Phase shift between joint rotation and actuation reflects dominant forces and predicts muscle activation patterns

During behavior, the work done by actuators on the body can be resisted by the body's inertia, elastic forces, gravity, or viscosity. The dominant forces that resist actuation have major consequences on the control of that behavior. In the literature, features and actuation of locomotion, for example, have been successfully predicted by nondimensional numbers (e.g. Froude number and Reynolds number) that generally express the ratio between two of these forces (gravitational, inertial, elastic, and viscous). However, animals of different sizes or motions at different speeds may not share the same dominant forces within a behavior, making ratios of just two of these forces less useful. Thus, for a broad comparison of behavior across many orders of magnitude of limb length and cycle period, a dimensionless number that includes gravitational, inertial, elastic, and viscous forces is needed. This study proposes a nondimensional number that relates these four forces: the phase shift (ϕ) between the displacement of the limb and the actuator force that moves it. Using allometric scaling laws, ϕ for terrestrial walking is expressed as a function of the limb length and the cycle period at which the limb steps. Scale-dependent values of ϕ are used to explain and predict the electromyographic (EMG) patterns employed by different animals as they walk.

Spring and latch dynamics can act as control pathways in ultrafast systems

Ultrafast movements propelled by springs and released by latches are thought limited to energetic adjustments prior to movement, and seemingly cannot adjust once movement begins. Even so, across the tree of life, ultrafast organisms navigate dynamic environments and generate a range of movements, suggesting unrecognized capabilities for control. We develop a framework of control pathways leveraging the non-linear dynamics of spring-propelled, latch-released systems. We analytically model spring dynamics and develop reduced-parameter models of latch dynamics to quantify how they can be tuned internally or through changing external environments. Using Lagrangian mechanics, we test feedforward and feedback control implementation via spring and latch dynamics. We establish through empirically-informed modeling that ultrafast movement can be controllably varied during latch release and spring propulsion. A deeper understanding of the interconnection between multiple control pathways, and the tunability of each control pathway, in ultrafast biomechanical systems presented here has the potential to expand the capabilities of synthetic ultra-fast systems and provides a new framework to understand the behaviors of fast organisms subject to perturbations and environmental non-idealities.

Biomechanics: Passive forces set the stage for stick insects

For small animals like insects, passive elastic forces within their joints are extremely important to control of limb motion. A new study shows that these passive forces are tuned to the needs of individual joints.

Jumping in lantern bugs (Hemiptera, Fulgoridae)

Lantern bugs are amongst the largest of the jumping hemipteran bugs, with body lengths reaching 44 mm and masses reaching 0.7 g. They are up to 600 times heavier than smaller hemipterans that jump powerfully using catapult mechanisms to store energy. Does a similar mechanism also propel jumping in these much larger insects? The jumping performance of two species of lantern bugs (Hemiptera, Auchenorrhyncha, family Fulgoridae) from India and Malaysia was therefore analysed from high-speed videos. The kinematics showed that jumps were propelled by rapid and synchronous movements of both hind legs, with their trochantera moving first. The hind legs were 20–40% longer than the front legs, which was attributable to longer tibiae. It took 5–6 ms to accelerate to take-off velocities reaching 4.65 m s⁻¹ in the best jumps by female Kalidasa lanata. During these jumps, adults experienced an acceleration of 77 g, required an energy expenditure of 4800 μJ and a power output of 900 mW, and exerted a force of 400 mN. The required power output of the thoracic jumping muscles was 21,000 W kg⁻¹, 40 times greater than the maximum active contractile limit of muscle. Such a jumping performance therefore required a power amplification mechanism with energy storage in advance of the movement, as in their smaller relatives. These large lantern bugs are near isometrically scaled-up versions of their smaller relatives, still achieve comparable, if not higher, take-off velocities, and outperform other large jumping insects such as grasshoppers.

Summary: Lantern bugs are large insects that jump at high-take-off velocities using a catapult mechanism that matches the performance of their much smaller planthopper relatives

Gravity and active acceleration limit the ability of killer flies (Coenosia attenuata) to steer towards prey when attacking from above

Insects that predate aerially usually contrast prey against the sky and attack upwards. However, killer flies (Coenosia attenuata) can attack prey flying below them, performing what we term 'aerial dives'. During these dives, killer flies accelerate up to 36 m s-2. Although the trajectories of the killer fly's dives appear highly variable, proportional navigation explains them, as long as the model has the lateral acceleration limit of a real killer fly. The trajectory's steepness is explained by the initial geometry of engagement; steep attacks result from the killer fly taking off when the target is approaching the predator. Under such circumstances, the killer fly dives almost vertically towards the target, and gravity significantly increases its acceleration. Although killer flies usually time their take-off to minimize flight duration, during aerial dives killer flies cannot reach the lateral accelerations necessary to match the increase in speed caused by gravity. Since a close miss still leads the predator closer to the target, and might even slow the prey down, there may not be a selective pressure for killer flies to account for gravity during aerial dives.

Adhesive latching and legless leaping in small, worm-like insect larvae

Jumping is often achieved using propulsive legs, yet legless leaping has evolved multiple times. We examined the kinematics, energetics and morphology of long-distance jumps produced by the legless larvae of gall midges (Asphondylia sp.). They store elastic energy by forming their body into a loop and pressurizing part of their body to form a transient ‘leg’. They prevent movement during elastic loading by placing two regions covered with microstructures against each other, which likely serve as a newly described adhesive latch. Once the latch releases, the transient ‘leg’ launches the body into the air. Their average takeoff speeds (mean: 0.85 m s−1; range: 0.39–1.27 m s−1) and horizontal travel distances (up to 36 times body length or 121 mm) rival those of legged insect jumpers and their mass-specific power density (mean: 910 W kg−1; range: 150–2420 W kg−1) indicates the use of elastic energy storage to launch the jump. Based on the forces reported for other microscale adhesive structures, the adhesive latching surfaces are sufficient to oppose the loading forces prior to jumping. Energetic comparisons of insect larval crawling versus jumping indicate that these jumps are orders of magnitude more efficient than would be possible if the animals had crawled an equivalent distance. These discoveries integrate three vibrant areas in engineering and biology – soft robotics, small, high-acceleration systems, and adhesive systems – and point toward a rich, and as-yet untapped area of biological diversity of worm-like, small, legless jumpers.

Insect jumping springs

A quick guide to the springs used by insects to achieve remarkable feats of jumping.

