Is radical trachelectomy a safe alternative to radical hysterectomy for patients with stage IA-B carcinoma of the cervix?

BACKGROUND

The prognosis associated with lymph node negative, early stage carcinoma of the cervix is excellent, with 5-year survival rates greater than 90%. Radical trachelectomy in combination with pelvic lymph node dissection (RVT + LPL) has emerged as an alternative to radical hysterectomy (RH) for these patients who desire preservation of fertility. However, there are limited data to support its efficacy and safety.

METHODS

All patient information was collected prospectively and was subsequently extracted from the cervical cancer surgery database of the Division of Gynecologic Oncology at the University of Toronto. Patients treated by RVT + LPL for fertility preservation were compared with two groups of patients treated by RH. One control group was matched for age, tumor size, histology, depth of invasion, presence of capillary lymphatic space involvement, lymph node metastases, and use of adjuvant radiation. The other control group consisted of patients with tumor sizes </=2 cm, negative pelvic lymph nodes who had not received adjuvant radiation therapy.

RESULTS

Thirty of 32 patients treated by RVT + LPL between March 1994 and November 1998 were matched. The only statistically significant difference in prognostic factors between the patients who underwent RVT + LPL and unmatched controls (556 patients) was the median depth of invasion in the adenocarcinomas (2. 0 mm vs. 4.0 mm, respectively; P < 0.02). The 2-year actuarial recurrence free survival was 95%, 100%, and 97% for the patients who underwent RVT + LPL, matched controls, and unmatched controls, respectively. The actuarial conception rate at 12 months was 37%.

CONCLUSIONS

Acknowledging the small numbers and short follow-up, RVT + LPL appears to be similar in efficacy to RH. If longer follow-up with more patients confirms the above, this procedure will represent an acceptable alternative to RH for patients with early Stage I carcinoma of the cervix who desire preservation of fertility.

The effects of angiotensin II, endothelin-1, and protein kinase C inhibitor on DNA synthesis and intracellular calcium mobilization in vascular smooth muscle cells from young normotensive and spontaneously hypertensive rats

Angiotensin II (Ang-II) and endothelin 1 (ET-1) are important peptides that induce a prolonged vasoconstriction and enhance proliferation of vascular smooth muscle cells (VSMC). These substances may have an important role in the development of hypertension and atherosclerosis. Our objectives were to determine whether there are inborn differences in the proliferation patterns of VSMC obtained from spontaneously hypertensive (SHR) and Wistar-Kyoto rats (WKY) by studying the effects of Ang-II and ET-1 on VSMC from those strains before the onset of hypertension, and to evaluate the roles of protein kinase C (PKC) and intracellular Ca2+ in the mechanism of action of ET-1 and Ang-II. VSMC from aortas of young (1- to 2-week-old) SHR and WKY rats were grown as primary cultures in plates for 48 h. The cells were incubated with Ang-II (0.1 to 1000 nmol/L) or ET-1 (0.1 to 100 nmol/L). VSMC were also incubated in the presence of various concentrations of a PKC inhibitor, chelerythrine (0.1-10 nmol/L). Thymidine incorporation into DNA was measured as an indicator of DNA synthesis. Intracellular free Ca2+ was determined by using FURA-2AM. ET-1 and Ang-II caused a marked dose-dependent enhancement of thymidine incorporation into DNA. The responses of VSMC from WKY and SHR to Ang-II and ET-1 were similar. In both strains, chelerythrine caused a dose-dependent suppression in the activity of ET-1 and Ang-II. However, VSMC from SHR incubated in the presence of ET-1 were more susceptible to the inhibitory effect of chelerythrine. Both Ang-II and ET-1 induced an increase of intracellular free Ca2+. ET-1 induced a larger increase than Ang-II (190% and 100% greater than baseline free Ca2+ levels, respectively), in spite of a lower concentration of ET-1 (ET-1 = 30 nmol/L; Ang-II = 100 nmol/L). Ang-II and ET-1 exerted a similar mitogenic effect on primary cultures of VSMC obtained from young SHR before the development of hypertension, compared with WKY. The mitogenic activity of Ang-II and ET-1 was accompanied by an increase of intracellular free Ca2+. The effect of ET-1 upon intracellular Ca2+ was stronger than that of Ang-II. VSMC cultures of SHR stimulated with ET-1 were more susceptible to PKC inhibition than those of WKY. The similarity of the effects of Ang- II and ET-1 on SHR and WKY does not exclude their role in the pathogenesis of hypertension and atherosclerosis, and further studies should be carried out to determine their role.

