Endometrial cancer patients’ assessment of the benefits of exercise

e20553

Background: Endometrial cancer patients remain at risk for other obesity related cancers and illnesses. Patients should be counseled to increase their physical activity, however, their belief concerning potential outcomes of exercise will affect how they are counseled. Methods: Patients treated for Stage I endometrial cancer with no other cancer diagnoses were asked if they had been exercising regularly for more than 6 months using the CDC definition of exercise (exercisers), how likely they thought regular exercise would result in health related outcomes (see Table ) and how important these outcomes are to them using Likert-like scales ranging from 1 to 5. A weighed calculation of how likely regular exercise would result in an outcome of importance to them was obtained by multiplying the two scores. Chi-square and t-tests were used to analyze data with SPSS V15. Results: 76 of 90 women approached completed the questionnaire (84%), mean age was 59.5 ± 1.1 (SEM). 45% were exercisers, their mean BMI was lower (31.2 ± 1.2 vs. 38.0 ± 1.4, p=0.001) and a non significantly lower proportion reported having diabetes (15% vs 26%) or hypertension (26% vs 43%). The majority of all women believed regular exercise would result in positive outcomes; a lower proportion of exercisers reported it very to extremely likely that regular exercise would reduce the risk of developing cancer (27% vs 54%, p=0.023) or osteoporosis (46% vs 73%, p=0.019). The majority reported these outcomes were very to extremely important to them; a lower proportion of exercisers reported reducing the risk of developing a new cancer or diabetes were (cancer 79% vs 98%, p=0.013; diabetes 78% vs 100%, p=0.003). Both groups believed feeling better physically and emotionally were important and likely consequences of exercise; exercisers were less likely to believe several other outcomes were important and likely consequences ( Table ). Conclusions: Women who exercise regularly and develop cancer may become disillusioned with the potential health benefits of exercise despite having improved health.

[Table: see text]

No significant financial relationships to disclose.

Spontaneous prolonged hypertonic uterine contractions (essential uterine hypertonus) and a possible infective etiology

The management of a pregnant woman presenting with prolonged hypertonic uterine contractions (essential uterine hypertonus) and mildly elevated temperature at term is described. Histology of the placenta, cord and membranes, following delivery, revealed evidence of chorioamnionitis, funisitis and deciduitis. Our findings raise the possibility that essential uterine hypertonus may have an infective or inflammatory component to its etiology.

Carcinoma of the vulva

Vulvar cancer will probably become a more common disease as the population ages. It is primarily a disease of the elderly. Fortunately, most vulvar cancers remain localized for extended periods of time and can be treated adequately with radical surgery.

Complementary and alternative medicine use in the Amish

OBJECTIVE

To examine the rate of utilization of complementary and alternative medicine (CAM) in Amish women, a population that traditionally uses non-mainstream medicine.

METHODS & RESULTS

Sixty-six Amish women completed a survey concerning their use of CAM. Thirty-six percent of the Amish women used at least one form of CAM, primarily reporting a use of diet and nutrition programs, herbal therapies, and chiropractic medicine. In addition, ten pregnant Amish women reported using echinacea, St. John's Wort, red clover, garlic and ginseng.

CONCLUSION

This survey highlights the need to address potential adverse effects of herbal therapies in young women who are a member of a group that may use non-mainstream medicine.

A comparison of complementary and alternative medicine use by gynecology and gynecologic oncology patients

Our objective was to describe and compare the use of complementary and alternative medicine (CAM) in gynecology and gynecological oncology patients. Five hundred and twenty-nine gynecology and gynecological oncology patients completed a questionnaire regarding CAM use. Overall, 56.3% of gynecology and gynecological oncology patients reported current use of CAM. Therapies used included nutritional supplements (20%), prayer as medical therapy (17%), exercise as medical therapy (12%), megavitamins (10%), and green tea (10%). While 69.5% believed CAM to be beneficial, only 31.6% discussed these therapies with their physician. The women spent a mean of $656.22 on CAM (range $0-$7,000), with 31.7% receiving some insurance reimbursement. Gynecologic oncology patients (n = 161) used CAM significantly more than gynecology patients (n = 368) (66% vs. 52%, 95% CI = 0.046-0.230, P = 0.004). Gynecological oncology patients also spent more for CAM, with a mean expenditure of $711 versus $622 by gynecology patients. Within the gynecological oncology patient group, there were 69 patients currently receiving modern medical treatments for cancer; among these patients, 58% reported using CAM; of these, 39.3% communicated their use of CAM to their physician. Patients in this group spent an average of $1,178 on CAM during their illness, with only 6.3% receiving insurance reimbursement. Benefits from CAM were perceived by 54.5% in this group. We concluded that cancer patients have a higher usage rate and expenditure for CAM, particularly while they are receiving medical therapy, and are more likely to discuss the use of alternative therapies with their physicians. CAM was perceived as helpful by patients despite the lack of scientific data about its effect.

