Normal reference-intervals for 20 biochemical variables in healthy infants, children, and adolescents

We determined normal reference values from data on sera of 2099 outpatient children (ages one week to 14 years) at our institution. Using a continuous-flow instrument (SMAC, Technicon), we determined the following analytes in each serum sample: glucose, creatinine, uric acid, inorganic phosphorus, sodium, potassium, chloride, total CO2, iron, cholesterol, triglycerides, total protein, albumin, total bilirubin, creatine kinase, lactate dehydrogenase, alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, and calcium. The resulting data were coded and subsequently processed in an IBM 370 computer, and the reference values (3rd and 97th percentiles) were defined for each analyte. A two-way analysis of variance was also done to determine the influence of age and sex on results of these 20 biochemical tests.

A multiple-site perineal applicator (MUPIT) for treatment of prostatic, anorectal, and gynecologic malignancies

Recently, transperineal interstitial-intracavitary applicators have been used to treat locally limited and advanced perineal and gynecologic malignancies. We have developed a single afterloading applicator, referred to as the "MUPIT" (Martinez Universal Perineal Interstitial Template), which with its prototypes has been utilized to treat 78 patients with malignancies of the cervix, vagina, female urethra, perineum, prostate, and anorectal region. The device basically consists of two acrylic cylinders, an acrylic template with a predrilled array of holes that serve as guides for trocars, and a cover plate. Some of the guide holes on the template are angled outward to permit a wide lateral coverage without danger of striking the ischium. The cylinders have an axial hole large enough to pass a central tandem or a suction tube for the drainage of secretions. Thus, the device allows for the interstitial placement of 192Ir ribbons as well as the intracavitary placement of either 137Cs tubes or 192Ir ribbons. In use, the cylinders are placed in the vagina and rectum and then fastened to the template, so that a fixed geometric relationship among the tumor volume, normal structures, and source placement is preserved throughout the course of the implantation. Hollow, closed-end, stainless steel trocars are then inserted through the guide holes that produce optimal coverage of the treatment volume. Appropriate computer programs also have been developed on a minicomputer for the corresponding dose-rate computations. These programs run with sufficient speed that they may be used for both the planning of the source placement beforehand and the computation of the actual dose-rate distribution obtained. The advantages of the system are (1) greater control of the placement of sources relative to the tumor volume and critical structures owing to the fixed geometry provided by the template and cylinders, and (2) improved dose-rate distributions obtained by means of computer-assisted optimization of the source placement and strength during the planning phase.

The effect of postoperative and primary radiation therapy on delivered dose of adjuvant Cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) chemotherapy in breast cancer

The dose of adjuvant chemotherapy for breast cancer may be an important factor in the success of the treatment program. In a retrospective analysis, the authors determined whether patients who were irradiated either postoperatively (N = 29) or as part of primary treatment (N = 13) received a lower dose of adjuvant cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) chemotherapy than patients who were not irradiated (N = 42). The 84 evaluable patients received either cyclical or weekly CMF. Radiation therapy included the chest wall or breast and regional lymph nodes. The mean percentage of maximum chemotherapy dose delivered (59.9% versus 73.5%; P less than 0.001), mean percent prescribable or theoretical maximum dose (83.1% versus 91.3%; P less than 0.001), and mean leukocyte count (3.9 versus 4.5; P less than 0.01) during therapy were statistically significantly lower in irradiated patients. The lower delivered chemotherapy dose in irradiated patients was not related to the radiation dose to the thoracic spine. The authors conclude that radiation therapy to the chest wall or breast and regional lymph nodes reduces the dose of adjuvant CMF that can be delivered.

Analysis of cosmetic results and complications in patients with stage I and II breast cancer treated by biopsy and irradiation

Between May, 1973 and December, 1980, 78 Stage I and II breast carcinomas in 76 patients were treated by biopsy and radiotherapy with curative intent. With a maximum follow-up of 10 years, a minimum of 2 1/2 years and a median follow-up of 3 1/2 years, a loco-regional control rate of 97% was obtained. Cosmetic results and treatment complications were studied. Patient characteristics, tumor size, excisional biopsy technique, axillary staging procedure and radiotherapy techniques were analyzed and all found to be important factors affecting cosmesis and complications. The most common complications included transient breast edema observed in 51% of patients, breast fibrosis (usually mild) seen in 23% of the population, axillary hematoma or seroma formation in 15%, mild arm edema in 14% and basilic vein thrombosis in 10% of patients. The causes of these and other less frequent complications are discussed. The overall cosmetic result was excellent in 78%, satisfactory in 18% and unsatisfactory in 4% of patients. Recommendations for improving cosmetic results minimizing complications are made. In our prospective trial, the high loco-regional control and good cosmesis supports the use of excisional biopsy and radiation therapy in patients with Stages I and II breast carcinoma.

