Squamous cell carcinoma of the vulva with bulky positive groin nodes-nodal debulking versus full groin dissection prior to radiation therapy.

Patients with clinical palpable involved groin lymph nodes and squamous cell cancer of the vulva are frequently treated by a full inguinal-femoral lymph node dissection followed by adjuvant radiotherapy to the groins and pelvis. Theoretically, less radical surgery for the groin such as nodal debulking, where only the macroscopically involved nodes are resected, allowing radiotherapy to treat any remaining microscopic disease may potentially decrease morbidity without compromising survival The objective of this retrospective study was to compare the groin recurrence rate and survival (disease specific and overall survival) of patients with clinically involved groin nodes and squamous cell carcinoma of the vulva treated either by a full inguino-femoral lymphadenectomy or by a nodal debulking followed by radiotherapy. Forty patients from three separate databases who met these criteria were identified. Patients were treated either by a full inguino-femoral lymphadenectomy or by a debulking of the clinically involved inguinal lymph nodes. All patients received adjuvant radiotherapy to the groins. In these two groups, there was no difference in groin recurrence rate expressed as groin recurrence-free survival (P= 0.247). In a univariate analysis, both overall and disease-free survival were better in the group of patients treated by nodal debulking. However, in a multivariate analysis, other variables such as extracapsular growth were independent predictors for survival while the method of surgical dissection for the groin had no independent significant impact on survival.

Lymphatic ascites following lymphadenectomy for gynecological malignancy.

Seven patients seen between January 1995 and December 1998 developed symptomatic lymphatic ascites following either pelvic or para-aortic lymph node dissection. The incidence of symptomatic lymphatic ascites during this 4-year period was 2.7% (7 of 263 cases). The accumulation of ascites postoperatively was associated with a prolonged postoperative ileus, abdominal pain, and extended postoperative hospitalization. Once the condition was recognized, abdominal paracentesis resulted in rapid improvement of symptoms in two patients but repeated paracenteses were required for a further two patients who had significant complications as a result of these procedures. Two patients improved following spontaneous drainage of a large amount of ascites per vagina and did not require further intervention. The final patient settled with observation only. This condition can be difficult to recognize and is a potential cause of significant postoperative morbidity.

National audit of the management of injured patients in 20 Scottish hospitals.

The Scottish Trauma Audit Group was established in 1991 to observe and improve the management of seriously injured patients in four Scottish teaching hospitals. There are currently 25 hospitals contributing to the national database. This prospective audit monitors the management of approximately 98% of seriously injured patients in Scotland. This report presents an analysis of the management of 23479 patients who were admitted to hospital for at least three days or who died in hospital as a result of their injuries. The audit has specifically addressed the concerns raised by the working party of the Royal College of Surgeons in 1988 and the National Audit Office in 1992. National standards were agreed and implemented by STAG in 1997. STAG has demonstrated that 73.5% of seriously injured patients presented outwith 'normal' working hours when staffing and support services are at their lowest level. Seniority of accident and emergency doctor was associated with improved outcome in injured patients. An increase in the presence of consultants in accident and emergency medicine, anaesthetics and surgery has been demonstrated and a reduction in the mortality of seriously injured patients is evident. There was no evidence of a trimodal distribution of death as a result of injury. There has been a significant increase in the survival of seriously injured patients over the last six years from 65.3% to 75.6%. In terms of survival, the management of injured patients in Scotland is significantly better than that of the rest of the UK.

Adjuvant small field pelvic radiation for patients with high risk, stage IB lymph node negative cervix carcinoma after radical hysterectomy and pelvic lymph node dissection. A pilot study.

