Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

0636 Using AI To Predict Future CPAP Adherence and the Impact of Behavioral and Technical Interventions

Introduction

Clinical management of CPAP adherence remains an ongoing challenge. Behavioral and technical interventions such as patient outreach, coaching, troubleshooting, and resupply may be deployed to positively impact adherence. Previous authors have described adherence phenotypes that retrospectively categorize patients by discrete usage patterns. We design an AI model that predictively categorizes patients into previously studied adherence phenotypes and analyzes the statistical significance and effect size of several types of interventions on subsequent CPAP adherence.

Methods

We collected a cross-sectional cohort of subjects (N = 13,917) with 455 days of daily CPAP usage data acquired. Patient outreach notes and resupply data were temporally synchronized with daily CPAP usage. Each 30-days of usage was categorized into one of four adherence phenotypes as defined by Aloia et al. (2008) including Good Users, Variable Users, Occasional Attempters, and Non-Users. Cross-validation was used to train and evaluate a Recurrent Neural Network model for predicting future adherence phenotypes based on the dynamics of prior usage patterns. Two-sided 95% bootstrap confidence intervals and Cohen’s d statistic were used to analyze the significance and effect size of changes in usage behavior 30-days before and after administration of several resupply interventions.

Results

The AI model predicted the next 30-day adherence phenotype with an average of 90% sensitivity, 96% specificity, 95% accuracy, and 0.83 Cohen’s Kappa. The AI model predicted the number of days of CPAP non-use, use under 4-hours, and use over 4-hours for the next 30-days with OLS Regression R-squared values of 0.94, 0.88, and 0.95 compared to ground truth. Ten resupply interventions were associated with statistically significant increases in adherence, and ranked by adherence effect size using Cohen’s d. The most impactful were new cushions or masks, with a mean post-intervention CPAP adherence increase of 7-14% observed in Variable User, Occasional Attempter, and Non-User groups.

Conclusion

The AI model applied past CPAP usage data to predict future adherence phenotypes and usage with high sensitivity and specificity. We identified resupply interventions that were associated with significant increases in adherence for struggling patients. This work demonstrates a novel application for AI to aid clinicians in maintaining CPAP adherence.

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Soft tissue sarcomas of the groin: diagnosis, management, and prognosis

BACKGROUND

Sott tissue sarcomas (STS) of the groin may present a difficult problem because or misdiagnosis as groin hernia and proximity to major neurovascular structures. We evaluated our management and survival in a large cohort of patients.

STUDY DESIGN

Patients treated between July 1, 1982 and July 1, 1998 with primary or recurrent STS of the groin were included. Groin sarcomas were defined as those tumors within 5 cm of the inguinal crease. Patient, tumor, clinical, and survival data were analyzed using a log rank test and Cox regression.

RESULTS

We treated and followed 88 patients with STS of the groin. The median age was 52 years (range 16 to 86 years) and 55 patients (63%) were male. Disease-specific survival was 72% at 5 years. Tumors tended to be larger than 5 cm (52%), deep (72%), and high-grade (60%). Unfavorable prognostic factors for disease-specific survival were high grade (p < 0.001), neurovascular invasion (p < 0.001), positive margin (p < 0.01), deep depth (p < 0.01), and selection for adjuvant therapy (p < 0.005). Multivariate analysis indicated age greater than 50 years (p < 0.05), high grade (p < 0.001), neurovascular invasion (p < 0.001), and positive microscopic margins (p < 0.001). Fourteen patients (16%) were diagnosed with STS at hernia operation then went on to a definitive operation with no impact on survival. Seventeen patients (19%) had involvement of a major vessel or nerve, and 5 of these ultimately required amputations, 3 for local recurrence.

CONCLUSIONS

High grade, neurovascular invasion, and positive microscopic margins are associated with poor outcomes. The biology of these tumors is similar to other extremity STS, and similar principles of management apply. Even with neurovascular involvement, most patients with primary groin STS do not require amputation.

Multifactorial analysis of long-term follow-up (more than 5 years) of primary extremity sarcoma

BACKGROUND

The majority of survival studies in patients with extremity soft tissue sarcoma have focused on early recurrence and mortality. There are few data addressing long-term follow-up and survival.