The use of para-aortic radiation therapy based on lymphangiogram interpretation in uterine cervical carcinoma

From January, 1965, to June, 1979, 79 nonrandomized patients with carcinoma of the uterine cervix had a bipedal lymphangiogram (LAG) prior to radiotherapy at the Stanford University Medical Center. In 32 patients the LAGs were interpreted as normal. Of the remaining 47 patients, 28 had LAGs interpreted as positive for metastatic involvement of pelvic nodes alone, 11 as positive for pelvic and para-aortic (PA) metastasis, and 8 as positive in PA nodes alone. Five-year survival and freedom from relapse (FFR) were found to be similar for patients with LAGs interpreted as normal or positive in pelvic nodes only (all stages combined). The addition of elective PA irradiation in those patients with positive pelvic nodes alone (median 5000 rad/5 weeks) did not enhance either survival or FFR in this group. The 19 patients with positive PA nodes had significantly worse survival and FFR when compared with the other groups. Survival was not enhanced by the addition of therapeutic PA irradiation (median 5000 rad/5 weeks) and the 7 patients in this group so treated appeared to have a reduced FFR when compared to the 12 untreated patients. Irrespective of the location of nodal abnormality on LAG and regardless of stage, the majority of relapses (16/23) occurred either centrally or at the pelvic sidewalls. It is concluded that the LAG is a good predictor of subsequent relapse and survival, but that the addition of either elective or therapeutic PA radiotherapy based on LAG interpretation does not affect survival of FFR and should, therefore, be considered for investigational or palliative use only.

Adenocarcinoma of the endometrium. Analysis of 256 cases with disease limited to the uterine corpus: treatment comparisons

Between 1959 and 1975, 256 patients with pathologic Stage I uterine adenocarcinoma were treated at Stanford University Hospital, Stanford, California. One hundred ninety-three patients were initially treated with surgery, and 63 received preoperative radium, reflecting different treatment philosophies of physicians operating at Stanford. Relapse rates for the two treatment groups were 9% (17 of 193) and 14% (9 of 63), respectively (P = 0.24). In both groups of patients, relapse rates were correlated with grade, although for those treated with initial surgery myometrial invasion was a much better predictor of relapse. Only one of the 127 patients without demonstrable myometrial invasion suffered a possible relapse. Sixteen of 66 patients with myometrial invasion (24%) relapsed after treatment. A review of the histologic material revealed 26 of 256 cases with a special histologic variant termed uterine papillary serous carcinoma, which was associated with a high relapse rate (50%) and a marked tendency for upper abdominal spread. It was found that the use of preoperative intracavitary radium was not demonstrated to be of value. Histologic information obtained from the hysterectomy specimen can be used to determine patients at high risk for relapse who may benefit from adjuvant treatment based on our understanding of the natural history of endometrial carcinoma.

Survival, prognostic factors, and relapse patterns in uterine cervical carcinoma

Between 1965 and 1979, 295 evaluable patients were treated with radiotherapy and/or surgery for invasive cervical carcinoma at the Stanford University Medical Center. The records of these patients were analyzed retrospectively with regard to survival, possible prognostic factors of freedom-from-relapse, and relapse patterns. Survival for the entire population at 5 years was 67%, with a median follow-up of 5 years. Five-year freedom-from-relapse (FFR) rates for stages I-IV were 88%, 61%, 33%, and 11%, respectively. Eighty-eight percent of all relapses occurred within 5 years. Several possible prognostic factors of FFR--including stage, histology, tumor differentiation, lymphangiogram status, treatment modality, age, presence of cervical stump, and initial serum hemoglobin value--were evaluated with a multivariate analysis. Stage was the best predictor of FFR, and lymphangiogram (LAG) status was the next most important covariate: 13 of 19 patients who showed involvement of paraaortic nodes on LAG relapsed within 1 year. There was no difference in survival or FFR between adenocarcinoma or squamous cell histologies. FFR in stage IB patients was independent of treatment modality; i.e., radiotherapy alone, surgery alone, or combined therapy. Initial serum hemoglobin (less than 12 vs. greater than 12) was not predictive of FFR or survival. Stage for stage, patients over 57 years of age tended to have better FFR than younger patients. The majority of relapses occurred centrally or at the pelvic sidewalls (58%), and future attempts to improve local control rates will rely more heavily on the individualized use of interstitial template applicators.

