Malignant melanoma of the vulva: an extension of cutaneous melanoma?

OBJECTIVE: To determine the prognostic significance of the 2002 revisions of the American Joint Committee on Cancer (AJCC) Staging System for cutaneous melanoma in melanoma of the vulva and review the current surgical utilized for treatment of this neoplasm. METHODS: Demographic, surgical and outcomes data were obtained from the records of vulvar melanoma patients treated from 1990 to 2006 at five academic medical centers. The 2002 modifications of the AJCC staging system for cutaneous melanoma, Breslow thickness and Clark level, were applied to all subjects. Kaplan-Meier Modeling and Linear Regression analysis were utilized for data analysis. Statistics were performed with SAS v 9.1. RESULTS: Seventy-seven patients were identified with a median age of 62 years. 73% had Stage I/II disease. Surgical radicality did not impact recurrence rates or survival. Breslow thickness was associated with recurrence (p=0.002) but not survival. Only the 2002 modified AJCC staging criteria were predictive of overall survival (p=0.006) in patients with malignant melanoma of the vulva. CONCLUSIONS: In the largest multi-site series of vulvar melanoma, the AJCC-2002 staging system for cutaneous malignant melanoma appears to be applicable to primary vulvar melanoma. Moreover, surgical radicality was associated with significant morbidity but not with improvement in survival. Utilization of standard operative staging and resection principles in cutaneous melanoma should be used for all vulvar melanoma patients. Moreover, these patients should also be considered for enrollment in cutaneous melanoma clinical trials.

Midpoint transverse process to pleura catheter placement for postoperative analgesia following video-assisted thoracoscopic surgery.

The ultrasound-guided midpoint transverse process to pleura block has been described as an alternative end-point for thoracic paravertebral blockade. Although originally described as a single-level block, midpoint transverse process to pleura blockade may cover more than one level when larger volumes of injectate are used. Moreover, a continuous catheter midpoint transverse process to pleura blockade technique was previously thought to be unfeasible. We report three cases where a midpoint transverse process to pleura continuous catheter technique was successfully used for postoperative analgesia following video-assisted thoracoscopic surgery.

Prolonged oral etoposide as second-line therapy for platinum-resistant and platinum-sensitive ovarian carcinoma: a Gynecologic Oncology Group study.

PURPOSE: A phase II trial was conducted to determine the activity of prolonged oral etoposide in platinum-resistant and platinum-sensitive ovarian carcinoma. PATIENTS AND METHODS: Platinum-resistant disease was defined as progression on platinum-based chemotherapy or recurrence within 6 months of completing therapy. The starting dose was 50 mg/m2/d (30 mg/m2/d for prior radiotherapy) for 21 days, every 28 days. A dose escalation to a maximum dose of 60 mg/m2/d was prescribed. RESULTS: Of 99 patients entered, 97 were assessable for toxicity and 82 were assessable for response. Among 41 platinum-resistant patients a 26.8% response rate (7.3% complete response [CR] and 19.5% partial response [PR] rate) occurred. The median response duration was 4.3 months (range, 1.3 to 8.7), median progression-free interval (PFI) was 5.7 months (range, 0.8 to 30.8+), and median survival time was 10.8 months (range, 1.9 to 45.8). Twenty-five of 41 platinum-resistant patients had also previously received paclitaxel; of which eight (32%) responded. Among 41 platinum-sensitive patients, a 34.1% response rate (14.6% CR and 19.5% PR rate) occurred. The median response duration was 7.5 months (range, 1.9 to 15.2+), median PFI was 6.3+ months (range, 0.9 to 20.4), and median survival time was 16.5+ months (range, 0.9 to 34.8). Of 97 patients assessable for toxicity, grade 3 or 4 hematologic toxicity was common, with leukopenia occurring in 41.2% (grade 3, 29%; grade 4, 12%), neutropenia in 45.4% (grade 3, 20%; grade 4, 25%), thrombocytopenia in 9% (grade 3, 5%; grade 4, 4%), and anemia in 13.4%. Three treatment-related deaths occurred: two from neutropenic sepsis and one from thrombocytopenic bleeding after an overdose. One patient developed leukemia. CONCLUSION: This regimen is active in platinum-resistant and platinum-sensitive ovarian carcinoma. Additionally, the regimen is active in paclitaxel-resistant ovarian carcinoma.

