Effect of anterior mandibular positioning on obstructive sleep apnea

This prospective case report series utilized an anterior mandibular positioning (AMP) device on obstructive sleep apnea (OSA) patients and evaluated the changes in the respiratory disturbance index (RDI) and subjective overall satisfaction with the treatment. The RDI was based on all-night polysomnographic studies performed before and after approximately 4 months of appliance use. Overall satisfaction with the treatment was rated using a Likert scale (0 to 10) after 6, 18, and 36 months of AMP device use. Although only 15 of the 24 subjects agreed to undergo post-appliance polysomnograms, 14 of the 15 subjects showed a clear decrease in the RDI. The effect on the other subjects is unknown, but even if the 9 subjects without polysomnograms had no change in the RDI from the AMP device, a minimum rate of 58% of the subjects (14 of 24) would have substantially improved the RDI at the 3-month time point. Of the 24 subjects, 2 subjects claimed no immediate benefit and stopped using the device, 4 subjects were lost to followup, 1 subject lost weight and stopped using the device, 1 subject had mandibular advancement surgery after using the appliance for a period of time, and 3 stopped using the appliance because of persistent temporomandibular pain problems. The remaining 12 of the 23 (52%) original subjects were still using the appliance successfully at 36 months. One subject died of non-apnea-related causes before the 18-month follow-up time point. The 16 subjects who responded at 36 months reported a mean overall satisfaction with treatment of 6.9 +/- 3.3 on a scale of 10.

Factors influencing local relapse and survival and results of salvage treatment after breast-conserving therapy in operable breast cancer: EORTC trial 10801, breast conservation compared with mastectomy in TNM stage I and II breast cancer

A (modified) radical mastectomy (RM) was compared with breast-conserving therapy (BCT) in stage I and stage II breast cancer patients. Treatment of the study arm comprised lumpectomy, axillary clearance and radiotherapy to the breast (50 Gy in 5 weeks external irradiation and a boost with iridium implant of 25 Gy). 902 patients were included. There were 734 TNM stage II patients. Patients with microscopically incomplete excision of the tumour were not excluded. After a median follow-up of 6 years, overall survival and local recurrence rates do not differ significantly between the two study arms. Actuarial survival at 8 years was 73% after RM and 71% after BCT; actuarial local recurrence at 8 years was 9% and 15%, respectively. In the mastectomy group tumour size did not affect local relapse, but after BCT the incidence of local recurrences was higher for tumours of 2-5 cm (16%) than for smaller tumours (7%) (at 8 years, P = 0.08). Results of salvage treatment for local recurrence so far were similar in both the BCT and the mastectomy group.

Effects of recombinant human inhibin and testosterone on gonadotropin secretion and subunit mRNA in superfused male rat pituitary cell cultures stimulated with pulsatile gonadotropin-releasing hormone

Effects of recombinant human inhibin (rh inhibin) and testosterone on follicle-stimulating hormone (FSH) and luteinizing hormone (LH) secretion and mRNA levels of gonadotropin subunits were investigated in superfused male rat pituitary cell cultures. During superfusion, the cells were stimulated with gonadotropin-releasing hormone (GnRH) pulses (10 nM, 6 min/h) and exposed to rh inhibin (2 ng/ml) and/or testosterone (10 nM) for up to 20 h. The concentrations of FSH and LH were measured in effluent media by radioimmunoassay (RIA), and subunit mRNAs were determined by Northern blot hybridizations using rat FSH beta, LH beta and alpha genomic and cDNA probes. Rh inhibin suppressed the secretion of FSH (30-40% of control) and the secretion of LH to 50-60% of control, but inhibited only FSH beta mRNA (to non-detectable levels). Testosterone alone suppressed the release of LH to 50% of control, whereas FSH release was increased to 130-160% (P less than 0.05) of control. This increase was due to higher interpulse values without significant changes in the pulse amplitude. Also FSH beta mRNA level was increased (1.5-fold, P less than 0.05) but only after 17-20 h of treatment. On the other hand, testosterone had no effect on LH beta and alpha subunit mRNA levels. Testosterone in combination with rh inhibin showed an inhibitory effect on LH beta mRNA; however, the pattern of LH release was not significantly different from that observed with rh inhibin or testosterone alone. Combined effects of testosterone and rh inhibin on FSH secretion and FSH beta mRNA were similar to those observed with rh inhibin alone.(ABSTRACT TRUNCATED AT 250 WORDS)

