Ports and complications for intraperitoneal chemotherapy delivery.

Intraperitoneal access ports are essential to the delivery of chemotherapy agents into the peritoneal cavity of women with ovarian cancer, but their malfunction and adverse effects are frequently responsible for the failure to complete planned therapy. Complications, such as obstruction of the catheter, infection, leakage, rotation, retraction, and pain, together with bowel and vaginal perforation, cause delays in treatment, patient suffering and the expenditure of medical resources. A wide variety of ports have been used, including vascular access devices and intraperitoneal access devices. This paper reviews the development and use of ports for intraperitoneal chemotherapy, their complications and reported methods of prevention.

Retinoids for preventing the progression of cervical intra-epithelial neoplasia.

BACKGROUND: Invasive cervical carcinoma is preceded by a precancerous phase, cervical intra-epithelial neoplasia (CIN), which can be detected on cervical smears and confirmed by colposcopy and biopsy. Moderate and severe intra-epithelial neoplasia (CIN2 and CIN3) are treated mainly with surgery to prevent progression to invasive carcinoma. Medical methods of preventing the progression or inducing regression of CIN are needed. Retinoids are potent modulators of epithelial cell growth and differentiation and may have potential for the treatment of CIN. OBJECTIVES: To ascertain whether retinoids can cause regression or prevent progression of CIN. SEARCH STRATEGY: Cochrane Gynaecological Cancer Review Group's Specialised Register and Non-Trials Database, Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2,2007),MEDLINE and EMBASE (June 2007). SELECTION CRITERIA: Randomized controlled trials (RCTs) and non-RCTs of retinoids for treating CIN in women. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data from the trials. Adverse effects information was also collected from the trials. MAIN RESULTS: Five RCTs comparing the efficacy of four different retinoids were identified. Two studies examined the effect on CIN2 and CIN3 of retinoids N-(4-hydroxyphenyl)retinamide (fenretinide) (Follen 2001) and 9-cis-retinoic acid (aliretinoin) (Alvarez 2003) given orally and two examined the effect of all-trans-retinoic acid given topically to the cervix (Meyskens 1994; Ruffin 2004). The fifth study investigated the use of 13-cis-retinoic acid (isotretinoin) given orally in HIV positive patients with CIN1 and condyloma (Robinson 2002).Four studies reported no significant effect of retinoids on the progression to higher grades of CIN, whilst the fifth did not report data on progression. In all studies retinoids had no significant effect on regression of CIN3. Two studies reported that retinoids were associated with regression of CIN2. One reported a greater complete regression of CIN2 over placebo, which was of borderline statistical significance, odds ratio(OR) = 0.5 (95% confidence interval (CI) 0.25 to 1.02). The other study reported a non-significant dose-related trend towards increased rates of complete and partial regression compared with placebo. One study reported a significantly worse outcome in women receiving retinoid, OR for regression = 6.00 (95% CI 1.00 to 35.91). In general, the retinoid medications were well tolerated. AUTHORS' CONCLUSIONS: The retinoids studied are not effective at causing regression of CIN3 but may have some effect on CIN2. The data on CIN1 is inadequate. Retinoids are not effective at preventing progression of CIN of any grade. At the doses given and duration of treatment studied, the retinoids were reasonably well-tolerated.

Enhancing adherence following abnormal Pap smears among low-income minority women: a preventive telephone counseling strategy.

