Outcome tools used for ambulatory children with cerebral palsy: responsiveness and minimum clinically important differences

This prospective longitudinal multicenter study of ambulatory children with cerebral palsy (CP) examined changes in outcome tool score over time, tool responsiveness, and used a systematic method for defining minimum clinically important differences (MCIDs). Three hundred and eighty-one participants with CP (Gross Motor Function Classification System [GMFCS] Levels I-III; age range 4-18y, mean age 11y [SD 4y 4mo]; 265 diplegia, 116 hemiplegia; 230 males, 151 females). At baseline and follow-up at least 1 year later, Functional Assessment Questionnaire, Gross Motor Function Measure, Pediatric Quality of Life Inventory, Pediatric Outcomes Data Collection Instrument, Pediatric Functional Independence Measure, temporal-spatial gait parameters, and oxygen cost were collected. Adjusted standardized response means determined tool responsiveness for nonsurgical (n=292) and surgical (n=87) groups at GMFCS Levels I to III. Most scores reaching medium or large effect sizes were for GMFCS Level III. Nonsurgical group change scores were used to calculate MCID thresholds for ambulatory children with CP. These values were verified by examining participants who changed GMFCS levels. Tools measuring function were responsive when a change large enough to cause a change in GMFCS level occurred. MCID thresholds assess change in study populations over time, and serve as the basis for designing prospective intervention studies.

Primary appendiceal cancer: Gynecologic manifestations and treatment options

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

BRCA1 expression in a large series of sporadic ovarian carcinomas: a Gynecologic Oncology Group study

BRCA1 is a tumor suppressor gene that, when mutated, is associated with the development of hereditary ovarian cancer. A role for BRCA1 in the pathoetiology of sporadic ovarian epithelial cancer (OEC) development has been suggested, although spontaneous mutations of the BRCA1 gene in this disease are uncommon. Loss of gene function by epigenetic alteration is observed more commonly, while other means of gene inactivation have not been intensively investigated. We examined expression and localization of the BRCA1 gene product by immunohistochemistry and sought to clarify the relationship between protein expression and tumor stage, grade, histopathologic subtype, and outcome. Among 230 spontaneous OEC tumors, we found a statistically significant decrease in BRCA1 protein expression with advancing stages of OEC. There was no relationship between expression and tumor grade. There was a statistically significant relationship between the pathologic subtypes of OEC and BRCA1 expression. Minimal BRCA1 expression was protective for survival. These findings confirm a high rate of loss of BRCA1 protein expression in sporadic OEC and suggest a role of BRCA1 in the progression of sporadic ovarian carcinoma.

BRCA1 expression in a large series of sporadic ovarian carcinomas: a Gynecologic Oncology Group study

BRCA1 is a tumor suppressor gene that, when mutated, is associated with the development of hereditary ovarian cancer. A role for BRCA1 in the pathoetiology of sporadic ovarian epithelial cancer (OEC) development has been suggested, although spontaneous mutations of the BRCA1 gene in this disease are uncommon. Loss of gene function by epigenetic alteration is observed more commonly, while other means of gene inactivation have not been intensively investigated. We examined expression and localization of the BRCA1 gene product by immunohistochemistry and sought to clarify the relationship between protein expression and tumor stage, grade, histopathologic subtype, and outcome. Among 230 spontaneous OEC tumors, we found a statistically significant decrease in BRCA1 protein expression with advancing stages of OEC. There was no relationship between expression and tumor grade. There was a statistically significant relationship between the pathologic subtypes of OEC and BRCA1 expression. Minimal BRCA1 expression was protective for survival. These findings confirm a high rate of loss of BRCA1 protein expression in sporadic OEC and suggest a role of BRCA1 in the progression of sporadic ovarian carcinoma.

The efficacy of adjuvant platinum-based chemotherapy in Stage I uterine papillary serous carcinoma (UPSC)

OBJECTIVE

To determine the efficacy of adjuvant platinum-based chemotherapy in Stage I uterine papillary serous carcinoma (UPSC).

METHODS

A retrospective multi-institutional investigation was performed to identify surgically staged patients with Stage I UPSC who were (1) treated after surgery with 3-6 courses of platinum-based chemotherapy without radiation from 1990-2003, and (2) followed for a minimum of 12 months, or until recurrence.

