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Primary adenomas are common in the gastrointestinal tract but exceedingly rare on the periurethral surface and vagina. The pathogenesis remains unknown but vaginal adenomas are hypothesized to arise from vaginal adenosis or embryonic cloacal remnants and possess malignant potential. We present a case of a large primary vaginal tubulovillous adenoma in an eighty-one-year-old, likely diethylstilbestrol naïve patient. To the best of our knowledge the patient's 7.4 x 4.5 × 1.4 cm primary vaginal tubulovillous adenoma is the largest ever reported in literature.

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Uterine leiomyosarcoma (uLMS) is a rare aggressive malignant mesenchymal tumor with high risk of recurrence and poor prognosis regardless of stage. It is often diagnosed postoperatively following myomectomy, hysterectomy or supracervical hysterectomy for presumed benign disease. Primary surgery at the diagnosis of uLMS is considered to affect outcomes. If the tumor was morcellated, the oncologist will encounter special problems that require knowledgeable management of peritoneal metastases. We previously reported that six patients who successfully underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) plus early postoperative intraperitoneal chemotherapy (EPIC) to manage the disease dissemination that must occur following morcellation. This is a study for long-term outcome of these patients. Six patients were treated with an absence of grade IV adverse events and no mortality. The median Peritoneal Cancer Index (PCI) was 18 and complete cytoreduction without peritoneal metastases visualized within the operative field at the completion of the surgical procedure (CC-0) was achieved in all patients. One patient was diagnosed leiomyomatosis peritonealis postoperatively. Among five patients who were confirmed uterine leiomyosarcoma, the 3-year overall survival was 40.0% and 5-year overall survival was 20.0% with the median follow-up of 18 months (range 5-73 months). The patient with PCI 0 at the time of CRS showed no evidence of disease (NED) at 73 months. We believe that prophylactic CRS contributed her favorable outcome. Therapeutic options for patients with uLMS post-morcellation are limited. Currently, CRS and HIPEC plus EPIC followed by adjuvant systemic chemotherapy may be considered an option for treatment. Further studies in a larger number of patients are needed.

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Granulosa cell tumors of the ovary (GCT) are the most common type of sex cord stromal tumors. Although most of patients are diagnosed at early stage and has favorable 5-year overall survival rate, 16-23% of GCT ultimately develop recurrent disease. Recurrences are characterized by disseminated peritoneal metastasis. The treatment options include systemic chemotherapy, secondary CRS or palliative localized radiation therapy have not yet standardized due to the rarity of disease. Aggressive CRS followed up by hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to provide benefit in other peritoneal disease but limited data available for recurrent GCT. We have a case of recurrent Adult-type GCT (AGCT) who was treated with CRS followed by HIPEC with mitomycin C and doxorubicin. The patient has no evidence of recurrence for approximately 11 years. An electronic search of the PubMed database with the following search terms: GCT, HIPEC showed that there were total 21 patients with recurrent GCT treated in seven different studies and 13 of 21 (61.9%) patients had no evidence of disease during follow-up ranging from 6 to 100 months. Three patients (14.2%) died of the disease. Six studies used cisplatin for HIPEC. At least 76.2% (16 of 21, data not available for five patients) had complete cytoreduction with total 16 cases of perioperative complications but no perioperative mortality was observed. Although further investigation is needed, we propose that CRS and HIPEC can be an effective therapeutic option for recurrent GCT at experienced institutions.

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As medics and doctors prepare for deployment to a combat zone, there are countless specified and implied tasks needed to prepare the medical support of an Infantry unit in theater. Appropriately, units spend the lion share of their efforts in trauma training and medical readiness (vaccinations, medication prescriptions, eye glasses, etc.) while ensuring that the sets, kits, and outfits are all fully stocked with the required items needed to execute the mission. Unfortunately, this training and preparation included little on the major challenges units currently face from rabies. With the unfortunate recent death of a soldier from rabies, medical personnel were required to become experts in animal control, the prevention of animal bites and scratches, and the most appropriate treatment of service members with potential exposure to rabid animals. This article will discuss the challenges of rabies management in Afghanistan, appropriate provider and unit preparation to minimize risk of developing rabies, the need for establishment of an animal control team and prerequisite training of soldiers, leaders, and medics before and during deployment. Finally, we will review published guidelines for treating individuals exposed to rabies with a discussion of our units experience with postexposure prophylaxis.