Muscle-spring dynamics in time-limited, elastic movements

Muscle contractions that load in-series springs with slow speed over a long duration do maximal work and store the most elastic energy. However, time constraints, such as those experienced during escape and predation behaviours, may prevent animals from achieving maximal force capacity from their muscles during spring-loading. Here, we ask whether animals that have limited time for elastic energy storage operate with springs that are tuned to submaximal force production. To answer this question, we used a dynamic model of a muscle-spring system undergoing a fixed-end contraction, with parameters from a time-limited spring-loader (bullfrog: Lithobates catesbeiana) and a non-time-limited spring-loader (grasshopper: Schistocerca gregaria). We found that when muscles have less time to contract, stored elastic energy is maximized with lower spring stiffness (quantified as spring constant). The spring stiffness measured in bullfrog tendons permitted less elastic energy storage than was predicted by a modelled, maximal muscle contraction. However, when muscle contractions were modelled using biologically relevant loading times for bullfrog jumps (50 ms), tendon stiffness actually maximized elastic energy storage. In contrast, grasshoppers, which are not time limited, exhibited spring stiffness that maximized elastic energy storage when modelled with a maximal muscle contraction. These findings demonstrate the significance of evolutionary variation in tendon and apodeme properties to realistic jumping contexts as well as the importance of considering the effect of muscle dynamics and behavioural constraints on energy storage in muscle-spring systems.

Take-off speed in jumping mantises depends on body size and a power-limited mechanism

Many insects such as fleas, froghoppers and grasshoppers use a catapult mechanism to jump, and a direct consequence of this is that their take-off velocities are independent of their mass. In contrast, insects such as mantises, caddis flies and bush crickets propel their jumps by direct muscle contractions. What constrains the jumping performance of insects that use this second mechanism? To answer this question, the jumping performance of the mantis Stagmomantis theophila was measured through all its developmental stages, from 5 mg first instar nymphs to 1200 mg adults. Older and heavier mantises have longer hind and middle legs and higher take-off velocities than younger and lighter mantises. The length of the propulsive hind and middle legs scaled approximately isometrically with body mass (exponent=0.29 and 0.32, respectively). The front legs, which do not contribute to propulsion, scaled with an exponent of 0.37. Take-off velocity increased with increasing body mass (exponent=0.12). Time to accelerate increased and maximum acceleration decreased, but the measured power that a given mass of jumping muscle produced remained constant throughout all stages. Mathematical models were used to distinguish between three possible limitations to the scaling relationships: first, an energy-limited model (which explains catapult jumpers); second, a power-limited model; and third, an acceleration -: limited model. Only the model limited by muscle power explained the experimental data. Therefore, the two biomechanical mechanisms impose different limitations on jumping: those involving direct muscle contractions (mantises) are constrained by muscle power, whereas those involving catapult mechanisms are constrained by muscle energy.

A buckling region in locust hindlegs contains resilin and absorbs energy when jumping or kicking goes wrong

If a hindleg of a locust slips during jumping, or misses its target during kicking, energy generated by the two extensor tibiae muscles is no longer expended in raising the body or striking a target. How, then, is the energy in a jump (4100-4800 μJ) or kick (1700 μJ) dissipated? A specialised buckling region found in the proximal hind-tibia where the bending moment is high, but not present in the other legs, buckled and allowed the distal part of the tibia to extend. In jumps when a hindleg slipped, it bent by a mean of 23±14 deg at a velocity of 13.4±9.5 deg ms(-1); in kicks that failed to contact a target it bent by 32±16 deg at a velocity of 32.9±9.5 deg ms(-1). It also buckled 8.5±4.0 deg at a rate of 0.063±0.005 deg ms(-1) when the tibia was prevented from flexing fully about the femur in preparation for both these movements. By experimentally buckling this region through 40 deg at velocities of 0.001-0.65 deg ms(-1), we showed that one hindleg could store about 870 μJ on bending, of which 210 μJ was dissipated back to the leg on release. A band of blue fluorescence was revealed at the buckling region under UV illumination that had the two key signatures of the elastic protein resilin. A group of campaniform sensilla 300 μm proximal to the buckling region responded to imposed buckling movements. The features of the buckling region show that it can act as a shock absorber as proposed previously when jumping and kicking movements go wrong.

The mechanics of azimuth control in jumping by froghopper insects

Many animals move so fast that there is no time for sensory feedback to correct possible errors. The biomechanics of the limbs participating in such movements appear to be configured to simplify neural control. To test this general principle, we analysed how froghopper insects control the azimuth direction of their rapid jumps, using high speed video of the natural movements and modelling to understand the mechanics of the hind legs. We show that froghoppers control azimuth by altering the initial orientation of the hind tibiae; their mean angle relative to the midline closely predicts the take-off azimuth. This applies to jumps powered by both hind legs, or by one hind leg. Modelling suggests that moving the two hind legs at different times relative to each other could also control azimuth, but measurements of natural jumping showed that the movements of the hind legs were synchronised to within 32 mus of each other. The maximum timing difference observed (67 micros) would only allow control of azimuth over 0.4 deg. to either side of the midline. Increasing the timing differences between the hind legs is also energetically inefficient because it decreases the energy available and causes losses of energy to body spin; froghoppers with just one hind leg spin six times faster than intact ones. Take-off velocities also fall. The mechanism of azimuth control results from the mechanics of the hind legs and the resulting force vectors of their tibiae. This enables froghoppers to have a simple transform between initial body position and motion trajectory, therefore potentially simplifying neural control.

The effect of leg length on jumping performance of short- and long-legged leafhopper insects

To assess the effect of leg length on jumping ability in small insects, the jumping movements and performance of a sub-family of leafhopper insects(Hemiptera, Auchenorrhyncha, Cicadellidae, Ulopinae) with short hind legs were analysed and compared with other long-legged cicadellids (Hemiptera,Auchenorrhyncha, Cicadellidae). Two species with the same jumping characteristics but distinctively different body shapes were analysed: Ulopa, which had an average body length of 3 mm and was squat, and Cephalelus, which had an average body length of 13 mm with an elongated body and head. In both, the hind legs were only 1.4 times longer than the front legs compared with 1.9–2.3 times in other cicadellid leafhoppers. When the length of the hind legs was normalised relative to the cube root of their body mass, their hind legs had a value of 1–1.1 compared with 1.6–2.3 in other cicadellids. The hind legs of Cephalelus were only 20% of the body length. The propulsion for a jump was delivered by rapid and synchronous rotation of the hind legs about their coxo-trochanteral joints in a three-phase movement, as revealed by high-speed sequences of images captured at rates of 5000 s–1. The hind tarsi were initially placed outside the lateral margins of the body and not apposed to each other beneath the body as in long-legged leafhoppers. The hind legs were accelerated in 1.5 ms (Ulopa) and 2 ms(Cephalelus) and thus more quickly than in the long-legged cicadellids. In their best jumps these movements propelled Ulopa to a take-off velocity of 2.3 m s–1 and Cephalelus to 2 m s–1, which matches that of the long-legged cicadellids. Both short-legged species had the same mean take-off angle of 56° but Cephalelus adopted a lower angle of the body relative to the ground(mean 15°) than Ulopa (mean 56°). Once airborne, Cephalelus pitched slowly and rolled quickly about its long axis and Ulopa rotated quickly about both axes. To achieve their best performances Ulopa expended 7 μJ of energy, generated a power output of 7 mW, and exerted a force of 6 mN; Cephalelus expended 23μJ of energy, generated a power output of 12 mW and exerted a force of 11 mN. There was no correlation between leg length and take-off velocity in the long- and short-legged species, but longer legged leafhoppers had longer take-off times and generated lower ground reaction forces than short-legged leafhoppers, possibly allowing the longer legged leafhoppers to jump from less stiff substrates.

