Discrimination of Frailty Phenotype by KinectTM-Based Stepping Parameters

Background

Frailty increases the risk of falling, hospitalization, and premature death, necessitating practical early-detection tools.

Objectives

To examine the discriminative ability of KinectTM-based stepping parameters for identifying frailty phenotype.

Design

Population-based cross-sectional study.

Setting

Eighteen neighborhoods near Tokyo Metropolitan Institute for Geriatrics and Gerontology, Itabashi, Tokyo, Japan.

Participants

In total, 563 community-dwelling older adults aged ≥75 years without mobility limitations, neurological disease, or dementia were included.

Measurements

Step number (SN) and knee total movement distance (KMD) during a 20-s stepping test were evaluated using the KinectTM infrared depth sensor.

Results

The number (%) of participants with frailty were 51 (9.1). The area under the receiver operating characteristic curves (95% confidence interval) of a parameter consisting of SN and KMD for frailty was 0.72 (0.64, 0.79).

Conclusions

Stepping parameters evaluated using KinectTM provided acceptable ability in identifying frailty phenotype, making it a practical screening tool in primary care and home settings.

Trajectory of criterion symptoms of major depression under newly started antidepressant treatment: sleep disturbances and anergia linger on while suicidal ideas and psychomotor symptoms disappear early

OBJECTIVE

In modern psychiatry, depression is diagnosed with the diagnostic criteria; however, the trajectory of each of the criterion symptoms is unknown. This study aims to examine this.

METHODS

We made repeated assessments of the nine diagnostic criterion symptoms with the Patient Health Questionnaire-9 (PHQ-9) among 2011 participants of a 25-week pragmatic randomised controlled trial of sertraline and/or mirtazapine for hitherto untreated major depressive episodes. The changes from baseline were estimated with the mixed-effects model with repeated measures. The time to disappearance of each symptom was modeled using the Kaplan-Meier survival analysis.

RESULTS

The total score on PHQ-9 was 18.5 (SD = 3.9, n = 2011) at baseline, which decreased to 15.3 (5.2, n = 2011) at week 1, to 11.5 (5.9, n = 1953) at week 3, to 7.8 (6.0, n = 1927) at week 9, and to 6.0 (5.9, n = 1910) at week 25. Suicidal ideas, psychomotor symptoms decreased rapidly, while anergia and sleep disturbance also decreased but only slowly. The survival analyses confirmed the primary analyses.

CONCLUSIONS

Upon initiation of antidepressant treatment, patients with newly treated major depressive episodes can expect their suicidal ideas and psychomotor symptoms to disappear first but sleep disturbances and anergia to linger on.

Development of Simple, Objective Chair-Standing Assessment of Physical Function in Older Individuals Using a KinectTM Sensor

BACKGROUND

With increasing interest in addressing quality of life of older individuals, tests such as the Functional Independence Measure (FIM) are widely used measures of infirmity and burden of care. However, these scales are largely qualitative and especially problematic when assessing movement-based tasks. While effective, reliable analysis of human movement is technically complicated and expensive; an infrared depth sensor is potentially a low-cost, portable devise which may provide a quantitative aspect to clinical testing.

OBJECTIVE

to assess the utility of the KinectTM sensor in providing an objective evaluation of human movement using an oft measured ADL (chair stand).

DESIGN

Cross-sectional study.

SETTING

Community, geriatric day-care center in Japan.

PARTICIPANTS

Men (n=136) and women (n=266) between 50 and 93 years of age, consisting of healthy (HE; n=312) and physically frail (FR; n= 90) individuals.

MEASUREMENTS

Subjects completed two trials of the chair stand, conducted without assistance. Trials were timed and recorded with KinectTM v2. Coronal plane angle (CPA) was determined by a line transecting the shoulder-center and waist relative to the vertical axis and was used to assess quality of the chair stand movement pattern.

RESULTS

Age, height, and body mass were not different between groups. CPA was significantly greater in FR (29.3 ± 8.3°) than HE (19.5 ± 6.5°). CPA and age were significantly related (r=0.148, p<0.01). An optimal threshold for CPA identifying frailty was determined by a receiver-operator characteristic curve with a CPA of 23.1° providing the greatest combination of sensitivity (79%) and specificity (73%).

CONCLUSION

During the chair stand, frail older adults adopted a forward lean position (increased CPA) compared to healthy older adults. This compensatory posture appears to facilitate torso rotation while reducing lower-limb muscular effort during standing. As such, CPA serves as an indicator of reduced lower-body function in older, frail adults.

Protocol registration and selective outcome reporting in recent psychiatry trials: new antidepressants and cognitive behavioural therapies

OBJECTIVE

The selective reporting of favorable outcomes has a serious influence on our evidence base. However, this problem has not yet been systematically investigated in the field of psychiatry. Our study aimed to evaluate registration and outcome reporting in randomized controlled trials (RCTs) of standard treatments for depression: cognitive behavioural therapy (CBT) or new-generation antidepressants (ADs).

METHOD

We searched for reports of RCTs examining the efficacy of CBT or AD for depression that were published between 2011 and 2013. We then compared their primary outcomes in the trial registries and those in publications.

RESULTS

We identified 170 trials. Among them, 92 trials (54.1%) were registered, 43 trials (25.3%) were properly registered, and only 32 (18.8%) trials were both properly registered and reported (the primary outcomes as recorded in the registries were reported in publications). There was no statistically significant difference in the proportions of properly registered and reported trials for CBT or AD (relative risk: 0.51, 95% CI: 0.25-1.03). High impact factor journals, commercial funding, publication of protocol, and relatively large sample size were significant predictors of proper registration and reporting.

