Development of a customized m-Health-based intervention to reduce loss to follow-up among patients undergoing treatment for cervical lesions at a rural referral Hospital, South Western Uganda

Background

Loss to follow-up (LTFU) in individuals undergoing cervical cancer treatment is a major challenge in many low resource settings. We describe development of a customized and tailored mHealth intervention for reducing LTFU among patients undergoing cervical cancer treatment at Mbarara Regional Referral Hospital (MRRH).

Methods

We interviewed all health care providers (HCPs) at the cervical cancer clinic of MRRH, between April and May 2023. Transcripts were subsequently derived, reviewed and coded to generate themes and categories using inductive content analytic approach. Four medical experts used this data to develop relevant SMS content, which was incorporated into an app.

Results

HCPs had owned a phone for 13.8 ≤ years, had worked at the clinic for 5 ≤ years, and used text messages regularly. Qualitative data revealed that the main challenge to re-engagement was absence of a reminder mechanism between HCPs and patients. HCPs preferred text and or audio mode of messaging to improve health care responsiveness to LTFUs, awareness, continuity of care, and health service uptake among the majority illiterate population; though with potential constraints of costs and workload. Identified key messaging content included; the importance of attending scheduled follow-ups, follow up visit date and clinic customization and tailoring the message to the intended recipient. SMS content was uploaded onto the cc-follow-up app platform and customized according to preferred language, day, frequency and time of delivery.

Conclusion

Tailoring an mHealth messaging intervention could help re-engage and reduce LTFU through improved information sharing, awareness, responsiveness, care engagement and medical compliance. A pilot study is required for our intervention in South Western Uganda.

Magnitude and trends in cervical cancer at Mbarara Regional Referral Hospital in South Western Uganda: Retrospective analysis of data from 2017-2022

High-income countries have documented a significant decline in the incidence and mortality of cervical cancer over the past decade but such data from low and middle-income countries such as Uganda is limited to ascertain trends. There is also paucity of data on the burden of cervical cancer in comparison to other gynaecologic malignancies and there is a likelihood that the incidence might be on the rise. To describe the current trends and magnitude of cervical cancer in comparison to other gynaecological malignancies histological types, we conducted a retrospective records review of charts of patients admitted with gynaecological malignancies on the gynaecological ward of Mbarara Regional Referral Hospital (MRRH) between January 2017 and December 2022. Of 875 patients with gynaecological malignancies admitted to the MRRH in the 6-year review period, 721 (82.4%) had cervical cancer. Patients with cervical cancer were significantly older than those with other gynaecological malignancies: (50.2±11.5 versus 43.8± 15.0 respectively, p<0.001). Between 2017 and 2022, cervical cancer rates increased by 17% annually compared to other gynaecological cancers (OR:1.17; 95% CI 1.06-1.28, p = 0.0046), with the majority of patients of cervical cancer patients (92.7%, n = 668) having squamous cell carcinoma. Most patients (87.9%, n = 634) had late-stage disease (stage 2 and above) and were referred to the Uganda Cancer Institute for chemoradiation. These results imply that there is a need to scale up screening services and other preventive measures such as vaccination against human papilloma virus.

High Rate of Loss to Follow-Up Among Patients Undergoing Treatment for Premalignant Cervical Lesions at Mbarara Regional Referral Hospital, Southwestern Uganda: A Retrospective Cohort Study

BACKGROUND

For a cervical cancer control program to be effective in reducing the incidence of the disease, there should be high compliance to treatment and follow-up of women diagnosed with precursor lesions. Screening programs in low-resource countries such as Uganda are challenged by poor adherence to follow-up following treatment for premalignant cervical lesions. This study sought to describe the burden and factors associated with loss to follow-up among women undergoing treatment for premalignant cervical lesions at a tertiary hospital in southwestern Uganda.

METHODS

This was a retrospective cohort study. We reviewed the registers at the Mbarara Regional Referral Hospital (MRRH) cervical cancer clinic for a period of four years from January 2017 to December 2020. Data on age, district of residence, diagnosis, date of diagnosis, date and type of initial treatment, and date of follow-up visit were collected. We also captured data on whether patients returned on the scheduled follow-up date or within three months after the scheduled follow-up date. We defined loss to follow-up as failure to return for follow-up either on the scheduled date or within three months after the scheduled date.

RESULTS

Out of the 298 patients who underwent treatment for premalignant cervical lesions in the study period, 227 (76.2%) did not return for follow-up at one year. At bivariate analysis, failure to attend the review visit at six weeks predicted the loss to follow-up at one year following treatment for premalignant lesions almost perfectly (risk ratio (RR)=2.84, 95% confidence interval (CI): 2.18-3.71, p<0.001). Negative HIV serostatus and receiving thermocoagulation slightly increased the risk of getting lost to follow-up, while being more than 45 years old reduced the odds. At multivariate analysis, treatment with thermocoagulation (adjusted risk ratio (aRR)=1.21, 95% CI: 1.07-1.36, p=0.03) was associated with loss to follow-up at one year.

CONCLUSION

The proportion of women who did not return for follow-up at one year following treatment for premalignant cervical lesions at Mbarara Regional Referral Hospital is very high. There is a need to implement strategies such as telephone-aided reminders to prompt patients to return for follow-up following treatment for premalignant cervical lesions.

Vulvar leiomyosarcoma: A case report

Vulvar leiomyosarcoma is a rare malignant smooth muscle tumor and the most common type of vulvar sarcoma. It can mimic benign tumors, and misdiagnosis may delay appropriate treatment. A 35-year-old woman presented to the outpatient gynecology clinic at the Mirebalais Teaching Hospital for a right vulvar mass. A complete excision of the mass was performed. Histopathology with immunohistochemistry demonstrated leiomyosarcoma. We describe the contextual challenges that ultimately compromised her care, highlighting the challenges to safe delivery of cancer care in our setting.

Association between obesity and cervical intraepithelial neoplasia: results from a case control study in south western Uganda

BACKGROUND

Though obesity has been said to be associated with a number of malignancies including cervical cancer, its association with cervical intraepithelial neoplasia (CIN) is still a contentious issue. This study was designed to determining the prevalence and association between obesity and CIN.

METHODS

This was an unmatched case control study, involving women with cervical intraepithelial neoplasia (cases) and those negative for intraepithelial lesions or malignancy (controls) at the cervical cancer clinic of Mbarara Regional Referral Hospital, in south-western Uganda, between April and November 2022. Cases and controls provided written informed consent and were recruited in a ratio of 1:1. Cases were identified by visual inspection with acetic acid (VIA) and subsequent confirmation with cytology and/or histology. Demographic information was collected using an enrolment form and height, weight and waist circumference were recorded. We calculated body mass index (BMI) and identified obese women as those with body mass index of ≥ 30 kg/m² from both case and control groups. Central obesity was defined as waist: height ration of ≥ 0.5. Data was analysed using STATA version 17. Categorical variables were analysed using proportions, chi-square and logistic regression analysis to determine association between obesity and CIN. Our level of statistical significance was set at ≤ 0.05.