BACKGROUND: After radical hysterectomy and pelvic lymph node dissection, an identifiable subgroup of patients with International Federation of Gynecology and Obstetrics Stage IB lymph node negative cervix carcinoma remains at high risk of pelvic recurrence. This study attempted to determine whether postoperative small field of pelvic radiation can improve the disease free survival (DFS) of this high risk group of patients without producing significant morbidity. METHODS: Between 1991 and 1995, after radical surgery, 25 patients with Stage IB lymph node negative cervix carcinoma were considered to be at high risk of pelvic recurrence on the basis of tumor dimension, depth of stromal invasion, and the presence of lymph-vascular space invasion. All had a score >/= 120 as determined by the Gynecologic Oncology Group (GOG) study. These patients received 50.4 gray of adjuvant radiation to a small central pelvic field and were followed prospectively. A Kaplan-Meier 5-year DFS curve was generated. A log rank analysis produced an estimated log rank P value (est P value) by comparing the 5-year DFS of the patients in the current study with the 5-year DFS of the corresponding high risk group of the GOG study (observation only). The morbidity of small field pelvic radiation was recorded. RESULTS: Among the 25 patients who received small field pelvic radiation, the mean GOG score was 166 (range, 120-263) and the mean follow-up was 32 months (range, 12-64 months). There was 1 recurrence (4%) recorded at 16 months. The log rank analysis demonstrated a significant improvement in the 5-year DFS for the group who received adjuvant small field pelvic radiation (est P value = 0.005) when compared with the DFS of the high risk GOG patients who were observed postoperatively. Four cases of minor morbidity were recorded: lymphedema (three cases) and mild rectal incontinence (one case). No major morbidity was reported. CONCLUSIONS: With low morbidity, adjuvant small field pelvic radiation appears to improve significantly the 5-year DFS of patients with high risk, lymph node negative Stage IB cervical carcinoma. However, this pilot study requires verification.

Corticosteroids in the management of bowel obstruction on a gynecological oncology unit.

The development of gastrointestinal obstruction commonly occurs as a complication of advanced gynecological cancer. While surgery remains the mainstay of treatment for these patients, it is not always feasible, and when it is performed, it does not always resolve the obstruction. In this prospective study of patients presenting to a gynecologic oncology unit, 13 patients were administered 8 mg of dexamethasone subcutaneously or intravenously for a minimum of 3 days to manage the symptoms of bowel obstruction. Nine patients (69%) had a response to this therapy with decreased pain, nausea, and vomiting and improved oral intake. This response was maintained for a median of 31 days, with 7 of the 9 patients maintaining this symptomatic response until death. Mean survival of those responding was 39 days, including a subgroup of patients with extremely limited prognosis who, at their request, were discharged from the hospital in order to die at home. This subgroup had a mean survival of 20 days. The mean survival for nonresponders was 54 days. In patients for whom surgery is not contemplated, corticosteroids may provide a palliative treatment for bowel obstruction secondary to malignancy, provided there are no contraindications.

Paclitaxel (Taxol) as salvage therapy for relapsed ovarian cancer.

Thirty-two patients with epithelial ovarian cancer received paclitaxel 175 mg/m2, by 3-hour infusion, in this prospective phase 2 study. All patients had relapsed or progressed after initial cisplatin/cyclophosphamide therapy. Thirteen patients received paclitaxel as second line therapy, 14 as third line therapy and 5 as fourth line therapy. One patient was excluded from efficacy analysis, due to a severe anaphylactic reaction to the first cycle of paclitaxel therapy. Of the 31 evaluable patients, complete remission was observed in 3 patients (9.7%) and partial remission in 11 patients (35.5%), with a total response rate of 45.2%. The median survival from diagnosis for the 31 evaluable patients was 32.5 months and the median survival following therapy with paclitaxel was 12.2 months (range 4-27 months). The 3 patients who achieved a complete response remain alive, at greater than 20 months, since commencing paclitaxel. Twelve patients (38.7%) who achieved a partial response, or had stable disease, had a median survival, after paclitaxel treatment, of greater than 18 months. This study confirms the activity of paclitaxel in relapsed ovarian cancer and demonstrates a prolonged survival benefit in greater than one third of this group of patients.

Cytology in the follow-up of cervical cancer.