Treatment of early epithelial ovarian cancer with chemotherapy and abdominopelvic radiotherapy: results of a prospective treatment protocol

PURPOSE

To test the hypothesis that the combination of adjuvant chemotherapy and abdominopelvic radiation (APRT) improves the outcome of patients with early ovarian cancer compared to treatment with APRT alone.

METHODS AND MATERIALS

Between 1991 and 1994, 93 patients with Stage I to III, optimally cytoreduced, invasive, epithelial ovarian cancer were treated with sequential chemotherapy and APRT. Treatment was assigned using a prognostic classification that was derived from previous cohorts of patients. Low-risk patients (n = 9) received APRT alone, intermediate-risk patients (n = 66) received two courses of cisplatin followed by APRT, and high-risk patients (n = 18) received 6 courses of cisplatin and cyclophosphamide followed by APRT.

RESULTS

Disease recurred in 22 patients, and was confined to the pelvis or abdomen in 15. Nine patients died and the remainder were alive with disease after receiving salvage chemotherapy. The 3-year disease-free and overall survivals were 78% and 91%, respectively. The prognostic classification used to assign treatment was the only factor that predicted disease-free survival (83% and 59% at 3 years for low/intermediate- and high-risk patients, respectively; p = 0.03). There was no detectable difference in outcome between the present series and an historical control group treated with APRT alone. Treatment was well tolerated and only 2 patients (2.5%) developed serious complications.

CONCLUSION

APRT is an effective adjuvant treatment for carefully selected patients with early ovarian cancer. The addition of chemotherapy as used in this study to APRT does not significantly improve outcome compared to APRT alone.

An acute ischaemic event associated with the use of venlafaxine: a case report and proposed pathophysiological mechanisms

Venlafaxine, a structurally novel antidepressant, belongs to a new generation of antidepressants--the serotonin/noradrenaline reuptake inhibitors. In clinical trials, venlafaxine was found safe and effective in most patients. However, significant changes in vital signs (hyper- and hypotension) and cardiac conduction abnormalities were observed in a few patients, notably in elderly patients. We present a case of an elderly woman with a pre-existing history of ischaemic heart disease, who was treated with venlafaxine, and developed acute myocardial ischaemia within the first week of treatment. This is the first report of a possible association between an acute cardiovascular event and venlafaxine. The association of venlafaxine treatment with ischaemic events could be explained by its unique pharmacological and haemodynamic properties.

Patient preference for the management of mildly abnormal Papanicolaou smears

Our objective was to investigate patient knowledge, desire for participation in medical decision making, and preference for the management of mildly abnormal Papanicolaou (Pap) smears (low-grade squamous intraepithelial lesions [LGSIL]) in the context of the continuing controversy between active (immediate colposcopy and biopsy) and surveillance (repeat Pap smears) management strategies. One hundred thirty-six women referred for a diagnostic colposcopy with a first-time mildly abnormal Pap smear result completed questionnaires before contact with either the nurse or physician. They were given the State-Trait Anxiety Inventory, the CESD Depression scale, and a knowledge about dysplasia quiz. They were then presented with the two management options and asked to state a preference, if any. They then completed the Problem Solving-Decision Making Scale, a measure of desire for involvement in medical decision making. The majority of women in this sample opted for the active management strategy. Management preference was related to anxiety, with the most anxious women more likely to choose the active management strategy. Management preference was not related to knowledge or to desire for an active role in decision making, although the more knowledgeable women also reported a desire for an active role in the decision-making process. Given the current controversy over the management of mildly abnormal Pap smears (LGSIL), as well as the fact that there is no conclusive evidence to support one strategy over another, the informed management preference of women affected by these decisions should be factored into the equation.