RESULTS

The prevalence of general and central obesity among cases was 25.5% (24/94) and 0% (0/94) respectively while the prevalence of general and central obesity among controls was 33.3% (37/111) and 0% (0/111) respectively. There was an increased prevalence of general obesity among women with low grade squamous intraepithelial lesions (LSIL). However, there was no statistically significant association between general obesity and CIN. Factors associated with general obesity included residing in Mbarara city (AOR 2.156, 95%CI 1.085-4.282, P-value 0.028), age group of 31-45 years (AOR 2.421, 95%CI 1.577-9.705, P-value 0.003) and ≥ 46 years (AOR 1.971, 95%CI 1.022-11.157, P-value 0.046).

CONCLUSION

We observed an increased prevalence of general obesity among women with LSIL. However, there was no association between obesity and CIN. Factors associated with general obesity included residing in Mbarara city, and being in the age groups of 31-40 and ≥ 46 years. This highlights the need to rethink management of CIN to control other non-communicable diseases that could arise due to general obesity.

Reaching the women with the greatest needs: Two models for initiation and scale-up of gynecologic oncology fellowship trainings in low-resource settings

Women in low- and middle-income countries (LMICs) are significantly more likely to develop and die from invasive cervical cancer, while rates of other gynecologic malignancies are comparable to those faced by women in high-income countries. Despite this increased need, there are few specialist physicians in LMICs available to treat women with gynecologic cancers. Training specialists in low-resource settings faces multiple challenges, including ensuring protected time from other clinical demands, access to best practice guidelines, training that is tailored to the specific challenges faced in the trainee's environment, and isolation from other fully trained professionals and securing support services. In addition, training specialists from LMICs in high-resource settings is costly and return of trainees to their own country is not guaranteed. Here we describe two approaches to gynecologic oncology training in LMICs. The International Gynecologic Cancer Society (IGCS) developed the Global Curriculum Mentorship and Training Program (Global Curriculum) to support gynecologic oncology fellowships in regions of the world that do not currently have formal training in gynecologic oncology. In India, on the other hand, leaders in world-class gynecologic oncology centers must find a way to meet the training needs of a vast and disparate country.

Abstract 95: “Women Are Reluctant to Make Long Journeys to Seek Screening Services While They Do Not Have Any Pain:” Providers' Experience on Cervical Cancer Screening in Primary Health Care Centers in Rwanda

Purpose: Cervical cancer screening reduces cervical cancer incidence and mortality. In Rwanda, cervical cancer screening is conducted predominately at primary health care centers. However, a significant number of age-eligible women who have not undergone screening present at primary health care centers with cervical cancer. The aim of our paper is to understand barriers and facilitators of cervical cancer screening from providers' perspectives.

Methods: We selected the ten top- and ten bottom-performing health centers for cervical cancer screening in the past five years within Rwanda. We identified three health care providers at each health center as key informants to be interviewed. A thematic analysis was conducted.

Results: We interviewed 33 providers. Providers consistently reported barriers for women to attend cervical cancer screening included: 1) women not seeking cervical cancer screening service while asymptomatic; 2) never having given birth at a health facility; 3) too busy with daily responsibilities to seek care; 4) being unfamiliar with gynecological service procedures; and 5) feeling uncomfortable with undergoing a pelvic exam and exposing their genitals. Reported facilitators to screening women included, health education activities, and providing multiple health services at the health center Services, such as family planning and child vaccination that attract women, which makes it easier for health care providers to provide them with educational information and offer them screening.

Conclusion: Health care providers reported patients with limited health-seeking behaviors as a barrier to cancer screening services but felt that educational sessions facilitated uptake among eligible women. Use of mass media to disseminate information on cervical cancer screening and prevention may encourage women to come to the clinic, at which time they may receive the education they need to undergo screening. Cervical cancer screening policies should evaluate and address existing health-seeking behaviors within their target population in order to achieve effective coverage.

Citation Format: Charles Ingabire, Amanda Pierz, Josephine Gasana, Francine Umwiza, Laura Drown, Athanase Munyaneza, Lydia Businge, Gallican Kubwimana, Gad Murenzi, François Uwinkindi, Alma Adler, Philip Castle, Thomas C. Randall. “Women Are Reluctant to Make Long Journeys to Seek Screening Services While They Do Not Have Any Pain:” Providers' Experience on Cervical Cancer Screening in Primary Health Care Centers in Rwanda [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 95.

A scoping review: Facilitators and barriers of cervical cancer screening and early diagnosis of breast cancer in Sub-Saharan African health settings

To address gaps in access to cervical cancer screening and early diagnosis of breast cancer services in Sub-Saharan African (SSA), this scoping review was conducted to explore facilitators and barriers that exist on the patient-, provider-, and system-level. An extensive literature search was conducted in accordance with scoping review methodology and the Cochrane guidelines. Our search criteria were limited to original research studies conducted in community or clinical settings in SSA within the last 10 years (2010-2020). Themes found from this review included patient knowledge and provider education, access to screening services, trust, health-related behaviors, attitudes, values, and practices, community and social values, health infrastructure, resource allocation, and political will. Identified barriers included lack of knowledge about cervical and breast cancer among patients, gaps in education and training among providers, and lack of resources and health infrastructure at the facility level and within the overall health system. Facilitators included perceived risk of cancer, support and encouragement of the provider, and utilization of novel approaches in low-resource settings by health systems. To better address individual-, provider-, and health system and facility-based facilitators and barriers to care, there is a need for political and financial investment and further research on the health service delivery in specific national health systems, especially in the context of the global campaign to eliminate cervical cancer as a public health problem.

Worthy of further consideration: An updated meta-analysis to address the feasibility, acceptability, safety and efficacy of thermal ablation in the treatment of cervical cancer precursor lesions

Treatment of preinvasive lesions is critical to the success of secondary prevention of cervical cancer. In many settings, however, excision or ablation of preinvasive lesions can prove challenging. Thermal ablation (TA) is a form of treatment for cervical precancer that may present fewer logistical challenges in resource limited settings. In 2013, Dolman and colleagues wrote a meta-analysis of publications reporting cure rates from TA. This included only one article from a low or middle-income country (LMIC). We updated Dolman's meta-analysis to include more recent articles from LMICs. A formal review of the world literature was performed for the years 2014-2017. Article titles and abstracts were reviewed for relevance; full articles were assessed for quality. The primary endpoint was treatment outcome for cervical intraepithelial neoplasia grade 2 or higher (CIN2+). The I2 statistic was used to assess heterogeneity between studies. Studies were stratified by geographic region, decade that the study was published, World Bank economic classification of the country where the study was performed, and other factors. We reviewed 34 total reports and included 23 in our meta-analysis, including 10,995 and 6371 patients, respectively. A total of 7 studies were performed in LMICs, including 6 studies included in the meta-analysis. The overall response rate for TA treatment of biopsy proven CIN2+ was 93.8%. Consistent with the wide variety of settings and patient populations, there was significant heterogeneity between studies. TA appears to be an effective treatment for CIN2+ across a variety of settings, including in LMICs.