BACKGROUND: Although the incidence of precancerous conditions of the cervix has recently been increasing, prompt initial and long-term follow-up care can effectively reduce unnecessary morbidity and mortality. For example, the 4-year survival rates among those individuals at greatest risk for cervical cancer (i.e., minority women of low socioeconomic status) approach 95% with early detection. Women who present with advanced disease have a much poorer outlook (0%-39% survival). Yet, high-risk individuals are least likely to adhere to recommended diagnostic regimens. PURPOSE: We tested the effectiveness of a brief telephone counseling intervention directed to low-income, inner-city women after they had received an abnormal Pap smear result. The women were counseled on the importance of having an initial and 6-month repeat follow-up diagnostic procedure (i.e., colposcopic examination of the cervix). METHODS: A randomized trial design was used to compare the effects on these women of telephone counseling with (n = 192) or without (n = 203) a booster counseling telephone call prior to the appointment for a repeat colposcopy 6 months later, with a telephone appointment confirmation/reminder call (n = 216) and with standard care (i.e., no telephone contact) (n = 217). The telephone counseling protocol probed for and addressed three psychologic barriers to adherence (i.e., attendance at appointment for colposcopy examination): 1) encoding/expectancy (e.g., did the patient understand her risk of developing cervical cancer?); 2) affective/emotional (e.g., was the woman worried about the condition and its consequences?); and 3) self-regulatory/practical (e.g., was the woman likely to forget medical appointments?). Logistic regression was used to analyze the effects of the intervention group and the type of psychologic barriers elicited on colposcopy adherence. RESULTS: The results of logistic regression analysis (using those who received an appointment confirmation/reminder telephone call as the comparison group) revealed that telephone counseling produced significantly higher adherence rates to the initial colposcopy visit compared with telephone confirmation (300 [76%] of 395 women versus 147 [68%] of 216; odds ratio [OR] = 1.50; 95% confidence interval [CI] = 1.04-2.17). Additionally, standard care resulted in significantly lower adherence rates than did telephone confirmation (109 [50%] of 217 women versus 147 [68%] of 216; OR = 0.47; 95% CI = 0.32-0.73). Regarding attendance at the 6-month repeat colposcopy appointments, the 80 patients who had received telephone counseling prior to the initial visit (and were recommended for follow-up colposcopy) were significantly more likely to adhere than were the 47 patients who had received telephone confirmation (49 [61%] of 80 women versus 17 [36.2%] of 47; OR = 2.70; 95% CI = 1.15-6.51). The 6-month adherence rates for patients in the telephone confirmation group and the standard care group (n = 30) were low and did not differ significantly (17 [36.2%] of 47 women versus nine [30.0%] of 30; OR = 1.08; 95% CI = 0.40-2.89). Forgetting medical appointments (OR = 0.31; 95% CI = 0.19-0.51) and having scheduling conflicts (OR = 0.45; 95% CI = 0.28-0.72) were also associated with lower rates of adherence. CONCLUSION: The use of telephone counseling appears to be an effective strategy for enhancing initial and long-term adherence to a follow-up cervical diagnostic procedure in a traditionally underserved population. Patients who respond to a positive Pap test result with a particular profile of psychologic barriers may require more intensive and targeted counseling interventions.

Intraplacental choriocarcinoma: a case report.

A recent paper has again drawn attention to the occurrence of intraplacental choriocarcinoma. We present a similar case in which a small intraplacental choriocarcinoma was identified after delivery of a full-term stillborn fetus. Interpretation of this lesion was influenced by the presence of normal villi and its full significance appreciated only after diagnosis of choriocarcinoma in the mother. This case presents histological proof that choriocarcinoma may arise from an otherwise normal placenta.

Serological survey of chlamydial antibody in post-natal sera.

Questionnaires (3426; 72.8%) and blood samples (3890; 82.6%) were analysed from 4704 women post-natally. The answers to the questionnaire confirmed that those patients living in areas with the highest percentage employed in agriculture were most likely to be in direct or indirect contact with sheep or sheep products. When the 788 (20.3%) of the sera with group specific antibody were examined for type-specific antibody, 291 (7.5%) reacted with Chlamydia trachomatis, 153 (3.9%) with Chlamydia pneumoniae, but only one (0.03%) with Chlamydia psittaci. Thus, it would appear that C. psittaci was not an important pathogen in this survey, despite the largest proportion of blood samples being submitted from those most likely to be employed in agriculture. However, in the course of this survey the three patients who had previously suffered chlamydia-associated abortion had successful pregnancies and submitted blood specimens. Serological studies on the serial bloods from these patients showed that, despite developing antibody to the C. psittaci pool and the ovine abortion strain of C. psittaci following abortion, this antibody waned. At the time of the subsequent successful pregnancy, serological results would not have detected a previous C. psittaci infection, but one due to C. pneumoniae. Thus, the results of a survey such as this must be interpreted with caution.

