Postoperative pelvic irradiation in early stage uterine mixed mullerian tumors

PURPOSE OF INVESTIGATION

To review our management experience with uterine mixed mullerian tumors (MMTs) in order to evaluate potential prognostic indicators, and assess the efficacy of various treatment modalities.

METHODS

A retrospective, clinicopathologic evaluation of 43 patients presenting for treatment of uterine MMTs between 1982 and 1992 was conducted. Diagnostic criteria for inclusion was the presence of both a malignant glandular or squamous epithelial component, and a homologous or heterologous stromal component.

RESULTS

Overall 2- and 5-year cancer related Kaplan-Meier survival estimates with 95% confidence intervals were 44 (.28, .59) and 26% [.12, .39], respectively. Survivals were 83 [.62, .99] and 58% [.31, .85] when disease was confined to the uterus, and 22 [.03, .41] and 7% [.01, .20] when disease extended beyond the uterus. Clinical staging was often inaccurate, with 29% of clinical stage I or II disease being upstaged at laparotomy. A significant survival advantage was found in patients with stage I or II disease treated with surgery plus pelvic irradiation (p = 0.001), as compared to those treated with surgery alone. The prognosis after disease recurrence was poor, irrespective of secondary therapy, with a median survival of 11 months.

CONCLUSIONS

A therapeutic advantage may be gained from postoperative pelvic irradiation in the treatment of surgical stage I or II uterine MMT.

Transrectal and transperineal sonography during guided intrauterine procedures

Transrectal sonography was used to provide intraoperative guidance for dilatation and curettage and placement of intrauterine tandem apparatus in 20 patients in whom the external cervical os could not be visualized adequately. Transrectal sonography was found to be useful in providing guidance for these procedures and at the same time helped avoid uterine perforation. This method also was used during cerclage placement in two patients who had undergone several conizations. Transperineal sonography was used in three patients whose area of abnormality was best approached transperineally. These cases included transvaginal biopsy of a metastatic trophoblastic tumor and one guided aspiration of a perirectal abscess after pelvic exenteration. The potential advantages and pitfalls in the intraoperative use of transrectal and transperineal sonography for guided intrauterine procedures are discussed and illustrated.

Surgical failures in the management of pelvic floor relaxation

There are a vast number of operations for the correction of symptomatic pelvic floor relaxation, and the pelvic surgeon is faced with a difficult task in selecting the most appropriate procedure(s) for an individual patient. A successful outcome not only depends on the surgeon's skill and operative technique, but also relies heavily on the preoperative recognition and evaluation of factors related to surgical failure. Most importantly, careful attention to all components of the pelvic floor will allow the surgeon to tailor an operation to the individual's particular needs. Awareness of the many pitfalls of pelvic reconstructive surgery should lead to the appropriate preoperative evaluation and patient counseling, thus ensuring the best opportunity for a favorable outcome.

Salvage carboplatin therapy for advanced ovarian cancer after first-line treatment with cisplatin

From April 1989 to August 1990, 17 patients with Stage 3 or 4 epithelial ovarian cancer (EOC) were treated with intravenous carboplatin (160-400 mg/m2) for refractory or recurrent disease after first-line treatment with cisplatin-based combination chemotherapy. Of fifteen patients evaluable for activity, two complete responses and two partial responses were seen, for a response rate of 27%. The duration of response was 4.5, 5, 8, and 9.2 months, respectively, and responders survived longer than nonresponders. Of the nine evaluable patients receiving carboplatin as the first salvage treatment, four responses were seen. Dose selection for the first cycle of carboplatin was based on previous treatment, and adjustments were made on the basis of myelosuppression. In general, treatment was well tolerated--severe myelosuppression occurred after 6 of 73 cycles. This review confirms previous reports of anti-tumor activity of carboplatin in patients with refractory or recurrent advanced EOC who respond to first-line treatment with cisplatin. Further evaluation may help define the toxicity and efficacy of salvage treatment with carboplatin compared to cisplatin in patients who recur after a prolonged disease-free interval after first-line cisplatin-based therapy.

Adenocarcinoma in a sigmoid conduit: case report

The increased risk of developing adenocarcinoma in the sigmoid colon after ureterosigmoidostomy has been acknowledged for some time. Development of adenocarcinoma in colonic conduits isolated from the fecal stream is rare. We report a case of adenocarcinoma arising in a sigmoid conduit that probably represents a metachronous adenocarcinoma of the colon.