Iridium implant treatment without external radiotherapy for operable breast cancer: a pilot study

A pilot study has been conducted to examine a new approach to the treatment of operable breast carcinoma. 27 patients with tumours measuring up to 4 cm in diameter have been treated by tumourectomy, axillary clearance and high dose iridium-192 implant (55 Gy) without any external beam radiotherapy. This enabled the entire local primary treatment of the breast carcinoma to be given in five days. The technique was compatible with adjuvant chemotherapy for those with involved axillary nodes. Local complications have been few and locoregional control has to date been satisfactory. With a relatively short median follow-up of 27 months, cosmesis was objectively rated as good or excellent in over 80% of cases and subjectively rated good/excellent in 96%. High dose brachytherapy now requires testing in a prospective clinical trial to determine whether it is as effective as standard breast conservation techniques for management of early breast cancer.

The effect of gamma-irradiation on collagen molecules, isolated alpha-chains, and crosslinked native fibers

This study shows how collagen molecules are readily damaged by gamma-radiation at dosages commonly used for sterilizing biomedical products. At 1 Mrad, while the reported effectiveness of the radiation at such a low dosage to completely sterilize a material is questionable, less damage was caused to the collagen peptide backbone. Above such dosage, however, significant damage was clearly demonstrated with collagen alone and collagen in a chemically crosslinked tissue matrix. The enzyme digestion study showed that the material exposed to a very high dosage of radiation resisted degradation by pronase. However, molecular weight analysis showed a significant number of peptide bonds being cleaved by the radiation which could cause considerable changes in the long-term characteristics of the material. Therefore, tissues exposed to high dosages of gamma-radiation should be tested for long term functional changes. We want to caution against the usage of the enzyme degradation assay as a universal test for all bioprosthetic derived from biological tissues.

Mechanism of crosslinking of proteins by glutaraldehyde. IV: In vitro and in vivo stability of a crosslinked collagen matrix

The use of native or reconstituted collagen as a bioprothesis for tissue augmentation requires the introduction of exogenous synthetic crosslinks. The degree of crosslinking determines the rate of resorption or replacement of the implanted materials by the host. Since biophysical and chemical methods to quantify these crosslinks have in general been difficult to evaluate, we have developed in vitro enzymatic approaches which enable us to correlate the degree of crosslinking with the rates of enzymatic degradation. When the number of stable crosslinks formed is large it is essential to partially unfold the collagen fibrils by heating or by exposure to denaturing agents to enhance their susceptibility to hydrolysis. In the present study we demonstrate that increasing the number of reactive amino groups on collagen by coupling 1,6-diaminohexane to carboxyl groups using a water soluble carbodiimide can significantly enhance the number of crosslinks introduced by glutaraldehyde. We also show that the enzymatic method developed correlates well with the biodegradation of radiolabeled crosslinked collagenous tissues implanted subcutaneously in rats.

Influence of radiotherapy on the dose of adjuvant chemotherapy in early breast cancer

399 patients with early breast cancer were randomly allocated to treatment by either modified radical mastectomy or lumpectomy and radiotherapy. 169 had histologically involved axillary nodes and were randomised to receive either adjuvant cytotoxic chemotherapy (76 patients) or no systemic adjuvant treatment (93 patients). Chemotherapy comprised a combination of oral cyclophosphamide and intravenous methotrexate and 5-fluorouracil (CMF) for 12 cycles over one year. Patients in the mastectomy group received a significantly higher percentage of the planned chemotherapy dose compared with those in the radiotherapy group (median 85% v. 71% p less than 0.05). Patients treated with radiotherapy were more frequently nauseated and developed more severe alopecia, but these differences were not statistically significant. At median follow-up of 37 months the relapse-rate and pattern of relapse were similar in both groups of patients receiving CMF.

