Patterns of First Recurrence and Oncological Outcomes in Locally Advanced Cervical Cancer Patients: Does Surgical Staging Play a Role?

BACKGROUND

We aimed to determine whether surgical aortic staging by minimally invasive paraaortic lymphadenectomy (PALND) affects the pattern of first recurrence and survival in treated locally advanced cervical cancer (LACC) patients when compared to patients staged by imaging (noPALND).

METHODS

This study was a multicenter observational retrospective cohort study of patients with LACC treated at tertiary care hospitals throughout Spain. The inclusion criteria were histological diagnosis of squamous carcinoma, adenosquamous carcinoma, and/or adenocarcinoma; FIGO stages IB2, IIA2-IVA (FIGO 2009); and planned treatment with primary chemoradiotherapy between 2000 and 2016. Propensity score matching (PSM) was performed before the analysis.

RESULTS

After PSM and sample replacement, 1092 patients were included for analysis (noPALND n = 546, PALND n = 546). Twenty-one percent of patients recurred during follow-up, with the PALND group having almost double the recurrences of the noPALND group (noPALND: 15.0%, PALND: 28.0%, p < 0.001). Nodal (regional) recurrences were more frequently observed in PALND patients (noPALND:2.4%, PALND: 11.2%, p < 0.001). Among those who recurred regionally, 57.1% recurred at the pelvic nodes, 37.1% recurred at the aortic nodes, and 5.7% recurred simultaneously at both the pelvic and aortic nodes. Patients who underwent a staging PALND were more frequently diagnosed with a distant recurrence (noPALND: 7.0%, PALND: 15.6%, p < 0.001). PALND patients presented poorer overall, cancer-specific, and disease-free survival when compared to patients in the noPALND group.

CONCLUSION

After treatment, surgically staged patients with LACC recurred more frequently and showed worse survival rates.

Postreatment squamous cell carcinoma antigen as a survival prognostic factor in patients with locally advanced cervical cancer. A Spanish multicenter study. The SEGO Spain-GOG group

OBJECTIVE

To evaluate the clinical value of postreatment plasmatic levels of the squamous cell carcinoma antigen (SCC-Ag) as a survival independent prognostic factor in patients with LACC.

METHODS

Retrospective, multicenter study including LACC patients (FIGO 2009 stages IB2, IIA2-IVA) managed at the Gynecology Oncological Units corresponding to eight reference hospitals in Spain between 2000 and 2016. Receiver operating characteristic (ROC) curve analysis was used to determine the cut-off values of postreatment SCC-Ag levels in prediction of survival. Survival curves were calculated by using the Kaplan-Meier method and were compared with the log-rank test. Cox models were used to analyze different factors in terms of their prognosis predictive value.

RESULTS

The study included 447 patients with a median follow-up time of 53 months (IQR 26-101) and median pre- and postreatment SCC-Ag levels of 3.4 ng/ml (IQR 1.2-11) and 0.8 ng/ml (IQR 0.5-1.2), respectively. The cut-off level of pretreatment SCC-Ag was 11.75 ng/ml (sensibility 37.5%; specificity 80.5%) and that of postreatment SCC-Ag was 1.24 ng/ml (sensibility 34.6%; specificity 83.1%). In a multivariate Cox regression analysis, factors that were independent predictors of OS were: FIGO stage (HR 2.12; 95%CI 1.18-3.8; p = 0.011), paraaortic lymph node involvement (HR 3.56; 95%CI 2.04-6.2; p < 0.0001), postreatment SCC-Ag level ≥ 1.2 ng/ml (HR 1.95; 95%CI 1.11-3.44; p = 0.02) and incomplete response to treatment (HR 4.5; 95%CI 2.5-8.11; p < 0.0001).

CONCLUSION

Postreatment plasmatic SCC-Ag level ≥ 1.2 ng/ml was an independent risk factor for the survival of patients with LACC. Further factors influencing survival included: paraaortic lymph node involvement, advanced disease and poor response to concomitant chemoradiotherapy.

