Corticosteroid dose and the risk of opportunistic infection in a national systemic lupus erythematosus cohort.

Objective This study investigated whether the incidence of opportunistic infection differed in systemic lupus erythematosus patients who received different doses of corticosteroids. Methods We included patients with diagnosed systemic lupus erythematosus from 1997 to 2010 using Taiwan national health insurance data. The index day for systemic lupus erythematosus patients was 3 months after the systemic lupus erythematosus diagnosis. A non-steroid cohort was matched 4:1 with the steroid cohort according to age, sex and index day. The end of the follow-up period was the day of opportunistic infection diagnosis, 1 year after the index day, or death. Results The overall cumulative incidence of opportunistic infection was 136-fold higher in the steroid cohort than in the non-steroid cohort. The adjusted hazard ratio for developing mycobacterium infection in the steroid cohort was 11, and the adjusted hazard ratio for developing herpes zoster was 43.6 compared to the non-steroid cohort after adjusting for immunosuppressive agents and comorbidities. The adjusted hazard ratio value for opportunistic infection was 1.40 (95% confidence interval (CI) 0.78-2.51) for a daily prednisone-equivalent dose of 7.5-15 mg, 1.72 (95% CI 1.02-2.91) for 15-30 mg, 1.96 (95% CI 1.17-3.28) for 30-60 mg and 2.24 (95% CI 1.26-4.00) for over 60 mg compared with low-dose steroids (<7.5 mg). Conclusion This study confirmed that the risk of opportunistic infection is higher in systemic lupus erythematosus patients treated with steroids in the first 3 months after diagnosis versus those not treated with steroids. Medium and high doses were associated with a higher risk of opportunistic infection compared with low doses. However, there was no controlling for disease activity, making it hard to know if increases in infection were due to disease itself or corticosteroids.

A KRAS mutation status-stratified randomized phase II trial of gemcitabine and oxaliplatin alone or in combination with cetuximab in advanced biliary tract cancer.

BACKGROUND: Previous clinical trials have not proved that adding epidermal growth factor receptor inhibitors to chemotherapy confers a survival benefit for patients with advanced biliary tract cancer (ABTC). Whether the KRAS mutation status of tumor cells confounded the results of past studies is unknown. PATIENTS AND METHODS: ABTC patients stratified by KRAS status, Eastern Cooperative Oncology Group performance status, and primary tumor location were randomized 1 : 1 to receive GEMOX (800 mg/m(2) gemcitabine and 85 mg/m(2) oxaliplatin) or C-GEMOX (500 mg/m(2) cetuximab plus GEMOX) every 2 weeks. The primary end point was objective response rate (ORR). RESULTS: The study enrolled 122 patients between December 2010 and May 2012 (62 treated with C-GEMOX and 60 with GEMOX). Compared with GEMOX alone, C-GEMOX was associated with trend to better ORR (27% versus 15%; P = 0.12) and progression-free survival (PFS, 6.7 versus 4.1 months; P = 0.05), but not overall survival (OS, 10.6 versus 9.8 months; P = 0.91). KRAS mutations, which were detected in 36% of tumor samples, did not affect the trends of difference in ORR and PFS between C-GEMOX and GEMOX. The two treatment arms had similar adverse events, except that more patients had skin rashes, allergic reactions, and neutropenia in the C-GEMOX arm. Of patients with C-GEMOX, the presence of a grade 2 or 3 skin rash was associated with significantly better ORR, PFS, and OS. CONCLUSIONS: Addition of cetuximab did not significantly improve the ORR of GEMOX chemotherapy in ABTC, although a trend of PFS improvement was observed. The trend of improvement did not correlate with KRAS mutation status. CLINICAL TRIALS NUMBER: This study is registered at ClinicalTrials.gov (NCT01267344). All patients gave written informed consent.

Gut microbiome and symptoms in females with irritable bowel syndrome: a cross-sectional analysis.