The role of hexamethylmelamine in the combination chemotherapy of advanced ovarian cancer: a comparison of hexamethylmelamine, cyclophosphamide, doxorubicin, and cisplatin (H-CAP) versus cyclophosphamide, doxorubicin, and cisplatin (CAP)

To evaluate the contribution of hexamethylmelamine (HMM) to the treatment of advanced ovarian cancer with combination chemotherapy, we compared the results of treatment with HMM, cyclophosphamide, doxorubicin, and cisplatin (H-CAP regimen) to treatment results using cyclophosphamide, doxorubicin, and cisplatin (CAP regimen). The treatment regimens were identical in dosage and schedule with the exception of the addition of HMM to one regimen. Fifty-five patients treated with H-CAP at Vanderbilt University Hospital between August 1977 and March 1980 were compared with a subsequent group of 22 patients who received CAP between October 1984 and October 1987. Following six months of therapy, patients were restaged either with second-look laparotomy or with clinical restaging. Fifty-three of 55 patients (96%) had objective responses to H-CAP compared with 14 of 21 patients (67%) treated with CAP (p = 0.001). The pathologic complete response rate was also higher in the patients who received H-CAP (35% versus 19%). The median survival of patients receiving H-CAP is 47 months compared to 21 months for the CAP patients. When patients with limited residual disease (maximum tumor diameter less than or equal to 3 cm) were compared, the median survival also favored the H-CAP treatment (101 months versus 21 months, p = 0.002). The median time to progression was also greater in patients receiving H-CAP versus those receiving CAP (67 months versus 16 months, p = 0.045). Treatment-related toxicity did not differ substantially between the two regimens. Our findings suggest that the addition of HMM to CAP chemotherapy prolongs the median survival in patients with ovarian cancer and limited residual disease following cytoreductive surgery.

Intraoperative guidance for intrauterine procedures with transrectal sonography

Transrectal sonography was used for intraoperative guidance in intrauterine tandem placement for intracavitary radiation therapy and in dilation and curettage procedures. The authors describe the method and three representative cases in which it was applied. It is concluded that the technique may prevent complications such as uterine perforation or bladder injury in tandem placement, and that it can facilitate dilation and curettage in complicated cases.

High-dose cisplatin combination chemotherapy in the treatment of advanced epithelial ovarian carcinoma

We treated 25 newly diagnosed patients with advanced epithelial ovarian cancer with an intensive induction chemotherapy regimen using high-dose cisplatin in combination with cyclophosphamide and doxorubicin. All patients had either stage IIIC or stage IV disease. Two intensive induction courses of chemotherapy were administered at 28-day intervals, which consisted of cisplatin 40 mg/m2 daily for 5 days, cyclophosphamide 500 mg/m2 day 1, and doxorubicin 40 mg/m2 day 1. Four courses of chemotherapy using cisplatin 60 mg/m2, doxorubicin 40 mg/m2, and cyclophosphamide 500 mg/m2 followed the high-dose induction therapy. Two of the first six patients died during high-dose induction therapy (one died of neutropenia and sepsis, one of intercurrent intracerebral hemorrhage). Doxorubicin was subsequently omitted from the induction therapy due to unacceptable myelosuppression; no deaths occurred in the remaining 19 patients, and myelosuppression was manageable. Peripheral neuropathy was the most severe side effect with this regimen. This complication was unpredictable, developed during the third or fourth month of treatment, and was disabling in five patients. Other toxicity included prolonged nausea and vomiting (eight patients), ototoxicity (five patients), and nephrotoxicity (two patients), but these did not compromise therapy. All 23 assessable patients had objective response to therapy. Four of 12 patients who underwent second-look laparotomy had pathologic complete response, while four additional patients had only microscopic residual disease. The median survival for the entire group was 25 months. Four patients remain continuously disease-free 23 to 48 months following completion of therapy. Although this regimen was tolerated by most patients, the unpredictable occurrence of disabling neuropathy may limit its usefulness.(ABSTRACT TRUNCATED AT 250 WORDS)

Preoperative assessment of myometrial invasion of endometrial adenocarcinoma by sonography (US) and magnetic resonance imaging (MRI)

The presence and/or depth of myometrial invasion of endometrial adenocarcinoma has important prognostic and therapeutic implications. Fifteen patients with histologically proven endometrial cancer underwent preoperative evaluation with sonography (US) and magnetic resonance imaging (MRI) to assess depth of invasion. Using criteria of greater than or equal to 50% of myometrial wall involvement as representing deep invasion, and less than 50% as superficial invasion, US was more accurate than MRI in five cases; in three MRI was more accurate than US; both MRI and US were equally accurate in four; neither was accurate in three. Polypoid lesions caused the greatest number of false positive reports of deep invasion with both MRI and US. Preliminary results indicate that US and MRI have promise as preoperative tests to assess the extent of myometrial invasion.

