The effects of centralisation of vascular surgical services in the Bath, Bristol and Weston area on the carotid endarterectomy pathway

Introduction Patients who experience a transient ischaemic attack are at the highest risk of having a subsequent stroke immediately after their symptoms. A carotid endarterectomy should be performed on symptomatic, surgically suitable patients who present with a greater than 50% North American Symptomatic Carotid Endarterectomy Trial stenosis of the internal carotid artery within 2 weeks of their symptoms. This study aimed to determine whether the effectiveness of the carotid endarterectomy pathway has been impacted by the centralisation of vascular surgical services in the Bath, Bristol and Weston area. Materials and Methods From October 2013 to October 2015, critical steps in the patient carotid endarterectomy pathway that vascular surgeons from the Royal United Hospital Bath, Bristol Royal Infirmary and North Bristol NHS Trust input into the Royal College of Surgeons National Vascular Registry were collected. The dates of patient's symptoms, referral, first scan, surgical team review and surgery were analysed. Results Carotid endarterectomy data was collected for 261 patients. Overall, no significant difference in median time (days) from symptom to surgery from precentralisation data compared with post-centralisation data was seen (P = .175), with 65% patients meeting the national target of symptom to surgery in less than 14days. Discussion and Conclusion Centralisation has not significantly impacted the overall efficiency of the carotid endarterectomy pathway. This study highlights areas where improvement across the vascular network is required. This includes addressing the 35% patients that are not currently meeting the 14-day target and standardising the provision of care to outlying communities. Further follow-up is required to assess the longer term effects of centralisation.

Abstract P6-11-02: Hospitalizations and costs during Implementation of a lay navigation program for older patients with breast cancer in the deep south

Background: Patient-centered strategies are needed to enhance the value of cancer care particularly at the end of life. Lay navigators (LN) can be trained to provide an extra layer of support for cancer patients from diagnosis through survivorship or end of life. We hypothesized that integrating LNs into the care team would reduce healthcare utilization and cost for patients with cancer, including those with breast cancer.

Methods: A prospective, observational study of Medicare claims data was conducted of beneficiaries ≥ 65 years old diagnosed with cancer after 2008 who received care within the UAB Health System Cancer Community Network (12 cancer centers of varying size located in AL, MS, TN, GA, and FL). The first breast cancer (BC) patient was enrolled in navigation in April 2013, and ∼18% of BC patients were navigated by the end of 2014. For this analysis, we report on the subset of patients with BC. The outcomes of interest were calculated per quarter from 2012-2014: (1) the proportion of patients with at least 1 hospitalization, (2) the proportion of the 492 deceased BC patients with a hospitalization in the last 30 and 14 days of life and (3) the Total costs for Medicare, excluding prescription drug costs. We used general linear models to evaluate changes in both health care utilization and cost over time, adjusting for age, sex, cancer stage, phase of care, and navigation group. Differential effects for navigated and non-navigated groups were tested with a group*time interaction. Healthcare utilization estimates are presented as Incidence Rate Ratios (IRR), and costs for Medicare as parameter estimates (β) in terms of dollar amounts.

Results: 4835 BC patients received care from 2012-2014: 622 received navigation services. 14.2 % of navigated BC patients were stage III/IV, compared to 9.33% of non-navigated patients. The proportion of hospitalizations trended downward from 7.9% in quarter 1 (Q1) 2012 to 5.7% in Q4 of 2014 (IRR 0.965, p =0.14), with similar decreases for navigated and non-navigated patients (IRR= 1.00, p > 0.05). Hospitalization in the last 30 days and last 14 days of life were 49.7% and 29.3%, respectively, with no between groups difference. Costs per beneficiary per quarter decreased overall from $4,161 in Q1 2012 to $3,010 in Q4 2014 (p <0.0001). In adjusted analysis, the navigated patients had an average $577 greater decline per quarter than the non-navigated patients (βNavigated=-$636; βnon-Navigated=-$59; p<0.0001).

Conclusions: Medicare costs declined during implementation of a lay navigation program, with greater reductions for navigated patients than non-navigated BC patients. Overall hospitalizations also declined, yet rates remain high for breast cancer patients at the end of life. Integration of LNs should be considered by health systems aiming to transition to value-based healthcare delivery.

The project described was supported by Grant Number 1C1CMS331023 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this abstract are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Citation Format: Rocque GB, Kvale EA, Jackson BE, Kenzik K, Lisovicz N, Demark-Wahnefried W, Meneses KM, Taylor RA, Acemgil A, Chambless C, Li Y, Martin M, Fouad M, Pisu M, Partridge EE. Hospitalizations and costs during Implementation of a lay navigation program for older patients with breast cancer in the deep south. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-11-02.

Molecular Mechanism Linking BRCA1 Dysfunction to High Grade Serous Epithelial Ovarian Cancers with Peritoneal Permeability and Ascites

Ovarian cancer constitutes the second most common gynecological cancer with a five-year survival rate of 40%. Among the various histotypes associated with hereditary ovarian cancer, high-grade serous epithelial ovarian carcinoma (HGSEOC) is the most predominant and women with inherited mutations in BRCA1 have a lifetime risk of 40-60%. HGSEOC is a challenge for clinical oncologists, due to late presentation of patient, diagnosis and high rate of relapse. Ovarian tumors have a wide range of clinical presentations including development of ascites as a result of deregulated endothelial function thereby causing increased vascular permeability of peritoneal vessels. The molecular mechanisms remain elusive. Studies have shown that fallopian tube cancers develop in women with BRCA1 gene mutations more often than previously suspected. Recent studies suggest that many primary peritoneal cancers and some high-grade serous epithelial ovarian carcinomas actually start in the fallopian tubes. In this article we have addressed the molecular pathway of a recently identified potential biomarker Ubc9 whose deregulated expression due to BRCA1 dysfunction can result in HGSEOC with peritoneal permeability and formation of ascites. We also discuss the role of downstream targets Caveolin-1 and Vascular Endothelial Growth Factor (VEGF) in the pathogenesis of ascites in ovarian carcinomas. Finally we hypothesize a signaling axis between Ubc9 over expression, loss of Caveolin-1 and induction of VEGF in BRCA1 mutant HGSEOC cells. We suggest that Ubc9-mediated stimulation of VEGF as a novel mechanism underlying ovarian cancer aggressiveness and ascites formation. Agents that target Ubc9 and VEGF signaling may represent a novel therapeutic strategy to impede peritoneal growth and spread of HGSEOC.

Predictors and Health Consequences of Epigenetic Changes Associated with Excess Body Weight in Women of Child-bearing Age

Background: Epigenetic alterations occurring during pregnancy have recently emerged as important factors for developmental programming of the fetus leading to obesity-related diseases in children. However, the role of excess body weight (EBW) in the modification of epigenetic patterns or its health consequences during child-bearing age is largely unknown. Because a lower degree of DNA methylation of long interspersed nucleotide element-1 (LINE-1) in PBMCs was shown to be associated with a higher risk of developing obesity-related diseases, for example cancer, the purpose of this study was to (1) evaluate the influence of indicators of obesity (BMI, WC, and % body fat) on PBMC LINE-1 methylation, (2) determine the predictors of PBMC LINE-1 methylation, and (3) determine the influence of PBMC LINE-1 methylation on biomarkers of obesity-related diseases.