Irritable bowel syndrome (IBS), a disorder of gut-brain interaction, is associated with abdominal pain and stool frequency/character alterations that are linked to changes in microbiome composition. We tested whether taxa differentially abundant between females with IBS vs healthy control females (HC) are associated with daily gastrointestinal and psychological symptom severity. Participants (age 18-50 year) completed a 3-day food record and collected a stool sample during the follicular phase. They also completed a 28-day diary rating symptom intensity; analysis focused on the three days after the stool sample collection. 16S rRNA gene sequencing was used for bacterial identification. Taxon abundance was compared between IBS and HC using zero-inflated quantile analysis (ZINQ). We found that females with IBS (n = 67) had greater Bacteroides abundance (q = 0.003) and lower odds of Bifidobacterium presence (q = 0.036) compared to HC (n = 46) after adjusting for age, race, body mass index, fibre intake, and hormonal contraception use. Intestimonas, Oscillibacter, and Phascolarctobacterium were more often present and Christensenellaceae R-7 group, Collinsella, Coprococcus 2, Moryella, Prevotella 9, Ruminococcaceae UCG-002, Ruminococcaceae UCG-005, and Ruminococcaceae UCG-014 were less commonly present in IBS compared to HC. Despite multiple taxon differences in IBS vs HC, we found no significant associations between taxon presence or abundance and average daily symptom severity within the IBS group. This may indicate the need to account for interactions between microbiome, dietary intake, metabolites, and host factors.

Cardiac hemangioma located at the apex of the left ventricle: a rare case report.

We report the case of a 67-year-old man who was found to have asymptomatic murmurs during his health check-up. Echocardiography revealed a mobile spherical mass in the left ventricle (LV), whereas magnetic resonance imaging (MRI) study revealed a well-circumscribed heterogeneous mass in the LV with its base attached to the LV apex. To the best of our knowledge, such a case of hemangioma, particularly its rare location at the apex of the LV, and its asymptomatic conduction disturbance has not yet been reported in the medical literature. Because of successful surgical intervention, the patient is in good health without any further tumor recurrence at 24 months after the diagnosis.

Predicting adverse drug effects: A heterogeneous graph convolution network with a multi-layer perceptron approach.

We apply a heterogeneous graph convolution network (GCN) combined with a multi-layer perceptron (MLP) denoted by GCNMLP to explore the potential side effects of drugs. Here the SIDER, OFFSIDERS, and FAERS are used as the datasets. We integrate the drug information with similar characteristics from the datasets of known drugs and side effect networks. The heterogeneous graph networks explore the potential side effects of drugs by inferring the relationship between similar drugs and related side effects. This novel in silico method will shorten the time spent in uncovering the unseen side effects within routine drug prescriptions while highlighting the relevance of exploring drug mechanisms from well-documented drugs. In our experiments, we inquire about the drugs Vancomycin, Amlodipine, Cisplatin, and Glimepiride from a trained model, where the parameters are acquired from the dataset SIDER after training. Our results show that the performance of the GCNMLP on these three datasets is superior to the non-negative matrix factorization method (NMF) and some well-known machine learning methods with respect to various evaluation scales. Moreover, new side effects of drugs can be obtained using the GCNMLP.

Effects of fermented soybean meal with Bacillus velezensis, Lactobacillus spp. or their combination on broiler performance, gut antioxidant activity and microflora.