RESULTS

Six patients (IA-2, IB-3, IC-1) were treated with carboplatin (AUC 6) or cisplatin (50 mg/m2) alone. One patient recurred to the vagina, was treated with chemo-radiation, and is alive and well at 122 months. One patient recurred to the lung, liver, and brain, and died of disease at 24 months. The remaining 4 patients are alive with no evidence of disease 15-124 months (mean 62 months) after treatment. Two patients (IB-1, IC-1) were treated with cisplatin (50 mg/m2) and cyclophosphamide (1000 mg/m2), and both are alive and well with no evidence of disease 75 and 168 months after treatment. Twenty-one patients (IA-5, IB-13, IC-3) were treated with a combination of carboplatin (AUC 6) and paclitaxel (135 mg/m2-175 mg/m2). One patient recurred to the vagina after 3 cycles of carboplatin/paclitaxel, and was treated with chemo-radiation. She is now without evidence of disease 10 months after treatment. At present, all 21 patients with Stage I UPSC treated following surgical staging with carboplatin/paclitaxel chemotherapy are alive and well with no evidence of disease 10-138 months (mean 41 months) after treatment.

CONCLUSION

Combination carboplatin/paclitaxel chemotherapy following surgery is effective in the treatment of Stage I UPSC.

Pilot study of growth hormone administration during the refeeding of malnourished anorexia nervosa patients

OBJECTIVE

In anorexia nervosa (AN), medical stabilization and nutritional repletion are pivotal steps toward physical and psychological recovery. Nutritional stabilization is often difficult in this patient group. Recombinant human growth hormone (rhGH) has been safely used as adjuvant therapy in other groups of malnourished patients. We hypothesize that rhGH treatment will hasten medical stabilization in AN patients.

STUDY DESIGN

Fifteen patients admitted for inpatient treatment for AN, ages 12-18 years, were enrolled in a 28-day randomized, double-blind, placebo-controlled study. Patients received rhGH (0.05 mg/kg subcutaneously) or an equivalent volume of placebo daily. Outcome measures included time to reach medical/cardiovascular stability, rate of weight gain, and duration of hospitalization. All patients received a standard refeeding protocol.

RESULTS

Mean admission body mass index was 14.5 kg/m2. The rhGH and placebo groups did not differ significantly in admission weight, BMI or daily caloric intake. Patients treated with rhGH reached medical/cardiovascular stability more rapidly than those treated with placebo (median 17 vs. 37 days, p = 0.02). Numerical but not statistically significant improvements were seen in weight gain and length of hospitalization in the rhGH group.

CONCLUSION

Patients treated with rhGH achieved medical/cardiovascular stability more rapidly than those treated with placebo, and this, in turn, decreased the length of stay.

Neurological complications of childhood malignancies

Between Jan 1982 to Jun 1994, 154 children with malignant non-central nervous system tumors, excluding leukemias and lymphomas, were admitted and treated at the UKMC. Fifty-one (33%) of these cases suffered with 64 neurological complications during the course of their diseases. Nine cases suffered with multiple neurological complications. Nervous system metastasis was the most common neurological complication (n = 24; 15.6%), which was followed by nervous system infection (n = 17; 11%). Twelve (7.7%) cases had treatment related peripheral or cranial neuropathies. Seven (4.5%) cases had new onset of grand-mall seizures. One case had paraneoplastic syndrome, one case had panhypopituitarism secondary to whole brain radiation, and one case had Horner's syndrome secondary to tumor removal. Ten cases suffered with neurological sequelae secondary to neurological complications. Three of these cases suffered with developmental delay and mental retardation. Fifty-one patients with neurological complications were followed for 9 to 102 months. While 30 (19.7%) patients were alive, 20 (13%) patients died and one case was lost during the analysis of the results. Neuroblastoma/ganglioneuroblastoma has the highest rate for causing neurological complication.

IN CONCLUSION

neurological complications were seen on 33% of childhood solid malignant tumors. Nervous system metastasis had the worst prognosis and the most frequent neurological complication. Neurological complications did not increase the mortality rate, but one-third of surviving patients with neurological complications suffered with neurological sequelae.