OBJECTIVE

To analyze survival and recurrence in patients with extremity soft tissue sarcoma who survive for more than 5 years.

METHODS

Patients who underwent treatment for primary tumors (July 1982 to July 1994) and were followed up for more than 5 years were the subject of study. Disease-specific and disease-free survival were determined actuarially. Significance was evaluated using log-rank testing for univariate analysis and Cox model stepwise regression for multivariate analysis.

RESULTS

A total of 495 patients with primary extremity tumors were treated before July 1989 and eligible for 5-year follow-up. Of these, 282 have been followed up for more than 5 years (median follow-up, 84.4 months). Actuarial disease-specific survival of patients who survive for longer than 5 years was 79%+/-7% (+/-SEM) at 10 years, and of those who were metastasis free at 5 years was 91%+/-4% at 10 years. On univariate analysis, post-5-year disease-specific survival was influenced by positive microscopic margin and initial tumor size of 5 cm or greater. On multivariate analysis, post-5-year disease-specific survival was influenced only by positive margins.

CONCLUSIONS

Based on these analyses, 21% of patients with primary extremity sarcoma who survive for 5 years will die of disease within 5 years. Even of those who are metastasis free at 5 years, 9% will die of disease within 5 years. In contrast to early mortality, tumor grade has no influence on post-5-year prognosis. Patients with positive microscopic margins are at risk for post-5-year disease-specific mortality and therefore require long-term follow-up and consideration for investigational therapy.

Phase II trial of paclitaxel in patients with soft-tissue sarcoma

The response rate (RR) to single-agent chemotherapy with doxorubicin or ifosfamide in patients with advanced soft-tissue sarcoma (STS) is in the range of 20%. Paclitaxel is clinically useful in treating several solid tumors and has demonstrated activity in a series of human sarcoma cell lines. Twenty-eight patients with measurable advanced STS participated in this phase II trial of paclitaxel at 250 mg/m2 administered as a 3-hr i.v. infusion once every 3 weeks. All patients received granulocyte colony-stimulating factor (G-CSF) beginning on the day after paclitaxel and lasting until recovery from neutropenia. No prior chemotherapy had been used in 17 patients; 10 patients had had prior doxorubicin-based therapy; and 1 patient had had intraperitoneal therapy with edatrexate. Two partial responses (PRs) (7%; 95% confidence interval [CI] = 1-23%) were observed. The responding patients included a patient with angiosarcoma of the scalp who had complete regression of cutaneous lesions and improvement of nonmeasurable pulmonary disease lasting 6 months. The other PR occurred in a woman with metastatic uterine leiomyosarcoma and lasted 9 months. Seven patients had stable disease for 3-4 months. Median time to progression for all patients was 3.5 months (range: 2.5-9 months). The mean nadir in the white-blood-cell (WBC) count was 3.8 x 10(3)/microliter (range: [0.2-16.2] x 10(3)/microliter), with a mean nadir in the absolute neutrophil count (ANC) of 2.4 x 10(3)/microliter (range: [0.0-7.1] x 10(3)/microliter). Three patients died while in the study. Two patients with angiosarcoma of the scalp who did not qualify for this study were treated with paclitaxel off protocol, and experienced dramatic tumor regression. The overall response to paclitaxel observed in this heterogeneous group of patients was disappointing. However, the activity seen in angiosarcoma of the scalp suggests that further evaluation is warranted in patients with STS.

SYT-SSX gene fusion as a determinant of morphology and prognosis in synovial sarcoma

BACKGROUND

Synovial sarcomas account for up to 10 percent of soft-tissue sarcomas and include two major histologic subtypes, biphasic and monophasic, defined respectively by the presence and absence of glandular epithelial differentiation in a background of spindle tumor cells. A characteristic SYT-SSX fusion gene resulting from the chromosomal translocation t(X;18)(p11;q11) is detectable in almost all synovial sarcomas. The translocation fuses the SYT gene from chromosome 18 to either of two highly homologous genes at Xp11, SSX1 or SSX2. SYT-SSX1 and SYT-SSX2 are thought to tunction as aberrant transcriptional regulators. We attempted to determine the influence of the two alternative forms of the SYT-SSX fusion gene on tumor morphology and clinical outcome in patients with this sarcoma.