Fat necrosis of the breast simulating recurrent carcinoma after primary radiotherapy in the management of early stage breast carcinoma

Between March 1973 and December 1980, 76 patients with Stage I or II breast carcinoma were treated by biopsy and definitive radiation therapy at Stanford University Medical Center. There were 78 treated breasts since two patients had bilateral carcinomas at presentation. During a median follow-up period of 29 months, eight patients developed discrete masses in the treated breast. In four of these patients biopsied tissue revealed recurrent carcinoma yielding a local control rate of 95%. Four additional patients had lesions which were clinically indistinguishable from recurrent cancer. Biopsy specimens, however, revealed fat necrosis of the breast. The clinical and pathologic features of this entity are described. It is imperative that clinicians be aware of this treatment sequelae so that conservative diagnostic procedures may be used and breast deformity minimized. If postirradiation fat necrosis is considered, mastectomy for suspected persistent or recurrent disease may be avoided.

Irradiation as an alternative to mastectomy for early breast cancer

Between May 1973 and December 1980 there were 76 patients (78 breasts) with clinical stage I or II breast carcinoma treated by biopsy and definitive radiotherapy at Stanford University Medical Center. Local-regional control has been achieved thus far in 76 of 78 cases (97 percent) with a median follow-up time of 26 months. Transient lymphedema of the breast, arm edema and breast fibrosis were the most commonly noted complications. The cosmetic result was analyzed and scored as excellent in 78 percent, satisfactory in 18 percent and unsatisfactory in 4 percent. The three unsatisfactory results occurred in patients in whom severe fibrosis developed as a result of suboptimal radiation techniques. Interdisciplinary cooperation among surgical, medical and radiation oncologists is important. The 97 percent local-regional control and the 96 percent excellent-to-satisfactory results support the use of primary radiotherapy in early stage breast carcinoma.

125Iodine implants as an adjuvant to surgery and external beam radiotherapy in the management of locally advanced head and neck cancer

125Iodine seeds either individually placed or inserted into absorbable Vicryl suture carriers were utilized in conjunction with surgery and external beam radiotherapy in an attempt to increase local control rates in patients with (1) advanced oropharyngeal and laryngopharyngeal cancers (T3-T4, N2-N3), (2) massive cervical lymphadenopathy (N3) and an unknown primary site and (3) locally recurrent head and neck cancers. Forty-eight patients were treated with 55 implants. The carotid artery was implanted in 15 patients, while seven patients had seeds inserted into the base of the skull region, and another three patients had implants near cranial nerves. Eighteen of the 48 patients were treated for cure. The actuarial survival at five years in this subgroup was 50%. The overall local control in the head and neck area was 58%. In this group no patients to date have had a local failure in the implanted volume. Seventeen patients with comparable stage of disease treated prior to 1974 with curative intent without 125I implants were analyzed retrospectively for comparison with the implanted patients. The actuarial survival of these patients was 18% and the overall head and neck control was 21%. These differences are statistically significant at a P value of 0.01 and 0.007, respectively. Seventeen patients received implants for local recurrence. The local control in the head and neck area was 50%; however, the 2.5 year actuarial survival was only 17%. The complication rate was 11% (six of 55 implants). The improved survival, the high local control, and the minimal complication rates in this series makes the intraoperative implantation of 125I seeds and effective adjunctive treatment to surgery and external beam irradiation.

