Management of recurrent cervical cancer: a review of the literature

OBJECTIVE

The aim of this narrative review is to update the current knowledge on the treatment of recurrent cervical cancer based on a literature review.

MATERIAL AND METHODS

A web based search in Medline and CancerLit databases has been carried out on recurrent cervical cancer management and treatment. All relevant information has been collected and analyzed, prioritizing randomized clinical trials.

RESULTS

Cervical cancer still represents a significant problem for public health with an annual incidence of about half a million new cases worldwide. Percentages of pelvic recurrences fluctuate from 10% to 74% depending on different risk factors. Accordingly to the literature, it is suggested that chemoradiation treatment (containing cisplatin and/or taxanes) could represent the treatment of choice for locoregional recurrences of cervical cancer after radical surgery. Pelvic exenteration is usually indicated for selected cases of central recurrence of cervical cancer after primary or adjuvant radiation and chemotherapy with bladder and/or rectum infiltration neither extended to the pelvic side walls nor showing any signs of extrapelvic spread of disease. Laterally extended endopelvic resection (LEER) for the treatment of those patients with a locally advanced disease or with a recurrence affecting the pelvic wall has been described.

CONCLUSIONS

The treatment of recurrences of cervical carcinoma consists of surgery, and of radiation and chemotherapy, or the combination of different modalities taking into consideration the type of primary therapy, the site of recurrence, the disease-free interval, the patient symptoms, performance status, and the degree to which any given treatment might be beneficial.

[Multiple non-responding ESWL lithiasis in ectopic pelvic kidney: laparotomic surgical management]

A 34 year-old male with multiple lithiasis of ectopic pelvic left kidney, which for 5 years had been causing pain in the left iliac region irradiating to ipsilateral inguinal region and testis. 4 ESWL treatments were unsuccessful. The diagnostic imaging (Angio-CT + Uro-CT) showed ectopic pelvic left kidney with abnormal vascularisation, characterised by multiple lithiasis extending in total area of 4x2 cm with shorter ureter. Right kidney was in normal position. A left pyelocalicolithotomy after DJ stent positioning was performed.

Multiple Non-Responding ESWL Lithiasis in Ectopic Pelvic Kidney: Laparotomic Surgical Management

A 34 year-old male with multiple lithiasis of ectopic pelvic left kidney, which for 5 years had been causing pain in the left iliac region irradiating to ipsilateral inguinal region and testis. 4 ESWL treatments were unsuccessful. The diagnostic imaging (Angio-CT + Uro-CT) showed ectopic pelvic left kidney with abnormal vascularisation, characterised by multiple lithiasis extending in total area of 4×2 cm with shorter ureter. Right kidney was in normal position. A left pyelocalicolithotomy after DJ stent positioning was performed.

α-Blockers in Benign Prostatic Hyperplasia: The Problem of “Floppy Iris Syndrome”. Results of a Case-Control Study to Evaluate the Surgical Risk through the Meausurement of Pupil Diameter

Objectives

α-blockers are a group of α-adrenoceptor antagonists used by urologists to treat lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Recent studies have suggested that these drugs – tamsulosin in particular – are involved in the development of iris complications during phacoemulsification. The objective of this study is to investigate the effects of α-blockers – especially tamsulosin – on pupil diameter.

Materials and Methods

We measured the photopic, mesopic and post-dilatation pupil diameters in both eyes of 24 patients (46 eyes in total), 16 of them treated with α-blockers and 8 of them (16 eyes in total) not treated with any drugs (controls).

Results

All patients treated with tamsulosin showed minor photopic, mesopic and post-dilatation diameters compared to controls. Patients treated with other α-blockers did not show any difference compared to controls.

Conclusions

Even if a small number of eyes was evaluated, our study shows that tamsulosin - through its selective effect on α1A receptors - is the most involved drug in the Intraoperative Floppy Iris Syndrome.

[a-blockers in benign prostatic hyperplasia: the problem of "floppy iris syndrome". Results of a case-control study to evaluate the surgical risk through the meausurement of pupil diameter]

OBJECTIVES. α-blockers are a group of α-adrenoceptor antagonists used by urologists to treat lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Recent studies have suggested that these drugs - tamsulosin in particular - are involved in the development of iris complications during phacoemulsification. The objective of this study is to investigate the effects of α-blockers - especially tamsulosin - on pupil diameter. MATERIALS AND METHODS. We measured the photopic, mesopic and post-dilatation pupil diameters in both eyes of 24 patients (46 eyes in total), 16 of them treated with α-blockers and 8 of them (16 eyes in total) not treated with any drugs (controls). RESULTS. All patients treated with tamsulosin showed minor photopic, mesopic and post-dilatation diameters compared to controls. Patients treated with other α-blockers did not show any difference compared to controls. CONCLUSIONS. Even if a small number of eyes was evaluated, our study shows that tamsulosin - through its selective effect on α1A receptors - is the most involved drug in the Intraoperative Floppy Iris Syndrome.