CONCLUSION

The prevalence of proper registration and reporting is still very low in depression trials.

Importance of platinum-free interval in second-line chemotherapy for advanced or recurrent endometrial cancer

PURPOSE

To investigate the effectiveness of platinum-based combination chemotherapy as second-line chemotherapy for patients with advanced or recurrent endometrial cancer treated initially by platinum-based combination chemotherapy.

MATERIALS AND METHODS

Subjects were patients who had received platinum-based combination chemotherapy as second-line chemotherapy: 56 patients with recurrent disease who had previously received postoperative adjuvant platinum-based combination chemotherapy (Category 1) and 21 patients who had received first-line chemotherapy but not adjuvant chemotherapy for advanced or recurrent disease (Category 2). Patients' records were searched for the response to second-line chemotherapy and survival, particularly in relation to the platinum-free interval (PFI).

RESULTS

APFI over 12 months was a predictor of response (64.7%) and overall survival time (23 months) in Category 1 patients. A PFI of less than three months was a negative predictor of response (0%) and overall survival (nine months) in Category 2 patients.

CONCLUSION

Platinum-based combination chemotherapy appears to be effective as second-line chemotherapy for endometrial cancer if the PFI is sufficiently long.

Impact of multimodal therapy on the survival of patients with newly diagnosed uterine carcinosarcoma

PURPOSE

To investigate treatment outcomes of uterine carcinosarcoma (CS) patients who underwent complete surgical resection of all visible disease and platinum-based adjuvant chemotherapy (multimodal therapy).

MATERIALS AND METHODS

The authors reviewed 127 uterine CS patients treated at this institution from 1990 to 2010. They operated 123 patients in clinical Stages 1-3, 97 of which underwent complete resection and systemic lymphadenectomy.

RESULTS

A total of 97 patients (FIGO 2008: Stage 1 in 50 patients, Stage 2 in six, Stage 3 in 37, and Stage 4 in four) underwent surgical staging, 74 of which were administered five cycles (median) of platinum-based adjuvant chemotherapy. The median overall survival (OS) associated with multimodal therapy 50.6 months compared with 34.9 months incomplete multimodal therapy. After multimodal treatment, 32.9% (32/97) patients showed recurrence (24/32 hematogenous).

CONCLUSION

Multimodal therapy increased survival among uterine CS patients, but the recurrence rate remained high. Further consideration of treatment options for uterine CS is required.

Second-line chemotherapy for carboplatin/paclitaxel-refractory ovarian cancer: are multi-agent chemotherapies of little value truly?

PURPOSE

We examined whether second-line multi-agent chemotherapies are of any value for carboplatin/paclitaxel (TC)-refractory ovarian cancer.

METHODS

Subjects included 60 patients with ovarian, peritoneal, or tubal carcinoma who received second-line platinum-based combination chemotherapy. Thirty-nine were treated with irinotecan/cisplatin or nedaplatin and 21 with docetaxel/cisplatin shortly after TC failure. Patients were divided between those who were refractory to initial platinum-based chemotherapy (n = 29, Group A) and those who were platinum-sensitive (n = 31, Group B). Efficacy and safety of the combination chemotherapies were compared between the two groups.

RESULTS

Response to the combination chemotherapy was 10.3% in Group A and 41.9% in Group B. Median time to disease progression was 4.02 months and 7.21 months, respectively (p = 0.006), and median survival time was 7.89 months and 9.23 months, respectively (p = 0.003). There was no difference in response between the two regimens. Grade 3-4 hematologic toxicities were more frequent with the docetaxel regimen.

CONCLUSION

The choice between agents for second-line chemotherapy for TC-refractory ovarian cancer should be based on whether the cancer was previously platinum-sensitive. With a history of such response, multi-agent chemotherapies are worth considering after TC failure. With no previous response, the expected efficacy of second-line multi-agent chemotherapy is low, suggesting the use of monochemotherapy.

The treatment of uterine leiomyosarcoma: clinical outcomes of 18 cases and the effectiveness of chemotherapy

PURPOSE

To investigate clinical outcomes with respect to the effectiveness of chemotherapy in the treatment of uterine leiomyosarcoma.

METHODS

Study subjects were 18 patients with uterine leiomyosarcoma treated surgically at our hospital between February 1986 and December 2007. A chemotherapy regimen that combined ifosfamide, epirubicine, and cisplatin (IEP) was used as the main first-line chemotherapy.

RESULTS

FIGO disease stages were as follows: Stage I (n = 11), Stage II (n = 1), Stage III (n = 3), Stage IV (n = 3). Five-year overall survival of patients with Stage I-III disease was 65.3% (95% CI: 46.1-92.4%). None of patients with Stage IV disease survived for more than two years. Of seven patients who suffered advanced or recurrent disease, six received IEP; the response rate was 50%, one complete response and two partial responses.

CONCLUSIONS

The combination of surgery and chemotherapy seems to be an acceptable treatment for uterine leiomyosarcoma. IEP may be an active regimen for this aggressive disease.

Clinical features of 215 stage I ovarian tumors in Japanese women

PURPOSE

Differences of the clinical features of Stage I borderline ovarian tumors and Stage I ovarian cancer need to be clarified.

METHODS

We retrospectively investigated 215 patients with Stage I ovarian tumors (67 with borderline tumors and 148 with ovarian cancer) treated between 1988 and 2001.

