Computable phenotype for diagnostic error: developing the data schema for application of symptom-disease pair analysis of diagnostic error (SPADE)

OBJECTIVES

Diagnostic errors are the leading cause of preventable harm in clinical practice. Implementable tools to quantify and target this problem are needed. To address this gap, we aimed to generalize the Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) framework by developing its computable phenotype and then demonstrated how that schema could be applied in multiple clinical contexts.

METHODS

We created an information model for the SPADE processes, then mapped data fields from electronic health records (EHR) and claims data in use to that model to create the SPADE information model (intention) and the SPADE computable phenotype (extension). Later we validated the computable phenotype and tested it in four case studies in three different health systems to demonstrate its utility.

RESULTS

We mapped and tested the SPADE computable phenotype in three different sites using four different case studies. We showed that data fields to compute an SPADE base measure are fully available in the EHR Data Warehouse for extraction and can operationalize the SPADE framework from provider and/or insurer perspective, and they could be implemented on numerous health systems for future work in monitor misdiagnosis-related harms.

CONCLUSIONS

Data for the SPADE base measure is readily available in EHR and administrative claims. The method of data extraction is potentially universally applicable, and the data extracted is conveniently available within a network system. Further study is needed to validate the computable phenotype across different settings with different data infrastructures.

Trends in invasive disease due to Candida species following heart and lung transplantation

Although invasive candidiasis (IC) causes significant morbidity and mortality in patients who undergo heart, lung, or heart-lung transplantation, a systematic study in a large cohort of thoracic organ transplant recipients has not been reported to date. Clinical and microbiological data were reviewed for 1305 patients who underwent thoracic organ transplantation at Stanford University Medical Center between 1980 and 2004. We identified and analyzed 76 episodes of IC in 68 patients (overall incidence 5.2% per patient).The incidence of IC was higher in lung (LTx) and heart-lung transplant (HLTx) recipients as compared with heart transplant (HTx) recipients (risk ratio [RR] 1.7, 95% confidence interval [CI] 1.1-2.7).The incidence of IC decreased over time in all thoracic organ transplant recipients, decreasing from 6.1% in the 1980-1986 time period to 2.1% in the 2001-2004 era in the HTx recipients, and from 20% in the 1980-1986 period to 1.8% in the 2001-2004 period in the LTx and HLTx recipients.The most common site of infection differed between the HTx and LTx cohorts, with bloodstream or disseminated disease in the former and tracheobronchitis in the latter. IC in the first year after transplant was significantly associated with death in both HTx (RR 2.9, 95% CI 1.8-4.6, P=0.001) and LTx and HLTx patients (RR 3.0, 95% CI 1.9-4.6, P<0.001). The attributable mortality from IC decreased during the 25-year period of observation, from 36% to 20% in the HTx recipients and from 39% to 15% in the LTx and HLTx recipients. There were a significant number of cases caused by non-albicans Candida species in all patients, with a trend toward higher mortality in the HTx group. In conclusion, the incidence and attributable mortality of IC in thoracic organ transplant recipients has significantly declined over the past 25 years.The use of newer antifungal agents for prophylaxis and treatment, the decrease in the incidence of cytomegalovirus disease, and the use of more selective immunosuppression, among other factors, may have been responsible for this change.

Intraperitoneal radioimmunochemotherapy of ovarian cancer: a phase I study

A phase I trial was designed to examine the feasibility of combining interferon and Taxol with intraperitoneal radioimmunotherapy (177Lu-CC49). Patients with recurrent or persistent ovarian cancer confined to the abdominal cavity after first line therapy, Karnofsky performance status > 60, adequate liver, renal and hematologic function, and tumor that reacted with CC49 antibody were enrolled. Human recombinant alpha interferon (IFN) was administered as 4 subcutaneous injections of 3 x 10(6) U on alternate days beginning 5 days before RIT to increase the expression of the tumor-associated antigen, TAG-72. The addition of IFN increased hematologic toxicity such that the maximum tolerated dose (MTD) of the combination was 40 mCi/m2 compared to 177Lu-CC49 alone (45 mCi/m2). Taxol, which has radiosensitizing effects as well as antitumor activity against ovarian cancer, was given intraperitoneally (i.p.) 48 hrs before RIT. It was initiated at 25 mg/m2 and escalated at 25 mg/m2 increments to 100 mg/m2. Subsequent groups of patients were treated with IFN + 100 mg/m2 Taxol + escalating doses of 177Lu-CC49. Three or more patients were treated in each dose group and 34 patients were treated with the 3-agent combination. Therapy was well tolerated with the expected reversible hematologic toxicity. The MTD for 177Lu-CC49 was 40 mCi/m2 when given with IFN + 100 mg/m2 Taxol. Interferon increased the effective whole body half-time of radioactivity and the whole body radiation dose. Taxol did not have a significant effect on pharmacokinetic or dosimetry parameters. Four of 17 patients with CT measurable disease had a partial response (PR) and 4 of 27 patients with non-measurable disease have progression-free intervals of 18+, 21+, 21+, and 37+ months. The combination of intraperitoneal Taxol chemotherapy (100 mg/m2) with RIT using 177Lu-CC49 and interferon was well tolerated, with bone marrow suppression as the dose-limiting toxicity.

The Society of Gynecologic Oncologists Outcomes Task Force. Study of endometrical cancer: initial experiences

OBJECTIVE

The aim of this study was to develop an outcomes measure, which incorporates patient reported information, for The Society of Gynecologic Oncologists (SGO) to establish benchmarks in the treatment of endometrial cancer and demonstrate quality to third parties.