Robotic modified radical hysterectomy with pelvic lymphadenectomy

Radical hysterectomy, the complete removal of a woman’s uterus, is usually performed via an abdominal incision that requires a 3–5 day hospital stay and a 6–8 week recovery period. Now, in a handful of hospitals around the world, new robotic technology allows doctors to perform this procedure through small incisions that require a recovery time of only one night in the hospital and a significantly shorter recovery period at home. Watch such a procedure being carried out at the European Institute of Oncology.

Effects of Growth Hormone Therapy on Glucose Metabolism and Insulin Sensitivity Indices in Prepubertal Children with Prader-Willi Syndrome

In Prader-Willi syndrome (PWS) growth hormone therapy (GHT) improves height, body composition, agility and muscular strength. In such patients it is necessary to consider the potential diabetogenic effect of GHT, since they tend to develop type 2 diabetes, particularly after the pubertal age. The aim of our study was to investigate the effects of GHT on glucose and insulin homeostasis in PWS children. An oral glucose tolerance test (OGTT) was performed in 24 prepubertal PWS children (15 male, 9 female, age: 5.8 +/- 2.8 years), 16 were obese (group A) and 8 had normal weight (group B), before and after 2.7 +/- 1.3 years GHT (0.22 +/- 0.03 mg/kg/week) and, only at baseline, in 35 prepubertal children with simple obesity (19 male, 16 female) (group C). Fasting glucose and insulin, glucose tolerance, insulin sensitivity index (ISI), homeostasis model assessment of insulin resistance (HOMA-IR), quick insulin check index (QUICKI), area under the curves (AUC) of glucose and insulin were estimated. At the start of GHT, all PWS children were normoglycaemic and normotolerant but two developed impaired glucose tolerance after 2.2 and 1.9 years of therapy, respectively. At baseline, group A showed lower fasting insulin levels, HOMA-IR and AUC of insulin, higher ISI, QUICKI and AUC of glucose than group C. Comparing groups A and B, AUC of insulin was higher and ISI lower in group A. During GHT, a significant increase of fasting insulin and glucose, a worsening of insulin resistance (HOMA-IR) and insulin sensitivity (QUICKI) was found only in group A while ISI did not change. The AUC of glucose decreased in both groups instead AUC of insulin did not change. BMI-SDS decreased in group A and increased in group B. The increased insulin resistance and decreased insulin sensitivity in obese PWS patients, as well as the occurrence of impaired glucose tolerance during GHT, suggest that a close monitoring of glucose and insulin homeostasis is mandatory, especially in treated obese PWS children.

Randomised study of systematic lymphadenectomy in patients with epithelial ovarian cancer macroscopically confined to the pelvis

No randomised trials have addressed the value of systematic aortic and pelvic lymphadenectomy (SL) in ovarian cancer macroscopically confined to the pelvis. This study was conducted to investigate the role of SL compared with lymph nodes sampling (CONTROL) in the management of early stage ovarian cancer. A total of 268 eligible patients with macroscopically intrapelvic ovarian carcinoma were randomised to SL (N=138) or CONTROL (N=130). The primary objective was to compare the proportion of patients with retroperitoneal nodal involvement between the two groups. Median operating time was longer and more patients required blood transfusions in the SL arm than the CONTROL arm (240 vs 150 min, P<0.001, and 36 vs 22%, P=0.012, respectively). More patients in the SL group had positive nodes at histologic examination than patients on CONTROL (9 vs 22%, P=0.007). Postoperative chemotherapy was delivered in 66% and 51% of patients with negative nodes on CONTROL and SL, respectively (P=0.03). At a median follow-up of 87.8 months, the adjusted risks for progression (hazard ratio [HR]=0.72, 95%CI=0.46–1.21, P=0.16) and death (HR=0.85, 95%CI=0.49–1.47, P=0.56) were lower, but not statistically significant, in the SL than the CONTROL arm. Five-year progression-free survival was 71.3 and 78.3% (difference=7.0%, 95% CI=–3.4–14.3%) and 5-year overall survival was 81.3 and 84.2% (difference=2.9%, 95% CI=−7.0–9.2%) respectively for CONTROL and SL. SL detects a higher proportion of patients with metastatic lymph nodes. This trial may have lacked power to exclude clinically important effects of SL on progression free and overall survival.

A rare association of synchronous intraductal carcinoma of the breast and invasive carcinoma of ectopic breast tissue of the vulva: case report and literature review

Only 17 cases of breast carcinoma arising in vulvar ectopic mammary tissue have been reported. We present a unique case of synchronous pure intraductal carcinoma of the breast (DCIS) and invasive carcinoma of ectopic breast tissue of the vulva. A 53-year-old woman presented with a 2-cm nodule in left labium major of the vulva. A surgical biopsy revealed an invasive carcinoma of ectopic mammary tissue. The mammography showed irregular microcalcifications of the right breast. The patient underwent left hemivulvectomy, bilateral inguinal sentinel lymph node biopsy, and radioguided breast resection (radioguided occult lesion localization) of the microcalcifications. The definitive histology revealed negative inguinal sentinel nodes, no further residual tumor in the vulva, and a high-grade (grade 3) DCIS in the breast. The synchronous occurrence of primary breast carcinoma and ectopic breast tissue carcinoma in the vulva is an extremely rare finding, only once previously being reported and leading to unsolved problems of differential diagnosis. The presence of a pure DCIS of the breast makes this case really unique, definitively confirming the independent primary origin of both mammary tumors. The inguinal sentinel node biopsy avoided a bilateral inguinal dissection.