Methods: The study population consisted of 470 child-bearing age women. We quantified the degree of PBMC LINE-1 methylation by pyrosequencing. Folate concentrations were measured using a microbiological assay. The degree of LINE-1 methylation (> median vs. ≤ median) was the dependent variable in logistic models that specified BMI (>25 vs. ≤ 25), WC (>88 cm vs. ≤ 88 cm), or % body fat (>33% vs. ≤ 33%) separately as the independent predictors of primary interest, adjusting for other relevant variables. The predictors and determinants of lower LINE-1 methylation were evaluated among women with EBW.

Results: Women with higher BMI, WC, or % body fat were 2.0, 1.9, and 1.8 times more likely to have lower LINE-1 methylation, respectively (P = 0.003, 0.005, and 0.01). The predictors and determinants of lower LINE-1 methylation yielded similar patterns with all three indicators of obesity. The following results are based on models run with BMI as the indicator for EBW. Women with higher plasma folate concentrations were less likely to have lower LINE-1 methylation (OR = 0.54, P = 0.0009). Higher LINE-1 methylation was associated with lower insulin resistance as indicated by HOMA (OR = 0.50, P = 0.02).

Conclusions: EBW-associated lower LINE-1 methylation in women of child-bearing age appears to have significant, and potentially transgenerational, health consequences. Higher folate status may exert beneficial effects on obesity-related health outcomes.

A qualitative study of exceptional survivors of cancer

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Background: An exceptional survivor of cancer is an individual who has outlived actuarial predictions for his/her particular form of cancer or experienced a complete regression. This pilot study was designed to determine if there were any biological, psychosocial, cultural or lifestyle characteristics exceptional survivors of cancer that can be measured and transferred through interventions to other cancer patients. Methods: The sample consisted of 21 survivors of cancer who were identified by oncologists at UAB as exceptional survivors. The study gathered qualitative data through semi-structured interviews and two validated scales measuring resilience, sense of coherence. A new cancer ‘catastrophizing’ scale based on the pain catastrophizing scale (PCS) was tested for its concordance with the two validated scales. The diagnosis and treatment information on these patients was collected through a questionnaire completed by the patient's oncologist. Results: Eight oncologists referred twenty-five patients to the study. Twenty-one patients agreed to participate. A unifying theme across all patient interviews was a deep spiritual connection with a supreme being. Praying for healing, intercessory prayer, and seeking guidance through faith with respect to best treatment options were common. The patients verbalized faith in physicians and were willing to seek more experimental treatments largely due to their spirituality. In general, the survivors were highly resilient as measured by the resilience scale and had a high sense of coherence as measured by the sense of coherence scale. They were also unlikely to conceptualize the diagnosis as a ‘catastrophe’ as measured by the new cancer catastrophizing scale. Conclusions: This study provides preliminary evidence of a relationship between spirituality and exceptional survivorship. Findings suggest exceptional survivors may be more willing to participate in clinical trials than other populations of cancer patients. Future studies should prospectively follow cancer patients to ascertain the temporal nature of the association between spirituality and exceptional survivorship.

No significant financial relationships to disclose.

BRCA1a has antitumor activity in TN breast, ovarian and prostate cancers

Breast cancer gene 1 (BRCA1) mutations predispose women to breast and ovarian cancers and men to increased risks for prostate cancer. We have previously showed BRCA1 splice variant BRCA1a/p110 to induce apoptosis of human breast cancer cells. In the current study, stable expression of BRCA1a/p110 resulted in inhibition of growth of estrogen receptor (ER)-positive and triple-negative (TN) human breast, ovarian, prostate and colon cancer cells and mouse fibroblast cells. Similar to wild-type BRCA1, only those cells with wild-type Rb were sensitive to BRCA1a-induced growth suppression and the status of p53 did not affect the ability of BRCA1a to suppress growth of tumor cells. BRCA1a also significantly inhibited tumor mass in nude mice bearing human CAL-51 TN breast cancer, ES-2 ovarian cancer and PC-3 prostate cancer xenografts. These results suggest that the majority of exon 11 sequences (residues 263-1365) are not required for the tumor suppressor function of BRCA1 proteins. This is the first report demonstrating antitumor activity of BRCA1a in human ER-positive and TN breast, hormone-independent ovarian and prostate cancer cells. Currently, there are no effective treatments against TN breast cancers and results from these studies will provide new treatments for one of the biggest needs in breast cancer research.

Outcomes for patients with fallopian tube carcinoma managed with adjuvant chemotherapy following primary surgery: a retrospective university experience

The aim is to evaluate disease-free (DFS) and overall survival (OS) of patients with fallopian tube carcinoma (FTCA) treated with adjuvant chemotherapy. An Institutional Review Board approved retrospective review identified 38 patients with FTCA that received adjuvant chemotherapy following primary surgery from 1975 to 2001. Median age was 56 (range 36-78) and 95% of patients were white. Twenty patients (53%) had FIGO stage III/IV FTCA. Seventeen patients underwent second-look laparotomy, 8 (47%) patients were found to have disease. Adjuvant chemotherapeutic regimens consisted of melphalan in 11 patients, platinum-based chemotherapy without paclitaxel in 17 patients, and the combination of paclitaxel and platinum in 10 patients. Although DFS was similar for the three chemotherapy cohorts (P= 0.19), patients receiving paclitaxel had superior OS compared to patients receiving either melphalan (P= 0.02) or platinum without paclitaxel (P= 0.04). Of the twenty patients with stage III/IV disease, 55% of patients had optimal cytoreduction performed at their initial surgery. Both median DFS, 68 versus 50 months (P= 0.14) and OS, 73 versus 50 months (P= 0.12) were greater in patients with optimal cytoreduction. When compared to historical chemotherapeutic regimens, the combination of paclitaxel and platinum has superior efficacy for the management of patients with FTCA. Although not statistically significant in our study, optimal cytoreduction likely improves both DFS and OS and should be the goal of all patients surgically managed for FTCA.

Primary appendiceal cancer: Gynecologic manifestations and treatment options

OBJECTIVE

To determine the presenting symptoms, gynecologic manifestations, and optimal intraoperative management of women with primary appendiceal cancer.

METHODS

A multi-institutional investigation was performed to identify female patients with primary appendiceal cancer who were treated from 1990 to present.

RESULTS

Forty-eight women with primary appendiceal cancer were identified from the tumor registries of participating institutions. The most common symptoms were abdominal pain (40%) and bloating (23%), but only 8% experienced rectal bleeding. Serum CEA was elevated (>2.5 U/ml) in 67% of patients, and serum Ca-125 was elevated (>35 U/ml) in 50% of patients. Thirty-one patients (65%) presented with a right adnexal or right lower quadrant mass and were operated on initially by a gynecologic oncologist. Ovarian involvement by metastatic appendiceal cancer was documented in 18 patients (38%). All of these patients underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and staging, but only 8 had a right hemicolectomy at the time of initial surgery. Forty-one patients (85%) presented with advanced stage appendiceal cancer (Stage III or IV) and 19 patients (46%) received postoperative chemotherapy, most commonly with a combination of 5-FU/Leukovorin. Following surgery, 22 patients (46%) experienced disease progression or recurrence, and 14 have died of disease. The most common sites of recurrence were abdominal or pelvic peritoneum (18), colon (2), and ovary (2). Patient survival was 70% at 2 years, and 60% at 5 years.

CONCLUSION

Women with primary appendiceal cancer frequently present with ovarian metastases, and initial surgical intervention is often performed by a gynecologic oncologist. All patients with mucinous epithelial ovarian cancer should undergo appendectomy at the time of surgical staging. The appendix should be examined intraoperatively, and if appendiceal carcinoma is identified, a right hemicolectomy and appropriate surgical staging should be considered.