Passive hinge forces in the feeding apparatus of Aplysia aid retraction during biting but not during swallowing

Swallowing and biting responses in the marine mollusk Aplysia are both mediated by a cyclical alternation of protraction and retraction movements of the grasping structure, the radula and underlying odontophore, within the feeding apparatus of the animal, the buccal mass. In vivo observations demonstrate that Aplysia biting is associated with strong protractions and rapid initial retractions, whereas Aplysia swallowing is associated with weaker protractions and slower initial retractions. During biting, the musculature joining the radula/odontophore to the buccal mass (termed the "hinge") is stretched more than in swallowing. To test the hypothesis that stretch of the hinge might contribute to rapid retractions observed in biting, we analyzed the hinge's passive properties. During biting, the hinge is stretched sufficiently to assist retraction. In contrast, during swallowing, the hinge is not stretched sufficiently for its passive forces to assist retraction, because the odontophore's anterior movement is smaller than during biting. A quantitative model demonstrated that steady-state passive forces were sufficient to generate the retraction movements observed during biting. Experimental measures of the relative magnitude of the hinge's active and passive forces at the protraction displacements of biting suggest that passive forces are at least a third of the total force.

The risk of nodal metastasis in early adenocarcinoma of the uterine cervix*

A functional and widely accepted definition of microinvasive cervical adenocarcinoma remains elusive. The purpose of this study was to determine at which depth of invasion the likelihood of lymph node metastasis or disease recurrence was so small that conservative surgery could be considered appropriate. Charts of patients with adenocarcinoma of the cervix (ACC) who underwent radical hysterectomy and pelvic lymphadenectomy (n = 98) at Indiana University Medical Center from 1987 to 1998 were retrospectively reviewed. Patients with stage IA1-IB1 lesions were included in the study. Patients treated with preoperative radiotherapy were excluded. Pathologic parameters evaluated included histologic type, depth of stromal invasion (DOI), and the presence of lymphatic vascular space invasion, or lymph node metastases. The patient median age was 39 years (20-65). The median time of follow-up was 30 months (4-124). Lymph node metastases were found in ten patients and 11 developed recurrences. The precise DOI could be measured in 84 patients. Of the 48 patients with cancers with a DOI </= 5 mm, none had involved parametria or nodes; whereas eight of the 36 with a DOI > 5 mm had nodal metastases (P = 0.00069). None of these 48 patients with a tumor DOI </= 5 mm developed a recurrence whereas six of the 36 patients with a tumor DOI > 5 mm developed recurrent disease (P = 0.0048). The risk of nodal metastases and recurrence is so low in patients with ACC and DOI </= 5 mm that for patients with such depth documented on conization with negative margins pelvic lymphadenectomy may be omitted.

The risk of nodal metastasis in early adenocarcinoma of the uterine cervix*

A functional and widely accepted definition of microinvasive cervical adenocarcinoma remains elusive. The purpose of this study was to determine at which depth of invasion the likelihood of lymph node metastasis or disease recurrence was so small that conservative surgery could be considered appropriate. Charts of patients with adenocarcinoma of the cervix (ACC) who underwent radical hysterectomy and pelvic lymphadenectomy (n = 98) at Indiana University Medical Center from 1987 to 1998 were retrospectively reviewed. Patients with stage IA1–IB1 lesions were included in the study. Patients treated with preoperative radiotherapy were excluded. Pathologic parameters evaluated included histologic type, depth of stromal invasion (DOI), and the presence of lymphatic vascular space invasion, or lymph node metastases. The patient median age was 39 years (20–65). The median time of follow-up was 30 months (4–124). Lymph node metastases were found in ten patients and 11 developed recurrences. The precise DOI could be measured in 84 patients. Of the 48 patients with cancers with a DOI ≤ 5 mm, none had involved parametria or nodes; whereas eight of the 36 with a DOI > 5 mm had nodal metastases (P = 0.00069). None of these 48 patients with a tumor DOI ≤ 5 mm developed a recurrence whereas six of the 36 patients with a tumor DOI > 5 mm developed recurrent disease (P = 0.0048). The risk of nodal metastases and recurrence is so low in patients with ACC and DOI ≤ 5 mm that for patients with such depth documented on conization with negative margins pelvic lymphadenectomy may be omitted.

Primary yolk sac tumor of the rectum

Extragonadal germ cell tumors are well recognized in men but have rarely been reported in women. Reports have primarily focused on the pediatric population and have suggested a poor prognosis for extragonadal yolk sac tumors. A 23-year-old woman with a yolk sac tumor arising in the rectum is described. A review of the English-language literature (MEDLINE 1966-1998) regarding extragonadal germ cell tumors in females is provided. Treatment with four courses of cisplatin, etoposide, and bleomycin was followed by surgical resection of the involved area. No residual tumor was identified. She remains disease free 3.5 years later. Previous reports are limited by the small number of patients, focus on the pediatric population, and treatment before the availability of cisplatin. Extragonadal germ cell tumors in women are extremely rare but can be successfully treated with aggressive chemotherapy and surgery similar to testis cancer.

Urine GABA levels in ovarian cancer patients: elevated GABA in malignancy

The association of malignancy with elevated diamine oxidase (DAO), an enzyme producing gamma-aminobutyric acid (GABA) is well documented. In ovarian cancer, increased DAO occurs in the malignant tissues and plasma. Since higher DAO levels cause GABA accumulation, elevated GABA may occur in ovarian cancer and be reflected in urine. We tested this hypothesis and found that half the ovarian cancer patients had a clearly elevated urine GABA, a result that is in agreement with previous reports on DAO and malignancy. The published findings on DAO, GABA and malignancy suggest that elevated GABA is associated with cancer. This proposal could lead to a GABA urine monitor or new directions in cancer treatment or research.

Phase I trial of paclitaxel and etoposide for recurrent ovarian carcinoma: a Gynecologic Oncology Group Study

A phase I study was performed to determine the maximum tolerated doses of intravenous etoposide and paclitaxel for women with previously treated persistent or recurrent ovarian cancer. Starting doses were paclitaxel 135 mg/m2 during 24 hours and etoposide 50 mg/m2/day for 3 consecutive days. The study was designed to escalate first the dose of etoposide, and then the dose of paclitaxel, in successive cohorts of patients. In an attempt to determine whether toxicity was affected by sequence of the drugs, the order of administration of the two drugs was reversed on alternate cycles. The starting doses of paclitaxel (135 mg/m2/24 hours) and etoposide (50 mg/m2/day x 3) caused severe neutropenia even with the addition of granulocyte colony-stimulating factor, and the trial was amended to administer the paclitaxel during 3 hours. However, this also proved too myelosuppressive without growth factor support. Twenty-one women were treated. A complete response was observed in one of nine patients with measurable disease, and a major decrease in CA-125 was noted in two patients who did not have measurable disease. Because of the severe myelosuppression observed in most patients, dose reduction was often required after the first cycle. The power to detect sequence-dependent variation in toxicity was minimal; however, no large differences were observed. A combination of the usual doses of these drugs will be difficult to administer in patients who have received previous chemotherapy for ovarian cancer.