HIV Infection and Survival Among Women With Cervical Cancer

Purpose Cervical cancer is the leading cause of cancer death among the 20 million women with HIV worldwide. We sought to determine whether HIV infection affected survival in women with invasive cervical cancer. Patients and Methods We enrolled sequential patients with cervical cancer in Botswana from 2010 to 2015. Standard treatment included external beam radiation and brachytherapy with concurrent cisplatin chemotherapy. The effect of HIV on survival was estimated by using an inverse probability weighted marginal Cox model. Results A total of 348 women with cervical cancer were enrolled, including 231 (66.4%) with HIV and 96 (27.6%) without HIV. The majority (189 [81.8%]) of women with HIV received antiretroviral therapy before cancer diagnosis. The median CD4 cell count for women with HIV was 397 (interquartile range, 264 to 555). After a median follow-up of 19.7 months, 117 (50.7%) women with HIV and 40 (41.7%) without HIV died. One death was attributed to HIV and the remaining to cancer. Three-year survival for the women with HIV was 35% (95% CI, 27% to 44%) and 48% (95% CI, 35% to 60%) for those without HIV. In an adjusted analysis, HIV infection significantly increased the risk for death among all women (hazard ratio, 1.95; 95% CI, 1.20 to 3.17) and in the subset that received guideline-concordant curative treatment (hazard ratio, 2.63; 95% CI, 1.05 to 6.55). The adverse effect of HIV on survival was greater for women with a more-limited stage cancer ( P = .035), those treated with curative intent ( P = .003), and those with a lower CD4 cell count ( P = .036). Advanced stage and poor treatment completion contributed to high mortality overall. Conclusion In the context of good access to and use of antiretroviral treatment in Botswana, HIV infection significantly decreases cervical cancer survival.

Cervical cancer in low and middle income countries: Addressing barriers to radiotherapy delivery

The global cervical cancer burden falls disproportionately upon women in low and middle-income countries. Insufficient infrastructure, lack of access to preventive HPV vaccines, screening, and treatment, as well as limited trained personnel and training opportunities, continue to impede efforts to reduce incidence and mortality in these nations. These hurdles have been substantial challenges to radiation delivery in particular, preventing treatment for a disease in which radiation is a cornerstone of curative therapy. In this review, we discuss the breadth of these barriers, while illustrating the need for adaptive approaches by proposing the use of brachytherapy alone in the absence of available external beam radiotherapy. Such modifications to current guidelines are essential to maximize radiation treatment for cervical cancer in limited resource settings.

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Challenges to radiation delivery for cervical cancer in LMIC are discussed.

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The efficacy of treatment with brachytherapy alone is presented.

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Limited resource settings require adaptive approaches to treatment guidelines.

Efforts towards erasing borders in gynecologic cancer?

•Cervical cancer is the second most common cancer among women in LMIC.•Major efforts to improve research in gynecologic cancer in LMIC are needed.•GOR provides a platform featuring research and review of cancer care in LMIC.

Cervical Precancer Treatment in Low- and Middle-Income Countries: A Technology Overview

Cervical cancer is the fourth leading cause of cancer-related death in women worldwide, with 90% of cases occurring in low- and middle-income countries (LMICs). There has been a global effort to increase access to affordable screening in these settings; however, a corresponding increase in availability of effective and inexpensive treatment modalities for ablating or excising precancerous lesions is also needed to decrease mortality. This article reviews the current landscape of available and developing technologies for treatment of cervical precancer in LMICs. At present, the standard treatment of most precancerous lesions in LMICs is gas-based cryotherapy. This low-cost, effective technology is an expedient treatment in many areas; however, obtaining and transporting gas is often difficult, and unwieldy gas tanks are not conducive to mobile health campaigns. There are several promising ablative technologies in development that are gasless or require less gas than conventional cryotherapy. Although further evaluation of the efficacy and cost-effectiveness is needed, several of these technologies are safe and can now be implemented in LMICs. Nonsurgical therapies, such as therapeutic vaccines, antivirals, and topical applications, are also promising, but most remain in early-stage trials. The establishment of evidence-based standardized protocols for available treatments and the development and introduction of novel technologies are necessary steps in overcoming barriers to treatment in LMICs and decreasing the global burden of cervical cancer. Guidance from WHO on emerging treatment technologies is also needed.

Strengthening care and research for women's cancers in Sub-Saharan Africa

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The burden of gynecologic cancers in low resource settings is overwhelming.

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Areas with the highest needs have few human resources and limited infrastructure.

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Cancer specialists can best help by leveraging ongoing work to assist local leaders.

Challenges in Prevention and Care Delivery for Women with Cervical Cancer in Sub-Saharan Africa

Virtually all cases of invasive cervical cancer are associated with infection by high-risk strains of human papilloma virus. Effective primary and secondary prevention programs, as well as effective treatment for early-stage invasive cancer have dramatically reduced the burden of cervical cancer in high-income countries; 85% of the mortality from cervical cancer now occurs in low- and middle-income countries. This article provides an overview of challenges to cervical cancer care in sub-Saharan Africa (SSA) and identifies areas for programmatic development to meet the global development goal to reduce cancer-related mortality. Advanced stage at presentation and gaps in prevention, screening, diagnostic, and treatment capacities contribute to reduced cervical cancer survival. Cost-effective cervical cancer screening strategies implemented in low resource settings can reduce cervical cancer mortality. Patient- and system-based barriers need to be addressed as part of any cervical cancer control program. Limited human capacity and infrastructure in SSA are major barriers to comprehensive cervical cancer care. Management of early-stage, locally advanced or metastatic cervical cancer involves multispecialty care, including gynecology oncology, medical oncology, radiology, pathology, radiation oncology, and palliative care. Investment in cervical cancer care programs in low- and middle-income countries will need to include effective recruitment programs to engage women in the community to access cancer screening and diagnosis services. Though cervical cancer is a preventable and treatable cancer, the challenges to cervical control in SSA are great and will require a broadly integrated and sustained effort by multiple stakeholders before meaningful progress can be achieved.

Holographic Assessment of Lymphoma Tissue (HALT) for Global Oncology Field Applications

Low-cost, rapid and accurate detection technologies are key requisites to cope with the growing global cancer challenges. The need is particularly pronounced in resource-limited settings where treatment opportunities are often missed due to the absence of timely diagnoses. We herein describe a Holographic Assessment of Lymphoma Tissue (HALT) system that adopts a smartphone as the basis for molecular cancer diagnostics. The system detects malignant lymphoma cells labeled with marker-specific microbeads that produce unique holographic signatures. Importantly, we optimized HALT to detect lymphomas in fine-needle aspirates from superficial lymph nodes, procedures that align with the minimally invasive biopsy needs of resource-constrained regions. We equipped the platform to directly address the practical needs of employing novel technologies for "real world" use. The HALT assay generated readouts in <1.5 h and demonstrated good agreement with standard cytology and surgical pathology.

