Randomized control trial comparing hygroscopic cervical dilators to cervical ripening balloon for outpatient cervical ripening

BACKGROUND

Outpatient term preinduction cervical ripening with mechanical agents has been associated with reduced length of stay, decreased cesarean delivery rates, low maternal and neonatal complications, and increased incidence of vaginal delivery within 24 hours.

OBJECTIVE

This study aimed to demonstrate equivalent efficacy between synthetic hygroscopic dilators and the single-balloon catheter for outpatient cervical ripening.

STUDY DESIGN

This randomized control equivalence trial compared synthetic hygroscopic dilators with the 30-mL silicone single-balloon catheter in primiparous and multiparous patients undergoing labor induction. The primary outcome was time from admission to delivery, with a prespecified 3-hour margin of equivalence. The secondary objectives were patient outcomes and perspectives.

RESULTS

Between March 1, 2019, and May 31, 2021, 1605 patients met the screening criteria, and 174 patients completed the study. The mean admission-to-delivery time was equivalent at 18.01 hours for the dilator group vs 17.55 hours for the balloon group (P=.04). The cesarean delivery rate of primiparous patients was similar at 28.1% with dilators vs 29.7% with the balloon. The groups had similar median cervical dilation and pain scores on insertion and admission. Overall patient satisfaction was high, 92.8% with dilators vs 96.2% with the balloon. The balloon group had significantly higher rates of early admission and device expulsion.

CONCLUSION

Although the enrollment goal was not met, our study suggests that synthetic hygroscopic dilators and the single-balloon catheter for outpatient cervical ripening are both efficacious with similar time from admission to delivery, pain scores, and patient satisfaction with the procedure.

Novel characterization of CASK variant c.1963 A>G (p.Asn655Asp) through whole-exome sequencing in a monochorionic diamniotic twin fetus with significant brain anomalies: A case report

Whole-exome sequencing is an evolving technology in perinatal diagnosis which allows identification of genetic etiologies that would otherwise go undetermined. In this case report, a 38-year-old Hispanic woman, G5P3013, with a monochorionic diamniotic twin gestation with one fetus displaying significant cranial abnormalities on prenatal ultrasound and magnetic resonance imaging (MRI) of the brain is presented. Fetal anomalies included bilateral ventriculomegaly, absent cavum septum pellucidum, and absent corpus callosum. Diagnostic amniocentesis with chromosome analysis, chromosomal microarray, alpha-fetoprotein, cytomegalovirus, toxoplasmosis, and parvovirus had normal results. Whole-exome sequencing for the anomalous fetus detected a de novo mosaic variant of uncertain significance (VUS) in the calcium/calmodulin dependent serine protein kinase (CASK) gene: c.1963 A > G (p.Asn655Asp). This variant was absent in the normal twin fetus, the mother, and the father. Pathogenic CASK gene mutations are associated with three syndromes: FG syndrome 4, intellectual developmental disorder and microcephaly with pontine and cerebellar hypoplasia (MICPCH), and intellectual developmental disorder with or without nystagmus. Whole-exome sequencing identified a potential etiology for the anomalies detected. The variant likely arose de novo and was the potential cause of the identified cranial abnormalities in one fetus of this monochorionic diamniotic twin gestation. Whole-exome sequencing may provide additional diagnostic utility when standard diagnostic testing is noncontributory.

Importance of the Third Trimester Complete Blood Count: A Case Report on Aplastic Anemia in Pregnancy

Aplastic anemia (AA) poses a significant threat to maternal and fetal health throughout the perinatal period. Diagnosis is based on complete blood count (CBC) and bone marrow biopsy with treatment varying based on severity of disease. This report highlights a case of AA incidentally identified by the third trimester CBC drawn in the outpatient office. Patient was referred for inpatient management to mobilize a multidisciplinary team of healthcare professionals including obstetricians, hematologists, and anesthesiologists to optimize maternal and fetal outcome. The patient received blood and platelet transfusions prior to delivering a healthy liveborn infant by cesarean section. This case highlights the importance for routine third trimester CBC screening to identify potential complications and decrease maternal and fetal morbidity and mortality.