METHODS

The Outcomes Task Force (OTF) developed an outcomes tool that included preoperative, intraoperative, and 120-day-postoperative assessments. Measures included demographics, patient-reported health status (SF36), comorbid conditions, living status, satisfaction surveys, operative events and disease characteristics. Patients (n = 297) were surveyed at 11 pilot sites from 10/1/97 to 9/1/99.

RESULTS

The mean age of patients was 64.4 years and their mean Quetelet index was 33.2 kg/m(2). Forty-eight percent were Medicare beneficiaries and 25% were HMO patients. Mean comorbidity score was 19.1 (maximum possible 100). This represents approximately three comorbidities per average patient. Seventy-four percent were FIGO stage I, 9% stage II, 11% stage III, and 5% stage IV. Forty percent were FIGO grade 1, 35% grade 2, and 24% grade 3. Ninety-two percent of patients were able to live independently preoperatively and 91% were independent postoperatively. Seventy-seven percent of patients underwent total abdominal hysterectomy, 8% radical abdominal hysterectomy, 9% laparoscopic hysterectomy, and 1% vaginal hysterectomy. Mean length of stay was 3. 3 days and mean operative time was 119 min. Ninety-nine percent were staged and 80% underwent lymph node sampling. Two patients required unplanned returns to surgery and 8 required blood transfusion (27 units total). Postoperatively, 20% received radiation therapy and 13% received cytotoxic chemotherapy. Mean satisfaction score (scale 0 to 100) preoperatively was 86 and postoperative was 83. SF36 component summaries were preoperatively and 120 days postoperatively: physical component 43.6 vs 43.1; mental component 49.1 vs 50.6.

CONCLUSION

The SGO has developed a tool for assessing outcomes for the treatment of endometrial cancer that can be made available to the membership to assess and objectively demonstrate quality of care to third parties.

Surgical management of endometrial adenocarcinoma using laparoscopically assisted staging and treatment

BACKGROUND

Because of inaccuracies in clinical staging, endometrial adenocarcinoma is now a surgically staged disease. This study was done to determine the safety and efficacy of a laparoscopically assisted approach in the treatment and staging of this disease.

METHODS

Using a retrospective chart review, we identified demographic characteristics, mean blood loss, operative findings, and complications of patients who had laparoscopically assisted staging and treatment for endometrial carcinoma from 1992 to 1997.

RESULTS

Of 34 patients, 28 had laparoscopic surgical staging that included pelvic and para-aortic lymph node assessment, peritoneal washings, bilateral salpingo-oophorectomy, and total vaginal hysterectomy; 23 patients (82%) had stage I disease, 2 (7%) had stage II disease, and 3(11%) had stage III disease. Complications included herniation through a 5 mm port site, necessitating small bowel resection, and a fatal myocardial infarction 10 days postoperatively.

CONCLUSION

Laparoscopic staging and treatment of endometrial carcinoma is appropriate in a select group of patients.

Response to salvage treatment in recurrent ovarian cancer treated initially with paclitaxel and platinum-based combination regimens

OBJECTIVE

The aim of this study was to evaluate the response to salvage treatment in recurrent ovarian cancer treated initially with paclitaxel-based chemotherapy.

METHODS

A retrospective review of patients with recurrent ovarian cancer treated with surgical debulking and paclitaxel-based chemotherapy was performed. All cases received second-line treatment with a response evaluated by clinical or surgical means. Data analysis was conducted using the SAS statistical package.

RESULTS

Fifty cases of advanced stage disease were available for review. Patients received paclitaxel and cisplatin or carboplatin with a 72.0% response rate. The median time to recurrence after primary treatment was 6 months. Second-line treatment included cisplatin or carboplatin (50%), Taxol (10%), or lutetium (22%), an intraperitoneal radiolabeled monoclonal antibody targeted to TAG-72. A 52.0% clinical response to salvage treatment was detected. With a median follow-up of 7 months, 68.0% of patients had experienced recurrence or progression of their disease. The median time to second recurrence was 5 months. Cases sensitive to initial paclitaxel-containing chemotherapy responded to any of the salvage treatments more frequently than chemotherapy-resistant tumors (88.5% versus 11.5%, P < 0.05).

CONCLUSIONS

Recurrent ovarian cancer patients initially treated with paclitaxel-based chemotherapy frequently responded to salvage treatment. However, the duration of response was brief, and hospitalization for treatment-related side-effects was common. Tumor response to initial paclitaxel/platinum treatment was predictive of future response to second-line agents. Current salvage therapies appear to provide little benefit in cases of tumors resistant to primary chemotherapy.

Treatment of the small unruptured ectopic pregnancy: a cost analysis of methotrexate versus laparoscopy

OBJECTIVE

To compare the economic costs between two strategies for management of the small unruptured ectopic pregnancy: initial treatment with methotrexate versus initial treatment with laparoscopic salpingostomy.

METHODS

We assumed that both treatment strategies would result in identical clinical outcomes: resolution of the ectopic pregnancy without maternal mortality or long-term morbidity. Based on a literature review, estimates were derived for the likely clinical outcomes of a single injection of methotrexate (50 mg/m2) and for the likely clinical outcomes of the laparoscopy strategy. A range of values was evaluated for the initial success rate of each strategy and varying assumptions made about the type of treatment modality used for initial treatment failures. Direct medical costs of each strategy were estimated based on actual reimbursement rates of a third-party payer for the components of each strategy. The treatment strategies were compared in best-case/worst-case scenarios to determine the potential range of differences in costs between the two strategies.