Second-line therapy with paclitaxel and carboplatin for recurrent disease following first-line therapy with paclitaxel and platinum in ovarian or peritoneal carcinoma.

PURPOSE: The combination of paclitaxel and a platinum compound is the most active first-line regimen for advanced ovarian carcinoma. The current study was undertaken to evaluate this combination in the re-treatment of patients with ovarian or peritoneal carcinoma who had disease recurrence > or = 6 months following this combination. METHODS: Twenty-five patients with recurrent ovarian or peritoneal carcinoma > or = 6 months after a complete clinical response with first-line paclitaxel and platinum chemotherapy were studied. Recurrent disease was documented by computed tomography (CT), elevated CA 125 level, or surgical findings. Second-line chemotherapy consisted of paclitaxel 135 mg/m2 as a 24 hour infusion and carboplatin at an area under the concentration-time curve (AUC) of 5 to 6 every 21 days. Response to therapy was classified as measurable or assessable. RESULTS: The median time to recurrence after first-line therapy was 10 months (range, 6 to 30). Among 20 measurable and assessable patients, 14 (70%) demonstrated a complete clinical response and four (20%) a partial clinical response. The response rate with measurable disease was 91% and with assessable disease was 89%. The median progression-free interval for all patients was 9.0+ months (range, 2 to 15). The median progression-free interval for patients with measurable or assessable disease was 9.0+ months and for nonassessable disease was 7.0+ months. Fifteen patients (60%) have developed recurrence after secondary therapy at a median interval of 9.0 months (range, 2 to 15). Only two patients have died with a median survival after secondary therapy of 10.0+ months (range, 2.0 to 21.0+). CONCLUSION: The use of this combination, in this sensitive population, has a high response rate and long progression-free interval. In a chemotherapy-sensitive population, the activity of alternative second-line agents must be interpreted with this perspective.

Paclitaxel and cisplatin as first-line therapy in recurrent or advanced squamous cell carcinoma of the cervix: a gynecologic oncology group study.

PURPOSE: On the basis of the activity of paclitaxel as a single agent in chemotherapy-naive squamous cell carcinoma of the cervix in a prior Gynecologic Oncology Group (GOG) trial, a phase II study of paclitaxel and cisplatin as first-line therapy was conducted by the GOG. PATIENTS AND METHODS: Eligibility included squamous cell cancer of the cervix not curable by surgery or radiation, measurable disease, WBC count > or = 3,000/microL, platelet count > or = 100, 000/microL, serum creatinine > or = 2 mg/100 mL, and adequate hepatic function. The starting dose was paclitaxel 135 mg/m(2) infused over 24 hours followed by cisplatin 75 mg/m(2) every 21 days. On the basis of toxicity, a dose escalation of paclitaxel to a maximum dose of 170 mg/m(2)/d was prescribed. RESULTS: Forty-seven patients were enrolled onto this study; 44 patients were assessable for toxicity and 41 for response. Forty (90.9%) had received prior radiation therapy. A median of six courses of chemotherapy was given (range, one to 10 courses). Neutropenia grade 3 (15.9%) and 4 (61.4%) was the most frequent severe adverse effect and was associated with fever in 13 patients (27.7%). Two patients (4.5%) died from neutropenic sepsis. Grade 4 thrombocytopenia occurred in 6.8% of patients. Of 41 assessable patients, five (12.2%) had complete responses and 14 (34.1%) had partial responses for an overall response rate of 46.3% (95% confidence interval, 30.7% to 62.6%). The median progression-free interval, was 5.4+ months (range, 0.3 to 22+ months) with a median survival of 10.0+ months (range, 0.9 to 22. 2 months). Response was more frequent in patients with disease in nonirradiated sites (70% v 23%, P =.008). CONCLUSION: This regimen seems highly active in advanced and recurrent squamous cell carcinoma of the cervix and is currently being evaluated by the GOG in a phase III randomized study comparing the combination of paclitaxel and cisplatin with cisplatin alone.

