Concomitant chemotherapy and radiation for the treatment of advanced-stage endometrial cancer.

INTRODUCTION: Ccombination chemotherapy and radiation therapy is used for adjuvant treatment of stage III-IV endometrial cancer. The goal of this study was to review the treatment duration, toxicity, and survival for patients treated with concomitant chemotherapy and radiation. METHODS: Women with stage III-IV endometrial cancer treated with concurrent chemotherapy and radiation between 2006 and 2013 were included. Toxicities were classified per CTCAE v3.0 and RTOG/EORTC late radiation morbidity scoring. Descriptive statistics were used to quantify treatment and toxicities. Kaplan-Meier method was used to estimate survival. RESULTS: Fifty-one patients met our inclusion criteria. Median age was 60 (range 33-85). Thirty-six patients (70.6%) had endometrioid histology, 13 patients (25.5%) had serous, clear cell, or mixed histology, and 2 women (3.9%) had carcinosarcoma. Forty-eight patients had stage III disease and three patients were stage IVB. Mean treatment duration was 107 ± 19 days. Forty-two patients received all planned chemotherapy, and 16 patients required a dose reduction. Thirty-four patients (66.7%) experienced grade 3-4 toxicities, the majority of which were hematologic. There were no deaths related to therapy. Eighty-six percent of patients received leukocyte growth factors, and 25% of patients received a blood transfusion. Seven late grade 3-4 complications occurred: four gastrointestinal and two genitourinary, and one patient had ongoing neuropathy. Median progression-free survival was 42.8 months (range 4.4-81.5 months) and median overall survival was 44.9 months (range 5.1-82.6 months). Three-year overall survival was 80%. CONCLUSION: Concomitant chemotherapy and radiation is an adequately tolerated treatment modality that allows for shorter treatment duration.

Immobilization of viral antigens on filter paper for a [125I]staphylococcal protein A immunoassay: a rapid and sensitive technique for detection of herpes simplex virus antigens and antiviral antibodies.

A new technique is described for the rapid detection and quantitation of herpes simplex virus (HSV) antigens and antiviral antibodies. It involves immobilization of HSV antigens on filter paper discs and subsequent analysis by 125I-labeled staphylococcal protein A (SPA) radioimmunoassay. A specially designed 96-well filtration device is employed which serves both as an incubation chamber and as a filtration manifold. It is rapid, simple, sensitive and specific, and requires only small volumes of antiserum and few target cells. The results may be readily and objectively quantitated. This technique permits the simultaneous assay of a large number of specimens in less than 1 h. Its sensitivity is considerably greater than that of other currently used immunologic techniques, and it is amenable to automation. These characteristics suggest that this [125I]SPA immunofiltration technique may be applicable to the rapid diagnosis of viral infections.

The growth of endothelium from human corneal rims in tissue culture.

The authors report the successful in vitro growth of human corneal endothelium derived from 12 of 31 corneal-scleral rims obtained following corneal transplantation. The average age of donors whose endothelium grew was 17.6 +/- 3.2 years. The average interval between death and culturing was 51.5 +/- 10.1 hr. The cells migrated from the explants within 3-7 days and were characterized by a flattened, polygonal shape with a centrally located nucleus. Cell growth exhibited a doubling time of 72-96 hr in the second and third tissue culture passages. A reduced growth rate was observed by cell lines maintained in vitro for over 6 months. Fibroblast growth factor, epidermal growth factor, and endothelial cell growth supplement all exerted a positive influence on cell proliferation. Corneal-scleral rims can be a valuable source of endothelial cells for corneal research.

M-K medium and postmortem cytologic damage.

Freshly enucleated rabbit eyes were refrigerated at +4 degrees C under standard eye bank conditions for 2, 6, 9, and 21 days. One group of corneas with a scleral rim were excised and placed in M-K medium, stored for 18, 24, or 48 hr at +4 degrees C; they were then removed, and endothelial cell viability was evaluated with nitroblue tetrazolium. The cells were examined by light microscopy and scanning and transmission electron microscopy. A second group of corneas were similarly obtained and then used as donor corneas from 6 mm transplants. Each recipient rabbit was evaluated daily by slit-lamp biomicroscopy and corneal pachometry. Fourteen days postoperatively, the rabbits were sacrificed, the eyes enucleated, and the excised corneas were evaluated in a fashion similar to those of group 1. M-K medium storage protected the morphology and functional integrity of the rabbit corneal endothelium up to 48 hr beyond moist chamber storage for 2, 6, and 9 days. However, M-K medium appeared to have no such effect on corneas that had been moist chamber--stored for 21 days. These results suggest that some human corneas with a prolonged time from death to moist chamber storage may be utilized for corneal transplantation after further storage in M-K medium.