OBJECTIVE: A series of experiment were conducted to evaluate the effects of replacing a part of soybean meal (SBM) at 6% of broiler diets with fermented soybean meal (FSBM) obtained by single or two-stage fermentation by measuring growth performance, antioxidant activity in the jejunum and distal intestinal microflora. METHODS: Soybean meal samples were prepared by single-stage fermentation using Bacillus velezensis (Bv) (FSBMB), or Lactobacillus spp. (as commercial control) (FSBML). Additional SBM sample was prepared by two-stage fermentation using Bv and subsequently using Lactobacillus brevis ATCC 367 (Lb) (FSBMB+L). Enzyme activity, chemical composition, trichloroethanoic acid-nitrogen solubility index (TCA-NSI) and antioxidant activity were measured. Then, in an in vivo study, 320 Ross308 broilers were divided into four groups with ad libitum supply of feed and water. Four groups were fed either a corn-soybean meal diet (SBM), or one of fermented SBM diets (FSBMB+L, FSBMB, and FSBML). Growth, serum characteristics, microflora, and the mRNA expression of selected genes were measured. RESULTS: Compared to SBM, FSBMB+L contained lower galacto-oligosaccharide, allergic protein, and trypsin inhibitor, and higher TCA-NSI by about three times (p<0.05). Reducing power and 1,1-diphenyl-2-picrylhydrazyl free radical scavenging ability correlated positively with the TCA-NSI content in FSBM. Growth performances were not significantly different among four groups. In jejunum of 35-day-old broilers, partial replacement of SBM by FSBMB+L increased the activity of superoxide dismutase and catalase (CAT), and the FSBMB group had the highest catalase activity (p<0.05). Partial replacement of SBM by FSBM increased relative mRNA expressions of nuclear factor erythroid 2-related factor 2 (Nrf2), heme oxygenase-1 (HO-1), and peptide transporter 1 (PepT1) (p<0.05); however, FSBMB+L increased CAT mRNA level to 5 times of the control (p<0.05). CONCLUSION: Using Bv- and Lb-processed SBM through two-stage fermentation to partially replace 6% of diets will improve the gut's antioxidant activity under commercial breeding in broilers.

Successful treatment for a large renal cell carcinoma with tumour thrombus.

We report the case of a 41-year-old man with symptoms of exertional dyspnoea and easy fatigue. Physical examination revealed a palpable mass with knocking pain over the right flank region and a cardiac murmur with jugular vein engorgement. Transoesophageal echocardiography revealed a right atrial mass that caused tricuspid inflow obstruction. Computed tomography revealed a giant mass (approximately 15 x 15 cm2) in the right kidney; this finding was consistent with renal cell carcinoma. Despite the metastatic status, right nephrectomy was performed and the intra-atrial tumour thrombus (TT) was resected under a cardiopulmonary bypass in order to relieve the tricuspid obstruction. Histological examination confirmed renal cell carcinoma with TT. The patient is healthy with satisfactory systolic function at 1-year follow-up.

In situ preparation of an ultra-thin nanomask on a silicon wafer.

Porous nanomasks have been prepared in situ on an insulating silicon wafer by anodization of an aluminum film grown on it. Ultra-thin nanomasks, around 50 nm thick, were fabricated by utilizing a stop signal, a vivid color appearing at the air-electrolyte interface, and the process involved showed excellent repeatability. Finally, 2D nanoscale p-n junction arrays were fabricated on a silicon on insulator (SOI) wafer using the ultra-thin nanomasks prepared. The experimental results are in good agreement with the simulated results on the characteristics of the anodization process involved.

Protamine-associated hypotension in patients on hemodialysis: retrospective study and prevalence of antiprotamine antibodies.

AIMS: Protamine, when administered to neutralize heparin in cardiovascular surgery, is associated with occasionally severe antigen-antibody reactions associated with substantial morbidity and mortality. The objective of this study is to investigate whether patients on hemodialysis are more susceptible to the protamine adverse effects. METHOD: First, a retrospective analysis of a protamine-associated hypotension episode (PAHE) in 239 patients undergoing coronary artery bypass grafting surgery was performed for the incidence study in the period of 1999 to 2005. Second, an ELISA determination of serum anti-protamine IgG antibody in 255 serum samples from individuals without previous surgical histories was conducted for prevalence survey. In both studies, patients on HD were matched for age with non HD patients. RESULTS: The highest incidence (57%) of PAHE occurred in patients on hemodialysis using of M-insulin (a mixed type of insulin aspart 30%, insulin aspart protamine 70%) formulation, and this group also exhibited a high anti-protamine IgG antibody titer in serum (odds ratio: 18.31). CONCLUSIONS: A substantial proportion of patients on hemodialysis are at high risk of acquiring protamine adverse effects, but definite conclusion about the association between uremia and PAHE, however, still needs to be made with caution.

Discrimination between Sjögren's and non-Sjögren's sicca syndrome by sialoscintigraphy and antibodies against alpha-fodrin and Ro/La autoantigens.

