were found. Only one of 16 patients in the treatment group and three of 18 in the placebo group were free of HPV infection at the 4- and 16-week evaluations. Our data suggest that treatment of subclinical HPV infection with trichloroacetic acid is ineffective at this concentration.
Ovarian carcinoma disseminates primarily through the shedding of cells into the peritoneal cavity and subsequent implantation onto peritoneal surfaces. Accurate evaluation of the extent of disease is important both at initial surgical evaluation for staging and at second-look operations to determine the necessity of further therapy. Techniques used for such assessment include node sampling, peritoneal washings, and random biopsies of peritoneal surfaces. Although random biopsies are used by some, others have found them to be of negligible value in the absence of gross disease. The use of cytologic smears of peritoneal surfaces offers a simple method by which cells from a large surface area may be evaluated, and uses equipment readily available to the gynecologist. We compared results of 125 cytologic smears with washings and biopsy specimens obtained during 33 laparotomies for ovarian carcinoma. Cytologic smears identified disease in 48 of 125 sites, whereas biopsy identified only 29 areas of disease. Thirteen of the positive Papanicolaou smears were obtained from clinically disease-free areas. Although the cytologic evaluation of the parietal peritoneal surfaces was more frequently positive than were biopsy specimens, each method identified disease in 16 patients when paired with standard techniques of examination and washing. We conclude that the peritoneal cytologic smear offers an alternative method of further evaluating the extent of disease, particularly when no gross evidence of extraovarian disease is detected.
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The optimal management of stage II carcinoma of the endometrium remains to be established. We reviewed our experience in treating 42 patients with stage II endometrial cancer by surgery, radiation, or combined radiation and surgery at the Hospital of the University of Pennsylvania. The overall 5-year survival was 47.6%. The 5-year survivals of patients treated by surgery only, radiation only, or combination radiation and surgery were 68.5, 36.5, and 46.1%, respectively, which were not significantly different. Histologic grade was found a significant prognostic factor but type of cervical involvement was not. Major complication rates were similar in each treatment group. We conclude that the majority of patients with stage II endometrial carcinoma are best treated by combination radiation and surgery, but in a select subset of patients, radical hysterectomy and lymphadenectomy constitute a reasonable treatment option.
Although many cases of Diethylstilbestrol (DES)-associated clear cell adenocarcinoma (CCA) of the cervix and vagina have occurred, few have arisen in patients whose initial gynecologic evaluation has revealed only nonmalignant DES-related changes. We report a case of a 32-year-old lady who developed a stage II CCA after 8 years of thorough gynecologic examinations. This case substantiates the need for long-term gynecologic assessment in DES daughters.
We are entering an era during which there will be a greater need for medical consultation in obstetric patients, a result of two major trends. The first is the improvement in medical management and surgical intervention which has enabled women with profound medical problems to live to a child-bearing age. The second trend is the delay in child-bearing by women born after 1950. Medical problems and complications increase in frequency with increasing maternal age. The unique features of medical consultations in pregnancy are discussed.