903 React! – An Aide Memoire to Guide Management of Extravasation Injuries

Introduction

Intravenous infusions are common practice but come with the risk of extravasation injury. Although overall incidence is low, in those undergoing chemotherapy and in children the risk is much greater (4.7% and 11-58% respectively). These injuries can have severe consequences ranging from skin necrosis to loss of function, some necessitating complex reconstruction. Prompt recognition and treatment reduces the chance of these outcomes. Whilst classically managed by plastic surgeons, many hospitals do not have such services locally. Time-delays introduced by remote referral or inadequate initial treatment result in poor outcomes. We describe a simple algorithm with accompanying video designed to enable confident immediate management.

Method

We devised a simple acronym describing the basic steps, based on the technique described by Gault. Accompanied by an instructional video demonstrating the technique they form a simple to follow guide.

Results

The initial treatment of an extravasation injury can be split into the following key steps:

These steps, detailed in a simple poster, sit alongside a descriptive video which could be accessed through hospital intranets and video publishing platforms, such as Youtube and Vimeo, can allow potential users access on their portable devices.

Conclusions

The combination of the REACT! acronym and video provides an example of an easy-to-use teaching tool, when combined with local training, could improve the initial management of extravasation injuries in hospitals where plastic surgery input is not immediately available, reducing poor outcomes.

Software-guided insulin dosing improves intrapartum glycemic management in women with diabetes mellitus

BACKGROUND

During labor, maintenance of maternal euglycemia is critical to decrease the risk of neonatal hypoglycemia and associated morbidities. When continuous intravenous insulin infusion is needed, standardized insulin dosing charts have been used for titration of insulin to maintain glucose in target range. The GlucoStabilizer software program (Indiana University Health Inc, Indianapolis, IN) is a software-guided insulin dosing system that calculates the dose of intravenous insulin that is needed based on metabolic parameters, target glucose concentration, and an individual's response to insulin. Although this tool has been validated and shown to reduce both hypoglycemia and errors in critical care settings, the utility of this software has not been examined in obstetrics.

OBJECTIVE

The purpose of this study was to determine whether the use of intravenous insulin dosing software in women with pregestational or gestational diabetes mellitus that requires intrapartum insulin infusion can improve the rate of glucose concentration in target range (70-100 mg/dL; 3.9-5.5 mmol/L) at the time delivery.

STUDY DESIGN

We performed a retrospective cohort study comparing laboring patients with diabetes mellitus that required insulin infusion who were dosed by standard insulin dosing chart vs the GlucoStabilizer software program from January 2012 to December 2017. The GlucoStabilizer software program, which was implemented in May 2016, replaced the standard intravenous insulin dosing chart. Inclusion criteria were women with pregestational or gestational diabetes mellitus who were treated with an intravenous insulin infusion intrapartum for at least 2 hours. Maternal characteristics, glucose values in labor, and neonatal outcomes were extracted from delivery and neonatal records. The primary outcome was the percentage of women who achieved the target glucose range (defined as a blood glucose between 70-100 mg/dL; 3.9-5.5 mmol/L) before delivery. Parametric and nonparametric statistics were used to compare both groups; a probability value of <.05 was considered statistically significant.

RESULTS

We identified 22 patients who were dosed by a standard insulin dosing chart and 11 patients who were dosed by the GlucoStabilizer software program during intrapartum management. The GlucoStabilizer software program was superior in achieving glucose values in target range at delivery (81.8% vs 9.1%; P<.001) compared with standard insulin dosing without increasing maternal hypoglycemia (0% vs 4.3%; P=.99). Patients whose insulin dosing was managed by the GlucoStabilizer software program also had lower mean capillary blood glucose values compared with the standard insulin infusion (102.9±5.9 mg/dL [5.7±0.33 mmol/L] vs 121.7±5.9 mg/dL [6.8±0.33 mmol/L]; P=.02). Before the initiation of the infusion, both groups demonstrated mean capillary blood glucose values outside of target range (122.6±8.8 mg/dL [6.7±0.49 mmol/L] for the GlucoStabilizer software program vs 131.9±10.1 mg/dL [7.3±0.56 mmol/L] for standard insulin treatment group; P=not significant). There were no significant differences in baseline maternal characteristics between the groups or neonatal outcomes.

CONCLUSION

This study is the first to demonstrate that the use of software-guided intravenous insulin dosing in obstetrics can improve intrapartum glycemic management without increasing hypoglycemia in women with both pregestational and gestational diabetes mellitus that is treated with an insulin infusion.