Positron emission tomography for evaluating para-aortic nodal metastasis in locally advanced cervical cancer before surgical staging: a surgicopathologic study.

PURPOSE: Positron emission tomographic (PET) scanning provides a novel means of imaging malignancies. This prospective study was undertaken to evaluate PET scanning in detecting para-aortic nodal metastasis in patients with locally advanced cervical carcinoma and no evidence of extrapelvic disease before planned surgical staging lymphadenectomy. MATERIALS AND METHODS: After 20 mCi of 2-[18F]fluoro-2-deoxy-D-glucose (FDG) were administered intravenously, the abdomen and pelvis were scanned. Continuous bladder irrigation was used to reduce artifact. Patients were classified by the presence or absence of FDG uptake in the primary tumor and in pelvic or para-aortic nodes. Para-aortic node metastases were classified as present or absent according to a standardized staging procedure. Pelvic node metastases were similarly classified in a subset of patients who underwent pelvic node resection. RESULTS: Thirty-two patients with stage IIB (n = 6), IIIB (n = 24), and IVA (n = 2) tumors were studied. Fluorodeoxyglucose was taken up by 91% of the cervical tumors. Six of eight patients with positive para-aortic node metastasis had PET scan evidence of para-aortic nodal metastasis. One of the two false-negatives had only one microscopic focus of metastatic cancer. In the para-aortic nodes, PET scanning had a sensitivity of 75%, a specificity of 92%, a positive predictive value of 75%, and a negative predictive value of 92%. Fluorodeoxyglucose para-aortic nodal uptake conferred a relative risk of 9.0 (95% confidence interval, 2.3 to 36.0) for para-aortic nodal metastasis. All 10 of 17 patients with metastasis were predicted by PET scanning (P < .001); five of these patients had abnormalities on computed tomographic scans. CONCLUSION: Cervical cancers have a high avidity for FDG. The use of PET-FDG scanning accurately predicts both the presence and absence of pelvic and para-aortic nodal metastatic disease.

Ninety-six-hour infusional paclitaxel as salvage therapy of ovarian cancer patients previously failing treatment with 3-hour or 24-hour paclitaxel infusion regimens.

PURPOSE: To test the hypothesis that prolonged infusion of paclitaxel (96 hours) might overcome resistance to shorter infusion schedules (3 or 24 hours) in ovarian cancer. PATIENTS AND METHODS: A total of 30 patients with advanced ovarian cancer (24 patients), primary carcinoma of the peritoneum (four patients), or fallopian tube cancer (two patients) who previously had received paclitaxel administered on either a 3-hour or 24-hour schedule were treated with the agent delivered as a 96-hour infusion (30 to 35 mg/m2/d x 4 days) on an every 3-week program. RESULTS: Although the regimen generally was well tolerated, no objective responses were observed. CONCLUSION: In patients with ovarian cancer who have shown resistance to shorter paclitaxel infusion schedules, ninety-six hour infusional paclitaxel is an inactive treatment strategy. This makes it less likely that protracted infusion of paclitaxel will improve outcome when used as part of primary therapy of ovarian cancer. An ongoing randomized study will answer that question.

Paclitaxel, an active agent in nonsquamous carcinomas of the uterine cervix: a Gynecologic Oncology Group Study.

PURPOSE: A phase II trial of paclitaxel was initiated in advanced nonsquamous carcinoma of the cervix to determine its activity in patients who had failed standard chemotherapy. PATIENTS AND METHODS: Eligible patients had at least one measurable lesion. The starting dose of paclitaxel was 170 mg/m(2) (135 mg/m(2) for patients with prior pelvic radiation) given as a 24-hour continuous intravenous infusion with courses repeated every 3 weeks. Dose escalation to 200 mg/m(2) and de-escalation to 110 mg/m(2) were allowed based on adverse effects. RESULTS: In this trial, 42 assessable patients were initially entered onto the study, and 13 responses were seen; four patients had a complete response, and nine patients had a partial response. The overall response rate was 31%. The primary and dose-limiting toxicity was neutropenia. CONCLUSION: The response rate to paclitaxel exceeds the rates reported using other single agents in nonsquamous carcinoma of the cervix.