RESULTS

The cost of the methotrexate strategy ranged from $438 to $1390, and the cost of laparoscopic salpingostomy ranged from $2506 to $2974; therefore, the methotrexate strategy was less costly than laparoscopy, with a cost difference ranging from $1124 (best-case laparoscopy-worst-case methotrexate scenario) to $2536 (worst-case laparoscopy-best-case methotrexate scenario). Sensitivity analyses demonstrated that initial therapy with methotrexate was less costly over a wide range of probability and cost estimates.

CONCLUSION

Initial methotrexate is a cost-effective alternative to laparoscopic salpingostomy in the treatment of the small unruptured ectopic pregnancy.

Technetium-99m-sulfur colloid SPECT imaging in infants with suspected heterotaxy syndrome

For the evaluation of a variety of hepatosplenic disorders, SPECT complements planar 99mTc-sulfur colloid liver/spleen imaging. By isolating small, ectopic or poorly functioning spleen(s) from overlying or adjacent liver, SPECT imaging should facilitate identification of splenic tissue in infants with suspected heterotaxy syndrome.

METHODS

During a 10-yr period, 10 planar-only and 9 planar-plus-SPECT liver/spleen scans were obtained from 15 infants, 13 of whom were less than 1 mo of age at first examination. Four of the planar-only group had follow-up planar-plus-SPECT imaging. Scintigraphic diagnosis regarding presence of splenic tissue was correlated with clinical diagnosis.

RESULTS

Thirteen infants had splenic tissue; two were asplenic. Planar-only imaging provided correct diagnoses in six [four with, two without spleen(s)] but was negative or equivocal in four infants. Planar-plus-SPECT imaging was positive in all in whom it was performed; moreover, in 4/13 infants (31%), splenic tissue was documented only by SPECT imaging.

CONCLUSION

Particularly when planar views are inconclusive, SPECT imaging is invaluable for identification and localization of functioning splenic tissue in infants with suspected heterotaxy syndrome.

T2/3 vulva cancer: a case-control study of triple incision versus en bloc radical vulvectomy and inguinal lymphadenectomy

The purpose of this case-control study was to compare outcome in T2/3 vulvar cancer patients treated with radical vulvectomy and inguinal lymphadenectomy using either a triple incision or en bloc technique. All T2/3 vulvar cancer patients treated by the triple incision technique were identified and compared to a control group consisting of similar T2/3 patients treated with an en bloc procedure at the same institution. Survival by surgical stage, lesion diameter, nodal status, and margin status was analyzed and compared between the two groups. Twenty-seven vulvar cancer patients with a T2/3 lesion underwent radical vulvectomy and inguinal lymphadenectomy using the triple incision technique; the control group consisted of 20 T2/3 vulvar cancer patients treated by en bloc resection. The two groups were matched for age, surgical stage, grade, lesion diameter, margin status, nodal status, and adjuvant treatment. The recurrence rate in the triple incision group was 37% compared to 35% in the en bloc group. (OR, 1.092, 95% CI, [0.327, 3.649], P = 0.9). There was no difference in the local recurrence rate between the two groups (80% in the triple incision group and 72% in the en bloc group) (P = 0.5). Five-year survival for the triple incision and the en bloc groups was similar, 64 and 82%, respectively (P = 0.15). Survival between the groups was not statistically different when analyzed according to surgical stage, lesion diameter, nodal status, and negative margin status. These data indicate that the triple incision technique provides survival outcomes similar to the standard en bloc radical vulvectomy in patients with T2/3 vulva cancer. Due to the significant morbidity that has been associated with the en bloc radical vulvectomy and inguinal lymphadenectomy, the triple incision technique should be considered as the preferred method of treatment for most vulvar cancer patients.

Adenocarcinoma of the endometrium: survival comparisons of patients with and without pelvic node sampling

From 1969 to 1990, 649 patients with adenocarcinoma of the endometrium were surgically managed by gynecologic oncologists from the University of Alabama at Birmingham. All patients underwent TAH-BSO and washings. Two hundred twelve patients had multiple-site pelvic node sampling (mean number of nodes, 11), 205 patients had limited site pelvic node sampling (mean number of nodes, 4), and in 208 patients, nodes were not sampled. Historical prognostic features, including tumor grade, depth of invasion, adnexal metastasis, cervical involvement, and positive cytology, were equally distributed in the three groups. Mean follow-up was 3 years. Patients undergoing multiple-site pelvic node sampling had significantly better survival than patients without node sampling (P = 0.0002). When patients were categorized as low risk (disease confined to the corpus) or as high risk (disease in the cervix, adnexa, uterine serosa, or washings) multiple-site pelvic node sampling again provided a significant survival advantage compared to patients without node sampling (high risk, P = 0.0006; low risk, P = 0.026). In a comparison of patients receiving whole pelvic radiation for grade III lesions or deep myometrial invasion, patients with multiple-site pelvic node sampling had better survival than those in whom nodes were not sampled (P = 0.0027). The significant survival advantage for patients having multiple-site node sampling, overall and in high- and low-risk groups, strongly suggests a therapeutic benefit. Additionally, adjuvant therapy may be more appropriate directed in these patients.

Staging ovarian cancer diagnosed during laparoscopy: accuracy rather than immediacy

Immediate staging and debulking of an unsuspected ovarian malignancy detected at the time of diagnostic laparoscopy is appropriate when personnel knowledgeable in these procedures are available. However, when assistance is unavailable, termination of the diagnostic laparoscopy and timely referral is acceptable. This report reviews techniques to preoperatively distinguish a benign from a malignant adnexal mass, steps to evaluate an adnexal mass during laparoscopy, and ovarian cancer staging procedures.

