Oral topotecan as single-agent second-line chemotherapy in patients with advanced ovarian cancer

PURPOSE

To evaluate oral topotecan as single-agent, second-line therapy in patients with ovarian cancer previously treated with a platinum-based regimen.

PATIENTS AND METHODS

Patients (N = 116) received oral topotecan 2.3 mg/m2 daily for 5 days every 21 days. Eligibility criteria included histologic diagnosis of International Federation of Gynecology and Obstetrics stage III or IV epithelial ovarian cancer, bidimensionally measurable disease, prior platinum-containing chemotherapy, age > or = 18 years, performance status < or = 2, and life expectancy > or = 12 weeks.

RESULTS

Overall response rate was 21.6% (25 of 116 patients). Median duration of response was 25.0 weeks; median time to response was 8.4 weeks. Median time to progression was 14.1 weeks; median survival was 62.2 weeks. Grade 4 neutropenia was experienced by 50.4% of patients in 13.4% of courses administered. Grade 4 thrombocytopenia was experienced by 22.1% of patients in 5.1% of courses. Grade 3 or 4 anemia was experienced by 29.2% of patients in 8.5% of courses. Most frequent nonhematologic toxicities were predominantly (> 90%) grade 1 or 2 and included nausea, alopecia, diarrhea, and vomiting.

CONCLUSION

Second-line oral topotecan administered at 2.3 mg/m2 for 5 days every 21 days demonstrated activity in patients with progressive or recurrent ovarian cancer after first-line platinum-based chemotherapy. This activity was comparable to that seen in previous studies with intravenous topotecan. Grade 4 neutropenia was less frequent with oral topotecan than previously reported for intravenous topotecan. Oral topotecan is an active, tolerable, and convenient formulation of an established agent for the second-line treatment of advanced epithelial ovarian cancer and may also facilitate exploring prolonged treatment schedules.

Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study

Disordered breathing during sleep is associated with acute, unfavorable effects on cardiovascular physiology, but few studies have examined its postulated association with cardiovascular disease (CVD). We examined the cross-sectional association between sleep- disordered breathing and self-reported CVD in 6,424 free-living individuals who underwent overnight, unattended polysomnography at home. Sleep-disordered breathing was quantified by the apnea-hypopnea index (AHI)-the average number of apneas and hypopneas per hour of sleep. Mild to moderate disordered breathing during sleep was highly prevalent in the sample (median AHI: 4.4; interquartile range: 1.3 to 11.0). A total of 1,023 participants (16%) reported at least one manifestation of CVD (myocardial infarction, angina, coronary revascularization procedure, heart failure, or stroke). The multivariable-adjusted relative odds (95% CI) of prevalent CVD for the second, third, and fourth quartiles of the AHI (versus the first) were 0.98 (0.77-1.24), 1.28 (1.02-1.61), and 1.42 (1.13-1.78), respectively. Sleep-disordered breathing was associated more strongly with self-reported heart failure and stroke than with self-reported coronary heart disease: the relative odds (95% CI) of heart failure, stroke, and coronary heart disease (upper versus lower AHI quartile) were 2.38 (1.22-4.62), 1.58 (1.02- 2.46), and 1.27 (0.99-1.62), respectively. These findings are compatible with modest to moderate effects of sleep-disordered breathing on heterogeneous manifestations of CVD within a range of AHI values that are considered normal or only mildly elevated.

The abandoned radical hysterectomy: a Gynecologic Oncology Group Study

OBJECTIVE

The aim of this study was to evaluate the frequency with which intended radical hysterectomy for cervical cancer is abandoned and the outcomes for those patients.

METHODS

A secondary evaluation of a prospective surgical pathological trial was performed. There were 1127 patients with Stage IB carcinoma of the cervix entered on Gynecologic Oncology Group Protocol No. 49. These patients were to undergo radical hysterectomy and pelvic lymphadenectomy with careful analysis of pathologic findings, complications, and outcomes.

RESULTS

Ninety-eight women were found, at operation, to have extrauterine disease and the proposed radical operation was abandoned at the discretion of the operating surgeon. The records of these patients were evaluated. Subgroups of patients with extrapelvic disease (30) and pelvic extension (26), including grossly positive pelvic nodes (12), other pelvic implants (8), and gross serosal extension (2), were identified. Sixty-three (93%) patients subsequently underwent pelvic radiation therapy and one or two intracavitary applications. Para-aortic fields were added for 8 patients who were found to have positive para-aortic nodes. Five patients received radiotherapy and chemotherapy; 4 patients received chemotherapy alone. One patient declined any further therapy. The disease-free survival was shorter for patients whose radical procedure was abandoned than for those patients who underwent radical hysterectomy. Among the abandoned-operation patients, those with extrapelvic disease had the shortest progression-free interval and survival and those with direct pelvic extension the longest.