Prednisolone improves the response to primary endocrine treatment for advanced breast cancer

Two hundred and twenty patients with progressive advanced breast cancer were given primary endocrine treatment (PET) according to menstrual status. Pre-menopausal patients received ovarian irradiation (O) and post-menopausal tamoxifen 10 mg bd (T). Patients were randomised to receive either no additional treatment or prednisolone 5 mg bd (P). Similar results were observed in each menstrual subgroup. In 194 evaluable patients, the response to PET + P was 49% and to PET alone 30% (P less than 0.01). P increased the median duration of response from 9 to 14 months (P less than 0.002) and the median time to disease progression from 5 to 9 months (P less than 0.001). Response to P after O or T alone occurred in only 2/62 (3%). Median survival in patients randomised to receive P at the outset of PET was prolonged by 4 months (P less than 0.05). The addition of P significantly improves the response to O or T in the treatment of advanced breast cancer.

Assessment of skin dose and its relation to cosmesis in the conservative treatment of early breast cancer

A conservation technique has been developed for the treatment of early breast cancer which involved removal of the tumor, axillary clearance, tumor site implantation with Iridium-192 wires for a boost dose and subsequent treatment of the breast with radical megavoltage external beam therapy. Although the cosmetic results were satisfactory in the majority of the patients, for some it was rated as fair or poor. One variable factor which could have carried some morbidity was the dose of radiation received by the skin. In 51 patients, doses were measured at several points over the treated breast using Thermoluminescent Dosimetry (TLD) at the time of the iridium implant and during the subsequent external beam therapy. Development of skin pigmentation, oedema, and fibrosis were unrelated to the dose received by the skin but the findings suggested that doses greater than 50 Gy to the skin increased the possibility of late (greater than 24 months) telangiectasia over the boosted area. Treatment of tumors in the lower half of the breast, or in large breasts, was associated with a higher incidence of poor cosmesis. This may have been the result of varying posture on the interstitial dose distribution from the Iridium-192 wires and comparison of dose distribution in both supine and erect positions was carried out.

Adjuvant androgen treatment of operable breast cancer--a 20 year analysis

One hundred and fifty-five patients with carcinoma of the breast treated by mastectomy were randomised to receive no additional treatment or to receive adjuvant testosterone. After a minimum follow up of 15 years there is no difference in either relapse free survival or overall survival between the treated and control groups. Stratification by pathological nodal status showed no benefit either for those with negative or positive axillary lymph node involvement.

Interstitial irradiation for squamous carcinoma of the oral cavity

Interstitial radiation delivered by iridium 192 implants was used to treat 38 patients with squamous carcinoma of the oral cavity. Thirty-six patients had either T1 or T2 tumours and no patient had palpable nodes at the time of implantation. Control of the primary tumour was achieved in all but 2 patients; these 2 were successfully treated by surgery. Fifteen patients (39%) went on to develop metastatic neck nodes. Nine were cured by radical neck dissection but the remaining 6 died of their disease. This gives a 5-year actuarial survival of 81%. Since all deaths occurred after the development of metastatic disease in the neck with control of the primary lesion, the evidence for and against prophylactic treatment of the neck lymphatics in clinically negative necks was reviewed. Prophylactic irradiation of the neck is probably preferable to any form of neck dissection but clear evidence that this improves long-term survival compared with careful follow-up and radical neck dissection for palpable nodes is still lacking.