METHODS

We analyzed SYT-SSX fusion transcripts in 45 synovial sarcomas (33 monophasic and 12 biphasic) by the reverse-transcriptase polymerase chain reaction and compared the results with relevant clinical and pathological data.

RESULTS

The SYT-SSX1 and SYT-SSX2 fusion transcripts were detected in 29 (64 percent) and 16 (36 percent) of the tumors, respectively. There was a significant relation (P=0.003) between histologic subtype (monophasic vs. biphasic) and SSX1 or SSX2 involvement in the fusion transcript: all 12 biphasic synovial sarcomas had a SYT-SSX1 fusion transcript, and all 16 tumors that were positive for SYT-SSX2 were monophasic. Kaplan-Meier analysis of 39 patients with localized tumors showed that the 15 patients with SYT-SSX2 had significantly better metastasis-free survival than the 24 patients with SYT-SSX1 (P=0.03 by multivariate analysis; relative risk, 3.0). There were no significant correlations between the type of SYT-SSX transcript and age, sex, tumor location and size, whether there were metastases at diagnosis, or whether patients underwent chemotherapy. Histologic subtype alone was not prognostically important.

CONCLUSIONS

The type of SYT-SSX fusion transcript correlates with both the histologic subtype and the clinical behavior of synovial sarcoma. SYT-SSX fusion transcripts are a defining diagnostic marker of synovial sarcomas and may also yield important independent prognostic information.

Multifocal extremity sarcoma: an uncommon and controversial entity

BACKGROUND

The primary site of metastasis from extremity sarcomas is the lung. When patients with extremity sarcoma present with the disease in more than one site but not in the lung, the question of whether the disease is multifocal or metastatic is difficult to resolve.

METHODS

We reviewed 1423 patients admitted with extremity sarcoma from 1982 through 1996. Patient demographics, primary site, other sites, local recurrence, distant metastasis, and survival were analyzed. Statistics were by Fischer exact test, chi 2, Kaplan-Meier method, and log-rank test where appropriate.

RESULTS

Sixteen (1%) patients were identified with multifocal disease out of 1423 patients with extremity sarcoma. There was no difference in sex, age, size, grade, depth, and margins between multifocal and unifocal disease. In a mean follow-up time of 57 months, 50% had local recurrence of primary tumor, 80% had distant metastasis, and only 30% were alive at the time of the analysis. Whereas 21% of all patients with solitary disease develop lung metastasis, 63% of patients with apparent multifocal disease develop lung metastasis. The 5-year disease-specific survival of patients with multifocal disease was not different from that of all patients presenting with metastatic disease to lung.

CONCLUSION

Whether multifocal disease exists or is merely a form of metastasis is unproven by this analysis, but the outcome is the same. Management algorithms should suggest treating patients with multifocal disease as if it is metastatic disease.

Analysis of prognostic factors in 1,041 patients with localized soft tissue sarcomas of the extremities

PURPOSE

To identify specific independent adverse clinicopathologic factors for event-free survival in a cohort of consecutively treated patients with extremity soft tissue sarcomas.

PATIENTS AND METHODS

Prospectively collected data from a population of 1,041 adult patients with localized (American Joint Committee on Cancer [AJCC] stage IA to IIIB) extremity soft tissue sarcomas were analyzed. Patients were treated at a single institution between 1982 and 1994. Patient, tumor, and pathologic factors were analyzed by univariate and multivariate techniques to identify independent prognostic factors for the end points of local recurrence, distant recurrence, disease-specific survival, and post-metastasis survival.

RESULTS

The 5-year survival rate for this cohort of patients was 76%, with a median follow-up time of 3.95 years. Significant independent adverse prognostic factors for local recurrence were age greater than 50 years, recurrent disease at presentation, microscopically positive surgical margins, and the histologic subtypes fibrosarcoma and malignant peripheral-nerve tumor. For distant recurrence, intermediate tumor size, high histologic grade, deep location, recurrent disease at presentation, leiomyosarcoma, and nonliposarcoma histology were independent adverse prognostic factors. For disease-specific survival, large tumor size, high grade, deep location, recurrent disease at presentation, the histologic subtypes leiomyosarcoma and malignant peripheral-nerve tumor, microscopically positive surgical margins, and lower extremity site were adverse factors. For post-metastasis survival, only large tumor size ( > 10 cm) was an adverse prognostic factor.