Second trimester marginal cord insertion is associated with adverse perinatal outcomes

Objectives: To determine the feasibility in visualizing placental cord insertion (PCI) during second-trimester fetal anatomical survey and the association between marginal cord insertion (MCI) and preterm delivery (PTD) and low birth weight (LBW). Our secondary objectives were to evaluate the association of MCI with adverse composite obstetrical and neonatal outcomes. Methods: A prospective cohort study was performed over a 28-month period. Women with singleton pregnancies presenting for routine anatomical survey between 18 and 22 weeks' gestation were included. PCI site was visualized on 2D grayscale and color Doppler and the shortest distance from the sagittal and transverse planes to the placental edge were recorded. MCI was diagnosed when any of measured distances was ≤2 cm. Correlations were assessed via bivariate chi-squared, independent t-test analyses and Fisher's exact tests. Regression models evaluated associations between MCI and adverse composite outcomes. Results: Three hundred one women were included and PCI was feasible in all cases. The incidence of MCI was 11.3% (n = 34). Baseline characteristics between those with and without MCI were similar, except for story of prior PTD, which was greater among those with MCI (17.65 versus 7.17%, p = .04). MCI was associated with increased likelihood of LBW (RR four; 95%CI, 1.46-10.99) and PTD (RR 3.2; 95%CI, 1.53-6.68); in multivariate analysis, we found associations between MCI and composite adverse obstetrical (RR 2.33; 95%CI, 1.30-4.19) and neonatal (RR 2.46; 95%CI, 1.26-4.81) outcomes. Conclusions: Evaluation of PCI is feasible in all cases. Second-trimester MCI is associated with increased likelihood for LBW, PTD, and composite adverse obstetrical and neonatal outcomes.

Immediate Postpartum Glucose Tolerance Testing in Women with Gestational Diabetes: A Pilot Study

Objective Due to poor adherence for glucose testing at 6- to 12-week postpartum among women with gestational diabetes, we sought to determine whether a 2-hour glucose tolerance test (GTT) during postpartum hospitalization is predictive of 6- to 12-week postpartum glucose testing.

Study Design An institutional review board–approved prospective cohort study was performed over 3 years. Patients underwent an inpatient fasting 75-g, 2-hour GTT on either postpartum days 2 through 4 and instructed to follow up in 6- to 12-weeks for postpartum glucose testing. Sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV) of the immediate GTT to predict abnormal 6- to 12-week postpartum glucose testing were determined.

Results Eighty women enrolled in the study completed the immediate GTT; of these, only 35 (44%) underwent 6- to 12-week postpartum glucose testing. The sensitivity, specificity, PPV, and NPV of the immediate GTT were 100, 42.8, 30.4, and 100%, respectively.

Conclusion More than 50% of our study patients did not undergo recommended postpartum glucose testing, coinciding with similar poor follow-up reported in the literature. With a high NPV and high sensitivity, a negative immediate GTT may obviate the need for the 6- to 12-week GTT, while a positive GTT may identify women who should follow up closely.

Down-regulation of placental neuropilin-1 in fetal growth restriction

BACKGROUND

Fetal growth restriction (FGR) is associated with adverse outcomes extending from fetal to adult life, and thus, constitutes a major health care challenge. Fetuses with progressive growth restriction show increasing impedance in the umbilical artery flow, which may become absent during end-diastole. Absent end-diastolic flow (AEDF) is associated with adverse perinatal outcomes including stillbirths and perinatal asphyxia. Placentas from such pregnancies demonstrate deficient fetoplacental vascular branching. Current evidence, moreover, indicates an antiangiogenic state in maternal circulation in several pregnancy complications including preeclampsia, small-for-gestational-age births, fetal death, and preterm labor. The angiogenic mediators in maternal circulation are predominantly of placental origin. Information, however, on the role of specific proangiogenic and antiangiogenic mechanisms operating at the placental level remains limited. Elucidation of these placenta-specific angiogenic mechanisms will not only extend our understanding of the causal pathway for restricted fetal growth but may also lead to the development of biomarkers that may allow early recognition of FGR.

OBJECTIVE

We sought to test the hypothesis that fetoplacental angiogenic gene expression is altered in pregnancies complicated with FGR and umbilical artery Doppler AEDF.