Regulation of BMP-induced ectopic bone formation by Ahsg

alpha2-HS-glycoprotein (Ahsg), also known as fetuin is a serum and bone resident glycoprotein, which binds to TGF-beta superfamily members including bone morphogenetic proteins (BMP) and inhibits dexamethasone-induced osteogenesis in bone marrow cultures in vitro. Here we demonstrate that Ahsg reduces cytokine binding to its cognate receptor in HOS osteocyte cells and suppresses intracellular signaling, while in vivo, we test the hypothesis that Ahsg-deficient mice are hyper-responsive to BMP-induced osteogenesis. Human native BMP was implanted into the hindquarter muscles of Ahsg(+/+), Ahsg(+/-) and Ahsg(-/-) mice and 4 weeks later, ossicle formation was analyzed by radiography, bone density scanning (DEXA) and histomorphometry. Alkaline phosphatase (AP) activity was measured in ossicles as a marker for bone cell differentiation, and was significantly higher in Ahsg(-/-) versus Ahsg(+/-) and/or Ahsg(+/+) mice. Ectopic ossicle size in the Ahsg(+/-) mouse was 4-fold greater than that in the wild type (Ahsg(+/+)), and intermediate to that shown in Ahsg(-/-) mouse. Bone mineral density (BMD) was lower in the Ahsg(-/+) and Ahsg(-/-) mice compared to Ahsg(+/+) littermates. The ratio of cortical to cancellous bone was found to be >2-fold higher in Ahsg(-/-) mouse in comparison to the Ahsg(+/+) mice with no significant change in the Ahsg(-/+) mouse. Finally, a significantly higher incidence of satellite ossification; small islands of immature bone, was shown in Ahsg(-/-) mice as compared to Ahsg(+/+) mice. Although Ahsg binds to TGF-beta/BMP and blocks receptor signalling, it may also sequester cytokines in matrix, thereby acting as a reservoir of osteoinductive activity when released. This may explain the non-linear relationship between ectopic bone formation characteristics and Ahsg(+/+), Ahsg(+/-) and Ahsg(-/-) genotypes, although the increase in satellite bone formation might also explain this phenomenon. Our results suggest that Ahsg may be useful for prevention of the heterotopic ossification and the regulation of osteoinductive effects of BMP used with grafts.

Human papillomavirus triage of patients with atypical squamous cells of undetermined significance on cervical Papanicolaou smear

INTRODUCTION

The recent development of affordable human papillomavirus (HPV) testing has prompted consideration of its use as adjuvant and primary screening for cervical dysplasia. This review focuses on the use of HPV testing in triage management of atypical squamous cells of undetermined significance (ASC-US) Pap smears.

MATERIALS AND METHODS

A Medline search was performed for articles relevant to HPV testing as a triage strategy for ASC-US Paps. Key references from other papers that were not included in the search were also reviewed. Findings from the major randomised trials were then summarised.

RESULTS

Reflex HPV testing with hybrid capture is at least as effective and potentially cheaper than repeat cytology for evaluation of an ASC-US Pap. It also avoids 50% of colposcopies that would normally be performed if immediate colposcopy were done for all ASC-US Paps, while retaining excellent negative predictive value.

CONCLUSION

Reflex HPV testing using liquid-based cytology is the preferred management strategy for triage of ASC-US Paps.

The use of dimethylsulfoxide as a vehicle in cell culture experiments using ovarian carcinoma cell lines

Dimethylsulfoxide (DMSO) is a well-known solvent that is commonly used in the laboratory. We selected DMSO as the vehicle for an experiment designed to determine if several nonsteroidal anti-inflammatory agents inhibit the growth of Caov-3, OVCAR-3, and SK-OV-3 ovarian carcinoma cell lines. Using the tetrazolium conversion assay, however, we observed some variability in the number of cells present in each ovarian carcinoma cell line with varying concentrations of DMSO (10(-6)-10(-2) M) compared to medium alone. Similarly, when Caov-3, OVCAR-3, and SK-OV-3 cells were treated with 10(-4) M DMSO plus medium (Dulbecco's Modified Eagle Medium with 10% fetal bovine serum) and plated on coverslips, the total number of cells present in 60 random fields increased significantly (P < 0.0001) for each ovarian carcinoma cell line treated with DMSO compared to medium alone. Ethanol did not demonstrate such prominent effects on cellular growth. Our observations are important to consider when selecting an appropriate solvent, especially for growth inhibition studies using Caov-3, OVCAR-3, and SK-OV-3 cell lines.

Light-based imaging of green fluorescent protein-positive ovarian cancer xenografts during therapy

OBJECTIVE

The purpose of the study was to develop a sensitive, noninvasive imaging method for monitoring ovarian xenografts during therapeutic intervention.

METHODS

Human ovarian tumor cells (SKOV3.ip1) were infected with a replication-deficient adenoviral (Ad) vector encoding green fluorescent protein (GFP). The GFP-positive tumor cells were imaged in vitro and in vivo with a fluorescence stereomicroscope. Using appropriate filters, both GFP fluorescence and adriamycin were simultaneously detected. Nude mice implanted with GFP-positive cells were imaged repeatedly, in a noninvasive manner.

RESULTS

SKOV3.ip1 cells infected with Ad-GFP showed high GFP fluorescence, which was eliminated after treatment with adriamycin. Loss of GFP fluorescence was confirmed to be dead cells. For in vivo imaging, intraperitoneal tumors as small as 0.2 mm in diameter were detected externally. Adriamycin uptake was detected in tumors by in vivo imaging, and reduction in tumor size was concurrent with decrease in GFP fluorescence. These findings were confirmed at necropsy.

CONCLUSIONS

Fluorescence stereomicroscopy monitored the response of ovarian xenografts to adriamycin therapy. For the first time, GFP and adriamycin were imaged simultaneously.

Intraperitoneal radioimmunochemotherapy of ovarian cancer: a phase I study

A phase I trial was designed to examine the feasibility of combining interferon and Taxol with intraperitoneal radioimmunotherapy (177Lu-CC49). Patients with recurrent or persistent ovarian cancer confined to the abdominal cavity after first line therapy, Karnofsky performance status > 60, adequate liver, renal and hematologic function, and tumor that reacted with CC49 antibody were enrolled. Human recombinant alpha interferon (IFN) was administered as 4 subcutaneous injections of 3 x 10(6) U on alternate days beginning 5 days before RIT to increase the expression of the tumor-associated antigen, TAG-72. The addition of IFN increased hematologic toxicity such that the maximum tolerated dose (MTD) of the combination was 40 mCi/m2 compared to 177Lu-CC49 alone (45 mCi/m2). Taxol, which has radiosensitizing effects as well as antitumor activity against ovarian cancer, was given intraperitoneally (i.p.) 48 hrs before RIT. It was initiated at 25 mg/m2 and escalated at 25 mg/m2 increments to 100 mg/m2. Subsequent groups of patients were treated with IFN + 100 mg/m2 Taxol + escalating doses of 177Lu-CC49. Three or more patients were treated in each dose group and 34 patients were treated with the 3-agent combination. Therapy was well tolerated with the expected reversible hematologic toxicity. The MTD for 177Lu-CC49 was 40 mCi/m2 when given with IFN + 100 mg/m2 Taxol. Interferon increased the effective whole body half-time of radioactivity and the whole body radiation dose. Taxol did not have a significant effect on pharmacokinetic or dosimetry parameters. Four of 17 patients with CT measurable disease had a partial response (PR) and 4 of 27 patients with non-measurable disease have progression-free intervals of 18+, 21+, 21+, and 37+ months. The combination of intraperitoneal Taxol chemotherapy (100 mg/m2) with RIT using 177Lu-CC49 and interferon was well tolerated, with bone marrow suppression as the dose-limiting toxicity.