GDNF protection against 6-OHDA: time dependence and requirement for protein synthesis

Glial cell line-derived neurotrophic factor (GDNF) injected intranigrally protects midbrain dopamine neurons against 6-hydroxydopamine (6-OHDA) toxicity. The timing between GDNF administration and exposure to 6-OHDA is critical in achieving optimal protection. When injected 6 hr before an intranigral injection of 6-OHDA, GDNF provides complete protection as measured by the number of surviving neurons in the substantia nigra of adult rats. The surviving neuronal population decreases by approximately 50% with 12 and 24 hr separating GDNF and 6-OHDA administrations. In controls with 6-OHDA lesions, there is <10% survival of nigral dopamine neurons. No significant increase in survival is seen with either concurrent injections of GDNF and 6-OHDA or 1 hr GDNF pretreatment. Based on HPLC measurements, striatal and midbrain dopamine levels are at least twofold higher on the lesioned side in animals receiving GDNF 6 hr before a 6-OHDA lesion compared with vehicle recipients. Protein synthesis is necessary for GDNF-induced neuroprotective effects because cycloheximide pretreatment that inhibits protein synthesis also blocks neuroprotection.

Dose response to intraventricular glial cell line-derived neurotrophic factor administration in parkinsonian monkeys

A double-blinded study was conducted to evaluate the dose response of hemiparkinsonian rhesus monkeys to intracerebroventricular (ICV) injections of recombinant methionine human glial cell line-derived neurotrophic factor (GDNF). Thirty rhesus monkeys with stable hemiparkinsonian features were divided into six treatment groups (vehicle, 10, 30, 100, 300 and 1000 microg GDNF; n = 5/group). Each animal received 4 ICV administrations spaced at four week intervals. In addition, the animals were followed for 4 mo after the last injection. Standardized video taped behavioral tests were used to rate parkinsonian features using a nonhuman primate rating scale and assess side effects from treatment. Significant behavioral improvements were measured in animals receiving 100 to 1000 microg GDNF. One month after the last GDNF administration, parkinsonian features in animals receiving 100 and 1000 microg GDNF began to return to baseline levels. However, 300 microg GDNF recipients continued to display behavioral improvements. Parkinsonian features significantly improved were: bradykinesia, rigidity, posture and balance. The most common side effect was a transient weight loss after GDNF administration. Only one other side effect was observed, one animal receiving 1000 microg GDNF displayed dyskinetic movements. The results provide additional information for evaluating the possible clinical application of GDNF for treating Parkinson's disease.

Glial cell line-derived neurotrophic factor-levodopa interactions and reduction of side effects in parkinsonian monkeys

Glial cell line-derived neurotrophic factor (GDNF) stimulates the nigrostriatal dopaminergic pathway and improves motor functions in animal models of parkinsonism. Sinemet is currently the most widely used drug for treating Parkinson's disease. The present study has evaluated GDNF-Sinemet interactions in parkinsonian rhesus monkeys. Both GDNF and Sinemet, when given alone, significantly improved total parkinsonian scores. The response to Sinemet did not change after intracerebroventricular vehicle injections. In contrast, there was a functional interaction between GDNF and levodopa. When comparing the levodopa dose response before and after GDNF treatment, significant behavioral improvements were seen after trophic factor administration at every levodopa dose level except 500 mg. Adverse responses to Sinemet treatment alone in parkinsonian animals included vomiting, dykinesias, dystonias, and stereotypic movements. Combined GDNF-Sinemet treatment significantly reduced the occurrence of these levodopa-induced side effects, with a >90% decrease in adverse responses seen at the mid-Sinemet (250 mg levodopa-25 mg carbidopa) dose level. The only side effect from GDNF treatment was a transitory weight loss. Thus, combined GDNF-Sinemet treatment could be of therapeutic value in treating parkinsonism, by producing a greater functional response and by mitigating adverse responses to Sinemet treatment.

Treatment of renal allograft rejection with T10B9.1A31 or OKT3: final analysis of a phase II clinical trial

BACKGROUND

Treatment of acute renal allograft rejection with the monoclonal antibody (mAb) OKT3 has been shown to be superior to treatment with polyclonal antisera. To date, only OKT3 has demonstrated consistent efficacy in reversing rejection crisis.

METHODS

From 1989 to 1993, a phase II trial comparing the mAb T10B9.1A31 (T10B9) with OKT3 for treatment of acute cellular rejection in renal allograft recipients was done at the University of Kentucky. We collected data from 178 patients potentially eligible to enter the study; 48 never rejected, 9 refused, 13 could not be biopsied, 16 received methylprednisolone, and 11 received antithymocyte globulin or OKT3. Altogether, 81 patients entered the study, 76 of whom were able to be evaluated. Patients with biopsy-confirmed acute rejection were randomly assigned to T10B9 or OKT3 for at least 10 days.