RESULTS

Only one patient with a borderline tumor developed recurrence, while recurrence was found in 20 patients with Stage I ovarian cancer. There was a significant difference in the recurrence rate between patients with Stage Ia or Ib ovarian cancer and those with Stage Ic cancer (p = 0.007). Clear cell adenocarcinoma showed a higher recurrence rate. Among our patients with recurrence, only five in whom the recurrent tumor could be surgically resected are currently alive and disease-free.

CONCLUSIONS

This study confirmed the low aggressiveness of Stage I borderline ovarian tumors and high aggressiveness of Stage Ic ovarian cancer or clear cell adenocarcinoma. In patients with recurrence, surgical resection may improve survival.

Evaluation of the therapeutic results of epiduroscopic adhesiolysis for failed back surgery syndrome

BACKGROUND

No data for patients with failed back surgery syndrome (FBSS) based on the location of adhesions separated by epiduroscopic adhesiolysis have been reported.

METHODS

We performed epiduroscopic adhesiolysis on 28 FBSS patients to examine the impact of differences in the locations of the separated regions on the treatment results. We performed fluoroscopic imaging through the sacral hiatus to assess the condition of adhesions in the epidural space during the post-adhesiolysis observation period.

RESULTS

In patients in whom only the epidural space was separated by adhesiolysis, there was a significant improvement in the Roland-Morris disability questionnaire (RDQ) score until 12 weeks after adhesiolysis, but the score gradually returned to the preoperative value thereafter. Among patients in whom the nerve root responsible for radicular pain was separated, there was a long-term improvement in the RDQ, Oswestry disability index 2.0 (ODI), and Japanese Orthopedic Association Assessment of Treatment (JOA) scores. Among patients in whom both the epidural space and the nerve root responsible for pain were separated, there was a 12 week improvement in the RDQ score and 24 week improvements in the ODI and JOA scores.

CONCLUSIONS

Progressive epidural imaging after adhesiolysis suggested that pain was caused by re-adhesion around the nerve root. Since re-adhesion of the nerve root required some time, the effect of adhesiolysis was maintained for extended periods in these cases. We suggest that epiduroscopic adhesiolysis is an effective therapy for FBSS patients, and that adhesiolysis of the nerve root may exhibit the long-term (24 weeks) efficacy in patients with pain.

New diagnostic reporting format for endometrial cytology based on cytoarchitectural criteria

OBJECTIVE

The aim of this study was to develop a new reporting format for endometrial cytology that would standardize the diagnostic criteria and the terminology used for reporting.

METHODS

In previous studies, cytoarchitectural criteria were found to be useful for the cytological assessment of endometrial lesions. To apply these criteria, an appropriate cytological specimen is imperative. In this article, the requirements of an adequate endometrial cytological specimen for the new diagnostic criteria are first discussed. Then, the diagnostic criteria, standardized on a combination of conventional and cytoarchitectural criteria, are presented. Third, terminology that could be used, not only for reporting the histopathological diagnosis, but also for providing better guidance for the gynaecologist to determine further clinical action, is introduced. The proposed reporting format was investigated using endometrial cytology of 58 cases that were cytologically underestimated or overestimated compared to the histopathological diagnosis made on the subsequent endometrial biopsy or surgical specimens.

RESULTS

Of the 58 cases, 12 were reassessed as being unsatisfactory for evaluation. Among the remaining 46 cases, 25 of the 27 cases, which had been underestimated and subsequently diagnosed as having endometrial carcinoma or a precursor stage on histopathological examination,were reassessed as recommended for endometrial biopsy. On the other hand, 19 cases overestimated by cytology were all reassessed as not requiring biopsy.

CONCLUSIONS

The reporting format for endometrial cytology proposed in this article may improve diagnostic accuracy and reduce the number of patients managed inappropriately.

Treatment of squamous cell carcinoma of the uterine cervix with radiation therapy alone: long-term survival, late complications, and incidence of second cancers

The objective of this retrospective study was to determine the survival rate, incidence of late complications, and incidence of second cancers when radiation therapy alone is used for carcinoma of the uterine cervix. Between 1971 and 1995, 1495 patients with squamous cell carcinoma of the uterine cervix (stages I–IV) were treated with radiation therapy alone in our hospital. Radiation therapy consisted of a combination of high-dose-rate intracavitary brachytherapy and external beam radiotherapy. The cumulative 5-year survival rates for stages Ib, II, and III/IVa carcinoma were 93.5, 77.0, and 60.3%, respectively, and the 10-year survival rates were 90.9, 74.5, and 56.1%, respectively. Local control rates for stages Ib, II, and III/IVa carcinoma were 92.0, 79.4 and 64.2%, respectively. Eighty-two (5.5%) patients suffered grade III/IV or V (fatal) complications. A second cancer developed in 13 (0.87%) patients. Second cancers were observed most frequently in the rectum (five cases), colon (three cases), and uterine body (two cases). Long-term follow-up data revealed that our method of radiation therapy alone for locally advanced carcinoma of the uterine cervix is effective, with low incidences of late complications and second cancers.

Peripheral primitive neuroectodermal tumor of the vulva: report of a case with imprint cytology

BACKGROUND

Peripheral primitive neuroectodermal tumor (PNET) of the vulva is an extremely rare disease, and, to our knowledge, only two cases have been previously reported.