OBJECTIVE: To determine the value of cytology in the follow-up of cervical cancer. STUDY DESIGN: The study group consisted of 230 patients with invasive cervical carcinoma who were followed for one to seven years. Forty-four patients developed recurrences or metastases. During this period, cytologic investigations involved 795 exfoliative smears from the cervix or vaginal vault, 10 fine needle aspirates and 5 fluids. RESULTS: Thirty-three patients had positive or inconclusive cervical or vault smears that were histologically proven to be recurrences, and the other 11 patients had clinically obvious recurrences that were not smeared. Cytology first alerted the clinicians to recurrence in eight patients. Of 25 cervical or vault smears reported as malignant, 24 (96%) were histologically confirmed, and 1 showed radiation change on biopsy. In all 22 cases of smears reported as inconclusive, a biopsy followed, and in 9 (41%) of these, recurrence was demonstrated histologically. Inability to distinguish radiation change from recurrent malignancy was the chief cause of inconclusive smears. Five fluids and seven fine needle aspirates were diagnosed as malignant, saving patients an invasive diagnostic procedure. CONCLUSION: Cytology is a useful, cost-effective, noninvasive and accurate investigation in the follow-up of cervical cancer.

Grapelike leiomyoma of the uterus.

A 24-year-old nulliparous woman underwent laparotomy for a large pelvic mass. Grapelike tumor extending from the uterus into the broad ligaments and peritoneal cavity was found. A diagnosis of sarcoma appeared likely, but radical surgery was avoided when frozen sections indicated a histologically benign smooth muscle tumor.

Extrauterine malignant mixed müllerian tumor of primary peritoneal origin.

The case of an extrauterine heterologous malignant mixed müllerian tumor (MMMT) of primary peritoneal origin occurring in a 63 yr old woman is presented. The tumor was a 19 cm, soft, friable mass arising from the serosa of the sigmoid colon and spreading to adjacent pelvic peritoneum. The uterus, tubes and ovaries were uninvolved. It was composed of sarcomatous areas showing cartilaginous and rhabdomyoblastic differentiation and sharply demarcated carcinomatous areas showing endometrioid and serous differentiation. This is the thirteenth reported case of an extragenital MMMT. It demonstrates the pluripotentiality of female pelvic peritoneum to differentiate into tumors resembling those of the genital tract.

The treatment of gynaecological malignancy in a general public hospital.

OBJECTIVE: To assess the adequacy of treatment of gynaecological cancer in a public hospital and to determine the influence of referral patterns on patient outcome. DESIGN: A retrospective analysis of clinical histories. SETTING: A tertiary-level general public hospital. PATIENTS: 89 patients admitted between 1 January 1979 and 31 December 1987 for primary treatment of a gynaecological malignancy. MAIN OUTCOME MEASURES: The primary study parameter was patient survival. During data analysis, the study parameters were altered to include the adequacy of initial surgery and survival time in relation to the involvement of the Gynaecology Unit. RESULTS: Initial presenting symptoms had a major influence on the referral patterns of patients with a gynaecological malignancy. All patients who presented with abnormal vaginal bleeding were managed by the Gynaecology Unit. Patients with ovarian cancer who presented with non-specific abdominal symptoms and ascites were often managed by other units. There was a statistically significant difference in the adequacy of initial surgery depending on whether the patient was managed by the Gynaecology or the Surgical Unit (P < 0.05). The median survival time of patients managed by the Gynaecology Unit was 20 months; this was considerably longer than the figure of 14 months for other units (P < 0.05). CONCLUSIONS: Patients with ovarian cancer who are managed by a specialised gynaecology unit are more likely to have adequate initial surgery and a longer median survival time. Female patients presenting with non-specific abdominal symptoms, ascites and other signs of intra-abdominal malignancy should be reviewed by a gynaecology unit before initial surgery.

Maximum effort in the management of ovarian cancer, including pelvic and para-aortic lymphadenectomy.

Patients treated for ovarian cancer at the Mercy Hospital for Women, Melbourne over a 5 1/2 year period were studied with an emphasis on the need for lymphadenectomy. There were 80 patients identified with ovarian cancer. Forty patients underwent pelvic and/or para-aortic lymphadenectomy and 25 (62.5%) were found to have lymph node metastases, in 7 of the 40 women the lymphadenectomy resulting in upstaging of the disease. FIGO has adopted a surgicopathological approach to the staging of ovarian cancer and this requires lymphadenectomy to be performed. The importance of accurate staging in clinically early ovarian cancer and maximum surgical effort in advanced disease is discussed with particular regard to the place of lymphadenectomy.