RESULTS

Demographically, there was no difference between the T10B9 or OKT3 cohorts. Actuarial graft survival at 4 years was 87% for patients receiving T10B9, 79% for those receiving OKT3, and 89% for those receiving both mAbs (P=0.55). Patient survival at 4 years was 94% for T10B9, 100% for OKT3, and 89% for both mAbs (P=0.45). Mean creatinines of the cohorts were no different at 1, 6, 12, 24, and 36 months. There was less cytokine nephropathy (P<0.001) observed in patients receiving T10B9. Untoward gastrointestinal, neurological, respiratory, and febrile effects were significantly more frequent in the OKT3 cohort after the first dose (day 0) and with later (day 1-9) administration. Cytokine levels (tumor necrosis factor alpha and interferon gamma) measured 2 hr after the first dose were three to six times higher in patients treated with OKT3 than in those treated with T10B9 (P<0.005). Infectious complications were not significantly different, although serious infections occurred only in patients receiving OKT3. No cases of posttransplant lymphoproliferative disorder were seen in either cohort. Human anti-mouse antibody development was as follows: titer 1:100, 30% T10B9, 42% OKT3; titer 1:1000, 3% T10B9, 3% OKT3. There was no cross-reactivity with OKT3 in patients treated with T10B9, and there was only 9.7% cross-reactivity to T10B9 in patients treated with OKT3.

CONCLUSIONS

T10B9 provides treatment for renal allograft acute cellular rejection as effective as that of OKT3 with fewer untoward effects, less cytokine release and nephropathy, fewer serious infections, and without increased development of human anti-mouse antibody. The lack of cross-reactivity offers an alternative therapy should the first mAb fail or re-rejection occur. A phase III trial should be initiated in renal allograft recipients, and phase I and phase II trials should be initiated in other solid-organ transplantations.

The prognostic implication of ascites in advanced-stage ovarian cancer

Ovarian carcinoma accounts for greater than 50% of the gynecologic cancer deaths in the United States each year. One of the central reasons for this dismal outcome is that many patients present with advanced disease. In this series, a retrospective review of 130 patients with stage III and IV invasive epithelial ovarian carcinoma was performed to determine the prognostic significance of ascites. Patients were divided into two study groups based upon the presence or absence of ascites. Survival for the entire study group was 15%, but differed markedly when separated for the presence of ascites. In these patients, ascites was associated with a statistically decreased 5-year survival of 5% versus 45% without ascites (P = 0.0001). Individuals were found to be similar in each group when examined for age, height, weight, cell type, grade, and surgical and chemotherapeutic treatment modalities. More patients proportionately with stage IIIC disease had ascites than those without ascites (P = 0.0015). More of the individuals without ascites underwent second-look laparotomies and achieved a negative result than those with ascites (P = 0.04; P = 0.0038). We conclude that ascites in the presence of stage III and IV disease produces an almost uniformly fatal outcome.

Zinc supplementation is associated with improved neurologic recovery rate and visceral protein levels of patients with severe closed head injury

Sixty-eight patients were entered into a randomized, prospective, double-blinded controlled trial of supplemental zinc versus standard zinc therapy to study the effects of zinc supplementation on neurologic recovery and nutritional/metabolic status after severe closed head injury. One month after injury, the mortality rates in the standard zinc group and the zinc-supplemented group were 26 and 12%, respectively. Glasgow Coma Scale (GCS) scores of the zinc-supplemented group exceeded the adjusted mean GCS score of the standard group at day 28 (p = 0.03). Mean motor GCS score levels of the zinc-supplemented group were significantly higher on days 15 and 21 than those of the control group (p = 0.005, p = 0.02). This trend continued on day 28 of the study (p = 0.09). The groups did not differ in serum zinc concentration, weight, energy expenditure, or total urinary nitrogen excretion after hospital admission. Mean 24-h urine zinc levels were significantly higher in the zinc-supplemented group at days 2 (p = 0.0001) and 10 (p = 0.01) after injury. Mean serum prealbumin concentrations were significantly higher in the zinc-supplemented group (p = 0.003) at 3 weeks after injury. A similar pattern was found for mean serum retinol binding protein level (p = 0.01). A significantly larger number of patients in the standard zinc group had craniotomies for evacuation of hematoma; thus a bias may have been present. The results of this study indicate that zinc supplementation during the immediate postinjury period is associated with improved rate of neurologic recovery and visceral protein concentrations for patients with severe closed head injury.