A longitudinal study of psychological adjustment to familial genetic risk assessment for ovarian cancer

OBJECTIVES

To evaluate the psychological adjustment of women during initial genetic ovarian cancer risk assessment and at clinic follow-up, 6-12 months later.

METHODS

Sixty-five subjects were assessed with the Centre for Epidemiological Studies Depression Scale (CESD), Spielberger's State Anxiety Inventory, and an 18-item, investigator-designed questionnaire yielding self-report on screening responses, worry about increased risk, identification of cancer-related deaths in relatives, worry about future cancer risks of daughters, alteration of future plans as a result of ovarian cancer risk, etc.

RESULTS

Thirty-three percent of subjects had CESD scores above the established cutoff for depression at baseline and 38% had scores above cutoff at follow-up. Sixteen percent of subjects had state scores on the State-Trait Anxiety Inventory higher than 1 standard deviation above average (norm) at baseline, while only 6% had scores higher than 1 SD above average at follow-up.

CONCLUSION

To identify factors associated with self-reported depression at follow-up, a series of demographic and self-reported variables (e.g., presence of identified problems in family, impact of genetic risk information, concern for daughter in the future) were entered in a multiple regression analysis with the CESD follow-up score as the dependent variable. Only one predictor accounted for a significant amount of variance in depression scores. Concern for daughter's risk in the future was associated with higher depression scores at follow-up (R = 0.33, P<0.02, R(2) = 11%).

Constitutive and conditional cadherin expression in cultured human ovarian surface epithelium: influence of family history of ovarian cancer

Epithelial ovarian carcinomas arise in a simple mesothelium (ovarian surface epithelium, OSE) but exhibit properties of oviductal and endometrial epithelia. Thus, during malignant progression, their differentiation proceeds from simple to complex, in contrast to carcinomas in other tissues. Related changes in OSE of women with a history of familial ovarian cancer indicate that this aberrant differentiation is initiated very early in neoplastic progression. The mechanisms underlying this process are not understood. Because cadherins are known regulators of differentiation, we investigated the relationship of the cadherins E, N and P to OSE morphology, growth patterns and differentiation in cultures of normal and metaplastic OSE from women with (FH-OSE) and without (NFH-OSE) a family history of ovarian cancer and in the ovarian carcinoma lines OVCAR-3 and CaOV3. We used immunofluorescence, RT-PCR, in situ hybridization and Western blotting. Our results define N-cadherin as the constitutively expressed cadherin of normal and metaplastic OSE and indicate that P-cadherin is undetectable while E-cadherin expression is conditional and related to genotype, stage of neoplastic progression and growth pattern. The altered expression of E-cadherin in apparently normal OSE of women with hereditary ovarian cancer syndromes in conjunction with the known capacity of E-cadherin to induce epithelial characteristics implicates this adhesion molecule as a possible inducer of the aberrant Mullerian differentiation which characterizes epithelial ovarian carcinomas. Abnormal differentiation in such (pre)-neoplastic tissues may represent an early, irreversible, non-mutational step in ovarian epithelial neoplastic progression.

Progression of myelinated retinal nerve fibers

PURPOSE

To present a case demonstrating progression of retinal nerve fiber myelin and to suggest that myelinated retinal nerve fibers be considered among the peripapillary choristomas.

METHOD

Case report. A 46-year-old woman demonstrated progression of myelinated retinal nerve fibers and associated retinal vascular anomalies.

RESULTS

Myelinated retinal nerve fibers can be progressive. We confirm earlier reports of vascular anomalies associated with retinal nerve fiber myelin and show that they can also be progressive.

CONCLUSIONS

The rarely progressive nature of myelinated retinal nerve fibers and the histopathologic studies published to date suggest that myelinated retinal nerve fibers represent a striking ophthalmoscopic feature resulting from ectopic oligodendrocytes; thus, the entity may be described as an oligodendrocytic choristoma.

Gynecologists' perspectives regarding ovarian cancer

OBJECTIVE

To document the perspectives, practices and knowledge of Canadian gynecologists regarding ovarian cancer.