Vaginal leiomyoma co-existing with broad ligament and multiple uterine leiomyomas

A 48 year old African American woman presented with bladder pressure leading to the diagnosis of broad ligament and multiple uterine leiomyomas. She was also found to have a lateral vaginal wall mass which was confirmed to be a leiomyoma. Unlike uterine leiomyomas, vaginal leiomyomas are uncommon and are most often found in Caucasian women. Cases of such coexisting tumors are rare and their etiologic relationship is uncertain.

The myths of laparoscopic surgery

Laparoscopic surgery has been rapidly accepted without rigorous scientific study. New procedures and technologies have advanced rapidly, and most gynecologists have embraced these techniques. I believe that the new technology has given rise to the following myths: (1) that there are associated cost savings, (2) that new technology is always better than the old, (3) that a steep learning curve is acceptable, (4) that market share will be lost without the new techniques, (5) that oncologic surgery is not different when performed laparoscopically, (6) that operations are the same with the laparoscope, and (7) that every gynecologist can do these procedures. A critical evaluation of new technology and of laparoscopic techniques needs to be performed.

Panniculectomy at the time of gynecologic surgery in morbidly obese patients

OBJECTIVE

Our goal was to demonstrate that panniculectomy performed at the time of gynecologic surgery aids in reducing the operative time and exposure and does not increase the wound infection rate in morbidly obese patients.

STUDY DESIGN

A retrospective survey was performed of massively obese patients who underwent panniculectomy at the time of gynecologic surgery at Northeastern Ohio Universities College of Medicine consortium hospitals from 1990-1999. Data collected during surgery included the patient's weight, operative opening and closing times, blood loss, and weight of the removed panniculus adiposus. Postoperative wound infection rates were monitored, and patients were followed up for 6 months.

RESULTS

Seventy-eight patients underwent the following operations: radical hysterectomy (n = 19), extrafascial hysterectomy (n = 18), standard hysterectomy (n = 32), or other gynecologic surgery (n = 9). The average blood loss was 71 mL. Opening and closing times were 27 and 33 minutes, respectively, adding a minimal amount of operative time to the required gynecologic surgery. The average removed panniculus adiposus weighed 4745 g. Efficiency in obtaining exposure to the operative site was noted. A total of 2 wound infections were recorded in the postoperative period. In 1 case debridement was required, and in the other healing occurred by secondary intention. Minimal separation occurred in 4 other cases and required no intervention.

CONCLUSION

Massively obese patients can safely undergo panniculectomy simultaneously with a gynecologic procedure. The difficulty with operative exposure is reduced, and these patients are better served intraoperatively. Postoperatively, the wound infection rates quoted for this population were markedly improved from prior studies and involved a larger group of patients.

The prevalence of thromboembolic events among women with extended bed rest prescribed as part of the treatment for premature labor or preterm premature rupture of membranes

OBJECTIVE

This study was undertaken to determine the prevalence of thromboembolic events among women with extended bed rest prescribed as part of the treatment of premature labor or preterm premature rupture of membranes.

STUDY DESIGN

A retrospective chart review was undertaken of all women who had bed rest of >/=3 days' duration prescribed as part of the treatment of premature labor or preterm premature rupture of membranes in the Akron General Medical Center Perinatal Unit during the period January 1, 1997-December 31, 1998. The prevalence of thromboembolic events in this population was determined. The charts of all additional gravid women with antepartum or postpartum deep vein thrombosis or pulmonary embolism diagnosed during the study period were also reviewed. The prevalence of these disorders among the pregnant population for whom extended bed rest was not prescribed as part of the treatment of premature labor or preterm premature rupture of membranes was also calculated. Statistical comparison of the prevalences in the 2 populations was undertaken by means of the chi(2) analysis with the Fisher exact test.