Randomized trial of systematic lymphadenectomy (LY) vs nodal sampling (SA) at second look surgery (SLS) in ovarian cancer patients: Final results

5068

Background: The role of systematic pelvic and para-aortic lymphadenectomy at SLS in ovarian cancer patients has not been addressed by randomized clinical trials (RCTs). We conducted a RCT to determine whether LY improves progression-free (PFS) and overall survival (OS) compared with SA. Methods: From January 1991 through December 1999, 303 eligible patients (i.e. patients with FIGO stage I-IV epithelial ovarian carcinoma at up front surgery and in complete remission after primary debulking surgery and first line chemotherapy) were randomly assigned to undergo LY (N = 156) or SA (N = 147) at the end of SLS. Survival was analyzed using a Cox multivariable regression analysis. All statistical tests were two-sided. Results: Median operating time was longer and the percentage of patients requiring blood transfusions was higher in the LY arm than the SA (240 vs 135 min., P < .001, and 30% vs 10%, P < .001, respectively). In the LY arm and SA arm the median number of removed nodes and the percentages of patients with nodal involvement was statistically different (44 vs 8, P < .0001, and 24% vs 13%, P = 0.018, respectively). At a median follow-up of 59 months, 156 events (i.e., recurrences or deaths) were observed, and 98 patients had died. The 5-year progression-free and overall survival was 41% and 65% for LY, 49% and 61% for SA, respectively. The risk for first event (hazard ratio [HR] = 1.11, 95% CI = 0.81 to 1.53; P = .50) and death (HR = 0.79, 95% CI = 0.53 to 1.18; P = .24) after adjustment for residual tumor at first surgery was not significantly different between the two arms. Conclusions: Although LY at SLS seemed to improve overall survival, this survival gain (21% decrease in the hazard of death) was not statistically significant and therefore the routine use of LY at SLS for ovarian cancer is not supported by this RCT.

No significant financial relationships to disclose.

Role of conservative surgery in ovarian cancer: the European experience

Although less frequently than in older women, about 15% of invasive epithelial ovarian cancer may occur in young women, for whom preservation of fertility potential is an important clinical goal. We reviewed the published evidences from the European literature on the role of conservative surgery in women with invasive epithelial ovarian cancer. Three reports were identified from the Italian and French literature; the data were analyzed together with our own experience in terms of relapse rate, relapse in the preserved ovary, survival, and fertility outcome. A total of 152 conservative surgeries were reported: 88 patients with stage IA, 2 with stage IB, 51 with stage IC, 2 with stage II, 3 with stage IIIA, and 6 with stage IIIC. Relapses occurred in 18/152 patients (11.8%) and involved the preserved ovary in 11 cases (7%). Fifty-three pregnancies were recorded with 38 uneventful term deliveries, 2 ectopic pregnancies, 6 spontaneous abortions, 4 terminations, and 2 with unknown outcome. Nine patients (5.9%) have died of disease. These findings confirm that young women with stage I invasive epithelial ovarian cancer may receive a successful treatment of their disease without sacrificing fertility.

A rare association of synchronous intraductal carcinoma of the breast and invasive carcinoma of ectopic breast tissue of the vulva: case report and literature review

Only 17 cases of breast carcinoma arising in vulvar ectopic mammary tissue have been reported. We present a unique case of synchronous pure intraductal carcinoma of the breast (DCIS) and invasive carcinoma of ectopic breast tissue of the vulva. A 53-year-old woman presented with a 2-cm nodule in left labium major of the vulva. A surgical biopsy revealed an invasive carcinoma of ectopic mammary tissue. The mammography showed irregular microcalcifications of the right breast. The patient underwent left hemivulvectomy, bilateral inguinal sentinel lymph node biopsy, and radioguided breast resection (radioguided occult lesion localization) of the microcalcifications. The definitive histology revealed negative inguinal sentinel nodes, no further residual tumor in the vulva, and a high-grade (grade 3) DCIS in the breast. The synchronous occurrence of primary breast carcinoma and ectopic breast tissue carcinoma in the vulva is an extremely rare finding, only once previously being reported and leading to unsolved problems of differential diagnosis. The presence of a pure DCIS of the breast makes this case really unique, definitively confirming the independent primary origin of both mammary tumors. The inguinal sentinel node biopsy avoided a bilateral inguinal dissection.

Solid-state characterization of a novel chemotherapeutic drug

We present the results of a thermal, spectroscopic, diffractometric, and microscopic study of a novel DNA intercalator synthesized by Novuspharma S.p.A. (code name BRR 2778, purity by high-performance liquid chromatography: 99.4%). We found that the form that is stable at room temperature contains 1.5 water molecules per unit of formula (or about 4.7% in mass): this water is reversibly lost in two stages below 80 degrees and 90 degrees C in dry and wet nitrogen atmosphere, respectively. The hydrated compound is a pseudo-polymorph and dehydration is accompanied by a structural change that modifies the diffraction pattern without changing the shape of the microcrystals. Annealing above 150 degrees C causes decomposition of the anhydrous form and (above 190 degrees C) amorphization of the solid residue occurs.