CONCLUSIONS

Retrospective comparisons of radical hysterectomy to radiation therapy are not valid unless the group of patients whose radical operation was abandoned is included. The morbidity of the operation is low even when followed by radiation therapy. However, no recommendations for optimal therapy can be made from this analysis.

Practical implications of noncompliance in randomized clinical trials for temporomandibular disorders

Randomized clinical trials are recognized as providing the most rigorous evidence of treatment efficacy. For temporomandibular disorders, randomized clinical trials have been used to evaluate the efficacy of low-cost occlusal appliances or the adjunct use of cognitive behavioral interventions. However, noncompliance with treatment regimens and losses to follow up are common randomized clinical trial protocol violations that compromise the desired rigor of the trial. At times it is not clear to the investigator how to deal with these issues during the trial and at the data analysis phase. Often treatment efficacy is based on the compliant subjects, subjects who may no longer represent randomized groups or yield the desired "fair" estimate of treatment efficacy. This study focuses on management of compliance issues, the description and collection of data needed to obtain a more accurate assessment of treatment efficacy, and results particularly relevant to actual clinical practice and patient care decisions. These are applied to a randomized clinical trial evaluating the efficacy of a cognitive-behavioral intervention for temporomandibular disorders.

Randomized comparison of fluorouracil plus cisplatin versus hydroxyurea as an adjunct to radiation therapy in stage IIB-IVA carcinoma of the cervix with negative para-aortic lymph nodes: a Gynecologic Oncology Group and Southwest Oncology Group study

PURPOSE

In 1986, a protocol comparing primary radiation therapy (RT) plus hydroxyurea (HU) to irradiation plus fluorouracil (5-FU) and cisplatin (CF) was activated by the Gynecologic Oncology Group (GOG) for the treatment of patients with locally advanced cervical carcinoma. The goals were to determine the superior chemoradiation regimen and to quantitate the relative toxicities.

METHODS

All patients had biopsy-proven invasive squamous cell carcinoma, adenocarcinoma, or adenosquamous carcinoma of the uterine cervix. Patients underwent standard clinical staging studies and their tumors were found to be International Federation of Gynaecology and Obstetrics stages IIB, III, or IVA. Negative cytologic washings and para-aortic lymph nodes were required for entry. Patients were randomized to receive either standard whole pelvic RT with concurrent 5-FU infusion and bolus CF or the same RT plus oral HU.

RESULTS

Of 388 randomized patients, 368 were eligible; 177 were randomized to CF and 191 to HU. Adverse effects were predominantly hematologic or gastrointestinal in both regimens. Severe or life-threatening leukopenia was more common in the HU group (24%) than in the CF group (4%). The difference in progression-free survival (PFS) was statistically significant in favor of the CF group (P = .033). The sites of progression in the two treatment groups were not substantially different. Survival was significantly better for the patients randomized to CF (P = .018).

CONCLUSION

This study demonstrates that for patients with locally advanced carcinoma of the cervix, the combination of 5-FU and CF with RT offers patients better PFS and overall survival than HU, and with manageable toxicity.

Relation of sleepiness to respiratory disturbance index: the Sleep Heart Health Study

Obstructive sleep apnea syndrome is a well recognized cause of excessive sleepiness; however, the relation of sleepiness to mild sleep-disordered breathing (SDB), which affects as much as half the adult population, is uncertain. In order to explore this relation, we conducted a cross-sectional cohort study of community-dwelling adults participating in the Sleep Heart Health Study, a longitudinal study of the cardiovascular consequences of SDB. The study sample comprises 886 men and 938 women, with a mean age of 65 (SD 11) yr. Sleepiness was quantified using the Epworth Sleepiness Scale (ESS). Sleep-disordered breathing was quantified by the respiratory disturbance index (RDI), defined as the number of apneas plus hypopneas per hour of sleep, measured during in-home polysomnography. When RDI was categorized into four groups (< 5, 5 to < 15, 15 to < 30, >/= 30), a significantly progressive increase in mean ESS score was seen across all four levels of SDB, from 7.2 (4.3) in subjects with RDI < 5 to 9.3 (4.9) in subjects with RDI >/= 30 (p < 0.001). There was no significant modification of this effect by age, sex, body mass index, or evidence of chronic restriction of sleep time or periodic limb movement disorder. The percentage of subjects with excessive sleepiness, defined as an ESS score >/= 11, increased from 21% in subjects with RDI < 5 to 35% in those with RDI >/= 30 (p < 0. 001). We conclude that SDB is associated with excess sleepiness in community-dwelling, middle-aged and older adults, not limited to those with clinically apparent sleep apnea.