RESULTS

There were 192 patients admitted during the study period who had extended bed rest prescribed as part of the treatment of premature labor or preterm premature rupture of membranes. Three of these women had thromboembolic events, for a prevalence of 15.6 cases per 1000 women. Five additional gravid women were admitted for the treatment of deep vein thrombosis or pulmonary embolism. There were 6164 deliveries among women not treated with extended bed rest for premature labor or preterm premature rupture of membranes during this period. Thus the prevalence of these phenomena among the remaining pregnant women was 0.8 cases per 1000 women. The prevalences of these disorders in the 2 populations were highly significantly different.

CONCLUSION

The prevalence of thromboembolic events among women for whom extended bed rest is prescribed as part of the treatment of premature labor or preterm premature rupture of membranes is significantly increased with respect to that among gravid women who do not receive this therapy and is substantially higher than previously reported. If this finding is confirmed in other populations, it may be prudent to undertake further studies to determine whether this prevalence can be reduced.

Alternative medicine in gynecologic oncology: A case report

A patient with Stage IIB squamous cell cancer of the cervix presented 10 days into her primary radiation therapy with neutropenic fever and diarrhea requiring hospitalization and delay in treatment. The patient's history revealed extensive use of alternative therapies including potential toxic botanicals. This case raises the possibility that a patient's use of alternative therapies may have caused toxicity and delayed primary therapy. Gynecologic oncology patients may be using alternative therapies justifying the need for incorporating this classification into the historical exam.

Laparoscopic port site implantation with ovarian cancer

We report the cases of 3 patients in whom tumor implantation developed at the port site at which ovarian cancer was removed laparoscopically. The 3 patients, who were aged 30, 32, and 40 years, all had an ovary that did not appear cancerous removed by laparoscopy through a port site. All 3 patients underwent re-exploration within 3 weeks and were found to have tumoral spread and port site implantation of tumor. When ovarian cancer is removed laparoscopically, the potential exists for intra-abdominal tumoral spread. When surgical staging is undertaken after laparoscopic removal of ovarian cancer, the port site should be excised in a full-thickness fashion.

The effects of carbon dioxide pneumoperitoneum on seeding of tumor in port sites in a rat model

OBJECTIVES

The use of laparoscopic surgical techniques for the resection of intraperitoneal malignancies has been rapidly increasing in recent years; concomitantly, tumor recurrences at trocar sites have also been reported. These reports bring into question the appropriateness of pneumoperitoneum and laparoscopic techniques for carcinoma removal. We hypothesized that the carbon dioxide pneumoperitoneum and instrumentation used during laparoscopic procedures contribute to a greater incidence of tumor implantation into the ventral peritoneal wall wound sites than seen with laparotomy. This study, which used port placement and carbon dioxide pneumoperitoneum in an animal model, was designed to determine the relative incidences of tumor implantation into wound sites of the ventral peritoneal wall for laparoscopy and laparotomy.

STUDY DESIGN

Viable MAT B III rat mammary adenocarcinoma cells were injected into the lower right quadrant of the peritoneal cavity of Fisher 344 rats (1 x 10(5) cells/rat). The animals were then divided into 4 groups: 1 group (n = 9) served as a control group and received no further manipulations; another (n = 8) underwent a midline laparotomy; another (n = 8) had four 18-gauge trocars inserted into the peritoneal cavity; and the last (n = 8) underwent induction of a 7- to 8-mm Hg carbon dioxide pneumoperitoneum in addition to the insertion of four 18-gauge trocars. All animals were maintained under surgical conditions for 2 hours. Animals were killed at 7 days, and the ventral peritoneal wall was examined for macroscopic evidence of tumor formation.

RESULTS

A total of 32 possible sites of tumor implantation were measured. The control group showed no significant macroscopic evidence of tumor translocation to the ventral peritoneal wall. Among the 32 measured sites the laparotomy group had an overall lower incidence of tumor implantation at the peritoneal wall wound sites (n = 5) than did the group with the trocars alone (n = 20) group (P =.003) and the group with trocars plus carbon dioxide insufflation (n = 29, P <.0001). The group with trocars alone had a lower incidence of tumor implantation than did the group with trocars plus carbon dioxide pneumoperitoneum (P =.02).