The Groshong catheter as an intraperitoneal access device in the treatment of ovarian cancer patients

With the development of new intraperitoneal treatments in ovarian cancer, safe and convenient access to the peritoneal cavity is now required. This report reviews the University of Alabama at Birmingham's experience with the Groshong catheter as an intraperitoneal access device. The Groshong was easily inserted intraperitoneally in 20 ovarian cancer patients and used to deliver 81 courses of intraperitoneal therapy over 2310 patient-days. There were no catheter-related complications during treatment and only one exit site infection after catheter removal. Further investigation of the Groshong catheter as a novel intraperitoneal access device appears warranted.

The validity and significance of substages of advanced ovarian cancer

No studies to date have evaluated the validity of the new FIGO substaging of advanced epithelial ovarian cancer nor assessed the importance of substage in relation to other elements such as age at diagnosis, debulking surgery, and second-look laparotomy. The purpose of this study was to determine the significance of these factors. One hundred sixty-seven patients with Stage III ovarian cancer were restaged according to the 1988 FIGO criteria (6% Stage IIIa, 15.6% Stage IIIb, and 78.4% Stage IIIc). The mean age at diagnosis was 40.5 for Stage IIIa, 51 for Stage IIIb, and 62 for Stage IIIc (P = 0.0001). Median survival was 2.5 years for patients age < 60 and 1.4 years for those age > or = 60 (P = 0.0001). Median survival for patients undergoing TAH/BSO was 2.06 years, bowel resection 1.39 years, and biopsy only 1.38 years (P = 0.0003). Only 61 of 131 Stage IIIc patients underwent second-look laparotomy. Seven of nine Stage IIIa, 6 of 17 Stage IIIb, and 14 of 61 Stage IIIc patients had negative second-look laparotomies (P = 0.004). Only 4 of the 14 patients with Stage IIIc and 8 of 13 Stage IIIa/b patients are alive after negative second look (P = 0.37). Median survival for Stage IIIa patients has not been reached and for Stages IIIb and IIIc was 2.29 years and 1.33 years, respectively (P = 0.0001). These data confirm the prognostic validity of FIGO substages for Stage III. The age differential by substages suggests that the natural history of Stage III disease is progressive over several decades. The appropriateness of aggressive cytoreductive surgery and second-look laparotomy must be reevaluated using the new FIGO staging system.

A matched comparison of single and triple incision techniques for the surgical treatment of carcinoma of the vulva

Thirty-two patients with invasive squamous cell carcinoma of the vulva (SCC) undergoing radical vulvectomy or radical local excision with bilateral superficial groin node dissection using a triple incision technique (TI) were matched for new FIGO stage, lymph node status, size of lesion, and site of lesion with patients with SCC undergoing traditional radical vulvectomy with en bloc bilateral groin (but not pelvic) node dissection using a single incision (SI) technique. Average operative time (134 min: 191 min), blood loss (424 ml: 733 ml), and hospital stay (9.7 days: 17.2 days) were significantly less in the TI group. After SI 6/32 (19%) patients and after TI 1/32 (3%) patients experienced complete breakdown of the groin wounds. There was no significant difference in overall survival (P = 0.56) or disease-free survival (P = 0.53) between the two groups. There was no significant difference in survival between the two groups by lesion size or by FIGO (1989) stage. Disease recurred in six patients after SI compared with seven after TI (P = 0.75). There were no skin bridge recurrences in the TI group. Two patients in each group had isolated vulvar recurrences and all four were successfully treated by local excision. These data indicate that outcome following TI surgery is essentially equal to that of SI in early-stage disease but major morbidity is much reduced.

Effect of deoxyribonucleic acid ploidy status on survival of patients with carcinoma of the endometrium

This retrospective study was performed to determine the clinical usefulness of deoxyribonucleic acid (DNA) ploidy and the amount of DNA in the nucleus of the tumor cell on the prognosis of patients with carcinoma of the endometrium. Five year follow-up study was obtained for 121 patients. Flow cytometric analysis was used to determine tumor cell ploidy from paraffin-embedded specimens. Patients were grouped according to ploidy, clinical stage and grade and whether or not they received postoperative radiation. The data were subjected to a Cox proportional hazards regression analysis, and only ploidy status and clinical stage were significantly associated with survival time. Of the 121 patients observed, 44.6 per cent were aneuploid and 55.4 per cent, euploid. Preliminary chi-square analysis indicated a strong survival advantage to those patients with euploid endometrial carcinoma. The over-all five year survival rate for patients with aneuploid tumors was 53.7 per cent, as opposed to 80.6 per cent for patients with euploid tumors (p less than 0.01). Eighty-seven patients were Stage I, 39 aneuploid, 48 euploid. The five year survival rate for patients with Stage I aneuploid was 71.8 versus 85.4 per cent for those who were euploid. Twenty-one patients were Stage II; seven aneuploid and 14 euploid. The five year survival rate for aneuploid patients was 14.3 versus 85.7 per cent for euploid patients. The over-all five year survival rate for those with Stage I and II was 85.5 per cent euploid and 63.0 per cent aneuploid, p less than 0.05. Patients with Stage III or IV had poor outcome regardless of ploidy status. These data show that patients with euploid Stage I and II carcinoma of the endometrium have a significant survival advantage over patients with aneuploid tumors. We, therefore, believe that ploidy status may be used to facilitate the determination of prognosis in carcinoma of the endometrium.