Peritoneal carcinomatosis of unknown primary site in women. A distinctive subset of adenocarcinoma

STUDY OBJECTIVE

To define the clinical features and results of systemic treatment in women with adenocarcinoma of unknown primary site involving predominantly the peritoneal surfaces.

DESIGN

Retrospective analysis of 18 patients treated at a single institution between 1978 and 1984.

PATIENTS

All 18 women had abdominal carcinomatosis and had no primary site identified at laparotomy. Nine patients had limited residual tumor (maximal tumor diameter, 3 cm or less) after initial cytoreductive surgery, and 9 patients had extensive residual disease.

INTERVENTIONS

In general, patients were treated according to standard guidelines for treatment of advanced ovarian carcinoma. All patients had initial laparotomy with attempted cytoreduction; of these 18 patients, 16 subsequently received cisplatin-based chemotherapy. Patients were restaged either clinically (10 patients) or with second-look surgery (8 patients).

RESULTS

The median survival for all patients was 23 months. Five patients had complete response to chemotherapy, and three patients remain disease-free 41, 59, and 77 months after diagnosis. Patients with limited residual disease had longer median survival than did those with extensive residual disease (31 months compared with 11 months).

CONCLUSIONS

Women with adenocarcinoma of unknown primary site involving predominantly the peritoneal surface should be distinguished from other patients with adenocarcinoma of unknown primary site because they have a more indolent disease course, a higher response rate to systemic therapy, and a chance for long-term, disease-free survival after therapy. Although optimal treatment is undefined, we recommend that these patients be treated using the guidelines established for therapy of advanced ovarian carcinoma, including initial surgical cytoreduction followed by cisplatin-based combination chemotherapy.

Menopausal hormone replacement therapy with continuous daily oral micronized estradiol and progesterone

The safety and efficacy of a daily combination of micronized estradiol (E2) (0.7-1.05 mg) and progesterone (200-300 mg) were evaluated in ten menopausal women with moderate to severe vasomotor symptoms and/or vaginal atrophy over a 12-month study interval. For comparison, five similar women were placed on conjugated estrogens, 0.625 mg daily, and medroxyprogesterone acetate, 10 mg daily, for the first 10 days of each calendar month for 12 months. Patients were evaluated at 0, 1, 3, 6, and 12 months. Estrogens rose significantly from baseline in both groups (P less than .01). Progesterone increased significantly above baseline in the E2 and progesterone group (P less than .01), but did not change in the conjugated estrogens and medroxyprogesterone acetate users. All women on E2 and progesterone had a decrease in total cholesterol and an increase in high-density lipoprotein cholesterol from baseline (P less than .01). Those on conjugated estrogens and medroxyprogesterone acetate had no significant change from baseline in total cholesterol; however, they did have an increase in high-density lipoprotein cholesterol values (P less than .01). In the E2 and progesterone group, the endometrial histology became completely quiescent and there was no uterine bleeding after 6 months of observation. Four of five women on conjugated estrogens and medroxyprogesterone acetate continued regular withdrawal bleeding throughout the study period, but no endometrial hyperplasia was encountered. This study demonstrates that the daily administration of a combination of micronized E2 and progesterone results in symptomatic improvement, minimal side effects, an improved lipid profile, and amenorrhea without endometrial proliferation or hyperplasia in menopausal women.

Occurrence of ovarian malignancy in childhood and adolescence: a community-wide evaluation

During childhood and adolescence, the rate of malignancy in ovarian enlargement is reported to be high-approximately 35% in many large series from tertiary centers. To assess whether this represents an overestimation because of the referral patterns of these institutions, a retrospective review was conducted at five hospitals in Nashville, Tennessee. In females 21 years of age and under, borderline or malignant ovarian neoplasms were identified in only eight (5.8%) of 137 individuals with ovarian enlargement and eight (9.8%) of 82 females with ovarian neoplasms. All six malignant neoplasms were of germ-cell origin. The borderline neoplasms were of epithelial origin, and occurred in females in their late teens. We conclude that the frequency with which ovarian enlargement represents malignancy in this age group appears to be much smaller than previously suggested. Nevertheless, because of the potential for malignant ovarian neoplasia in young females, the presence of an abdominal-pelvic mass requires prompt and thorough attention.