Practical recommendations for the use of ACE inhibitors, beta-blockers and spironolactone in heart failure: putting guidelines into practice

Surveys of prescribing in both hospitals and primary care have shown delays in translating improved survival data from clinical trials into clinical practice thereby denying patients the benefits of proven treatments, such as the angiotensin converting enzyme inhibitors. This may be due to unfamiliarity with clinical guidelines and concerns about adverse events. Recent trials have shown that substantial improvements in survival are associated with spironolactone and beta-blocker therapy. In order to accelerate the uptake of these treatments, and to ensure that all eligible patients should receive the most appropriate medications, a clear and concise set of clinical recommendations has been prepared by a group of clinicians with practical expertise in the management of heart failure. The objective of these recommendations is to provide practical guidance for non-specialists in order to support the implementation of evidenced-based therapy for heart failure. These practical recommendations are meant to supplement rather than replace existing guidelines.

[Magnetic resonance imaging in the evaluation of parametrial invasion of carcinoma of the cervix uteri: optimization of the study protocol]

PURPOSE

To determine the efficacy of three different MR sequences in the evaluation of parametrial invasion by early-stage cervical cancer.

MATERIAL AND METHODS

Eighteen consecutive patients with cervical cancer clinically assessed as stage IB1 underwent MR imaging examination with the use of the following sequences: FSE T2-weighted, FSE fat-suppressed T2w, and SE fat-suppressed Gadolinium-enhanced T1w. In all cases, the presence or absence of parametrial invasion on both sides per each sequence used was evaluated. Subsequently all the sequences have been considered together for the evaluation of tumor invasion. Gold standard of the study was the histopathologic analysis of the surgical specimens.

RESULTS

At histological examination, parametrial invasion by tumor was found in 6 out of 36 parametria evaluated. The accuracy achieved with each of the sequences used was as follows: 94% with FSE T2w; 86% with FSE fat-suppressed T2w; and 67% with SE fat-suppressed Gadolinium-enhanced T1w. The simultaneous evaluation of all 3 sequences obtained an accuracy level similar to that achieved with FSE T2w. The difference between the accuracy of T2w sequences and that of fat-suppressed contrast-enhanced T1w sequences was statistically significant (p<0.01).

DISCUSSION AND CONCLUSIONS

Our data suggest that the MR imaging protocol for the evaluation of parametrial tumor invasion could be restricted to FSE T2w sequences. These proved to have the highest negative predictive value (97%) which allows a reliable selection of patients who can be surgically treated.

Molecular and genomic analysis of genes encoding surface-anchored proteins from Clostridium difficile

The gene slpA, encoding the S-layer precursor protein in the virulent Clostridium difficile strains C253 and 79--685, was identified. The precursor protein carries a C-terminal highly conserved anchoring domain, similar to the one found in the Cwp66 adhesin (previously characterized in strain 79--685), an SLH domain, and a variable N-terminal domain mediating cell adherence. The genes encoding the S-layer precursor proteins and the Cwp66 adhesin are present in a genetic locus carrying 17 open reading frames, 11 of which encode a similar two-domain architecture, likely to include surface-anchored proteins.

Medical therapy of advanced malignant epithelial tumours of the ovary

Despite improvements seen in median and overall survival using a combination of platinum-compounds and paclitaxel (PTX), long-term survival rates for patients with advanced epithelial ovarian carcinoma remain disappointing and ongoing efforts have aimed to develop more effective primary therapy. In the early 1990Os the drug PTX was first tested in ovarian cancer. In the Gynaecological Oncology Group (GOG) trial 111 the cisplatin (CP)+PTX regimen was judged to be superior compared to the platinum-based control arm with an improvement of overall response rate, median progression-free interval and overall median survival. These favourable data were confirmed by a European-Canadian Intergroup trial (OV10). In contrast, in a further GOG trial (GOG132) there was no difference in survival between CP alone and the combination of PTX and CP. The International Collaborative Ovarian Neoplasm Study (ICON)3 is the first and only trial comparing PTX plus carboplatin against carboplatin alone or a (non-taxane) CP-based control arm. The last analysis performed with a total of 1,293 events showed an estimated absolute difference in one-year progression-free survival of 1% and in two-year overall survival of 2% both in favour of PTX plus carboplatin. The results of ICON3, in accordance with GOG132 study, appear to contradict the earlier positive results seen for PTX and CP in the GOG-111 and OV10 trials and suggested that single agent carboplatin, CY-adriamycin-CP are safe and effective first-line treatments for women requiring chemotherapy for ovarian cancer. A meta-analysis with individual patient data is warranted to better clarify the issue of PTX in the front line therapy of advanced ovarian cancer. Salvage chemotherapy is often utilised in patients with advanced ovarian cancer, due to the high frequency of recurrent disease even after a clinical or pathological complete response after primary chemotherapy. Main objectives of salvage chemotherapy include: i. improvement in quality of life and symptoms; ii. tumour load reduction and survival advantage; iii. evaluation of potentially active new drugs to be included in first-line. Since the goal is palliation in most cases, monotherapy is generally indicated. However, the chances of response are directly related to the treatment-free interval, with a response rate nearly equivalent to that of primary chemotherapy when the treatment-free interval exceeds 24 months. Extension of the platinum-free interval before re-treatment with platinum or taxanes may allow partial reversal of resistance to these agents which can therefore still show significant activity in relapsing patients. Unfortunately, durable response to salvage chemotherapy is rare and cure is almost impossible. The sequential use of the agents currently available for salvage treatment in monotherapy may transform ovarian cancer into a chronic disease and confers long survival to the patients. Perhaps, the most interesting role of second-line chemotherapy is to identify new potentially active drugs, which can be moved up-front. Most of the compounds used in second line (gemcitabine, topotecan, liposomal doxorubicin) are in fact under investigation to develop alternative schedules and sequences of drug administration. A new phase III multi-national randomised study for patients with advanced stage epithelial ovarian or primary periperitoneal carcinoma will evaluate the impact of incorporating a new drug within either a platinum-based triplet (new drug + platinum + PTX) or a sequential-doublet (new drug + platinum followed by platinum + PTX) in order to identify one or more experimental regimens able to improve long-term survival with acceptable toxicity.