Integration of robotics into two established programs of minimally invasive surgery for endometrial cancer appears to decrease surgical complications

Objective

To compare peri- and postoperative outcomes and complications of laparoscopic vs. robotic-assisted surgical staging for women with endometrial cancer at two established academic institutions.

Methods

Retrospective chart review of all women that underwent total hysterectomy with pelvic and para-aortic lymphadenectomy by robotic-assisted or laparoscopic approach over a four-year period by three surgeons at two academic institutions. Intraoperative and postoperative complications were measured. Secondary outcomes included operative time, blood loss, transfusion rate, number of lymph nodes retrieved, length of hospital stay and need for re-operation or re-admission.

Results

Four hundred and thirty-two cases were identified: 187 patients with robotic-assisted and 245 with laparoscopic staging. Both groups were statistically comparable in baseline characteristics. The overall rate of intraoperative complications was similar in both groups (1.6% vs. 2.9%, p=0.525) but the rate of urinary tract injuries was statistically higher in the laparoscopic group (2.9% vs. 0%, p=0.020). Patients in the robotic group had shorter hospital stay (1.96 days vs. 2.45 days, p=0.016) but an average 57 minutes longer surgery than the laparoscopic group (218 vs. 161 minutes, p=0.0001). There was less conversion rate (0.5% vs. 4.1%; relative risk, 0.21; 95% confidence interval, 0.03 to 1.34; p=0.027) and estimated blood loss in the robotic than in the laparoscopic group (187 mL vs. 110 mL, p=0.0001). There were no significant differences in blood transfusion rate, number of lymph nodes retrieved, re-operation or re-admission between the two groups.

Conclusion

Robotic-assisted surgery is an acceptable alternative to laparoscopy for staging of endometrial cancer and, in selected patients, it appears to have lower risk of urinary tract injury.

Racial differences in surgeons and hospitals for endometrial cancer treatment

PURPOSE

To determine whether (1) black and white women with endometrial cancer were treated by different surgical specialties and in different types of hospitals and (2) differences in specialty and hospital type contributed to racial differences in survival.

METHODS

Retrospective cohort study of 12,307 women aged 65 years and older who underwent surgical treatment of endometrial cancer between 1991 and 1999 in the 11 Surveillance Epidemiology and End Results registries.

RESULTS

Black women were more likely to have a gynecologic oncologist to perform their surgery and to be treated at hospitals that were higher volume, larger, teaching, National Cancer Institute centers, urban, and where a greater proportion of the surgeries were performed by a gynecologic oncologist. In unadjusted models, black women were over twice as likely as white women who died because of cancer (hazards ratio [HR]: 2.33), but nearly all of the initial racial difference in survival was explained by differences in cancer stage, and grade as well as age and comorbidities at presentation (adjusted HR: 1.10). Surgical specialty was not associated with survival and, of the hospital characteristics studied, only surgical volume was associated with survival (P < 0.005). Adjusting for hospital characteristics did not change the racial difference in survival (HR: 1.10). Adjustment for the specific hospital where the woman was treated eliminated the association between race and surgeon specialty and slightly widened the residual racial difference in survival (HR: 1.23 vs. 1.10).

CONCLUSIONS

In contrast to several studies suggesting that blacks with breast cancer, colon cancer, or cardiovascular disease are treated in hospitals with lower quality indicators, black women diagnosed with endometrial cancer in Surveillance Epidemiology and End Results regions between 1991 and 1999 were more likely to be treated by physicians with advanced training and in high volume, large, urban, teaching hospitals. However, except for a modest association with hospital surgical volume, these provider and hospital characteristics were largely unrelated to survival for women with endometrial cancer. The great majority of the difference in survival was explained by differences in tumor and clinical characteristics at presentation.

Robotic-assisted laparoscopic exenteration in recurrent cervical cancer Robotics improved the surgical experience for 2 women with recurrent cervical cancer

Pelvic exenteration can be used to cure women with a central pelvic recurrence or persistence of gynecologic malignancy after initial definitive therapy. Refinements in patient selection, operative techniques, and surgical instrumentation have significantly improved outcomes over the past 60 years, but the procedure is still associated with significant mortality, morbidity, and recovery time. New technologies have made it possible to approach radical gynecologic surgeries in a minimally invasive fashion. We present 2 patients successfully treated with robotic-assisted anterior pelvic exenteration for treatment of persistent or recurrent cervical cancer after definitive radiotherapy.

Surgical outcomes of robotic-assisted surgical staging for endometrial cancer are equivalent to traditional laparoscopic staging at a minimally invasive surgical center

OBJECTIVE

To compare peri- and post-operative complications and outcomes of robotic-assisted surgical staging with traditional laparoscopic surgical staging for women with endometrial cancer.

METHODS

A retrospective chart review of cases of women undergoing minimally invasive total hysterectomy and pelvic and para-aortic lymphadenectomy by a robotic-assisted approach or traditional laparoscopic approach was conducted. Major intraoperative complications, including vascular injury, enterotomy, cystotomy, or conversion to laparotomy, were measured. Secondary outcomes including operative time, blood loss, transfusion rate, number of lymph nodes retrieved, and the length of hospitalization were also measured.

RESULTS

275 cases were identified-102 patients with robotic-assisted staging and 173 patients with traditional laparoscopic staging. There was no significant difference in the rate of major complications between groups (p=0.13). The mean operative time was longer in cases of robotic-assisted staging (237 min vs. 178 min, p<0.0001); however, blood loss was significantly lower (109 ml vs. 187 ml, p<0.0001). The mean number of lymph nodes retrieved were similar between groups (p=0.32). There were no significant differences in the time to discharge, re-admission, or re-operation rates between the two groups.

CONCLUSION

Robotic-assisted surgery is an acceptable alternative to laparoscopy for minimally invasive staging of endometrial cancer. In addition to the improved ease of operation, visualization, and range of motion of the robotic instruments, robotic surgery results in a lower mean blood loss, although longer operative time. More data are needed to determine if the rates of urinary tract injuries and other surgical complications can be reduced with the use of robotic surgery.

Does Ovarian Cancer Treatment and Survival Differ by the Specialty Providing Chemotherapy?

Purpose

Chemotherapy for ovarian cancer is usually administered by medical oncologists (MOs) or gynecologic oncologists (GOs). GOs perform a broad spectrum of surgical and medical activities while managing a limited number of diseases; MOs specialize in the administration of chemotherapy but manage a broad array of diseases. We asked whether survival, treatment, and toxicity differed according to the type of specialist providing the chemotherapy after surgery.