Wound healing in cultured corneal endothelial cells.

Following the application of needle, intraocular lens, freeze, and laser wounds to the center of discrete 1 cm2 areas, density-limited monolayers of cultured rabbit corneal endothelium demonstrate wound healing responses similar to those seen in in vivo corneas. The wounded monolayer reforms in a time period consistent with that seen in both in vivo and in vitro organ culture models, thus suggesting that cell motility characteristics are not dependent upon an underlying Descemet's membrane. Density-limited, cultured monolayers of corneal endothelial cells present a good model for studying the response of the endothelium to a variety of stimuli.

Intermediate filaments and their organization in human corneal endothelium.

The native intermediate filament network within human corneal endothelium was identified by a monoclonal antibody to vimentin intermediate filament protein. Human corneal endothelial cells in tissue culture were shown to react positively to this monoclonal antibody by indirect immunofluorescence microscopy. In cryostat sections of human cornea, only the endothelial cells and keratocytes stained for vimentin. Fluorescent staining patterns of the cultured endothelial cells demonstrated that vimentin forms arrays of cytoplasmic filaments which encapsulate the nucleus and anchor in the apical junctions. These results reveal a previously undescribed cytoskeleton in human corneal endothelium and suggest that the intermediate filament vimentin comprises this structural network which is, in part, responsible for nuclear centration and cell-to-cell contacts. In addition, these results may indicate the possible embryogenesis of the corneal endothelium, since vimentin is a marker for cells of mesenchymal origin.

Evaluation of an electronic corneal pachometer.

Sixteen patients who had never worn contact lenses underwent measurement of their central corneal thicknesses with the standard corneal pachometer and a new electronic corneal pachometer. Both instruments were able to produce repeatable and accurate results, although the overall measurements obtained were thicker with the electronic pachometer. The advantage of the electronic pachometer over the standard pachometer is that one is able to easily measure areas other than the central cornea with repeatable accuracy. With the addition of a microcomputer and print-out system, large populations can be studied, and changes in corneal thickness can be recorded on a day-to-day or hour-to-hour basis.

Requirement for vitamin A in long-term culture of human cornea.

PURPOSE: To develop an in vitro model for the study of vitamin A functions in the cornea by determining the morphologic responses to its absence and to the addition of varying concentrations in long-term (21-day) human organ culture. METHODS: Donor corneas were cultured for 21 days in an air-liquid environment designed to maintain normal corneal morphology in long-term culture. Corneas were graded by light microscopy and were further analyzed by transmission electron microscopy. RESULTS: Epithelium of human corneas cultured in the absence of vitamin A for 21 days showed characteristics of vitamin A deficiency: multilayering of squamous cells, bundling of tonofilaments to form keratofibrils, increased desmosomes, and loss of microplicae on the surface cells. The cells responded to the addition of vitamin A in concentrations ranging from 5 x 10(-9) to 5 x 10(-6) M. At the lowest concentration, cell differentiation and morphology appeared normal. Cells developed secretory morphology at higher concentrations of vitamin A, with intracellular vesicles, basement membrane overproduction, and reduced cell-cell and cell-substrate attachments. Keratocytes and endothelial cells showed increased intracellular vacuoles in the presence of higher concentrations of vitamin A. CONCLUSIONS: Cultured adult human corneas showed primary, dose-related responses to vitamin A in the absence of inflammatory, neuronal, or humoral factors. The epithelium was most sensitive to the absence of vitamin A and showed a dose-related response to additional vitamin A. All corneal cell layers showed morphologic changes at the highest concentration of vitamin A used.

Corneal surface ablation by 193 nm excimer laser and wound healing in rabbits.

The 193 nm argon fluoride excimer laser was used to ablate a 6 mm diameter area of the central rabbit cornea under various conditions of power, beam configuration and exposure time. High repetition rates or prolonged exposures produced charring and prevented rapid epithelial wound closure. Endothelial vacuolization, reduction in density, and displacement of cell material into Descemet's layer resulted in these experiments. A beam of low and uniform power intensity (40 pulses per second, 100 seconds at 23 mJ/cm2) reduced stromal damage, cellular infiltration, and epithelial irregularities including punctate staining and cell exfoliation. Epithelial rehealing occurred within two days. Basal lamina and hemidesmosomes were reformed by one week. Endothelial damage was not detected. Excimer laser ablation may allow removal of superficial dystrophies or scars, followed by rapid healing from normal corneal reparative processes.

High-voltage electron microscopy of normal human cornea.