Both Sjögren's syndrome (SS) and non-Sjögren's syndrome (NSS) can present with the sicca symptoms of dry eyes and a dry mouth but they are distinct pathological entities that require diagnostic discrimination. This study included 82 sicca syndrome patients and examined the ability of sialoscintigraphy and antibodies against the autoantigens alpha-fodrin, Ro and La to discriminate between SS and NSS. A total of 30.8% of SS patients compared with 58.8% of NSS patients were alpha-fodrin positive. The prevalence of Ro positivity was 69.4% for SS patients compared with 0% for NSS patients. The prevalence of La positivity was 52.4% for SS compared with 0% for NSS patients. Sialoscintigraphy showed that more NSS patients had grade III salivary gland impairment compared with SS patients (64.7% versus 19.4%). These data suggest that using sialoscintigraphy in combination with measuring the levels of serum alpha-fodrin, Ro and La might be useful for SS and NSS discrimination.

Prognostic factors and adjuvant therapy in uterine carcinosarcoma.

PURPOSE OF INVESTIGATION: The objective of this retrospective study was to investigate prognostic variables and impact of adjuvant therapy in uterine carcinosarcoma. METHODS: The clinical information and pathological confirmation were reviewed for cases with uterine carcinosarcoma from 1984 to 2005. A total of 45 patients were eligible for analysis. RESULTS: The median follow-up for survivors was 84 months. Five-year overall survival and progression-free survival (PFS) rates were 36.5% and 33.8%, respectively for Stage I-IV. Distant site metastasis with/without pelvic failure occurred in 83.3% of those with recurrence/progression. By multivariate analysis, older age (p = 0.001) and more than half of myometrial invasion (p = 0.002) were significant predictors of death, while only myometrial invasion (p = 0.022) was significantly associated with PFS. Stratified analyses demonstrated a monotonic trend of chemotherapy or chemoradiation to decrease death. CONCLUSIONS: Our results suggested that age and depth of myometrial invasion were significant prognostic factors, and chemotherapy or chemoradiation seemed to be beneficial for uterine carcinosarcoma.

Peritoneal metastasis in primary cervical cancer: a case report.

PURPOSE OF INVESTIGATION: Peritoneal metastasis presenting at initial diagnosis of squamous carcinoma of the uterine cervix is extremely rare. However, one such case was treated successfully with curative treatment. CASE: A 43-year-old woman presented with FIGO Stage IVA cervical carcinoma and underwent concurrent chemoradiation (CCRT) with weekly cisplatin. During CCRT, she suffered from acute lower abdominal pain, high fever, and leukocytosis. Computed tomography (CT) favored a tubo-ovarian abscess, while [18F] fluorodeoxyglucose positron emission tomography (FDG-PET) showed a lesion midway between the umbilicus and symphysis pubis. An exploration by laparoscopy, an omental metastasis adhering to the bladder dome was excised. This patient finished CCRT encompassing the disease extent including the trochar sites and no evidence of disease was noted 50 months after initial diagnosis. CONCLUSION: Though peritoneal metastasis above the pelvis seems ominous, curative treatment may still be viable in selected patients, even in surgical Stage IVB.

Detection of Epstein-Barr virus DNA in the peripheral-blood cells of patients with nasopharyngeal carcinoma: relationship to distant metastasis and survival.