Trisomy 21 associated with ovarian dysgerminoma

A 13-year-old G(0)P(0) white female with trisomy 21 presented with a complex pelvic mass. She underwent resection of the mass and complete staging for what was found to be a stage IIIC completely resected dysgerminoma. She was treated with three cycles of bleomycin, etoposide, and cisplatin chemotherapy and remains free of disease 1 year later. This association is presented as a rare case that may illustrate the relative increase in germ cell neoplasms in female patients with Down's syndrome. While the association of seminoma with Down's syndrome has been documented in a number of cases in males, the female counterpart of this tumor, dysgerminoma, in trisomy 21 has been reported quite infrequently. The potential for germ cell tumors in both male and female trisomy 21 is therefore illustrated.

Cancer-associated retinopathy in a patient with advanced epithelial ovarian carcinoma

BACKGROUND

Paraneoplastic phenomena, such as retinopathy, may herald an unsuspected gynecologic malignancy.

CASE

A 75-year-old woman presented to a neuro-ophthalmologist with abrupt onset of unilateral visual loss. A diagnosis of branch retinal artery occlusion was made and she was treated with aspirin. An echocardiogram subsequently revealed atrial dilation and she was placed on coumadin therapy. Her vision worsened and a cancer-associated retinopathy was entertained. A serum cancer-associated retinopathy antibody was detected; subsequent computed tomographies of the abdomen and pelvis revealed findings consistent with a primary ovarian carcinoma.

CONCLUSION

Patients with unexplained ophthalmologic symptoms may harbor an underlying gynecologic cancer.

Hormonal treatment of an endometrial stromal nodule followed by local excision

BACKGROUND

Endometrial stromal nodule is a rare subtype of endometrial stromal tumor. Although such nodules are benign, hysterectomy has been considered the treatment of choice, because evaluation of the margin is required for diagnosis. The similarity between low-grade stromal sarcoma and stromal nodule suggests that stromal nodules might respond to hormonal management.

CASE

Twenty-one-year-old nulligravida, diagnosed with endometrial stromal nodule, which decreased in size with leuprolide acetate treatment, underwent local excision of the tumor with preservation of reproductive function.

CONCLUSION

Hormonal therapy was successful in decreasing the size of this stromal nodule which allowed for conservative management.

Transforming growth factor-beta differentially inhibits epithelial ovarian carcinoma cells from primary and metastatic isolates without up-regulation of p21WAF1

BACKGROUND

Transforming growth factor-beta (TGF-beta) is known to inhibit primary epithelial ovarian carcinoma cells. The mechanism by which this inhibitory response is achieved is poorly understood. Furthermore, whether this response is consistent in cells from metastatic sites compared with the primary site cells is unknown. The authors wanted to determine whether TGF-beta differentially inhibited ovarian carcinoma cells from primary tumor sites compared with metastatic sites and to establish whether this response was associated with up-regulation of p21WAF1 or overexpression of p53.

METHODS

Tumor cells were purified from primary and metastatic sites in five patients with advanced epithelial ovarian carcinoma. TGF-beta effect at concentrations of 10, 1, and 0.1 ng/mL was determined by tritiated thymidine incorporation assay. Expression of p21WAF1 was determined by Northern and slot blot analysis. p53 was detected by immunocytochemistry.

RESULTS

Metastatic tumor isolates were more responsive to the inhibitory effect of TGF-beta compared with their corresponding primary tumor isolates at 0.1 ng/mL. Increasing TGF-beta concentration conferred no additional inhibitory effect on the metastatic isolates; however, a dose-related phenomenon was observed in primary tumor isolates. p21WAF1 mRNA was up-regulated in only 2 of 10 primary and metastatic isolates. There was no correlation between TGF-beta responsiveness, p21WAF1 up-regulation, and p53 overexpression.

CONCLUSIONS

Differential inhibition was observed between primary and metastatic tumor isolates. p21WAF1 up-regulation and p53 overexpression were not major modulators in TGF-beta regulation of primary and metastatic tumor growth in early passaged ovarian carcinoma cells.

Gynecologic cancers metastatic to the breast

BACKGROUND

We report a series of gynecologic cancers metastatic to the breast, illustrating the diagnostic and prognostic implications of this rare event.

STUDY DESIGN

By reviewing the gynecologic oncology data base, we identified 10 women with gynecologic cancer metastatic to the breast who were treated at Indiana University School of Medicine between August 1978 and February 1995. Medical records were reviewed for pertinent data concerning the presentation, evaluation, and treatment of the primary gynecologic malignancy and the metastatic breast tumor.

RESULTS

The mean patient age was 56.8 years (range, 30-80 years). The most common gynecologic malignancy was ovarian cancer (five patients), followed by cervical cancer (two patients) and cancers of the vagina, endometrium, or peritoneum (one patient each). A palpable solitary breast mass was found in 8 of 10 patients (80%), and the upper outer quadrant of the breast was the most common site of tumor involvement. One woman presented with examination findings resembling inflammatory breast cancer, and one patient presented with multiple firm subcutaneous nodules. Despite further treatment, which in all cases consisted of systemic chemotherapy, 83% of the patients died with a breast metastasis within 1 year of presentation.

CONCLUSIONS

Secondary breast malignancy should be suspected in any patient with a breast tumor and a known history of gynecologic cancer. A breast metastasis implies widespread tumor dissemination and a poor prognosis. Radical breast surgery should be avoided.

A prospective controlled trial of early postoperative oral intake following major abdominal gynecologic surgery

OBJECTIVE

The objective was to determine whether, when compared with traditional dietary advancement, early oral intake following major gynecologic surgery leads to a reduction in the length of hospitalization.

METHODS

Patients undergoing major abdominal gynecologic surgery were invited to participate in this study. After informed consent was obtained, they were randomized to one of two groups. The control group (group 1) was treated traditionally. Oral intake was initiated only after documentation of bowel function, which was defined by two of the following three criteria: (1) bowel sounds; (2) flatus or bowel movement; and (3) subjective hunger. Those assigned to the study group (group 2) were given a clear liquid diet on postoperative day 1. Once 500 cc was tolerated, a regular diet was given. Patients were evaluated on a daily basis for bowel sounds, flatus, bowel movement, hunger, nausea, vomiting, and need for nasogastric tube decompression. The groups were compared with regard to length of hospital stay, length of postoperative ileus, and incidence of adverse effects including nausea, vomiting, and postoperative complications. Statistical analyses were performed with the Student t and chi 2 tests.

