Unreliability of modified inguinal lymphadenectomy for clinical staging of penile carcinoma

BACKGROUND

In 1988, Catalona proposed a modified bilateral inguinal lymphadenectomy for staging of lymph node metastasis from penile carcinoma. All three patients with penile carcinoma submitted to this procedure and without histologically confirmed metastases were free of disease within a mean follow-up time of 14.6 months.

METHODS

In a prospective study, the authors evaluated thirteen patients staged by the TNM system and submitted to modified bilateral inguinal lymphadenectomy.

RESULTS

None of the patients had histologic metastases in the medial quadrant lymph nodes. Two of these patients developed regional lymph node metastases within 13.2 months (mean follow-up time).

CONCLUSIONS

Catalona's procedure was not reliable. We therefore recommend standard inguinal lymphadenectomy as the minimal treatment for patients with infiltrating carcinoma of the penis.

Prognostic factors in 291 patients with pulmonary metastases submitted to thoracotomy

Pulmonary metastases are among the most common sites for the spread of cancer, particularly with mesenchymal tumors. Despite improvements in cancer therapy, the prognosis remains poor, except for the highly selective group of patients who are considered eligible for surgical treatment and those with chemosensitive tumors. The main objective of this study was to evaluate survival results of 291 patients who underwent thoracotomy due to pulmonary metastases between 1953 and 1986. The number of metastases ranged from a minimum of 1 to as many as 30. The type of resection depended on site, size, and number of pulmonary lesions: 154 wedge resections, 49 lobectomies, and 9 pneumectomies. The tumor was not resectable in the remaining 79 patients. Of the prognostic factors analyzed, only type of pulmonary resection (wedge vs. lobectomy vs. pneumectomy vs. unresectable) and disease free interval (DFI) between primary treatment and pulmonary metastases diagnosis (< or = 6 months vs. 7-12 months vs. > 12 months) were selected as independent predictors of the risk of death in multivariate analysis. A reduced model for bone tumors included disease free interval, sex and histology.

Use of glycoconjugates for trypanosomatid taxonomy

Glycoconjugates from five trypanosomatid genera--Crithidia, Herpetomonas, Endotrypanum, Leishmania, and Trypanosoma--were extracted with Triton X-114 and analyzed by sodium dodecyl sulfate polyacrylamide gel electrophoresis followed by periodic acid-Schiff staining. Most of the glycoconjugates were detected in the hydrophobic phase, indicating the presence of anchored glycoconjugates. All the trypanosomatids expressed a glycoconjugate with a low molecular weight (below 20 kDa) in this phase. In each species, however, a characteristic and specific pattern of glycoconjugates was also observed in both phases. In the hydrophobic phase: 14-29 kDa glycoconjugates in C. guilhermei; 24-70 kDa in C. fasciculata, C. luciliae, E. schaudinni, and T. cruzi Y and G strains; 45-66 kDa in C. oncopelti and H. samuelpessoai; above 36 kDa in T. dionisii; 20-24 kDa, 36-45 kDa, and 70 kDa in L. tarentolae and T. mega. In the hydrophilic phase, typical glycoproteins were observed in some trypanosomatids: 60 kDa in T. mega and T. cruzi Y strain; 70 kDa in H. samuelpessoai; 66 kDa in C. oncopelti; 20-70 kDa in C. luciliae. These findings suggest that Triton X-114-extracted glycoconjugates could be useful markers for trypanosomatid taxonomy.

Prognostic significance of lymph node variables in squamous cell carcinoma of the vulva

BACKGROUND

In patients with squamous cell carcinoma of the vulva, lymph nodal, surgicopathologic variables have been studied rarely, although lymph node status is by far the most important prognostic factor. This study was designed to investigate surgicopathologic variables of lymph node metastases to evaluate their prognostic significance.

METHODS

In 75 patients with inguinal and/or pelvic lymph node metastases from squamous cell carcinoma of the vulva, the following parameters were studied: size and location of the tumor, depth of invasion, grade, lymph-vascular space involvement (LVSI), local immune reaction, presence and degree of dystrophic changes in the surrounding skin, FIGO stage, number of positive lymph nodes, greatest dimension of the metastasis within the lymph node, percentage of lymph node replacement, number of lymph nodes with replacement greater than 50%, number of lymph nodes replaced completely by tumor, extracapsular spread, and active immunologic response within the lymph node.