STUDY DESIGN

Placental samples were collected from FGR pregnancies complicated with umbilical artery Doppler AEDF (study group, n = 7), and from uncomplicated pregnancies (control group, n = 7), all delivered by cesarean during the last trimester of pregnancy. Angiogenic oligonucleotide microarray analysis was performed and was corroborated by quantitative real-time polymerase chain reaction, Western blot analysis, and immunohistochemistry. The Student t test with Bonferroni correction was used with P < .05 considered statistically significant. Independent groups t test was used to analyze the immunostain intensity scores with a P < .05 considered statistically significant.

RESULTS

Our microarray results showed that among several differentially expressed angiogenic genes in the growth-restricted group, only the down-regulation of neuropilin (NRP)-1 was most significant (P < .0007). Quantitative real-time polymerase chain reaction confirmed a significantly lower NRP-1 gene expression in the FGR group than in the control group (mean ± SD (ˆ)cycle threshold: 0.624 ± 0.55 and 1.325 ± 0.84, respectively, P = .04). Western blot validated significantly lower NRP-1 protein expression in the FGR group than in the control group (mean ± SD NRP-1/β-actin ratio: 0.13 ± 0.04 and 0.34 ± 0.05, respectively, P < .001). Finally, immunohistochemistry of placental villi further corroborated a significantly decreased expression of NRP-1 in the FGR group (P = .006).

CONCLUSION

The study demonstrated significant down-regulation of placental NRP-1 expression in FGR pregnancies complicated with AEDF in umbilical artery. As NRP-1 is known to promote sprouting angiogenesis, its down-regulation may be involved in the deficient vascular branching observed in FGR placentas suggesting the presence of an antiangiogenic state. Further studies may elucidate such a causal role and may lead to the development of novel diagnostic and therapeutic tools.

Diabetes, antidiabetic medications, and pancreatic cancer risk: an analysis from the International Pancreatic Cancer Case-Control Consortium

BACKGROUND

Type 2 diabetes mellitus has been associated with an excess risk of pancreatic cancer, but the magnitude of the risk and the time-risk relationship are unclear, and there is limited information on the role of antidiabetic medications.

PATIENTS AND METHODS

We analyzed individual-level data from 15 case-control studies within the Pancreatic Cancer Case-Control Consortium, including 8305 cases and 13 987 controls. Pooled odds ratios (ORs) were estimated from multiple logistic regression models, adjusted for relevant covariates.

RESULTS

Overall, 1155 (15%) cases and 1087 (8%) controls reported a diagnosis of diabetes 2 or more years before cancer diagnosis (or interview, for controls), corresponding to an OR of 1.90 (95% confidence interval, CI, 1.72-2.09). Consistent risk estimates were observed across strata of selected covariates, including body mass index and tobacco smoking. Pancreatic cancer risk decreased with duration of diabetes, but a significant excess risk was still evident 20 or more years after diabetes diagnosis (OR 1.30, 95% CI 1.03-1.63). Among diabetics, long duration of oral antidiabetic use was associated with a decreased pancreatic cancer risk (OR 0.31, 95% CI 0.14-0.69, for ≥15 years). Conversely, insulin use was associated with a pancreatic cancer risk in the short term (OR 5.60, 95% CI 3.75-8.35, for <5 years), but not for longer duration of use (OR 0.95, 95% CI 0.53-1.70, for ≥15 years).

CONCLUSION

This study provides the most definitive quantification to date of an excess risk of pancreatic cancer among diabetics. It also shows that a 30% excess risk persists for more than two decades after diabetes diagnosis, thus supporting a causal role of diabetes in pancreatic cancer. Oral antidiabetics may decrease the risk of pancreatic cancer, whereas insulin showed an inconsistent duration-risk relationship.

A novel approach to teaching placement of a B-lynch suture: description of technique and validation of teaching model

INTRODUCTION

Postpartum hemorrhage is a major cause of maternal morbidity and mortality throughout the world and uterine atony is the leading cause of postpartum hemorrhage. The B-Lynch brace suture is a fertility-sparing approach to treating intractable uterine atony at the time of cesarean delivery. However, many obstetricians lack confidence to perform this procedure, which they may not have performed during residency. In order to train all residents to perform the B-Lynch brace suture, we developed a realistic model by using a flank steak to imitate a gravid uterus.

METHODS

A convenience sample of obstetrics-gynecology faculty and residents at different levels of training at a single large hospital participated in this pilot project. Each physician reported self-perceived understanding of and confidence in performing the B-Lynch procedure before and immediately after practicing the technique using the flank-steak model, via a Likert-type survey (scale 1  =  low, 5  =  high). A Wilcoxon matched-pairs signed rank test was used to compare the before and after responses.