Locate: An application of computed tomography in radiation therapy treatment planning with emphasis on tumor localization

Computed tomography can provide precise information for radiation therapy treatment planning. However, inaccuracies in radiation field design may occur when the radiation oncologist attempts to transfer information about tumor location from the transverse plane of the CT scan to the longitudinal plane of the simulation film. This report describes a new computer program, LOCATE, which addresses this problem. The program uses operator generated information from the cross sectional CT images to draw an outline of tumor on AP and lateral longitudinal scanned projection radiographs. The resultant images are useful because they are in the same plane as radiographs obtained on a therapy simulator. The impact of LOCATE on radiation treatment planning for 26 patients is discussed along with several cases in which LOCATE was particularly helpful.

A new combined approach to the conservative treatment of early breast cancer

A combined surgical and radiotherapeutic technique is described that aims to: (1) achieve permanent local control of disease; (2) give full information on the histology and biochemistry of the tumor; (3) detail axillary node status; and (4) be compatible with adjuvant endocrine therapy or chemotherapy. This treatment is accomplished with minimal cosmetic defect and, in the majority of patients, with almost total conservation of the breast form. The surgical procedures are carried out during one hospital admission and performed with one anesthetic. No prosthetic replacement or augmentation of the breast is involved.

Adenocarcinoma of the proximal colon. Sites of initial dissemination and patterns of recurrence following surgery alone

Seven hundred ninety-five patients were adenocarcinomas of the proximal colon were reviewed. Two hundred forty-five patients presented with disseminated disease at the time of diagnosis, and were analyzed to identify mechanisms and sites of disease spread. Five hundred fifty patients underwent radical resection, and were followed for a minimum of 48 months or until time of documented relapse. One hundred eighty-six patients (34%) manifested recurrent carcinoma, 64 (34.5%) of whom underwent second laparotomy at the time of initial recurrence. In 139 patients (74.5%), the distribution of clinical recurrence was confined to the abdomen, retroperitoneum, and liver. Prognostic influence of initial stage and tumor grade are analyzed, and possible implications for surgical staging and adjuvant therapy are discussed.

Adenocarcinoma of the proximal colon. Sites of initial dissemination and patterns of recurrence following surgery alone

Seven hundred ninety-five patients were adenocarcinomas of the proximal colon were reviewed. Two hundred forty-five patients presented with disseminated disease at the time of diagnosis, and were analyzed to identify mechanisms and sites of disease spread. Five hundred fifty patients underwent radical resection, and were followed for a minimum of 48 months or until time of documented relapse. One hundred eighty-six patients (34%) manifested recurrent carcinoma, 64 (34.5%) of whom underwent second laparotomy at the time of initial recurrence. In 139 patients (74.5%), the distribution of clinical recurrence was confined to the abdomen, retroperitoneum, and liver. Prognostic influence of initial stage and tumor grade are analyzed, and possible implications for surgical staging and adjuvant therapy are discussed.

Second laparotomy for proximal colon cancer. Sites of recurrence and implications for adjuvant therapy

Sixty-four patients with primary adenocarcinomas of the colon proximal to the peritoneal reflection underwent exploratory laparotomy at the time of first recurrence of their cancers. Local recurrence, retroperitoneal lymph node metastases, parenchymal liver metastases, and diffuse peritoneal seeding were identified as frequent components of the overall pattern of recurrence. The significance of these findings has been discussed herein, relative to refinements of operative technique and selection of appropriate adjuvant therapy.

Adenocarcinoma of the cecum: natural history and clinical patterns of recurrence following radical surgery

One hundred and forty-three patients with previously untreated primary adenocarcinomas of the cecum were analyzed. Fifty-three patients manifesting disseminated disease at diagnosis were analyzed to define mechanisms of disease spread. Ninety patients were analyzed following attempted curative resection to determine anatomical distribution of initial clinical recurrences. Twenty-eight patients recurred (31%), of whom 9 underwent a second laparotomy. Nineteen of the 28 patients who recurred (68%) demonstrated an initial pattern of relapse clinically confined to the abdomen, liver, and retroperitoneum. Analysis was performed to determine the influence of stage and grade of the primary tumor on prognosis. Implications for adjuvant therapy are discussed.