Efficacy of Endometrial Cancer Follow-up Protocols: Time to Change?

OBJECTIVE

 The aim of the present study was to analyze relapse rates and patterns in patients with endometrial cancer with the aim of evaluating the effectiveness of current follow-up procedures in terms of patient survival, as well as the convenience of modifying the surveillance strategy.

METHODS

 Retrospective descriptive study including all patients diagnosed with endometrial cancer relapse at the Department of Gynecology and Obstetrics of the Complejo Hospitalario Insular-Materno Infantil de Canarias, between 2005 and 2014.

RESULTS

 Recurrence was observed in 81 patients (10.04% of the sample); 66.7% of them suffered relapse within 2 years and 80.2% within 3 years after the termination of the primary treatment; 41.9% showed distant metastases while the rest corresponded to local-regional (40.7%) or ganglionar (17.4%) relapse; 42% of these were symptomatic; 14 patients showed more than 1 site of relapse. Relapse was detected mainly through symptoms and physical examination findings (54.3%), followed by elevated serum marker levels (29.6%), computed tomography (CT) images (9.9%) and abnormal vaginal cytology findings (6.2%). No differences in global survival were found between patients with symptomatic or asymptomatic relapse.

CONCLUSION

 Taking into account that the recurrence rate of endometrial cancer is low, that relapse occurs mainly within the first 3 years post-treatment and that symptom evaluation and physical examination are the most effective follow-up methods, we postulate that a modification of the current model of hospital follow-up should be considered.

The extent of aortic lymphadenectomy in locally advanced cervical cancer impacts on survival

OBJECTIVE

The prognostic impact of surgical paraaortic staging remains unclear in patients with locally advanced cervical cancer (LACC). The objective of our study was to evaluate the results of the surgical technique of preoperative aortic lymphadenectomy in LACC related to tumor burden and disease spread to assess its influence on survival.

METHODS

Data of 1,072 patients with cervical cancer were taken from 11 Spanish hospitals (Spain-Gynecologic Oncology Group [GOG] working group). Complete aortic lymphadenectomy surgery (CALS) was considered when the lymph nodes (LNs) were excised up to the left renal vein. The extent of the disease was performed evaluating the LNs by calculating the geometric means and quantifying the log odds between positive LNs and negative LNs. The Kaplan-Meier method was used to estimate the survival distribution. A Cox proportional hazards model was used to account for the influence of multiple variables.

RESULTS

A total of 394 patients were included. Pathological analysis revealed positive aortic LNs in 119 patients (30%). LODDS cut-off value of -2 was established as a prognostic indicator. CALS and LODDS <-2 were associated with better disease free survival and overall survival than suboptimal aortic lymphadenectomy surgery and LODDS ≥-2. In a multivariate model analysis, CALS is revealed as an independent prognostic factor in LACC.

CONCLUSION

When performing preoperative surgical staging in LACC, it is not advisable to take simple samples from the regional nodes. Radical dissection of the aortic and pelvic regions offers a more reliable staging of the LNs and has a favorable influence on survival.

Prevalence and genotype distribution of cervical human papilomavirus infection in the pre-vaccination era: a population-based study in the Canary Islands

OBJECTIVE

National Spanish studies show that prevalence of cervical human papillomavirus (HPV) infection in the female population is increasingly frequent, with an overall estimate of 14% in women aged 18-65 years. The objective of this study is to know the prevalence and distribution of HPV types in the female population of the Canary Islands prior to the introduction of HPV vaccines and to investigate the associated clinical and sociodemographic factors.

METHODS

Based on the Primary Health Care database, a sample of adult women (aged 18-65 years) of Gran Canaria (GC) and Tenerife (TF) stratified into nine age groups was carried out between 2002 and 2007. Women were contacted by postal letter and telephone call and were visited in their primary care centre. A clinical-epidemiological survey was completed and cervical samples were taken for cytological study and HPV detection. HPV prevalence and its 95% CI were estimated, and multivariate analyses were performed using logistic regression to identify factors associated with the infection.