CASE

A 45-year-old woman presented with a mass in the right labium major. Three years after removal of the tumor, she noticed a new lesion in the same place and underwent a partial vulvectomy. The imprint cytology of the recurrent tumor showed a monomorphic appearance, composed of small round cells with scant cytoplasm against a hemorrhagic background. These tumor cells were loosely connective, but rosettelike structures were observed focally. On pathologic examination, the neoplasm was composed of small round tumor cells showing sinusoidal, diffuse or micropapillary growth. Immunohistochemically, the neoplastic cells stained positively for neuron-specific enolase, vimentin and HBA 71 and negatively for cytokeratin, HBA 45 and muscle-specific actin. The morphologic characteristics of the disease were well expressed in the imprint cytology, and this influenced the selection of immunohistochemical studies.

CONCLUSION

Cytologic examination for vulvar tumors, even imprint cytology, can be a useful tool in obtaining an accurate pathologic diagnosis of a rare disease, such as peripheral PNET.

Validation of the functional fitness age (FFA) index in older Japanese women

Functional fitness age (FFA), which we previously described, is a measure of functional age that reflects a person's overall physical ability to complete daily tasks such as preparing meals and performing various household chores. The purpose of this study was to validate FFA in two elderly populations: 1) older subjects from different communities, and 2) older subjects participating in an exercise intervention program. FFA was calculated from 4 performance tests: performing arm curls; moving beans with chopsticks; demonstrating functional reach; and sitting and walking around two cones. The first study group was selected from 4 different communities (N=127), and was subdivided into a less active group (N=87) and an active group (N=40). The results of the 4 tests for the less active group were not significantly different from those for the original validation group used in developing the FFA equation. The FFA of the less active group (71.1+/-7.7 yrs) was not different from their chronological age (70.4+/-6.6 yrs). In the active group, except for the arm curls, test scores were significantly higher than those of the original validation group. The FFA of the active group (66.2+/-5.1 yrs) was significantly younger than their chronological age (70.9+/-4.2 yrs). Another group of 14 older women (79.5+/-3.9 yrs) was recruited for pre- and post-training testing. After the 3-month exercise program, they showed significant improvements in sitting and walking around two cones and functional reach; their FFA decreased significantly from 81.5+/-5.0 yrs to 78.3+/-4.5 yrs. The control group selected from the same community (N=16, 79.8+/-5.3 yrs) showed no significant changes in the 4 performance tests, and their FFA remained unchanged. These results indicate that our FFA is highly cross-validated for different Japanese communities, and is sensitive to changes associated with participation in an exercise intervention program.

Positive peritoneal cytology in endometrial cancer: enhancement of other prognostic indicators

OBJECTIVE

The goal of this study was to investigate the prognostic significance of positive peritoneal cytology in endometrial cancer.

METHODS

A clinicocytopathological study was performed in 534 patients with endometrial cancer to assess the prognostic value of positive peritoneal cytology. The study population was divided into three groups: a low-risk group (disease limited to the uterus, grade 1, and depth of invasion < or =1/2), a moderate-risk group (disease limited to the uterus, grade 2 or 3, and/or depth of invasion >1/2), and a high-risk group (extrauterine disease). In each group, disease-free survival was compared in the patients who were positive or negative for malignant cells.

RESULTS

The overall incidence of positive peritoneal cytology was 22.3% (119/534). The 5-year disease-free survival of patients positive or negative for malignant cells was 98.1% versus 100% in the low-risk group (n = 250), 77.5% versus 91.3% in the moderate-risk group (n = 211), and 42.9% versus 72.1% in the high-risk group (n = 73). A significant difference was noted in the moderate-risk (P = 0.044) and high-risk (P = 0.015) groups, but not in the low-risk group (P = 0.56).

CONCLUSIONS

Positive peritoneal cytology is not a negative prognostic indicator itself, but it potentiates other prognostic indicators for endometrial cancer. Our findings also suggest that patients with positive peritoneal cytology in the absence of other adverse prognostic factors do not need upstaging.

Identification of a high-risk subgroup in cytology-positive stage IIIA endometrial cancer

OBJECTIVE

To identify a high-risk subgroup among patients with cytology-positive stage IIIA endometrial cancer.

STUDY DESIGN

Fifty-four stage IIIA endometrial cancer patients who were positive only on peritoneal cytology were divided into two groups based on the cytologic pattern of their peritoneal smears. In group A, malignant cell clusters had well-defined edges, while the tumor cell clusters had scalloped edges in group B. The prognostic significance of these findings was investigated.

RESULTS

The five-year disease-free survival rate was 97.5% in group A (n=40) versus 50% in group B (n = 14). Multivariate analysis confirmed that the cytologic pattern had an independent influence on survival.

CONCLUSION

Positive peritoneal cytology composed of malignant cell clusters with well-defined edges has no impact on survival. Only endometrial cancer patients who show tumor cell clusters with scalloped edges in peritoneal smears are worth considering for upstaging.

Müllerian adenosarcoma of the uterus: report of a case with imprint cytology

BACKGROUND

Müllerian adenosarcoma is a rare morphologic variant of uterine sarcoma that, although well described histologically, is scarcely mentioned in the cytologic literature.