Patients and Methods

Using Surveillance, Epidemiology, and End Results (SEER) -Medicare data for patients ≥ 65 years old from 1991 through 2001 from eight SEER sites, we identified 344 patients with ovarian cancer who were treated with chemotherapy by a GO after surgery. Using optimal matching and propensity scores based on 36 characteristics, we matched these patients to 344 similar patients who were operated on and staged by the same type of surgeon but who received chemotherapy from an MO.

Results

MOs administered chemotherapy over more weeks than did the GOs (16.5 v 12.1 weeks, respectively; P < .0023), and MO patients had substantially more weeks that included chemotherapy-associated adverse events than GO patients (16.2 v 8.9 weeks, respectively; P < .0001). However, there was no difference in 5-year survival rate between the GO and MO groups (35% v 34%, respectively; P = .45).

Conclusion

GO- and MO-treated patients who were closely matched on prognostic characteristics experienced very different rates of chemotherapy-associated adverse events and very different chemotherapy treatment styles by specialty type; however, their survival was virtually identical.

Variation in chemotherapy utilization in ovarian cancer: the relative contribution of geography

OBJECTIVE

This study investigates geographic variation in chemotherapy utilization for ovarian cancer in both absolute and relative terms and examines area characteristics associated with this variation.

DATA SOURCES

Surveillance, Epidemiology, and End Results (SEER) Medicare data from 1990 to 2001 for Medicare patients over 65 with a diagnosis of ovarian cancer between 1990 and 1999. Chemotherapy within a year of diagnosis was identified by Medicare billing codes. The hospital referral region (HRR) represents the geographic unit of analysis.

STUDY DESIGN

A logit model predicting the probability of receiving chemotherapy by each of the 39 HRRs. Control variables included medical characteristics (patient age, stage, year of diagnosis, and comorbidities) and socioeconomic characteristics (race, income, and education). The variation among HRRs was tested by the chi2 statistic, and the relative contribution was measured by the omega statistic. HHR market characteristic are then used to explain HRR-level variation.

PRINCIPAL FINDINGS

The average chemotherapy rate was 56.6 percent, with a range by HRR from 33 percent to 67 percent. There were large and significant differences in chemotherapy use between HRRs, reflected by a chi2 for HRR of 146 (df = 38, p < .001). HRR-level variation in chemotherapy use can be partially explained by higher chemotherapy rates in HRRs with a higher percentage of hospitals with oncology services. However, an omega analysis indicates that, by about 15 to one, the variation between patients in use of chemotherapy reflects variations in patient characteristics rather than unexplained variation among HRRs.

CONCLUSIONS

While absolute levels of chemotherapy variation between geographic areas are large and statistically significant, this analysis suggests that the role of geography in determining who gets chemotherapy is small relative to individual medical characteristics. Nevertheless, while variation by medical characteristics can be medically justified, the same cannot be said for geographic variation. Our finding that density of oncology hospitals predicts chemotherapy use suggests that provider supply is positively correlated with geographic variation.

Osteomyelitis of the pubic symphysis in pregnancy

BACKGROUND

Pubic symphysis osteomyelitis during the antepartum period of pregnancy is rare.

CASE

We report a patient in the third trimester who presented with pubic pain, low-grade fever, and altered gait. She was found to have a retropubic abscess at the time of cesarean delivery. Radiologic imaging showed findings consistent with osteomyelitis of the pubic symphysis and multiple pus collections in the pelvis and labia. The patient was treated with surgical debridement of the affected bone and placement of antibiotic-impregnated beads.

CONCLUSION

Osteomyelitis of the pubic symphysis can have serious complications. The diagnosis should be considered in pregnant patients with clinical findings unusual for pubic symphysis diastases. It can be treated with antibiotic-impregnated beads.

Saphenous vein sparing during inguinal lymphadenectomy to reduce morbidity in patients with vulvar carcinoma

OBJECTIVES

To compare short- and long-term morbidity associated with saphenous vein sparing versus ligation during inguinal lymphadenectomy for vulvar carcinoma.

METHODS

A retrospective evaluation of patients with carcinoma of the vulva that underwent inguinal lymphadenectomy was performed. Operative reports were evaluated and patients were divided into those who had sparing of the saphenous vein versus ligation. Postoperative short- and long-term complications were compared between the two groups using Pearson chi squared analysis.

RESULTS

There were a total of 49 inguinal lymphadenectomies performed on 29 patients. The saphenous vein was spared in 18 (37%) groin dissections compared to 31(63%) in which the saphenous vein was ligated. The two groups were similar in regards to clinical characteristics. All patients received closed suction drains and prophylactic antibiotics. Median number of nodes dissected was similar. Cellulitis was more common in the vein-ligated group compared to the vein-spared group (45% vs. 0%; P < 0.001). Wound breakdown occurred in 25% of dissections where the saphenous vein was ligated versus 0% in dissections where the vein was spared (P = or < 0.02). Short-term edema (< or = 6 months) was similar between vein-ligated and vein-spared groups (67% vs. 72%, P < 1.0). Subsequently, chronic lymphedema (> 6 months) persisted in 38% of the vein-ligated group compared to 11% in the vein-spared group (P < 0.05). The incidence of recurrent disease was similar in both groups (19.3 % vs. 22.2% P < 0.1).

CONCLUSIONS

Routine preservation of the saphenous vein during inguinal lymphadenectomy for vulvar carcinoma may reduce the incidence of wound cellulitis, wound breakdown, and chronic lymphedema.

Differences in Treatment and Outcome Between African-American and White Women With Endometrial Cancer

Purpose: To investigate disparities in treatment and outcomes between African-American and white women with endometrial cancer.

Patients and Methods: We analyzed 1992 to 1998 Surveillance, Epidemiology, and End Results data for 21,561 women with epithelial cancers of the endometrium. Sequential Cox proportional hazard models were used to determine the association between tumor characteristics (stage, grade, and histologic type), sociodemographic characteristics (age and marital status), and treatment (surgery and radiation therapy) and the racial difference in mortality.

Results: The unadjusted hazard ratio (HR) for death from endometrial cancer for African-American women compared with white women was 2.57. However, African-American women were significantly more likely to present with advanced-stage disease and have poorly differentiated tumors or tumors with an unfavorable histologic type and were significantly less likely to undergo definitive surgery at all stages of disease. Adjusting for tumor and sociodemographic characteristics lowered the HR for African-American women to 1.80. Further adjustment for the use of surgery reduced the HR to 1.51. The association between surgery and survival was stronger among white women (HR, 0.26) than among African-American women (HR, 0.44).

Conclusion: African-American women with endometrial cancer are significantly less likely to undergo primary surgery and have significantly shorter survival than white women with endometrial cancer. Racial differences in treatment are associated with racial differences in survival. The association between use of surgery and survival is weaker among African-American than white women, raising questions about potential racial differences in the effectiveness of surgery.