RESULTS

The demographic characteristics of the control (N = 47) and study groups (N = 49) were similar, with no significant differences in underlying medical conditions, prior abdominal surgery, or diagnosis of a malignancy. The groups did not vary statistically in the number of subjects who required postoperative antiemetics or postoperative biscodyl suppository. There was a statistically significant reduction in the length of hospitalization for those patients on the early feeding regimen. The average length of stay for group 1 was 4.02 days +/- 0.30 (SEM), while that for group 2 was 3.12 days +/- 0.16 (P = 0.008). While there was a significantly higher incidence of emesis in the study population, this was not associated with any untoward outcome, and this group actually tolerated a solid diet nearly one full day earlier (2.72 days +/- 0.14 vs 1.88 days +/- 0.14, P < 0.0001).

CONCLUSIONS

Early postoperative oral intake results in a decreased length of hospitalization and is well tolerated when compared with traditional dietary management in patients undergoing abdominal surgery on a university gynecologic oncology service.

Increased thymidine kinase and thymidylate synthase activities in human epithelial ovarian carcinoma

BACKGROUND

Thymidylate synthase (dTMP synthase, EC 2.1.1.45) is responsible for the de novo biosynthesis of thymidylate (dTMP) whereas thymidine kinase (TdR kinase, EC 2.7.1.21) is the salvage enzyme which leads to the production of dTMP even in presence of d TMP synthase inhibition. The current study was undertaken to compare the steady-state activities of d TMP synthase and TdR kinase in extracts of human epithelial ovarian carcinoma and normal ovaries.

MATERIAL AND METHODS

Tissue extracts of epithelial ovarian carcinomas and normal ovaries were analyzed for activities of d TMP synthase (by a method that measures released 3H2O) and TdR kinase (by polyethyleneimine impregnated (PEI) cellulose plate radioassay), methods established in this laboratory.

RESULTS

The dTMP synthase activity (mean +/- S.E.) in extracts of ovarian carcinomas (N = 11) was 0.198 +/- 0.069 and in extracts of normal ovaries (N = 12) it was 0.025 +/- 0.0004 nmol/hr/mg protein. By contrast, TdR kinase activity in extracts of ovarian carcinoma (N = 13) was 27.7 +/- 8.5 compared to 1.0 +/- 0.3 nmol/hr/mg protein in extracts of normal ovaries (N = 15).

CONCLUSION

The observed 140-fold higher TdR kinase activity suggests that DNA synthesis may continue despite inhibition of dTMP synthase with current schedules of 5-fluorouracil (5-FU) and leucovorin. The addition of azidothymidine, a competitive inhibitor of TdR kinase, to 5-FU and leucovorin might be a rational biochemical strategy to employ in patients with refractory ovarian carcinoma.

Vulvar keratoacanthoma

BACKGROUND

Keratoacanthomas are neoplastic proliferations of keratinocytes thought to originate from follicular epithelium. There is only one previously reported case in which keratoacanthoma involved the vulva.

CASE

A 54-year-old woman presented with a nonulcerated vulvar lesion of approximately 1 month's duration. The lesion was 1 cm in diameter, located on the mid-right labium majus, with no surrounding induration or hyperkeratosis. The patient underwent wide local excision and the clinical-pathologic diagnosis was keratoacanthoma. After 2 years, she remains free of vulvar recurrence.

CONCLUSION

Because of similarities in clinical presentation and histology to squamous cell carcinoma, the diagnosis of keratoacanthoma can be challenging. History and physical examination findings should be correlated with the histologic diagnosis, with consideration for dermatopathology consultation.

Collagenase expression in ovarian cancer cell lines

BACKGROUND

There are several distinct forms of the matrix metalloproteinases (MMP) that degrade collagen in the extracellular matrix. Most involved in the metastatic process are collagenases exhibiting specificity for type IV collagen, the collagen that makes up the backbone of the basement membrane. We chose to examine the expression of one type IV collagenase, MMP-9, in several ovarian cancer cell lines.

METHODS

Under the influence of phorbol esters such as TPA, the fibrosarcoma cell line HT1080 is known to express MMP-9. We examined the effect of TPA on MMP-9 expression with Northern analysis, and on MMP-9 collagenase activity with polyacrylamide gel electrophoresis-zymography, in HT1080 cells (positive control) and in six ovarian cancer cell lines: Hey, HeyA8, CAOV3, PA-1, SKOV3, and OVCAR3. Cells were grown to 70% confluence and the growth medium was changed to a serum-free medium for 24 hr. Cells were then treated with 12 ng/mL TPA or its vehicle for an additional 24 hr. Medium was collected for PAGE-zymographic analysis. The cells were lysed and their RNA collected for Northern analysis.

RESULTS

PA-1, a teratocarcinoma, expressed more than 10-fold the amount of RNA for MMP-9 than the other lines following TPA treatment. Both Northern analysis and zymography showed that four of the six ovarian cell lines responded to TPA with increased collagenase expression and activity. The other two cell lines showed no MMP-9 activity either before or after TPA treatment.

CONCLUSIONS

These results suggest that ovarian cancer cell lines express collagenase and that this expression may be regulated by phorbol esters which activate the protein kinase C pathway.

A phase II Gynecologic Oncology Group trial of ifosfamide and mesna in advanced or recurrent adenocarcinoma of the endometrium

In other Gynecologic Oncology Group (GOG) studies, ifosfamide demonstrated antineoplastic activity against ovarian epithelial tumors, squamous carcinomas of the cervix, uterine sarcomas, and trophoblastic disease. Responses were also observed in 15% of patients with endometrial adenocarcinoma previously exposed to chemotherapy. This is a phase II trial of ifosfamide in patients with chemotherapy-naive advanced or recurrent endometrial adenocarcinoma. Thirty-seven patients with advanced adenocarcinoma of the endometrium recurrent after surgery and/or radiotherapy were treated with ifosfamide 1.2 g/m2 intravenously daily for 5 days every 4 weeks and mesna 300 mg/m2 intravenously every 4 hr for 3 doses daily for 5 days with each course. Three patients were ineligible--one due to a second primary, one did not have an endometrial primary, and the other because of wrong cell type. One patient was inevaluable for response; thus, 33 were evaluable for response. All patients had undergone hysterectomy and 24 had received radiotherapy before entering the trial. Eleven had GOG performance status of 0, 18 had a status of 1, and 4 had performance status of 2. Median age was 68 years (range, 41-86 years). Grade 3 or 4 neutropenia occurred in eight patients each and grade 3 thrombocytopenia was observed in one patient. One patient had a grade 4 neurotoxicity. Complete responses were observed in two patients (6.1%) and partial responses in six (18.2%) for an overall response rate of 24.3%. Ifosfamide in this dose and schedule is an active drug in the treatment of patients with advanced or recurrent adenocarcinoma of the endometrium.

Steroid cell tumor of the broad ligament arising in an accessory ovary

OBJECTIVE

To determine the histogenesis of an unusual steroid cell tumor that occurred in the broad ligament.

PATIENT AND METHODS

The tumor occurred in a 29-year-old woman who had evidence of virilization. The preoperative testosterone level was greater than 700 ng/dL, but it returned to normal after surgery. She was living and well without evidence of recurrent tumor 1 year after operation. The tumor was examined using light and electron microscopy and immunohistochemical stains.