Phase II study of paclitaxel and valspodar (PSC 833) in refractory ovarian carcinoma: a gynecologic oncology group study.

PURPOSE: A phase II study was conducted to determine the efficacy of paclitaxel and valspodar (PSC 833) in patients with advanced epithelial ovarian cancer. Valspodar, a nonimmunosuppressive cyclosporine D analogue that reverses P-glycoprotein-mediated multidrug resistance, in combination with paclitaxel might be active in paclitaxel-resistant and refractory ovarian cancer. PATIENTS AND METHODS: Patients received valspodar 5 mg/kg orally qid x 12 doses. Paclitaxel (70 mg/m(2) intravenously for 3 hours) was administered on day 2, 2 hours after the fifth or sixth dose of valspodar. This treatment was repeated every 21 days. One blood sample was collected before the sixth dose of valspodar for the first three cycles to evaluate valspodar trough concentration. Tumor tissue was obtained from patients for immunohistochemical staining of P-glycoprotein. RESULTS: Of 60 patients entered, 58 were assessable for response. There were five partial responses (8.6%; 90% confidence interval [CI], 3.8 to 20.0; median duration of response, 5.0 months [range, 1.9 to 10.5 months]). Median progression-free survival was 1.5 months (90% CI, 1.4 to 2.4). Grade 3 or 4 toxicities observed were neutropenia, anemia, nausea and vomiting, peripheral neuropathy, and cerebellar ataxia. The trough concentrations of valspodar were > or = 1,000 ng/mL in all but two of 40 patients in the first cycle. Immunohistochemical staining for P-glycoprotein was positive for one of two responding patients. CONCLUSION: Valspodar in combination with paclitaxel has limited activity in patients with paclitaxel-resistant ovarian carcinoma. An international randomized clinical trial of paclitaxel and carboplatin with or without valspodar as first-line therapy in advanced ovarian cancer is underway.

Phase I study of paclitaxel, carboplatin, and increasing days of prolonged oral etoposide in ovarian, peritoneal, and tubal carcinoma: a gynecologic oncology group study.

PURPOSE: Given the activity of prolonged oral etoposide in platinum and paclitaxel-resistant ovarian carcinoma, a phase I trial was conducted that combined increasing days of oral etoposide therapy with paclitaxel and carboplatin in chemotherapy-naive patients with ovarian peritoneal and tubal carcinoma to establish a maximum-tolerated dose (MTD) of this combination. PATIENTS AND METHODS: Paclitaxel at 175 mg/m(2) given over 3 hours and carboplatin at an area under the curve of 5 were administered on day 1 followed by oral etoposide 50 mg/m(2)/d beginning on day 2. The number of days of etoposide therapy was escalated on the basis of toxicity. Toxicity end points included neutropenic sepsis, grade 4 thrombocytopenia, or grade 3 neutropenia or thrombocytopenia during etoposide administration. Cycles were repeated every 21 days for a maximum of six courses. Due to hematologic toxicity, the duration of the paclitaxel infusion was decreased to 1 hour for a second stage of accrual. RESULTS: Of 52 patients studied, 29 were in the first stage of accrual. Dose-limiting toxicity occurred with 8 days of oral etoposide, making the MTD six days of therapy. Twenty-three patients were entered into the second stage of accrual. Dose-limiting toxicity occurred at 12 days of oral etoposide, making the MTD 10 days of therapy. Three patients developed acute myeloid leukemia 16, 27, and 35 months after receiving a cumulative dose of 200 mg/m(2), 1,200 mg/m(2), and 2,400 mg/m(2), respectively. CONCLUSION: One-hour paclitaxel, carboplatin, and oral etoposide at 50 mg/m(2)/d for 10 days is tolerable without supportive therapy. The leukemogenic potential is cause for concern and precludes its use in chemotherapy-naive ovarian carcinoma.

Phase II study of liposomal doxorubicin in platinum- and paclitaxel-refractory epithelial ovarian cancer.