RESULTS

6010 women participated in the study, 3847 from GC and 2163 from TF. The overall prevalence of HPV infection was 13.6% (CI 12.8%-14.5%) and 11.1% (CI 10.3%-11.9%) for high-risk types. The most frequent HPV type was 16 followed by types 51, 53, 31, 42 and 59. HPV types included in the nonavalent vaccine were detected in 54.1% of infected women. Factors associated with an increased risk of infection were: young ages (18-29 years), the number of sexual partners throughout life, not being married, being a smoker, and having had previous cervical lesions or genital warts.

CONCLUSIONS

It is confirmed that prevalence of HPV infection in the female population of the Canary Islands is high, but similar to that of Spain, HPV 16 being the most frequent genotype. The determinants of infection are consistent with those of other populations.

Does iatrogenic tumor rupture during surgery have prognostic implications for the outcome of uterine sarcomas?

OBJECTIVE

Tumor rupture during surgery is a risk factor for recurrence of sarcomas in other locations. However, the independent impact of rupture on prognosis is uncertain in uterine sarcomas. The aim of this study was to evaluate whether uterine rupture impacts outcomes in patients with uterine sarcoma.

METHODS

A retrospective analysis was carried out of all consecutive patients with uterine sarcoma managed at the Department of Gynecology and Obstetrics of the Complejo Hospitalario Universitario Insular-Materno Infantil of the Canary Islands, Spain between January 1990 and December 2016. Inclusion criteria included all patients with histologically proven uterine sarcoma. Exclusion criteria included patients with endometrial carcinoma (non-sarcomatous) and carcinosarcomas. During this period, 1981 patients were diagnosed with a uterine malignancy; 1799 were excluded because of a diagnosis of endometrial carcinoma and 85 patients were excluded for a diagnosis of carcinosarcoma. Thus, the final sample included 97 patients with uterine sarcoma (4.9%). These included leiomyosarcoma, endometrial stromal sarcoma, adenosarcoma, and liposarcoma. Surgical resection was the primary treatment, including open, laparoscopic and vaginal surgery. Survival rates were analyzed using the Kaplan-Meier method.

RESULTS

The median age was 52 years (range 25-90); 49.5% (48) were pre-menopausal. Distribution per histological type was: 46.4% (45) leiomyosarcoma, 23.7% (23) high-grade endometrial stromal sarcoma, 17.5% (17) low-grade endometrial stromal sarcoma, 11.3% (11) adenosarcoma, and 1% (1) liposarcoma. Uterine leiomyoma was the most frequent pre-operatively suspected diagnosis (49.5%). Iatrogenic rupture of the tumor during surgery occurred in 25.3% of cases (23). International Federation of Gynecology and Obstetrics stages I-II and III-IV were identified in 74.2% (72) and 25.8% (25) of patients, respectively. The median tumor size was 8 cm (range 2-40). The recurrence rate was 47.8% (11) for patients with intra-operative tumor rupture and 25% (17) for patients without uterine rupture (p=0.03). Disease-free survival rates at 1, 2, and 5 years for patients with uterine rupture were 72.7%, 55.4%, and 13.9%, respectively, with a median time of 39 months (95% CI 2.9 to 75). For those patients without uterine rupture, disease-free survival rates at 1, 2, and 5 years were 84.8%, 76.1%, and 71.3%, respectively, with a mean time of 208.6 months (95% CI 169 to 248.3) (p=0.01). Multivariate analysis showed that stage, histological type, and iatrogenic tumor rupture during surgery were all independent prognostic factors for overall survival (OR 7.9, 95% CI 1.6 to 38.2, p=0.01); OR 5.3, 95% CI 2.1 to 13, p<0.0001; and OR 2.6, 95% CI 1.1 to 6.5, respectively, p=0.03).

CONCLUSION

Considering that uterine sarcomas, especially leiomyosarcomas, often occur in pre-menopausal women as bulky tumors requiring laparotomy and that they are rarely diagnosed pre-operatively, efforts should be made to avoid iatrogenic uterine rupture during surgery as it impairs patient survival.