RESULTS

The tumor was composed of polygonal cells with prominent eosinophilic cytoplasm. No significant nuclear atypia or mitotic activity was identified; however, the tumor was large, and necrosis and hemorrhage were identified on gross and microscopic examination. A graafian follicle and a primordial follicle were present at the periphery of the tumor within the connective tissue stroma in one section, providing evidence for the presence of an accessory ovary. A separate normal ovary was present on the same side. The tumor mass was connected to the surface of the eutopic ovary by thin membranous tissue.

CONCLUSION

To our knowledge, we report the first case in the modern literature of an extraovarian steroid cell tumor arising in the broad ligament, and we present evidence supporting its origin from an accessory ovary.

Pelvic exenteration for malignant melanomas of the vagina or urethra with over 3 mm of invasion

Pelvic exenteration has usually been employed as salvage treatment for gynecologic malignancies which have failed primary radiotherapy. The therapeutic mainstay for vulvar melanomas has become wide local excision with or without concurrent regional node dissection. Patients with primary melanoma of the vagina who undergo exenteration as primary therapy may experience 50% 5-year survival if the pelvic nodes are free of metastases. However, the overall 5-year survival for vaginal melanoma is 15%. In our patient population, there have been four patients with vaginal or urethral melanomas treated primarily with pelvic exenteration. The purpose of this study was to report that patients with vaginal or urethral melanomas over 3 mm in thickness may benefit from primary pelvic exenteration. Four patients underwent pelvic exenteration at Indiana University Medical Center for malignant melanoma of the vagina or urethra between 1986 and 1992. The pathologic specimens of all patients were analyzed for thickness, growth pattern, and nodal metastases. Patient age ranged from 50 to 71. Thickness of the melanomas ranged from > 3 to 12 mm. All four patients underwent exenterations, three total and one anterior. All patients had negative pelvic and inguinal nodes at the time of surgery. None of the patients has experienced a recurrence. Three of four patients are alive without evidence of disease at 31 to 97 months following their exenteration. One patient died postoperatively of cardiopulmonary complications. Patients with melanomas of the vagina and female urethra, greater than 3 mm in thickness, may benefit from primary pelvic exenteration.

Flow cytometric DNA analysis of extramammary Paget's disease of the vulva

Vulvar extramammary Paget's disease (EMPD) is an uncommon disease entity that occurs predominantly in postmenopausal white women. The clinical behavior of this neoplasm is extremely variable, reflecting the various histological patterns that have been reported with this lesion. Flow cytometry has been used as a method of obtaining prognostic information about a number of gynecological neoplasms, yet to date there have been no flow cytometric studies performed on this unusual neoplasm. We performed flow cytometric analysis of 14 cases of paraffin-embedded vulvar EMPD in patients ranging from 45 to 86 years of age. We correlated histological features and clinical recurrence risk with DNA analysis. Although we were unable to show a statistically significant correlation between DNA ploidy or S-phase and time to recurrence, we did show a statistically significant correlation between DNA ploidy and histological features. Aneuploidy appears to be associated with in situ sweat gland adenocarcinoma, invasive carcinoma, and lymphatic invasion. These results suggest that Paget's cells with aneuploid DNA stem lines may be associated with the potential for aggressive biologic behavior.

The fate of the ovaries after radical hysterectomy and ovarian transposition

To assess the effectiveness of lateral ovarian transposition in preserving normal ovarian function, the medical records of 200 consecutive women with stage I-IIA cervical cancer treated primarily with radical hysterectomy and pelvic lymphadenectomy were reviewed. Lateral ovarian transposition was performed at the time of radical hysterectomy in 132 (66%) patients and 28 (21%) received postoperative pelvic radiation therapy. Menopausal symptoms (vaginal dryness, hot flushes) and follicle-stimulating hormone (FSH) levels were used to define ovarian function. Only 3/104 (2.9%) patients who underwent lateral ovarian transposition without postoperative pelvic radiotherapy experienced menopausal symptoms; however, FSH levels in all three cases suggested continued ovarian function. In 14/28 (50%) patients who received postoperative pelvic radiation therapy ovarian failure occurred. The risk of ovarian failure with pelvic radiation therapy after lateral ovarian transposition was significant (RR = 17.3; 95% CI = 5.35-56.13). The incidence of adnexal disease in transposed ovaries requiring analgesics or further surgery was 3%. These data suggest minimal risk to the patient when the ovaries are conserved. Unfortunately, lateral ovarian transposition preserves ovarian function in only 50% of patients undergoing pelvic radiotherapy following radical hysterectomy.

Synergistic cytotoxic and antitumor effects of irradiation and taxol on human HeLa cervix carcinoma and mouse B16 melanoma cells

Several articles have appeared in the scientific literature which report that taxol has the ability to block and/or prolong cells in the G2/Mp phase of the cell cycle by inducing extremely stable microtubules. The G2/M phase is known to be the most radiosensitive phase of the cell cycle. It is the purpose of this study to evaluate the effect of combination taxol and ionizing radiation on tumor cell lines which have not been previously reported in the literature. Decrease in viability and inhibition of proliferation of HeLa and B16 cells induced by irradiation were dose-dependent and significantly enhanced by pretreatment the cells with taxol. Similar antitumor effects of irradiation and taxol were demonstrated by flow cytometric analysis of chromatic fragment formation induced in these cells. The exact mechanism by which taxol enhanced the tumoricidal effect of irradiation is not known. Cell cycle analysis showed that taxol was effective in blocking HeLa and B16 cells at the G2/M stage, at which the tumor cells are believed to be most sensitive to irradiation. This study is in agreement with others who have found that taxol is a powerful radiation sensitizer. Clinical research protocols have been developed and are under way to determine if taxol produces similar synergistic effects in patients undergoing radiation therapy.

Growing teratoma syndrome after chemotherapy for germ cell tumors of the ovary

BACKGROUND

The growing teratoma syndrome has been described with regard to gonadal and extragonadal germ cell neoplasms in males, but few cases have been reported in the female population. In this condition, masses that enlarge during or after chemotherapy are found to contain mature teratoma without malignant elements.

CASES

Three patients had either persistent or growing masses despite chemotherapy for germ cell malignancies of the ovary. All cases fit the description of the growing teratoma syndrome. The patients were aged 20-22 years. All three patients had immature teratomas before chemotherapy. The stages of disease ranged from Ia to IIIc. All patients had normal tumor markers while their masses showed growth or persistence. All were free of disease 6-31 months after diagnosis.

CONCLUSION

Growth or persistence of a tumor after chemotherapy for malignant teratoma does not necessarily imply progression of malignancy, especially if tumor markers are normal. However, these masses should be resected because they may cause obstruction, compression, or displacement of adjacent organs, or undergo sarcomatous degeneration.