PURPOSE: Stealth liposomal doxorubicin (Alzal Corp, Palo Alto, CA) has a slower clearance rate than free doxorubicin, resulting in sustained serum levels. Liposomal encapsulation also leads to increased concentration of drug in tumor tissue. Meta-analysis of previous studies has shown that doxorubicin has activity in epithelial ovarian cancer. The current study was developed to examine the activity of Stealth liposomal doxorubicin in platinum- and paclitaxel-refractory ovarian cancer. PATIENTS AND METHODS: Patients had epithelial ovarian cancer that either progressed on or recurred within 6 months of completion of platinum and paclitaxel chemotherapy. All patients had measurable disease. Stealth liposomal doxorubicin was administered at 50 mg/m(2) every 4 weeks as a 1-hour infusion. RESULTS: Eighty-nine patients were treated and included in an intent-to-treat analysis. There were 82 patients who were platinum and paclitaxel refractory and met all study criteria. There was one complete response and 14 partial responses, for a total response rate of 16.9% (95% confidence interval [CI], 9.1% to 24.6%). For platinum- and paclitaxel-refractory patients, the response rate was 18.3% (95% CI, 9.9% to 26.7%). Median time to progression was 19. 3 weeks for the entire population. Ten patients (11.2%) withdrew because of adverse events related to the drug (palmar-plantar erythrodysesthesia [PPE], n = 3; asthenia, n = 2; cardiac, n = 2; neutropenia, n = 1; stomatitis, n = 1; and edema, n = 1). There were no drug-related fatal events. There were only eight grade 4 adverse events attributable to the drug. Stomatitis, PPE, and skin lesions were managed with dose reductions and delays in most cases. CONCLUSION: Stealth liposomal doxorubicin has activity in refractory epithelial ovarian cancer. PPE and stomatitis can usually be managed by dose adjustment. The ease of administration makes this an attractive agent.

Chemoradiotherapy for cervical cancer.

Cervical cancer remains a major health problem worldwide, despite advances in screening. For patients with locally advanced stage disease, failure to obtain local-regional control usually results in death. In an effort to improve local-regional tumour control, neoadjuvant and concurrent chemoradiation has been tested. Recently, five randomised trials performed by the Gynecologic Oncology Group (GOG), Radiation Therapy Oncology Group (RTOG) and the SouthWest Oncology Group (SWOG) studying cisplatin-based chemoradiation have demonstrated a significant survival advantage. Three of the trials compared cisplatin-based concurrent chemotherapy and radiation to radiation alone and two trials compared cisplatin-based concurrent chemotherapy and radiation to radiation with hydroxyurea. In all of the trials, cisplatin-based chemotherapy administered concurrently with radiation therapy was more effective at reducing the risk of death by 30-50%. Acute toxicities, principally neutropenia and gastrointestinal, were more common with chemoradiation, but were transient and the rates of late complications (complications that persisted or occurred for more than 60 days after the treatment) were similar. Based on the results of these five randomised trials, the National Cancer Institute (NCI) released a Clinical Announcement stating that cisplatin-based chemotherapy, as used in these trials (i.e. concurrently with radiation therapy), as the new standard of therapy for cervical cancer.

Amifostine cytoprotection with chemotherapy for advanced ovarian carcinoma.