PURPOSE: Nasopharyngeal carcinoma (NPC) has been proved to be an Epstein-Barr virus (EBV)-associated cancer. By use of nested polymerase chain reactions (PCRs), we examined whether the presence of EBV DNA in the peripheral-blood cells (PBC) can serve as a prognostic indicator for NPC. PATIENTS AND METHODS: Peripheral blood from 124 patients with NPC who had no evidence of distant metastasis and 114 healthy volunteers with serologically positive findings for EBV infection was collected prospectively. Plasma and erythrocytes were separated. DNA was extracted from PBCs and analyzed by a nested PCR using primers specific to Epstein-Barr virus nuclear antigen 1 (EBNA-1). All patients were treated by radiotherapy with or without chemotherapy. Clinical parameters and status of EBNA-1 in PBCs were used for survival analysis using the Kaplan-Meier method and the Cox proportional hazards model. RESULTS: Positive rates of EBNA-1 DNA in PBCs of NPC patients and healthy volunteers are 71% and 14%, respectively (P =.001). No significant difference was observed with regard to the clinical characteristics of patients who were EBNA-1-positive (n = 88) and those who were EBNA-1-negative (n = 36). After a median follow-up period of 38 months (range, 24 to 56 months), 29 of 88 EBNA-1-positive patients and only one of 36 EBNA-1-negative patients developed distant metastases (P =.00015). Kaplan-Meier estimates of overall survival (P =.0010), metastasis-free survival (P =.0004), and progression-free survival (P =.0004) were significantly lower for the patients in the EBNA-1-positive group than for those in the EBNA-1-negative group. Multivariate Cox analysis confirmed the same results. CONCLUSION: The presence of EBNA-1 DNA in PBCs is a novel, important risk factor for patients with NPC that indicates a significantly higher risk of developing distant metastasis as well as a lower survival rate.

Randomized trial of neoadjuvant cisplatin, vincristine, bleomycin, and radical hysterectomy versus radiation therapy for bulky stage IB and IIA cervical cancer.

PURPOSE: To compare the efficacy of neoadjuvant chemotherapy (NAC) followed by radical hysterectomy with that of radiotherapy (R/T) for bulky early-stage cervical cancer. PATIENTS AND METHODS: Women with previously untreated bulky (primary tumor >/= 4 cm) stage IB or IIA non-small-cell carcinoma of the uterine cervix were randomly assigned to receive either cisplatin 50 mg/m(2) and vincristine 1 mg/m(2) for 1 day and bleomycin 25 mg/m(2) for 3 days for three cycles followed by radical hysterectomy (NAC arm) or receive primary pelvic radiotherapy only (R/T arm). The ratio of patient allocation was 6:4 for the NAC and R/T arms. Women with enlarged para-aortic lymph nodes on image study were ineligible unless results of cytologic or histologic studies were negative. RESULTS: Of the 124 eligible patients, 68 in the NAC arm and 52 in the R/T arm could be evaluated. The median duration of follow-up was 39 months. Thirty-one percent of patients in the NAC arm and 27% in the R/T arm had relapse or persistent diseases after treatment, and 21% in each group died of disease. Estimated cumulative survival rates at 2 years were 81% for the NAC arm and 84% for the R/T arm; the 5-year rates were 70% and 61%, respectively. There were no significant differences in disease-free survival and overall survival. CONCLUSION: NAC followed by radical hysterectomy and primary R/T showed similar efficacy for bulky stage IB or IIA cervical cancer. Further study to identify patient subgroups better suited for either treatment modality and to evaluate the concurrent use of cisplatin and radiation without routine hysterectomy is necessary.

Treatment-associated severe thrombocytopenia affects survival rate in esophageal cancer patients undergoing concurrent chemoradiotherapy.

BACKGROUND: Esophageal cancer is commonly treated with surgery, concurrent chemoradiotherapy (CCRT), or a combination of both. The correlation between the hematological parameters during CCRT and early survival of esophageal cancer has not been fully evaluated. MATERIALS AND METHODS: We analyzed the records of 65 esophageal cancer patients treated by CCRT between 2007 and 2010 retrospectively. The association between CCRT-associated myelosuppression, demographic variables, and survival rates were analyzed by univariate and multivariate analysis. RESULTS: The univariate analysis showed that tumor extent of T3-4, a higher stage of tumor, a lower albumin level, grade 3 or higher anemia and thrombocytopenia, and interruptions in treatment affected survival rates. Further, the multivariate analysis revealed that stage IV (P = 0.030) is an independently negative prognostic factor for a one-year survival rate. Stage IV (P = 0.035), tumor extent of T3-4 (P = 0.002), and grade 3-4 thrombocytopenia (P = 0.015) are independently negative prognostic factors for a two-year survival rate. CONCLUSIONS: Severe decrease in platelet count during CCRT independently affects survival of esophageal cancer patients in addition to stage of the tumor.