Implications of extraperitoneal paraaortic lymphadenectomy to the left renal vein in locally advanced cervical cancer. A Spanish multicenter study

OBJECTIVE

Paraaortic lymph node involvement is an important prognostic factor in locally advanced cervical cancer (LACC), but the anatomic limit of aortic lymphadenectomy is controversial. We assessed the impact of extraperitoneal paraaortic lymphadenectomy up to the left renal vein in patients with LACC undergoing pretherapeutic staging.

METHODS

A retrospective, multicenter study of patients with LACC stages FIGO 2009 IB2 and IIA2-IVA treated in 10 Spanish reference hospitals in gynecological oncology between 2000 and 2016. Sites of metastatic paraaortic lymph nodes above or below the inferior mesenteric artery were evaluated. Procedural-related intraoperative and early and late complications were assessed.

RESULTS

We included 634 patients undergoing paraaortic lymphadenectomy, in 616 (97.2%) of which the left renal vein was the upper limit of dissection (laparoscopy 592, robotic-assisted 24). The median surgical time was 150 min (interquartile range (IQR) 120-180), blood loss was 50 mL (range 20-80), and the length of stay was 2 days (range 2-3). Metastatic paraaortic involvement was found in 114 patients (18.5%), with infrarenal metastases in 73 (64%) of them. There were 11 patients (9.6%) with infrarenal metastases only, whereas in the remaining 62 (54.4%) patients concomitant infrarenal and inframesenteric metastases were observed. Intraoperative, early, and late postoperative complications occurred in 3.6%, 7.0%, and 4.5% of patients, respectively.

CONCLUSIONS

In this study of patients with LACC undergoing surgical staging, paraaortic lymphadenectomy up to the left renal vein detected skip or isolated infrarenal metastasis in 9.6% of patients, with an acceptable surgical morbidity.

Prognostic Value and Therapeutic Implication of Laparoscopic Extraperitoneal Paraaortic Staging in Locally Advanced Cervical Cancer: A Spanish Multicenter Study

PURPOSE

To assess the impact of laparoscopic extraperitoneal paraaortic staging in therapeutic planning and prognosis of patients with locally advanced cervical cancer (LACC) as compared with imaging staging.

METHODS

Retrospective multicenter study of stage IB2 and IIA2 to IVA (FIGO 2009) LACC patients who were candidates for primary chemoradiotherapy. The study (surgical) group included 634 patients undergoing laparoscopic/robotic extraperitoneal paraaortic staging treated with extended-field radiotherapy (EFRT) if lymph node involvement was confirmed. The control (imaging) group included 288 patients treated with EFRT when lymph node involvement was suspected on positron emission tomography-computed tomography scans and/or magnetic resonance imaging.

RESULTS

In the study group, a median of 13 (range 9-17) lymph nodes were removed, with a rate of positive paraaortic nodes of 18%, with metastatic size ≤ 5 mm in 20.4% of cases. Paraaortic EFRT was administered to 18% of patients in the study group and in 58% of controls. In 34% of patients from the surgical group, EFRT was modified according to surgical findings with respect to imaging staging. The median follow-up in the study and control groups was 3.7 and 4.8 years, respectively. In both groups, the overall survival and cancer-specific disease-free survival were similar. The time interval between diagnosis and starting EFRT was 18 days longer in the study group, without differences in overall survival as compared with controls (hazard ratio 1.00, 95% confidence interval 0.998-1.005; p = 0.307).

CONCLUSIONS

Laparoscopic extraperitoneal paraaortic staging in LACC patients is safe and modified therapeutic planning, allowing better selection of candidates for EFRT.

Management of endometrial cancer in patients aged 80 years and older: Identifying patients who may benefit from a curative treatment

OBJECTIVE

The goal of this study was to evaluate the demographic characteristics, pathology, treatment, prognostic factors and survival rates in elderly patients with endometrial cancer, and to compare their results with those of younger ones, in order to define the specific characteristics of this malignancy in this population.