To determine the efficacy of pretreatment with amifostine in diminishing the hematologic and nonhematologic toxicities of cyclophosphamide and cisplatin in previously untreated patients with stage III/IV ovarian cancer, a multicenter randomized controlled trial of cyclophosphamide (1,000 mg/m(2)) and cisplatin (100 mg/m(2) with or without amifostine (910 mg/m(2)) was performed. Two hundred forty-two patients with stage III/IV epithelial ovarian cancer were enrolled. Following primary surgery, patients were stratified and randomized to either cyclophosphamide/cisplatin (CP; 120 patients) or amifostine plus CP (122 patients) every 3 weeks for six cycles. Patient characteristics were similar in both groups. Cytoprotective end points and tumor response were evaluated, including the need to delay or discontinue therapy because of toxicity and the incidence of febrile neutropenia with associated complications. Fourteen patients treated with CP discontinued protocol therapy because of hematologic or renal toxicity (eight hematologic and six renal). In contrast, only one patient treated with amifostine plus CP discontinued protocol therapy for hematologic or renal toxicity (P < .001). Forty-three percent of CP patients compared with 22% of amifostine plus CP patients had grade 4 neutropenia (P = .001); total days in hospital were reduced from 258 in the CP arm to 11 in the amifostine plus CP arm (P = .009, two-sided). Sixty-five percent of the CP patients and 41% of the amifostine plus CP patients (P = .004) had the next cycle of CP delayed because of an absolute neutrophil count below 1,500/microL at day 22. Platelet and red blood cell transfusion support were substantially reduced in the group that received amifostine. The serum creatinine failed to return to < or = to 1.5 mg/dL by day 22, requiring a delay in chemotherapy in 15% and 5%, respectively, of the CP and amifostine plus CP groups (P = .014). Over the six cycles, the incidence and severity of peripheral neuropathy were also significantly reduced in the amifostine-treated group (P = .029). Pathologic response rates and survival curves were equivalent. The significant reduction in the CP-induced acute and cumulative hematologic, renal, and neurologic toxicities by amifostine pretreatment with equivalent response and survival indicates selective cytoprotection. This selective effect has the potential to affect quality of life and medical economic considerations.

Surgery for recurrent ovarian cancer.

Recurrent ovarian cancer is associated with a poor long-term prognosis and optimal management for this problem is not well defined. The benefits of primary surgical cytoreduction in prolonging survival rates in advanced ovarian cancer have prompted examination of the potential role of secondary cytoreductive surgery in patients with recurrent disease or disease that progresses or stabilizes during primary adjuvant chemotherapy. No randomized clinical trials have been performed to evaluate secondary surgery in these settings. Based on available data, secondary surgery does not appear to improve survival in patients whose disease progresses or stabilizes during primary adjuvant chemotherapy and therefore is not recommended. The most promising experience with secondary surgery has been in patients with recurrent disease following optimal primary surgical resection with a recurrence-free interval of at least 1 year. While secondary surgery is feasible, it has not yet been proven to improve survival, as similar survival rates have been reported using chemotherapy alone. Consequently, it is critical to minimize the risk of morbidity through careful patient selection when secondary surgery is used.

Radiation therapy for surgically proven para-aortic node metastasis in endometrial carcinoma.

The impact of para-aortic field radiation therapy upon survival was studied among 26 patients with para-aortic nodal metastases from carcinoma of the endometrium. Seventeen of these 26 patients received postoperative radiation therapy to the para-aortic field as a part of their primary therapy. Sixteen of the 17 also received adjuvant hormonal therapy. Nine of 17 patients (53%) are alive without evidence of disease (18-55 months) with a median survival time of 27 months. Of the remaining eight patients, six (35%) died of endometrial cancer at 6-38 months, with a median survival time of 14.5 months. Five of these patients had distant disease. Two of the 17 patients (12%) died of intestinal obstruction felt to be secondary to radiation enteritis, one of whom was disease free. No difference in survival was detected in patients treated with radiation therapy with microscopic versus macroscopic nodal involvement. Of the nine patients who did not receive para-aortic radiation, eight were treated with hormonal therapy (n = 6) or chemotherapy (n = 2). Seven patients died of disease from 5-28 months, with a median survival time of 13 months. One patient is alive at 12 months. Survival in the 17 patients treated with para-aortic radiation was better than the eight patients not treated with para-aortic radiation (p = 0.004). This survival difference remained significant for patients with microscopic but not macroscopic nodal disease. Para-aortic field radiation appears to improve survival, but has a significant complication rate, and should be reserved for patients with histologic evidence of para-aortic metastases.

Primary radiation therapy for endometrial carcinoma: a case controlled study.