DESIGN

A mailed survey questionnaire was followed by a reminder card and a second mailing of the questionnaire.

SETTING

A sample of all gynecologists practising in Canada.

MAIN OUTCOME MEASURES

Knowledge related to ovarian cancer. Practices related to the screening and detection of ovarian cancer. Attitudes towards ovarian cancer. Perceived role in the care of women at risk of, or diagnosed with, ovarian cancer. Perceived educational needs of gynecologists regarding ovarian cancer.

RESULTS

A total of 504 completed questionnaires were returned, providing a response rate of 46%. Most gynecologists indicated that they knew the basic facts about ovarian cancer and risk factors. Practices related to asymptomatic, low-risk women were found to be mostly in accord with current guidelines and the lack of evidence for the effectiveness of tests. Practices regarding women with suspected early or late-stage ovarian cancer varied, particularly with regard to referral to gynecologic oncologists. Many respondents indicated that they have an important role to play in the care of women after they have been diagnosed with ovarian cancer or referred to another specialist. Respondents also expressed interest in obtaining additional information about ovarian cancer.

CONCLUSIONS

This study shows that there is a need for the development and dissemination of evidence-based guidelines regarding ovarian cancer. It also pinpoints areas where educational efforts could be directed.

Relationship between type of insurance and care during the early course of psychosis

OBJECTIVE

Little is known about the relationship between insurance and care in the early course of psychosis. This study explored the insurance status of first-admission psychotic patients and the relationship between type of insurance and care received up to this admission.

METHOD

Data are from the Suffolk County Mental Health Project, an epidemiologic study of first-admission psychosis. Data on insurance status (N=525) were pooled from hospital records, respondents, and significant others. Logistic regression analysis, controlling for key background variables and diagnosis, was used to study the relationship between insurance and care.

RESULTS

At first admission, 233 (44%) of the patients had no insurance, 78 (15%) had Medicaid or Medicare, 203 (39%) had private insurance, eight (1.5%) were insured by the Veterans Administration, and the insurance status of three (1.5%) was unknown. Having private insurance increased the likelihood of having received previous mental health treatment (psychotherapy specifically), being admitted voluntarily, being hospitalized in a community hospital rather than a public hospital, and being hospitalized within 3 months of onset of psychosis. Having Medicaid/Medicare increased the likelihood of receiving nonantipsychotic medication before this hospitalization, admission to a community hospital rather than a public hospital, having received previous mental health treatment in general, and voluntary admission.

CONCLUSIONS

During the early course of psychotic illness, many people lack any type of health insurance, and this is associated with a decreased likelihood of obtaining care before their first hospital admission.

Evaluating the Israeli health care reform: strategy, challenges and lessons

Evaluating the implementation of health care reform provides important information on its effect, as well as a factual basis for deciding upon mid-course modifications. Although researchers in various countries are addressing the impact of reform, only few governments have initiated a structured, planned evaluation to accompany reform efforts. In Israel, the 1995 National Health Insurance Law earmarked 0.1% of the health care budget for research on the law, coordinated by the National Institute for Health Policy and Health Services Research. This paper describes the evaluation strategy of the JDC-Brookdale Institute which is taking part in the research efforts. Implementation of the evaluation strategy and the challenges of evaluating a major reform of the health system are discussed. The evaluation strategy combines elements of formative and summative evaluation using a 'case study' approach which seeks to integrate in-depth understanding of the changing health system and of health care provider's organizational behavior, with a variety of outcome measures. The Israeli case provides support for the proposition that an integrated approach to evaluating health reform provides a better understanding of the subject under review and thus a better basis for making useful recommendations to policy makers. In addition, such an approach enhances the validity and credibility of the data and thus the probability of making an impact, which is a main objective of formative evaluation. Examination of the Israeli case, provides important insights about evaluation of health system reform, and may benefit researchers in other countries attempting to evaluate health care reform.

