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The following is a discussion of dyspareunia and its role as an aid to diagnosing pelvic neoplasms. The great majority of cases of dysparenia are psychosomatic in origin, and in a large proportion of the remaining cases, painful coitus is an indicator of benign problems. Nevertheless, painful coitus is a symptom which requires careful pelvic examination to rule out the possibility of pelvic neoplasm and to discover treatable causes of dyspareunia.
Ten patients with abnormal pelvic lymphangiograms underwent fluoroscopically directed percutaneous fine needle aspiration biopsy of retroperitoneal lymph nodes. In all cases, the primary diagnosis had already been established by biopsy or resection. In nine cases, aspiration cytology was positive for the same cell type identified in the primary neoplasm. In one of these nine cases, electron microscopy was utilized to further study the malignant cells in the aspirate. In the tenth case, the aspirate was negative for tumor, and the patient continues to be followed. Cytologic confirmation of lymphangiographically positive or suggestive nodes is useful in pelvic neoplasms and may obviate exploratory surgery in assessing the extent of disease and aid in planning therapy.
The recent development of the high resolution transvaginal probe has increased the diagnostic sensitivity and specificity of transabdominal sonography. This article reviews the applications of transvaginal sonography with pulsed and color flow Doppler imaging to the diagnosis and management of uterine, ovarian, and metastatic pelvic neoplasms.
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The prevalence of inferior vena caval occlusion associated with the Simon nitinol filter (SNF) was studied at two institutions in the follow-up of filters placed over a 13-month period. Twenty-four consecutive patients with defined indications (contraindication to anticoagulation with pulmonary embolism or deep venous thrombosis [DVT], recurrent pulmonary embolism despite anticoagulation, or extensive DVT [eg, iliofemoral]) underwent placement of a SNF. This patient group includes a high proportion with pelvic or renal malignancy (54%, 13 of 24) or a history of other malignancy. Of these 24, physical examination at follow-up identified 10 symptomatic patients with unilateral or bilateral leg swelling. Of these 10, magnetic resonance imaging, with spin-echo and gradient-echo techniques, demonstrated IVC occlusion in five patients (50%). These data suggest that vena caval occlusion following SNF placement occurs more commonly than previously recognized. Possible contributing factors include reduced venous inflow in patients with prior nephrectomy or pelvic neoplasms, pelvic venous compression by tumor mass, and hypercoagulable states.
It has been traditional to exclude patients with radiation-recurrent carcinoma of the uterine cervix or other pelvic neoplasms, incapacitating pelvic pain, postirradiation fistulas, hemorrhage, or malodorous draining tumor necrosis from pelvic exenteration if cure of the malignant disease is not achievable. This negative attitude is a direct result of the reported high morbidity, prohibitive mortality, and low salvage rate previously associated with pelvic exenteration, the only acceptable surgical approach to these diseases. A recent experience with eighteen patients who underwent pelvic exenteration for advanced primary or recurrent carcinoma of the cervix, urinary bladder, or rectum has led us to challenge several traditional concepts regarding this operative procedure. We have observed but one operative death and our morbidity has been minimal. This may reflect our belief that an aggressive pelvic lymphadenectomy in those patients with direct visceral involvement from radiation-recurrent carcinoma of the pelvic viscera is not advantageous since no significant survival has ever been documented for patients with pathologic visceral involvement and positive lymph nodes. In addition, significant morbidity has always been associated directly with pelvic lymphadenectomy in the irradiated pelvis, and elimination of this phase of the operation in selected patients with radiation-recurrent carcinoma is indicated. Moreover, the considerable decrease in morbidity and the minimal mortality observed have led us to adopt a very liberal attitude toward preoperative selection criteria, and we regularly now use pelvic exenteration not only for cure but as intentional palliation in selected patients. We strongly believe that elimination of pain, fistulas, pelvic sepsis, hemorrhage, and malodorous areas of tumor necrosis are important for improving the quality of life for both the patient and family.
A report is presented concerning 31 patients treated by laparoscopic approach under both elective and emergency conditions. The mini-invasive approach to an abdominal disease allows both the making of a direct visual diagnosis and the carrying out of biopsy or actual therapy without the need for laparotomy. Elective diagnostic laparoscopy has proved efficacious in the screening of patients affected by abdomino-pelvic neoplasms, determining the extension of the latter, staging them and judging their operability. Under emergency condition this method lends itself in particular to the study and the treatment of some cases of traumatic haemoperitoneum, intestinal obstructions resulting from adhesions and peritonitis of dubious aetiology. Explorative laparoscopy thus constitutes a valuable diagnostic and therapeutic aid, its possibilities being destined to increase with the improvement of laparoscopic techniques.
Soft tissue sarcomas are the fourth most frequent solid tumors in children. They arise at many sites, most frequently in the orbit, head and neck, and pelvis. Diagnostic radiologic studies play an integral role in patient evaluation, allowing direct visualization of the primary lesion, its vascular supply, its direct and regional extensions; of distant metastases; and of anomalies. They aid in staging and selecting treatment, and later, in evaluating results. Radiation therapy is a vital tool in today's multidisciplinary approach. Irradiation has produced a 90% recurrence-free rate, and a 67% cure rate, for orbital rhabdomyosarcoma. A similar improvement in local tumor control rates may apply at other primary sites when an adequate dose is delivered to the affected volume. Multidrug chemotherapy programs provide hope for an increased cure rate. Sufficient time has not yet elapsed to judge fully the late anatomical and physiological costs of these more vigorous multidisciplinary treatments.