Conventional transmission electron microscopy (CTEM) was compared with high-voltage electron microscopy (HVEM) on 11 normal human corneas (age range, 30 weeks of gestation to 92 yr). Epithelial anchoring fibrils were noted between the basal epithelial cells and Bowman's layer (BL) as previously reported. Parallel pairs of fibers, 27.5 nm in diameter, were observed crossing into the anterior stromal lamellae from BL; their termination sites, however, were not identified. The lateral termination of BL was marked by the presence of a keratocyte lying directly below the end of the multilaminar basal lamina. In this region, BL tapered and became interwoven with the scleral collagen fibrils in the substantia propria. The HVEM accentuated the orthogonal relationship of collagen bundles apparently emerging from the stromal keratocytes. The posterior corneal stroma appeared to be attached to the anterior surface of Descemet's membrane (DM) by fibers 22.3 nm in diameter that were associated frequently with a dense amorphous material. In the periphery, DM tapered to a thin strand, 0.5 microns in thickness, containing cable-like strands of banded collagen. The posterior nonbanded portion continued laterally and anteriorly in a series of folds between the fibrous collagen sheets of the anterior trabecular meshwork. In addition, HVEM enhanced the visibility of extracellular matrix interactions in the lateral terminations of BL and DM, attachment fibers from BL to the stroma and from the stroma to DM, and keratocyte and collagen fiber orientations not seen easily by CTEM.

Morphology of hydrogel implants used for refractive keratoplasty.

The pathology of 14 keratophakia procedures in nine nonhuman primates using various hydrogel lenses as donor lenticles is presented. The lenses were treated as if they were human donor corneas using currently practiced keratophakia procedures. This included microkeratome resection of the recipient cornea, staining of the lenses before cryolathing and, in most instances, lathing according to a modified computer program after which the lenses were inserted into the previously dissected recipient lamellar bed. There was no histologic evidence of an inflammatory reaction to the hydrogels. The major pathologic feature was the presence of activated keratocytes lining the dissected intrastromal pockets.

Growth characteristics of primate (baboon) corneal endothelium in vitro.

Primate (baboon) corneal endothelial cells have been grown continuously in vitro for over 40 passages. Endothelial cells migrated from the explants within three to five days. Growth became confluent by 14 to 21 days; the cells in culture were polygonal in shape and formed a compact monolayer. In passages one to four, cells divided with a doubling time of 72 hours; this increased to 96 hours after the 16th passage. Even though the general morphological appearance was unchanged in passages greater than 10, the cells became irregular, exhibiting an enlarged and elongated profile. The addition of epidermal growth factor to the medium resulted in increased cell growth. Cultured cells were successfully transplanted onto Descemet's membrane of de-endothelialized baboon corneas. This study demonstrates that primate corneal endothelial cells can be grown continuously in tissue culture and subsequently transplanted in vitro.

Evaluation of through-and-through corneal sutures.

Sutures placed at the level of Descemet's membrane were compared with sutures placed through and through the full corneal thickness in 42 rabbit corneas using cataract and corneal wounds. The rabbits were killed, and sutures were removed at various postoperative periods up to four weeks. Evaluation of the wounds demonstrated that although the through-and-through technique provided good wound closure in the immediate postoperative period, the technique produced more damage to Descemet's membrane and to the endothelial cells, both at the time of suturing and at the time of suture removal, and tended to produce greater retrocorneal membrane formation. In addition, the through-and-through suturing technique was technically more difficult. In this study performed in rabbits, the one advantage of the through-and-through suture, ie, immediate posterior wound closure, was outweighed by its many disadvantages.

A continuous-wear hydrophilic lens. Prophylactic topical antibiotics.

Seventeen patients, who were fitted with a continuous-wear hydrophilic lens for 12 weeks, received topical neomycin sulfate-polymyxin B sulfate-gramicidin (Neosporin) eyedrops in one eye only at a frequency of 3.7 times per day. The continuous wear of a hydrophilic lens in and of itself did not after normal bacterial flora, and the use of the antibiotic drops did not alter normal conjunctival flora. In addition, the eyedrops were not more effective when used in conjunction with the hydrophilic lens and did not appear to produce resistant organisms during the 12-week study. In normal eyes, a continuously worn hydrophilic soft contact lens that is well tolerated does not adversely affect the bacterial flora and the addition of neomycin sulfate-polymixin B-gramicidin drops at a frequency of 3.7 times per day does not appear to be beneficial or necessary.

The pathologic findings of epithelial ingrowth.