CASE

A 75-year-old female was suspected of having atypical endometrial hyperplasia on an endometrial smear. However, subsequent imaging techniques revealed the presence of a bulky, polypoid mass filling the uterine cavity. On pathologic examination of the hysterectomy specimen, the polypoid tumor was diagnosed as mullerian adenosarcoma, homologous, with sarcomatous overgrowth, in which the sarcomatous component was compatible with high grade endometrial stromal sarcoma. Imprint smears of the tumor consisted of two morphologic patterns, sarcomatous and glandular. The sarcomatous tumor cells, with coarse chromatin and relatively scant cytoplasm, formed small aggregates or appeared alone. These cells were semiround or oval and had conspicuous nucleoli. In addition to these observations, small and large clusters of glandular cells with mild atypism were interspersed with the sarcomatous cells.

CONCLUSION

Cytologic examination of müllerian adenosarcoma well reflects its pathologic features.

Malignant potential of positive peritoneal cytology in endometrial cancer

OBJECTIVE

To investigate the malignant potential of positive peritoneal cytology in endometrial cancer.

METHODS

Fifty patients with clinical stage I-II endometrial cancer in whom the disease was completely surgically resected and positive peritoneal smears were found at surgery formed the study population. In these patients, a tube for cytologic analyses was inserted into the peritoneal cavity when closing the abdomen. The peritoneal cavity was irrigated with physiologic saline, and washings were obtained through the tube 7 and 14 days after the operation.

RESULTS

Persistence of positive peritoneal cytology was observed in four of seven patients with adnexal metastasis, zero of nine patients with nodal disease, and one of 34 patients with disease confined to the uterus, for a total of 10% (5 of 50). In the remaining 45 (90%) patients, no malignant cells were found in any of the washings.

CONCLUSION

The current series suggests that endometrial cancer cells found in the peritoneal cavity usually disappear within a short time and seem to have a low malignant potential. It also seems that only malignant cells from special cases, such as adnexal metastasis, may be capable of independent growth, and are possibly associated with intraperitoneal recurrence.

Effects of increasing expenditure of energy during exercise on psychological well-being in older adults

The purpose of present study was to examine the effects on psychological well-being of energy expended as a result of the exercise intervention. 33 older adults (M age=68.6 yr., SD=4.7) participated in three supervised water-based exercise sessions per week for 12 wk. Based on the relative changes in daily energy expenditure as measured by questionnaire between pre- and posttraining, the subjects were split into three groups. This classified each subject as either having experienced a relatively low change (n=11), moderate change (n= 11), or high change (n= 11) in daily energy expenditure. Our data showed that the group with the greater increase in energy expenditure as a result of exercise, when compared pre- and posttraining, improved only on Depression-Dejection on the Profile of Mood States more than did the group with low change. Consequently, we concluded that the amount of energy expended was partially related to improvement in psychological well-being.

Prognostic value of the colposcopic tumor size in stage IB squamous cervical cancer

BACKGROUND AND OBJECTIVES

To determine the prognostic significance of the colposcopic tumor size in the management of cervical cancer.

METHODS

Clinicopathological analysis was performed in 751 consecutive patients with stage IB squamous cervical cancer who were surgically treated in a single institute. The colposcopic tumor size was measured postoperatively on surgical specimens. Univariate and multivariate analyses were performed to determine the prognostic significance of various pathological factors.

RESULTS

Among the pathological factors examined, lymph node metastasis, parametrial extension, deep stromal invasion, vessel permeation, endometrial extension, and colposcopic tumor size were found to be prognostic factors in univariate analysis, whereas multivariate analysis has confirmed that only three factors, i.e., lymph node metastasis, parametrial involvement, and colposcopic tumor size were independently associated with the disease-free interval.

CONCLUSIONS

These results indicate that the colposcopic tumor size is an independent prognostic factor in squamous cervical cancer and can be used as an indicator of treatment options.

Clinical value of tumor markers for early detection of recurrence in patients with cervical adenocarcinoma and adenosquamous carcinoma

OBJECTIVE

The clinical value of tumor markers for early detection of recurrence was investigated in 32 patients with cervical adenocarcinoma or adenosquamous carcinoma who had recurrent tumors.

METHODS

Serum levels of CA 125, CA 19-9, carcinoembryonic antigen (CEA), and squamous cell carcinoma antigen (SCC), in addition to clinical status at the time of recurrence were investigated.

RESULTS

Among the 32 patients, 26 had no symptoms at the time of recurrence. In 20 patients, elevated serum levels of tumor markers were the first sign of recurrence. In 21 patients with recurrent adenocarcinoma, the positive rates were 14% (CA 125), 62% (CA 19-9), 29% (CEA), and 5% (SCC). There were 71% of cases positive for CA 19-9 and/or CEA. In 11 patients with recurrent adenosquamous carcinoma, the corresponding positive rates were 37% (CA 125), 46% (CA 19-9), 64% (CEA), and 55% (SCC), with 100% positive for CA 19-9, CEA, and/or SCC.

CONCLUSIONS

The combination of CA 19-9 and CEA is probably the most promising for detection of recurrent cervical adenocarcinoma. For adenosquamous carcinoma, the additional use of SCC is recommended.