Health education goes Hollywood: working with prime-time and daytime entertainment television for immunization promotion

This article presents an entertainment education strategy used to influence Hollywood prime-time and daytime television programs to add storylines on the importance of immunizations to their shows. Rather than giving information about immunizations to show producers, directors, actors, and writers, we furnished "log lines" and true stories about immunizations that could be used to inspire scripts that included immunization themes. By working through personal contacts within the entertainment television industry's closed system of networks, we were able to gain entree and some airtime for our campaign agenda. Embedded messages aired on eight popular shows in the 1996-1997 broadcast season, with five scheduled to air in the 1997-1998 season. These efforts were evaluated qualitatively, focusing on issues of personal networks, content of aired messages, and comparative costs for paid airtime. The strategy developed can be adapted for a range of entertainment education interventions.

Cocaine decreases cortical cerebral blood flow but does not obscure regional activation in functional magnetic resonance imaging in human subjects

The authors used functional magnetic resonance imaging (fMRI) to determine whether acute intravenous (i.v.) cocaine use would change global cerebral blood flow (CBF) or visual stimulation-induced functional activation. They used flow-sensitive alternating inversion recovery (FAIR) scan sequences to measure CBF and blood oxygen level-dependent (BOLD) sensitive T2* scan sequences during visual stimulation to measure neuronal activation before and after cocaine and saline infusions. Cocaine (0.6 mg/kg i.v. over 30 seconds) increased heart rate and mean blood pressure and decreased end tidal carbon dioxide (CO2). All measures returned to baseline by 2 hours, the interinfusion interval, and were unchanged by saline. Flow-sensitive alternating inversion recovery imaging demonstrated that cortical gray matter CBF was unchanged after saline infusion (-2.4 +/- 6.5%) but decreased (-14.1 +/- 8.5%) after cocaine infusion (n = 8, P < 0.01). No decreases were detected in white matter, nor were changes found comparing BOLD signal intensity in cortical gray matter immediately before cocaine infusion with that measured 10 minutes after infusion. Visual stimulation resulted in comparable BOLD signal increases in visual cortex in all conditions (before and after cocaine and saline infusion). Despite a small (14%) but significant decrease in global cortical gray matter CBF after acute cocaine infusion, specific regional increases in BOLD imaging, mediated by neurons, can be measured reliably.

Expression of the verotoxin receptor glycolipid, globotriaosylceramide, in ovarian hyperplasias

The presence of cell surface receptor glycolipid, globotriaosylceramide (Gb3), is essential to confer susceptibility to the E. coli-derived verotoxin (VT). Our earlier studies showed that Gb3 is expressed in ovarian carcinoma cell lines. The Gb3 content of normal ovary, benign and malignant primary ovarian tumors, and their metastases have now been compared by verotoxin thin-layer chromatogram (TLC) overlay of the glycolipid tissue extracts. FITC-labeled VT1 B subunit binding to frozen tumor sections was also monitored histochemically. Low to undetectable levels of Gb3 were found in "normal" ovarian tissue. Gb3 was markedly increased in both benign and malignant tumors, suggesting that increased Gb3 may be related to proliferation, rather than malignancy per se. Mucinous tumors showed the least Gb3 elevation; serous tumors were variable, showing higher levels of Gb3 in less differentiated malignant tumors. By far the highest Gb3 content was observed for secondary ovarian metastases and tumors refractory to chemotherapy. Frozen sections of neoplastic ovarian tissue overlaid with fluorescein-conjugated VT1 B subunit show extensive binding to tumor cells, particularly in poorly differentiated samples and blood vessels adjacent to, and within, the tumor mass. Tumor foci were stained but stromal tissue was consistently negative both in primary tumors and metastases. VT staining of well-differentiated primary ovarian tumor sections was weak, corresponding to their low Gb3 content, but strong staining was observed in sections from a highly differentiated primary tumor from a patient who was unexpectedly refractory to clinical chemotherapy. These studies suggest that verotoxin/Gb3 targeting may provide the basis for new treatments for ovarian cancer.