Reliability of scoring respiratory disturbance indices and sleep staging

STUDY OBJECTIVES

Unattended, home-based polysomnography (PSG) is increasingly used in both research and clinical settings as an alternative to traditional laboratory-based studies, although the reliability of the scoring of these studies has not been described. The purpose of this study is to describe the reliability of the PSG scoring in the Sleep Heart Health Study (SHHS), a multicenter study of the relation between sleep-disordered breathing measured by unattended, in-home PSG using a portable sleep monitor, and cardiovascular outcomes.

DESIGN

The reliability of SHHS scorers was evaluated based on 20 randomly selected studies per scorer, assessing both interscorer and intrascorer reliability.

RESULTS

Both inter- and intrascorer comparisons on epoch-by-epoch sleep staging showed excellent reliability (kappa statistics >0.80), with stage 1 having the greatest discrepancies in scoring and stage 3/4 being the most reliably discriminated. The arousal index (number of arousals per hour of sleep) was moderately reliable, with an intraclass correlation (ICC) of 0.54. The scorers were highly reliable on various respiratory disturbance indices (RDIs), which incorporate an associated oxygen desaturation in the definition of respiratory events (2% to 5%) with or without the additional use of associated EEG arousal in the definition of respiratory events (ICC>0.90). When RDI was defined without considering oxygen desaturation or arousals to define respiratory events, the RDI was moderately reliable (ICC=0.74). The additional use of associated EEG arousals, but not oxygen desaturation, in defining respiratory events did little to increase the reliability of the RDI measure (ICC=0.77).

CONCLUSIONS

The SHHS achieved a high degree of intrascorer and interscorer reliability for the scoring of sleep stage and RDI in unattended in-home PSG studies.

Quality assurance and quality control in longitudinal studies

As we have presented, it is evident that cohort studies are confronted with their own special, non-trivial issues of quality assurance and quality control. Such studies are typically large-scale designs and involve an extensive amount of data to be collected and processed, the quality of which depends on a variety of factors related to study personnel and equipment. The fact that data are collected over an extended period of time and at several centers greatly increases the magnitude of the data processing task, significantly increasing the likelihood of discrepancies and measurement error in the data. As presented in tables 1 and 2, the quality assurance and quality control procedures span the entire course of the study and include a multitude of tasks. Such tasks are delegated to various committees and/or are undertaken by participating centers, all of which must take responsibility for understanding, implementing, and following through on all procedures that maximize data quality. The quality of the quality assurance/quality control process is highly correlated with the quality of the communication within and between centers and all researchers. Maintaining standardization of procedures across centers and long-term stability of equipment and analytic procedures are integral components of quality control. In conclusion, the magnitude of the quality control process in a multicenter longitudinal study should not be underestimated, requiring a significant commitment of study resources. The quality control process is key to the integrity of the study, and an integral part of the design of the study. In a well-designed study, with a good quality control process and dedication to the process by the research team, the validity of the conclusions of the cohort study can be established.

Correlates of daytime sleepiness in 4578 elderly persons: the Cardiovascular Health Study

OBJECTIVES

To describe the prevalence of self-reported daytime sleepiness in older men and women and to describe their relationships with demographic factors, nocturnal complaints, health status, and cardiovascular diseases (CVD).

DESIGN

Cross-sectional survey and clinical exam.

SETTING

Participants in the Cardiovascular Health Study, 4578 adults aged 65 and older, recruited from a random sample of non-institutionalized Medicare enrollees in four U.S. communities.

MEASURES

Daytime sleepiness measured by the Epworth Sleepiness Scale (ESS), magnetic resonance imaging of the brain (MRI), cognitive function tests, and standardized questionnaires for cardiopulmonary symptoms and diseases, depressive symptoms, social support, activities of daily living, physical activity, and current medications.