RESULTS

Thirty-four participants completed the flank-steak model training and pretraining/posttraining surveys. The median score (range) for self-perceived understanding was 4 (2-5) and increased to 5 (4-5) (P < .01) after exposure to the training model. The confidence scores rose from 3 (1-5) to 5 (4-5) (P < .01) after training.

CONCLUSION

The flank-steak model for teaching the B-Lynch suture significantly improved resident and faculty self-perceived understanding of and confidence in performing this procedure, which is otherwise rarely practiced in residency.

Materials science. The hardest known oxide

A material as hard as diamond or cubic boron nitride has yet to be identified, but here we report the discovery of a cotunnite-structured titanium oxide which represents the hardest oxide known. This is a new polymorph of titanium dioxide, where titanium is nine-coordinated to oxygen in the cotunnite (PbCl2) structure. The phase is synthesized at pressures above 60 gigapascals (GPa) and temperatures above 1,000 K and is one of the least compressible and hardest polycrystalline materials to be described.

K-ras oncogene mutation as a prognostic marker in non-small cell lung cancer: a combined analysis of 881 cases

The treatment of non-small cell lung cancer (NSCLC) remains unsatisfactory, with most patients succumbing to metastatic disease within 5 years of diagnosis. Improved selection of patients for aggressive adjuvant therapy may contribute to improved survival. Mutation of the k-ras oncogene is considered a potentially clinically useful prognostic biomarker for this purpose. This report presents the results of a meta-analysis performed to determine whether the existing data support such a role for k-ras mutations in NSCLC. Two year survival data derived from 881 NSCLC patients in eight published studies were analyzed using a general variance-based meta-analytical method employing confidence intervals. The outcome of interest was a summary relative risk (RR(s)) reflecting the risk of death at 2 years associated with k-ras mutation-positive versus k-ras mutation-negative disease. Prior to calculation of RR(s), analysis for heterogeneity showed Q to equal 15.52 (7 df, P = 0.03). This indicated heterogeneity across the analyzed studies in terms of their estimate of effect. Possible sources of heterogeneity were identified and included selection bias and various other sources of uncontrolled confounding. Although a RR(s) of 2.35 (95% CI = 1.61-3. 22) was found when all eight studies were combined (favoring a negative prognostic role for k-ras mutation), it is unclear whether the magnitude of the RR(s) would persist after adjusting for other well-established prognostic indicators (e.g. stage). The existing data suggest that k-ras mutation may be associated with shortened survival in NSCLC, although this finding awaits confirmation in well-designed multivariate analyses which adjust for the effect of known prognostic indicators.

Multi-drug versus single agent chemotherapy for high grade astrocytoma; results of a meta-analysis

BACKGROUND

The addition of chemotherapy to postoperative radiation therapy in the treatment of high grade astrocytoma results in a modest increase in 12 and 24 month survival. It is, at present, unclear whether single agent or combination drug therapy constitutes the best drug regimen for these patients. Despite this uncertainty, multi-drug regimens have become standard therapy for some high grade astrocytomas.

METHODS

One year survival data derived from over 2,100 patients enrolled in 9 randomized clinical trials were analyzed using the meta-analytic techniques previously described by Peto et al. This analysis compared the proportion of patients surviving one year treated with multi-drug regimens versus single agent treatment (usually BCNU). All patients included in this analysis also underwent surgery and radiation therapy as part of their clinical management.

RESULTS

A summary odds ratio was calculated following a statistical analysis showing a lack of heterogeneity among the included studies in terms of their estimate of effect. The calculated Peto odds ratio was 1.22 with a 95% confidence interval of 0.99-1.36. These data indicate that combination drug treatment is associated with an approximately 22% decreased 1 year survival as compared with single agent therapy.

CONCLUSION

This analysis suggests that the available data do not support the use of combination chemotherapy regimens in this patient population. Additional randomized clinical trials are needed to clearly determine whether any multidrug treatment scheme is superior to currently available single agent therapies.

Planned preoperative radiation therapy in muscle invasive bladder cancer; results of a meta-analysis

BACKGROUND

The role of pre-operative radiation therapy in the treatment of muscle invasive bladder cancer is unclear. The objective of this report is to present a meta-analysis of the published clinical trial data on this topic to determine whether pre-operative radiation improves survival in patients with this disease.

