Long-term impact of postoperative radiotherapy in carcinoma of the vulva FIGO I/II

PURPOSE

Between 1953 and 1978, postoperative radiotherapy was used as an adjuvant therapy for carcinoma of the vulva that had not been treated with radical vulvectomy. We evaluated long-term results and possible prognostic factors.

METHODS AND MATERIALS

Ninety-two patients were treated. Surgical procedures were simple vulvectomy, electrocoagulation, or local excision. Radiotherapy doses to the vulva ranged from 0 to 90 Gy. All patients received radiotherapy to the inguinal lymph nodes, ranging from 30 to 60 Gy. Thirty-year retrospective follow-up was done evaluating the records and statistical survival rates.

RESULTS

Five-year actuarial survival rates in T1 patients were 71% (77% cause-specific survival rate), for T2 patients 43% (48% cause-specific survival rate). The difference between T1 and T2 patients was significant (p < 0.05). Patients with tumors of the labia minora had a significantly higher survival rate than those with different sites affected. Doses of 45 Gy or more to the vulva were sufficient to increase the 5-year cause-specific survival rate from 55% to 88%. The results in three subgroups were analyzed, group 1 having received electrocoagulation, but no radiotherapy of the vulva; group 2, local excision and doses of 40 Gy to the vulva; group 3, local excision and doses of 60 Gy to the vulva. There was a significant effect on 10-year cause-specific survival rates: 48% in group 1, 11% in group 2, and 88% in group 3. In multivariate analysis, the significant independent factors were T classification, tumor sites and-with only marginal significance-radiation doses to the vulva.

CONCLUSIONS

The prognosis in early vulva carcinoma after nonradical surgery primarily depends on T classification and the site of the primary tumor. With univariate analyses, the dose has a significant effect on survival. In multivariate analyses the dose is a marginal independent factor in the whole group of patients. After nonradical surgery of early vulva carcinoma, the vulva should be irradiated resulting in better long-term survival.

A PCR-based approach to distinguish important Diadegma species (Hymenoptera: Ichneumonidae) associated with diamondback moth, Plutella xylostella (Lepidoptera: Plutellidae)

The diamondback moth, Plutella xylostella (Linnaeus) has a cosmopolitan distribution and is one of the major pests on cruciferous plants. Biological control, especially with species of the genus Diadegma, has been successfully employed in several parts of the world, mainly in South East Asia. The taxonomy of this genus based on classical morphological characters is still unclear and misidentifications are reported. In the present study seven Diadegma species associated with P. xylostella were separated using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analyses. The second internal transcribed spacer (ITS2) of the ribosomal DNA (rDNA) was successfully amplified in all 167 individuals and digested using 11 different restriction enzymes. One restriction enzyme (CfoI) showed different restriction profiles in all species and also between two population samples of D. mollipla (Holmgren) from eastern and southern Africa. In addition, a new Diadegma species associated with P. xylostella from Ethiopia was discovered.

A comprehensive influenza campaign in a managed care setting

Group Health Cooperative, a large, membership-governed, staff model health maintenance organization (HMO), has designed a comprehensive influenza campaign for identifying, recruiting and vaccinating enrollees at increased risk for influenza-related complications. The Cooperative's Centre for Health Promotion is responsible for the overall planning, implementation and evaluation of the influenza campaign. The model for delivering influenza immunizations has been designed to build on the strengths and capabilities of a staff model HMO with sophisticated automated information systems. The model permits area medical centres (AMCs) and physicians to use the materials and intervention strategies generated by the Centre for Health Promotion, while at the same time allowing them flexibility to design and use their own intervention strategies to increase compliance. More importantly, the model reduces resource requirements on AMCs and physicians to plan and maintain internal immunization efforts. Recommendations for improving the influenza campaign are discussed.

Awakening the sleeping giant: mainstreaming efforts to decrease tobacco use in an HMO

Group Health Cooperative (GHC) of Puget Sound is developing, within a framework of quality improvement, a comprehensive population-based approach to decreasing the prevalence of tobacco use. Broad organizational support has been obtained, centralized support is being integrated with clinic-level activity, local ownership of outcomes is encouraged with empowerment of health care teams, and support for community and policy-based activities is being provided. GHC's smoking prevalence has decreased from 25% to 15.5% over the past decade, while the state of Washington's prevalence declined from 23.7% to 21.8%.

Use of an automated pharmacy system and patient registries to recruit HMO enrollees for an influenza campaign

OBJECTIVE

To develop methods to identify, recruit, and vaccinate HMO enrollees at increased risk for influenza-related complications as part of a comprehensive influenza campaign.

SETTING

Group Health Cooperative (GHC) is a large, membership-governed, managed care organization that serves 395,000 members in the Puget Sound area.

APPROACH

An automated pharmacy system and patient data registries were used to identify enrollees with chronic illness. Enrollees with chronic illness and all enrollees 65 years of age and older were considered "high-risk" enrollees to be recruited for vaccination. Postcard reminders coupled with a publicity and education campaign were used to recruit high-risk enrollees to special influenza clinics.

RESULTS

Our approach identified 2.5% of children (persons < 18 years of age) and 10.5% of adults (persons 18 to 65 years of age) as chronically ill and thus at high risk for influenza-related complications. Most high-risk children were identified through prescriptions for steroids, autonomic inhalers, or both or because they were enrolled in the asthma registry. Most high-risk adults were identified because of prescriptions for steroids, insulin, or oral hypoglycemic agents; because they had received pneumococcal vaccine; or because they were enrolled in the diabetes registry. Influenza coverage rates for all seniors (persons > or = 65 years of age) increased from 34% in 1984 to more than 72% in the 1996-1997 campaign year. Coverage rates were much lower for high-risk children (36%) and adults (46%).

CONCLUSIONS

Influenza coverage rates can still be substantially improved for adults younger than 65 years of age and children at high risk for influenza-related complications.

Long-term results of radiotherapy alone for carcinoma of the vulva

From 1953 to 1978, definitive radiotherapy for carcinoma of the vulva without surgery was used as a standard therapy at a university hospital in Germany. We retrospectively reviewed the records of 170 patients treated mainly with electron-beam radiation to the vulva and Co-60 to the inguinal lymph nodes. Total doses to the vulva ranged from 6 to 90 Gy. A 30-year retrospective follow-up was accomplished. Tumor and node classification, tumor location, and parity were significant independent factors affecting survival. Actuarial survival was 52% for women with T1 disease, 25% for T2 disease, 10% for T3 tumors, and 0% for T4 tumors; survival with N0 tumors was 39% versus 13% with N2 lesions. Tumors of the labia minora were associated with a better survival rate (40.8% at 5 years) than were tumors at other locations (15%-21% at 5 years). Patients with zero to three children had significantly better results (32% at 5 years) than patients with four to seven children (11%). A dose of 60 Gy did not produce better long-term survival rates compared with lower doses, perhaps because low electron energy missed microscopic disease in deep vulvar tissues. On the basis of this review, patients with vulvar carcinoma should have at least a complete tumor resection. The therapeutic window between tumor control probability and the normal tissue complication rate in nonresected patients is too narrow: local recurrences are quite frequent with lower dose schedules, and survival rates are very poor, whereas complication rates are high with radical dose schedules that nevertheless provide acceptable cure rates.