RESULTS

Approximately 20% of the participants reported that they were "usually sleepy in the daytime". Although elderly black men were less likely to report frequent awakenings than those in the other three race and gender groups, they had significantly higher mean ESS scores. The following were independently associated with higher ESS scores in gender-specific models: non-white race, depression, loud snoring, awakening with dyspnea or snorting, frequent nocturnal awakenings, medications used to treat congestive heart failure, non-use of sleeping pills, a sedentary lifestyle, and limitation of activities of daily living in both men and women; additional correlates included hip circumference and current smoking in men, and hayfever in women. The following were not independently associated with ESS in the models: age, education, use of wine or beer to aid sleep, use of tricyclic antidepressants, long- or short-acting benzodiazepines, asthma, angina, myocardial infarction, congestive heart failure itself, forced vital capacity, social support, cognitive function, or MRI evidence of global brain atrophy or white matter abnormality.

CONCLUSIONS

Daytime sleepiness is common in the elderly, probably due to nocturnal disturbances such as frequent awakenings and snoring. The occasional use of sleeping pills for insomnia is associated with reduced daytime sleepiness in the elderly, while the use of medications for congestive heart failure is associated with daytime sleepiness. Surprisingly, anatomic abnormalities such as evidence of previous strokes and brain atrophy (as seen on brain MRI scans) were not associated with daytime sleepiness in these non-institutionalized elderly persons.

Recognition of antigenic epitopes in lipopolysaccharide and protein from Actinobacillus actinomycetemcomitans by serum antibodies in untreated rapidly progressive periodontitis patients

Actinobacillus actinomycetemcomitans has been associated with early-onset periodontitis, including the localized juvenile and rapidly progressive forms. The immunodominant antigens of A. actinomycetemcomitans recognized by rapidly progressive periodontitis patients remain unidentified. Sera from 22 patients with rapidly progressive periodontitis and 20 periodontally normal subjects were tested by enzyme-linked immunosorbent assay (ELISA) for immunoglobulin G antibodies to whole-cell sonicate, protein, purified lipopolysaccharide and lipopolysaccharide fractions of A. actinomycetemcomitans. The median titers of rapidly progressive periodontitis patients and control subjects to whole-cell sonicate were 25.0 and 14.5 ELISA units, respectively (not significantly different). Binding of antibody from patient sera occurred to both the lipopolysaccharide and the protein fractions, with greater binding to lipopolysaccharide than to protein. We show for the first time that patient sera contain antibodies that bind specifically to antigenic epitopes in lipid A and in the core carbohydrate of lipopolysaccharide that were previously considered to be inaccessible and unavailable, as well as to epitopes in the O side chains. Sera manifesting antibody titers 2-fold or greater than the median titer for control sera were judged to be seropositive. More patients were seropositive for lipid A than for any of the other antigen preparations studied, and the median titer for patient sera to lipid A but to none of the other purified lipopolysaccharide fractions was significantly elevated relative to control values. Of 22 patients, 10 were seropositive to whole-cell sonicate, 7 to protein, 8 to lipopolysaccharide, 7 to the high-molecular-weight lipopolysaccharide-polysaccharide fraction rich in O side chains, and 16 to lipid A. The core carbohydrate did not adhere to the test plate surface, and this precluded ELISA measurements. However, when the core carbohydrate was used in the ELISA inhibition assay, it reduced antibody binding to lipopolysaccharide-coated plates by up to 45%, thereby demonstrating antibody binding to core carbohydrate. The core carbohydrate fraction from the Re mutant of Salmonella minnesota known to contain no O-side chains also inhibited binding of specific antibody to plates coated with A actinomycetemcomitans lipopolysaccharide. Overall, there was extreme variation in responses among patients to the various antigen preparations, with no single pattern dominating. Lipopolysaccharide and its components appear to be the immunodominant epitopes, since most rapidly progressive periodontitis patients are seropositive for lipopolysaccharide and/or its components and they have titers relative to those for proteins.

The relationship between price of services, quality of care, and patient time costs for general dental practice

OBJECTIVE

To examine the relationships between price of services, quality of care, and patient time costs in private practices of general dentists.

DATA SOURCE/STUDY SETTING

In October 1992, a 3.7 percent sample of eligible general dentists in part-time or full-time private practice in 1991 was randomly drawn from a sampling frame tailored from data gathered by the 1991-1992 American Dental Association Distribution of Dentists census of all United States dentists.

DATA COLLECTION

A mail survey was used to collect data on dentist demographic characteristics, dental practice characteristics practice finances, and insurance. The survey was completed and returned by 3,048 general dentists (77 percent response rate). Local area population characteristics were obtained from secondary sources.

STUDY DESIGN

Two-stage least squares regression was used to evaluate the structural relationships between price of services, quality of care, and time costs to patients. Structural equations were estimated for four different quality of care measures and two time costs.