Adenocarcinoma of the retroperitoneal ascending and descending colon: sites of initial dissemination and clinical patterns of recurrence following surgery alone

One hundred twenty-seven patients with previously untreated primary carcinomas of proximal, retroperitoneal large bowel were retrospectively analyzed. Sites of involvement in 33 patients with surgically incurable (disseminated) disease were analyzed to define patterns of initial spread. Ninety-four patients were analyzed following attempted curative resection to determine anatomical distribution of initial clinical recurrences. Thirty-one patients recurred (33%). Twenty-four of these patients (77.5%) demonstrated an initial pattern of relapse clinically confined to the abdomen and retroperitoneum. Analysis was performed to identify factors of prognostic significance. Implications for adjuvant therapy are discussed.

Adenocarcinoma of the sigmoid colon: sites of initial dissemination and clinical patterns of recurrence following surgery alone

Three hundred and fifty-five patients with primary adenocarcinoma of the sigmoid colon were retrospectively reviewed. One hundred and eighteen patients who had disseminated disease at diagnosis were analyzed to identify sites and mechanisms of disease spread. Two hundred and thirty-seven patients treated by surgery alone with curative intent were analyzed to determine clinical patterns of recurrence and identify prognostic factors. Operative findings in 27 patients undergoing second laparotomy at the time of initial disease recurrence are described, and implications for adjuvant therapy discussed.

Contribution of prednisolone to the primary endocrine treatment of advanced breast cancer

Two hundred and four patients with progressive locally advanced or metastatic breast cancer not controllable by local therapy alone, and who had had no prior systemic therapy for advanced disease, were treated by primary endocrine therapy according to menopausal status. Premenopausal patients received ovarian irradiation (O) whilst postmenopausal patients received tamoxifen 10 mg b.d. (T). Patients were randomised to receive either no additional treatment or prednisolone 5 mg b.d. (P). In 180 evaluable patients, T + P induced significantly more responses than T alone (26/73 vs 9/72, P less than 0.01) and the addition of P to O in premenopausal patients also induced more responses than O alone (7/16 vs 4/19), but this difference was not significant and accrual of premenopausal patients continues. There was a trend for patients receiving T + P to have a longer survival than those receiving T alone (median 25 vs 16 months). These trends occurred in patients with tumours positive for oestrogen receptors and when receptor status was unknown; patients with receptor-negative tumours had a negligible response to endocrine treatment. P mitigated the occurrence of hypercalcaemia and tumour flare sometimes seen with T alone.

Oestrogen receptors, clinical features and prognosis in stage III breast cancer

One hundred and twenty-four patients with stage III breast cancer who had oestrogen receptor analyses (ER) performed on primary tumour were studied. For operable disease (T3a, N0.1, M0), patients with ER-negative (ER less than 5 fmol/mg cytosol protein) tumours had a shorter duration of symptoms, but no other differences were observed at presentation. In patients with inoperable (T3b,4, N0.1, M0 or any T, N2.3, M0) tumours there were no differences in the clinical characteristics that rendered the primary tumour inoperable between those with ER+ or ER- tumours. The median disease-free interval (DFI) in patients with operable tumours and uninvolved axillary nodes was significantly longer in those with ER+ tumours (P less than 0.05). Median survival was significantly longer in patients with ER+ tumours than in those with ER- tumours (50 vs 27.5 months, P less than 0.05), and when survival was analysed according to various methods of initial treatment, it was significantly prolonged in patients with operable (T3a, N0.1, M0) ER+ tumours compared to those with operable ER- tumours. In patients with inoperable tumours no effect of ER status on prognosis was demonstrated. These results suggest that oestrogen receptor content may be a prognostic variable in patients with operable stage III breast cancer, but further studies of patients with similar methods of initial treatment are needed to confirm this. Patients with operable stage III tumours should be considered separately from those with locally advanced inoperable tumours in view of the significant differences in their survival prospects.