Considerable progress is being made in the chemotherapy of some gynecologic cancers. A random study comparing postoperative irradiation therapy with chemotherapy shows the two to be equally effective. Chemotherapy has the advantages of added safety and of being much less expensive for the patient. Postoperative chemotherapeutic treatment with VAC of patients with embryonal carcinoma of the ovary can prevent recurrence of this frequently fatal tumor. In some patients with advanced embryonal carcinoma of the ovary, chemotherapy with VAC may produce permanent remissions. Combined irradiation and chemotherapy and vincristine and actinomycin-D may be curative for some patients with advanced sarcomas in the pelvis or abdomen. This treatment combination is associated with severe complications; however, some are preventable.
Fourteen cases of yolk sac carcinoma, 10 occurring in gonadal, and four in extragonadal sites, seen at the Indiana University Hospitals from 1949 to 1974, were analyzed with respect to pathologic features, laboratory findings, and clinical course. Their histologic appearance was similar regardless of the site of origin. Two basic histologic types were observed--the more common endodermal sinus pattern and the rare polyvesicular vitelline form. The prognosis is unfavorable, but three of our cases exhibited objective responses to chemotherapy. In our small series, the better prognosis of testicular yolk sac carcinomas in children found by some authors was not evident. Four of the 6 patients with yolk sac carcinoma in which serum alpha-fetoprotein determinations were performed showed positive results. Three of these cases had residual or metastatic disease clinically. The demonstration of alpha-fetoprotein in the serum of patients with yolk sac carcinoma lends further support to the yolk sac origin of these tumors and could also prove to be of prognostic value by indicating the presence of residual or recurrent disease.
The successful management of cancer with high energy radiation requires precise knowledge of the tumor position relative to the body surface and normal organs. Diagnostic ultrasound assists in determining the size and location of tumors and vital normal structures in patients undergoing radiation therapy. Radiation fields can be established dynamically under direct ultrasound imaging, and anatomical information about the tumor, normal organs, and body contour utilized in dosimetry calculations. Diagnostic ultrasound is a safe, noninvasive technique of acquiring anatomical information that cannot be obtained by other routine diagnostic methods. Its application in clinical radiation therapy planning has the potential of improving cure rates and decreasing complication rates.
The optimum radiation treatment plan for any given clinical situation can be achieved by combining various irradiation modalities and beam energies. The availability of equipment that provides photon and electron beams of energies from 4 MeV to 25 MeV permits optimal dose distribution throughout the treatment volume. Since no difference in the biological effectiveness of electrons compared with megavoltage photons has been demonstrated in laboratory studies, there is no hesitation in combining electrons with photons. The selection of the various energies, the combination of electrons with photons, and the ratio of the given doses of each beam depend on the location of the tumor and the maximum depth to be treated. With the use of one beam alone, a combination of 25 MeV and 4 to 6 MeV photon beams, or a combination of photons and electrons, the most effective treatment plan with the available beams can be designed for any clinical situation.
CT body scans obtained on 98 patients before, during, and after radiotherapy were evaluated for their utility in radiotherapy treatment planning and in follow-up after radiotherapy. Twenty-two patients were studied after irradiation. Four received additional treatment, and continuing or planned treatment was withheld from another four on the basis of CT data. Tumor extent was clearly delineated on CT scan in 48/76 cases (63%), suggestive in 25/76 (33%), and not seen in only three (4%). Utilizing CT data relative to all other available tests, in 75 patients, total treatment volume was altered in 34 (45%), tumor coverage was marginal or inadequate in 35 (47%), and volume of normal tissue irradiated was changed in 34 (45%). CT scan data was judged essential for treatment planning in 41, or 55%, of patients studied. Unsuspected areas of tumor involvement were seen in 32 of 75 cases (43%). Use of the CT scan as a patient contour for radiotherapy treatment planning and alternative techniques for inputting the CT data to treatment planning computers are discussed. A simple inexpensive device to accomplish this is described. Speculations are made regarding the impact of CT scanners on transverse axial tomography units and treatment simulators as well as the potential application of the technique in brachytherapy dose computation.
Twenty-six cases of ultrasonically guided percutaneous fine-needle aspiration biopsies of abdominal masses are reported. Included are masses in the pancreas, retroperitoneum, liver, kidney, and pelvis. Aspiration biopsies accurately diagnosed or excluded malignancy in 21 patients (81%). The procedure, performed under local anesthesia, is rapid, simple and almost painless. No complications occurred; specifically, there was no hemorrhage, peritonitis, or spread of tumor along the needle tract.
Because of the recent reports indicating the high incidence of unsuspected diaphragmatic metastases in presumed localized ovarian cancer, we have carried out peritoneoscopy on 14 consecutive patients referred with the diagnosis of Stage I or II ovarian cancer. Of the 14 women none was demonstrated to have diaphragmatic metastases, but 35 per cent were found to have cytologic washings demonstrating malignant cells. The significance of these findings is discussed.
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Ten cases of archenteronoma are reviewed with a follow-up between 2 mo and 7 yr. Their presentation was similar to that of rhabdomyosarcoma except for testicular tumors that may present as a hydrocele. A good prognosis was found with tumors amenable to primary resection and chemotherapy. Other tumors are best treated initially with chemotherapy before relatively conservative surgery, radiotherapy being used either pre- or postoperatively.