Functional-anatomic correlates of object priming in humans revealed by rapid presentation event-related fMRI

Human functional-anatomic correlates of object repetition were explored in a cohort of 20 subjects using fMRI. Subjects performed an object classification task where the target objects were either novel or repeated. Objects appeared rapidly, one every 2 s, in a randomly intermixed task design similar to traditional behavioral, event-related potential (ERP), and single-unit physiological studies. Recently developed event-related fMRI methods were used to analyze the data. Clear effects of repetition were observed. Brain areas in midlevels of the processing hierarchy, including extrastriate visual cortex extending into inferotemporal cortex and left dorsal prefrontal cortex, showed reductions in the amount of activation after repetition. By contrast, early visual areas and output motor areas were activated equally by both novel and repeated objects and did not show effects of repetition, suggesting that the observed correlates of repetition were anatomically selective. We discuss these findings in relation to previous positron emission tomography (PET) and fMRI studies of item repetition and single-unit physiological studies; we also address the broad impact that rapid event-related fMRI is likely to have on functional neuroimaging.

The feasibility of assessing women's perceptions of the risks and benefits of fertility drug therapy in relation to ovarian cancer risk

OBJECTIVE

To determine the feasibility of asking women undergoing fertility treatment the maximum increased risk of ovarian cancer they would be willing to tolerate in order to take ovulation-induction drugs.

DESIGN

A prospective pilot study of women attending fertility clinics over a 2-month period.

SETTING

Two tertiary care fertility clinics in Toronto.

PATIENT(S)

Sixty-one English-speaking women were approached and 85% (n = 52) were enrolled.

INTERVENTION(S)

A self-administered questionnaire with fertility-specific questions. Thirty-eight women also were asked to complete standardized scales of anxiety and optimism.

MAIN OUTCOME MEASURE(S)

Women's report of the maximum level of lifetime risk of ovarian cancer they were willing to tolerate in order to undergo fertility treatment.

RESULT(S)

Seventy-nine percent were willing to accept an increased risk of ovarian cancer. Only 24% understood that treatment for ovarian cancer usually was not curative.

CONCLUSION(S)

A majority of patients were willing to tolerate a modest increase in their lifetime risk of ovarian cancer because of fertility treatment, most basing their estimate of acceptable risk on limited awareness of the issue.

Diagnosis, treatment, and six-month outcome status in first-admission psychosis

Six-month outcome status was examined in 202 first-admission inpatients with DSM-III-R schizophrenia spectrum (N = 96), psychotic bipolar disorder (N = 64), and psychotic depression (N = 42) drawn from 10 facilities in Suffolk County, New York. Schizophrenics fared significantly worse on all outcome variables rehospitalization, which ranged from 17.7 to 23.4%. Bipolars had good psychosocial outcomes regardless of clinical outcome, while the two outcome domains were uncorrelated among schizophrenics and psychotic depressed. Schizophreniform patients had significantly better outcome than those with schizophrenia or schizoaffective disorder. Posthospital treatment was generally unrelated to outcome except that fewer rehospitalized schizophrenics received continuous treatment, and patients with psychotic depression with poorer psychosocial outcome received medication less frequently. These findings highlight the different treatment needs of these diagnostic groups, especially as regards the provision of more intensive rehabilitation for schizophrenic patients and the "poor-outcome" psychotic depressed.

Rapid sequence analysis of gene trap integrations to generate a resource of insertional mutations in mice

Gene trapping in murine embryonic stem cells is a proven method for the simultaneous identification and mutation of genes in the mouse. Gene trap vectors are designed to detect insertions within genes through the production of a fusion mRNA transcript, making the identification of the endogenous gene possible by 5' rapid amplification of cDNA ends (RACE). Although the amplification of specific cDNAs can be achieved rapidly, cloning and screening of informative-sized cDNAs has proven to be time consuming. To eliminate the need for cloning, we have developed a method for solid-phase sequencing of 5' RACE products. More than 150 independent gene trap cell lines were analyzed, and sequence information was obtained for every line successfully amplified by RACE. With the vector used in this study, 40% of the cell lines were found to contain properly spliced gene trap events. The remaining lines were either spliced inefficiently or contained deletions of the vector. These results highlight the advantage of sequencing gene trap integrations before further characterization. This work now paves the way for large-scale gene trap screens in mice and should greatly accelerate the functional analysis of the mammalian genome.