PRINCIPAL FINDINGS

Price of services and quality of care were significantly related to each other. Higher quality of care was associated with higher price of services and, reciprocally, higher price of services was associated with higher quality of care. Shorter waits for a new patient appointment were associated with higher prices. Higher price of services, lower quality of care, and longer waits for a new patient appointment were related to shorter in-office waiting time.

CONCLUSIONS

The implication of these findings is that if price of services is constrained, then the quality of care provided by the dentist may also be reduced.

Macaca fascicularis as a model in which to assess the safety and efficacy of a vaccine for periodontitis

We have assessed Macaca fascicularis as a potential model in which to test the efficacy and safety of a vaccine for periodontitis. Twenty-eight animals were surveyed and 20 studied in more detail. Clinical periodontal status was assessed, the subgingival microflora analyzed especially for the presence and proportions of Porphyromonas gingivalis and titers and avidities of serum antibodies reactive with P. gingivalis measured. Probing depths ranged from 0.90 mm to 3.80 mm, Gingival Index scores from 0.00 to 4.00 and Plaque Index scores from 0.00 to 3.00. About 40% of sites bled on probing. The animals manifested a subgingival flora characteristic of the anaerobic gram-negative bacteria found in human periodontal pockets, including Actinobacillus actinomycetemcomitans, P. gingivalis, Bacteroides forsythus, Campylobacter rectus, Prevotella intermedia and Fusobacterium nucleatum. P. gingivalis was detected in 70 of 80 samples studied, ranging from 0.01% to 20% of the total flora. Serum antibody reactive with antigens of P. gingivalis was observed in all animals, with titers ranging from 1.0 enzyme-linked immunosorbent assay (ELISA) unit to 25 ELISA units and avidities from 0.10 M to 2.20 M. Antibody titer and maximum percentage of P. gingivalis were inversely correlated, indicating that a humoral immune response may be effective in reducing P. gingivalis overgrowth. M. fascicularis appears to be an excellent model for use in vaccine development.

Effects of treatment on antibody titer to Porphyromonas gingivalis in gingival crevicular fluid of patients with rapidly progressive periodontitis

Twenty-eight patients diagnosed as having rapidly progressive periodontitis (RPP) were enrolled in a study in which samples of subgingival microflora were harvested from test teeth and assayed for the presence of Porphyromonas gingivalis, and GCF collected and analyzed by ELISA for specific antibody for P. gingivalis. Clinical conditions were measured and recorded, and treatment by scaling and root planing provided at baseline and at 3, 6, 9, and 12 months. Reduction in pocket depth, stabilization of attachment level, and resolution of inflammation were comparable to previously reported values. By 3 months, mean and median specific antibody concentration had decreased, and continued to decrease through 12 months. The proportion of samples in which specific antibody was not detectable increased from 27% at baseline to 73% at month 12. GCF samples from sites at which P. gingivalis was present had greater than 2-fold higher median specific antibody than samples from P. gingivalis-negative sites. At baseline, specific antibody titer of 30-second GCF samples positively correlated with pocket depth, and GCF volume significantly correlated with antibody titer and concentration, and with pocket depth. In addition, change in specific antibody titer of 30-second samples from baseline to both 6 and 12 months correlated positively with pocket depths. Thus sites infected by P. gingivalis manifested high levels of specific antibody, and levels were related to clinical status. Following treatment, antibody levels decreased significantly as pocket depths decreased, attachment levels stabilized, and inflammation resolved.

Titer and subclass distribution of serum IgG antibody reactive with Actinobacillus actinomycetemcomitans in localized juvenile periodontitis

Most patients with localized juvenile periodontitis (LJP) manifest serum IgG antibodies specifically reactive with antigens of Actinobacillus actinomycetemcomitans serotype b (Aa-b). Whether these antibodies are protective, destructive, or irrelevant to the progress of the disease remains unclear. We report results of studies aimed at assessing the subclass IgG responses in 35 LJP patients and 35 periodontally normal control subjects using well-characterized monoclonal antibody subclass reagents in an enzyme-linked immunosorbent assay. Our data show that the mean value for total IgG reactive with antigens of Aa-b was more than sevenfold higher for patients than for normal control sera (2349.6 micrograms/ml for patients vs 332.2 micrograms/ml for controls). Individual patients and control subjects were classified as high- or low-titer, using twice the median value for total anti-Aa-b IgG in control sera as the cutoff. Of 35 patients, 26 (74%) were high-titer, and 9 (26%) were low-titer. This compares to 5 normal control subjects (14%) high-titer and 30 (86%) low-titer. IgG2 accounted for the major quantitative response in both patients and control subjects. Indeed, the mean IgG2 values for both concentration and percentage of total specific IgG were greater than the combined values for specific anti-Aa-b IgG1, IgG3, and IgG4. Of the 26 high-titer sera, IgG2 predominated in 24, with IgG1 and IgG3 predominating in 1 each; IgG2 predominated in only 2 of the low-titer sera.