A case of postcataract epithelial ingrowth that occurred when a chronic fistula was produced after a discussion of a secondary membrane is reported. The ingrowth was examined preoperatively with the specular microscope, and the excised anterior segment was examined with correlative microscopy. The patient recovered 6/18 (20/60) visual acuity after a subsequent penetrating keratoplasty. The characteristics of the epithelial ingrowth consisted of nonkeratinized squamous epithelium with surface microvilli, wide intercellular borders with occasional desmosomes, multiple tonofilaments more prominent in the leading edge of the ingrowth, hemidesmosomes attached to a subepithelial connective tissue layer, and uneven sizes and shapes of epithelial cells. These findings suggested that the source of the ingrowth was from the conjunctival epithelium. We found the leading edge of the ingrowth as well as the type of damage inflicted to the underlying endothelium.

Scarring of a recipient cornea following epikeratoplasty.

A recipient cornea gradually developed wrinkling and opacification in Bowman's layer following an uneventful myopic epikeratoplasty. The process continued after removal of the lenticule, and the best corrected visual acuity decreased from 20/20 to 20/60. Glare, especially at night, severely compromised the vision in this eye. Six months after removal of the lenticule, a homoplastic myopic keratomileusis was performed to remove the corneal opacity and correct the residual myopia. Morphologic analysis of the patient's excised cornea demonstrated wrinkles and folds in Bowman's layer. To our knowledge, this is the first reported case of scarring of a patient's own cornea after epikeratoplasty and of treatment of a failed epikeratoplasty with homoplastic myopic keratomileusis.

A comparison of wound healing in sutured and unsutured corneal wounds.

We compared corneal wound healing in 25 clear transplants with 26 keratotomy specimens and sutured and unsutured corneal wounds in a monkey model. Monkey wounds healed faster than human wounds, but healing time within the same species varied. Sutured wounds were characterized by subepithelial fibroplasia, recovery of collagen fiber continuity and absence of epithelial plugs. Unsutured wounds had no subepithelial fibroplasia but had fibroblasts and collagen fiber orientation parallel to wounds. Unsutured wounds in corneas containing sutures had subepithelial fibroplasia, and fibroblast orientation and fiber deposition parallel to the wound. Epithelial ingrowth and incarceration of Bowman's layer and/or Descemet's membrane in unsutured wounds appeared to disrupt wound healing. Abnormalities in wound healing in sutured or unsutured wounds are associated with lamellar distortion, a modified inflammatory response, and individual wound healing responses.

Why do some epikeratoplasties fail?

We performed a morphologic analysis of nine epikeratoplasty lenticules that were removed due to nonhealing epithelial defects, interface opacity, and/or haze of the donor lenticule. Structural abnormalities were found in all layers of the donor lenticules, with the major changes being present in the surface epithelium and Bowman's layer. Significant changes in the stromal collagen were documented. Similar changes were found in a previous analysis of never-used, factory-prepared lenticules that had been prepared following the use of a corneal press and a lyophilization process. This study suggests that the presently used process of tissue preparation may be deleterious to the structure of the donor lenticule and may adversely affect surface reepithelialization. The placement of the lenticule above the recipient's Bowman layer may be an additional retardant to postoperative reepithelialization.

Keratoconjunctivitis and soft contact lens solutions.

Three patients with soft contact lenses had acute onset of a red eye that clinically appeared consistent with an adenoviral keratoconjunctivitis. The signs and symptoms cleared within five to ten days in all three patients. When the patients reinserted their lenses after their initial episodes, the same signs and symptoms again developed, including follicular conjunctivitis, punctate keratitis, and subepithelial infiltrates. All three were using preserved solutions for soft lens disinfection, and when switched to thermal disinfection with saline tablets, a recurrence of the syndrome did not develop when the lenses were replaced. This syndrome seems related to a toxic or allergic reaction to the preservatives in the contact lens disinfecting solutions. Similar patients who have an acute or chronic, red, irritated eye should stop their lens wear and later should change their disinfection technique to one that uses unpreserved saline solution to eliminate the problem.

Laboratory evaluation of freeze vs nonfreeze lamellar refractive keratoplasty.

Four pairs of human eyes were operated on to correct 10 diopters of myopia. One eye underwent standard myopic keratomileusis, and the mate underwent planar lamellar refractive keratoplasty (PLRK). Cryolathing produced morphologic alterations in all layers. Planar lamellar refractive keratoplasty produced a smoother stromal surface in the optic zone. Peripheral triangular surface depressions in the lenticule, corresponding to fixation facets on the PLRK unit, were the only morphologic alterations noted. It appears that PLRK eliminates many adverse features associated with tissue freezing and lyophilization.