Immunohistochemical expression of molecular markers in an avian model: a potential model for preclinical evaluation of agents for ovarian cancer chemoprevention

OBJECTIVE

A significant obstacle confronting the evaluation of potential chemopreventive compounds in ovarian carcinoma is the absence of an animal model of spontaneous ovarian carcinogenesis. A potential model of adenocarcinoma has been described in the laying hen (Gallus domesticus). The purpose of this study was to evaluate the immunohistochemical expression of available antibodies that have been utilized in chemoprevention studies in this potential model of epithelial carcinoma.

METHODS

Two hundred 2-year-old hens were sacrificed at Auburn University in accordance with IUACUC guidelines. Of these hens, 8 animals were thought grossly to have ovarian carcinoma and ascites. The tumors from these 8 hens were fixed in neutral-buffered formalin and processed to paraffin blocks. Hematoxylin and eosin stains were used to document the histologic presence of adenocarcinoma. Immunohistochemical evaluation for expression of antigen was performed using the following antibodies: CA125, CEA, cytokeratin, EGFR, erbB-2, Ki-67, Lewis Y, p27, PCNA, Tag 72, TGF-alpha, Muc 1, and Muc 2.

RESULTS

Upon microscopic examination by a pathologist eight specimens were documented as adenocarcinomas. Several antibodies to antigens that are frequently expressed in human ovarian cancer were cross-reactive in the laying hen. Of these, cytokeratin AE1/AE3, pan cytokeratin, EGFR, Lewis Y, CEA, Tag 72, and erbB-2 stained the chicken carcinomas. EGFR and p185erbB-2 stained diffusely, and cytokeratin AE1/AE3, pan cytokeratin, Lewis Y, CEA, and Tag 72 were focally positive in the tumor. The aforementioned antibodies which have been useful as surrogate endpoints in chemoprevention trials and which also stained the chicken carcinomas included PCNA, p27, and TGF-alpha Antibodies that were not cross-reactive include CA 125, Ki-67, Muc 1, and Muc 2.

CONCLUSION

The data presented in this pilot study support the potential utility of an avian model of spontaneously arising adenocarcinoma in which to study chemopreventive agents. More importantly, the influence of chemoprevention protocols on the expression of relevant antigens can be determined using available antibodies that are cross-reactive in this model. Thus, changes in the phenotypic expression of surrogate endpoint biomarkers as identified by cross-reactive antibodies can aid in the development of chemoprevention trials for human ovarian cancer.

Statewide Tuskegee Alliance for clinical trials. A community coalition to enhance minority participation in medical research

BACKGROUND

Cancer mortality rates for all sites are nearly 2.5 times greater for African-Americans compared with whites. In addition, there are data implying that cancer treatment outcomes for minorities are unfavorable compared with whites. Whether this is due to poor access to health care or a biologic property of malignancies occurring in specific populations remains to be determined. Because of these unknown factors, targeting minorities for clinical trials may contribute toward the reduction of the overall morbidity and mortality associated with specific cancers.

METHODS

The current study describes the establishment of a genuine collaborative partnership between the targeted minority community and clinical investigators at the University of Alabama at Birmingham. This partnership was formed for the purpose of identifying strategies that would enhance the accrual and retention of minority participants into current and future cancer prevention and control trials. Focus groups and key informant interviews were conducted to ascertain the community's perception of participating in clinical trials.

RESULTS

The majority of focus group participants were unclear regarding the nature of clinical trials. Participants indicated that they would participate in research studies if they received adequate information regarding the purpose and benefits of the study, and if the charge came from a pastor or physician. Barriers to participation included time commitments, family obligations, whether blood was involved, and past experiences. The majority of the participants indicated that their knowledge of the Tuskegee Syphilis Study did not influence their decision to participate in research. A major outcome of the conference was the formation of the Statewide Tuskegee Alliance Coalition. The planning coalition decided to continue their efforts to work with communities and promote cancer awareness among minorities. After the conference, the coalition conducted several meetings and in July 1998, 1 year after the conference, the coalition selected a chair, co-chair, and a formal name for the organized group.

CONCLUSIONS

The planning, development, and implementation of this conference provided a valuable experience for researchers and community members. It was discovered that community involvement in the early phase of this project contributed to its success. Furthermore, the partnership that developed between researchers (academic institutions) and communities successfully provided an infrastructure that supported the interest of both groups.

Minority recruitment in clinical trials: a conference at Tuskegee, researchers and the community

PURPOSE

This article describes the planning, implementation, and evaluation of a 2-day conference designed to examine the factors related to the participation of African Americans in cancer clinical trials.

METHODS

Pre-conference formative evaluations (e.g., focus group discussions and key informant interviews with community leaders and health providers) were conducted in several rural and urban counties in the state of Alabama to determine African Americans' perceptions of participation in clinical research. The findings from these evaluations were used to develop a conference format and agenda. The 2-day conference included: (i) a pretest of African Americans' perceptions of cancer research, participation factors, and communication and recruitment issues; (ii) individual presentations high-lighting community leaders, church leaders, and researchers' perspectives regarding minority participation in research; (iii) working group discussions regarding the barriers and solutions to minority participation in research; and (iv) a posttest evaluation to measure changes in African Americans' perceptions of research.

RESULTS

Several recruitment barriers and solutions were identified and reported by the working groups. Comparisons of the pretest and posttest measures showed significant (p > .05) and favorable shifts in the areas of perceptions of cancer research, participation factors, communication issues, and recruitment issues. Participation in the conference reflected a positive change in attitudes on these measures. However, the theme, "barriers that contributed to nonparticipation," did not show any significant changes during the two testing periods. The most critical lesson that resulted from this conference was the need for researchers and community members to have open dialogue about participation in research.

CONCLUSIONS

This conference demonstrated that progress can be made when all parties are at the "table" and can be heard. In this model, community members proved to be valuable resources in providing researchers with information that was vital to the success of recruitment and retention studies and trials.

A patient presenting with a pelvic mass, elevated CA-125, and fever

BACKGROUND

Tuberculous peritonitis is a rare event which can mimic advanced stage ovarian cancer. A pelvic mass and an elevated CA-125 is suggestive of an ovarian malignancy; however, benign conditions may be discovered, especially in the premenopausal patient.

CASE

A patient with a pelvic mass, ascites, and an elevated CA-125 underwent an exploratory laparotomy for presumed ovarian cancer. Final pathology revealed pelvic tuberculosis without any pulmonary involvement. Acid-fast bacilli were confirmed with polymerase chain reaction in the surgical specimen.

DISCUSSION

Pelvic tuberculosis is an uncommon gynecologic condition that presents with ascites, a pelvic mass, and fever. An elevated CA-125 is not specific for ovarian malignancy.