CONCLUSIONS

Trocar use during laparoscopic surgical procedures led to greater translocation of free tumor cells to peritoneal wall wound sites than did laparotomy in this animal model. The addition of carbon dioxide pneumoperitoneum further increased implantation of tumor cells at trocar sites. These results provide evidence that the use of laparoscopic techniques for resection of intraperitoneal malignancy needs further long-term study.

The role of AT1 angiotensin receptor activation in the pathogenesis of preeclampsia

OBJECTIVES

Preeclampsia is characterized by an increase in vascular tone associated with reduced uteroplacental flow. The nature of hypertension arising in pregnancy suggests that the abnormal increase in blood pressure is dependent on some humoral factor that mediates vasospasm. There is evidence that preeclampsia results from a breakdown in the balance between vasodilators such as prostacyclin and prostaglandin E2 and nitric oxide and the vasoconstrictors angiotensin II, thromboxane A2, serotonin, and endothelin. Furthermore, vascular reactivity to angiotensin II is greatly enhanced in preeclampsia as opposed to normal pregnancies. The increased vascular tone and the enhanced thromboxane production noted in preeclampsia may be mediated by the increased sensitivity to angiotensin II because angiotensin II coupled to an AT1 receptor is a potent vasoconstrictor and stimulates the accumulation of free arachidonic acid, the precursor of thromboxane and the prostaglandins.

STUDY DESIGN

We used a rat model that has been shown to express the relevant clinical features of human preeclampsia to investigate the involvement of the AT1 angiotensin receptor in this pathologic condition. Pregnant rats were divided into three groups that were either infused with saline or endotoxin on the 14th day of pregnancy. One of the endotoxin-infused groups was further treated with the AT1-selective antagonist losartan from day 11 until day 19 of pregnancy.

RESULTS

Perinatal outcome, blood pressure, and urine protein were monitored for each group. We observed that endotoxin infusion resulted in a decrease in pup weight and number of pups and caused an increase in mean arterial pressure as well as increased proteinuria when compared with saline solution-infused animals. In contrast, endotoxin-infused rats receiving losartan exhibited no change in number or weight of pups when compared with control, and losartan tended to diminish the rise in mean arterial pressure. In addition, the increase in urinary protein excretion was completely blocked by losartan.

CONCLUSIONS

Endotoxin infusion in pregnant rats appears to be a suitable model for the study of preeclampsia. Moreover, the angiotensin II-dependent activation of an AT1 receptor appears to mediate a portion of the pathophysiologic features associated with preeclampsia.

Uterine problems discovered after presumed hysterectomy: the Manchester operation revisited

BACKGROUND

The Manchester operation consists of amputation of the cervix, leading some patients to believe that they have undergone a hysterectomy.

CASES

A 69-year-old woman with vaginal discharge proved to have a well-differentiated adenocarcinoma in the retained uterine corpus. Another 69-year-old woman with a central fluid-filled pelvic mass proved to have a retained blood-filled corpus with an early-stage fallopian tube cancer. The third patient was a 90-year-old woman with symptoms of constipation and urinary frequency, who was found to have a large fluid-filled central mass. At surgery, the retained corpus was distended and filled with mucoid material.

CONCLUSION

Patients who have undergone a Manchester operation may develop disease in the retained uterine corpus, which should be considered in the differential diagnosis of a pelvic mass.

The effect of intermittent-release intraperitoneal chemotherapy on wound healing

OBJECTIVE

Our purpose was to study the effect on wound healing when intraperitoneal chemotherapy was instilled on a daily basis.

STUDY DESIGN

Intraperitoneal carboplatin, Taxol, or saline solution was instilled daily into 70 rats after they underwent laparotomy. The animals were killed and analyzed for adhesions. An area measuring 5 x 5 cm including the incision was also harvested for biomechanical testing. The wound thickness was measured, and the Shore Western Materials Testing System (Monrovia, Calif.) was used to test the force required to break the wound, the stress, and the stiffness.