Paradoxical effects of nitrous oxide on human memory

Using the method of adjusted learning, subjects learned number-noun pairs while breathing either placebo or 30% nitrous oxide. Subjects breathing nitrous oxide required more acquisition trials to attain a learning criterion than did subjects breathing placebo. Two weeks later, half of the subjects from each group were administered either placebo or nitrous oxide and were asked to recall the noun that had accompanied each number cue. Results showed that: 1) nitrous oxide inhalation can decrease the accessibility of to-be-recalled material and 2) nitrous oxide administered during the acquisition of material can paradoxically improved the recall of that material 2 weeks later. The additional number of acquisition trials subjects received during nitrous oxide inhalation could potentially account for this paradoxical enhancement of delayed recall; however, correlational analyses suggest this was not the case. No evidence for any state-dependent effects of nitrous oxide on cued recall were found.

Humoral immune responses to Porphyromonas gingivalis before and following therapy in rapidly progressive periodontitis patients

We have performed studies aimed at elucidating the nature of the humoral immune response in rapidly progressive periodontitis (RPP). We analyzed the sera of 36 periodontally normal subjects and 36 RPP patients for titers and avidities of IgG antibodies reactive with the antigens of Porphyromonas gingivalis using ELISA, prior to and following treatment. We used whole-cell sonicate, purified lipopolysaccharide (LPS), and total extractable protein as plate antigens. Twelve of the patients had antibody titers at least 2-fold greater than the median of the controls and were designated as seropositive. The remaining 24 patients had titers that did not exceed twice the median titer of the controls and were designated as seronegative. For both patient groups, antibody titers were highest when whole-cell antigen was used, intermediate for LPS, and lowest for the protein fraction. Following treatment, median titer for seropositive patients decreased from pretreatment values of 241.7 to 76.5, while median titer for seronegative patients increased from 39.5 to 80.1. Avidities of pretreatment sera from both patient groups for all 3 antigen preparations were lower than the median avidities of the control sera. Avidity significantly increased following treatment to levels greater than those for control sera in both patient groups. Thus, some young adults with severe periodontitis mount a humoral immune response and produce high levels of serum IgG antibodies reactive with antigens of P. gingivalis, while others do not. The antibodies produced are of relatively low avidity, and may therefore be relatively ineffective biologically. Therapy, which greatly reduces antigen load, appears to stimulate production of higher avidity IgG antibodies in both patient groups; in the seropositive group, low avidity antibodies appear to be replaced by antibodies of higher avidity. Both the purified LPS and protein fractions contain reactive antigen(s), although LPS binds more antibody. Our data are consistent with the idea that many RPP patients do not produce protective levels of biologically functional antibody during the course of their natural infection, but they may be stimulated to do so by treatment.

The intrauterine device and pelvic inflammatory disease: the Women's Health Study reanalyzed

The Women's Health Study (WHS) was a large, widely accepted and influential case-control study of the relationship between the use of intrauterine contraceptive devices (IUDs) and pelvic inflammatory disease (PID). The data were collected at 16 hospitals in 9 cities across the U.S.A. from October 1976 through August 1978. The first paper on this research was published in 1981 and concluded that IUDs increase the risk of PID. The report cited an estimated RR (relative risk) of PID for current IUD users vs nonIUD users of 1.6 with a 95% confidence interval of (1.4, 1.9). However, careful examination of the report reveals that the data support conclusions antithetical to those at which the author arrived. When the second report on the WHS was published in 1983, it was anticipated that many of the shortcomings of the first report would be corrected, but they were not. In 1983 we undertook a complete reanalysis of the same WHS data using more appropriate criteria and the results were compared to the first two published reports. The reanalysis revealed an RR of 1.02 (0.86, 1.21) for current IUD users compared to noncontraceptors. The conclusion of the WHS should have been that IUDs do not increase the risk of PID.

Endometrial response to endogenous hormones after pelvic irradiation for genital malignancies

Two cases are presented which demonstrate histologically an endometrial response to endogenous hormones after pelvic teletherapy and brachytherapy in patients who have undergone lateral ovarian transposition. Reasons for such a response are briefly discussed.