Extreme Hyperlactatemia After Heart Transplantation: One Center's Experience.

INTRODUCTION: Hyperlactatemia may occur early after cardiac surgery and is correlated with prognosis. This study was conducted to analyze the perioperative variables and postoperative outcomes among heart transplant recipients with extremely high lactate levels (>15 mmol/L). METHODS: The single-center medical records of heart transplantation from June 2006 to May 2013 were retrospectively reviewed for patient characteristics, perioperative hemodynamic variables, arterial blood gas analysis data, and postoperative mortality. RESULTS: Among 58 consecutive heart transplant recipients, lactate levels over the detectable upper limit (>15 mmol/L) were identified in 12 patients after intensive care unit admission, with peak time at 1.9 ± 2.0 (range 0-6.1) hours. The maximal preoperative lactate level was 3.1 mmol/L, and most (11/12) postoperative lactate levels returned to <4 mmol/L at 27.5 ± 12.8 hours after surgery (range 15-58, median 24), displaying a trend toward delayed extubation time in 10 recipients (P < .01). Blood glucose levels elevated significantly from preoperative 148.9 ± 45.2 to 375.7 ± 96.9 mg/dL at peak lactate level (P < .01). Four patients died in the ICU (range 5-32 days), 4 died after discharge (range 5-57 months), with 6 in total surviving over 1 year. CONCLUSION: Extreme hyperlactatemia commonly occurred early after heart transplantation and mostly recovered within 30 hours; however, with delayed extubation time after operation.

The GroEL protein of Porphyromonas gingivalis accelerates tumor growth by enhancing endothelial progenitor cell function and neovascularization.

Porphyromonas gingivalis is a bacterial species that causes destruction of periodontal tissues. Additionally, previous evidence indicates that GroEL from P. gingivalis may possess biological activities involved in systemic inflammation, especially inflammation involved in the progression of periodontal diseases. The literature has established a relationship between periodontal disease and cancer. However, it is unclear whether P. gingivalis GroEL enhances tumor growth. Here, we investigated the effects of P. gingivalis GroEL on neovasculogenesis in C26 carcinoma cell-carrying BALB/c mice and chick eggs in vivo as well as its effect on human endothelial progenitor cells (EPC) in vitro. We found that GroEL treatment accelerated tumor growth (tumor volume and weight) and increased the mortality rate in C26 cell-carrying BALB/c mice. GroEL promoted neovasculogenesis in chicken embryonic allantois and increased the circulating EPC level in BALB/c mice. Furthermore, GroEL effectively stimulated EPC migration and tube formation and increased E-selectin expression, which is mediated by eNOS production and p38 mitogen-activated protein kinase activation. Additionally, GroEL may enhance resistance against paclitaxel-induced cell cytotoxicity and senescence in EPC. In conclusion, P. gingivalis GroEL may act as a potent virulence factor, contributing to the neovasculogenesis of tumor cells and resulting in accelerated tumor growth.

Molecular modelling studies of lysozyme catalysed hydrolysis of synthetic substrates.

Kinetic data for the lysozyme catalysed hydrolysis of aryl chitooligosides were surveyed. Both electron-donating and electron-withdrawing substituents on the departing aryl aglycones enhance the rate of hydrolyses. The parallel pH-rate profiles implicate that identical catalytic residues are involved in the hydrolytic fission of the glycosyl-aryloxy bond of these two groups of synthetic substrates. Molecular modelling studies of lysozyme complexes with aryl diN-acetyl chitobiosides and their intermediates were performed. The two synthetic substrates bearing aryl aglycones with opposite electronic effects bind to the active site of lysozyme in different conformations. Based on the energetic and geometric considerations, the oxocarbonium ion whose pyranose ring D in a sofa conformation is the most plausible reaction intermediate for the lysozyme catalysed hydrolysis of the synthetic substrates. The modelling study also suggests that considerable conformational changes of both the lysozyme binding site and the chitobiosyl group accompany the formation of the glycosyl enzyme intermediate. In particular, the chitobiosyl group undergoes a dislocation of the pyranose ring C from the subsite C and a constraint of the pyranose ring D to form a boat conformer.