METHODS

Data from 5 randomized trial were pooled using the meta-analytic techniques previously described by Peto et al. Three and five year survival were compared between patients receiving pre-operative radiation therapy followed by cystectomy versus patients treated with cystectomy alone.

RESULTS

A summary odds ratio was calculated following a statistical analysis showing a lack of heterogeneity among the included studies in terms of their estimate of effect. The calculated Peto odds ratio was 0.71 favoring the use of preoperative radiation (95% CI 0.48-1.06). Due to possible biases in this original analysis due to study design deficiencies, a sensitivity analysis showed a "corrected" odds ratio of 0.94 with a 95% confidence interval of 0.57- 1.55, a non-statistically significant result.

CONCLUSION

The available clinical trial data do not support a role for routine use of pre-operative radiation therapy in the treatment of muscle invasive bladder cancer. Additional well designed trials are needed to address this issue.

Treatment of recurrent high grade astrocytoma; results of a systematic review of 1,415 patients

OBJECTIVE

The optimum treatment strategy for recurrent high grade glioma (anaplastic astrocytoma and glioblastoma multiforme) remains undefined. The objective of this report is to present a systematic analysis of the published clinical trial literature on the therapy of this disease.

METHODS

A study protocol was prospectively developed outlining the objectives and methods of the analysis such as; literature search strategy, eligibility criteria for published trials to be included, key data elements to be extracted, and a plan for statistical analysis. Variables of interest were, those describing key features of the study such as publication date and geographic location of reporting institution, characteristics of study population including functional status, details of patient treatment, treatment sequencing and data on clinical outcomes of interest, i.e. time to tumor progression and overall survival. Data were analyzed using SAS version 6.11. Summary statistics were calculated for the primary outcome variables. Data on recognized prognostic variables were recorded in order to adjust the analysis for these parameters.

RESULTS

A total of 40 trials (36 non-randomized controlled trials; nRCTs and 4 randomized controlled trials: RCTs) were included in the analysis. Thirty-two of the eligible trials were chemotherapy trials while 7 were radiation therapy trials. One surgical trial met eligibility criteria. A total of 47 treatment arms were analysed which included 1,415 patients. Five chemotherapy groups were studied, i.e. interferons, nitrosoureas, platinums, platinums + nitrosoureas and others. The nitrosoureas were found to significantly extend time to tumor progression compared to all other drugs (26.9 weeks). The nitrosoureas and platinums appear to be the most active agents with regard to overall survival (over 32.0 weeks) as compared with the other drug categories. Patients treated with both a nitrosourea and a platinum compound showed the longest overall survival (40.0 weeks) although this was not significantly different from these drugs used as single agents. Average median survival for patients treated with radiation therapy was 44.7 weeks although selection bias makes these data difficult to compare with those derived from studies of chemotherapy. No definite conclusions can be made regarding surgical therapy in this setting due to limited data.

CONCLUSIONS

The nitrosoureas and platinums, either as single agents or as combination chemotherapy, appear to be the most active agents in this disease although few, well designed chemotherapy trials are available for analysis. Due to the limitations of the available data on radiation therapy and surgery, as outlined in this report, additional, well designed clinical trials are needed to define the appropriate role for these modalities in the treatment of recurrent high grade glioma.

Serum prostate-specific antigen as a predictor of staging abdominal/pelvic computed tomography in newly diagnosed prostate cancer

BACKGROUND

The standard staging evaluation for prostate cancer includes digital rectal examination, measurement of serum tumor markers, and radionuclide bone scan. In many institutions, abdominal/pelvic computed tomography (CT) scan or nuclear magnetic resonance imaging (MRI) is performed. We retrospectively reviewed 425 cases of newly diagnosed, untreated adenocarcinoma of the prostate to evaluate the ability of serum prostate-specific antigen (PSA) to predict results of staging abdominal pelvic CT.

METHODS

The medical records of 425 newly diagnosed, untreated prostate cancer patients were reviewed. The following information was collected on a standard data form: age, clinical stage based on digital rectal exam, method of diagnosis, histological grade, serum PSA level, and results of abdominal pelvic CT including adenopathy and abnormalities of the upper urinary tract. The results of this review were tabulated and analyzed with regard to the ability of serum PSA level to predict positive results of abdominal pelvic CT.