Second-look laparotomy and salvage therapy: a research modality only?

Two hundred twelve patients who underwent second-look laparotomy as part of their treatment for epithelial ovarian cancer were evaluated. Factors associated with positive second looks were initial stage, tumor grade, age, and residual disease (P less than 0.05). One factor not of significance was whether adjuvant therapy was platinum based. Initial stage only was associated with recurrence after a negative second look (P less than 0.001). When controlled for volume of disease no difference in survival between various salvage therapies could be demonstrated. Survival between patients with recurrence after negative second look and patients with microscopic residual disease was similar even though the former group was not treated until recurrence (P = 0.75). Second-look laparotomy does not improve survival with currently existing salvage modalities and should primarily be confined to those patients willing to participate in research protocols evaluating new second-line therapy.

Primary surgical therapy of ovarian cancer: how much and when

From July 1975 through December 1985, 328 patients with ovarian malignancies were treated. Of these, 302 had epithelial invasive malignancies and constitute the study group. The impact of the operative procedure, findings, and subsequent treatment is evaluated. Patients who underwent extensive debulking procedures such as bowel resection and peritoneal stripping did not have improved survival compared with those patients who did not undergo these procedures and yet had residual disease remaining (P = 0.7 and P = 0.34). Reoperating patients felt to be unresectable at the time of referral did not increase survival over reoperating patients after an attempt at chemotherapeutic reduction (P = 0.34).

Endometrial cancer, obesity, and body fat distribution

A case-control study was undertaken to evaluate the roles of obesity and body fat distribution in the etiology of endometrial cancer. The study also included an evaluation of the associations of serum estrone, estradiol, and androstenedione with obesity, body fat distribution, and endometrial cancer risk. The study included 168 cases and 334 control subjects identified at an optometry clinic. A strong, positive relationship between overall obesity and endometrial cancer was found. The relative rate of endometrial cancer for women in the upper 90th percentile of a body mass index compared to those below the median was estimated as 5.5 with 95% confidence limits of 3.2-9.6. There was no association between endometrial cancer and the waist to hip ratio, an index of upper versus lower body fat distribution. A statistical test of trend across the four quartiles of the waist to hip ratio yielded a P value of 0.45 after adjustment for confounding by the body mass index. On the other hand, there was a statistically significant, independent positive effect of a high subscapular to tricep skinfold ratio, a measure of central versus peripheral obesity, on endometrial cancer risk. The relative rates of endometrial cancer for the second, third, or fourth quartile compared to the first quartile of this index were 1.5, 1.9, and 2.7, respectively (P = 0.007), after adjustment for the body mass index. Serum estrone and estradiol, but not androstenedione, were statistically significantly correlated with the body mass index among control subjects (r = 0.37 and 0.40 for estrone and estradiol, respectively). On the other hand, each of the sex hormones was uncorrelated with the waist to hip ratio after adjustment for body mass. The correlations between each of the three hormones and the subscapular to tricep skinfold ratio among controls were weak and were not statistically significant (0.10, 0.10, and 0.14 for estrone, estradiol and androstenedione, respectively). Cases had statistically significantly higher mean serum estrogen and androstenedione levels than did controls and these elevations did not simply reflect a higher prevalence of obesity among them. The findings are equivocal with respect to fat patterns and endometrial cancer. We suggest that future epidemiological studies of cancer and body fat distribution more carefully distinguish among the various types of fat patterns.

The immediate effects of cessation of cigarette smoking on gastroesophageal reflux

Cigarette smoking is thought to adversely affect gastroesophageal reflux. Eight male patients with endoscopic evidence of gastroesophageal reflux had 24-h esophageal pH monitoring while smoking at least 20 cigarettes. This was repeated while abstaining from smoking the following day. In the initial study period, 28.3% of the reflux time occurred within 20 min of smoking a cigarette. There were fewer reflux episodes in the nonsmoking period (95.7 episodes vs 70.0). The patients had significant improvement while in the upright position (57 reflux episodes vs 28.5). Yet, total reflux time was not significantly changed (pH less than 4.0 11.2% of total time smoking vs 10.1% total time nonsmoking). Immediate cessation of smoking decreases the number of daily reflux episodes, but does not significantly affect total esophageal acid exposure in symptomatic patients with endoscopic evidence of gastro-esophageal reflux disease.

Clinical and histopathologic factors predicting recurrence and survival after pelvic exenteration for cancer of the cervix

Between September 1969 and January 1, 1986, 143 pelvic exenterations for recurrent cervical cancer were performed by the gynecologic oncologists at the University of Alabama at Birmingham. Of this group, 78 patients underwent total pelvic exenteration, 63 patients had anterior exenteration, and two had posterior exenteration. The overall operative mortality rate was 6.3%, mostly associated with total pelvic exenteration. The 5-year survival rates were 50% overall, 63% with anterior exenteration and 42% with total exenteration. Univariate and multivariate analyses were performed to identify clinical and histopathologic factors predictive of prolonged survival. Using three clinical factors (duration from initial radiation therapy to exenteration, size of the central mass, and presence of preoperative sidewall fixation), low-, intermediate-, and high-risk groups were constructed; the 5-year survival rates for these groups were 82, 46, and 0%, respectively. Inclusion of one histopathologic factor (margin status of the surgical specimen) added to the ability to predict 2- and 5-year survival rates. The best candidates for cure by pelvic exenteration were those with recurrent small (less than 3 cm), mobile central masses who were a year or longer from the time of their previous radiation therapy. Attempts to resect bulky pelvic recurrences that impinge on the pelvic sidewall, especially in the case of persistent or early recurrent disease (within 6 months), or continuation of exenterative procedures in women known to have nodal metastases or extrapelvic spread, are generally futile. For those women falling between the two extremes, sound clinical and operative judgment is imperative in regard to selecting the treatment offering the best quality of life.