STUDY DESIGN

Retrospective analysis of all endometrial cancer patients managed at the University Hospital of the Canary Islands (Spain) between 1990 and 2016. Survival curves were calculated by using the Kaplan-Meier method and compared with the log-rank test. Logistic regression analysis was used to assess the independent effect of different variables on cancer-specific survival. Statistical significance was considered for p < 0.05.

RESULTS

The study included 1799 endometrial cancer patients; 170 of them (9.4%) were 80 years old or older. Elderly patients received less surgery (68.2% vs. 92.4%), lymphadenectomy (10.3% vs. 26.2%) and adjuvant treatment (37.1% vs. 51.2%) than younger ones, and presented higher probability of receiving palliative treatment (27.6% vs. 4%). Endometrioid tumors were more frequently diagnosed in younger patients (78.8% vs. 62.9%), while type 2-endometrial cancer was more frequently diagnosed in elderly ones (37.1% vs. 21.2%). Cancer-specific survival in older patients was significantly poorer than in younger ones, with a mean of 61.4 months (95%CI 51.7-71.1) versus 226 months (95%CI 218.9-233.1), respectively. In a multivariate analysis: age, FIGO stage, histology, tumor differentiation and adjuvant treatment were independently associated with survival.

CONCLUSION

Although endometrial cancer is more aggressive in older patients, they are less likely to receive optimal treatment, which negatively affects their survival. Specific guidelines for the management of this population, including a comprehensive geriatric assessment, should be developed to improve their prognosis.

Metastatic adenocarcinoma of mammary-like glands of the vulva successfully treated with surgery and hormonal therapy

Vulvar cancer is a rare malignancy; most tumors are squamous cell type while adenocarcinomas are rare. Primary adenocarcinomas of the vulva predominantly include extramammary Paget's disease and sweat gland carcinomas. Greene first described a rare form of adenocarcinoma in 1936, which was called adenocarcinoma of mammary-like glands of the vulva because of its morphologic and immunohistochemical resemblance to breast adenocarcinomas. In the management of this entity, varying combinations of surgery, radiation therapy, systemic chemotherapy and/or hormonal therapy may be used, as in patients with orthotopic breast carcinoma. However, hormonal therapy leads the way in patients with positive hormonal receptors, where other therapies cannot be used due to comorbidities or advanced age. We present the first reported case of an elderly patient with metastatic vulvar adenocarcinoma arising from mammary-like glands, successfully treated with a combination of surgery and hormonal therapy.

Ascorbate-dependent decrease of the mucosal immune inflammatory response to gliadin in coeliac disease patients

BACKGROUND

The IL-15/NF-κB axis has an important role in coeliac disease (CD) and may represent a molecular target for immunomodulation. Ascorbate (vitamin C) is known to show inhibitory effects on NF-κB. Therefore, we studied if ascorbate supplementation to gliadin gliadin-stimulated biopsy culture could down-regulate the mucosal immune response to gliadin in CD.

METHODS

Duodenal biopsy explants from treated CD patients were gliadin challenged in vitro (100 μg/ml) with and without 20mM ascorbate. An extra tissue explant in basal culture was used as internal control. Secretion levels of nitrites (3h), and IFNγ, TNFα, IFNα, IL-17, IL-13, and IL-6 (24h) were measured on the supernatants. IL-15 was assayed by western-blot on whole protein duodenal explants.

RESULTS

The addition of ascorbate to in vitro culture gliadin-challenged biopsies blocked the secretion of nitrites (p=0.013), IFNγ (p=0.0207), TNFα (p=0.0099), IFNα (p=0.0375), and IL-6 (p=0.0036) compared to samples from non-ascorbate supplemented culture. Cytokine secretion was downregulated by ascorbate even to lower values than those observed in basal cultures (IFNγ: p=0.0312; TNFα: p=0.0312; IFNα: p=0.0312; and IL-6: p=0.0078). Gliadin-challenge induced IL-15 production in biopsies from treated CD patients, while the addition of ascorbate to culture medium completely inhibited IL-15 production. Moreover, the inhibition of IL-15 by ascorbate took place even in the only treated CD-patient who had basal IL-15 production.