CONCLUSION

The independent adverse prognostic factors for distant recurrence and disease specific survival differ from those identified for subsequent local recurrence. Patients with microscopically positive surgical margins or patients who present with locally recurrent disease are at increased risk for subsequent local recurrence and tumor-related mortality. Specific histopathologic subtypes are associated with increased risks for local failure and tumor-related mortality.

Prognostic significance of a positive microscopic margin in high-risk extremity soft tissue sarcoma: implications for management

PURPOSE

A positive microscopic margin (PMM) is a significant prognostic variable and leads to local recurrence (LR) in high-grade soft tissue sarcoma (STS) patients. Its effect on the rate of distant metastasis (DM) and tumor mortality (TM) remains controversial.

PATIENTS AND METHODS

One hundred sixty-eight primary, high-risk (high-grade, deep, > or = 5 cm) extremity STS patients were identified from our data base, of which 42 had a PMM. Limb-sparing surgery (LSS) was the primary surgical therapy in 144 patients; 24 received amputation (AMP). Statistical analysis was by log-rank test and Cox model. Significance was defined as a P value less than .05.

RESULTS

A PMM was a significant negative prognostic factor for both DM and TM (P = .002 and .002, respectively). However, those patients who received LSS with 28% PMMs showed no significant difference in the rate of DM or TM compared with patients who received AMP with only 8% PMMs (log-rank, P = .057 and .28, respectively). A PMM was significantly associated with > or = 1,000 mL blood loss and more than 3 hours of operating time (P < .006 and .001, respectively).

CONCLUSION

The strong statistical significance that relates a PMM to DM and TM in high-risk STS of the extremity is likely related to biologically aggressive tumors and LSS. Residual microscopic disease is not a guarantee of LR. The main problem in this group of patients is not LR, but DM and subsequent death. Therefore, to increase a disability with further surgery or amputate a patient's limb without clear evidence of LR in this group at high risk for distant recurrence is not recommended.

Molecular diagnosis of synovial sarcoma and characterization of a variant SYT-SSX2 fusion transcript

The translocation t(X;18)(p11;q11) is seen in > 80% of synovial sarcomas (SS) with informative karyotypes. The breakpoints of the t(X;18) have been cloned and shown to involve two novel genes, SSX (at Xp11) and SYT (at 18q11), which produce a chimeric SYT-SSX transcript as a result of the translocation. Recently, SSX has been shown to be duplicated, with both copies, SSX1 and SSX2, located within distinct subregions of Xp11. We performed a reverse transcriptase polymerase chain reaction (RT-PCR) assay for both chimeric SYT-SSX transcripts in a series of 35 SS (29 monophasic, 6 biphasic) to assess its usefulness in molecular diagnosis and to evaluate the incidence of molecular variants. Of the 35 cases, 29 (83%) showed a specific SYT-SSX RT-PCR product, using a consensus primer for SSX1 and SSX2 Upon excluding three negative cases that had poor quality RNA, the proportion of positives rose to 91% (29/32). The 29 positive cases were further studied using primers specific for either SSX1 or SSX2; 19 cases were positive for SYT-SSX1 and 10 for SYT-SSX2. The relationship of histological subtype (monophasic versus biphasic) to SSX1 or SSX2 involvement was not statistically significant. In a single histologically unremarkable monophasic SS, a slightly larger SYT-SSX2 RT-PCR product was observed. Sequencing of this novel variant showed a 129-bp segment inserted between the usual SYT and SSX2 fusion points, of which 126 bp were derived from a more proximal (5') portion of SSX2 The 3 bp immediately 5' to the fusion point could not be assigned to either SYT or SSX2 and may represent an insertion-deletion or a cryptic splicing event. This fragment maintains the reading frame of the chimeric product and encodes a predicted protein larger by 43 amino acids, which nevertheless replaces the region homologous to the transcriptional repression domain Kruppel-associated box, recently recognized in the 5' portion of the SSX genes, with all but the 3' end of the SYT transcript. Thus, a diagnosis of SS may be confirmed in > 90% of cases using RT-PCR detection of the chimeric transcript resulting from the t(X;18), and the incidence of molecular variants appears low.