Gynecologic causes of the acute abdomen

Acute surgical emergencies of gynecologic origin occur for the most part in women of reproductive age but occasionally in newborn and adolescent patients and rarely in the postmenopausal patient. The most common and most important conditions to be considered include pelvic inflammatory disease (PID) with abscess, ectopic pregnancy, hemorrhage from a functional ovarian cyst, and adnexal or ovarian torsion.

Advanced ovarian cancer: long-term results of treatment with intensive cisplatin-based chemotherapy of brief duration

STUDY OBJECTIVE

To determine the efficacy of a 6-month course of combination chemotherapy with hexamethylmelamine, cyclophosphamide, doxorubicin, and cisplatin (H-CAP) in the treatment of advanced ovarian carcinoma.

DESIGN

Prospective, non-randomized, single-institution trial with a 6-month course of chemotherapy, followed by second-look laparotomy for restaging. Minimum follow-up after completion of therapy is 83 months.

PATIENTS

Fifty-five patients with advanced (stage III or IV), intermediate- or high-grade epithelial carcinoma of the ovary. Twenty patients had limited residual tumor (3 cm or less maximal tumor diameter) after initial cytoreductive surgery; 35 had extensive residual disease.

INTERVENTIONS

All patients received chemotherapy with hexamethylmelamine (150 mg/m2 body surface area orally on days 1 to 14), cyclophosphamide (350 mg/m2 intravenously on days 1 and 8), doxorubicin (20 mg/m2 intravenously on days 1 and 8), and cisplatin (60 mg/m2 intravenously on day 1). Courses were repeated at 4-week intervals; 41 patients (75%) received six courses; 10 patients received five courses, 3 patients received four courses, and 1 patients received three courses. Forty-seven patients underwent second-look laparotomy after completion of therapy; 8 had their disease restaged clinically.

RESULTS

Fifty-three of fifty-five patients (96%) had either partial or complete response to treatment. Nineteen of forty-seven patients who had a second-look laparotomy had a surgically documented complete response; 17 of these 19 patients began chemotherapy with limited residual tumor. Ten patients (18%) remain disease-free 83 to 108 months after therapy, whereas three additional patients died of other diseases without clinical evidence of recurrent ovarian cancer. Nine of twenty patients who began chemotherapy with limited residual tumor remain disease-free, as compared to only 1 of 35 patients with more extensive tumor (P less than 0.001). All long-term, disease-free survivors had surgically documented complete response at second-look laparotomy.

CONCLUSIONS

Treatment with cisplatin-based combination chemotherapy after aggressive cytoreductive surgery should be considered standard treatment for advanced ovarian carcinoma. Our intensive, 6-month course of treatment produced results comparable to those previously reported with prolonged treatment.

Simultaneous radiation and chemotherapy for advanced carcinoma of the cervix

Six patients with poor prognosis carcinoma of the cervix were treated with external radiation therapy simultaneously with cisplatin, bleomycin, and vincristine. Toxicity was very mild with nausea and vomiting and mild myelosuppression being the major toxicities. At a median of 36 months follow-up, four of six patients are alive, three with no evidence of disease. The median survival after diagnosis is 25+ months. The data suggest that radiation therapy and cytotoxic therapy administered together in patients with advanced cervix carcinoma is well tolerated. Further study to determine therapeutic efficacy is warranted.

Combination chemotherapy for patients with advanced carcinoma of the cervix: trial of mitomycin-C, vincristine, bleomycin, and cisplatin

Sixteen patients with metastatic or recurrent carcinoma of the cervix were treated with combination chemotherapy consisting of mitomycin-C, vincristine, bleomycin, and cisplatin. Seven of 14 (50%) evaluable patients responded. In 2 patients all measurable disease resolved. Median duration of response was 4.5 months. Toxicity was severe and consisted of myelosuppression, pulmonary fibrosis, nausea, vomiting, stomatitis, asthenia, and fever. Two treatment-related deaths occurred. This combination chemotherapy regimen appears to have a response rate similar to other cisplatin containing regimens. Response durations were short and toxicity was severe.