RESULTS

Among the variables related to the primary carcinomas, only size of the tumor and LVSI were correlated with survival (P < 0.003 and P < 0.02, respectively). On the contrary, all pathologic variables regarding the lymph nodes significantly influenced survival by univariate analysis. On multivariate analysis, extracapsular spread was the most significant independent prognostic factor (P < 0.0004), followed by FIGO stage (P < 0.03). For patients with only one positive lymph node, the most important prognostic factor was the greatest dimension of the metastasis within the lymph node (P < 0.01).

CONCLUSIONS

These data, if confirmed in larger series, can contribute to a more accurate identification of low and high risk patients and, therefore, to a more appropriate employment of adjuvant therapies.

Thrombocytosis as a prognostic factor in women with cervical cancer

BACKGROUND

Thrombocytosis (a platelet count > 400 x 10(9)/l) is found frequently in association with malignant disease and recently has been suggested to be a poor prognostic indicator in patients with cervical cancer. The authors decided to see if these findings could be verified.

METHODS

The pretreatment platelet counts of 643 women treated for cervical cancer between 1983 and 1992 were reviewed and correlated to each patient's age, stage of disease, histologic type, node status (when available), and outcome. Differences between groups were analyzed using the chi 2 test, and survival was compared using the log rank test on Kaplan-Meier life tables.

RESULTS

The 5-year survival rate for patients with thrombocytosis was 57.1%, which was significantly worse than the 76.5% for those with normal platelet counts (P < 0.01). When adjusted for stage of disease, however, thrombocytosis failed to have a significant effect on patient survival. There was also no relation between thrombocytosis and the incidence of positive lymph nodes.

CONCLUSION

Thrombocytosis was not found to be an independent prognostic factor in patients with carcinoma of the cervix in this series of 643 patients.

Pelvic exenteration: a review of the Gateshead experience 1974-1992

OBJECTIVE

To examine morbidity and survival among women treated by pelvic exenteration for gynaecological malignancy.

DESIGN

Retrospective review by analysis of case records.

SETTING

Department of Gynaecological Oncology, Queen Elizabeth Hospital, Gateshead, UK.

SUBJECTS

Eighty-three consecutive patients referred from within the UK from 1974 to 1992 for initial treatment of advanced gynaecological malignancy or management of recurrent disease following unsuccessful initial therapy.

RESULTS

Overall five year actuarial survival was 41%, falling to 36% at 10 years. Serious morbidity was low, and there were only three peri-operative deaths.

CONCLUSIONS

For patients with limited options for treatment of advanced primary or recurrent cancer, exenteration offers a reasonable prospect of survival with good quality of life.

Squamous cell carcinoma antigen: pretreatment levels as an indicator of advanced or metastatic disease

Pretreatment values of squamous cell carcinoma antigen (SCC) were obtained in 100 consecutive patients with squamous cell carcinoma of the cervix presenting to the Regional Gynaecological Oncology Centre in Gateshead, UK. Nine patients deemed to have locally advanced disease not suitable for primary surgery had elevated levels. Ninety-one patients were suitable for primary surgery. Sixty-seven had normal SCC levels, two of which had lymph node metastases. Twenty-four had elevated SCC levels, 14 of which had lymph node metastases. Two early recurrences have been detected in the raised SCC group where no lymph node metastases were present. Elevated levels of SCC in the pretreatment assessment indicate a high risk of lymph node metastases and of developing recurrent disease after primary surgery.

Radical vulvectomy and groin node dissection in a patient with chronic neutropenia-maintenance of leucocyte count using granulocyte colony-stimulating factor

A patient was referred for consideration of radical surgery in the presence of chronic neutropenia. We report the successful maintenance of an adequate neutrophil count during the perioperative period using Granulocyte colony-stimulating factor (GCSF), resulting in successful primary healing of the wounds in the absence of infective complications. The use of GCSF in gynecology is briefly reviewed.