Bowel obstruction in patients with ovarian carcinoma: analysis of prognostic factors

A retrospective study was performed in which patients with both bowel obstruction and ovarian carcinoma admitted to the gynecologic oncology service at the Milton S. Hershey Medical Center between July 1, 1980, and June 30, 1987, were examined. Thirty-three patients were identified who fulfilled the inclusion criteria for bowel obstruction that did not occur in the postoperative period. Historical, physical, nutritional, and laboratory variables thought to contribute to patient survival were evaluated by a retrospective chart review. Survival time was not significantly related to presence or absence of tumor at obstruction, type of intervention whether medical or surgical, patient age, or interval from initial diagnosis of ovarian cancer to obstruction. Survival time was found to be significantly related to the prognostic index initially proposed by H. B. Krebs and D. R. Goplerud [Obstet. Gynecol. 61, 327-330 (1983)], P = 0.002. This prognostic index incorporates a multifactorial assessment of patient status including age, nutritional status, tumor spread, ascites, and prior chemotherapy and radiotherapy and can be used to evaluate patients at the time of presentation with intestinal obstruction and to help select optimal treatment for palliation.

Biopsy of the scalene fat pad in carcinoma of the cervix uteri metastatic to the periaortic lymph nodes

Fifty-five patients with squamous cell carcinoma of the cervix uteri metastatic to high common iliac or periaortic lymph nodes underwent biopsy of the left scalene fat pad as part of a prospective clinical trial. Patients without metastasis to the scalene nodes were subsequently treated with extended field radiation therapy and were then eligible for a randomized trial of systemic chemotherapy. Only four patients were found to have micrometastases to the scalene fossa. This figure is appreciably lower than that reported in previous literature. While geographic failure continues to be a problem for this group of patients, routine use of left scalene fat pad biopsy before treatment is not recommended.

Use of second-look laparotomy in the management of patients with ovarian epithelial malignancies

Between June 1976 and January 1986, 94 evaluable patients with stage I-IV disease underwent second-look laparotomy as part of their treatment for ovarian epithelial carcinomas. Stage and residual tumor size after initial debulking surgery demonstrated a significant association with absence of disease at reexploration. Forty-nine patients (52%) had no evidence of disease at second-look laparotomy. Thirty patients (32%) had macroscopic residual tumor, and 15 patients (16%) had microscopic disease at reexploration. Patients with a negative second-look laparotomy had an excellent prognosis; uncorrected 2- and 5-year survival rates exceed 90%. None of the patients with stage I or II disease developed recurrent tumor after a negative second-look laparotomy. However, 7 of the 25 (28%) patients with stage III disease and a negative second-look have demonstrated recurrent carcinomas. Recurrences were documented from 15.4 to 51.7 months after second-look laparotomy and were located within the abdominal cavity. Life table methods demonstrated improved survival for patients with microscopic disease as compared to those with gross tumor at second-look survey. Both groups had similar mean patient ages and tumor stage distributions. Patients with microscopic residual disease had uncorrected 2- and 5-year survival rates of 76 and 64%. The 2-year uncorrected survival rate for patients with gross tumor at second-look laparotomy was 25%. Thirty patients with macroscopic disease at second-look laparotomy underwent a repeat attempt at tumor debulking. Seventeen patients completed second-look surgery with residual disease less than 1 cm in maximum dimensions. Life table methods demonstrated improved survival when residual disease was less than 1 cm. Regardless of residual tumor size after reexploration, patients with gross tumor had a worse survival than those with microscopic disease.

CA 125 for the monitoring of ovarian carcinoma during primary therapy

Thirty-one patients with ovarian cancer were monitored with the CA 125 antigenic determinant in the interval between cytoreductive surgery and the completion of subsequent chemotherapy. Distinct CA 125 assay trends have emerged from prospective serial monitoring. Among patients who were clinically and surgically free of disease after the completion of cytoreductive chemotherapy, the CA 125 assay always fell to levels under 35 U/mL within the first three months of cytoreductive chemotherapy, and stayed at low levels. Patients with partial cytoreduction operations had decreases in serum CA 125 levels only if there was a response to further therapy. The rate of fall of the CA 125 levels correlated with clinical outcome. All 13 patients with serum CA 125 above 35 U/mL after three months of treatment invariably had persistent tumors after subsequent chemotherapy, whereas in patients showing reduction of the CA 125 to levels below 35 U/mL, there were no surgically detectable tumors. Measurement of CA 125 during treatment might permit an early change to alternative and optimal forms of therapeutic management. The CA 125 level three months after treatment appears to be a critical predictor of response to therapy.