Malignant mixed mesodermal tumors of the uterus and ovary treated with cisplatin-based combination chemotherapy

Twelve patients with malignant mixed mullerian tumors were treated with combination chemotherapy at Vanderbilt University Hospital from 1977 through 1981. Nine patients, all of whom received combination chemotherapy with hexamethylmelamine, cyclophosphamide, doxorubicin, and cisplatin (HCAP), were evaluable for response. Objective responses (all partial responses) were noted in 3 (33.3%) (response rate greater than 10% and less than 55% with 90% confidence limits), a minimal response was noted in one patient, and stable disease in four (50%) patients. Responders survived longer (calculated from the initiation of HCAP) than nonresponders (median 112 vs 19 weeks). These results are not at present statistically different from previous studies utilizing doxorubicin alone, cisplatin alone, the combination of doxorubicin and DTIC, or the combination of vincristine, actinomycin D, and cyclophosphamide.

Abdominopelvic computed tomography: evaluation in patients undergoing second-look laparotomy for ovarian carcinoma

Preoperative abdominopelvic computed tomography results and operative findings were compared in 52 patients undergoing second-look laparotomy to confirm tumor status. Seventeen true-negative, 22 false-negative, and 13 true-positive scans were found. The sensitivity was 0.38, specificity was 1.0, and diagnostic accuracy was 0.58. Negative studies were associated with positive findings at laparotomy in 42% of all cases. Fourteen patients were identified who had computed tomography that would have enabled an attempt at the diagnosis of persistent cancer by computed tomography-directed needle aspiration or biopsy, thus avoiding laparotomy. Assuming 80% accuracy of needle aspiration, the cost of computed tomography in all 52 patients is considerably outweighed by the savings that could have been realized by eliminating the need for second-look surgery in these 11 women.

Reactivation blastomycosis presenting as a tuboovarian abscess

A 32-year-old Korean woman presented with a rapidly enlarging abdominal mass six months after an undiagnosed illness of fever and a large pleural effusion. Exfoliative cytology of a cervical discharge revealed Blastomyces dermatiditis. At laparotomy, a large peritoneal inclusion cyst was found surrounding a tuboovarian abscess with involvement from the cervix to the peritoneum. B dermatiditis was cultured from the excised uterus and fallopian tube. Female genital blastomycosis has rarely been described. The importance of cytology in making the diagnosis in the present case is emphasized.

Preservation of anal function after total excision of the anal mucosa for Bowen's disease

Six women with Bowen's disease of the anogenital area were treated by total excision of the anal mucosa, perianal skin and, in some cases, partial vulvectomy. Two patients had foci of microinvasive squamous carcinoma. Adequate tumor margins were determined by frozen sections. The resulting mucosal and cutaneous defects were grafted with medium split-thickness skin grafts applied to the anal canal and sutured circumferentially to the rectal mucosa. Grafts were held in place by a finger cot inserted in the anal canal and stuffed with cotton balls. Patients were constipated five or six days with codeine. The skin grafts healed per primam. One additional patient was similarly treated for a chronic herpetic ulceration of the anus and healed. Contrary to dire predictions, all patients were able to distinguish between gaseous and solid rectal contents and sphincter function was preserved. In one patient, Bowen's disease has recurred in the grafted perianal skin.

Phase II study of vinblastine in advanced refractory ovarian carcinoma

Fourteen patients with advanced ovarian carcinoma previously treated with chemotherapeutic agents including cisplatin were treated with vinblastine 0.1 mg/kg intravenously every week. There were no responses in 13 evaluable patients. The median survival was 19+ weeks following the initiation of vinblastine (VBL) therapy. Toxicity consisted of minimal myelo-suppression (WBC count less than 2500/microliter in 8/78 courses, WBC count less than 1500/microliter in 0/78 courses, platelets less than 150,000/microliter in 0/78 courses), nausea (4/13 patients), vomiting (2/13 patients), neuropathy (4/13 patients), and weakness and fatigue (6/13 and 5/13 patients, respectively). Although data derived from the human tumor stem cell assay (HTSCA) suggest that VBL may be an active agent against previously treated ovarian carcinoma, this study in patients with refractory advanced disease suggests that VBL is inactive (less than 20% response rate with 90% confidence levels) in that setting. Whether significant durable benefit can be achieved with VBL therapy in patients whose tumor is sensitive in the HTSCA remains to be seen.