Interstitial therapy of perineal and gynecological malignancies

Thirty-five patients, 38 to 88 years of age, were treated with 125-Iodine or 192-Iridium interstitial implants at Stanford University Medical Center between July 1974, and December, 1978. There were 25 primary epithelial malignancies, eight extensions from intrapelvic organs and two metastatic tumors (hypernephroma and Hodgkin's disease). The involved sites were: urethra (6 patients); vulva (9 patients); vagina (8 patients); anus (7 patients); cervix (5 patients). Implantation was usually performed to treat evident or microscopic disease in conjunction with external beam pelvic treatment with or without local excision. Computerized implant preplanning was used. 125-Iodine seeds were inserted either directly or within absorbable suture Polyglactin 910; 192-Iridium in nylon carriers was placed by suture or transperineal template. Two patients were lost to follow-up leaving 33 patients, 27 of whom are alive and free of local disease from 37 to 76 months. The overall local control rate was 88%, or 29/33 patients. All four local recurrences appeared before 24 months. Minor complications included: 10 patients with transient mucositis, four with superficial ulcers, and one patient with infection at the implanted site. Two major complications occurred: a necrotic rectal ulcer requiring a colostomy and a contracted, painful bladder necessitating a urinary diversion. We conclude that in selected cases interstitial irradiation provides good local control of perineal and gynecological malignancies with low morbidity in this elderly and quite often fragile group of patients.

Nuclear alterations induced by cadmium chloride and L-canavanine in HeLa S3 cells. Accumulation of perichromatin granules

The effects of L-canavanine and cadmium on the ribonucleoprotein constituents of HeLa S3 cells have been analyzed. Both chemicals induce a similar pattern of alterations in different RNP structures as well as in both RNA and protein synthesis. Pulse and chase autoradiographic experiments reveal that both canavanine and cadmium induce a preferential inhibition of nucleolar RNA synthesis and a slowdown in the transport or processing of nucleolar and extranucleolar RNA. Nucleoli become round and compact. Accumulation of perichromatin granules and fibrils occurs, there is a depletion of interchromatin fibrils, and nuclear formations appear which seem to be involved in the morphogenesis of perichromatin granules accumulated during the treatments. The appearance of clusters of 29- to 35-nm granules might be related with a deficient assembling of constituents of perichromatin granules. The effects of different inhibitors of the transcriptional processes on the accumulation of perichromatin granules suggest that these granules represent a particular subpopulation of hnRNP.

Lower abdominal radiotherapy for stages I, II, and selected III epithelial ovarian cancer: 20 years experience

Between 1956 and 1975, lower abdominal radiotherapy was administered as primary postoperative treatment to 82 patients with stages I, II, and selected III epithelial ovarian carcinoma and with varying amounts of postoperative residual disease. The median follow-up was 7.5 years, and the overall freedom from relapse (FFR) at 10 years for the entire group was 57%. The FFR at 10 years for stages I, II, and III was 78, 60, and 24% respectively, and these results are better than published series of similarly staged patients treated with surgery alone. Ten-year FFR was 79% for patients with no residual disease (NRD), 49% for patients with minimal residual disease (MRD) of less than 2 cm, and 24% for patients with gross residual disease (GRD) of greater than 2 cm. Control within the irradiated lower abdomen was achieved in 97% of patients with NRD, 84% of patients with MRD, and in 55% of those with GRD. Of all relapses, 33% occurred in the pelvis (almost all in patients with GRD), 37% in the untreated upper abdomen, 21% in distant sites, and 9% had an undetermined intraabdominal site of relapse. Among those patients with stage I and II disease or favorable residual tumor (NRD and MRD), approximately 50% of relapses occurred in the untreated upper abdomen alone.

Entrapment of the median nerve after posterior dislocation of the elbow

The authors present two cases of complete median nerve paralysis due to entrapment after posterior dislocation of the elbow. Previous literature on the subject matter is reviewed, and management and therapeutic indication of these lesions are discussed.