The Wallace technique of ureteroileal anastomosis and its use in gynecologic oncology: a study of 81 cases

OBJECTIVE

To report the indications for surgery, morbidity, and results of treatment using the Wallace ileal conduit for supravesical urinary diversion.

METHODS

Over a 15-year period (1977-1991), 81 patients, all with an underlying gynecologic malignancy requiring urinary diversion, had ileal conduit surgery performed at the Regional Department of Gynecological Oncology, Gateshead, England using the Wallace technique. Patient details stored in a computerized data base were reviewed retrospectively.

RESULTS

Thirty-nine patients (48%) had received radiotherapy before conduit surgery. In 70% of cases, urinary diversion was performed as part of an exenterative procedure. Early postoperative complications occurred in 56% of cases and were mainly related to infection. Long-term complications included fistula (three), stoma retraction (three), loss of renal function (three), tumor metastases (two), and stoma herniation (one). There was one postoperative death secondary to septicemia. By 1991, 42 patients (52%) had died of their primary disease.

CONCLUSION

We believe that for urinary diversion in the gynecologic oncology patient, the ileal conduit, in particular the Wallace technique, is the procedure of choice.

The Royal College of Obstetricians and Gynaecologists micro-invasive carcinoma of the cervix study: preliminary results

OBJECTIVES

To determine how micro-invasive carcinoma of the cervix is diagnosed and treated in the United Kingdom. To record the frequency of the various pathological features which comprise the histological diagnosis of micro-invasion, and to assess their relevance to outcome.

DESIGN

Prospective observational study.

SETTING

Hospitals throughout the United Kingdom.

SUBJECTS

Two hundred and eighty-six cases were submitted for entry into the study. Following independent review of the histological material 116 cases were excluded: 41 were not accompanied by histological slides for review, 55 had no evidence of invasive disease, 17 had invasive disease greater than FIGO Stage 1a, and three were adenocarcinomas. The remaining 170 cases were registered for the study but follow up was incomplete in 18. This report concerns the 152 women with complete follow up to 1991.

RESULTS

The age of the 152 women ranged from 22 to 65 years (median 36 years). In 116 women (76%) the diagnosis was made by cone biopsy (cold knife, loop diathermy, or laser) or wedge biopsy, in 9 women (6%) the diagnosis was made by hysterectomy, and in 27 women (18%) punch biopsy suggested an invasive lesion and subsequent excisional treatment (including radical hysterectomy with node dissection in three) demonstrated micro-invasion. The depth of invasion was up to 3 mm in 142 women (93%) and 3.1 to 5 mm in 10 women (7%). Capillary-like space involvement was present in 12 women (8%). Treatment methods used were local cervical surgery in 79 women (52%), simple hysterectomy in 63 (41%), and radical hysterectomy in 10 (7%). There was only one known recurrence and death due to cervical carcinoma.

CONCLUSION

There is no uniformity in the management of micro-invasive carcinoma of the cervix. The frequency of recurrence, lymph metastases, and death is low. Nonradical surgery appears to give satisfactory results.

The case for conservative management of "incomplete excision" of CIN after laser conization

Three hundred thirteen laser cone biopsies were performed for cervical intraepithelial neoplasia (CIN) over a 4-year period. The mean age of the patients was 39.9 years and average cytology follow-up was just under 3 years. Six patients defaulted colposcopic review and were excluded from analysis. Of the 75 cases with CIN extending to the endocervical resection margin, 9 (12%) were found to have residual disease. Only 2 (3.6%) of 56 cases with CIN extending to the ectocervical margin had residual CIN detected. In the 176 cases in which the CIN lesion was excised completely there have been no cases of residual CIN. The overall detection of residual disease was 3.6%. Further surgery in those cases with CIN extending to the resection margin is excessive. These patients should be managed conservatively with regular cytological follow-up.

Prefabricated flaps for the head and neck: a preliminary report

The authors present some clinical applications of the concept of flap prefabrication. Three cases are described where reconstructions around the head and neck were accomplished. The radial vascular territory of the forearm was selected for prefabrication of structures which were then transferred by microsurgical techniques. In two cases, a sensate flap was used, with nerve repair in the neck.