Secondary therapy for epithelial ovarian cancer--1994

In women with recurrent epithelial ovarian cancer, secondary treatment options include surgery and chemotherapy. Surgery should be considered in patients with persistent disease at the time of second-look laparotomy and before chemotherapy in those whose disease recurs following long-term remission. With regard to secondary chemotherapy, active agents include cisplatin, carboplatin, ifosfamide, and paclitaxel. The effectiveness of hexamethylmelamine as salvage therapy is less clear, although it may be of use in patients who relapse soon after receiving primary platinum chemotherapy. Patients who receive platinum therapy initially and relapse after long periods of remission often respond to second-line platinum treatment. Ifosfamide may be effective in patients receiving one or two prior cisplatin-containing regimens, but is contraindicated in those with hepatic or renal insufficiency. Paclitaxel is the drug of choice for patients who have developed primary resistance to platinum therapy.

Epithelial ovarian cancer complicating renal transplantation

Patients taking immunosuppressive therapy are at substantial risk for malignant disease. We report two cases of epithelial ovarian cancer occurring in women after renal transplantation with subsequent poor clinical outcome. Clinicians are advised to thoroughly investigate adnexal masses in this patient population.

Chyloperitoneum following treatment for advanced gynecologic malignancies

BACKGROUND

Chyloperitoneum is an uncommon complication following retroperitoneal surgery. Blunt abdominal trauma, abdominal surgery, abdominal or pelvic radiation, cirrhosis, lymphoma, tuberculosis, and congenital defects of lacteal formation may also lead to chylous ascites.

CASES

Two patients developed chylous ascites after treatment for gynecologic malignancies. One, who also received pelvic and abdominal radiation, developed chylous ascites 11 months after retroperitoneal lymph node dissection for advanced endometrial cancer. She was treated with a diet low in fat and high in medium-chain triglycerides, as well as with intravenous hyperalimentation. She had recurrences of chylous ascites, which responded to paracentesis and intravenous hyperalimentation. The second patient developed chylous ascites 2 months after retroperitoneal lymph node dissection for advanced fallopian tube cancer. She was treated with a medium-chain triglyceride diet, which resulted in resolution of her symptoms.

CONCLUSION

Chyloperitoneum is an uncommon complication following treatment for gynecologic malignancies. Our second case is the first reported in which retroperitoneal lymph node dissection for gynecologic malignancy resulted in chyloperitoneum. However, because gynecologic malignancies frequently metastasize to the periaortic lymph nodes, chylous ascites may be an important cause of morbidity following treatment.

A phase II trial of ifosfamide and mesna in patients with advanced or recurrent mixed mesodermal tumors of the ovary previously treated with platinum-based chemotherapy: a Gynecologic Oncology Group study

A phase II trial of ifosfamide and mesna in women with mixed mesodermal tumors of the ovary who had previously received platinum-containing chemotherapy was conducted by the Gynecologic Oncology Group (GOG). The starting dose of ifosfamide was 1.2 g/m2 daily iv for 5 days. Mesna was given intravenously with and at 4 and 8 hr following the administration of ifosfamide. Each dose of mesna was 20% of the total daily dose of ifosfamide. Thirty-two patients were placed on the study; 31 were evaluable for toxicity and 28 for response. Twenty-seven patients (87.1%) had previously undergone surgery and three (9.3%) had received radiotherapy before this trial. GOG grade 3 or 4 granulocytopenia occurred in 11 (35.5%) patients, and one (3.2%) developed grade 4 thrombocytopenia. Two patients (6.4%) had grade 3 neurotoxicity. A complete response was observed in one patient (3.6%) and partial responses in four patients (14.3%) for a total response rate of 17.9% (95% confidence interval = 6.1-36.9%). In conclusion, ifosfamide has activity in previously mixed mesodermal tumors of the ovary.

Phase II study of ifosfamide and mesna in refractory adenocarcinoma of the endometrium. A Gynecologic Oncology Group study

BACKGROUND

Ifosfamide has antitumor activity in previously treated ovarian epithelial tumors, squamous carcinomas of the cervix, trophoblastic disease, and untreated uterine sarcomas in Gynecologic Oncology Group (GOG) trials. Because cyclophosphamide and other alkylating agents are known to produce responses in adenocarcinoma of the endometrium, a Phase II trial of ifosfamide and the uroprotector, mesna, was undertaken.

METHODS

Fifty-two patients with advanced adenocarcinoma of the endometrium recurrent after surgery and/or radiation therapy and refractory to first-line chemotherapeutic agents were treated with ifosfamide, 1.2 g/m2 intravenous daily for 5 days every 4 weeks, and mesna, 300 mg/m2 intravenous every 4 hours for 3 doses daily for 5 days. Two patients were ineligible--one due to prior therapy and one due to a second malignancy. Three patients had an inadequate trial, and 7 were inevaluable for response, leaving 47 patients evaluable for toxicity and 40 patients evaluable for response. Thirty-seven patients had undergone hysterectomy, 30 had received radiation therapy, and 32 had received prior cisplatin-based chemotherapy. All patients were GOG performance status 0, 1, or 2.

RESULTS

Complete responses were observed in three (7.5%) and partial responses in three patients (7.5%), for a response rate of 15% (95% confidence interval for the true response rate was 5.5%-29.8%). Severe (Grade 3 or 4) leukopenia and anemia were seen in 25 and 4 patients, respectively. Severe thrombocytopenia was observed in 7 patients. Five patients had Grade 3 or 4 neurotoxicity, and one had Grade 3 renal impairment. Reversible alopecia was universal.

CONCLUSIONS

This dose and schedule of ifosfamide and mesna is active in patients with adenocarcinoma of the endometrium failing platinum-based therapy. Phase II testing in untreated patients is under way.

Phase II trial of menogaril in patients with squamous carcinoma of the cervix: a Gynecologic Oncology Group study

A phase II trial of 200 mg/m2 menogaril was conducted by the Gynecologic Oncology Group (GOG) in women with advanced or recurrent squamous carcinoma of the cervix who had received no previous chemotherapy. Twenty-three patients were placed on the study; 22 are evaluable for toxicity and for response. One patient had incomplete data and was inevaluable. Nine patients (40.9%) had previously undergone surgery, and 21 (95.5%) had received radiotherapy before this trial. GOG grade 3 granulocytopenia occurred in 1 patient (4.5%) but none developed grade 3 or 4 thrombocytopenia. One patient (4.5%) had grade 3 gastrointestinal toxicity. Neither complete nor partial responses were observed in this trial, although 9 patients (40.9%) had stable disease lasting 2 months or more. Menogaril at this dose and schedule is inactive in advanced or recurrent squamous carcinoma of the cervix.

Vulvar melanoma reconsidered

BACKGROUND

Melanoma of the vulva has traditionally been treated with radical vulvectomy and bilateral inguinofemoral lymphadenectomy. Cutaneous nonvulvar melanoma has been successfully treated with local excision with selective therapeutic regional node dissection.

METHODS

A retrospective analysis of 16 patients with primary malignant melanoma of the vulva who underwent surgery from 1973 to 1988 at Indiana University Hospital was conducted. The purpose of this analysis was to determine if less radical surgery, such as that performed for cutaneous nonvulvar melanoma, might be adopted for patients with vulvar melanoma without compromising 5-year survival results.