Tumor-derived vascular endothelial growth factor up-regulates angiopoietin-2 in host endothelium and destabilizes host vasculature, supporting angiogenesis in ovarian cancer

Vascular remodeling in host tissues surrounding growing tumors is implicated in the successful development of tumor neovasculature. Cooperation between vascular endothelial growth factor (VEGF) and angiopoietins (Angs) is considered to be critical in this context. However, the mechanisms regulating the coordinated expression of these molecules remain, to date, elusive. In this study, we used a murine ovarian cancer angiogenesis model induced by overexpression of VEGF, as well as 52 human ovarian cancer specimens and 36 established cancer cell lines to characterize the expression and regulation of Ang-2 in the context of tumor angiogenesis. Using a combination of immunohistochemistry, laser capture microdissection and real-time quantitative reverse transcription-PCR, we showed that tumor-derived VEGF significantly up-regulated the expression of Ang-2 in host stroma endothelial cells, resulting in markedly increased Ang-2/Tie-2 mRNA copy number ratio in vivo. In vitro experiments showed that VEGF directly up-regulated Ang-2, which is mediated via VEGF receptor-2/flk-1/KDR pathway, in cultured endothelial cells through transcriptional activation rather than the enhanced mRNA stability. In human ovarian cancer, Ang-2 was primarily expressed in stroma endothelial cells and detectable in tumor cells of only 12% tumor specimens; however, it was not detected in the majority of established ovarian cancer cell lines. In addition, a significant correlation was observed between VEGF and Ang-2 mRNA expression (P < 0.01) but not between VEGF and Ang-1 or Tie-2 in human ovarian cancer specimens. In the mouse ovarian cancer model, up-regulation of Ang-2 in host stroma endothelial cells was significantly associated with pericyte loss and instability of the host vasculature surrounding the tumor. Our study suggests a novel mechanism by which tumor-derived VEGF interacts with Angs/Tie-2 system in host stroma endothelial cells and induces in a paracrine manner the remodeling of host vasculature to support angiogenesis during tumor growth.

Vaginal cuff recurrence of endometrial cancer treated by laparoscopic-assisted vaginal hysterectomy

BACKGROUND

Laparoscopic-assisted vaginal hysterectomy (LAVH) has been suggested as an alternative to total abdominal hysterectomy (TAH) for the treatment of early endometrial cancer. Although studies have reported good results with equivalent rates of recurrence and survival, the need for use of intrauterine manipulators during the LAVH raises the concern for operative dissemination of tumor cells.

CASES

We report three patients with stage I, noninvasive or superficially invasive endometrial cancer with vaginal cuff recurrence within 9 months of treatment by LAVH.

CONCLUSION

While LAVH may be a technically acceptable alternative to TAH for the management of early-stage endometrial cancer, its routine use should be undertaken with caution, as the long-term risks for recurrence and survival have yet to be defined in a randomized, controlled fashion.

Cost-effectiveness of raloxifene and hormone replacement therapy in postmenopausal women: impact of breast cancer risk

OBJECTIVE

To examine the life expectancy and cost-effectiveness of hormone replacement therapy (HRT) and raloxifene therapy in healthy 50-year-old postmenopausal women.

METHODS

We performed a cost-effectiveness analysis using a Markov model, discounting the value of future costs and benefits to account for their time of occurrence.

RESULTS

Both HRT and raloxifene therapy increase life expectancy and are cost-effective relative to no therapy for 50-year-old postmenopausal women. For women at average breast cancer and coronary heart disease risk, lifetime HRT increases quality-adjusted life expectancy more (1.75 versus 1.32 quality-adjusted life years) and costs less ($3802 versus $12,968) than lifetime raloxifene therapy. However, raloxifene is more cost-effective than HRT for women at average coronary risk who have a lifetime breast cancer risk of 15% or higher or who receive 10 years or less of postmenopausal therapy. Raloxifene is also the more cost-effective alternative if HRT reduces coronary heart disease risk by less than 20%.

CONCLUSIONS

Assuming the benefit of HRT in coronary heart disease prevention from observational studies, long-term HRT is the most cost-effective alternative for women at average breast cancer and coronary heart disease risk seeking to extend their quality-adjusted life expectancy after menopause. However, raloxifene is the more cost-effective alternative for women at average coronary risk with one or more major breast cancer risk factors (first-degree relative, prior breast biopsy, atypical hyperplasia or BRCA1/2 mutation). These results can help inform decisions about postmenopausal therapy until the results of large scale randomized trials of these therapies become available.

Survival of BRCA1 negative ovarian cancer patients based on family history

OBJECTIVE

To compare survival of ovarian cancer patients with and without a family history of breast or ovarian cancer who are known to be without mutations in BRCA1.

METHODS

Patients with ovarian cancer were tested for germline mutations in BRCA1 by polymerase chain reaction amplification of DNA for single-strand conformation polymorphism and direct sequencing analysis to examine the 22 coding exons of BRCA1 in fresh and archived tumor specimens. Demographic and survival data were collected for statistical analysis. Survival data were calculated by the method of Kaplan and Meier and compared by the log-rank test.

RESULTS

Of the 110 patients tested at our institution, 100 were noted to be negative for BRCA1 mutations. After exclusion of nonepithelial histologies, benign tumors, primary peritoneal carcinoma, and incomplete staging, 87 patients remained for analysis, of which 37 demonstrated a family history of breast or ovarian cancer. The two groups showed similar age at diagnosis, stage, grade, residual disease, and type of chemotherapy. Median actuarial survival was 75 months for those patients with a family history versus 70 months for those without (P = 0.73). Evaluation of patients with two or more relatives with breast or ovarian cancer also revealed no differences in survival.

CONCLUSIONS

Family history of breast or ovarian cancer does not affect survival of patients with ovarian cancer in the absence of mutations in BRCA1. Previously described differences in survival among patients with BRCA1 mutations may be more related to genetic factors than to biases introduced by the presence of family history.

Cytoreductive surgery for ovarian cancer

Cytoreductive surgery is a crucial component of the management of cancer of the ovary. Surgical cytoreduction of ovarian cancer volume has been associated with an increase in survival in all settings in which it has been studied. This association seems strongest, and the benefits of aggressive surgery are generally greatest, in patients with chemosensitive disease. Effective surgical management of ovarian cancer, therefore, requires competence in surgical anatomy and cytoreductive techniques and a thorough understanding of the patient's disease status and therapeutic goals.

Management of intestinal obstruction in the patient with ovarian cancer

Intestinal obstruction in the patient with ovarian cancer is a difficult situation for both patient and physician. In women presenting with ovarian cancer, obstruction is almost never complete. These women should undergo aggressive bowel surgery only if it is part of an optimal surgical cytoreduction. Women known to have ovarian cancer who develop intestinal obstruction have a poor prognosis: Few will live more than a year from the time of obstruction. Some, however, have an excellent performance status, and would be relatively unimpaired were it not for their obstruction. These women, who usually have a discrete obstruction and still display some response to chemotherapy, may benefit from surgical correction of the obstruction. Women who are not candidates for surgery can be effectively palliated pharmacologically so that they are comfortable with the obstruction, often without intestinal drainage. Algorithms are available to assist in the management of ovarian cancer patients with obstruction, but ultimately the treatment decision rests with the patient. The oncologist must use his or her knowledge and clinical judgment to help the patient develop an appropriate, individualized plan.