CONCLUSIONS

Ascorbate decreases the mucosal inflammatory response to gluten in an intestinal biopsy culture model, so it might have a role in future supplementary therapy in CD.

Follow-up after LLETZ: a study of 682 cases of CIN 2-CIN 3 in a single institution

OBJECTIVE

To evaluate the importance of resection margins in the risk of persistent/recurrent lesions and to investigate other factors such as detection of high-risk HPV, which could potentially predict persistent/recurrent disease before patients engage in follow-up.

STUDY DESIGN

682 women with a histologically confirmed diagnosis of CIN 2-3 treated by loop electrosurgical excision procedure (LEEP) were included, between January 2000 and December 2006. Age, high-risk HPV detection determined by Hybrid Capture II and cone margins were evaluated as possible predictors of persistent/recurrent disease.

RESULTS

The mean age at diagnosis was 37.8 years (range 18-73). The mean follow-up period was 39.9 months (SD 25.8). 6.6% of patients (45/682) were lost to follow-up. 64.7% of patients (441/682) had clear margins in the specimen and 20.1% of patients had positive surgical margins (137/682). In 8.6% of patients (59/682) the resection margins were uncertain. Positive endocervical sweep was found in 10.8% of cases (73/682). Residual/recurrent disease was demonstrated by colposcopy-guided biopsy in 13.9% of patients (88/637); 77.3% (68/88) of them developed CIN 1 while only 22.7% (20/88) developed high-grade premalignant lesions or carcinomas during the follow-up. We found significant differences in the frequency of persistent/recurrent disease depending on the status of margins: 24.8% of cases with positive margins vs 11.1% of cases with negative margins (p<0.0001). Multivariate analysis showed that only post-treatment high-risk HPV detection and status of the cone margins were significantly predictive of persistent/recurrent disease (OR 4.1, 95%CI 2.4-7.3, p<0.0001 and OR 2.7, 95%CI 1.5-4.7, p=0.001; respectively).

CONCLUSION

The combination of histological examination of resection margins plus post-treatment tests for HPV detection would help to classify LEEP-treated patients into categories at different risk of recurrence.

Serous and mucinous borderline ovarian tumors: are there real differences between these two entities?

OBJECTIVE

To evaluate the clinical outcome and pathological features of patients with borderline ovarian tumors (BOT) with special emphasis on serous and mucinous histology.

STUDY DESIGN

Medical and anatomopathological records were reviewed in the Gynecological Oncology Department of the Canarian University Hospital between 1990 and 2005. Survival rates were analyzed by using the Kaplan-Meier technique.

RESULTS

The study included 163 patients. Serous tumors corresponded to 68 cases and mucinous tumors to 91 cases. Eighty-nine percent of patients were at FIGO stage I, 1.2% at stage II and 9.8% at stage III. Serous histology was significantly related to the presence of peritoneal implants (22.4% vs 3.6%; p=0.001), positive peritoneal cytology (35.7% vs 8.5%; p=0.001) and bilaterality (27.9% vs 1.1%, p<0.0001). Event-free survival (EFS) rates at 2, 5 and 10 years were 96.7%, 92.7% and 90.5%, respectively, with a mean survival time of 183 months (CI 95% 172-193). Thirteen recurrence cases were found (7.9%) with a mean time to recurrence of 39.6 months (range 4-140). Overall survival (OS) rates at 2, 5 and 10 years were 100%, 96.4% and 93.6%, respectively, with a mean time of 189 months (CI 95% 179-198). Mucinous BOT were associated with significantly lower OS rates than serous BOT (10 years OS: 88.5% vs 98.2%; p=0.01).

CONCLUSIONS

Serous tumors present more unfavorable anatomopathological characteristics but are associated with better prognosis than mucinous tumors. If mucinous BOT diagnosis is retained physicians should be aware that their aggressive potential is not negligible.