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Stage I ovarian carcinoma is relatively uncommon, and data on prognostic factors are conflicting. The clinical and pathologic features of 51 International Federation of Gynecology and Obstetrics stage I ovarian carcinomas were analyzed. There were 22 stage IA, 1 stage IB, and 28 stage IC cases. The mean follow-up was 6.1 years. The 5-year and 10-year disease-specific survival rates for the entire cohort were 92% and 78%, respectively. Among 51 patients, there were 6 tumor deaths, and 1 patient died of unrelated causes. All patients who died of disease were stage IC. Significant adverse prognostic factors were serous histology [relative risk (RR) 5.4, 95% confidence interval (CI) 1.3-22.0] and stage IC (RR 1.3, 95% CI 1.1-1.5). Among factors associated with stage IC, only positive washings or ascites affected survival (RR 9.25, 95% CI 1.9-44.4). The 5-year survival rates for stages IA and IC were 100% and 83%, respectively (P<0.025, log rank test). For comprehensively staged patients, the 5-year survival rate was 96% as compared with 72% for all others (P<0.025, log rank test). Tumor rupture, surface involvement, histologic grade and clear cell histology were not of adverse prognostic significance. Serous histology and positive washings or ascites are adverse prognostic factors in stage I. The prognostic importance of tumor grade, rupture, surface involvement and clear cell histology remains unclear. Patients who are International Federation of Gynecology and Obstetrics stage I on the basis of comprehensive surgical staging have an excellent prognosis.

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BACKGROUND: Diffuse laminar endocervical glandular hyperplasia is extremely rare with only 14 cases reported in the literature. Diffuse laminar endocervical glandular hyperplasia is a benign lesion that is easily confused with malignancy. CASE REPORT: We present a 22-year-old woman referred to our gynecologic oncology service with a 2.0 x 4.0-cm exophytic cervical mass. Colposcopic-directed cervical biopsies were diagnosed as adenocarcinoma, suggestive of minimal deviation adenocarcinoma. Computed tomographic scans of the abdomen and the pelvis failed to reveal any metastatic foci. A radical abdominal hysterectomy with pelvic and para-aortic lymph node sampling was performed without complications. Final pathology revealed diffuse laminar endocervical glandular hyperplasia. CONCLUSIONS: Diffuse laminar endocervical glandular hyperplasia is an uncommon histological type of pseudoneoplastic glandular lesions that may be found in the cervix, and this entity should be considered in the differential diagnosis of a potentially malignant endocervical glandular lesion.

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PURPOSE: Folate receptor alpha (FOLR1) is a membrane bound receptor involved in the transport of folate as well as other regulatory cellular processes. The purpose of this study was to examine the expression of FOLR1 in uterine cancers and to identify changes in gene expression that are associated with overexpression of FOLR1. EXPERIMENTAL DESIGN: Fifty-eight frozen uterine cancer specimens were stained for FOLR1 using immunohistochemistry and results were correlated with transcript expression noted on quantitative PCR. Total RNA from 16 cases of uterine serous carcinoma (USC) was analyzed for gene expression using the Affymetrix HG-U133A and HG-U133B GeneChip set. USCs overexpressing FOLR1 were compared to cancers with an absence of FOLR1 using binary comparison and template matching of data was used to identify genes that correlate with FOLR1 expression. Selected targets from this analysis were evaluated by quantitative PCR as well as in an independent set of USC represented in quadruplicate on a tissue microarray (TMA). RESULTS: Overexpression of FOLR1 was observed in 11/16 (69%) of USC and 0/10 normal endometrium cases using frozen tissue specimens. Binary comparison between FOLR1 positive and negative cases identified 121 genes altered by 2-fold at p<0.01 of which 45 are well correlated with FOLR1 expression pattern. Using quantitative PCR, both mesothelin (MSLN) and PTGS1 (COX1) were significantly increased in FOLR1 overexpressing tumors (p=0.014 and p=0.006 respectively). TMA confirmed that overexpression of FOLR1 and MSLN respectively occurred in 23/48 (48%) and 17/54 (32%) of pure USC. CONCLUSION: Both FOLR1 and MSLN are cell surface targets that are co-expressed at high levels in USC and are appealing targets for biologic therapy.

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OBJECTIVE: To describe the epidemiologic characteristics of gynecologic malignancies in patients 25 years of age or younger. METHODS: The Automated Central Tumor Registry (ACTUR), the cancer registry for the Department of Defense, was used to identify children, adolescents, and young adults diagnosed with gynecologic malignancies. Specifically, primary ovarian, uterine, cervical, vaginal, and vulvar malignancies diagnosed between 1990 and 2002 were included in the analysis. Data from the Department of Defense tumor registry were then compared with results obtained from the national Surveillance, Epidemiology, and End Report (SEER) program database. RESULTS: Two hundred fifty-one cases were identified in the Department of Defense tumor registry. The most common primary site was ovary, with 116 cases (46%), followed by cervix, with 108 cases (43%). The most common histological types were germ cell (35%) for ovary, squamous cell (52%) for cervix, choriocarcinoma (18%) for uterus, and squamous cell (30%) for vulva/vagina. The 21- to 25-year-old age group had the greatest number of cases for the entire cohort (23%). Most patients had only local disease at time of diagnosis, and the 5-year survival percentage was 86% (95% confidence interval 80-91) for all patients with ovarian and cervical carcinoma. Data from the SEER program demonstrated a similar distribution and incidence pattern. CONCLUSION: The ovary and cervix are the most common primary sites of gynecologic malignancies in patients 25 years of age or younger. Health maintenance programs for patients in this age group should continue to include pelvic exams and Pap test screening.