RESULTS

Surgical therapy included radical vulvectomy with bilateral inguinofemoral lymphadenectomy (n = 11), radical vulvectomy alone (n = 1), and wide local excision (n = 4). Treated International Federation of Gynecology and Obstetrics (1971) stages included I (n = 12), II (n = 3), and III (n = 1). The median age of the patients was 59 years (range, 29-79 years). The median depth of invasion according to the Breslow method was 3 mm (range, 0.1-8 mm). Patients were observed for a median of 24 months (range, 3-143 months). The Kaplan-Meier 5-year survival estimate was 30%. There were nine recurrences: five distant, one central, one nodal, and two mixed. A median depth of 0.9 mm (range, 0.1-1.75 mm) was noted in those who remained disease-free versus 4.6 mm (range, 3-8 mm) in those who experienced a recurrence (P < 0.01). None of the patients with lesion depths of 1.75 mm or smaller experienced a recurrence, whereas all of those with lesion depths larger than 1.75 mm suffered a recurrence (P = 0.0004).

CONCLUSIONS

Patients with lesion depths of 1.75 mm or smaller may be treated with wide local excision. Patients with greater lesion depths are at high risk for the development of distant metastases. The patients with well-lateralized lesions may be equally well served with a less morbid procedure deferring therapeutic node dissection until there is a regional recurrence.

Blood transfusion and the risk of recurrence in squamous carcinoma of the vulva

OBJECTIVE

Our purpose was to determine if postoperative transfusion increases the risk of recurrence in patients who have undergone operation for squamous carcinoma of the vulva.

STUDY DESIGN

Data from 154 patients with squamous carcinoma of the vulva treated at Indiana University Medical Center from 1974 through 1988 were retrospectively analyzed to determine the influence of postoperative transfusion on recurrence risk. Patients were evaluated for International Federation of Gynecology and Obstetrics stage, lesion size, lesion depth, grade, patient age, number of transfusions, and recurrence with chi 2 analysis, Fisher's exact test, and the Student t test where appropriate.

RESULTS

Transfusions were given to 57 patients (37%) with a mean of 2.2 units delivered (range 1 to 5 units). Transfused patients differed significantly from those not transfused in that they had more advanced stage (p = 0.002), more positive nodes (p = 0.03), and higher grade lesions (p = 0.03), and they were older (p = 0.005). Recurrences developed in 25 patients (16.2%). Recurrences were more common in those with positive nodes (10-39, 25.6%) than in those with negative nodes (8/99, 8%), (p = 0.01). Only nodal status was predictive of recurrence in this series. Transfused patients had a 14% (8/57) rate of recurrence, whereas the recurrence risk was 17.5% (17/97) in those not transfused (p = 0.65).

CONCLUSIONS

We have been unable to confirm that postoperative transfusions increase the risk of recurrence in patients with squamous carcinoma of the vulva.

Phase II study of ifosfamide and mesna in nonsquamous carcinoma of the cervix: a Gynecologic Oncology Group study

A phase II trial of ifosfamide (IFX) and mesna was conducted by the GOG in patients with recurrent or advanced nonsquamous carcinoma of the cervix. A starting dose of 1.5 g/m2 IFX iv daily for 5 days and 300 mg/m2 mesna iv every 4 hr with three doses daily after IFX were given. In patients who had received prior radiotherapy or chemotherapy, the starting dose of IFX was reduced to 1.2 g/m2. Forty-six patients were entered, and 41 are evaluable for toxicity. Forty patients are evaluable for response. Age range was 30-72 yr. GOG performance status was 0-1 for all but 2 patients. Fifteen patients (37.5%) developed GOG grade 3 or 4 granulocytopenia, and 1 developed grade 4 thrombocytopenia. One patient developed transient renal insufficiency. There was one complete response and five partial responses (12.5%) for a response rate of 15.0%. Median response duration was 4.2 months (range, 1.7-22.6 months). Three responses were seen in areas with pelvic disease only. Three responses were observed in extrapelvic sites. IFX possesses activity which compares favorably with that of other agents in this disease.

Phase II trial of ifosfamide and mesna in patients with advanced or recurrent squamous carcinoma of the cervix who had never received chemotherapy: a Gynecologic Oncology Group study

OBJECTIVE

Our objective was to determine the activity of ifosfamide and mesna in women with advanced or recurrent squamous carcinoma of the cervix who had never received chemotherapy.

STUDY DESIGN

This is a phase II drug study in which the starting dose of ifosfamide was 1.5 gm/m2 daily intravenously for 5 days. The starting dose of ifosfamide was reduced to 1.2 gm/m2 daily in patients who had received prior radiotherapy. The uroprotector mesna was given intravenously with, and at 4 and 8 hours after, the administration of ifosfamide. Each dose of mesna was 20% of the total daily dose of ifosfamide.

RESULTS

Fifty-six patients were placed in the study; 52 were evaluable for toxicity and 51 for response. Twenty-eight (54.9%) patients had previously undergone surgery and 46 (90.2%) had received radiotherapy before this trial. Gynecologic Oncology Group grade 3 or 4 granulocytopenia occurred in 7 (13.5%) patients, and 2 (3.9%) had grade 3 thrombocytopenia. Six (11.5%) patients had grade 3 or 4 neurotoxicity. Complete response was observed in 2 (3.9%) patients and partial responses in 6 (11.5%) patients, for a total response rate of 15.7% (95% confidence interval 7.02% to 28.59%).

CONCLUSIONS

This response rate is higher than that reported by the Gynecologic Oncology Group in patients with previously treated squamous carcinoma of the cervix. Our findings fail to confirm that ifosfamide is a highly active agent in patients with squamous carcinoma of the cervix as reported by others; nonetheless, the observed activity of this drug deserves further study in combination therapy of squamous carcinoma of the cervix.

Gynecologic Oncology Group studies with ifosfamide

The Gynecologic Oncology Group has conducted a series of phase II studies with ifosfamide and mesna since 1985. Previously untreated patients received ifosfamide 1.5 g/m2 intravenously daily for 5 days. Mesna was given intravenously every 4 hours three times daily at 20% of the daily ifosfamide dose. Because of the toxic effects observed in previously treated patients with ovarian cancer, the ifosfamide dose was reduced to 1.2 g/m2/d in patients with prior chemotherapy or radiotherapy. In epithelial ovarian cancer, responses were observed in eight (20%) of 41 evaluable patients, with three (7%) complete responses. In patients with squamous carcinoma of the cervix, an 11.1% response rate (three of 27 patients) was observed in those who had received prior platinum therapy. In 51 previously untreated patients, the response rate was 15.7%. In nonsquamous cervical carcinomas, there were three partial responses among 25 patients (12%). An 8.6% response rate was observed among 23 patients with previously treated endometrial adenocarcinomas. In uterine sarcomas, response rates were 30.7% in mixed müllerian tumors, 17.2% in leiomyosarcomas, and 27.3% in endometrial stromal sarcomas. Patients with ovarian sarcomas responded in 27.8% of cases. Studies with ifosfamide combinations are currently under way by the Gynecologic Oncology Group.