Pure papillary serous tumors of the endometrium: a clinicopathological analysis of 61 cases from a single institution

OBJECTIVE

The aim of this study was to evaluate the clinicopathological data and prognosis factors corresponding to patients with papillary serous carcinoma of the endometrium treated at a single institution.

METHODS

Medical and anatomopathological records were reviewed in the Department of Gynecological Oncology of the Canarian University Hospital between 1989 and 2006. Only pure cases of papillary serous carcinoma of the endometrium were included. Survival rates were analyzed using the Kaplan-Meier technique.

RESULTS

The study included 61 patients. Stages I, II, III, and IV were identified in 32.8%, 19.7%, 31.1%, and 8.2% of patients, respectively. Event-free survival rates after 5 and 10 years were 59% and 40%, respectively, with a median time of 83 months (95% confidence interval, 63-110). Relapse occurred in 40.5% of the patients. Overall survival rates after 5 and 10 years were 37.7% and 29%, respectively, with a median time of 55 months (95% confidence interval, 40-70). A univariate analysis showed that prognosis factors were tumor markers, stage, myometrial infiltration, lymphovascular invasion, and ganglia involvement. A multivariate analysis showed that tumor markers, stage, and myometrial infiltration had an independent influence on overall survival.

CONCLUSIONS

Papillary serous carcinoma of the endometrium is a very aggressive type of endometrial carcinoma that behaves more similar to ovarian carcinoma than to endometrial carcinoma. Tumor markers at diagnosis, stage, and myometrial infiltration mainly determine prognosis at our institution.

Clinicopathologic analysis of uterine sarcomas from a single institution in the Canary Islands

OBJECTIVE

To evaluate the clinicopathologic data and prognostic factors for patients with uterine sarcomas treated at a single institution, with special emphasis on malignant mixed müllerian tumors (MMMT).

METHODS

Medical and anatomic pathology records were reviewed. Survival rates were analyzed using the Kaplan-Meier method.

RESULTS

The study included 89 patients: 48.4% with MMMT; 22.4% with leiomyosarcomas; 20.2% with endometrial stromal sarcomas; and 9% with adenosarcomas. FIGO stages I, II, III, and IV were identified in 57.3%, 9.0%, 22.5%, and 7.8% of patients respectively. Event-free survival rates after 2, 5, and 10 years were 70%, 61%, and 55% respectively, with a median time of 90 months (95% CI, 41-140 months). Overall survival rates after 2, 5, and 10 years were 50%, 45%, and 39% respectively, with a median time of 43 months (95% CI, 3-83 months). Multivariate analysis showed that stage, histology, tumor size, and parity had an independent influence on overall survival.

CONCLUSIONS

MMMT are the most aggressive tumors and their behavior strongly resembles that of high-grade endometrial adenocarcinoma. Prognostic factors affecting survival were stage, histology, tumor size, and parity.

Influence of a mine tailing accident near Doñana National Park (Spain) on heavy metals and arsenic accumulation in 14 species of waterfowl (1998 to 2000)

This article presents the impact on waterbirds in Doñana National Park (Spain) of an accidental release of 5 million m3 acid waste produced by the processing of pyrite ore. Heavy metals (zinc, copper, cadmium, and lead) and arsenic were measured in several soft tissues (liver, kidney, and muscle) taken from 14 waterfowl species collected between April 1998 and May 2000. The main source of copper and zinc found in the waterfowl species examined was the spill waste, whereas cadmium, lead, and arsenic could also came from other sources. Kidney was the primary organ for cadmium and lead accumulation, whereas liver accumulated the most zinc and copper. Arsenic was concentrated in both muscle and liver tissue. The degree of contamination of the area where the birds lived, their age, their sex their size, and the time since the spill were found to have less influence than species and trophic level on the accumulation of metal in organs and tissues. Four species (Anser anser, Ciconia ciconia, Larus ridibundus, and Porphyrio porphyrio) were found to have the highest levels of the 5 elements.