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BACKGROUND: Split-thickness skin grafts are often utilized for vulvo-vaginal reconstruction. Unfortunately, infection and sloughing may occur in up to 22% of patients with standard techniques especially at irradiated recipient sites. CASES: We report seven cases of vulvo-vaginal reconstruction using split-thickness skin grafts. In this series, we used fibrin tissue adhesives with and without vacuum-assisted closure devices to augment graft adherence and viability. We briefly describe the clinical history, surgical techniques, and outcomes of the cohort. CONCLUSION: Fibrin tissue adhesives and wound vacuum-assisted closure devices may improve the viability of split-thickness skin grafts during vulvo-vaginal reconstruction.

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BACKGROUND: Extra-adrenal pheochromocytomas are catecholamine-secreting tumors that arise from chromaffin cells of the paraganglion sympathetic system. All of the previously reported cases have described surgical resection during the antepartum period. CASE: At 14 weeks of gestation, a multiparous patient was diagnosed with an extra-adrenal dopaminergic pheochromocytoma. A decision was made to delay surgical intervention until the postpartum period. Phenoxybenzamine, 10 mg per day, was subsequently started. At 35 + 2 weeks of gestation, the patient delivered a 2,600 g infant via an uncomplicated cesarean. Three weeks later, the extra-adrenal pheochromocytoma was removed, and she also underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and rectosigmoid resection with end-to-end colostomy. CONCLUSION: Conservative management of dopaminergic-secreting extra-adrenal pheochromocytomas can result in favorable maternal and fetal outcomes.

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BACKGROUND: In the current study, the authors sought to examine the prognosis and recurrence risk for patients with cervical squamous intraepithelial lesions (SILs) diagnosed during pregnancy. METHODS: A retrospective review of all women who gave birth at Walter Reed Army Medical Center (Washington, DC) or the National Naval Medical Center (Bethesda, MD) between 1986 and 1997 was performed. One hundred fifty-seven patients with SILs who underwent antepartum and postpartum evaluation were identified from a total of 6248 records of birth at these two institutions. Patient demographics and cervical cytology and histology were reviewed. RESULTS: One-hundred twenty-nine patients were diagnosed with low-grade squamous intraepithelial lesions (LSILs) antepartum. Of these patients, 49 (38%) had a previous history of abnormal cervical cytology (30 LSILs and 19 high-grade squamous intraepithelial lesions [HSILs]). Twenty-eight patients were diagnosed with HSIL antepartum. Of these patients, 24 (86%) had a history of abnormal cervical cytology. Sixty-two percent of patients with antepartum LSILs had disease regression postpartum, 32% had persistent LSILs postpartum, and 6% experienced progression of an LSIL to an HSIL. All cases of HSIL that were diagnosed antepartum persisted on postpartum cytologic examination. Three patients were found to have microinvasive squamous cell carcinoma after postpartum conization. Five years of follow-up data were available for 98 patients (60%), 78 of whom had antepartum LSILs and 20 of whom had antepartum HSILs. Sixty percent of patients with antepartum LSILs detected on Pap smear developed recurrent LSILs within 5 years, and all 20 patients with antepartum HSILs developed recurrent HSILs within 5 years. CONCLUSIONS: Most cases of LSIL regressed or remained stable during pregnancy. All cases of HSIL diagnosed antepartum persisted in the postpartum period, and 11% of patients with antepartum HSILs were found to have invasive carcinoma postpartum. High rates of recurrence for both LSIL and HSIL were noted 2-5 years after the diagnosis of SIL in the antepartum.

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BACKGROUND: Patients with morbid obesity or pulmonary disease are at a higher risk for complications during advanced laparoscopic procedures. Higher intraperitoneal carbon dioxide pressures required to elevate the pannus can negatively impact hemodynamic and respiratory parameters. CASES: We describe a technique that uses a combination of a mechanical retractor and a Foley catheter inserted midway between the umbilicus and the pubic symphysis that assists in elevating the anterior abdominal wall. In 3 cases this technique allowed for a low-pressure pneumoperitoneum during advanced laparoscopic pelvic surgery, which resulted in improved hemodynamic parameters and pulmonary function in these high-risk patients. CONCLUSION: The Foley Lap-Lift facilitated laparoscopy through mechanical abdominal wall elevation and allowed for a lower-pressure pneumoperitoneum. This technique is an addition to traditional operative laparoscopy in select high-risk patients.

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