RESULTS

Groups of 10 rats received saline solution control, carboplatin 6 mg/kg, 7 mg/kg, 8 mg/kg, or Taxol 2.5 mg/kg, 3.0 mg/kg, or 3.5 mg/kg. The total dose was divided into seven equal amounts, administered daily. No significant adhesions developed in any of the animals. The carboplatin group experienced no significant decrease in wound thickness whereas the higher-dose Taxol group had a significant decrease in thickness from 1.06 mm to 0.72 mm (p = 0.02). The wound-breaking strength (force) also decreased for the highest-dose Taxol group from 710 gm to 411 gm (p = 0.02). The wound stiffness was also decreased from 69 gm/mm to 46 gm/mm (p = 0.01). The other measured parameters for both the Taxol and carboplatin groups were not significantly decreased when compared with those of controls.

CONCLUSION

The immediate instillation of divided daily carboplatin did not influence wound strength whereas the use of Taxol on a similar schedule significantly decreased wound strength.

Endometrial rollerball ablation

OBJECTIVE

To study a standardized technique for endometrial rollerball ablation and various methods of preoperative preparation.

STUDY DESIGN

All patients had refractory symptomatic menorrhagia and previously failed conservative surgery and other forms of medical therapy, such as progestogens. Patients received a preoperative regimen of either leuprolide acetate, danazol, Nolvadex or Depo-Provera. They then underwent hysteroscopically controlled rollerball ablation at 80-100 W with 1.5% glycine as the distending medium. The endometrium was evaluated hysteroscopically and considered to be completely atrophic, intermediate or no response.

RESULTS

Refractory symptomatic menorrhagia was treated successfully in 38 of 40 patients. Nineteen reported amenorrhea; the other 21 reported subjective and objective improvement of bleeding. Three patients, despite improvements in flow, were unhappy with the overall result. Two did not wish repeat ablation and subsequently underwent vaginal hysterectomy. The third underwent repeat ablation and became amenorrheic. The ability to achieve complete endometrial atrophy prior to ablation was improved with leuprolide acetate (19/24) and danazol (5/6) when compared to tamoxifen (0/4) and Depo-Provera (0/6). Attainment of amenorrhea after ablation was significantly improved when complete atrophy (19/24) was achieved prior to ablation as compared to the ability to achieve amenorrhea when no endometrial response was achieved (0/7). The only significant complication was one uterine perforation in a patient undergoing repeat ablation.

CONCLUSION

Endometrial rollerball ablation is a safe, effective means of controlling refractory menorrhagia. Amenorrhea is best attained when complete preoperative atrophy is achieved. Leuprolide and danazol were superior to tamoxifen and Depo-Provera.

Microinvasive squamous cell carcinoma of the cervix

The International Federation of Gynecologists and Obstetricians (FIGO) definition of microinvasive carcinoma of the cervix changed recently. We clinically reviewed our treatment of superficially invasive cancer of the cervix in light of those changes. The review covered all patients treated at the University of Michigan from 1970 to 1985 who had stage I squamous cell carcinoma of the cervix, with the Society of Gynecologic Oncologists (SGO) and new FIGO criteria for microinvasion used. Using SGO criteria, 43 patients were treated as follows: total abdominal hysterectomy (32), total vaginal hysterectomy (7), radical hysterectomy (2) and cone biopsy (2). One patient, who had multifocal disease with a maximum depth of 1.5 mm, developed a recurrence and died of the disease. A review of 345 patients considered to have stage IB disease under SGO criteria showed 30 patients who were reclassified as having stage IA2. All these patients were treated with radical surgery and survived, and all had negative lymph nodes. Radical surgery for patients with more than microinvasion according to SGO criteria provides excellent survival rates. Radical therapy may also be indicated for multifocal lesions.

Wound seeding associated with endometrial cancer

We report a patient with well-differentiated adenocarcinoma of the endometrium who developed a recurrence in the anterior abdominal wall probably secondary to wound seeding at the time of her original surgery. She underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy. She then received 15 mCi of 32P for positive peritoneal washings. She was free of disease until 2 years later when a large lower incision mass developed. She had no evidence for intra-abdominal disease and a radical resection with a myocutaneous flap was undertaken. Radical resection for isolated metastases may be of benefit for patients with endometrial cancer. Patients with positive cytology should be observed closely for incisional recurrence.