Advanced minimal residual ovarian carcinoma: abdominopelvic irradiation following combination chemotherapy

Seventeen patients with advanced ovarian carcinoma who had minimal residual intraabdominal disease after six months of combination chemotherapy were treated with abdominopelvic irradiation. All 17 patients had residual intraabdominal tumor nodules with a cross-sectional diameter of less than 2 cm. Eleven had only microscopic residual disease at the time of irradiation. Fourteen have relapsed at a median of eight months after the completion of radiotherapy. All but two had intraabdominal recurrences. Myelosuppression was common and severe, causing marked delays or discontinuation of radiotherapy in ten of 17 patients. Patients receiving the entire planned dose of radiotherapy had longer disease-free survival (14 months median) than did patients receiving only partial doses (seven months median). However, six of seven patients receiving full dose irradiation have relapsed. Abdominopelvic irradiation in the schedule employed here is poorly tolerated and is not an effective salvage treatment in patients with limited or microscopic residual tumor following initial combination chemotherapy.

Resistant gestational choriocarcinoma: successful treatment with vinblastine, bleomycin, and cisplatin (VBP)

Two patients with resistant gestational trophoblastic neoplasms were treated with vinblastine, bleomycin, and cisplatin (Einhorn regimen). Both patients had failed multiple conventional therapeutic regimens including methotrexate, dactinomycin, high-dose methotrexate, and the modified Bagshawe regimen. Both patients achieved complete remissions and remain free of disease at 20 and 33 months following completion of therapy. The combination of vinblastine, bleomycin, and cisplatin is highly active in patients with resistant gestational trophoblastic neoplasms, and should be used as second-line therapy for poor-prognosis patients failing initial treatment.

Cushing's syndrome with small cell carcinoma of the uterine cervix

A 28 year old white women was found to have a cervical tumor in the 25th week of pregnancy. Pathologic examination revealed a nonkeratinizing small cell carcinoma. After delivery by cesarean section, pelvic lymph node exploration was carried out, and all 15 nodes were free of tumor. Her condition was staged as II-A, and she was treated with local radiation. Metastatic disease became manifest almost a year later and was histologically similar to her primary disease. A Cushingoid appearance was noticed and plasma cortisol levels were elevated. Twenty-four hour urinary 17-hydroxycorticosteroid (17-OHCS) and 17-ketosteroid (17-KS) levels were elevated and failed to suppress with dexamethasone. Plasma adrenocorticotropin (ACTH) level was elevated. Electron microscopic examination of the tumor tissue revealed neurosecretory granules. Immunoperoxidase stains for ACTH were positive. The patient's course was one of progressive decline and eventual death. A literature review revealed two other cases in which carcinoma of the uterine cervix was considered to be the source of ectopic ACTH. Some small cell carcinomas of the cervix may arise from cells of the APUD series. Small cell carcinoma of the uterine cervix may behave differently from the more commonly encountered keratinizing and large cell nonkeratinizing carcinomas of the cervix and may not respond as well to standard therapy. Ectopic hormone production, production of abnormal peptides or of vasoactive amines may be more common in small cell carcinoma of the cervix than is currently recognized, and these products may be clinically useful as tumor markers.

The visual evoked potential in children after kwashiorkor

An index of the long-term effects of kwashiorkor on the electrocortical development of the child was obtained by recording the visual evoked potential (VEP) of 4 groups of children aged 6--12 years. The malnourished group, consisting of 30 Black children hospitalized for treatment of kwashiorkor during the first 27 months of life, was age-matched with 3 control groups. Some evidence of right hemisphere VEP deficit was found in the kwashiorkor group.

Radioactive phosphorus and external radiation as an adjuvant to surgery for ovarian carcinoma

At the Johns Hopkins Hospital between the years 1967 and 1973, 40 patients with primary ovarian carcinoma were treated with radioactive phosphorus. Of these, 19 were treated with external radiation in addition. The morbidity from the radioactive phosphorus alone was negligible. Dosages of less than 5000 rads to the pelvis were usually well tolerated even when given in combination with the isotope. Pathologic changes in the bowel are discussed.

Long-term effects of kwashiorkor on psychomotor development

The long-term effects of kwashiorkor on psychomotor development were assessed by means of 3 tests. A group of 31 children aged from 6 to 12 years, who had been hospitalized for the treatment of kwashiorkor during infancy, was age-matched with 2 control groups, consisting of a group of siblings and a group of yardmates, none of whom had been exposed to acute infantile malnutrition. The test scores for the groups were not significantly different. The results are discussed in the light of suggestions that marasmus has a more damaging effect on human development than kwashiorkor.