Effect of perioperative blood transfusion on recurrence and survival in 232 primary high-grade extremity sarcoma patients

BACKGROUND

Allogeneic blood transfusion (BT) has been implicated as an unfavorable factor influencing cancer recurrence and overall survival.

METHODS

To investigate this, 232 consecutive localized, high-grade extremity soft tissue sarcoma (STS) patients admitted between January 1, 1983, and December 31, 1989, were analyzed from our prospective database by univariable and Cox multivariable statistical methods.

RESULTS

Twenty-eight patients developed a local recurrence (LR). Factors found significantly unfavorable for the rate of developing an LR by uni- and multivariable tests were age > 60 years and positive microscopic margin. Eighty-nine patients developed a distant metastasis (DM) and 72 patients died of their tumor. Median follow-up of survivors was 48 months. Unfavorable factors for DM and tumor mortality (TM) by univariable analysis included large size, deep tumor (that involved or was below the superficial fascia), positive microscopic margin, invasion of a vital structure, operative blood loss, duration of operation, and perioperative BT (whole blood or packed cells -24 to +48 h of curative operation). Multivariable analysis found large size, deep tumor, and positive margin significant independent unfavorable factors for DM and TM. The effect of BT was not a significant independent prognosticator for LR, DM, or TM by multivariable analysis (p = 0.26, 0.56, 0.08, respectively). The only factor that was found to be significant in a multivariable analysis of factors contributing to postmetastasis survival was time < 6 months until metastasis (p = 0.008). BT had no significant impact on postmetastasis survival (p = 0.42). There was a significant association between BT and deep, large tumors. As the size of deep tumors increased from < 5, > or = 5 < 10, > or = 10 < 15, or > or = 15 cm, the amount transfused was 15, 16, 49, and 68% (p < 0.00001). Also, BT was significantly (p < 0.005) associated with low hematocrit at initial diagnosis, blood loss during surgery, and the length of the surgical procedure.

CONCLUSIONS

These data emphasize the importance of size, depth, and margin on distant recurrence and death for localized high-grade extremity STS. In the absence of a randomized trial, the impact of allogeneic blood transfusion would appear to be due to its strong association with large size and deep tumor invasion. This study also highlights the importance of a multivariable analysis and long-term follow-up to better define this controversial question.

Management of small soft-tissue sarcoma of the extremity in adults

To determine the significance of small (< or = 5 cm in diameter) soft-tissue sarcoma of the extremity, 174 adult patients were identified from information that had been entered prospectively into a database of 1742 patients between July 1982 and December 1990. Median follow-up was 48 months. The majority of tumors were high grade (n = 114; 66%). Local recurrence (n = 17) was seen in patients with both high-grade (11%) and low-grade tumors (7%). Distant metastases were seen in 7% of high-grade tumors and in no low-grade tumors. The overall 5-year survival rate was 94% for all patients. Grade, depth, location, type of operation, and sex did not affect 5-year survival or local recurrence-free survival. Neither postoperative adjuvant chemotherapy nor radiation therapy resulted in superior 5-year survival or local recurrence-free survival when compared with no postoperative treatment. The prognosis of these lesions is favorable, and no additional prognostic factors were identified. Inclusion of these patients into adjuvant therapy trials examining survival is inappropriate.

Germ cell tumors in children: gonadal and extragonadal

Sixty-three pediatric patients with germ cell tumors are presented with details of symptoms, histological findings, staging, serological markers, treatment, and response to therapy. The primary sites were: ovarian 32, testicular 17, presacral 7, mediastinal 3, intraabdominal 2, vaginal 1, and right inguinal canal 1. These patients were treated with T2 (sequential use of dactinomycin, doxorubicin, vincristine, and cyclophosphamide, with or without radiation), T6 (combination chemotherapy with cyclophosphamide, bleomycin, dactinomycin, doxorubicin, methotrexate, vincristine), or VAB treatment protocols (velban, dactinomycin, bleomycin, cisplatin). The cure rate for stage I ovarian and testicular germ cell tumors was 100%; for stage III, all primary sites, 82% and for stage IV, all primary sites, 75%. Histology was prognostic in ovarian tumors of the immature malignant teratoma type; the neural type immature teratoma, grades II and III, had the worst prognosis. Initial debulking surgery in combination with chemotherapy and radiation plays an important role in germ cell tumors. Stages II, III, and IV germ cell tumors require aggressive treatment with surgery, radiation, and chemotherapy. For stage I patients, with primary ovarian malignant tumor, cure with surgery alone can be achieved in 50% of the cases and in testicular tumors in about 70% of the patients. For those with stage I and elevated serological markers, it is feasible to follow these markers and give no treatment until there is evidence of persistent elevation or a rise in titers after an initial fall. In those without elevated serological markers, one should take into consideration the size of the tumor and the histological type before taking the "wait and see" approach. These stage I tumors are highly curable when they first present but, if allowed to recur, chemotherapy may not offer the patient such a favorable response and cure rate.