Overexpression of p53 is not a feature of benign and early-stage borderline epithelial ovarian tumors

Since overexpression of mutant p53 protein is a common feature of invasive epithelial ovarian cancers, we investigated whether overexpression of the p53 tumor suppressor gene product occurs in benign and borderline epithelial ovarian tumors. Immunohistochemical staining for p53 was performed in frozen samples of 17 benign tumors and in 49 borderline tumors (4 frozen, 45 paraffin embedded). Overexpression of p53 was observed in 0/17 (0%) benign ovarian tumors and 2/49 (4%) borderline tumors. Overexpression of p53 in borderline tumors was only seen in advanced stage cases; overexpression was seen in 2/8 (25%) stage III cases, but not in any of 41 stage I/II cases. In conclusion, overexpression of p53 is not a feature of benign epithelial ovarian tumors or early-stage borderline ovarian tumors. Similar to invasive epithelial ovarian cancers, however, a fraction of metastatic borderline tumors also overexpress p53.

Magnetic resonance imaging to avoid laparotomy in pregnancy

OBJECTIVE

To determine whether magnetic resonance imaging (MRI) in pregnancy would help define a benign pelvic mass, thereby avoiding laparotomy.

METHODS

During a 2-3-year period, five pregnant women with adnexal masses suspected to be leiomyomas underwent MRI.

RESULTS

Four patients had evidence of leiomyoma and one had a benign cystic teratoma. All avoided laparotomy because of the almost certain radiologic findings of a benign process. In two women, there was an important effect on the pregnancy; one had fetal growth retardation and the other an outlet obstruction precluding vaginal delivery. Four of the patients underwent cesarean delivery.

CONCLUSIONS

Magnetic resonance imaging can be used in the differential diagnosis of an adnexal mass in pregnancy. This will enable some pregnant patients to avoid laparotomy and its concomitant risks.

The effect of immediate intraperitoneal carboplatinum on wound healing

The effect of introducing intraperitoneal carboplatinum on wound healing immediately after wound closure was studied using a rat model. All animals were opened through a midline incision. A bowel anastomosis was then performed in a single-or two-layer fashion using 6-O suture. Immediately after closing the abdominal wall, each animal was percutaneously injected with either normal saline for controls (n = 11), or carboplatinum, 3 (n = 8), 9, (n = 19, or 12 mg/kg (n = 4). Abdominal and skin incisions were closed separately using 4-O silk suture. Animals were sacrificed 7 days postoperatively. Adhesions were blindly assessed on the following scale: 0 (no adhesions), 1 (filmy adhesions), 2 (firm adhesions), and 3 (dense adhesions). Anastomoses were assessed for leakage. Three centimeters of the incision were harvested to evaluate wound breaking strength. Analysis of abdominal wound breaking strengths showed control = 1320 g +/- 220, 3 mg = 1055 g +/- 155, 9 mg = 891 g +/- 127, and 12 mg = 594 g +/- 165 (P < 0.025). Evaluation for dense adhesions resulted in control = 27%, 3 mg/kg = 50%, 9 mg = 63%, and 12 mg = 100% (P < 0.0001). Immediate instillation of intraperitoneal carboplatinum had a significant effect on wound healing with a decrease in abdominal tensile strength directly related to the dose instilled. It also had a significant effect on adhesion formation with a higher dose leading to a higher incidence of adhesion formation. Based on animal model data, it appears that the immediate instillation of intraperitoneal carboplatinum at the time of laparotomy incision closure could lead to significant problems with wound strength and adhesion formation.

Prognostic factors in advanced stage squamous cell cancer of the cervix

BACKGROUND

This study was undertaken to review prognostic factors for advanced squamous cell cancer of the cervix.

METHODS

A clinicopathologic review of patients diagnosed with advanced stage squamous cell cancer of the cervix was performed at the University of Michigan Medical Center, Ann Arbor, Michigan, from 1970-1985.