A matched study of surgically treated stage IB adenosquamous carcinoma and adenocarcinoma of the uterine cervix.

Thirty-eight patients with surgically treated stage IB adenosquamous carcinoma of the uterine cervix (AS) have been matched with patients with other histologic subtypes of adenocarcinoma (A) for stage, lesion size, node status, grade of adenocarcinoma and age at diagnosis. An additional six patients with AS were unable to be matched. Overall 5-year survival and disease-free survival for the matched AS and A were not significantly different, 83 vs. 90%, and 78 vs. 81% nor were the number of recurrences, 8/38 AS vs. 6/38 A, but the mean time to recurrence was significantly shorter in the AS group: 11 vs. 32 months (P = 0.003). A subgroup of AS with a high risk of a poor outcome can be identified based on either lesion size >/= 4 cm, depth of invasion >/= 10 mm or plevic lymph node metastasis. These patients may be suitable candidates for adjuvant therapy before or after surgical treatment.

Carcinoma of the cervix in women up to 35 years of age.

50 women aged up to 35 years were diagnosed as having carcinoma of the cervix in Brighton, England between 1980 and 1985. The overall 5-year actuarial survival was 65% and 73% for stage IB. The 5-year survival for those aged 29 years or less was significantly worse than for those aged between 30 and 35 years, 39% versus 80%. There was a higher incidence of advanced stage and high-grade tumours in the younger women. It is suggested that the natural history of the tumour in women under 30 years is shorter than that in older women, and this is likely to be associated with high-grade, rapidly advancing carcinomas of poor prognosis.

Sheep-acquired severe Chlamydia psittaci infection in pregnancy.

There have been five confirmed cases of severe Chlamydia psittaci infection during pregnancy, three having been treated in Edinburgh, Scotland. The most recent case is presented and previous experience is reviewed. The illness usually causes thrombocytopenia with disseminated intravascular coagulation, renal failure and hepatic dysfunction during the late second and early third trimester. The outcome for the fetus is usually fatal and the infection only resolves after delivery or abortion. The main hope is for education to prevent infection occurring in susceptible populations.

Synchronous colonic adenocarcinoma and extragenital malignant mixed mesodermal tumour.

A synchronous occurrence of large bowel adenocarcinoma and extragenital malignant mixed mesodermal tumour (MMMT) is reported. This case represents the sixth extragenital MMMT reported in the literature.

Differential expression of T-cell CD3-zeta chains in patients with cervical dysplasia before and after treatment.

This study addresses whether CD3-zeta suppression associated with cervical intraepithelial neoplasia (CIN) I, II, and III is mediated by a circulating factor and if this suppression is reversed following treatment. Serum was isolated from patients with CIN before and after curative therapy. Jurkat T cells were incubated with patient-derived sera for 4 days, and CD3-zeta expression was analyzed by western immunoblot. Sera from control female volunteers did not suppress CD3-zeta expression of Jurkat cells, while sera from women with CIN I, II, and III suppressed 58.9%, 75.3%, and 80.5%, respectively. Suppression observed in women with CIN I was significantly different from that observed with CIN II and III. Posttreatment zeta suppression was noted to be reversed in women with CIN II and III although the decreased suppression in CIN III patients was not statistically significant. Our study demonstrates that in vivo suppression of zeta chains in patients with CIN can be the result of a circulating factor. In vitro zeta expression increased in patients with CIN II and III after treatment, although the increase was only statistically significant in patients with CIN II.