[Effect of olprinone hydrochloride on cerebral blood flow in patients after cardiac surgery]

This study was designed to investigate the effect of olprinone hydrochloride on cerebral blood flow in ten patients after cardiac surgery by transcranial Doppler sonography (TCD). We assessed cerebral blood flow in the middle cerebral artery by transtemporal approach and in the carotid siphon by transorbital approach. We measured the mean blood flow velocity in the left middle cerebral artery (Vmca) and the left carotid siphon (Vlca) and calculated the pulsatility index in the left middle cerebral artery (PImca) and the left carotid siphon (PIlca) using 2 MHz transcranial Doppler ultrasound system (DWL Multidop-P). After baseline measurement, the olprinone hydrochloride loading dosage was increased from 0.15 to 0.3 microgram.kg-1.min-1 every 60 minutes. The mean blood flow velocity was measured at each point. Vmca and Vlca significantly increased, and PImca and PIlca significantly decreased at the infusion rate of 0.3 microgram.kg-1.min-1. There were significant linear correlations between CI and Vmca, CI and Vlca, SVRI and Vmca, as well as SVRI and Vlca. Dose-response relationships were observed in CI, SVRI, Vmca, and Vlca. In conclusion, we demonstrated that olprinone hydrochloride led to an increase of cerebral blood flow in the patients after cardiac surgery.

[Hemodynamic effects of propofol as an anesthesia induction agent in hyperthyroidism patients on chronic beta-blocker]

This study was designed to investigate the effect of propofol on the heart rate and blood pressure in the patients on chronic beta-blocker. Seventy two hyperthyroidism patients scheduled for subtotal thyroidectomy were enrolled. Thirty six patients who were on chronic beta-blocker received either propofol (group beta-P) or thiamylal (group beta-T) as an anesthesia induction agent. In control groups, patients who were not on beta-blocker also received either propofol (group C-P) or thiamylal (group C-T). Anesthesia was maintained with nitrous oxide in oxygen and sevoflurane. Heart rate and systolic blood pressures were monitored and recorded before and during anesthesia. Heart rate decreased significantly in group beta-P compared to three other groups through this study. Significant decreases in systolic blood pressure were observed in the groups beta-P and beta-T compared to group C-P. These results suggest that careful attention should be paid to the patients on chronic beta-blocker when propofol was selected as an anesthesia induction agent.

Comparison of water- and land-based exercise in the reduction of state anxiety among older adults

This study examined the effect of an acute exercise program of different exercise conditions on state anxiety among older adults. 73 healthy subjects were recruited and randomly assigned to either water exercise group (n = 36) or land exercise group (n = 37). State anxiety was assessed before exercise and following exercise. Subjects in the water exercise performed a 70-min. exercise program consisting of a 10-min. warm-up, a 20-min. brisk walking, a 20-min. rhythmic dancing, a 10-min. resistance training, and a 10-min. cool down exercise. The land exercise program contained a 10-min. warm up and a 30-min. combined endurance and resistance exercise, followed by a 10-min. cool down exercise. Analysis showed that both exercise groups scored significantly (p<.001) lower on anxiety after exercise, but there was no significant interaction for group by trial for scores on state anxiety. The data indicate that elderly persons who participate in these types of exercise report lower state anxiety.

Treatment of fallopian tube cancer. Review of the literature

OBJECTIVE

To contribute toward the understanding of the therapeutic management of fallopian tube cancer.

METHODS

Recent studies related to the treatment of fallopian tube cancer were reviewed.

RESULTS

Current evidence indicates that even patients in early stages have nodal disease, and often experience relapses in distant sites. In advanced stages, survival prolongation by the use of platinum-based chemotherapy has been demonstrated. Aggressive cytoreductive surgery followed by chemotherapy and negative second-look laparotomy offer the possibility of long-term survival. However, a significant fraction of patients eventually relapses after negative second-look laparotomy, and a poor survival rate after positive second-look laparotomy has been observed.

CONCLUSIONS

This series suggests the need for thorough evaluation of lymph nodes at the time of surgery. The use of platinum-based chemotherapy is probably the best adjuvant therapy for both early stages and advanced stages. The clinical value of second-look laparotomy will remain limited until effective salvage therapy is developed. The potential benefits of neoadjuvant chemotherapy and the use of paclitaxel will be increasingly important.

Genetic aberrations detected by comparative genomic hybridization in ovarian clear cell adenocarcinomas

Genetic abnormalities were detected by comparative genomic hybridization (CGH) in 12 ovarian clear cell adenocarcinomas. DNA sequence copy number abnormalities (CNAs) occurring in more than 20% of the cancers included increased copy numbers of 8q11-q13, 8q21-q22, 8q23, 8q24-qter, 17q25-qter, 20q13-qter and 21q22-qter and reduced copy numbers of 19p. Increases in copy numbers of 8q11-q13, 8q21-q22, 8q23 and 8q24-qter occurred more frequently in disease-free patients than in recurrent/non-surviving patients (p < 0.05). However, increases in copy numbers of 17q25-qter and 20q13-qter occurred more frequently in recurrent/non-surviving patients than in disease-free patients (p < 0.05). Furthermore, increases in copy numbers of 17q25-qter and 20q13-qter occurred together (p < 0.05). Additionally, there were negative correlations between increases in copy numbers of 8q21-q22 and 17q25-qter, and between 8q21-q22 and 20q13-qter (p < 0.05). It appears that ovarian clear cell adenocarcinomas can be classified into two subtypes, one being cancer with an increase in copy numbers of 8q and the other being cancer with increases in copy numbers of 17q25-qter and 20q13-qter.

Utility of the monoclonal antibody HIK1083 in the diagnosis of adenoma malignum of the uterine cervix

OBJECTIVES

The aim of this study was to qualify a staining technique for the diagnosis of adenoma malignum.

METHODS

The gastric mucin expression of adenoma malignum, ordinary endocervical adenocarcinoma, and normal cervical glands was immunohistochemically compared using the monoclonal antibody HIK1083.