The response to endocrine therapy in patients with advanced breast cancer in Great Britain and Japan

A prospective study has been carried out to compare the response rates to endocrine therapy of Japanese and British women with breast cancer. Premenopausal women were treated by ovarian ablation, patients who were up to five years postmenopausal were prescribed androgen therapy and patients who were more than five years postmenopausal were treated with oestrogens. No differences in response rate, response time or survival could be detected in the three categories of patients. Significantly more Japanese patients presented with pulmonary metastases in the pre- and postmenopausal groups. In postmenopausal Japanese patients treated with oestrogens, those with pulmonary metastases survived significantly longer.

The palliation of symptomatic osseous metastases: final results of the Study by the Radiation Therapy Oncology Group

Different dose fractionation irradiation schedules have been evaluated in a randomized Radiation Therapy Oncology Group (RTOG) study to determine their palliative effectiveness in patients with osseous metastases. The frequency, promptness and duration of pain relief were utilized as measures of response. Ninety percent of patients experienced some relief of pain and 54% achieved eventual complete pain relief. Important prognosticators included the initial pain score and the site of the primary lesions. Administration of steroid or chemotherapy during the one-month on-study period did not influence the frequency of pain relief. The low-dose, short-course schedules were as effective as the high-dose protracted programs.

Carcinoma of the tonsillar region: results of external irradiation

A retrospective analysis is made of 104 patients treated with photon megavoltage radiotherapy for squamous cell carcinoma of the tonsillar region during the period 1965--1975. Moderately differentiated squamous cell carcinoma was the most common histological grade. Fifty-three per cent of the cases presented with cervical lymphadenopathy with three cases of bilateral involvement. The three year local control rate was 100% for Stage I, 74% Stage II, 49% Stage III, and 33% Stage IV. Two Stage III cases and one Stage IV case developed subsequent contralateral neck disease. No patient with either T1N0 or T2N0 tumor failed in the ipsilateral or contralateral neck despite the fact that 42% of the T1N0 cases and 37% of the T2N0 cases were treated with unilateral portals. The prognostic significance of the T and N stages, treatment techniques, as well as dose response relationships are analyzed and the literature is reviewed.

Fast neutron teletherapy for advanced carcinomas of the oral cavity and soft palate

A retrospective study was performed to determine the efficacy of using fast neutron radiation for treating advanced squamous cell carcinomas of the oral cavity and soft palate. The majority of patients were judged to have less than a 10% 5-year survival with conventional medical treatment. Fifteen patients with oral cavity tumors were treated for cure with neutrons alone and six were treated with a combination of neutrons and photons as part of a mixed beam fractionation scheme. In the neutron-only group, the complete regression rate was 33% in the mixed beam group, the rate was 50%. Five patients who had squamous cell carcinomas of the soft palate were treated for cure, one with neutrons alone and four with a mixed beam regimen. The complete regression rate was 100%. The two-year NED results are comparable with literature results for more selected groups of patients with oral cavity and soft palate tumors treated by conventional photon therapy. The acute treatment morbidity was perhaps somewhat greater in the subgroup of patients treated with neutrons alone, and this subgroup later developed a more pronounced subcutaneous fibrosis. Morbidity associated with the mixed beam treatment regimen was comparable to that associated with conventional radiotherapy.

Aromatic retinal analogues and their interaction with cattle opsin

The preparation of seven aromatic analogues of retinal, the isolation and characterization of their geometric isomers, and the interaction of these isomers with cattle opsin are reported. Within certain limitations, it has been demonstrated that stable aromatic rhodopsin analogues can be prepared. In general, the stereoselectivity of isomers of these compounds in their interaction with opsin and the absorption properties of the resultant pigments are similar to those of the parent retinal.