Retraction of an intraperitoneal chemotherapy port: a case report and literature review.

Delivery of chemotherapy directly into the peritoneal cavity is becoming part of the standard frontline management of patients with optimally cytoreduced ovarian carcinoma. Traditionally, the peritoneal access devices used for this have had relatively high complication rates including infection, blockage, leakage, and difficulties with port access. In order to reduce the risk of infection, we have been using a Bard 9.6F silastic infusaport that does not have a Dacron cuff to secure it into the tissues of the anterior abdominal wall. It has the added advantage of being more easily removed at the end of treatment. We report a case of spontaneous retraction of such a port out of the peritoneal cavity into the subcutaneous tissues. This complication associated with a silastic cuffless port is presented to raise awareness of this possible complication and suggest ways of preventing it.

Cytoreduction and intraperitoneal heated chemotherapy for the treatment of endometrial carcinoma recurrent within the peritoneal cavity.

Our experience with hyperthermic intraperitoneal chemotherapy (IPHC) in conjunction with surgical resection for endometrial cancer recurrent within the abdominal cavity was reviewed. Eligible patients underwent exploratory laparotomy with the aim of resecting disease to < or =5 mm maximum dimension followed immediately by intraperitoneal perfusion of cisplatin (100 mg/m(2)) heated to 41-43 degrees C (105.8-109.4 degrees F) for 1.5 h. Data for analysis was extracted from retrospective chart review. Five patients underwent surgery and IPHC between September 2002 and January 2005 for abdomino-pelvic recurrence. Original stage and histology were 1A papillary serous (1), 1C endometrioid with clear cell features (1), and 1B endometrioid (3). Mean age was 61 (41-75) years, mean prior laparotomies were 1.4 (1-2), and mean chemotherapy agent exposure was 1.6 (0-4). Mean time from initial treatment to surgery and IPHC was 47 (29-66) months. Mean length of surgery was 9.8 (7-11) h after which three patients had no residual disease and two had < or =5 mm disease. The mean duration of hospital stay was 12.6 (6-20) days. Postoperative surgical complications included wound infection with septicemia in one patient. Mean maximum postoperative serum creatinine was 1.02 (0.6-1.70) mg/dL. There was no ototoxicity or neuropathy and no perioperative mortality. No patients have been lost to follow-up. Two are living disease free at 28 and 32 m and two are living with disease at 12 and 36 m. One patient died at 3 m without evidence of cancer. Two patients who had no residual macroscopic disease at the end of surgery are alive at 32 and 36 m. The combination of IPHC with surgery for recurrent endometrial carcinoma is relatively well tolerated. The unexpectedly long survival seen in this cohort supports a phase II trial of IPHC with cisplatin for recurrent endometrial cancer.

A comparison of gemeprost (Cervagem) pessaries and Lamicel tents for cervical preparation for abortion by dilatation and suction.

In a randomized, single-blind trial, 78 women having vaginal termination of pregnancy were treated with either a 1-mg gemeprost (Cervagem) pessary or a Lamicel tent inserted 3-4 h before operation. Both agents produced satisfactory cervical softening but dilatation was significantly easier after gemeprost. Pre-operative side-effects were more frequent after gemeprost but did not increase the need for analgesia. There were no differences between the two groups with regard to either postoperative symptoms and analgesic requirements or pre-operative and postoperative temperature, pulse rate and blood pressure. Gemeprost pessaries are easier, faster and less uncomfortable to administer.