PURPOSE: Primary radiation therapy is generally considered inferior to a surgical approach for patients with endometrial carcinoma and is reserved for patients with a high operative risk. These patients are usually elderly, have multiple medical problems and frequently die of intercurrent disease. To evaluate the efficacy of primary radiation therapy a case controlled analysis comparing corrected survival of patients treated with primary radiation to patients treated with surgical therapy with or without radiation therapy was performed. METHODS AND MATERIALS: Sixty-four patients treated with primary radiation therapy were retrospectively studied. A Kaplan-Meier product limit survival analysis was used to estimate survival among patients treated with primary radiation therapy. A case control study matched by clinical stage, tumor grade, and time of diagnosis was performed. The Mantel-Cox statistic was used to evaluated the equality of the survival curves. RESULTS: Primary radiation therapy was used to treat 9.0% of the patients with endometrial carcinoma during the study period. Cardiovascular disease, diabetes, age greater than 80 and morbid obesity were the most common indications. Ninety percent of patients had either Stage I or II disease. Forty-eight of the 64 patients (75%) completed treatment which included both teletherapy and brachytherapy. Ten patients received brachytherapy only. Twelve complications, both acute and chronic, occurred in eleven patients (17%). Intercurrent disease accounted for 13 of the 36 (36%) of the deaths. Clinical stage of disease and histologic grade of the tumor were significant predictors of survival, p = 0.0001 and p = 0.013, respectively. The case controlled study of Stage I and II patients treated by primary radiation therapy matched to surgically treated controls showed no statistical difference in survival. Dilatation and curettage after the completion of radiation therapy was predictive of local control, p = 0.003. CONCLUSION: Although surgery followed by tailored radiation therapy has become widely accepted therapy for Stage I and II endometrial carcinoma, even in patients who are a poor operative risk, the survival with primary radiation therapy is not statistically different.

Cervical carcinoma metastatic to para-aortic nodes: extended field radiation therapy with concomitant 5-fluorouracil and cisplatin chemotherapy: a Gynecologic Oncology Group study.

PURPOSE: A multicenter trial of chemoradiation therapy to evaluate the feasibility of extended field radiation therapy (ERT) with 5-fluorouracil (5-FU) and cisplatin, and to determine the progression-free interval (PFI), overall survival (OS), and recurrence sites in patients with biopsy-confirmed para-aortic node metastases (PAN) from cervical carcinoma. METHODS AND MATERIALS: Ninety-five patients with cervical carcinoma and PAN metastases were entered and 86 were evaluable: Stage I--14, Stage II--40, Stage III--27, Stage IVA--5. Seventy-nine percent of the patients were followed for 5 or more years or died. ERT doses were 4500 cGy (PAN), 3960 cGy to the pelvis (Stages IB/IIB), and 4860 cGy to the pelvis (Stages IIIB/IVA). Point A intracavitary (IC) doses were 4000 cGy (Stages IB/IIB), and 3000 cGy (Stages IIIB/IVA). Point B doses were raised to 6000 cGy (ERT + IC) with parametrial boost. Concomitant chemotherapy consisted of 5-FU 1000 mg/m2/day for 96 hours and cisplatin 50 mg/m2 in weeks 1 and 5. RESULTS: Eighty-five of 86 patients completed radiation therapy and 90% of patients completed both courses of chemotherapy. Gynecologic Oncology Group (GOG) grade 3-4 acute toxicity were gastrointestinal (18.6%) and hematologic (15.1%). Late morbidity actuarial risk of 14% at 4 years primarily involved the rectum. Initial sites of recurrence were pelvis alone, 20.9%; distant metastases only, 31.4%; and pelvic plus distant metastases, 10.5%. The 3-year OS and PFI rate were 39% and 34%, respectively, for the entire group. OS was Stage I--50%, Stage II--39%, and Stage III/IVA--38%. CONCLUSIONS: Extended field radiation therapy with 5-FU and cisplatin chemotherapy was feasible in a multicenter clinical trial. PFI of 33% at 3 years suggests that a proportion of patients achieve control of advanced pelvic disease and that not all patients with PAN metastases have systemic disease. This points to the importance of assessment and treatment of PAN metastases.

Persistence of diminished bone mineral content following renal transplantation in childhood.