The efficacy of a sonographic morphology index in identifying ovarian cancer: a multi-institutional investigation

Transvaginal sonography (TVS) has been shown to be the most effective means to screen for ovarian cancer. TVS is associated with a high sensitivity and specificity. However, the positive predictive value associated with TVS in the diagnosis of malignancy is low. A morphologic scoring index for use with TVS has been used at the University of Kentucky since 1991. The current study was performed to more fully evaluate the efficacy and interobserver variation in ultrasonographic morphology index scores attributed to ovarian tumors. Ultrasound records of 213 patients from five participating centers were reviewed by three independent observers. Morphology index scores were assigned to each tumor in a blinded fashion. The morphology index scores were then compared with the final histopathologic findings. One hundred sixty-nine patients had benign tumors and 44 patients had ovarian malignancies. The mean morphology index scores were significantly higher in malignant ovarian tumors (MI 7.3 +/- 1.9) than in benign ovarian tumors (MI 3.3 +/- 1.8). Statistical evaluation of the morphology index scores revealed a sensitivity of 89% and a positive predictive value of 46%. Interobserver variation was lowest in assessing ovarian volume and higher in the evaluation of wall structure and septal structure. A multilogistic regression model was used to evaluate the predictive power of each component of the morphology index. The use of a morphology index is an effective and cost-efficient method of increasing the positive predictive value of TVS screening for ovarian cancer. Use of this index in large numbers of patients will generate data which should help refine appropriate structural scoring categories and reduce interobserver variation.

Geographic distribution of hospitalization rates, case fatality, and mortality from stroke in the United States

We analyzed state-specific stroke-hospitalization, case-fatality, and mortality rates for the US Medicare population for 1989, using national data resources of the Health Care Financing Administration (HCFA), the National Center for Health Statistics, and the Bureau of the Census. State-specific hospital admission rates for stroke ranged from 0.66 to 1.26%, compared with the national value of 0.94%. Both hospital-usage rates and deviations of observed rates from predicted values (based on statistical models of the HCFA) showed significant spatial autocorrelation, with high rates clustered in the southeastern United States and low rates clustered in the Mountain census division of the West and also somewhat in the Northeast. Case-fatality rates increased nationally from 14.9% at 15 days after hospital admission to 31.2% at 180 days after hospital admission. State-level case-fatality rates showed relatively little interstate variation and no clear or consistent spatial pattern, although there was statistically significant spatial autocorrelation at several intervals after hospital admission. Admission rates and case-fatality rates were not significantly associated at any interval after admission to 180 days, suggesting that variation in case-fatality rates was not simply a result of differences in severity-of-illness thresholds for hospital admission. State-specific stroke-mortality rates ranged from 294.5 to 523.5 per 100,000 population, compared with the national value of 415.3 per 100,000 population. State-specific mortality rates for stroke showed significant spatial autocorrelation, with high rates clustered in the South and low rates clustered in the Northeast and the Mountain census division of the West. The spatial distribution of stroke-mortality rates strongly resembled the spatial distribution of hospitalization rates but did not resemble the spatial distribution of case-fatality rates at any interval from 15 to 180 days after hospital admission. Indeed, in univariate spatial-regression models fitted to the data using a maximum likelihood procedure and weighted for non-constant variances, the best predictor of state-level stroke-mortality rates was the hospital-utilization rate for stroke; attempts to improve the model by including case fatality at various intervals and interaction terms did not yield a significant improvement. These data suggest that factors determining stroke occurrence and hospital utilization are more important than factors determining case fatality in terms of explaining the long-standing distribution of stroke mortality in the United States. Factors affecting only case fatality but not hospitalization, such as the quality of medical care provided in the hospital, cannot explain the geographic distribution of stroke mortality in the United States.

Nutritional and metabolic variables correlate with amino acid forearm flux in patients with severe head injury

OBJECTIVE

To measure the arterial-venous amino acid flux across the forearm muscle in patients with severe head injury.

DESIGN

Prospective, interventional study.

SETTING

Level I trauma hospital in the neurosurgery intensive care unit (ICU) at a university medical center.

PATIENTS

Eight nonsteroid-treated patients with severe head injury.

INTERVENTIONS

Patients were prospectively randomized to receive either standard or supplemental intravenous zinc therapy.