PIP: In a clinical trial, a physician treated 78 women having an abortion with either a Lamicel tent or a 1 mg gemeprost (Cervagem) pessary 3-4 hours before surgery. Researchers matched the women to age, parity, gestational age, and previous uterocervical surgery. The physician or the assistant chose the specific treatment in strict numerical order from randomly ordered sealed envelopes. Prior to surgery, an assistant used a speculum to empty the vagina of all traces of the Lamicel tent or the gemeprost pessary. Therefore each surgeon remained "blind" to the treatment used to dilate the cervix. Even though there was no significant difference in the blood and fluid loss between the 2 groups (t = .67; p = .5), both surgeons did observe a greater resistance of cervices to dilate after Lamicel than after gemeprost (p .001). Patients who received gemeprost experienced more adverse effects preoperatively, especially abdominal pain (74%) and bleeding (18%), than did those who were treated with Lamicel (50%. and 7.5% respectively). Despite a higher percentage of women experiencing side effects with gemeprost, there was not a corresponding increased need to administer analgesia. Postoperative side effects were similar in both the gemeprost and Lamicel groups. Additionally, no significant differences existed between the 2 groups in regards to postoperative analgesic requirements or preoperative and postoperative temperature, pulse rate, and blood pressure. Notwithstanding the side effects of gemeprost, it was more effective in dilating the cervix, easier to insert, and less uncomfortable than Lamicel.

A prospective study of the use of ultrasound in vaginal legal abortion before 20 weeks of pregnancy.

PIP: A prospective study was carried out to determine the incidence and nature of retained products of conception following legal abortion before the 20th week of pregnancy. Placental tissue was retained in 13 out of 39 cases in the 1st trimester. Ultrasound was used during the procedure to aid evacuation of retained products in 3 cases. Fetal parts were retained in 3 of the remaining 11 patients in the 2nd trimester of pregnancy. The finding of a 33% rate of retained products in the 1st trimester is higher than other estimates obtained when complications such as hemorrhage or infection occurred, necessitating uterine exploration. It is probable that in many cases retained products do not cause significant complications and are passed spontaneously through the vagina. It is interesting to note that, of the 4 cases where products were retained during the 2nd trimester, 2 involved retention of the fetal head. It is suggested that ultrasound screening of the uterine cavity at the end of the 2nd-trimester abortion procedure represents a better method of confirming completeness of evacuation than the reassembling of fetal parts. Routine use of ultrasound during dilatation and evacuation also has the potential to reduce the morbidity associated with induced abortion.^ieng

Uterine activity in the second stage of labour and the effect of epidural analgesia.

Uterine activity was measured during the second stage of normal labour in 20 patients with and 31 patients without epidural analgesia. There was a significantly lower uterine activity integral (UAI) in patients having epidural analgesia, and it is suggested that this may contribute to the increased rate of instrumental delivery associated with epidural analgesia.

Aspiration cytology of solid renal tumours.

The results of needle aspiration cytology of solid renal lesions in Brighton from 1977 have been reviewed. Thirty-one lesions were aspirated and of the 21 malignant tumours, cytology accurately diagnosed 19 (90%) when sufficient material was sent for analysis. Of the eight avascular solid renal space-occupying lesions aspirated, cytology gave a correct differentiation (benign versus malignant) in seven (87%). The results compare favourably with those of other published experience. A modification is suggested to the accepted diagnostic pathway.

Surgical management of 'lymphangioma circumscriptum'.

The results of surgery in 29 patients with 'lymphangioma circumscriptum' have been reviewed 2-8 years after operation. They show that in regard to management there are two varieties: small lesions, less than 7 cm diameter, in favourable sites of the body, which are potentially curable; and large lesions, greater than 7 cm diameter on the skin with an even larger area of subcutaneous cysts, in which complete excision of all the skin and subcutaneous vesicles would require skin grafting. Nine patients had small lesions excised. Seven have had no recurrence. Twenty patients had large lesions treated by a radical excision of all or as much of the cyst bearing subcutaneous tissues and skin as possible, but leaving enough skin to permit a primary suture, even though it meant leaving skin vesicles. The lesion was controlled and the cosmetic appearance improved in 16 patients. Subsequent regression of many of the vesicles not excised supports the aetiological hypothesis of the skin lesions proposed by Whimster.