The ENACT study: a pan-European survey of acute coronary syndromes. European Network for Acute Coronary Treatment

AIM

The European Network for Acute Coronary Treatment (ENACT) study was designed to collect prospective information across Europe on the relative frequency, diagnosis and management of the whole spectrum of acute coronary syndromes.

METHODS

Cardiologists, who were respondents to mailings sent out to 17 European countries with the target of reaching one centre per million inhabitants, completed a prospective patient record, each physician providing information on 10 consecutive patients with a working diagnosis on admission of acute coronary syndrome, and a questionnaire.

RESULTS

A total of 390 responses were received (0.91/10(6)population) with data on 3092 patients in 29 countries. The patient population comprised 1431 (46%) with an initial working diagnosis of unstable angina/non-ST-segment elevation myocardial infarction, 1205 (39%) with myocardial infarction and 445 (14%) with suspected acute coronary syndrome. The ratio of unstable angina to myocardial infarction was 1.2:1 and this was similar across Europe. An initial diagnosis of myocardial infarction was more likely to be confirmed than unstable angina or suspected acute coronary syndrome. There were wide variations in the rates of angiography and percutaneous coronary intervention across Europe. Most unstable angina patients received aspirin, nitrates and heparin (unfractionated heparin 44% intravenous, 16% subcutaneous; low-molecular-weight heparin 50%). Overall, 50% of unstable angina patients and 34% of myocardial infarction patients received low-molecular-weight heparin and 6% and 8% respectively received a glycoprotein IIb/IIIa inhibitor, but there were large inter-country differences. There were also national differences in the use of calcium antagonists, angiotensin-converting enzyme inhibitors and beta-blockers.

CONCLUSION

The ENACT study provides robust data, for the first time, on the relative frequency of unstable angina and acute myocardial infarction across Europe. It provides insight into differences in management across Europe and a reference benchmark of current treatment.

The role of myocardial viability in deriving benefit from reestablishing infarct-related artery flow after acute myocardial infarction

Early, sustained patency of the infarct-related artery (IRA) induces myocardial salvage, which preserves left ventricular (LV) function and mediates better long-term outcome. However, the time course and the mechanisms of muscle recovery after myocardial infarction are not completely understood. A large body of evidence suggests that most of the improvement occurs during the hospital phase and is related to early and sustained thrombolysis in myocardial infarction 3 flow in the IRA. Nevertheless, the relationship between IRA status and regional and global LV mechanics in the chronic phase of the disease remains controversial. Some late recovery may occur, either spontaneously or after revascularization, even in the absence of documented myocardial ischemia. The interplay between vessel patency, coronary flow grade and severity of the residual stenosis, and the presence of stunned or hibernating myocardium in the area at jeopardy may explain this delayed improvement. Although there seems to be a limited time window in which myocardium can be salvaged, timely testing for viability, particularly in patients with poor LV function, is justified even in a later phase of the disease to challenge potential cardiac recovery.

Physico-chemical characterization of a novel tricyclic beta-lactam antibiotic

GV118819X, a novel tricyclic beta-lactam antibiotic of GlaxoWellcome, is a racemic mixture of two diastereoisomers, A and B. Of the two diastereoisomers, only A is available as a pure compound. By analyzing mixtures of GV118819X and A, a partial phase diagram is constructed, which indicates the presence of a eutectic when the A fraction is approximately 39%. Moreover, the melting enthalpies of the eutectic mixture and of diastereoisomer B can be estimated. With the exception of the pure A form, all mixtures undergo important modifications in morphology and microstructure as a consequence of thermal treatments, which induce melting/amorphization of the eutectic, and crystallization of the A form. Analyses of the sieved fractions of GV118819X demonstrate that it consists of acicular crystals of different composition, with the larger crystals having a larger A fraction than the smaller ones. Grinding causes melting/amorphization of the eutectic and, following hours-long treatments, the formation of a substantial fraction of submicron particles with unusually low melting temperatures.