Recurrent squamous cell carcinoma of the vulva: a study of 73 cases

In a study of 73 patients, diagnosed with recurrent squamous cell carcinoma of the vulva between 1975 and 1990, the effect of clinical variables on the outcome was evaluated. The overall 5-year survival rate was 35.2%. Of the 73 patients, 33 (45.2%) originally had Stage I or II disease and 40 (54.8%) Stage III or IVA; 49 (67.1%) recurred less than 2 years and 24 (32.9%) more than 2 years after initial surgery; and 39 (53.4%) recurred on the vulva only, while 34 (46.6%) recurred beyond the vulva. Of 59 patients who had groin lymph node dissection at initial surgery, 26 (44%) had negative and 33 (56%) had positive nodes. By means of univariate analyses, a significant worsening in outcome was demonstrated with advancing original stage of disease (P < 0.001), positivity of groin lymph nodes (P < 0.01), shortening of recurrence-free interval (P < 0.001), and extension of recurrence beyond the vulva (P < 0.001). In a multivariate analysis (Cox proportional hazards model) recurrence site was the strongest and the only significant predictor of survival. The death risk showed a 3.7-fold increase (95% confidence intervals: 1.6 to 8.7, P = 0.002) for recurrence beyond the vulva over recurrence on the vulva only. For patients who recurred in the vulva only, wide radical local excision provided acceptable survival results, while for all other patients, regardless of type of treatment, the outcome was poor.

Histological incomplete excision of CIN after large loop excision of the transformation zone (LLETZ) merits careful follow up, not retreatment

OBJECTIVE

To quantify and analyse the influence of a histological report of incomplete excision of CIN after LLETZ on frequency of detection of residual CIN.

DESIGN

Review of a computerised database of sequential women treated by LLETZ. Initial follow-up was three months post-treatment.

SETTING

The Colposcopy Clinic, Regional Department of Gynaecological Oncology, Queen Elizabeth Hospital, Gateshead, Tyne and Wear, UK.

SUBJECTS

721 women with CIN diagnosed histologically on LLETZ specimens.

RESULTS

In spite of a first time treatment success rate of 95% at 3 months, only 56% of the women were reported to have complete histological excision of CIN. A report suggesting incomplete excision was more likely with more severe CIN, extensive lesions and involvement of the endocervical canal. Furthermore, 21% with residual CIN had apparent complete excision of CIN at LLETZ.

CONCLUSIONS

A histological report of incomplete excision of CIN at LLETZ does not equate with residual disease. The high treatment success rate of LLETZ means that a report of incomplete excision should stimulate close colposcopic and cytologic follow-up to identify the small number of women with residual CIN after therapy.

Surgical treatment of colon and rectum adenocarcinoma in elderly patients

The results are presented of disease-free interval and overall survival in 53 elderly patients with colon or rectum adenocarcinoma treated with curative surgery. The average age was 75.3 years (median = 75.0); 21 patients were male and 32 were female. Tumor location was as follows: rectum 18 (34%), sigmoid 17 (32.1%), right colon 14 (26.4%), and transverse colon 4 (7.5%) All patients were surgically treated following the classical patterns for tumor resection. After pathological examination, which included the histological grade differentiation, the disease stage was reevaluated following the pTNM system. Overall and disease-free survival at 5 years, for all patients, independent of histological grade differentiation and disease stage, were 75.3% and 55.5%, respectively. Overall survival at 5 years for patients with grades I and II histological differentiation was 74.1% and 85.0%, respectively. None of the grade III patients (2 cases) survived more than 1 year. The 5 years disease-free survival for patients with histological grade differentiation I and II was 56.8% and 60%, respectively. There was no statistically significant difference in overall survival for patients with stages SI, SII, and SIII, but the disease-free survival at 5 years by stages was found to be significant with rates of 100%, 67.6%, and 22.6%. Postoperative mortality was 4 (7.5%). The postoperative mortality and survival rates obtained in this group of patients encourage us not to consider age as a limiting factor for curative surgical treatment.