RESULTS

All patients had squamous cell disease and were divided according to the following stages: Stage IIIa (4), Stage IIIb (113), Stage IVa (32), and Stage IVb (26). The cumulative 5-year survival was as follows: Stage IIIa (50%), Stage IIIb (37%), Stage IVa (14%), and Stage IVb (4%). Prognostic features for Stage IIIb disease showed that the intravenous pyelogram status significantly predicted cumulative 5-year survival (P = 0.00001). When the intravenous pyelogram was normal, 47% survived. When ureteral obstruction was present without renal failure, 29% survived, and when renal failure occurred, all patients were dead of disease by 16 months. The lymph node status significantly influenced cumulative 5-year survival (P = 0.004). When lymph nodes were negative, 47% survived. When three or fewer were positive, 44% survived. When more than three were positive, 11% survived. When pelvic lymph nodes were positive and paraaortic node status was determined, 25% survived when paraaortic lymph nodes were negative, while 8% survived when these were positive (P = 0.06). Factors that did not influence 5-year survival included one or both sidewall involvement (P = 0.77), tumor grade (P = 0.23), diabetes (P = 0.92), hypertension (P = 0.85), and obesity (P = 0.47). The diagnosis of Stage IVa disease was made by the presence of fistula at initial presentation (n = 8), cystoscopy (n = 21), and sigmoidoscopy (n = 1). One patient developed a treatment-related vesicovaginal fistula when bladder involvement was diagnosed by cystoscopy. All 18 patients who presented with renal failure (Stage IIIb, 9; Stage IVa, 9) were analyzed as a group, and only 1 patient survived. The median survival in 15 patients who underwent nephrostomy was 8 months, range 1-36 months. Ten of 15 patients (66%) were dead of disease within 1 year. Three patients refused renal bypass, and these three patients died at 1, 2, and 3 months, respectively.

CONCLUSIONS

Advanced stage disease represents a significant challenge, and when ureteral obstruction or renal failure is present, the prognosis is markedly decreased.

Radical vulvectomy. The decision for the incision

BACKGROUND

An analysis of survival and complications related to the type of radical vulvectomy operation performed is reported.

METHODS

Clinical records and pathology reports were reviewed for the time period 1975-1989. The operation, complications, and site of recurrent disease were recorded.

RESULTS

The following types of surgical vulvectomies were used: radical vulvectomy (28 cases), the technique with three separate incisions (42 cases), and en bloc radical vulvectomy (94 cases). There was no significant difference in survival between the patients receiving en bloc radical vulvectomy or three separate incisions when analyzed by stage of disease. The following numbers of local/regional recurrences occurred among patients receiving the following treatment regimens: radical vulvectomy, seven; the technique with three separate incisions, six; and en bloc radical vulvectomy, five. Three patients treated by the separate-incision technique had a bridge recurrence. Complications were more frequent in those receiving the en bloc technique compared with those receiving the technique with three separate incisions: wound breakdown, 64% versus 38%, respectively (P = 0.005); wound infection, 20% versus 12%, respectively (P = 0.4); wound cellulitis, 21% versus 14%, respectively (P = 0.4); and lymphocyst formation, 28% versus 14%, respectively (P = 0.08). Drain placement or prophylactic antibiotics did not reduce wound infection or wound breakdown significantly. The most common sites of metastatic disease were the lungs and subcutaneous tissues of the leg. Hypercalcemia occurred in four patients, with the sites of metastatic disease being the subcutaneous tissue of the thigh (three patients) and pubic bone (one patient).

CONCLUSIONS

The technique with three separate incisions provides satisfactory survival results with less morbidity compared with the en bloc technique of radical vulvectomy.

Primary treatment of stage III ovarian carcinoma with sequential chemotherapy and whole abdominal radiation therapy

A prospective phase II clinical treatment trial of 13 patients with previously untreated optimal surgically resected (< or = 1 cm stage III ovarian carcinoma was conducted at the University of Michigan Hospitals. The treatment regimen after surgical resection consisted of chemotherapy followed by whole abdomen and pelvic radiation therapy. Chemotherapy consisted of four cycles of 50 mg/m2 cisplatin and 1000 mg/m2 cytoxan. This was followed by whole abdomen radiation therapy with a planned total dose of 30 Gy to the whole abdomen and then a 20-Gy boost to the pelvis. Six of 13 patients received a paraaortic radiation boost. There was minimal acute toxicity, but delayed toxicity was encountered with 38% of patients developing a bowel obstruction. Nine patients had reassessment laparotomy: 5 second-look laparotomies and 4 laparotomies for bowel obstruction. Two of these 9 patients died of septic complications after surgery. Nine patients died with disease, 1 patient is alive with advanced disease, and only 3 patients are alive with no evidence of disease. Actuarial 3-year survival and progression-free interval was 26 and 20%, respectively. Primary treatment consisting of sequential chemotherapy and whole abdomen radiation in the dose and scheme utilized did not improve the survival over what could be expected utilizing one of these treatments alone. It was associated with increased delayed toxicity.