Treatment of nonmetastatic gestational trophoblastic disease with sequential intramuscular and oral methotrexate

Thirty-seven patients with nonmetastatic gestational trophoblastic disease (NMGTD) were treated with one or more cycles of oral methotrexate following intramuscular methotrexate as part of induction chemotherapy. Remission was achieved in 31 patients (83.8%). All failures were readily cured with alternate regimens. Prospective studies using this safe, easily administered modality are needed to verify its apparent efficacy.

Intraperitoneal chromic phosphate in ovarian cancer: risks and benefits

Between March 1977 and December 1985, 59 patients were treated with intraperitoneal chromic phosphate at The University of Alabama Birmingham Hospitals and its affiliates. Twenty-seven patients received primary adjuvant therapy. Thirty-two patients were treated "secondarily" after tumor recurrence or after a "positive" second-look laparotomy. Associated morbidity was noted to be 12% with reoperation required in 7%. Early stage and grade tumors demonstrate a good prognosis. Little, if any, benefit was demonstrated in "secondary" therapy of advanced stage and grade tumors.

Treatment of nonmetastatic gestational trophoblastic disease with oral methotrexate

Fifteen patients with nonmetastatic gestational trophoblastic disease were treated solely with methotrexate given orally rather than intramuscularly. Remission, defined as a beta-human chorionic gonadotropin titer of less than 5 mIU/ml for 3 consecutive weeks, was attained in 13 (87%) of the 15 patients. Level of toxicity was acceptable. Patient comfort, convenience, and less time off work and in the physician's office are significant advantages to this efficacious, well-tolerated method of therapy.

Surgical treatment of women found to have invasive cervix cancer at the time of total hysterectomy

Twenty-three patients were referred after the unexpected finding of invasive cervix cancer at the time of total hysterectomy. Each was deemed a candidate for additional therapy and was treated surgically with a radical reoperation consisting of a lymphadenectomy, radical parametrectomy, and upper vaginectomy. When compared with patients undergoing radical hysterectomy at this institution, this reoperation was not technically more difficult as judged by the objective measures of operative time and blood loss. The risk of perioperative morbidity was not greater than radical hysterectomy. The surgical findings obviated the need for additional radiation therapy in more than 73% of patients. While therapy for all patients must be individualized, a radical reoperation should be considered a safe and efficacious alternative to pelvic radiation for patients who are deemed to require additional therapy in this clinical situation.

Endometrial adenocarcinoma after in utero diethylstilbesterol exposure

The association of cervicovaginal adenocarcinoma and in utero diethylstilbesterol exposure is well known. There is concern that offspring exposed in utero may be predisposed to develop other malignancies as well. Presented is a case of endometrial adenocarcinoma occurring in this clinical setting. To the best of the authors' knowledge this association has not been reported previously.

Ureteral strictures and fistulae following radical hysterectomy

Three hundred patients have undergone radical hysterectomy and pelvic node dissection at The University of Alabama in Birmingham (UAB). Uretero-vaginal fistulae occurred in four (1.3%). None of these were associated with recurrent carcinoma. Two occurred because of intraoperative trauma and two were unexplained. Ureteral strictures occurred in 13 (4.3%). Three were early (within 3 months) and were due to benign causes. Ten were late (after 3 months) and were due to recurrent cancer. Thirty-two patients received whole pelvis radiation therapy for positive pelvic nodes or positive margins. None of these developed uretero-vaginal fistulae. Two developed ureteral obstruction and recurrent cancer was the etiology. Four patients received postoperative vaginal ovoids for positive vaginal margins. None developed a fistulae, but two developed ureteral obstruction secondary to recurrent cancer. Two patients received both whole pelvis and vaginal ovoid irradiation. No fistulae occurred, but one developed ureteral obstruction from recurrent cancer. Recurrent cancer causing ureteral obstruction was a serious finding as only 2 of 10 patients have been salvaged.

Hemodynamic parameters following pelvic exenteration

Hemodynamic parameters were prospectively studied in 31 patients who underwent pelvic exenteration. With the use of a thermistor-tipped pulmonary artery catheter, hemodynamic parameters were calculated during the intraoperative and acute (less than 48 hours) postoperative interval. The mean operative time was 5.5 +/- 0.8 hours, and volume replacement (mean, 21.6 ml/kg/hr) consisted of crystalloid, colloid, and blood. Postoperative urine production (mean, 1.9 ml/kg/hr) was maintained with crystalloid (mean, 2.5 ml/kg/hr), colloid (0.2 ml/kg/hr), and blood (0.4 ml/kg/hr). Despite individual variations, the important parameters of cardiovascular function were maintained in the physiologic range. No patient developed cardiovascular or respiratory failure. We believe that the lack of perioperative morbidity and mortality was related, in substantial part, to this type of cardiovascular monitoring, which allows for the prompt diagnosis of potential problems and enables the physician to make appropriate interventions to correct these problems.

