Unscheduled DNA synthesis following excimer laser ablation of the cornea in vivo.

The amount of unscheduled DNA synthesis (UDS) produced in the cells adjacent to excimer laser ablations in the cornea was compared for 193-nm and 248-nm laser wavelengths. UDS is interpreted to indicate the process of excision repair of pyrimidine dimers formed in DNA. 193-nm laser ablation did not produce a statistically significant difference in the amount of UDS as compared to a negative control (diamond-knife corneal incision). However, 248-nm laser ablation did produce a highly statistically significant difference in the amount of UDS as compared to both the negative control (P < 0.001) and the 193-nm laser irradiation (P < 0.001). Other forms of DNA damage (single-strand DNA chain breaks and DNA-protein crosslinks) are not measurable by UDS and need to be investigated in the evaluation of the oncogenic potential of 193-nm laser ablation.

Successful pregnancy after previous conservative treatment of an advanced cervical pregnancy.

Cervical pregnancy was diagnosed at 12 weeks' gestation in a young nulliparous woman presenting with vaginal bleeding. Initial treatment with methotrexate was unsuccessful. The patient was ultimately treated by internal iliac artery ligation, hysterotomy, and intracervical balloon tamponade. Nineteen months after surgery, the patient delivered a healthy infant at 36 weeks' gestation by cesarean section.

Endolymphatic sac tumors: histopathologic confirmation, clinical characterization, and implication in von Hippel-Lindau disease.

The term "endolymphatic sac tumor" (ELST) was coined to identify the likely origin of aggressive papillary tumors of the temporal bone. To evaluate the validity of this designation, the temporal bone collection at the Massachusetts Eye and Ear Infirmary was accessed in an effort to determine the pathologic relationship between these tumors and the endolymphatic sac. The search resulted in the identification of a de-novo papillary epithelial lesion arising within the confines of the endolymphatic sac in a patient with von Hippel-Lindau (VHL) disease who harbored a large, destructive ELST in the opposite temporal bone. This finding provides the most substantial evidence to date regarding the origin of the ELST and the accuracy of its nomenclature. Seven additional clinical cases of ELST were identified and analyzed in order to define the natural history of these tumors. All patients had a history of sensorineural hearing loss diagnosed an average of 10.6 years prior to tumor discovery. The presence of a polypoid external auditory canal mass, facial paralysis, and evidence of a destructive mass arising on the posterior fossa surface of the temporal bone were common physical and radiographic findings. The management of these patients, as well as those who are probably prone to such tumors (i.e., VHL patients), is discussed.

Electroglottography in the pediatric population.

OBJECTIVE: To establish normative electroglottography (EGG) data in the pediatric population. DESIGN: Clinical study with EGG data gathered on children with normal voices. SETTING: Major children's hospital and specialty eye and ear hospital. PATIENTS: A total of 164 children, 79 girls and 85 boys, aged 3 to 16 years. METHODS: Children with normal voices, determined through subjective evaluation and a voice use history questionnaire, underwent EGG recording. The EGG data were analyzed with commercially available software for fundamental frequency, jitter, open quotient, closing quotient, and opening quotient. RESULTS: Normative EGG data were established for children aged 3 to 16 years. Jitter, open quotient, closing quotient, and opening quotient were all found to have no significant dependence on age. CONCLUSIONS: Children as young as 3 years can easily tolerate EGG, making it possible to establish this initial set of normative pediatric EGG data. These preliminary results suggest that EGG may have potential to assist clinicians with noninvasive documentation of vocal function in the pediatric population. This maybe particularly important for tracking treatment-related changes in the vocal function of children who are difficult to examine endoscopically.

Management of distal tracheal stenosis.

OBJECTIVE: To evaluate the treatment, perioperative management, and outcome of infants who underwent repair of congenital tracheal stenosis. We hypothesized that early resection and tracheoplasty with early weaning of ventilatory support results in less mucosal injury, and thus better outcome. DESIGN: Retrospective study from 1986 to 1996. SETTING: Tertiary care children's hospital. PATIENTS: Seventeen consecutive infants with congenital tracheal stenosis, aged from birth to 16 months. Fifteen patients had complete tracheal rings, 6 of whom also had a left pulmonary artery sling. Fourteen patients underwent either tracheoplasty or resection and reanastomosis of the trachea, both facilitated by cardiopulmonary bypass. RESULTS: Six patients underwent resection and reanastomosis; 4 patients were extubated within 2 to 5 days without sequelae. There was 1 unrelated perioperative death. Two patients required reintubation. Eight patients required tracheoplasty due to severe tracheal stenosis and had variable postoperative courses. Seven of 14 patients required 0 to 1 postoperative bronchoscopies. Seven of 14 patients required 2 to 7 bronchoscopies for granulation tissue formation, cicatrix, graft collapse, and tracheitis. One patient required numerous procedures and revision tracheoplasty for cicatrix and stenosis. CONCLUSIONS: Correction of short-segment (<5 rings) tracheal stenosis by resection and reanastomosis of the trachea with the aid of cardiopulmonary bypass and early weaning of ventilatory support is recommended. Tracheoplasty using either the castellation technique or slide tracheoplasty is recommended in the treatment of infants with severe (long segment) tracheal stenosis.