Actinic rectitis--the role of colostomy

From 4132 patients treated with radiation therapy due to gynecological malignancy from 1974 to 1988, 527 (12.75%) developed some grade of actinic rectitis with clinical manifestation. The authors analyzed the efficacy of colostomy in the management of 10 women with actinic rectitis grades I and II (Sherman classification) submitted to clinical treatment without response. Pelvic radiation therapy, clinical findings, proctoscopy and rectal biopsy were the basis for the diagnosis and staging of the actinic rectitis. All colostomies were made in the transverse colon and the median follow up from colostomy to last review was 53 months. Eight patients had complete remission of clinical findings after colostomy, but one had recurrence of symptoms 2 years later. One patient had incomplete remission but with clinical improvement and one patient had tumor recurrence. From 8 patients with complete clinical remission, 2 had the colostomies closed, but in 1 was restored 3 months later due to rectum-vaginal fistula.

Malignant melanoma of the vulva: a clinicopathologic study of 18 cases

In a study of 18 patients diagnosed with vulvar malignant melanoma between 1975 and 1991, the effect of clinical and pathologic variables on the survival was evaluated. The overall 5-year survival rate was 28.6%. In 14 cases the tumor was retrospectively microstaged with use of Breslow depth and Chung levels. International Federation of Gynecology and Obstetrics (FIGO) stage and Breslow depth did not correlate well with survival. Positivity of groin lymph nodes at initial surgery was associated with an insignificant worsening in survival. An inverse correlation, although statistically not significant, was demonstrated between advancing Chung levels and survival. It is concluded that since the data with respect to microstaging of vulvar malignant melanoma is, as yet, still limited, great caution should be used in electing less aggressive surgery than radical vulvectomy and bilateral groin lymphadenectomy for patients with early-microstage localized disease.

Bias produced by fast guessing in distribution-based tests of race models

A comparison involving cumulative probability distributions of reaction time (RT) has been used to test race models of the redundancy gain observed in certain divided-attention paradigms. It has been pointed out, however, that the presence of fast guesses would interfere with this test, biasing it to accept race models. The present paper reports simulations carried out to determine the size of the bias introduced by fast guesses. In absolute terms, this bias can be quite large--exceeding 175 msec in some conditions. Simulations indicate that the bias increases with the percentage of fast guesses and with the latency difference between the lower tails of guess and nonguess RT distributions. Discarding and rerunning errors reduces bias somewhat, but a more elaborate "kill-the-twin" procedure reduces it much more.

Sudden cardiac death while taking amiodarone therapy: the role of abnormal repolarization

Torsade de pointes may occur as a complication of amiodarone therapy. We report a patient receiving amiodarone who was resuscitated from cardiovascular collapse and documented ventricular fibrillation. At subsequent electrophysiology study, while the patient was taking amiodarone therapy, monophasic action potentials with early after depolarisations were recorded which were not present when the patient was restudied 6 weeks after discontinuation of amiodarone. Early after-depolarisations may be important in the genesis of polymorphic ventricular tachycardia complicating amiodarone therapy.

IIB osteosarcoma. Current management, local control, and survival statistics--São Paulo, Brazil

Ninety-two patients with IIB osteosarcoma of the extremities were treated with intraarterial (IA) cisplatinum (CDDP) followed by surgery [amputation (61.6%) or resection with endoprosthesis (38.4%)]. Postoperative chemotherapy alternating adriamycin and CDDP was used. The total three-year survival was 62.1%, and the disease-free survival was 41.1%. The pathologic evaluation of the degree of tumor necrosis in response to the IA CDDP showed that in 53.2%, the necrosis was over 90%. The multivariate analysis of prognostic factors has shown that the highest survival was among females with tumors smaller than 15 cm. Patients with lesions equal to or larger than 15 cm were three times as likely to die of the disease. A second, more aggressive study is now underway, in which high dose methotrexate (HDMTX) is preoperatively combined with adriamycin and CDDP. Following operation, ifosfamide is added to the cases with a smaller degree of tumor necrosis, while the other group of patients will continue with HDMTX, in addition to CDDP and adriamycin (these last two drugs are used in both arms). Until now, complete remission has been achieved in 82% and 86%, respectively, with a follow-up examination varying from four to 26 months (average, 14 months). This is of extreme importance, because the majority of the authors' patients have tumors at initial evaluation larger than 10 cm in diameter.