Noncontraceptive estrogen use and epithelial ovarian cancer

The relation of noncontraceptive estrogen use to epithelial ovarian cancer was evaluated in a case-control study conducted in hospitals mainly in the northeastern United States. There were 377 cases diagnosed within the year before hospital admission and 2,030 hospital controls; data were collected by interview in the hospital. Compared with women who never took noncontraceptive estrogens, the overall relative risk estimate for women whose estrogen use lasted at least one year and was not combined with progestogens or testosterone was 1.2 (95% confidence interval (CI) 0.8-1.9), after taking into account risk factors for ovarian cancer. There were 55 cases of the endometrioid, clear cell, or malignant mixed mesodermal cell type; the corresponding relative risk estimate was 0.9 (95% CI 0.3-3.0). There were 26 cases of undifferentiated cell type, with a relative risk estimate of 3.6 (95% CI 1.2-11). Relative risk estimates were similar in a subset of the cases (57%) for which pathology slides were reviewed. For estrogen use of long duration, use of high-dose preparations, or use in the distant past, the relative risk estimates were not significantly different from 1.0. The estimates were elevated for some categories of use, but not consistently--for example, for an interval of 5-9 years since estrogen use began (relative risk (RR) = 2.7), but not after shorter or longer intervals, and for use of conjugated estrogens with a dose of 0.3 mg (RR = 3.2) or 1.25 mg (RR = 2.4), but not for doses of 0.625 mg or 2.5 mg. The relative risk estimate was also elevated for use by nulliparous women (RR = 2.4). The results suggest that, overall, noncontraceptive estrogen use is not associated with the risk of epithelial ovarian cancer. Furthermore, our data do not support the hypothesis that estrogens increase the risk of endometrioid ovarian cancer. The elevated estimates could be due to multiple stratification of the data, but they should be explored in further studies, given the lethality of ovarian cancer and the common use of estrogens by postmenopausal women.

Virilizing hilus (Leydig) cell tumor of the ovary: the challenge of an accurate preoperative diagnosis

A 73-year-old woman developed temporal balding and "hoarseness" over a 3-year interval. Investigation including extensive endocrinologic screening, abdominal computed tomography scanning, pelvic ultrasonography, iodocholesterol (NP-59) adrenal scanning, and selective retrograde venous sampling revealed only an elevated serum testosterone level without localization of the source. At laparotomy a 2.0 cm left ovary was found to contain a hilus (Leydig) cell tumor. The testosterone level in a blood sample from the left ovarian vein obtained intraoperatively was 9000 ng/dl, whereas a blood sample from the right ovarian vein contained 213 ng/dl. One week later her peripheral blood testosterone level was normal (8 ng/dl). The records of six other patients with ovarian hilus cell tumors were reviewed from the Memorial Hospital Registry (from 1959 to 1982). All tumors were small (ovaries were 2 to 4 cm in diameter) and benign. The average patient's age was 63 years (range: 57 to 73 years). Only three of the seven patients in our series were first seen with virilization; the tumors in the remaining four patients were found incidentally. Ovarian hilus cell tumors are rare and are difficult to diagnose, but surgeons and endocrinologists should think of this tumor when they investigate older female patients with virilization. Careful intraoperative examination of even normal-appearing ovaries is imperative, particularly if no adrenal disease is found.