Management of gynecologic oncology emergencies.

Gynecologic malignancies are the third most common cancer among women in the United States. Because of often subtle early findings, the diagnosis may not be made before the widespread dissemination of the disease. The Emergency Department physician will commonly encounter a woman with vaginal bleeding, pelvic pain, or a symptomatic abdominal mass. In this article, we have described the epidemiology, recognized patterns of spread, and associated findings of gynecologic tumors. The proper Emergency Department evaluation and management of these problems is emphasized with guidelines for the timing of referrals and consultation with the gynecologic oncologist. The treatment of gynecologic malignancies is often complicated and responsible for Emergency Department visits. The various modalities are addressed according to the organ systems affected and include sections on postoperative problems, gastrointestinal complaints, urologic complications of therapy, radiation therapy and its complications, with an emphasis on the most serious complications necessitating either careful outpatient management or hospital admission. As cost-containment pressure grows, we have included sections on chemotherapy and total parenteral nutrition, both of which are becoming common outpatient events for the cancer patient.

An evaluation of the clinical staging of endometrial cancer.

Therapeutic approaches to endometrial cancer have traditionally been based on preoperative clinical staging. We conducted a retrospective review of 56 women with diagnoses of stage I and II endometrial cancer in order to compare preoperative clinical staging with postoperative staging based on pathologic data. We found a change in stage based on surgical findings in 41.1% of the cases. Endocervical curettage was falsely positive in 92.8% of cases. In addition, an overall change in tumor grade occurred in 39.3% of patients. Preoperative clinical staging of endometrial cancer is associated with a large margin of error when compared to surgical pathologic data.

Intrapartum outcome of term pregnancy after cervical cryotherapy.

Fifty-nine patients who underwent cryotherapy on the uterine cervix at University Hospital of Jacksonville between September 1974 and September 1980 subsequently gave birth at that institution. Of these patients, three had repeat cesarean sections and three had D&Cs in the interval between cryotherapy and pregnancy. The remaining 53 patients were matched with 53 controls for age, parity, fetal weight and absence of cervical surgery. Data were gathered and compared with respect to the cesarean section rate, precipitous dilation, cervical lacerations, postpartum hemorrhage, oxytocin augmentation of labor, Apgar scores, use of forceps and other obstetric complications. There were no significant differences in any of these parameters between the two groups. However, 19 cases had precipitous labor as opposed to 11 controls (0.1 greater than p greater than 0.05). Cryotherapy for cervical dysplasia does not appear to have any deleterious effects on the outcome of term labor.

Cefonicid vs. cefoxitin for cesarean section prophylaxis.

A randomized, prospective study compared a long-acting, second-generation cephalosporin, cefonicid (Monocid), with a short-acting, second-generation cephalosporin, cefoxitin (Mefoxin), for cesarean section prophylaxis. One hundred thirty-nine patients were enrolled, with 81 receiving a 1-g intravenous dose of cefonicid after cord clamping and 58 receiving a 2-g dose of intravenous cefoxitin after cord clamping and at 6, 12 and 18 hours postpartum. In those patients receiving cefonicid prophylaxis, endometritis incidence was 17.3% (14 of 81). This finding was not statistically significant (P less than .397) when compared to the 12.1% incidence of endometritis (7 of 58) with cefoxitin. In addition, the febrile morbidity incidence for cefonicid prophylaxis was 23.5% (19 of 81) as compared to 15.5% (9 of 58) for cefoxitin (P less than .25). Because the two drugs appear to be equally efficacious, cefonicid may be the better choice because of its markedly lower cost.

Keratoacanthoma of the vulva.

A 65-year-old white woman noted a "pea-sized" lump of the right labium majus. At the initial examination a few weeks later, the mass was 1.5 cm in maximum diameter. An excisional biopsy was interpreted as well-differentiated squamous cell carcinoma. The biopsy material was subsequently reviewed prior to recommended radical surgery. Upon review, the lesion was interpreted as a keratoacanthoma. No further surgery was performed and the patient has remained free of recurrent disease for over 2 years. This case is presented in an effort to alert gynecologic oncologists and pathologists of the possibility of this lesion occurring on the vulva.

Diethylstilbestrol-associated vaginal adenosis followed by clear cell adenocarcinoma.

A young woman was examined because of a history of in utero exposure to diethylstilbestrol and was identified as having vaginal adenosis. Fourteen months later, on routine follow-up, a small vaginal clear cell adenocarcinoma was recognized. She refused any therapy other than wide local excision. She was seen intermittently for several years with no recurrence. Five and one-half years after initial diagnosis she was found to have multiple sites of clear cell adenocarcinoma in the upper third of the lateral and anterior vaginal walls. Cases of vaginal adenosis followed later by the development of clear cell adenocarcinoma (metachronous cases) are distinctly unusual. The authors have collected the other recorded cases in the literature or in the Registry for Research on Hormonal Transplacental Carcinogenesis and have attempted to compare these cases with the larger group of patients who present with clear cell adenocarcinoma and have associated vaginal adenosis (synchronous cases). The authors have found few differences between the two groups. Most of the differences can be accounted for by the close follow-up of patients with known vaginal adenosis. However, it has been noted that the location of the clear cell adenocarcinoma is apparently different in the two groups. The reasons for this apparent difference are briefly discussed.