Prolonged remission of recurrent, metastatic placental site trophoblastic tumor after chemotherapy

BACKGROUND

Placental site trophoblastic tumor (PSTT) is a form of gestational trophoblastic neoplasm that is frequently resistant to chemotherapy. In most cases disease is confined to the uterus and can be cured by curettage or simple hysterectomy. Patients with metastases, however, frequently have progression of disease and die despite aggressive multiagent chemotherapy.

CASE

A 31-year-old woman was found on review of uterine curettings to have a PSTT. Imaging studies revealed multiple lung lesions, a liver lesion, and an enlarged irregular uterus. Hysterectomy and staging surgery revealed a large tumor in the endometrial cavity and multiple metastases. She was treated with etoposide-methotrexate-dactinomycin and cyclophosphamide-vincristine and had a complete clinical remission. Six months later, however, she had a recurrence. She was then treated with six cycles of etoposide-methotrexate-dactinomycin and etoposide-cisplatin. Three years after completion of the second regimen she is without evidence of disease.

CONCLUSION

Treatment with multiagent chemotherapy can produce long-term remission, even in patients with recurrent, metastatic PSTT. Addition of platinum may be helpful in patients who have recurred or progressed after treatment with non-platinum-containing regimens.

Surgical management of ovarian cancer

Ovarian cancer affects over 25,000 women each year in the United States. The performance of appropriate surgery for ovarian cancer is critical in directing further therapies and improving survival. Systematic surgical staging must be performed in patients who appear to have early stage ovarian cancer because a significant proportion of these women have occult metastases. A marked improvement in survival has been demonstrated in patients with bulky disease if all masses larger than 2 cm can be surgically removed. Despite the dramatic effect of surgery on the subsequent course of the disease, recent studies show that only a minority of women with ovarian cancer receive appropriate initial surgery. We review the evidence and rationale for systematic surgical treatment of ovarian cancer.

Complete hydatidiform mole. A disease with a changing profile

OBJECTIVE

To retrospectively evaluate the clinical presentation of complete molar pregnancies in an academic primary obstetrics and gynecology practice over the past decade.

STUDY DESIGN

All cases of abnormal pregnancy presenting to our institution during the first half of gestation were identified through a computerized database. Clinical presentation and course of complete moles were analyzed.

RESULTS

Twenty-four complete molar pregnancies were identified among 2,431 abnormal early gestations (1%). The patients' mean age was 24.5 years, and the mean gestational age was 9.5 weeks of amenorrhea (range, 8-25). Seventy-five percent of the patients presented with vaginal bleeding and 54% with excessive uterine size. None had hyperemesis gravidarum, preeclampsia, clinical hyperthyroidism or ovarian enlargement. All patients had abnormally elevated serum beta-hCG. Transvaginal ultrasound was diagnostic in more than half the patients, while it was suggestive of the diagnosis in the remainder. One patient experienced postevacuation trophoblastic embolization and developed persistent gestational trophoblastic disease.

CONCLUSION

Due to the routine use of transvaginal ultrasound and serum beta-hCG in the workup of early gestational abnormalities, complete molar pregnancy rarely presents today with the traditional signs and symptoms. Despite their absence, the potential for persistent trophoblastic disease still exists, and careful follow-up is warranted.

Ten-year follow-up of ovarian cancer patients after second-look laparotomy with negative findings

OBJECTIVE

To determine long-term survival and predictors of recurrence in patients with platinum-treated ovarian cancer who were followed for 10 years after second-look laparotomy with negative findings.

METHODS

Records were reviewed of 91 consecutive patients with negative findings on second-look laparotomy after platinum-based chemotherapy between January 1978 and January 1987. Statistical analysis used Kaplan-Meier survival curves, Cox proportional hazards, and multiple logistic regression.

RESULTS

Mean age of patients was 57 (range 30-79) years. Distribution by stage and grade was as follows: stage I, ten; II, 18; III, 57; IV, six; grade 1, 18; 2, 28; 3, 45. Forty-seven of 91 women had optimal initial cytoreduction. Recurrence-free survival rates for all subjects were 75% at 2 years, 55% at 5 years, and 52% at 10 years. For women with stage I disease, the recurrence-free survival rate was 90% at 2, 5, and 10 years. For women with stage II disease, recurrence-free survival rates were 78, 72, and 66% at 2, 5, and 10 years, respectively. Patients with stage III or IV disease had recurrence-free survival rates of 72, 44, and 40% at 2, 5, and 10 years, respectively. Risk of recurrent disease was related to tumor stage (relative risk [RR] 2.02; 95% confidence interval [CI] 1.2, 3.3; P = .005), grade (RR 2.00; 95% CI 1.3, 3.2; P = .004), and presence of a residual tumor of more than 2 cm at the end of initial surgery (RR 3.19; 95% CI 1.2, 8.5; P = .02).

CONCLUSION

Ovarian cancer patients face an appreciable risk of recurrence in the first 5 years after second-look laparotomy with negative findings after platinum-based chemotherapy, but those who remain disease free at 5 years have excellent long-term survival rates. Tumor stage, grade, and presence of a residual tumor of more than 2 cm after initial surgery are significant predictors of recurrence.

Germline mutations of the BRCA1 and BRCA2 genes in a breast and ovarian cancer patient

A patient with breast carcinoma diagnosed at the age of 30 years and ovarian carcinoma diagnosed at the age of 41 years was found to have germline mutations in both the BRCA1 and the BRCA2 genes. The patient was of Ashkenazi Jewish descent and the BRCA2 mutation was 6174delT, known to be very common in this population. The BRCA1 mutation, however, was 3888delGA, a mutation not previously reported in this ethnic group. The patient's breast cancer exhibited loss of heterozygosity (LOH) at the BRCA1 locus but not at BRCA2, and her ovarian cancer sustained LOH at BRCA1 and BRCA2. The BRCA1 mutation originated from patient's father, who had no personal or family history of cancer. The patient's mother, who was found to carry the BRCA2 mutation, was affected by late-onset breast cancer and her tumor exhibited LOH at BRCA2. These findings indicate that compound heterozygotes for germline mutations of BRCA1 and BRCA2 exist and may be expected to develop normally and that either gene may contribute to breast or ovarian cancer development in such individuals. The implications of this case in regard to genetic testing and counseling are also substantial.

Clinical characteristics of clear cell carcinoma of the ovary

OBJECTIVE

The aim of this study is to evaluate the clinical characteristics of clear cell carcinoma of the ovary.