MEASUREMENTS AND MAIN RESULTS

Net forearm alanine, glutamine, tyrosine, phenylalanine, and branch-chain amino acid forearm flux were measured and compared with metabolic markers of energy expenditure and nitrogen excretion. There was a significant inverse relationship between the measured energy expenditure/predicted energy expenditure ratio and glutamine flux (r2 = .62; p < .05). The patients with the highest measured energy expenditure/predicted energy expenditure ratio had the greatest release of glutamine from forearm muscle. Nitrogen balance was significantly correlated with leucine flux (r2 = .53; p < .05) and with isoleucine flux (r2 = .67; p < .05). The patients with the most positive nitrogen balance had the least release of branch-chain amino acids from skeletal muscle. Tyrosine flux was highly correlated with net amino acid flux (r2 = .76; p < .01). Tyrosine flux was therefore indicative of overall muscle catabolism. Four patients had an overall negative flux of amino acids from skeletal muscle. Three patients had an overall negative flux of branch-chain amino acids.

CONCLUSIONS

This preliminary descriptive report suggests that increased skeletal muscle efflux of amino acids correlates significantly with metabolic variables of hypermetabolism and hypercatabolism in nonsteroid-treated, head-injured patients.

Neurologic complications of cervical cancer. A review of 2261 cases

The authors reviewed the records of 2261 patients with histologically proven cervical cancer. Among the 1042 patients with carcinoma in situ, four neurologic complications occurred (0.4%), including three strokes and one seizure. None of the neurologic complications were related to cervical cancer. Among the 1219 patients with International Federation of Gynecology and Obstetrics (FIGO) Stage I or greater disease, 99 neurologic complications occurred (8%). Metastatic neurologic complications were twice as common as nonmetastatic neurologic complications and included lumbosacral plexopathy (50 patients), peripheral nerve compressions (eight patients), spinal cord compressions (two patients), and brain metastases (six patients). Nonmetastatic neurologic complications were less frequent and included stroke (11 patients), encephalopathies (three patients), infectious complications (two patients), effects of therapy (six patients), and seizures (11 patients). In conclusion, neurologic complications are rare in cervical cancer and virtually nonexistent in Stage 0 disease. Metastatic neurologic complications were more common than nonmetastatic complications and lumbosacral plexopathy caused by retroperitoneal lymph node metastases was the most common neurologic complication.

Dose-response and failure pattern for bulky or barrel-shaped stage IB cervical cancer treated by combined photon irradiation and extrafascial hysterectomy

From 1975 to 1987, 80 patients with bulky or barrel-shaped Stage IB cervical cancer were treated with preoperative irradiation and Cs-137 intracavitary implant therapy, before a planned extrafascial abdominal hysterectomy, using a consistent treatment policy. Of the hysterectomy specimens obtained, 37% were positive histologically at 89 +/- 2.3 days after the start of radiotherapy and at 4 to 6 weeks after the completion of radiation therapy. Sixty-three percent were negative after a total external and internal cervix irradiation dose of 9642 cGy at point T. The average point A dose contributed by intracavitary therapy was 2104 cGy. The survival rate at 5 years was 84%: At 10 years the survival rate was 78%. The failure pattern was analyzed for patients who had positive and negative specimens. The patients with positive specimens failed pelvically or pelvically and distantly. Patients with negative specimens failed in extrapelvic or distant metastatic sites. Preoperative radiotherapy led to excellent local and pelvic control of tumor, and the failures became predominantly distant metastases. The combined radiosurgical therapy was tolerated well and allowed surgical staging of disease. This permitted earlier and selective consideration of adjunctive therapy (i.e., paraaortic irradiation, chemotherapy, or chemoradiotherapy). The dose-response data give insight into the effects of photon radiotherapy on bulky or barrel Stage IB cervical cancers and correlate histologic status with failure pattern, outcome, and long-term survival.

Small cell carcinoma of the uterine cervix

From 1962 to 1985, 2201 patients with invasive cervical cancer were staged, evaluated, and treated at the University of Kentucky Medical Center. After a thorough evaluation, 25 cases (1.1%) fulfilled the histologic criteria for small cell cancer defined by Reagan and coworkers. These patients were computer-matched for age, disease stage, and lesion size to 25 patients with large cell nonkeratinizing cancer and 25 patients with keratinizing squamous cell cancer. Morphometric analyses of nuclear size and maximum nuclear diameter were performed on all cases without knowledge of cell type. Small cell cancers were characterized by a nuclear area of 160 mu 2 or less and a maximum nuclear diameter of 16.2 mu, which was significantly lower than that for large cell tumors. Thirty-three percent of the small cell carcinomas stained positively for the neuroendocrine markers (neuron-specific enolase [NSE] and chromogranin [CGR]), whereas the remainder contained only epithelial markers such as cytokeratin (CYK) and epithelial membrane antigen (EMA). Small cell cancers were associated with a high frequency of lymph-vascular space invasion and a diminished lymphoplasmacytic response. Patients with small cell cancer had a significantly higher recurrence rate, particularly to extrapelvic sites, than the matched patients with large cell cancers, and their survival was lower. Clinical trials to determine the efficacy of adjuvant chemotherapy in the treatment of small cell cervical cancer are needed.