Bone mineral content (BMC) was measured in the nondominant arm of 18 children (aged 3 7/12 to 17 1/2 years) for a total 783 months after renal transplantation. Using photon absorptiometry, 89 measurements were made; 17 of the 18 patients had a functioning graft and one patient died. Significant demineralization, a BMC greater than -2 SD below appropriate control volumes, was found in 11 of 18 patients (62%) and 55 of 89 measurements (61%). Bone loss was progressive; among the 16 patients followed for more than 6 months, ten showed a decline of more than 0.5 SD in BMC, five had no change, and only one showed improvement. No relationship was found between BMC and the use of furosemide, type of transplant (15 living, seven cadaver), prior renal disease (six with glomerulonephritis, 11 tubulointerstitial), need for a second graft (five patients), chronic anticonvulsant therapy, or serum calcium and phosphate values. BMC was slightly correlated (P less than .05) with alkaline phosphatase values. BMC was more strongly correlated with serum creatinine (y = -0.48x + 1.25, r = -.042, P less than .001) and prednisone dose (mg/kg/d) (y = -0.65x + 0.481, r = -.543, P less than .001) in an inverse relationship. Patients whose serum creatinine value was less than 1 mg/dL had a BMC of -0.71 +/- 0.34 SD; those with serum creatinine value greater than 2 mg/dL had BMC of -3.32 +/- 0.31 SD, different at P less than .001. Patients receiving daily prednisone therapy had a significantly lower BMC than those receiving alternate-day therapy (-3.11 +/- 1.23 SD v -1.72 +/- 1.29 SD, P less than .005).(ABSTRACT TRUNCATED AT 250 WORDS)

Bone mineral status measured by direct photon absorptiometry in childhood renal disease.

Bone width (BW), bone mineral content (BMC), and their ration (BMC/BW ratio) were measured in renal patients using direct photon absorptiometry. Serial measurements were made on the radius and ulna in 74 children with renal diseases. Values were compared to age-, sex-, height-, and weight-matched controls. The SD from the mean in normal subjects is +/- 10%. Significant demineralization (greater than -2 SD) was found in 42% of all patients and in 75% with tubulointerstitial disease. Twelve patients with nephrotic syndrome and two with systemic lupus erythematosus, all of whom were receiving prednisone therapy and had a serum creatinine level less than 1.0 mg/dl, and three treated with anticonvulsants had significant demineralization. Severe demineralization (greater than -3 SD) was found in four rachitic patients with tubulointerstitial disease. Normal mineralization was present in 32 patients with various primary glomerular diseases, seven of whom had a serum creatinine level greater than 1.5 mg/dl. BMC declined with daily prednisone therapy but increased with alternate-day dosage in seven patients. This study suggests that demineralization is more common in patients with tubulointerstitial disease and in patients with primary glomerular disease who are receiving prednisone (16 patients) or anticonvulsants. Photon absorptiometry appeared more useful than conventional radiographic evaluation in assessing skeletal involvement in childhood renal disease.

Chemoradiotherapy: the new standard care for invasive cervical cancer.

Cervical cancer remains a major health problem worldwide, despite advances in screening. For patients with locally advanced stage disease, failure to obtain local-regional control usually results in death. In an effort to improve local-regional tumour control, neoadjuvant and concurrent chemoradiation have been tested. Recently, 5 randomised trials performed by the Gynecologic Oncology Group, Radiation Therapy Oncology Group and the Southwest Oncology Group studying cisplatin-based chemoradiation have demonstrated a significant survival advantage. Three of the trials compared cisplatin-based concurrent chemotherapy and radiation to radiation alone and 2 trials compared cisplatin-based concurrent chemotherapy and radiation to radiation with hydroxyurea. In all trials, cisplatin-based chemotherapy administered concurrently with radiation therapy was the more effective therapy, reducing the risk of death by 30 to 50%. Acute toxicities, principally neutropenia and gastrointestinal, were more common with chemoradiation but were transient and rates of late complications were similar between treatment groups. Based on the results of these 5 randomised trials, the National Cancer Institute released a Clinical Announcement stating that cisplatin-based chemotherapy as used in these trials concurrently with radiation therapy should be the new standard of therapy for high risk early stage and locally advanced stage cervical cancer.