Sentinel node biopsy in early vulvar cancer

Lymph node pathologic status is the most important prognostic factor in vulvar cancer; however, complete inguinofemoral node dissection is associated with significant morbidity. Lymphoscintigraphy associated with gamma-probe guided surgery reliably detects sentinel nodes in melanoma and breast cancer patients. This study evaluates the feasibility of the surgical identification of sentinel groin nodes using lymphoscintigraphy and a gamma-detecting probe in patients with early vulvar cancer. Technetium-99m-labelled colloid human albumin was administered perilesionally in 37 patients with invasive epidermoid vulvar cancer (T1-T2) and lymphoscintigraphy performed the day before surgery. An intraoperative gamma-detecting probe was used to identify sentinel nodes during surgery. A complete inguinofemoral node dissection was then performed. Sentinel nodes were submitted separately to pathologic evaluation. A total of 55 groins were dissected in 37 patients. Localization of the SN was successful in all cases. Eight cases had positive nodes: in all the sentinel node was positive; the sentinel node was the only positive node in five cases. Twenty-nine patients showed negative sentinel nodes: all of them were negative for lymph node metastases. Lymphoscintigraphy and sentinel-node biopsy under gamma-detecting probe guidance proved to be an easy and reliable method for the detection of sentinel node in early vulvar cancer. This technique may represent a true advance in the direction of less aggressive treatments in patients with vulvar cancer.

Comparison of candesartan, enalapril, and their combination in congestive heart failure: randomized evaluation of strategies for left ventricular dysfunction (RESOLVD) pilot study. The RESOLVD Pilot Study Investigators

BACKGROUND

We investigated the effects of candesartan (an angiotensin II antagonist) alone, enalapril alone, and their combination on exercise tolerance, ventricular function, quality of life (QOL), neurohormone levels, and tolerability in congestive heart failure (CHF).

METHODS AND RESULTS

Seven hundred sixty-eight patients in New York Heart Association functional class (NYHA-FC) II to IV with ejection fraction (EF) <0.40 and a 6-minute walk distance (6MWD) <500 m received either candesartan (4, 8, or 16 mg), candesartan (4 or 8 mg) plus 20 mg of enalapril, or 20 mg of enalapril for 43 weeks. There were no differences among groups with regard to 6MWD, NYHA-FC, or QOL. EF increased (P=NS) more with candesartan-plus-enalapril therapy (0.025+/-0.004) than with candesartan alone (0.015+/-0.004) or enalapril alone(0.015+/-0.005). End-diastolic (EDV) and end-systolic (ESV) volumes increased less with combination therapy (EDV 8+/-4 mL; ESV 1+/-4 mL; P<0.01) than with candesartan alone (EDV 27+/-4 mL; ESV 18+/-3 mL) or enalapril alone (EDV 23+/-7 mL; ESV 14+/-6 mL). Blood pressure decreased with combination therapy (6+/-1/4+/-1 mm Hg) compared with candesartan or enalapril alone (P<0.05). Aldosterone decreased (P<0.05) with combination therapy (23.2+/-5.3 pg/mL) at 17 but not 43 weeks compared with candesartan (0.7+/-7.8 pg/mL) or enalapril (-0.8+/-11. 3 pg/mL). Brain natriuretic peptide decreased with combination therapy (5.8+/-2.7 pmol/L; P<0.01) compared with candesartan (4. 4+/-3.8 pmol/L) and enalapril alone (4.0+/-5.0 pmol/L).

CONCLUSIONS

Candesartan alone was as effective, safe, and tolerable as enalapril. The combination of candesartan and enalapril was more beneficial for preventing left ventricular remodeling than either candesartan or enalapril alone.

Characterization of surface layer proteins from Clostridium difficile by liquid chromatography/electrospray ionization mass spectrometry

Surface layers (S-layers) are regularly ordered protein subunits found as the outermost cell envelope component of many bacteria. Most S-layers are composed of a single protein or glycoprotein species with a molecular weight varying between 40 and 200 kDa. Clostridium difficile is the most common cause of antibiotic associated diarrhea (AAD) and pseudomembranous colitis (PMC) in humans. Detection of the S-layer in some C. difficile strains, and preliminary characterization of two glycoproteins, P36 and P47, involved in the composition of the S-layer of one of these strains (C. difficile C253), led us to investigate the most appropriate conditions for purification and chemical characterization of these proteins. This work describes the results obtained when liquid chromatography (LC) coupled to mass spectrometry (MS) using electrospray ionization was applied to the analysis of C. difficile S-layer proteins (SLPs). In this way the molecular weights of the two SLP components, P36 and P47, were detected to be 34,258 +/- 2 and 39,545 +/- 3 Da, respectively. These data deviate from sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) results by 1.85 and 7.5 kDa. To confirm the LC-MS results, an alternative molecular weight analysis was performed: the two S-layer proteins were isolated by semipreparative high performance liquid chromatography (HPLC), concentrated, and analyzed by matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF). The two SLP subunits were digested with protease V8, and the peptide maps were determined by LC-MS using a C18 column. Finally, preliminary results about peptide glycosylation were obtained.