Former cancer patients as counselors of newly diagnosed cancer patients

This study tested the hypothesis that counseling of newly diagnosed cancer patients by former cancer patients will increase the use of coping strategies and reduce psychological stress beyond what can be accomplished by just counseling from professional staff. Thirty-two newly diagnosed patients in a gynecologic oncology service were subjects in this study. All subjects received supportive services from professionals assigned to the service. Control group patients received just the professional support program, while the experimental group patients received professional support plus additional counseling by former cancer patients that emphasized four coping strategies characteristic of patients who have adapted well to cancer. Results 6 and 12 weeks after entering the study showed no statistically significant differences in emotional status between experimental and control groups and only one significant difference in coping behaviors that was opposite to what was predicted. The findings do not support the hypothesis.

Growth of cavernous hemangioma with puberty

There is a clinical impression among physicians that puberty may prompt growth of hemangiomas. We observed significant growth of a large cavernous hemangioma in a patient at the onset of puberty despite absent estrogen and progesterone receptors in the hemangioma tissue.

Plasminogen activator activity in human endometrial carcinoma

Plasminogen activator activity (PAA) has been proposed as an indicator of aggressiveness of tumors and has been shown to be hormonally modulated. To test this hypotheses in human endometrial carcinoma, tumor explants were assayed for PAA secretion and the results correlated with histopathologic criteria of aggressiveness. The effect of medroxyprogesterone acetate (MPA) on PAA secretion was also investigated. Lower levels of PAA were found to be associated with tumors displaying aggressive tendencies. MPA generally decreased PAA secretion. No apparent correlation was found between estrogen or progesterone receptor concentrations and PAA levels.

The preservation of ovarian function in young women undergoing pelvic radiation therapy

Because cervical carcinoma rarely metastasizes to the ovaries, it became logical to preserve ovarian function by the method of lateral ovarian transposition as part of the management of young women with this disease. This technique prevents castration should subsequent radiation therapy be planned or become necessary. Forty patients with carcinoma of the cervix or vagina underwent unilateral or bilateral ovarian transposition. Eighteen patients received radiation therapy. Of these, 16 had gonadotropin measurements and only 6 (37%) had levels elevated to the postmenopausal range. If patients whose ovaries were not shielded or who received paraaortic radiotherapy are excluded, then only two (17%) had elevated gonadotropin values. It is concluded that, if properly performed, lateral ovarian transposition and ovarian shielding will protect ovarian function in patients receiving pelvic radiotherapy.

Spontaneous occurrence of synergistic bacterial gangrene following external pelvic irradiation

A case of spontaneous synergistic bacterial gangrene occurring after external pelvic irradiation is presented in a 25-year-old woman with invasive cervical cancer. Treatment consisted of aggressive antibiotic therapy and extensive excision and debridement followed by split-thickness skin grafting. Both recovery and cosmetic results were satisfactory. The pathophysiology, predisposing factors, and treatment modalities are presented.

The prognostic significance of vascular channel involvement and deep stromal penetration in early cervical carcinoma

Eighty-eight patients with FIGO Stage Ib and IIa squamous cell carcinoma of the cervix underwent radical hysterectomy with pelvic and paraaortic lymphadenectomy. The records and histopathologic material were reviewed to determine the prognostic significance of vascular channel involvement and deep stromal penetration by tumor. Seventy-four patients (84%) were alive and free of disease for more than 2 years and 14 (16%) developed recurrent carcinoma within that time. A positive correlation was found between depth of stromal penetration by tumor and the degree of vascular channel involvement (p less than 0.05). Vascular involvement in itself did not significantly affect nodal status, survival or the rate of recurrence. Depth of penetration was associated with a higher incidence of positive nodes (p less than 0.05). There was a trend towards a lower survival rate and a higher recurrence rate in patients with deep stromal penetration as compared to those with superficial tumors. Microscopic nodal disease increased the rate of recurrence and had an adverse effect on survival. The combination of deep tumor penetration and positive nodes in the same patient was associated with the highest recurrence rate and the lowest survival (p less than 0.05). Nodal status was a more significant prognostic indicator than depth of tumor penetration because patients with deeply penetrating tumors and positive nodes had more than twice the recurrence rate than did patients with deep tumors and negative nodes. Postoperative radiation therapy was beneficial to patients whose tumors demonstrated deep stromal penetration and microscopic metastases to pelvic lymph nodes.