Pelvic radiation therapy for gynecologic malignancy in geriatric patients.

Thirty-one patients, aged 75 years or older, who received pelvic radiation therapy as part of primary treatment for a gynecologic malignancy, were reviewed. Ten patients (32%) failed to complete their treatment and 4 patients (13%) died of treatment-related complications. The treatment-related complications were independent of increasing age, but did correlate closely with the patients' pretreatment ECOG performance status. Ten patients with performance levels of 2 or higher had a mortality rate of 30%, while 70% failed to complete treatment. Treatment fractions of greater than 220 cGy per day also resulted in unacceptably high complication rates. Alternative treatment formats should be considered in geriatric patients with poor initial performance levels.

Biosynthesis of an insulin precursor by islet tissue of cod (Gadus callarias).

1. At 15 degrees , slices of cod islet tissue incorporated [U-(14)C]proline into proteins soluble in acid-ethanol at a linear rate for 6hr. 2. Initially, all the radioactivity was associated with a polypeptide that had a molecular weight of about 10000 and was appreciably more basic than cod insulin. After 1hr. there was also a significant and progressive increase in the radioactivity of insulin and of fractions intermediate in molecular size and basicity between the polypeptide and insulin. 3. O-Ethyl O-p-nitrophenyl phenylpropylphosphonate markedly decreased the radioactivity both of the intermediate fractions and of insulin, but had no significant effect on the biosynthesis of the polypeptide. In contrast, puromycin inhibited the incorporation of radioactivity into all the fractions. 4. The polypeptide had an activity of less than 0.2 international unit/mg. in the epididymal-fat-pad bioassay. Treatment with low concentrations of trypsin caused a progressive increase in the formation of an insulin-like material, judged by bioassay and ion-exchange chromatography of the digest. 5. Gel filtration of the polypeptide after oxidative sulphitolysis indicated that it was a single polypeptide chain. 6. The results suggest that the polypeptide is an insulin precursor whose formation is inhibited by puromycin and that the steps involved in the conversion of precursor into product are sensitive to O-ethyl O-p-nitrophenyl phenylpropylphosphonate.

The sequence of amino acids in insulin isolated from islet tissue of the cod (Gadus callarias).

1. S-Aminoethylcysteinyl derivatives of the A and B chains of cod insulin were prepared from the individual S-sulpho chains. 2. Studies on small peptides derived from the S-aminoethylated peptide chains by treatment with trypsin allowed the amino acid sequences in the region of the cysteinyl residues of the A and B peptide chains to be defined. 3. The six amide groups in cod insulin were located by complete digestion of small peptides from the A and B chains with aminopeptidase followed by amino acid analyses. 4. The results, together with previous studies on the oxidized A and B chains, define the sequences of the 51 amino acids that constitute cod insulin.

Isolation and a partial amino acid sequence of insulin from the islet tissue of cod (Gadus callarias).

1. Insulin has been isolated by gel filtration and ion-exchange chromatography from extracts of the discrete islet tissue of cod. The final preparation yielded a single band on electrophoresis at two pH values. The biological potency was 11.5 international units/mg. in mouse-convulsion and other assay procedures. 2. Glycine and methionine were shown to be the N-terminal amino acids of the A and B chains respectively. An estimate of the molecular weight together with amino acid analyses indicated that cod insulin, like the bovine hormone, consists of 51 amino acid residues. In contrast, the amino acid composition differs markedly from bovine insulin. 3. Oxidation of insulin with performic acid yielded the A and B peptide chains, which were separated by ion-exchange chromatography. Sequence studies on smaller peptides isolated from enzymic digests or from dilute acetic acid hydrolysates of the two chains have established the sequential order of 14 of the 21 amino acid residues of the A chain and 25 of the 30 amino acid residues of the B chain.