Effect of lesions of the nucleus basalis magnocellularis and of treatment with posatirelin on cholinergic neurotransmission enzymes in the rat cerebral cortex

The effect of 4 and 8 weeks of treatment with the thyrotropin releasing hormone (TRH), analogue posatirelin (L-6-ketopiperidine-2-carbonyl-L-leucyl-proline amide), on the changes of cholinergic neurotransmission enzymes, choline acetyltransferase (ChAT) and acetylcholinesterase (AChE), caused by lesions of the nucleus basalis magnocellularis (NBM), was investigated in the rat frontal cortex. ChAT and AChE were demonstrated with immunohistochemical and histochemical techniques, respectively associated with image analysis and microdensitometry. Monolateral and bilateral lesions of NBM area caused a significant loss of ChAT-immunoreactive nerve cell bodies in the NBM, as well as a remarkable decrease of ChAT-immunoreactive fibres and of AChE reactivity in the frontal cortex ipsilateral to the lesion or of both sides, respectively. The number of ChAT-immunoreactive nerve cell bodies in the lesioned NBM was higher in posatirelin-treated rats for 8 weeks in comparison with control NBM-lesioned rats. Moreover, the compound increased the number of ChAT-immunoreactive fibres in the frontal cortex of monolaterally and bilaterally NBM-lesioned rats at 8 weeks after lesion, but was without effect on these fibres in sham-operated rats. The same is true for AChE reactivity, developed in the neuropil of the frontal cortex, which was restored in part by an 8-week treatment with posatirelin in NBM-lesioned rats. These findings suggest that treatment with posatirelin rescues cholinergic neurons of the NBM and cholinergic projections to the cerebral cortex affected by lesioning of the NBM. The functional relevance of these observations and their possible applications should be evaluated in future studies.

Intravenous correction of neonatal hypomagnesemia: effect on ionized magnesium

OBJECTIVES

Neonatal hypomagnesemia is defined as total magnesium (TMg) < or = 0.65 mmol/L (1.6 mg/dl). However, magnesium (Mg) deficiency and sufficiency overlap at serum values of 0.57 to 0.74 mmol/L (1.4 to 1.8 mg/dl). We hypothesized that (1) some infants with TMg < or = 0.65 mmol/L (1.6 mg/dl) have normal ionized Mg values (normal neonatal range 0.40 to 0.56 mmol/L (0.97 to 1.36 mg/dl)); (2) the dose (6.0 mg of elemental Mg/kg) used to correct hypomagnesemia does not lead to elevation of ionized Mg; (3) after intravenous magnesium sulfate infusion, ionized calcium increases in patients with low baseline ionized Mg and decreases in patients with normal baseline ionized Mg.

STUDY DESIGN

We recruited 22 neonates with TMg < or = 1.6 mg/dl. They received intravenous sulfate (6 mg elemental Mg/kg) over a 1-hour period. Serum TMg, ionized Mg, and ionized Ca were measured before and after magnesium sulfate infusion. An ion-selective electrode was used to allow direct measurement of ionized Mg and ionized Ca.

RESULTS

Thirteen (59%) of 22 neonates with TMg < or = 0.65 mmol/L (1.6 mg/dl) had normal IMg. In 7 (31%) of 22 cases ionized Mg increased slightly above 0.56 mmol/L (1.36 mg/dl); the maximum value was 0.61 mmol/L (1.48 mg/dl). The change in ionized Ca concentrations and the baseline ionized Mg value were inversely correlated (r = -0.79; p < 0.0001).

CONCLUSIONS

(1) Measurement of ionized Mg should prevent overdiagnosis and treatment of hypomagnesemia. (2) The dose used in this study is safe. (3) Ionized Mg concentrations are inversely correlated to the response of ionized Ca concentrations to an Mg load.

Predischarge two-dimensional echocardiographic evaluation of left ventricular thrombosis after acute myocardial infarction in the GISSI-3 study

Left ventricular (LV) thrombosis can be found in patients with acute myocardial infarction (AMI). No wide multicenter trial on AMI has provided information about LV thrombosis until now. The protocol of the GISSI-3 study included the search for the presence of LV thrombosis in patients from 200 coronary care units that did not specifically focus on LV thrombosis. We examined the GISSI-3 database results related to 8,326 patients at low to medium risk for LV thrombi in which a predischarge echocardiogram (9 +/- 5 days) was available. LV thrombosis was found in 427 patients (5.1%): 292 of 2,544 patients (11.5%) with anterior AMI and in 135 of 5,782 patients (2.3%) with AMI in other sites (p <0.0001). The incidence of LV thrombosis was higher in patients with ejection fraction < or = 40% (151 of 1,432 [10.5%] vs 276 of 6,894 [4%]; p <0.0001) both in the total population and in the subgroup with anterior AMI (106 of 597 [17.8%] vs 186 of 1,947 [9.6%]; p <0.0001). Multivariate analysis showed that only the Killip class > I and early intravenous beta-blocker administration were independently associated with higher LV thrombosis risk in the subgroup of patients with anterior AMI (odds ratio 1.75, 95% confidence interval 1.28 to 2.39; odds ratio 1.32, 95% confidence interval 1.02 to 1.72, respectively). In patients with anterior AMI, oral beta-blocker therapy given or not given after early intravenous beta-blocker administration does not influence the occurrence of LV thrombosis. The rate of LV thrombosis was similar in patients treated or not treated with nitrates and lisinopril both in the total population and in patients with anterior and nonanterior AMI. In conclusion, in the GISSI-3 population at low to medium risk for LV thrombi, the highest rate of occurrence of LV thrombosis was found among patients with anterior AMI and an ejection fraction < 40%. Killip class > I and the early intravenous beta-blocker administration were the only variables independently associated with a higher predischarge incidence of LV thrombosis after anterior AMI.