Solitary plasmacytoma of bone and soft tissues

Between 1956 and 1978, nine patients with solitary plasmacytoma of bone (SPB) and seven with extramedullary plasmacytoma (EMP) were treated at the University of Washington Hospital and Swedish Tumor Institute. All but one patient had local radiotherapy. In the SPB group, six of nine patients progressed to multiple myeloma (MM) and five died of disease within three years after dissemination. Three of the nine patients are alive at 5, 8, and 16 years, respectively. In the EMP group, none of the seven patients progressed to MM. Five are alive 16 months to 23 years after radiotherapy. Since there are no reliable criteria for prospectively distinguishing true solitary plasmacytoma from occult MM, all patients with apparently isolated plasmacytoma should receive local radiotherapy with curative intent.

Fast neutron teletherapy for advanced carcinoma of hypopharynx and supraglottic larynx

The results of a Phase I clinical trial using fast neutron teletherapy for advanced squamous cell carcinoma of the hypopharynx and supraglottic larynx are reported. Ten patients with hypopharyngeal tumors were treated for cure using neutrons alone and 6 patients with hypopharyngeal tumors were treated for cure using a combination of neutrons and photons as part of a mixed beam fraction scheme. In the neutron-only group, the initial complete remission rate was 4/10 (40%). The mean survival of this group of patients with initial complete remission was only 5.75 months (range 2--10) but all patients died without evidence of recurrent tumor at the primary site. In the mixed beam group, the initial complete remission rate was 5/6 (83%) but the local control rate dropped rapidly to 41 per cent when displayed on an actuarial plot. Six patients with advanced tumors of the supraglottic larynx were treated for cure, 5 with neutrons alone and one with a mixed beam regime. The initial complete remission rate was 3/6 (50%) but 2 of these patients rapidly recurred, which reduced the local control rate on an actuarial plot to 16 per cent. The relative adverse effects of the neutron-only treatment regime appear to be substantially greater than those of the mixed beam treatment regime.

Complications of combined surgery and neutron radiation therapy in patients with advanced carcinoma of the head and neck

A total of 135 patients with advanced squamous-cell carcinoma of the head and neck were treated with cyclotron-generated fast neutrons. Thirty-eight had major surgery before or after irradiation. Major complications (fistula formation, carotid artery exposure or blowout requiring ligation, or major wound breakdown) occurred in 37%. The complication rates associated with surgery prior to irradiation, planned surgery following irradiation, and salvage surgery following irradiation were 0/12, 4/5, and 10/21, respectively. The complication rate for surgery following neutron irradiation alone was 73%; for surgery following mixed-beam irradiation it was 20%. The age of the patient and the interval between surgery and irradiation had no influence on the complication rate.

Limited epithelial carcinoma of the ovary treated with curative intent by the intraperitoneal installation of radiocolloids

Between January 1960 and September 1972, 104 patients with limited epithelial carcinoma of the ovary received intraperitoneal radiocolloid. Fifty-six of these patients also received external beam radiation therapy to the pelvis (pelvic RT). Five-year actuarial no-evidence-of-disease survival rates were 95% for stage Iai, 82% for Iaii, 73% for Ib, 67% for Ic, 67% for IIa, 67% for IIb without gross residual tumor (GRT), 25% for IIb with GRT, and 50% for III with minimal or no GRT. The addition of pelvic RT following radiocolloid could not be shown to affect survival of patients with Stage I and IIa tumors. Small bowel complications were related to the use of pelvic RT, however, occurring in 2.2% of patients treated with radiocolloid alone and 24% of patients treated with colloid and pelvic RT (p less than 0.005). In patients who underwent abdominal surgery following treatment of ovarian cancer, no excessive complication rate was observed. We conclude that for patients with stages Iaii through IIa, postoperative radiocolloid appears to provide the greatest chance of survival with the least chance of complication. For patients with Stage IIb and III lesions in whom there is minimal or no GRT, radiocolloid followed by pelvic RT produced survival rates comparable or superior to any other form of postoperative therapy.