African-American attitudes regarding cancer clinical trials and research studies: results from focus group methodology

Despite federal recommendations highlighting the need to include special population groups (mainly minorities and women) in clinical research, recruitment and retention of these groups present a great challenge to researchers. This paper describes a focus group study that was conducted to examine factors related to minority participation and retention in cancer clinical research studies. In 1996, the National Cancer Institute submitted a request for applicants to receive support for regional conferences. The purpose of the proposed conferences was to share current information and strategies to aid cancer clinical investigators in recruiting and retaining minority participants in clinical cancer research and to stimulate local/regional adaptations of these strategies. The University of Alabama at Birmingham (UAB), The University of Alabama, and Tuskegee University collaborated to respond to the request. Funding was granted by NCI for the regional conference in Alabama. The conference was held in Tuskegee, Alabama, the site of the infamous US Public Health Syphilis Study at Tuskegee. In planning for the conference, focus group sessions were conducted with African-American men and women who represented all regions of Alabama. The focus group information was used to identify important issues to be addressed at the conference.

American Joint Committee on Cancer prognostic factors consensus conference

BACKGROUND

The American Joint Committee on Cancer (AJCC) published the 1st edition of the Cancer Staging Manual in 1977 and began using T (tumor extent), N (regional lymph node status), and M (the presence or absence of distant metastasis) in an organized staging scheme to express the extent of disease in a number of cancer sites. The goal of this program has been to provide physicians and others with a useful methodology to plan treatment, project prognosis, and measure outcome end results. Until recent years, this system has incorporated only elements of anatomic extent of the tumors determined by clinical and pathologic methods. At the present time an increasing number of nonanatomic cancer prognostic factors are being identified and studied. Some of these factors currently are being used for outcome predictions and treatment decisions.

METHODS

To begin the process of identifying and validating these prognostic factors to refine the present TNM system, the AJCC convened a Prognostic Factors Consensus Conference to evaluate the roles of biologic, genetic, molecular, and other nonanatomic factors in staging cancer. Working groups were appointed for carcinomas of the breast, colorectum, prostate, and ovary and experts in each of these areas were invited to participate. Emphasis was placed on evaluating existing data and the correlation of these data with survival.

RESULTS

None of the groups believed that there were sufficient data at the present time to merit incorporation of serum markers into the TNM system for the four tumors under consideration, although this soon might become possible in prostate carcinoma after the evaluation of survival data from multiple institutions. Recommendations were made regarding the emerging sentinel lymph node technique, the need for an increased use of histopathology in the staging of breast and ovarian carcinomas, and the use of additional histologic staining techniques for the detection of "micrometastases" in lymph nodes. A number of additional recommendations were made for changes to the TNM system that did not involve serum markers and other nonanatomic cancer prognostic factors.

CONCLUSIONS

These recommendations are presented for the purpose of discussion and evaluation and do not yet represent formal proposals for a change in the AJCC TNM system of staging.

Surgical management of endometrial adenocarcinoma using laparoscopically assisted staging and treatment

BACKGROUND

Because of inaccuracies in clinical staging, endometrial adenocarcinoma is now a surgically staged disease. This study was done to determine the safety and efficacy of a laparoscopically assisted approach in the treatment and staging of this disease.

METHODS

Using a retrospective chart review, we identified demographic characteristics, mean blood loss, operative findings, and complications of patients who had laparoscopically assisted staging and treatment for endometrial carcinoma from 1992 to 1997.

RESULTS

Of 34 patients, 28 had laparoscopic surgical staging that included pelvic and para-aortic lymph node assessment, peritoneal washings, bilateral salpingo-oophorectomy, and total vaginal hysterectomy; 23 patients (82%) had stage I disease, 2 (7%) had stage II disease, and 3(11%) had stage III disease. Complications included herniation through a 5 mm port site, necessitating small bowel resection, and a fatal myocardial infarction 10 days postoperatively.

CONCLUSION

Laparoscopic staging and treatment of endometrial carcinoma is appropriate in a select group of patients.

Effects of an allatostatin and a myosuppressin on midgut carbohydrate enzyme activity in the cockroach Diploptera punctata

Neuropeptides of the cockroach allatostatin (AST) family are known for their ability to inhibit the production of juvenile hormone by the corpora allata of cockroaches. Since their discovery, they have also been shown to modulate myotropic activity in a range of insect species as well as to act as neurotransmitters in Crustaceans and possibly in insects. The midgut of cockroaches contains numerous endocrine cells, some of which produce AST whereas others produce the FMRFamide-related peptide, leucomyosuppressin (LMS). We have determined if ASTs and LMS are also able to influence carbohydrate-metabolizing enzyme activity in the midgut of the cockroach, Diploptera punctata. Dippu-AST 7 stimulates activity of both invertase and alpha-amylase in a dose-dependent fashion in the lumen contents of ligatured midguts in vitro, but not in midgut tissue, whereas the AST analog AST(b)phi2, a cyclopropyl-ala, hydrocinnamic acid analog of Dippu-AST 6, has no effect. Leucomyosuppressin also stimulates enzyme activity in lumen contents only, although the EC50 is considerably greater than for Dippu-AST. Dippu-AST is also able to inhibit proctolin-induced contractions of midgut muscle, and this action had already been described for LMS [18]. Thus, in this organ, AST and LMS have at least two distinct physiological effects.

Epithelial ovarian cancer: prevention, diagnosis, and treatment

The leading cause of death from gynecologic malignancies in the United States is epithelial ovarian cancer. The significant risk factor for development of ovarian cancer is advancing age, although there is clearly a genetic predisposition--often associated with the BRCA1 and BRCA2 genes--in at least 5% to 10% of all epithelial ovarian cancers. Oral contraceptives are known to reduce the risk for development of ovarian cancer and should be considered as a method of birth control in women at increased risk. Currently, there is no acceptable method of screening for this disease, although measurement of CA-125 level and transvaginal ultrasound have been utilized. Ovarian cancer is a surgically staged disease. In apparent early-stage disease, complete surgical staging is critical for the selection of adjunctive therapy. In advanced-stage disease, the goal is primary cytoreduction. Standard postoperative therapy for advanced-stage ovarian cancer includes platinum-based chemotherapy with the substitution of paclitaxel for cyclophosphamide occurring in the last decade. Despite these advances in chemotherapy, ovarian cancer continues to be fatal in far too many cases.

A comparison of treatment strategies for endometrial adenocarcinoma: analysis of financial impact

OBJECTIVE

The aim of this study was to investigate the influence of three treatment strategies for adenocarcinoma of the endometrium on the utilization of adjuvant radiation therapy and the medical charges associated with each pattern of practice.

METHODS

Three clinical algorithms felt to represent practice patterns for patients with endometrial cancer were considered: (1) comprehensive surgical staging of all patients, with adjuvant pelvic radiation reserved for documented cases of extrauterine disease, (2) total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH/BSO) with lymph node dissection reserved for cases of myometrial invasion, followed by adjuvant radiation based on the presence of uterine risk factors, and (3) TAH/BSO followed by intraoperative pathologic assessment of the uterus and consultation with a "surgical" oncologist for comprehensive staging. Each algorithm was applied to a cohort of 190 surgically staged patients identified through a retrospective medical records review. The use of radiation in each algorithm was quantified and the associated financial impact was estimated using hospital charges.

RESULTS

Treatment algorithm 1 yielded the lowest charges per patient at $12,778.52. Treatment algorithms 2 and 3 had associated charges per patient of $15,997.02 and $17,343.44, respectively.

CONCLUSION

Approaches to care that lead to cost-effective utilization of health care resources should be pursued.