The management of midtrimester abortion failures by vaginal evacuation

The management of 58 failed midtrimester primary abortion procedures by vaginal uterine evacuation is described. The indications, technic, and complications of this procedure are presented. This method was the only means of managing failed primary abortion over a 3-year period in which 2045 elective midtrimester abortions were performed. With the development of experience this technic offers significant advantages over other procedures, such as hysterotomy, in the management of such patients.

Intra-amniotic urea and prostaglandin F2 alpha for midtrimester abortion: a modified regimen

A study comparing intra-amniotic urea plus intravenous oxytocin and intra-amniotic urea with 10 mg. prostaglandin F2 alpha was completed. In addition, the results obtained with a further 150 patients receiving urea and prostaglandin are reported. Mean injection-abortion intervals ranged from 15.75 hours for urea-prostaglandin to 18.93 hours for urea-oxytocin. The advantages of urea-prostaglandin and suggested improvements are discussed. Over all, the method appears efficacious though incomplete abortions and cervical laceration are persistent problems.

A case of male pseudohermaphroditism associated with elevated LH, normal FSH and low testosterone possibly due to the secretion of an abnormal LH molecule

A 27 year old female is described who had 46,XY chromosome complement, ambiguous external genitalia with elevated LH, slightly above normal FSH and low testosterone. Her plasma testosterone level increased 15-20 fold after HCG stimulation (5000 IU X 3). then returned to prestimulation level 3 months later. This was possibly due to the secretion of an abnormal LH molecule which is immunoreactive but biologically inactive in the human.

The influence of aspirin on the course of induced midtrimester abortion

Prostaglandins appear to mediate the uterine contractions of abortion and labor, and aspirin has been shown to be an inhibitor of prostaglandin synthesis. In this double-blind, placebo-controlled, prospective, and randomized study, aspirin was administered orally in doses of 600 mg. every 6 hours to patients undergoing induced midtrimester abortions with hyperosmolar urea and oxytocin augmentation. The mean injection-abortion interval was significantly prolonged by aspirin in nulliparous patients (aspirin 32.3 +/- 3.3 hr. vs. placebo 21.5 +/- 3.5 hr.) and no aspirin-treated nullipara aborted in less than 18 hours. There was no significant difference between treatment groups in the mean injection-abortion interval in the multiparous patients at the dose of aspirin used. The effectiveness of aspirin in the prolongation of the injection-abortion interval has potential therapeutic implications for the treatment of premature labor.

The possible deleterious effects of the intramyometrial injection of hypertonic urea

Hypertonic urea has been shown to be an effective midtrimester abortifacient. Although safer than hypertonic saline when injected intravascularly, it has not been compared to saline in the case of inadvertent intramyometrial injection. This report documents that intramyometrial injection of hypertonic urea will result in the same type of muscle necrosis as that produced by saline.

Pharmacokinetics of intra-amniotically administered hyperosmolar urea in rhesus monkeys

Three rhesus monkeys in midgestation were injected intra-amniotically with hyperosmolar 14C-urea (58 per cent weight/volume, 2.3 Gm. per kilogram, 25 muc) and the concentration of 14C-urea measured serially for 24 hours in amniotic fluid, maternal serum, and maternal urine. The volume of the amniotic space was measured by isotope dilution of 99mTc-albumin. The experimental values were fitted to a three-compartment mathematical model with the aid of a digital computer program for nonlinear data. The computer-derived concentration versus time curves were in close agreement with the measured values when the flux of urea was primarily from amniotic fluid to fetal water to maternal water with insignificant direct transport between the amniotic fluid and maternal serum. The half-times for distribution of urea into fetus and mother were approximately 30 minutes and 7 hours, respectively. Thus, although the uptake of urea by the fetus from surrounding amniotic fluid is rapid, the further movement of urea from fetus to mother is relatively slow.