Heavy metal, total arsenic, and inorganic arsenic contents of algae food products

The total arsenic, inorganic arsenic, lead, cadmium, and mercury contents of 18 algae food products currently on sale in Spain were determined. The suitability of the analytical methodologies for this type of matrix was confirmed by evaluating their analytical characteristics. The concentration ranges found for each contaminant, expressed in milligrams per kilogram of dry weight, were as follows: total arsenic, 2.3-141; inorganic arsenic, 0.15-88; lead, < 0.05-1.33; cadmium, 0.03-1.9; and mercury, 0.004-0.04. There is currently no legislation in Spain regarding contaminants in algae food products, but some of the samples analyzed revealed Cd and inorganic As levels higher than those permitted by legislation in other countries. Given the high concentrations of inorganic As found in Hizikia fusiforme, a daily consumption of 1.7 g of the product would reach the Provisional Tolerable Weekly Intake recommended by the WHO for an average body weight of 68 kg. A more comprehensive study of the contents and toxicological implications of the inorganic As present in the algae food products currently sold in Spain may be necessary, which might then be the basis for the introduction of specific sales restrictions.

Kinetic study of transformations of arsenic species during heat treatment

The combination of temperatures and pH levels applied in domestic or industrial cooking and in the sterilization of seafood might cause the transformation of certain species of arsenic into other more toxic species, which could pose a risk to the consumer. To clarify the effect of the temperatures traditionally used in cooking or sterilization on the stability of the various species of arsenic, a kinetic study was carried out, using standards of arsenobetaine (AB), dimethylarsinic acid (DMA), monomethylarsonic acid (MMA), trimethylarsine oxide (TMAO), tetramethylarsonium ion (TMA(+)), and arsenocholine (AC) heated at different temperatures (85--190 degrees C) and for different treatment times. Various pH levels (4.5, 5.5, 6.5, and 8.0) were applied during the heating process. The results obtained indicated that there were no transformations of arsenic species after temperature treatments up to 120 degrees C. However, when temperatures between 150 and 190 degrees C were used, a partial decomposition of AB was achieved, producing TMAO at 150 degrees C and TMAO and TMA(+) at temperatures of 160 degrees C or above, in proportions that varied according to the temperature and duration of the heat treatment.

Accumulation of heavy metals and As in wetland birds in the area around Doñana National Park affected by the Aznalcollar toxic spill

The impact of the spill from the mine in Aznalcollar (Seville, Spain) on waterfowl in the Doñana National Park is assessed. The concentrations of Cu, Pb, Cd, Zn nd As in the liver and eggs of 16 species of waterfowl found dead in the Park between April and November 1998 were determined. The highest levels were found for Zn, followed by Cu, Pb, Cd and As. The main parameters related to the accumulation of these elements in the waterfowl studied were species and trophic level. The other variables studied--distance from the spill, days of exposure, sex, size, and age--are important, although this depends on the element studied. Zn and Cu from the spill have entered the food chain of the aquatic birds studied, but Cd, Pb and As have not. There is currently no evidence to suggest that the trace element concentrations measured have reached toxic levels.

Trace elements in blood collected from birds feeding in the area around Doñana National Park affected by the toxic spill from the Aznacóllar mine

A long-term monitoring plan was established to study if bird populations around Doñana National Park were affected by the toxic spill from the Aznalcóllar mine. The concentrations of Zn, Pb, As, Cu, Sb, Co, Tl and Cd in the blood of 11 bird species feeding in the area were determined. The parameters which most affect the accumulation of trace elements in the birds studied are, firstly, species and secondly, trophic position, sex, days of exposure and weight. In some individuals, Zn and Cu occurred at higher levels than the reference values for contaminated areas. Concentrations of Pb and Cd in a considerable number of individuals were higher than those found in birds from uncontaminated areas. The present data, together with the lack of data on blood metal concentration prior to the spill, do not offer any conclusive evidence of the influence of the spill on avian blood metal concentrations.