A phase I study of paclitaxel, doxorubicin, and cisplatin in patients with previously untreated epithelial ovarian cancer

OBJECTIVE

Although doxorubicin is not currently popular as a primary agent in ovarian cancer, overviews of previous studies suggest that the inclusion of doxorubicin may have improved outcome. The purpose of this phase I study was to determine the maximal dose of doxorubicin that could be added to standard doses of paclitaxel and cisplatin with G-CSF support.

METHODS

Women with FIGO stage III or IV epithelial ovarian cancer were primarily treated with escalating doses of doxorubicin in combination with paclitaxel (135 mg/m2 over 24 h) and cisplatin (75 mg/m2) every 3 weeks. Doxorubicin was started at 30 mg/m2 and escalated by 10 mg/m2 per treatment level. All patients received G-CSF support.

RESULTS

Eleven patients were treated at two dose levels. Dose limiting toxicity (DLT) was reached at the 40 mg/m2 dose of doxorubicin. All patients experienced grade 4 neutropenia although none required hospitalization. DLT included renal toxicity and prolonged thrombocytopenia. Despite vigorous antiemetic regimens 60% of patients experienced severe nausea and vomiting. Nine patients were assessable for response. Eight patients have had a complete clinical response (89%). Of the five patients undergoing second-look laparotomy two were negative.

CONCLUSIONS

The maximum tolerated dose of doxorubicin in this three-drug regimen is 30 mg/m2 with standard doses of paclitaxel and cisplatin. Hematologic toxicity is manageable using G-CSF. Doxorubicin appears to increase the renal toxicity of cisplatin which may be exaggerated by marked nausea and vomiting. This is an active but toxic regimen and alternative sequences and strategies should be evaluated.

The National Cancer Data Base: ten years of growth and commitment

The National Cancer Data Base (NCDB), now 10 years old, was created to provide a resource for assessing patient care and outcomes nationally and to circulate this information to the medical community. Dr. Partridge says the NCDB clearly has succeeded in fulfilling this and other goals and can be expected to continue to be an important source for evaluating patterns of cancer care in the United States.

Response to salvage treatment in recurrent ovarian cancer treated initially with paclitaxel and platinum-based combination regimens

OBJECTIVE

The aim of this study was to evaluate the response to salvage treatment in recurrent ovarian cancer treated initially with paclitaxel-based chemotherapy.

METHODS

A retrospective review of patients with recurrent ovarian cancer treated with surgical debulking and paclitaxel-based chemotherapy was performed. All cases received second-line treatment with a response evaluated by clinical or surgical means. Data analysis was conducted using the SAS statistical package.

RESULTS

Fifty cases of advanced stage disease were available for review. Patients received paclitaxel and cisplatin or carboplatin with a 72.0% response rate. The median time to recurrence after primary treatment was 6 months. Second-line treatment included cisplatin or carboplatin (50%), Taxol (10%), or lutetium (22%), an intraperitoneal radiolabeled monoclonal antibody targeted to TAG-72. A 52.0% clinical response to salvage treatment was detected. With a median follow-up of 7 months, 68.0% of patients had experienced recurrence or progression of their disease. The median time to second recurrence was 5 months. Cases sensitive to initial paclitaxel-containing chemotherapy responded to any of the salvage treatments more frequently than chemotherapy-resistant tumors (88.5% versus 11.5%, P < 0.05).

CONCLUSIONS

Recurrent ovarian cancer patients initially treated with paclitaxel-based chemotherapy frequently responded to salvage treatment. However, the duration of response was brief, and hospitalization for treatment-related side-effects was common. Tumor response to initial paclitaxel/platinum treatment was predictive of future response to second-line agents. Current salvage therapies appear to provide little benefit in cases of tumors resistant to primary chemotherapy.

Cancer incidence among predominantly black, rural-poor populations in southern states

BACKGROUND

A seven-county, predominantly black, rural-poor population in Alabama is targeted for a program aimed at improving access to state-of-the-art cancer care. This paper presents combined age-adjusted cancer incidence rates for predominantly black, rural counties in North Carolina and Georgia similar to the Alabama counties and compares these rates with Surveillance, Epidemiology, and End Results (SEER) incidence rates.

METHODS

Cancer incidence data from 1990 to 1993 were obtained from the Georgia Center for Cancer Statistics for 10 rural counties with predominantly black populations. Likewise, cancer incidence data from 1990 to 1993 were obtained for seven rural-poor counties in North Carolina from the North Carolina Central Cancer Registry. SEER incidence rates from 1990 to 1992 were obtained for nine SEER sites.

RESULTS

The overall cancer incidence rate from North Carolina and Georgia is lower by 22% than the SEER rate. Cancer incidence rates for cancers of the breast, colon/rectum, lung, and prostate were at least 15% lower than the SEER rates, while the invasive cervical cancer rate was 1.78 times higher than the SEER rate.

CONCLUSION

Blacks comprise about 50% of the population in these counties. In contrast, the SEER population is predominantly white, and the black population is primarily urban. Estimates of the number of cancer cases in black, rural-poor populations based on SEER incidence rates is not reflective of the cancer experience in these populations.

Rectal immunization for induction of specific antibody in the genital tract of women

The purpose of the current study was to examine potential routes of vaccine administration for the induction of antigen-specific responses in the genital tract of women. Sixteen women were enrolled in this study, and the level of influenza-specific antibodies induced in the genital tract was measured after rectal or intramuscular immunizations. Both methods of administration induced significant increases in the concentration of flu-specific IgA found in cervical secretions within 28 days after vaccination. Initially flu-specific IgG antibodies were not induced in the genital tract by either route. As expected both IgA and IgG flu-specific antibodies were dramatically increased in serum after intramuscular vaccination. In contrast, rectal administration did not induce significant IgA responses, and only small flu-specific IgG increases in serum. Six months after administration, IgA flu-specific antibody concentrations were significantly higher than baseline levels in vaginal secretions and saliva isolated from both subject groups and flu-specific IgG concentrations in cervical secretions were high in the rectal immunization group. The long-term presence of both IgG and IgA antibody in genital secretions suggests that rectal immunization may be an effective method for induction of immune protection in the genital tract of women.

Intraperitoneal radioimmunotherapy of ovarian cancer with 177Lu-CC49: a phase I/II study

BACKGROUND

Twenty-seven ovarian cancer patients who failed chemotherapy entered a phase I/II trial of intraperitoneal 177Lu-CC49 antibody.

METHODS

Patients had disease confined to the abdominal cavity +/- retroperitoneal lymph nodes, adequate organ function, and no previous radiation.

RESULTS

The most common side effects were delayed, transient arthralgia (10/27) and marrow suppression with 1.665 GBq/m2 (45 mCi/m2), which was considered the maximum tolerated dose. One of thirteen patients with gross disease had >50% tumor reduction after therapy, whereas most others with gross disease progressed (one went off study with stable disease at 11 weeks). Seven of nine patients with <1-cm nodules progressed in < or =21 months, and two of nine remain without evidence of disease at 4 to 5 months. Of patients with microscopic or occult disease, one relapsed at 10 months and four of five remain without evidence of disease at >6 to 35 months.

CONCLUSIONS

Marrow suppression was the dose-limiting toxic effect of intraperitoneal immunotherapy with 177Lu-CC49. Antitumor effects were noted against chemotherapy-resistant ovarian cancer, even at lower dose levels, and resulted in prolonged disease-free survival of most patients with microscopic disease. This form of treatment deserves further study.