Comparative effects of hyperosmolar urea administered by intra-amniotic, intravenous, and intraperitoneal routes in rhesus monkeys

Hypertonic urea solutions (58 per cent weight/volume) were injected rapidly into ten anesthetized rhesus monkeys at a dose of approximately 2 Gm. per kilogram by the intravenous, intraperitoneal, or intra-amniotic routes. An additional monkey received an intra-amniotic dose of 12.5 Gm. per kilogram. A tracer dose 14C-urea was included for measuring absorption and elimination. The following parameters were monitored before and for four hours after urea injection: arterial and cerebrospinal fluid pressures, heart and respiration rates, urine flow, and urea clearance. Serum electolytes, hematocrit and white count, and cumulative urea excretion were measured for one week. Monkeys were observed for three to six months after injection. At doses up to approximately twice the human dose (on a body weight basis) there were no urea-related deaths and no serious side effects noted in any of the experiments. These results support the suggestion that urea is a relatively safe hyperosmolar agent for inducing midtrimester abortions, especially with regard to inadvertent systemic injection.

Continuing education of obstetricians and gynecologists in fertility management

One of the current fundamental problems in medicine is the massive quantity of new information that continues to develop and the requirement for the application of these data to good patient care. New techniques of merit need to be placed rapidly in the patient-care arena and the time lag between the steps from laboratory to clinic minimized. One approach to the achievement of the goal in fertility management is described in the following report; namely, a summary of the results of an education program in fertility management established in November, 1972, for the continued education of obstetricians and gynecologists from "developing countries". This report reviews the experience and data derived from the first 95 physicians completing a course in population dynamics. An estimate of the factual knowledge that these individual physicians possessed at the beginning of the course is compared with an estimate of the knowledge acquired within the 4 week training program. In a similar manner, an important part of this survey was a study of the attitudes of the clinical fellows in the areas of sex education, contraception, sterilization, and abortion. The results of this study suggest that newly developed techniques in clinical medicine may be taught to a specific and highly motivated group in an effective and efficient manner. The initial interest and response of physicians for admission to this program have demonstrated the need for the development of more similar educational programs.

Menstrual extraction

This report documents the clinical outcome of 137 consecutive menstrual extractions. The pre- and postprocedural pregnancy testing is correlated with histologic examination of tissue obtained. This report reviews the management of the unsuccessful cases.

Intra-amniotic urea as a midtrimester abortifacient: clinical results and serum and urinary changes

Seventy-four patients, from 16 to 20 weeks pregnant, received intra-amniotic urea (80 Gm.) and intravenous oxytocin for the purpose of inducing abortion. Seventy-one of the 74 patients were successfully aborted by the primary method with a mean injection-to-abortion interval of 18.33 hours. There were no serious side effects, and the mean hospital stay was 32 hours. Following urea injection, the mean serum urea nitrogen rose to 33 mg. per cent at 4 hours. Maximum changes in serum electrolytes occurred at 8 to 12 hours after injection and included a decrease in the mean concentrations of sodium, chloride, and carbon dioxide and an increase in serum potassium. An increase in the urinary excretion of urea began within 4 hours, but significant diuresis did not occur in the presence of intravenous oxytocin administration. There was a significant increase in the leukocyte concentration while hematocrit values remained unchanged. Beginning approximately 8 hours following urea injection, the mean plasma fibinogen concentrations decreased by approximately 15 per cent and the mean platelet count showed a drop of approximately 18 per cent. Fibrinogen-fibrin degradation products were significantly increased in 36 per cent of the patients studied.

A Quantitative in Vitro Study of the Chromatographic Distribution and Immunoglobulin Characteristics of Human Blocking Antibody

This report describes the immunoglobulin and chromatographic characteristics of human blocking antibody. Studies were carried out on a pool of serum from 20 allergic donors who had been immunized with ragweed antigen E as a form of therapy for ragweed hay fever. The serum and serum fractions were subjected to chromatography on DEAE-Sephadex, CM-cellulose, DEAE-cellulose and Sephadex G 200. Blocking activity was assayed by an in vitro technique: the inhibition of antigen E induced histamine release from isolated human leukocytes. This technique is more than 10 times as precise as the usual skin assay. Immunoglobulins were determined qualitatively by immunodiffusion against specific antisera and quantitatively by the Preer technique. Recovery of blocking activity was about 70%. In each fractionation procedure blocking antibody and IgG eluted together. Purified IgA had less than 1% the activity of IgG preparations and IgM antibody contributed less than 1% to the activity of the whole serum. Absorption of the serum with anti-IgA and treatment with 2-mercaptoethanol did not decrease its blocking titer, while absorption with anti-IgG caused a decrement of more than 97%. Circulating reaginic antibody appeared to account for less than 1% of the total serum activity. It was concluded that blocking activity is essentially a function of IgG molecules.