Elective irradiation of the lower cervical region in patients at high risk for recurrent cancer at the tracheal stoma

The results of treatment for recurrent cancer at the tracheal stoma have been poor. From 1971 to 1976, elective postoperative irradiation of the neck was given to 26 high-risk patients with carcinoma of the larynx and hypopharynx. None of the 22 patients whose stomas were irradiated developed stomal or peristomal recurrence, while 2 of the 4 patients whose stomas were shielded had stomal recurrence. Elective irradiation of the tracheal stoma was effective in preventing stomal recurrence; we recommend inclusion of the stomal area in preoperative or postoperative irradiation to the lower cervical region for high-risk patients.

Alkylating derivatives of amino acids and peptides. Synthesis of N-maleoylamino acids, [1-(N-maleoylglycyl)cysteinyl]oxytocin. Effects on vasopressin-stimulated water loss from isolated toad bladder

A method for the preparation of N-maleoylamino acids and esters is reported. These compounds were shown to inhibit both the oxytocin-induced smooth muscle contraction in the isolated rat uterus and the vasopressin-induced water loss from the isolated toad bladder. The inhibitory ability of the maleimides in the toad bladder assay was found to be related to their corresponding partition coefficients by the equation: log 1/C = -0.055 (log P) 2 + 0.227 log P + 3.96. N-Maleoylamino acids can be coupled to peptides to form alkylating reagents which react rapidly with sulfhydryl groups. The synthesis of [1-(N-maleoylglycyl)cysteinyl]oxytocin (3) and [1=(N-maleoyl-11-aminoundecanoyl)cysteinyl]oxytocin (4) as potential affinity labeling reagents is described. These oxytocin analogs were shown to readily react with sulfhydryl-containing compounds; however, neither 3 nor 4 was seen to inhibit in the rat uterus assay at concentrations up to 3 times 10(-5)M. When tested on the mucosal and serosal surfaces of the toad bladder, assay inhibition was seen only on the mucosal surface. These results are discussed with respect to the possible existence of sulfhydryl groups at neurohypophyseal receptors.

Postmastectomy lymphangiosarcoma-temporary response to cyclophosphamide chemotherapy in 2 cases

Two cases of lymphangiosarcoma developing in oedematous arms following radical mastectomy (Stewart-Treeves syndrome) are reported. Both patients showed marked symptomatic improvement and tumour regression on cyclophosphamide therapy although remission was only temporary.

Cryptococcal meningitis as a complication of systemic lupus erythematosus treated with systemic corticosteroids

Cryptococcosis, a disease of world-wide distribution, is uncommon in the British Isles where it usually presents as meningitis affecting patients with malignant disease of the reticulo-endothelial system, diabetes mellitus or those receiving systemic treatment with corticosteroids. The clinical features and physical signs of the disease are often non-specific and resemble those of tuberculous meningitis. The diagnosis is made upon recognizing the encapsulated Cryptococcus neoformans on Indian Ink preparations of the cerebrospinal fluid, or by demonstrating precipitating antibodies to the organism in the patient's serum. The treatment is by intravenous administration of amphotericin B for a period of 6-12 weeks, supplemented in severe or relapsing cases by intrathecal therapy; alternatively, 5-fluorocytosine may be given by mouth. A case is reported of cryptococcal meningitis occurring in a 46-year-old woman with systemic lupus erythematosus treated with methylprednisolone. Treatment with amphotericin B was successful in suppressing the infection, but was accompanied by side-effects and some temporary impairment of renal function.

Haemorrhagic necrosis of the breast complicating anticoagulant therapy and mitral stenosis

A case of necrosis of the breast following apparent spontaneous haemorrhage is reported. The patient was receiving anticoagulant therapy with phenindione for multiple pulmonary emboli complicating mitral stenosis.