Extracellular volume expansion and delayed resolution of hypertension after canine aortic coarctectomy

The hemodynamic changes occurring after surgical correction of thoracic aortic coarctation were studied in two neonatally coarcted dogs at six months of age and compared to sham surgery in two littermate controls. Excision of the tight iatrogenic aortic band with direct aortic reanastomosis abolished pressure gradients. Post-coarctectomy systemic pressure rose, after an early transient fall, to pre-operative proximal levels and was sustained for two to four weeks before decreasing to control normotensive values. Femoral systolic pressure (and renal perfusion pressure) rose by 47-57 mmHg in coarcted dogs (p less than .001). Extracellular volume (ECV) increased in both coarcted animals, peaking 28-32 cc/kg (7.1-7.6% increase) above precoarctectomy levels. Peak ECV expansion coincided with the peak post-coarctectomy blood pressure. Fluid administration, blood losses and plasma renin activity (PRA) were comparable in all animals. Post-coarctectomy tachycardia was also noted in coarcted dogs (p less than .001), whereas neither ECV nor heart rate changes occurred in control animals. We postulate that post-coarctectomy baroreceptor stimulation results in sympathetically-mediated renal sodium retention, not only preventing a pressure diuresis, but resulting in overt volume expansion. Failure of PRA suppression despite increased distal pressure and volume excess may also reflect sympathetic activation. Data are compatible with the view that sympathetic activation and consequent volume expansion transiently sustain hypertension in the post-coarctectomy setting until baroreceptor re-adjustments permit normalization of blood pressure.

Dysgerminoma of the ovary

From 1938 to 1977, 21 patients with pure dysgerminoma were treated at Memorial and James Ewing Hospitals, now Memorial Sloan-Kettering Cancer Center. Twelve patients were considered to have their initial therapy begun or completed at our institution. Eleven (91.7%) of 12 patients were found free of disease from 2 to 38 years (median 6 years). Nine patients were referred with recurrent disease. Only 4 (45%) could be salvaged 2 to 21 years (median 9 years). Because of the lower survival rate in the treatment of recurrent disease in this series, it is difficult to advocate overly conservative therapy initially in all early lesions. The survival rate depends on the original size of the tumor, initial adequate staging and appropriate therapy based on the extent of disease. Recommendations for a treatment protocol are proposed.

Biostatistical basis of elective node dissection for malignant melanoma

During the years 1954 through 1964, 259 individuals with primary malignant melanoma had an elective node dissection. Microscopic metastases were found in 15% of these patients. The presence of only a microscopic focus of involvement gave a 10-year cure rate of 67%; metastasis larger than a microscopic focus in a single node, 50%; and more than one node, 15%. One hundred forty-five individuals were treated by wide excision alone with 18% subsequently requiring a therapeutic lymphadenectomy with a ten-year cure of only 6%. A prospective study was then initiated which was concerned with efficacy of selection of patients for elective node dissection. Clark's level of invasion was determined for 258 patients treated since January 1972. The depth of invasion of the primary lesion was found to correlate directly with the absence of lymph node metastases, extent of nodal involvement, and rate of recurrence. It is concluded that the concept of elective node dissection is valid.

Effects of cell mediated immunity in influenza virus infection in mice

The role of cell mediated immune responses in recovery of mice from influenza virus infection was studied by immunosuppression and by adoptive immunization. Virus infections persisted longer and produced more severe lung lesions in animals injected with anti-thymocyte serum (ATS), and immunosuppressed animals failed to mount a serum HI antibody response. Mice injected with ATS after the 4th day of infection produced antibody in titers equivalent to those of control animals but still did not recover from infection as rapidly. Passive immunization with antibody late in infection did not facilitate clearance of virus from ATS injected animals. Adoptive transfer of spleen cells obtained from syngeneic animals sensitized intraperitoneally resulted in more rapid clearance of virus and less severe lung lesions in infected recipient animals. This effect was associated with a lower antibody response in recipient mice. Adoptive immunization was still effective after depletion of beta lymphocytes from the transferred cell population. These effects correlate with in vitro assays of the cytotoxic T cell response and antibody forming cell response of sensitized mice. From these observations we conclude that T lymphocytes may play a role in recovery from influenza virus infection by mechanisms other than helper effects.