Efficacy of brachytherapy with californium-252 neutrons versus cesium-137 photons for eradication of bulky localized cervical cancer: single-institution study

A fast-neutron-emitting radioisotope, 252Cf, is being tested in clinical trials of neutron brachytherapy for cervical cancer. The efficacy for histological eradication of bulky stage IB cervical tumors (mean diameter, approximately 6 cm) using combined radiation and surgery was studied in 65 patients treated with 137Cs or 252Cf before surgery during 1983-1986. Forty-four patients were treated with 137Cs and 21 were treated with 252Cf at equivalent doses of radiation. Fifteen of the 44 specimens (34%) were positive after 137Cs therapy. Only one of the 21 specimens was positive after 252Cf therapy (P = .025), and that patient was treated in a delayed schedule 21 days after the start of external-beam irradiation rather than early in the course. 252Cf therapy required a much lower radiation dose and shorter treatment time. The study compared tumor destruction of an identically staged human cervical tumor in situ by direct histological means, using 252Cf neutron therapy or conventional photon therapy at an identical and equivalent dose adjusted by a relative biological effectiveness of 6.0 for 252Cf.

Phase I-II clinical trial of Californium-252. Treatment of stage IB carcinoma of the cervix

Intracavitary Californium-252 combined with whole-pelvis photon radiotherapy was tested as the sole form of treatment for 22 patients with Stage IB carcinoma of the cervix. Californium-252 (Cf) is a fast neutron-emitting radioisotope currently being tested in trials of neutron brachytherapy (NT). The outcomes of the treated group of patients were traced for local tumor control, survival, patterns of failure, and complications. The Cf intracavitary therapy combined with whole-pelvis photon radiotherapy resulted in 95% 2-year and 91% 5-year actuarial survival. There were 9% Grade II-III complications by the Stockholm scale and 4% local failures. These results were obtained in an early clinical trial with a group of largely poor-risk patients with tumors of mean diameter of 4.3 cm.

Treatment of primary radiogenic C57BL mouse cell leukemia/lymphoma by 1,3-bis(2-chloroethyl)-1-nitrosourea chemotherapy and adjuvant cellular therapy

Primary radiation-induced or radiation leukemia virus (RadLV)-induced T-leukemias/lymphomas were treated in vivo in an early to advanced state by using 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU). BCNU was given at various times after the tumor induction procedure. Death from RadLV lymphomas which had been initiated in 33 +/- 3 day old C57BL mice by intrathymic injection of RadLV was scored in untreated, BCNU-treated or BCNU and cellular adjuvant treated mice. Intrathymic RadLV injection in 33 +/- 3 day old mice produced tumors in 98% of injected mice. Median survival time (MST) was increased by BCNU and by BCNU plus bone marrow cell therapy whether done 33 or 47 days after RadLV. There was increased in MST from 108 days to 171 days by BCNU and bone marrow cell therapy given 33 days after tumor initiation and to 195 days when therapy was given 47 days after initiation. In radiation-induced lymphomas produced by 190 rad every week X 4 of 33 +/- 3 day old mice, spleen cell (X 1) therapy or BCNU treatment increased the MST of treated mice from 142 days to 177 days after iv spleen cells or to 195 days after iv-ip spleen cells, and this protocol produced 31% long-term cures. Cellular adjuvant therapy combined with BCNU chemotherapy was effective for curing the lymphomas but cellular adjuvant therapy alone was also highly effective for therapy.