Positive results of endocervical curettage as an indication for conization of the cervix.

At University Hospital of Jacksonville (Fla) during the years 1981 through 1984, 37 patients had conization of the uterine cervix for the sole indication of dysplastic cells found on endocervical curettage. Eighteen of the 37 (48.7%) were found to have a more dysplastic lesion than that diagnosed by colposcopic biopsy. In two of the 37 (5.4%) a previously undiagnosed invasive cancer was found. We conclude that dysplastic cells found on endocervical curettage must be further evaluated with cold conization of the cervix.

Infrared laser bone ablation.

The bone ablation characteristics of five infrared lasers, including three pulsed lasers (Nd:YAG, lambda = 1,064 micron; Hol:YSGG, lambda = 2.10 micron; and Erb:YAG, lambda = 2.94 micron) and two continuous-wave lasers (Nd:YAG, lambda = 1.064 micron; and CO2, lambda = 10.6 micron), were studied. All laser ablations were performed in vitro, using moist, freshly dissected calvarium of guinea pig skulls. Quantitative etch rates of the three pulsed lasers were calculated. Light microscopy of histologic sections of ablated bone revealed a zone of tissue damage of 10 to 15 micron adjacent to the lesion edge in the case of the pulsed Nd:YAG and the Erb:YAG lasers, from 20 to 90 micron zone of tissue damage for bone ablated by the Hol:YSGG laser, and 60 to 135 micron zone of tissue damage in the case of the two continuous-wave lasers. Possible mechanisms of bone ablation and tissue damage are discussed.

Clinical correlation of hormone receptor status in epithelial ovarian cancer.

Cytoplasmic estrogen receptor (ER) and progesterone receptor (PR) levels were measured in ovarian epithelial carcinomas from 37 patients using a dextran-coated charcoal assay prior to any treatment. Sixty-eight percent of the tumors were ER positive, forty-nine percent were PR positive, forty-one percent were positive for both receptors, and twenty-seven percent were negative for both receptors. Receptor status in epithelial ovarian carcinomas was found to have no clinical significance when correlated with age, parity, race, cigarette smoking, surgical stage, histologic type, histologic grade, progression-free interval, or patient survival.

Audiometric monitoring of cis-platinum ototoxicity.

A prospective study was performed on 37 patients receiving 50 mg/m2 of cis-platinum every 3 to 4 weeks. These patients received a baseline audiogram evaluation and subsequent testing before each dose. Ototoxicity was noted to occur in 46% of the patients during therapy. Fourteen percent of this group showed a hearing loss in the speech frequency range. Four variables were analyzed to determine their correlative value for subsequent ototoxicity: (i) Pretreatment (baseline) audiograms, (ii) cumulative dose in milligrams, (iii) dosage in milligrams per square meter, and (iv) mean serum creatinine. Of these parameters, only a pretreatment abnormal audiogram was shown to have a prognostic value at a level of P = 0.095. Recommendations for audiometric monitoring of this high-risk group are discussed.

Coexisting adenocarcinoma and cystadenofibroma (malignant cystadenofibroma) of the ovary.

We have described an adenocarcinoma observed as a grossly discrete area within a cystadenofibroma of the ovary. Fewer than 35 cases of malignant cystadenofibroma have been reported. We find our observations lend support to the prevailing thought that these neoplasms most often originate from preexisting cystadenofibromas.

The use of methylprednisolone and metoclopramide in control of emesis in patients receiving cis-platinum.

cis-Platinum is a chemotherapeutic agent with benefits often limited by the severe gastrointestinal reactions it produces in nearly all patients. Persistent anorexia, nausea, and vomiting may continue for days after therapy and are poorly controlled by conventional antiemetics. Patients at times refuse continuation of cis-platinum chemotherapy because of these severe gastrointestinal side effects. Intravenous methylprednisolone (Solu-medrol) as well as intravenous metoclopramide (Reglan) have been shown effective in the treatment of chemotherapy-induced nausea and vomiting. This randomized, double-blind study is a comparison of the efficacy of Solu-medrol vs Reglan, as well as, the combination of Solu-medrol and Reglan in the prevention of cis-platinum-induced nausea and vomiting. In this study patients receiving Reglan had better protection from vomiting than patients receiving Solu-medrol (P = 0.0564). Patients receiving the combination of Reglan and Solu-medrol had better protection from vomiting than patients receiving Reglan alone (P = 0.0332), or patients receiving Solu-medrol alone (P = 0.0010). Finally, older patients experienced less vomiting than younger patients, regardless of the anti-emetic drugs used (P = 0.0730).