Selection of the optimum surgical treatment of stage I melanoma by depth of microinvasion: Use of the combined microstage technique (Clark-Breslow)

The methods of histologic staging of primary Stage I melanoma and the relation to lymph node metastases and survival after surgery was evaluated in 151 patients with extremity melanoma only. Microstaging by depth of invasion showed a better prognostic correlation than by histologic typing (into superficial spreading, or nodular melanoma). A correlation existed between depth of invasion (Clark's levels) and incidence of nodal metastases at elective node dissection. This incidence was 5% at Level II, 4% at Level III, 25% at Level IV and 75% at Level V. The measured depth of invasion added prognostic insight to each Clark's level; the minimal invasion at which nodal metastases occurred was 0.6 mm for Level II, 0.9 mm for Level III, 1.5 mm for Level IV and over 4 mm for Level V. The 5 year disease-free survival after surgery was 100% for Clark Level II, 88% for Level III, 66% for Level VI and 15% for Level V. There was a direct relation between the measured depth of invasion and survival and mortality from disease at 5 years. Mortality from disease at 5 years could be directly equated with 10 times microinvasion in mm. Microstaging by direct measurement gave a better prognostic correlation than was found using Clark's levels for more deeply invading melanoma. At this time there is suggestive evidence that patients with certain higher risk lesions may do significantly better with wide excision and elective node dissection than with wide excision alone. These high risk lesions include Clark Level III to V, lesions measuring 0.9 mm or greater and all nodular melanomas.

Malignant melanoma of the extremities: a clinicopathologic study using levels of invasion (microstage)

A clinicopathologic study was done in 151 patients with malignant melanoma of the extremities who were surgically treated in Memorial Hospital and had 5-to 9-year followup. Microstaging was done according to the depth of invasion, as determined by Clark's levels as well as by direct measurement. This was related to treatment and to clinical course. There was a correlation between the depth of invasion by Clark's levels and the incidence of lymph node metastases in patients with Stage I melanoma who had elective node dissection. The incidence of nodal metastases was 4% for Level II, 7% FOR Level III, 25% for Level IV, and 70% for Level V. There was a correlation between Clark's level of invasion and survival aftter surgery. The 5-year cure rate was 100% for Level II, 88% for Level III, 60% for Level IV, and 15% for Level V melanoma. The presence of nodal metastases augured a much worse prognosis than Clark's level per se. In patients with Level IV melanoma, the 5-year cure rate was 82% in patients with negative nodes and 27% in those with nodal metastases after elective node dissection. Microstaging primary melanoma according to Clark's levels serves as a useful standard with which to compare surgical results. In this series of extremity melanomas there was no difference between local recurrence and lymphadenectomy for Level II melanoma. For Level III and Level IV melanoma, wide excision and lymphadenectomy gave higher cure rates than wide excision only, both at 5 and 9 years after surgery. The results were significant only for patients with Level III, however. Use of the measured depth of invasion added significant clinicopathologic information. The incidence of nodal metastases at elective node dissection was 5 to 9% for melanoma showing 0.6 to 2.0 mm of invasion, 22% for melanoma measuring 2.1 to 3.0 mm, and 39% for melanoma invading beyond 3.0 mm. The 5-year cure rate was 100% for melanoma measuring less than 1.0 mm, 83% for melanoma invading 1.1 to 2.0 mm, 58% for lesions measuring 2.1 to 3.0 mm, and 55% for melanoma invading over 3.0 mm. The microstage technique combining Clark's levels and the measured depth of invasion has an important use as a prognostic index and as a standard upon which to select treatment for primary melanoma of the extremities.

Lymphocytes: circulation altered by trypsin

Rat thoracic duct lymphocytes altered by trypsin in vitro do not circulate normally. At early intervals after transfusion of lymphocytes labeled with chromium-51 selective accumulation of radioactivity in the lymph nodes is abolished, while uptake in the spleen is not reduced. Later, the cells appear to "home" to lymph nodes and recirculate to the lymph.

Phytohemagglutinin: inhibition of the agglutinating activity by N-acetyl-D-galactosamine

The effect of simple sugars on the agglutinating activity of phytohemagglutinin was studied. N-Acetyl-d-galactosamine selectively inhibits the agglutination of leukocytes and erythro- cytes by phytohemagglutinin.