Subcortical correlates of the auditory brainstem potentials in the monkey: referential responses

Referential responses correlated with the vertex auditory brain-stem potentials (ABSP) were recorded from different brainstem and diencephalic structures of large monkeys under barbiturate anesthesia. Polarity, latency, and amplitude of various response components were determined from structures located 2 mm apart along five different vertical trajectories aiming at the trapezoid body (TB), superior olivary complex (SOC), mesencephalic reticular formation (MRF), medial geniculate nucleus thalami (MG), and inferior colliculus (IC). Latency correlations, amplitude differences, voltage profiles, current-source-density-distribution, and current flows of the various response components were subsequently calculated. Subcortical referential responses were formed by seven initial fast positive components (I, II, A, B, C, D and E) and one late slow negative component (F) correlated to waves I to VII and SP3 of the vertex ABSP respectively. Positive components C and D' also correlated to SP1 and SN1 of ABSP respectively. Amplitude of component B at contralateral SOC and C, D' and F at contralateral MRF was significantly larger than those of other subcortical responses and vertex ABSP. A single component of the subcortical referential responses accompanied changes in voltage, CSD, and current flows of various brainstem structures. However, considering only major changes in these parameters, component B accompanied a voltage positive and a CSD positive-negative peak and an ascending current flow at the SOC; component C accompanied similar changes at MRF, and components D' and F accompanied voltage negative and CSD negative-positive-negative peaks and ascending and descending current flows at MRF. In contrast, no systematic changes in voltage, CSD and current flows accompanied components I, II, A, D and E.

Simultaneous presentation of carcinoma involving the ovary and the uterine corpus

Twenty-nine patients had simultaneous malignant epithelial neoplasms of the uterine corpus and ovary. Three groups were defined on the basis of tumor histology: Group A: those with endometrioid carcinoma in both the uterus and ovary; Group B: those with special variants of corpus carcinoma (papillary, clear cell, mucinous) and identical neoplasms in the ovary; and Group C: those whose uterine and ovarian carcinomas were of dissimilar histologic types. Sixteen women had endometrioid carcinoma in both sites. The median age at diagnosis, 41 years, was younger than is usual for corpus or ovarian cancer. For all 16 patients, the grade of the ovarian endometrioid carcinoma was similar to that of the endometrioid carcinoma of the uterine corpus. Seven patients had bilateral ovarian neoplasms. Only one patient had myometrial invasion by the corpus carcinoma. No patient with simultaneous ovarian and uterine endometrioid carcinoma, regardless of grade, has died of cancer although one vaginal relapse was treated successfully. This excellent survival of patients with simultaneous endometrioid carcinomas is better than would be expected for either Stage III adenocarcinoma of the endometrium or Stage II ovarian carcinoma. These simultaneously occurring endometrioid neoplasms of ovary and endometrium are considered to be separate primary tumors. The morphologic reasons for this view and therapeutic implications are discussed. In contrast to the patients with endometrioid carcinoma, the eleven patients with other histologic types of carcinoma in the ovary and corpus were older (median age, 61 years) and more often postmenopausal (90%). These neoplasms were more aggressive, with frequent deep myometrial involvement (63%), tubal involvement (27%), and extension to other pelvic tissues (36%) at the time of initial diagnosis. Six of these 11 patients succumbed to their cancer despite surgical therapy and radiation. The distribution of tumor in some of these patients with nonendometrioid types of carcinoma is suggestive of a single primary with metastases. The therapeutic implications of these findings are discussed.

Breast edema following staging axillary node dissection in patients with breast carcinoma treated by radical radiotherapy

Seventy-four patients with carcinoma of the breast were treated by irradiation without a mastectomy at Stanford between May 1973 and March 1980. Seventy-six breasts were treated because two patients had bilateral simultaneous cancers. Breast edema was noted in 41% of these cases. Analysis of potential predisposing factors revealed that this complication occurred primarily in patients who received a staging axillary lymph node dissection. Lymphedema occurred in 26 of 33 breasts (79%) in patients who had staging axillary dissections; this complication developed in only three of 12 (25%) with axillary samplings and two of 31 (6%) with no axillary surgery. Two groups of patients were identified: (1) 28 patients whose breast edema occurred early (prior to or during radiation therapy), and (2) three patients with late onset edema that developed several months postirradiation. The early edema, which is clearly related to axillary lymph node dissection, gradually improved during the follow-up period with complete or near complete resolution expected by three years. Late onset edema was rare, appears to be related to an axillary radiation dose greater than 5500 rad, and may be irreversible. There was no correlation of breast edema with tumor stage, radiation time/dose factors, the use of bolus, patient weight, or breast size.