RESULTS

The three categories were clearly distinguished, with 90% (9/10) of cases with positive adenoma malignum, 30% (3/10) of cases with weakly positive ordinary cervical adenocarcinoma, and no (0/10) cases of positive normal cervical glands.

CONCLUSIONS

This preliminary report indicates that the use of HIK1083 is valuable in the diagnosis of adenoma malignum.

Low-grade endometrial stromal sarcoma with cardiovascular involvement--a report of three cases

BACKGROUND

In low-grade endometrial stromal sarcoma, it has been reported that vascular space involvement in surgical specimens is found in over 50% of patients. However, in contrast to intravenous leiomyomatosis, it has been thought that further tumor extension to large vessels is rarely observed.

CASES

We present three cases of low-grade endometrial stromal sarcoma with cardiovascular involvement by recurrent tumors observed on imaging studies. Two cases demonstrated tumor infiltration inside the inferior vena cava while the other case showed tumor growth in the left ventricle.

CONCLUSION

This report suggests that attention should be paid to the possibility of cardiovascular invasion during the entire course of this disease.

Morphologic analyses of positive peritoneal cytology in endometrial carcinoma

OBJECTIVE

To investigate the relationship between the morphologic features of endometrial adenocarcinoma cells in peritoneal fluids (effusions and washings) and macroscopic intraabdominal adenocarcinoma at laparotomy as well as prognosis.

STUDY DESIGN

Seventy-one patients with endometrial adenocarcinoma who showed positive peritoneal cytology at laparotomy were clinically divided into three groups: 25 patients with macroscopic neoplastic seeding in the peritoneal cavity (type 1), 38 patients without macroscopic peritoneal metastasis who survived with no evidence of disease (type 2) and 8 patients without macroscopic peritoneal metastasis who later developed recurrence of adenocarcinoma (type 3). Morphologic features of the adenocarcinoma cells in smears of peritoneal fluids were examined.

RESULTS

Most of the smears from type 1 patients showed moderate to high cellularity, scalloped edges of cell clusters and isolated adenocarcinoma cells, whereas these features were seldom observed in type 2 patients. Although not all type 3 patients demonstrated these three features, patients in the series whose specimens exhibited none of the three features did not show any peritoneal lesions or have a recurrence of their disease.

CONCLUSION

The finding of endometrial adenocarcinoma cells exhibiting high cellularity, scalloped edge of cell clusters and isolated cells in smears of peritoneal fluid is associated with the presence of intraabdominal macroscopic metastatic lesions and could be regarded as a risk factor for intraabdominal recurrence of carcinoma.

Assessment of the revised International Federation of Gynecology and obstetrics staging for early invasive squamous cervical cancer

OBJECTIVE

The aim of this study was to investigate the value of the International Federation of Obstetrics and Gynecology (FIGO) classification (1995) for early invasive cervical cancer. Methods. Clinico-pathological analysis was performed in 402 patients with invasive squamous cervical cancer in whom the depth of stromal invasion was 5 mm or less.

RESULTS

The incidence of lymph node metastasis was 1.2% (1/82) in patients with 3 mm or less depth of invasion; the node-positive patient was in stage IA1. The incidence of lymph node metastasis was 6.8% (5/73) in patients with 3-5 mm depth of invasion; this increased with increasing horizontal spread from 3.4% for 7 mm or less to 9.1% for more than 7 mm. None of the patients in this series had metastasis to the parametrial tissues. Of 4 patients with recurrence, 3 had horizontal spread of more than 7 mm and the remaining patient was in stage IA2.

CONCLUSION

The FIGO definition of early squamous cervical cancer is generally acceptable in its present form.

Ovarian metastasis in endometrial carcinoma

A retrospective study was conducted to investigate the clinical significance of ovarian metastasis in 439 patients with clinical stage I endometrial cancer surgically treated by performing total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy. Histologic examination revealed that 22 patients (5%) had ovarian metastasis. The maximum diameter of the ovarian metastases ranged from 1 to 100 mm. In 18.2% (4/22) of patients with ovarian metastasis, the maximum diameter was less than 2 mm. Patients with metastasis limited to the ovarian surface showed 100% positive peritoneal cytology, 0% lymph node metastases, and 50% recurrence, while patients with metastasis inside the ovary showed 10% positive peritoneal cytology, 36% lymph node metastases, and 53% recurrence. The prognosis of patients with ovarian metastasis alone was situated midway between that of patients with cancer limited to the uterus and that of patients with lymph node metastasis alone. The lymph node status was of importance to determine the prognosis of patients with ovarian metastasis. The series also suggests that there may be two routes for ovarian metastasis; one is a route via the fallopian tube to the ovarian surface and the other is a route via the lymphatics to the inside of the ovary.

A clinicocytopathologic study of adenoma malignum of the uterine cervix

OBJECTIVES

To investigate the nature and the clinical course of adenoma malignum (the so-called minimal deviation adenocarcinoma) of the uterine cervix by conducting a retrospective study of 6 cases consecutively treated in a single institute.

METHODS

The pathologic classification of adenoma malignum was performed according to the WHO classification (1994).

RESULTS

These tumors accounted for only 1.32% (6/453) of invasive cervical adenocarcinomas. All the cases showed either a watery discharge or atypical genital bleeding, or both, at the time of diagnosis. The preoperative cytologic diagnosis of adenoma malignum was made in 83.3% (5/6) of cases. The preoperative punch biopsy, on the other hand, failed to confirm the diagnosis of adenoma malignum in all cases, although the presence of the disease was suspected in 2 cases (33%). The 5-year survival rate and 5-year disease-free survival rate were 100 and 83.3%, respectively.