RESULTS

The mean PSA level of the study group was 22.1 ng/ml. Fourteen patients (3.6%) presented with a positive abdominal/pelvic CT (12 with adenopathy, one with a renal cell tumor, and one with an adrenal metastasis). Eleven of these (79%) had serum PSA levels of 30.0 ng/ml or greater, ranging from 30.0 to 234 ng/ml. No patient with a positive study presented with a normal serum PSA level. Two patients with a positive study had a serum PSA level between 4.1 and 10.0 ng/ml (0.6%), and one had a PSA level between 10.1 and 20 ng/ml (0.3%).

CONCLUSION

We conclude that in asymptomatic patients with newly diagnosed, untreated prostate cancer and serum PSA levels of less than 20 ng/ml the likelihood of positive findings on abdominal/pelvic CT is extremely low (<1.0%). Abdominal/pelvic CT does not appear necessary in this setting. With 200,000 cases of newly diagnosed prostate cancer each year in the United States, elimination of staging abdominal/pelvic CT in these patients could reduce medical expenditures for prostate cancer management by $20-50 million per year.

Treatment and survival in diffuse malignant pleural mesothelioma; a study of 83 cases from the Massachusetts General Hospital

The influence of treatment on clinical outcome in pleural mesothelioma (PM) is uncertain. We studied 83 patients with PM treated at our institution to evaluate the impact of treatment modality on survival, Methods. Medical records of 83 patients with PM treated between 1978 and 1994 were reviewed. The following data were tabulated for each patient; age, sex, date of diagnosis, history of asbestos exposure, smoking history, method of diagnosis, histologic subtype, type of treatment and survival from diagnosis. Four treatment groups were analyzed; chemotherapy (C), surgery (S), combined modality (CM i.e. S + C with or without radiation therapy) and supportive care alone (SC). Survival curves were calculated and adjustment made for age. Survival curves were compared using Wilcoxon Chi-square analysis. Results. Seventy-one males and 12 females with a mean age of 67 years were analyzed. Seventy-five percent were smokers and 74% reported definite or probable asbestos exposure. Treatment groups did not vary according to smoking or asbestos history. The CM group and SC groups contained similar proportions of patients with epithelial tumors (54% v 56%). Median survival for patients in the CM group was 23.9 months versus 4.5 months among those receiving SC (p < 0.01). Discussion. This analysis suggest prolonged survival among patients with PM receiving CM versus SC or single modality treatment.

Parental cancer and genetic predisposition in malignant pleural mesothelioma: a case-control study

Familial clustering of pleural mesothelioma (PM) has been previously reported suggesting that genetic factors (predisposition) may be involved in PM. We studied parental cancer history in a cohort of 39 cases of PM and 259 age matched controls to assess the possible influence of family history on PM risk. Cases consisted of 39 patients with PM treated at our institution between 1978 and 1993. An age frequency matched control group (by 5-year age groups) consisted of 259 subjects who were spouses or friends of patients undergoing resection of primary lung cancer. Data were obtained by interview of controls and interview of the patient or next of kin (usually spouse) for cases. The following data were obtained using a standard questionnaire and medical record review; age, sex, date of diagnosis, history of asbestos exposure, smoking history, method of diagnosis, histologic subtype, type of treatment, parental cancer history and tumor type. Cases and control frequency of parental cancer and site specific tumor frequency were compared using chi-square analysis. Twenty-eight (71%) cases reported a parental history of cancer versus 114 (44%) in the control group (P<0.01). Gastrointestinal malignancies were the predominant tumor type among parents of cases, i.e. 11 cases (40%) versus 25% of controls (P<0.01). No other tumor site showed an increased frequency among cases. These data suggest a possible role for family history in the development of PM. Genetic predisposition may be important in the etiology of this tumor.

Genetic characteristics of prostate cancer

Prostate cancer is the most commonly diagnosed malignancy in united States males. Unfortunately, numerous controversies surround clinical management for early stage disease and the utility of population screening. Much of this controversy stems from the lack of knowledge about the biology of prostate cancer, including the lack of clearly defined risk factors, absence of markers indicative of aggressive clinical behavior, as well as a lack of a clear understanding of its underlying genetic features. This paper reviews currently available evidence regarding the genetic characteristics of adenocarcinoma of the prostate, including the impact of family history of disease risk, the nature of structural genetic aberrations, and the possible role of oncogenes and tumor suppressor genes in its pathogenesis. A clearer understanding of these issues will hopefully lead to more effective and rational treatment policies in addition to the development of effective disease prevention strategies.