Comparison of combination therapy with paclitaxel and cisplatin versus cyclophosphamide and cisplatin in patients with suboptimal stage III and stage IV ovarian cancer: a Gynecologic Oncology Group study

This prospective study compared the combination of paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) and cisplatin with the standard therapy of cyclophosphamide/cisplatin in women with suboptimal stage III and stage IV ovarian cancer. Of the initial 410 women who presented with advanced disease and greater than 1 cm residual masses after initial surgery, 386 met all eligibility criteria and were randomly assigned to receive a regimen of cisplatin 75 mg/m2 and cyclophosphamide 750 mg/m2 or cisplatin 75 mg/m2 and paclitaxel 135 mg/m2 delivered over 24 hours. Dosage reductions were permitted in the event of significant toxicity. Among 216 patients with measurable disease, responses were reported in 73% of those receiving cisplatin/paclitaxel and in 60% of those receiving cisplatin/cyclophosphamide. Median progression-free survival was significantly longer (P < .001) in the group treated with cisplatin/paclitaxel, compared with those receiving cisplatin/cyclophosphamide (17.9 v 12.9 months, respectively).

The effects of the PDQ patient information file (PIF) on patients' knowledge, enrollment in clinical trials, and satisfaction

BACKGROUND

This study examined the outcomes of providing a copy of the PDQ Patient Information File (PIF) to cancer patients.

METHODS

Patients with cervical, endometrial, and ovarian cancers were randomized to two groups: 1) verbal communication only and 2) verbal communication plus PIF. Cancer knowledge and satisfaction with the PIF and the information received were assessed with telephone interviews. Clinical trial registries were reviewed to determine enrollment in clinical trials.

RESULTS

The overall reaction to the PIF was good or excellent for 92% of the patients surveyed, but there was no significant difference between the two groups in their cancer knowledge, enrollment in clinical trials, or satisfaction with the information they received from their physicians. The majority of patients from both groups lacked basic knowledge about their disease, did not use any source of information other than their physicians and/or nurses, and were satisfied with the information they received.

CONCLUSIONS

Patients appreciate receiving written cancer information, although it may not increase their cancer knowledge.

The National Cancer Data Base report on ovarian cancer treatment in United States hospitals

BACKGROUND

Epithelial ovarian cancer continues to challenge clinicians. There is no accepted method of screening for ovarian cancer, and most patients present with advanced disease. In spite of advances in surgery and chemotherapy, survival continues to be poor.

METHODS

The data, comprising the ovarian cancer caseloads of 940 hospitals, are from the National Cancer Data Base. The 15,254 patients, diagnosed in 1988 or 1993, had no prior cancer diagnosis.

RESULTS

Data quality had improved by 1993; 89.4% of the records included American Joint Committee on Cancer (AJCC) staging information in 1993, compared with 67.9% in 1988. Borderline epithelial tumors and germ cell tumors were most commonly found in younger women and were more likely to be diagnosed at Stage I. The percentage of women with carcinoma treated only with surgery increased substantially by 1993. Relative survival decreased with increasing tumor stage or grade. Five-year survival was considerably lower for women with carcinoma (38%) than for women with either borderline carcinoma (95%) or germ cell tumors (86%). The addition of chemotherapy to the treatment of Stage I carcinoma did not improve outcome, nor was dramatic improvement in survival brought about by the addition of chemotherapy to the treatment of Stage II and III low grade disease. Chemotherapy was beneficial to patients with Stage II or III disease, Grade 3 or 4, and Stage IV disease.

CONCLUSIONS

Most women with epithelial ovarian cancers continue to present with advanced disease. No improvements in early detection were apparent in the reference years studied. The benefits of the addition of chemotherapy to the treatment of this disease were most obvious in patients with Stage II and III disease, Grade 3 or 4, and those with Stage IV disease. These benefits were less clear in early stage disease. However, there continues to be significant room for improvement in the diagnosis and treatment of this disease.

Cyclophosphamide and cisplatin versus paclitaxel and cisplatin: a phase III randomized trial in patients with suboptimal stage III/IV ovarian cancer (from the Gynecologic Oncology Group)

Administration of an alkylating agent plus a platinum coordination complex is standard therapy for advanced epithelial ovarian cancer in the United States. The most commonly used combination is cyclophosphamide/ cisplatin; however, the benefit of this combination in overall survival has not been compelling. We report a prospective comparison of this regimen versus a combination of cisplatin with paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ), a new and well-tolerated agent with documented activity in cisplatin-refractory ovarian cancer. Three hundred eighty-six patients with advanced ovarian cancer and greater than 1 cm residual masses following initial surgery were randomly assigned to receive a regimen of cisplatin (75 mg/m2) and cyclophosphamide (750 mg/m2), or cisplatin (75 mg/m2) and paclitaxel (135 mg/m2), delivered over 24 hours. Dose reductions in cyclophosphamide or paclitaxel were permitted for significant toxicity. In 216 patients with measurable disease, responses were reported in 73% of those randomized to the cisplatin/paclitaxel arm and in 60% randomized to the cisplatin/cyclophosphamide arm. Progression-free survival was significantly longer (P < .001) with cisplatin/paclitaxel (median, 12.9 v 17.9 months). Overall survival was also significantly longer (P < .001) with cisplatin/paclitaxel (median, 37.5 v 24.4 months). Incorporating paclitaxel into first-line therapy for patients with suboptimally debulked stage III and stage IV ovarian cancer can increase the duration of the progression-free interval and extend overall survival while maintaining an acceptable toxicity profile.

Treatment of cervical dysplasia with large loop excision of the transformation zone: is endocervical curettage necessary?

Endocervical curettage (ECC) is done during most colposcopic examinations. To evaluate the need for routine ECC, we reviewed the records of all new patients seen in the colposcopy clinic at our institution from July 15, 1992, to April 15, 1993. During the study period, ECC was done in 341 patients with an adequate colposcopy. Only one case of mild dysplasia was discovered after ECC in the 123 patients referred for evaluation of cervical intraepithelial neoplasia (CIN) I or atypia seen on Pap smear. ECC specimens were positive for dysplastic cells in only 3 of 203 patients (1.4%) in whom biopsy revealed CIN I or atypia, and Pap smears for all 3 patients were suggestive of more severe lesions. Routine ECC during the initial colposcopic examination adds expense and may cause significant patient discomfort. ECC can be safely omitted in patients with CIN I on referral Pap smear and before large loop excision of the transformation zone for treatment of more severe lesions.

Intraperitoneal radioimmunotherapy of ovarian cancer with lutetium-177-CC49

Twelve ovarian cancer patients who failed chemotherapy entered a Phase I trial of intraperitoneal 177Lu-CC49 antibody.

METHODS

Patients had disease confined to the abdominal cavity +/- retroperitoneal lymph nodes, adequate organ function and no previous radiation.

RESULTS

Side effects included mild discomfort with administration (1/12), delayed transient arthralgia (2/12), and mild marrow suppression (calculated marrow doses of 11-54 cGy). The maximum tolerated dose has not been reached with levels of 10, 18, 25 and 30 mCi/m2. Radioimmunoscintigraphy revealed localization consistent with tumor in 11 of 12 patients. One of eight patients with gross disease had > 50% tumor reduction after therapy, while six progressed and one went off study with stable disease. Of patients with microscopic or occult disease, one relapsed at 10 mo and three remain without evidence of disease after 18 mo.

CONCLUSION

Intraperitoneal radioimmunotherapy with 177Lu-CC49 is well tolerated and appears to have antitumor activity against chemotherapy-resistant ovarian cancer in the peritoneal cavity.