The prognostic significance of pre- and posttreatment SCC levels in patients with squamous cell carcinoma of the cervix treated by radiotherapy.

PURPOSE: To investigate the prognostic significance of the pre- and posttreatment serum squamous cell carcinoma antigen (SCC) levels in patients with Stage I-IVA squamous cell carcinoma of the cervix primarily treated by radiotherapy. MATERIALS AND METHODS: 401 patients with squamous cell carcinoma of cervix primarily treated with radiotherapy (RT) were included in this study. All had preRT, and 249 patients had postRT serum SCC values. The association of pretreatment SCC level with the clinical parameters, including stage, hemoglobin (Hb) level, age, cell differentiation, and lymph node status, was assessed by univariate and multivariate analysis. The prognostic significance of pretreatment SCC level and these clinical parameters were evaluated. The impact of postRT residual induration and SCC levels on survival was analyzed. RESULTS: 1. PreRT SCC level strongly correlated with stage. After controlling for stage, only SCC levels higher than 10 ng/ml were associated with enlarged lymph nodes shown in CT scan. No association of preRT SCC level with other clinical parameters was found. 2. SCC level higher than 10 ng/ml, but not between 2-10 ng/ml, had significant impact on survival in a multivariate analysis. Stage, Hb levels (<10 g/dl) and positive lymph node shown by CT scan were also independent prognostic factors for survival. No significant difference in failure pattern in terms of local and/or distant sites was found in patients with different SCC levels. 3. Patients with residual induration and/or persistently elevated SCC level at 2-3 months after RT had a significantly higher incidence of treatment failure. Persistently elevated SCC level is a stronger predictor for treatment failure than residual induration by pelvic examination, and is associated with a higher incidence of distant metastasis. One third of patients with initial SCC level higher than 10 ng/ml had persistently elevated SCC. CONCLUSION: Pretreatment SCC levels higher than 10 ng/ml are an independent predictor for poor prognosis in patients included in this study, and can be used as one of the prognostic factors for selection of patients for intensive treatment. Persistently elevated SCC levels after RT is a strong predictor for treatment failure. A combination of clinical pelvic examination and SCC levels provides useful information for the need of further work-up and management.

Isolated paraaortic lymph node recurrence after definitive irradiation for cervical carcinoma.

PURPOSE: To evaluate the clinical features of isolated paraaortic lymph node (PALN) recurrence after definitive radiotherapy, and analyze the prognostic factors and effect of salvage treatment. METHODS AND MATERIALS: Of a total 876 patients who received pelvic radiotherapy after the diagnosis of primary cervical carcinoma, 26 were found to have isolated PALN recurrence as the first recurrent site, and these patients enrolled in this study. Only those with primary-site carcinoma controlled and who were free of other distant metastases were eligible. Nineteen of the 26 patients accepted salvage therapy. Fourteen patients accepted concurrent chemoradiation (CCRT), 1 accepted radiation to the paraaortic region, and 4 accepted chemotherapy alone. Clinical parameters evaluated included tumor markers (SCC and CEA) and image studies. RESULTS: Seven of the 26 patients were alive and disease-free. All 7 survivors had salvage treatment with radiation to the paraaortic region and concurrent cisplatin-based chemotherapy. None of the patients receiving chemotherapy or radiation alone enjoyed long-term, disease-free survival. The 5-year survival rate for isolated PALN recurrence of the 14 patients who accepted salvage concurrent chemoradiation (CCRT) was 51.2%. The presence of a clinical symptom at the time of PALN recurrence was analyzed. Seven of the 12 asymptomatic patients and none of the 14 symptomatic patients survived without disease after salvage treatment. The SCC levels at recurrence showed a statistically significant relationship to disease-free survival. CONCLUSIONS: An SCC level of < or = 4 ng/ml and a lack of symptoms at the time of recurrence were good prognostic factors in isolated PALN recurrence after primary radiation therapy. In addition to concurrent CCRT, periodical surveillance with tumor markers and imaging studies allowed early detection and salvage of those patients.