METHODS

Between 1986 and 1996, 45 patients with clear cell carcinoma of the ovary were identified by scanning the medical records department and the tumor registry at our institution.

RESULTS

Median age was 55 years (range 31-80 years). Tumors were 60% (27/45) stage I, 11% (5/45) stage II, 20% (9/45) stage III, and 9% (4/45) stage IV. All patients presented with a pelvic mass ranging in size from 2 x 3 to 20 x 30 cm and all except 1 had optimal cytoreduction. All patients received postoperative platinum-based chemotherapy, 47% (21/45) in combination with paclitaxel. One stage Ia patient refused therapy. Of the 6 stage III/IV patients with measurable residual tumor, 67% (4/6) partially responded to first line chemotherapy by CT scan or second look laparotomy. Recurrences occurred in 37% (10/27) stage I patients, including 18% (2/11) stage Ia, 33% (1/3) stage Ib, and 54% (7/13) stage Ic. Time to recurrence was 16 and 38 months for the two stage Ia patients and 35 months (median, range 18-56 months) for the stage Ic patients. Survival after recurrence was significantly related to disease-free interval after primary chemotherapy. With a median follow-up of 40 months (range 4-145 months), 93% (25/27) of stage I patients are alive, 20% (5/25) with disease, while 46% (6/13) of stage III/IV patients are alive. Median survival for the stage III/IV patients was 22 months (range 4-70 months).

CONCLUSIONS

Clear cell tumors of ovary frequently present at early stages. However, these tumors have a propensity for recurrence even after primary chemotherapy in early stage tumors.

Progestin treatment of atypical hyperplasia and well-differentiated carcinoma of the endometrium in women under age 40

OBJECTIVE

To determine the efficacy of conservative management of atypical hyperplasia and well-differentiated carcinoma of the endometrium in women under age 40.

METHODS

Pathology records were searched to identify women under age 40 diagnosed with atypical hyperplasia or well-differentiated carcinoma of the endometrium between January 1990 and January 1996. All available biopsy, curettage, and hysterectomy specimens were reviewed. Follow-up was obtained from the patients' gynecologists.

RESULTS

Sixty-seven records were identified. Atypical hyperplasia was found in 32 patients and well-differentiated carcinoma in 35 patients. Seven patients were excluded from analysis; four declined all treatment and follow-up, and three received no further treatment or tissue sampling from their physicians. Among 27 remaining patients with atypical hyperplasia, eight underwent hysterectomy, two were treated with ovulation induction, and 17 were treated with progestins, of whom 16 had regression of their lesions, and one had a persistent lesion. Among 33 women with well-differentiated carcinoma, 19 underwent hysterectomy, one was treated with bromocriptine, one was treated with oral contraceptives, and 12 were treated with progestins, of whom nine had regression of their lesions and three had persistent lesions. The median length of treatment required for a regression was 9 months. At a mean follow-up of 40 months, all patients were alive and well without evidence of progressive disease. Twenty-five women attempted to become pregnant, and five delivered healthy, full-term infants.

CONCLUSION

Treatment of atypical hyperplasia and well-differentiated carcinoma of the endometrium with progestins appears to be a safe alternative to hysterectomy in women under age 40.

Recombinant human IL-1 alpha and -1 beta potentiate IgE-mediated histamine release from human basophils

In this study, we have explored the relationship between interleukins and human basophil activation. Previous studies by ourselves and others have found that recombinant human (rh) IL-3 causes histamine release. The ability to release histamine has also been claimed for IL-1 but we cannot confirm this. In experiments with the basophils of 29 donors (excluding one D2O responder), histamine release with 100 ng/ml rhIL-1 alpha was 1.3 +/- 1% (SEM), whereas with rhIL-1 beta, it was 0.8 +/- 1%. Both IL-1 alpha and -1 beta were also used at concentrations of 0.01 to 1000 ng/ml without causing release. Neither increasing the Ca2+ concentration nor adding D2O or cytochalasin B caused IL-1 alpha and -1 beta to become secretagogues. rhIL-1, however, did augment IgE-dependent histamine release. The enhancement was similar with both rhIL-1 alpha and -1 beta, i.e. they were dose-dependent between 0.1 and 3 ng/ml and reached a plateau from 3 to 100 ng/ml. At submaximal histamine release (less than 10%), there was enhancement of three IgE-dependent secretagogues: 125% with goat anti-human IgE (n = 7), 215% with Ag E (n = 10), and 260% with a histamine releasing factor (n = 7). Non-IgE-dependent stimuli (formyl-methionine-leucine-phenylalanine and the ionophore A23187, n = 10) were enhanced less than 5%. rhIL-1-enhancement persisted after cell washing (n = 10). rhIL-1 was active in preparations of 50 to 75% pure basophils in which mononuclear cells were reduced by greater than 95% (n = 4), and mAbH34 to IL-1 beta blocked the enhancement caused by that molecule. We postulate that basophils have an IL-1 receptor which, when occupied, upregulates the response to IgE-related signals. Thus, this work characterizes a second interaction between interleukins and the cells central to the allergic response.

Recombinant human IL-1 alpha and -1 beta potentiate IgE-mediated histamine release from human basophils

In this study, we have explored the relationship between interleukins and human basophil activation. Previous studies by ourselves and others have found that recombinant human (rh) IL-3 causes histamine release. The ability to release histamine has also been claimed for IL-1 but we cannot confirm this. In experiments with the basophils of 29 donors (excluding one D2O responder), histamine release with 100 ng/ml rhIL-1 alpha was 1.3 +/- 1% (SEM), whereas with rhIL-1 beta, it was 0.8 +/- 1%. Both IL-1 alpha and -1 beta were also used at concentrations of 0.01 to 1000 ng/ml without causing release. Neither increasing the Ca2+ concentration nor adding D2O or cytochalasin B caused IL-1 alpha and -1 beta to become secretagogues. rhIL-1, however, did augment IgE-dependent histamine release. The enhancement was similar with both rhIL-1 alpha and -1 beta, i.e. they were dose-dependent between 0.1 and 3 ng/ml and reached a plateau from 3 to 100 ng/ml. At submaximal histamine release (less than 10%), there was enhancement of three IgE-dependent secretagogues: 125% with goat anti-human IgE (n = 7), 215% with Ag E (n = 10), and 260% with a histamine releasing factor (n = 7). Non-IgE-dependent stimuli (formyl-methionine-leucine-phenylalanine and the ionophore A23187, n = 10) were enhanced less than 5%. rhIL-1-enhancement persisted after cell washing (n = 10). rhIL-1 was active in preparations of 50 to 75% pure basophils in which mononuclear cells were reduced by greater than 95% (n = 4), and mAbH34 to IL-1 beta blocked the enhancement caused by that molecule. We postulate that basophils have an IL-1 receptor which, when occupied, upregulates the response to IgE-related signals. Thus, this work characterizes a second interaction between interleukins and the cells central to the allergic response.