Small cell carcinoma of the esophagus. The Massachusetts General Hospital experience, 1978 to 1993

Thirteen patients with small cell carcinoma of the esophagus were treated at the Massachusetts General Hospital between 1978 and 1993. These patients accounted for 1.6% of all patients with esophageal neoplasms seen at our institution during this period. Five patients presented with extensive disease while eight were noted to have limited disease at diagnosis. Seven patients were treated with primary chemotherapy while four patients received radiation therapy alone. No patient in this series underwent surgical resection. Four complete responses to treatment were observed although overall survival was only 7 months. One patient receiving chemotherapy, external beam radiation therapy, and endoesophageal brachytherapy is alive and well without evidence of disease 24 months from diagnosis.

Serum prostate-specific antigen as a predictor of radiographic staging studies in newly diagnosed prostate cancer

The standard staging evaluation of prostate cancer includes digital rectal examination, measurement of serum tumor markers, radionuclide bone scan, and abdominal pelvic computed tomography (CT) or nuclear magnetic resonance imaging (MRI). We retrospectively reviewed 300 cases of newly diagnosed, untreated adenocarcinoma of the prostate to evaluate the ability of serum prostate-specific antigen (PSA) to predict results of staging radiographic studies (bone scan, CT/MRI). The medical records of 300 newly diagnosed, untreated prostate cancer patients were reviewed. The following information was collected on a standard data form: age, clinical stage based on digital rectal examination, method of diagnosis, histological grade, serum PSA level, results of radionuclide bone scan and additional radiographic studies to confirm bone scan results, results of abdominal pelvic CT/MRI, and presence or absence of bone pain. The results of this review were tabulated and analyzed with regard to the ability of serum PSA level to predict positive results of radiographic staging studies. The mean PSA level of the study group was 24.6 ng/ml. Ten patients (3.6%) presented with positive bone scan results with 5 of these having serum PSA levels greater than 20 ng/ml (range 27.6 ng/ml-144 ng/ml, mean 66.3 ng/ml). The 5 remaining patients all had elevated PSA levels ranging between 4.1 and 20.0 ng/ml. No patient with a positive staging bone scan presented with a normal serum PSA. Ten patients (4.0%) presented with a positive abdominal/pelvic CT/MRI (adenopathy only; no patients had radiographic evidence of abnormalities of the upper urinary tract). Eight had serum PSA levels greater than 20 ng/ml, ranging from 30.0 to 234 ng/ml. No patient with a positive study presented with a normal serum PSA level. No patient with either positive bone scan or abdominal pelvic CT/MRI presented with bone pain. We conclude that in asymptomatic patients with newly diagnosed, untreated prostate cancer and serum PSA levels of less than 10 ng/ml, a staging radionuclide bone scan may not be necessary. Likewise, in patients with serum PSA levels of less than 20 ng/ml the likelihood of positive findings on abdominal/pelvic CT/MRI is extremely low. Abdominal/pelvic CT/MRI does not appear necessary in this setting. With over 130,000 cases of newly diagnosed prostate cancer each year in the United States, elimination of staging radiographic studies in the patients outlined above could result in economic savings on the order of 30-80 million dollars per year.

Vitamin supplement use in a hospital-based population

Vitamin supplement histories were taken from a sample of approximately 3,600 individuals (2,461 men and 1,181 women) from a hospital-based population. Multivitamin preparations were the most commonly used vitamin supplements (32% of men, 37% of women) followed by vitamins C (men 11%; women 16%) and E (men 17%; women 23%). The most common combination of supplements among the multi-users was vitamins C and E. Vitamin supplement use was positively associated with education in both sexes. Among women, there was a negative association between vitamin supplement consumption and Quetelet Index. No association was found between vitamin use and smoking status or alcohol use or amount of alcohol consumed.

Metastatic laryngeal carcinoma mimicking pleural mesothelioma

We describe an unusual case of metastatic poorly differentiated laryngeal carcinoma to the pleura resembling pleural mesothelioma in a patient with a positive history of exposure to asbestos. This case not only describes an unusual presentation of metastatic laryngeal carcinoma, but also highlights the need for special pathological techniques to distinguish nonmesothelial tumors from primary pleural mesotheliomas.