The snapping hip: clinical and imaging findings in transient subluxation of the iliopsoas tendon

OBJECTIVE

To define the clinical, ultrasonographic and magnetic resonance imaging (MRI) findings in patients with painful snapping of the hip secondary to transient subluxation of the iliopsoas tendon.

PATIENTS AND METHODS

Seven patients, ranging in age from 17 to 30 years, with a total of eight painful snapping hips were examined with static and dynamic ultrasonography and MRI during hip motion producing the painful snapping. The duration of symptoms, the level of disability and the response to therapy were recorded.

RESULTS

Static ultrasonography showed thickening of the iliopsoas tendon (tendinitis) in two cases and a peritendinous fluid collection in two cases. In all cases dynamic ultrasonography of the iliopsoas tendon during hip motion showed distinct abnormal motion of the tendon corresponding temporally to the painful palpable and audible sensation. MRI showed normal intra-articular structures in all cases, tendinitis in two cases and iliopsoas bursitis in one case. Clinically, subluxation of the iliopsoas tendon is a chronic (mean duration of symptoms in this series, 23 months) disabling condition that may be relieved by surgical tendon release.

CONCLUSIONS

Dynamic ultrasonography is useful for detecting transient subluxation of the iliopsoas tendon in patients with a painful snapping hip. MRI is useful for excluding intra-articular abnormalities in patients with this condition.

Immunoglobulin-containing plasma cells recruited to cervical neoplasia

OBJECTIVE

To determine the number and isotype of immunoglobulin (Ig)-containing cells that infiltrate various stages of cervical neoplasia from no lesion to invasive cancer.

METHODS

By three-color immunofluorescent microscopy, the number and isotype of stromal plasma cells were determined for 91 specimens representing a spectrum of cervical epithelial neoplasia as follows: no lesion (n = 12), koilocytic atypia (n = 13), mild dysplasia (n = 21), high-grade squamous intraepithelial lesions (SIL; n = 22), and invasive carcinoma (n = 23).

RESULTS

The Ig-positive cell counts were markedly increased under the low-grade SIL. Specifically, the mean number of IgG-positive plasma cells was significantly increased (P < .003) under the subepithelial stroma of mild dysplasia as compared with no SIL, high-grade SIL, or invasive carcinoma. These immunocyte infiltrates were clustered in the stroma beneath koilocytes, which also demonstrated IgG-positive intracellular staining.

CONCLUSION

Low-grade cervical lesions are infiltrated by IgG plasma cells to a greater extent than high-grade or invasive cervical lesions, suggesting that antibody responses are preferentially recruited in early cervical neoplasia, giving credence to the concept that low-grade lesions represent a human papillomavirus infection of the cervix rather than a neoplastic condition.

The National Cancer Data Base report on endometrial cancer

BACKGROUND

Previous Commission on Cancer data from the National Cancer Data Base (NCDB) have examined time trends in stage of disease, treatment patterns, and survival for selected cancers. The most current (1992) data for endometrial cancer are described here.

METHODS

Four calls for data have yielded a total of 560,455 cancer cases diagnosed in 1986-1987, and 599,597 cancer cases diagnosed in 1992, from hospital cancer registries across the United States.

RESULTS

Data were received for 36,341 endometrial cancer patients. No significant change in stage distribution for patients who were staged was noted with time, however, markedly fewer patients were reported with unknown stage in 1992 (15.6%) compared with 1986-1987 (45.1%). Blacks and low income groups were more likely to present with advanced stage disease. A 12.6% increase in patients undergoing nodal dissection as part of their surgical treatment occurred during this time period. More patients received surgery only as part of their treatment in 1992 (53.8%) vs. 42.6%). Advancing age, minority status, low income, and increasing grade all had a negative impact on survival. Blacks experienced a 25% reduction in survival compared to non-Hispanic Whites and Hispanics.

CONCLUSIONS

Lack of improvement in detecting early disease indicates the lack of acceptable screening methodology for this disease. Blacks present with more advanced disease and subsequently have a decreased survival compared to non-Hispanic Whites. Time trends indicate that nodal dissection is becoming a more common surgical practice in this disease, and that radiation therapy is utilized less often. The current American Joint Committee on Cancer staging accurately reflects differences in prognosis by stage.

Cyclophosphamide and cisplatin compared with paclitaxel and cisplatin in patients with stage III and stage IV ovarian cancer

BACKGROUND

Chemotherapy combinations that include an alkylating agent and a platinum coordination complex have high response rates in women with advanced ovarian cancer. Such combinations provide long-term control of disease in few patients, however. We compared two combinations, cisplatin and cyclophosphamide and cisplatin and paclitaxel, in women with ovarian cancer.

METHODS

We randomly assigned 410 women with advanced ovarian cancer and residual masses larger than 1 cm after initial surgery to receive cisplatin (75 mg per square meter of body-surface area) with either cyclophosphamide (750 mg per square meter) or paclitaxel (135 mg per square meter over 24 hours).

RESULTS

Three hundred eighty-six women met all the eligibility criteria. Known prognostic factors were similar in the two treatment groups. Alopecia, neutropenia, fever, and allergic reactions were reported more frequently in the cisplatin-paclitaxel group. Among 216 women with measurable disease, 73 percent in the cisplatin-paclitaxel group responded to therapy, as compared with 60 percent in the cisplatin-cyclophosphamide group (P = 0.01). The frequency of surgically verified complete response was similar in the two groups. Progression-free survival was significantly longer (P < 0.001) in the cisplatin-paclitaxel group than in the cisplatin-cyclophosphamide group (median, 18 vs. 13 months). Survival was also significantly longer (P < 0.001) in the cisplatin-paclitaxel group (median, 38 vs. 24 months).

CONCLUSIONS

Incorporating paclitaxel into first-line therapy improves the duration of progression-free survival and of overall survival in women with incompletely resected stage III and stage IV ovarian cancer.

Squamous cell carcinoma of the uterine cervix. Patterns of thoracic metastases

RATIONALE AND OBJECTIVES

Distant metastasis of cervical cancer, once considered rather uncommon, has become more common in recent years because of longer survival of the patients. The purpose of this study is to evaluate the radiographic patterns of its thoracic metastases correlating with the pathways of metastatic tumor spread.

METHODS

The conventional radiographs (62 cases), thoracic computed tomography images (20 cases), and medical records of 62 patients with advanced squamous cell carcinoma of the uterine cervix with thoracic metastases who died of extensive disease and its complications during a recent 5-year period were reviewed retrospectively.

RESULTS AND CONCLUSIONS

In addition to the most typical pattern of multiple pulmonary nodules (71%), mediastinal and hilar lymphadenopathy (32%) and pleural metastases (27%) were frequently observed. Rare findings included bone metastases (6%), endobronchial obstruction (5%), and lymphangitic carcinomatosis (3%). The mechanisms of metastasis in relation to the above manifestations are proposed.

Facial artery pseudoaneurysm: diagnosis by colour Doppler ultrasonography

Pseudoaneurysms of the facial region are rare and usually result from direct penetrating or blunt trauma. The authors report a pseudoaneurysm of the facial artery in a 22-year-old man injured in a motor vehicle accident. Colour Doppler ultrasonography was used to locate the aneurysm sac and establish its relation to the adjacent facial artery. Successful operative repair of the aneurysm was performed on the basis of the sonographic findings alone, without selective angiography.