CONCLUSIONS

This series demonstrates that cytologic examination is a potent screening method to detect this rare disease. When the presence of this disease is suspected by the cytologic examination, a deep biopsy is necessary to make an accurate diagnosis. An ordinary cervical biopsy is usually insufficient to detect deeply positioned tumor glands. The prognosis of the disease may be better than that for ordinary cervical adenocarcinoma.

Prognostic validity of neoplastic cells with notable nuclear atypia in endometrial cancer

OBJECTIVE

To investigate how the architectural grade of endometrial adenocarcinoma should be adjusted in the presence of neoplastic cells with notable nuclear atypia in order to assign the histologic grade.

METHODS

Four hundred seventy-six patients with stage I endometrial cancer (endometrioid type) who were surgically treated in a single institute formed the study population. The architectural grade and the proportion of tumor cells with notable nuclear atypia were examined for each case. The effects of notable nuclear atypia on the disease-free survival of each architectural grade were analyzed.

RESULTS

The disease-free survival of architectural grade 1 and grade 2 tumors was significantly affected and was worse than that of architectural grade 3 tumors when more than 25% of the tumor cells showed notable nuclear atypia. Tumors that had 26% to 50% of neoplastic cells with notable nuclear atypia showed a similar probability of recurrence as did tumors that had more than 50% of neoplastic cells with notable nuclear atypia.

CONCLUSION

The series suggests that the upgrading of architectural grade 1 or 2 tumors, in which more than 25% of the neoplastic cells show notable nuclear atypia, into a grade 3 tumor may be more practical than upgrading by one architectural grade 1 or 2 tumors, in which the majority of neoplastic cells show notable nuclear atypia.

The value of squamous cell carcinoma antigen as a predictor of nodal metastasis in cervical cancer

Preoperative serum squamous cell carcinoma antigen (SCC) levels were examined in 148 cases of stage Ib squamous cervical cancer undergoing radical hysterectomy. The effect of the pelvic lymph node status on the marker level was examined by comparing 113 cases with cancer limited to the uterus and 23 cases with cancer confined to the uterus and pelvic lymph nodes using two different multivariate analyses. Ninety-five percent of patients with cancer limited to the uterus showed SCC levels of 4 ng/ml or below. Nearly two-thirds (65%) of patients with serum levels above 4 ng/ml exhibited pelvic lymph node metastasis. The marker values exceeding 4 ng/ml increased the risk of nodal metastasis by eight times, compared with serum levels of 4 ng/ml or below. Multivariate analyses confirmed that the pelvic lymph node metastasis had a larger impact on the marker level than did tumor size or depth of stromal infiltration. SCC levels greater than 4 ng/ml can be considered a high-risk zone for nodal metastasis.

Clinical usefulness of endometrial aspiration cytology and CA-125 in the detection of fallopian tube carcinoma

OBJECTIVE

To determine the clinical usefulness of endometrial aspiration cytology and CA-125 in the detection of fallopian tube carcinoma.

STUDY DESIGN

Positive rates of gynecologic cytology and serum levels of CA-125 were examined in 20 consecutive patients with primary fallopian tube carcinoma before any treatment.

RESULTS

The positive rates were 25% (5/20) for cervicovaginal smears and 50% (10/20) for endometrial aspiration smears in the absence of endometrial invasion. The positivity of endometrial aspiration cytology was not influenced by clinical staging or tumor differentiation. The presence of disease in all asymptomatic patients (4/4) was suspected by abnormal endometrial cytology. The features of endometrial cytology were consistent with those of extrauterine adenocarcinoma, from which ovarian carcinoma was unable to be differentiated. Serum levels of CA-125 increased with clinical staging. The positive rate for CA-125 was 20% in stage I, 75% in stage II, 88.9% in stage III, 100% in stage IV and 70% (14/20) in all cases. Eighty-five percent (17/20) of cases exhibited either positive endometrial cytology or elevated CA-125 levels.

CONCLUSION

The series suggests that the use of endometrial cytology combined with determination of serum CA-125 levels covers most cases of fallopian tube carcinoma and is a potent aid in the detection of this rare disease.

Prognostic value of peritoneal cytology in patients with carcinoma of the uterine cervix

Peritoneal cytology was obtained in 374 patients with carcinoma of the uterine cervix (stage IB-IIB) in whom gross intraperitoneal disease was absent at the time of radical hysterectomy and node dissections. The relevance of positive peritoneal cytology in relation to the cell type of the tumor was examined. An exceedingly small rate of peritoneal cytologic positivity was found in patients with squamous cell carcinoma (1.7%, 4/242). One of the four patients with positive cytology developed a lung recurrence. On the other hand, the incidence of positive peritoneal cytology in patients with adenocarcinoma and adenosquamous carcinoma was 11.4% (15/132). The 3-year disease-free survival rate in patients having adenocarcinoma and adenosquamous carcinoma with positive peritoneal cytology was 57.8%, while it was 80.7% in patients with negative peritoneal cytology. However, this factor was closely associated with other adverse prognostic factors. A multivariate analysis revealed that positive peritoneal cytology was not an independent prognostic factor in patients with adenocarcinoma and adenosquamous carcinoma. In addition, intraperitoneal recurrence was not correlated with the presence of cancer cells in the peritoneal fluid. The series indicates that peritoneal cytology in cervical cancer is of little value in treatment planning.