Tumor recurrence and survival in stage IB cancer of the cervix

Clinical records of 371 women with carcinoma of the cervix, Stage IB, treated in the decade 1969-1979 were reviewed. Cancer recurred in 67 women (18.1%). A group of 171 patients treated by radiation, including 25 who were surgically staged prior to treatment, was compared to 200 patients treated by radical abdominal hysterectomy and pelvic node dissection, including 35 who had postoperative whole pelvis radiation. A multifactorial analysis included time to recurrence, site of recurrence, treatment for recurrence, and survival after recurrence. Pathology review and clinicopathological correlation included tumor configuration, histologic type, size of tumor in greatest dimension, and rate of node metastases in patients undergoing either radical hysterectomy or surgical staging procedures. Lesion size was found to be the most accurate predictor of disease-free survival; this was true whether the patient was treated by surgery or radiation and was not significantly affected by the tumor histology. Nodal metastases were associated with increasing size of lesions and predicted high recurrence rates. Node metastasis rates were not affected by the histology of the tumor.

Correlation of perioperative morbidity and conization to radical hysterectomy interval

Between October 1969 and December 1980, radical hysterectomies were performed on 311 patients at the University of Alabama Medical Center in Birmingham. The hospital records of these patients were reviewed for perioperative morbidity. One hundred twenty-two patients (39.2%) had had previous cold knife conization. The conization to radical hysterectomy interval varied between 48 hours and 8 weeks. An analysis of the perioperative morbidity was performed comparing patients with to those without prior conization. Previous cervical conization, regardless of the interval, was not associated with increased hospital stay, operative time, blood loss, or febrile morbidity in patients undergoing radical hysterectomy. These findings suggest that a radical hysterectomy may be safely performed after cervical conization, regardless of the intervening interval.

Urinary diversion in patients undergoing pelvic exenteration

Between October, 1969, and April, 1981, gynecologic oncologists at the University of Alabama Medical Center in Birmingham have performed 119 pelvic exenterations. One hundred fifteen of these patients had a concurrent supravesical urinary diversion. Fifty-six patients (48.7%) had an anterior exenteration and 59 patients (51.3%) had a total exenteration. An ileal segment was used as a conduit in 97 patients while the segment of transverse colon was used in 16 patients. Two patients had sigmoid conduits. Eighty-five patients (73.9%) had the intestinal anastomosis and conduit constructed with gastrointestinal staplers. Stapler use shortened the mean operating time for the exenterative procedure by approximately 30%. No increase in postoperative gastrointestinal complications was noted. Urinary diversion preformed as part of a pelvic exenteration has been associated with short- and long-term complications. The use of ureteral stents and the gastrointestinal staplers shortens the procedure without predisposing the patient to major urologic complications. The use of a segment of unirradiated bowel (transverse colon) in conjunction with these techniques constitutes the preferred method of supravesical urinary diversion in patients undergoing a pelvic exenteration.

Cervical intraepithelial neoplasia associated with exposure to diethylstilbestrol in utero: a clinical and pathologic study

The anatomic, colposcopic, cytologic, and histologic findings of the cervix in 300 women exposed to diethylstilbestrol (DES) in utero are reported. Structural cervical abnormalities were found in 51.7% of these patients and an abnormal colposcopic examination was present in 50.6%. The initial interpretation of the pathologic specimens revealed that 26.6% of patients had cytologic or histologic evidence of cervical dysplasia. A uniform pathologic review demonstrated that 10.8% of the cytologic specimens and 37.5% of the histologic specimens had been overread by the initial pathologist. A correlation of the review cytology and histology revealed that the Papanicolaou smear sensitivity for the prediction of abnormal histology was 83.9% and specificity was 86.3%. The probability of an atypical cytologic finding predicting an abnormal histologic pattern was highly significant (P less than .00001). Colposcopic and structural cervical abnormalities were not predictive of an abnormal histologic diagnosis. Of the 18 patients (6%) with histologic evidence of mild-moderate dysplasia, 12 have been followed with no treatment, and cytologic and colposcopic examination has been normal. Marked dysplasia-carcinoma in situ was found in 14 patients (4.7%). Their therapy is summarized. These data strongly suggest that women exposed to DES may be followed safely with Papanicolaou smears and colposcopic examinations provided that both cytopathologists and colposcopists are cognizant of the metaplastic changes in the DES progeny that distinguish them from patients with cervical intraepithelial neoplasia (CIN) who were not exposed to DES. Biopsy should be performed only if indicated by cytologic atypia, colposcopic evidence of advanced CIN, or the presence of an invasive lesion.

Cryosurgery of cervical intraepithelial neoplasia

Nine hundred sixty-eight patients with cervical intraepithelial neoplasia (CIN) were evaluated with colposcopy and treated with cryosurgery; 722 had a pretreatment diagnosis of CIN I or II and 246 had CIN III. Of those patients available for 2 follow-up smears, histologically proved persistence of CIN was found in 10% of patients with CIN I and II and 20% of patients with CIN III. Recurrent disease was detected in 3.2 and 3.8%, respectively. No patients had a recurrence after 5 negative Papanicolaou smears. One patient had invasive carcinoma 30 months after treatment. Failure of patients to return for follow-up was a significant problem. When the present results were compared to those published in the literature, cryosurgery was found to be less effective than conization in treating CIN III.

Verrucous lesions of the female genitalia. I. Giant condylomata

Small condylomata acuminata are easily diagnosed clinically and are not often difficult to treat. Giant condylomata, however, can pose real problems in diagnosis and treatment. They must be distinguished from verrucous carcinomas or giant condylomata with squamous malignant change. Large biopsy specimens that include the stroma are necessary in order to make the correct diagnosis, since these entities have somewhat similar histologic features. Treatment should be surgical because radiation and podopyhyllum have both proved to be of little benefit. Surgical removal also allows excellent pathologic study to determine the presence of squamous malignant change or verrucous carcinoma.