Platin-based chemotherapy and salvage surgery in recurrent ovarian cancer following negative second-look laparotomy

AIM

To evaluate the role of platin-based chemotherapy followed by salvage surgery in patients with recurrent ovarian cancer after negative second-look laparotomy.

METHODS

A retrospective chart review was conducted on 38 patients with recurrent ovarian cancer after a pathologic complete response to first-line chemotherapy. After diagnosis of recurrence all patients underwent retreatment with platin-based chemotherapy followed by radical salvage surgery.

RESULTS

Recurrent disease was diagnosed at a median interval of 22 months after second-look surgery. All patients had complete surgical debulking with no macroscopic tumor at the completion of the surgical procedure. Eight patients (21%) required an intestinal resection but no colostomy was performed. Two operative deaths occurred (5%). Twenty-two patients (58%) experienced a second recurrence after salvage surgery The median survival time for all patients after diagnosis of recurrent disease was 29 months (range 6-96 months), with nine patients (25%) surviving more than three years. Survival time after diagnosis of recurrence was not significantly related either to known prognostic factors of ovarian cancer or to the length of the clinical remission time.

CONCLUSION

Retreatment with platin-based chemotherapy followed by salvage surgery should be offered to recurrent ovarian cancer patients and would appear to prolong survival in a highly selected group of patients.

Effect of treatment with the neuroactive peptide posatirelin on microanatomical changes of frontal cortex and hippocampus caused by lesions of the locus coeruleus

The influence of monolateral and bilateral lesions of the Locus coeruleus (LC) on the number of nerve cell and glial fibrillary acidic protein (GFAP)-immunoreactive astrocyte profiles, on silver-gold impregnated fibres and on tyrosine hydroxylase (TH) immunoreactivity was assessed in the rat frontal cortex and hippocampus. The influence of treatment for 4 and 8 weeks with a 10 mg/kg/day dose of the neuroactive peptide posatirelin on the above parameters was also investigated. Lesions of the LC decreased the number of nerve cell profiles in the frontal cortex 8 weeks after lesioning and were without effect on nerve cell profiles in the frontal cortex 4 weeks after lesioning and in the hippocampus at both 4 and 8 weeks after LC lesioning. Glial fibrillary acidic protein (GFAP)-immunoreactive astrocytes were not affected by lesions of LC. Silver-gold impregnated fibres were decreased in the frontal cortex but not in the hippocampus of LC-lesioned rats at 8 weeks after lesioning. TH immunoreactivity, which was localized in nerve fibre-like structures both in the frontal cortex and in the hippocampus was decreased in the frontal cortex and in the hippocampus from the 4th week after LC lesioning. Treatment with posatirelin was without effect on the number of nerve cell and of GFAP-immunoreactive astrocyte profiles at both 4 and 8 weeks after LC lesioning, with the exception of nerve cells of the frontal cortex in monolaterally-lesioned rats which were increased 8 weeks after lesioning. The compound increased silver-gold impregnated fibres in the frontal cortex of monolaterally lesioned rats after 8 weeks of treatment, but did not affect TH immunoreactivity both in the frontal cortex or in the hippocampus. The above results suggest that treatment with posatirelin exerts a neuroprotective effect on the frontal cortex consisting of the partial restoration of some microanatomical changes caused by lesions of LC. The possible significance of this effect is discussed.

A randomized comparison of continuous versus interrupted mass closure of midline incisions in patients with gynecologic cancer

OBJECTIVE

To address the incidence of deep wound dehiscence and incisional hernia formation with two types of mass closure after vertical midline laparotomy performed in patients with gynecologic cancer.

METHODS

Continuous and interrupted mass closures were compared randomly in 632 patients. Both methods were performed with absorbable material. Of the 614 subjects who could be evaluated, 308 underwent a continuous, non-locking closure with looped polyglyconate suture, and 306 were closed with interrupted polyglycolic acid according to the Smead-Jones technique.

RESULTS

Three (1%) subjects with the continuous closure and five (1.6%) with the interrupted closure had an abdominal wound infection (P = .50). One patient whose incision was closed with continuous suturing had a deep wound dehiscence (without evisceration). The follow-up period was 6 months to 3 years. No patient had evidence of chronic sinus drainage. Thirty-two (10.4%) of the patients who had the continuous closure and 45 (14.7%) of those who were closed with the interrupted method had evidence of incisional hernia (P = .14). No hernia developed in any patient with a wound infection. Four (1.3%) hernias after the continuous closure and eight (2.6%) after the interrupted closure required surgical repair because of patient discomfort (P = .38).

CONCLUSION

The interrupted closure was not superior to the continuous closure for short- and long-term wound security. The continuous method was preferable because it was more cost-efficient and faster.