Motor proficiency in depressed adolescent inpatients: biochemical and clinical diagnostic correlates

A pilot investigation was conducted on 25 adolescents, ages 11 to 18 years, admitted to a six-bed psychiatric unit in a university hospital in order to explore relationships among motor proficiency and categories of depressive illness. The investigators endeavored to determine whether (a) depressed adolescents would perform as well as normals on the Bruininks-Oseretsky Test of Motor Proficiency and (b) whether the method of diagnosing major depressive episode (MDE), using DSM-III criteria or the Dexamethasone Suppression Test, was related to motor proficiency. Results indicate that depressed adolescents performed less well on balance, bilateral coordination, upper limb coordination, and response speed than normals. Major depressive episode (MDE) patients, as defined by the Dexamethasone Suppression Test, performed less well than patients with Adjustment Disorder with Depressive Mood. Patients diagnosed as MDE on the basis of DSM-III criteria had motor proficiency scores similar to those of the other patients with depressive mood adjustment disorders. The method of diagnosis is critical if prescribed physical activity therapy is to be effective.

Echogenicity of fetal lung: relation to fetal age and maturity

Reports of echogenicity of the fetal lung as it relates to maturity of that organ are scant and at variance. A study was undertaken to determine if any correlation between fetal age and/or lung maturity and echogenicity could be determined in a clinical setting. Studies were performed with either linear array or mechanical sector real-time devices. Echogenicity of the fetal lung was compared with that of the fetal liver in the same longitudinal (parasagittal or coronal) sonogram. Lung echogenicity was judged to be hypodense, isodense, slightly hyperdense, or markedly hyperdense as compared with the liver texture. One hundred eighty-five studies were evaluated; of these, some 37 patients also underwent amniocentesis for determination of lecithin/sphingomyelin ratios (L/S) and presence of phosphatidyl glycerol (PG). Linear regression analyses were performed to determine if lung echogenicity would serve as an indicator of fetal maturity. No clinically applicable relation was established between fetal lung echogenicity and gestational age, L/S, or presence of PG in amniotic fluid with current methodology. The possibility persists that tissue characterization techniques may find application in such an investigation.

Clinical trial of 252Cf neutron brachytherapy vs. conventional radiotherapy for advanced cervical cancer

252Cf, a neutron emitting radioactive transplutonium isotope, was tested for its efficacy against advanced bulky Stage III-IV cancers of the cervix in a clinical trial at the University of Kentucky Medical Center. Eighty-two patients were treated during 1976-1979 and followed for 5-year survival and tumor control. Three different treatment methods went on sequentially and concurrently, that is, (a) conventional whole pelvis photon with delayed 137Cs implants, (b) conventional photon therapy with delayed 252Cf implants, and (c) 252Cf implants ("early") preceding photon therapy. There were 12% 5-year survival for Stage IIIB cancers by conventional therapy, and 15% by delayed 252Cf implant therapy. For early 252Cf implant therapy there were 54% 5-year survivals with 4% complications and 65% 5-year local control, but distant metastases became a prominent delayed failure pattern.

Feasibility study: results of treatment of primary and recurrent adenocarcinoma of the corpus uteri with californium-252

A trial of Cf-252 for the radiotherapy of primary or recurrent corpus adenocarcinoma was carried out at the University of Kentucky. The patients with primary tumors were of advanced age, poor general medical condition, and had multiple chronic medical illness, poorly differentiated tumors and/or metastatic Stage IVB disease. Fourteen patients with primary tumors were treated and all achieved complete local tumor control. The five year actuarial disease-free survival rate by the Kaplan-Meier method was 100% for Stage I-III disease, although 36% died of other, usually medical, causes. For eight patients treated with recurrent tumors, long term tumor control was 40% four year actuarial disease survival. Local control was 100% for vault recurrences of 3 cm diameter size, but only 6/8 (75%) cleared their pelvic tumors completely. Those that did not had tumors of massive size, distant metastatic disease and adenosquamous or poorly-differentiated (G3) pattern. One additional cut across, infected tumor was controlled for 26 months. Corpus carcinoma was highly sensitive to Cf-252 neutron radiation therapy.

Neutron brachytherapy is better than conventional radiotherapy in advanced cervical cancer

Californium-252 (252Cf), a fast-neutron emitting radioisotope, was used for neutron brachytherapy (NT) of 82 patients with advanced (stage III and IV) cervical cancer. The results were compared with caesium-137 brachytherapy; both isotopes were given in combination with high-dose fractionated pelvic radiotherapy. In patients with stage IIIB disease (ie, tumour to the pelvic side-wall), 252Cf intracavitary therapy resulted in 54% 5-year survival compared with 12% in the caesium group. To be effective, Cf-NT must be given before external beam (photon) therapy.