Verrucous lesions of the female genitalia. II. Verrucous carcinoma

Verrucous carcinoma is a variant of squamous cell carcinoma that often presents as a large cauliflower-like lesion with locally destructive growth. A high index of suspicion on the part of the clinician and pathologist is needed for an accurate diagnosis since the pathologic findings may be benign on an individual cell basis or may even resemble those of a condyloma. Deep biopsy that includes the base of the lesion is needed for accurate histologic diagnosis, and the pathologist should be aware of the aggressive nature of the lesion. The treatment of choice is surgical, with wide local excision being sufficient in most cases. Radiotherapy often fails to eradicate the lesion and may even cause it to become more anaplastic.

The Swan-Ganz catheter and management of patients undergoing pelvic exenteration

A Swan-Ganz catheter has been used in 10 consecutive patients undergoing pelvic exenteration and has made the intraoperative and postoperative management of these patients a much easier task. Use of this catheter eliminates the guesswork involved in managing fluid and volume status by providing an accurate assessment of left ventricular end diastolic pressure. The complication rate is reported as 5% and consists mostly of ruptured balloons, infection, coiling of the catheter, and cardiac irritability. There have been no complications in the 10 patients in whom we have used the catheter. We believe that the use of the Swan-Ganz catheter in these difficult-to-manage patients is justified because of its low complication rate, easy use, and the accurate valuable information obtained.

Southern Regional Trophoblastic Disease Center, 1972--1977

The experience of the Southern Regional Trophoblastic Disease Center includes 222 patients who were referred from January 1972 to October 1977. The initial tissue diagnosis was hydatidiform mole in 212 patients and choriocarcinoma in ten. There was spontaneous remission of 142 (69%) of the moles and one of the choriocarcinomas, and 77 patients developed persistent trophoblastic disease. Of these, 58 had no evidence of metastasis, and all achieved remission with single-drug therapy. Nineteen patients developed metastases; 13 were in the "good prognosis" category, and all achieved remission with single-drug therapy. Five (83%) of the six patients with metastases in the "poor prognosis" group achieved remission with triple chemotherapy; one died of her disease.

Colposcopy or cervical conization? An economic comparison

Costs of colposcopic evaluation of patients with abnormal Papanicolaou smears versus evaluation by conization are compared. The average colposcopic evaluation costs $106, and the average conization costs $923.70. Additional savings ensue if a colposcopic diagnosis, rather than conization of the cervix, precedes a definitive hysterectomy. All criteria for an adequate colposcopic examination and tissue diagnosis must be met to make this comparison.

The significance of age in the colposcopic evaluation of women with atypical apanicolaou smears

As women age, atypical Papanicolaou smears are associated with more advanced cervical neoplasia. The woman under age 30 had less than one chance in a hundred of having invasive carcinoma if she has an atypical Papanicolaou smear, while the woman over age 60 has one chance in six of this finding. An atypical Papanicolaou smear does not necessarily mean neoplasia is present; 23% of the women evaluated for atypical smears had a negative evaluation, and this included women over age 60. Endocervical currettings containing neoplastic tissue frequently are seen after age 30 and may contribute significant information to the final diagnosis; stenosis of the endocervix, however, may prevent curettage in postmenopausal women. Diagnostic conizations of the cervix rarely are necessary prior to age 30 if colposcopic technics are used. The need for conizations increases by decade of age and is required in at least one-third of postmenopausal women evaluated initially by colposcopy.

Outpatient evaluation of patients with atypical Papanicolaou smears: contribution of endocervical curettage

A series of 603 patients referred with atypical Papanicolaou smears was evaluated by repeat smears, colposcopically directed cervical biopsies, and endocervical curettage. These techniques as a unit can establish an accurate outpatient diagnosis superior to any of these modalities used alone and comparable with findings in conization and hysterectomy specimens. Endocervical curettage has made a unique contribution to the evaluation of such patients; these curettings have allowed examination of tissue fragments and are more reliable in diagnosing neoplasia than are endocervical smears. Invasive carcinoma and its precursors confined to the anatomic endocervical canal can be recognized by this technique, and conversely the absence of neoplastic epithelium in adequate endocervical curettings rules out occult carcinoma. Indications for conization of the cervix are discussed in reference to the other biopsy and cytologic findings, and guidelines are presented for patient management, stressing clinicopathologic correlation and cooperation.

The contribution of endocervical smears to cervical cancer detection

Data from a Colposcopy Clinic have been presented in which endocervical and cervical smears were evaluated in singly and in combination for accuracy and effectiveness. In patients with marked dysplasia, carcinoma in situ and early invasive cancer, false negative results rarely occurred using either cervical or endocervical smears; more false negatives were encountered in the minimal to moderate dysplasia group of lesions. Endocervical smears were found to be unreliable in determining the distribution of cervical neoplasia when correlated with endocervical curettage specimens. These smears contributed little as supplemental screening procedures for early cervical neoplasia since less procedures for early cervical neoplasia since less than three per cent of lesions would have been missed had only a cervical scrape smear been performed. It should be pointed out, however, that this was a young population in which cervical eversion with exposure of endocervical tissue and the neoplastic lesions was the rule. The accuracy of endocervical aspiration and endocervical swab techniques was similar although there was a much higher proportion of unsatisfactory specimens with the dry cotton swab technique.