Prognostic significance of DNA content and nuclear morphology in borderline ovarian tumors

We used the technique of image analysis to simultaneously measure DNA content and nuclear morphology of 21 borderline ovarian tumors. Aneuploidy was identified in 9 of 21 tumors and was unrelated to tumor stage or nuclear grade. Morphometric nuclear features that were measured included size, shape, texture, and average density. Nuclear size and shape were positively correlated (r = 0.507), and nuclear size and average density were negatively correlated (r = -0.772). Six tumors recurred and recurrence was significantly associated with tumor aneuploidy (P = 0.046), stage III tumors (P = 0.03), and increased nuclear texture (P = 0.07). These results suggest that measurement of DNA ploidy and nuclear morphology using image analysis can provide important prognostic information in patients with borderline ovarian tumors.

Pelvic exenteration for the treatment of vulvar cancer

BACKGROUND

Advanced vulvar cancer can be treated by pelvic exenteration.

METHODS

A clinical review of patients treated by exenteration surgery for vulvar cancer was performed.

RESULTS

From 1950 through 1989, 19 patients underwent pelvic exenteration for advanced or recurrent squamous cell cancer of the vulva. The mean age was 53 years (median, 50 years; range, 40-74 years). The cumulative 5-year survival was 60%. Fourteen patients had posterior exenteration; 2 had anterior exenteration; and 3 had total exenteration. The survival was significantly influenced by lymph node status. When lymph nodes were not involved, 10 of 14 patients survived, whereas all 5 patients with lymph node involvement died of disease (P = 0.002). When exenteration was performed as primary therapy, 7 of 11 patients survived, whereas 3 of 8 survived when exenteration was performed for recurrent disease (P = 0.4). The extent of vulvar involvement did not influence survival (P = 0.99). There was no mortality, but ten patients had complications, including vesicovaginal fistula (three); stomal hernia (two); abscess (one); stress urinary incontinence (one); deep venous thrombosis (one); conduit leak (one); enterocutaneous fistula (one); and small intestinal obstruction (one).

CONCLUSIONS

Acceptable survival for advanced or recurrent vulvar cancer can be achieved with pelvic exenteration, but the presence of metastatic disease to lymph nodes markedly decreases survival.

Pelvic exenteration for the treatment of vulvar cancer

BACKGROUND

Advanced vulvar cancer can be treated by pelvic exenteration.

METHODS

A clinical review of patients treated by exenteration surgery for vulvar cancer was performed.

RESULTS

From 1950 through 1989, 19 patients underwent pelvic exenteration for advanced or recurrent squamous cell cancer of the vulva. The mean age was 53 years (median, 50 years; range, 40-74 years). The cumulative 5-year survival was 60%. Fourteen patients had posterior exenteration; 2 had anterior exenteration; and 3 had total exenteration. The survival was significantly influenced by lymph node status. When lymph nodes were not involved, 10 of 14 patients survived, whereas all 5 patients with lymph node involvement died of disease (P = 0.002). When exenteration was performed as primary therapy, 7 of 11 patients survived, whereas 3 of 8 survived when exenteration was performed for recurrent disease (P = 0.4). The extent of vulvar involvement did not influence survival (P = 0.99). There was no mortality, but ten patients had complications, including vesicovaginal fistula (three); stomal hernia (two); abscess (one); stress urinary incontinence (one); deep venous thrombosis (one); conduit leak (one); enterocutaneous fistula (one); and small intestinal obstruction (one).

CONCLUSIONS

Acceptable survival for advanced or recurrent vulvar cancer can be achieved with pelvic exenteration, but the presence of metastatic disease to lymph nodes markedly decreases survival.

Malignant placental site trophoblastic tumor associated with placental abruption, fetal distress, and elevated CA-125

The second pregnancy of 27-year-old woman, gravida 2, para 2 was complicated by a low alpha-fetoprotein and symptoms of chronic placental abruption. She delivered by cesarean section at 35 weeks for fetal distress at which time a biopsy of the uterus revealed a placental site trophoblastic tumor (PSTT). She rapidly developed intraabdominal spread of the neoplasm which did not respond to chemotherapy and she died 10 weeks later. Her CA-125 was elevated to 5360 mu/ml and this decreased after hysterectomy. This patient is reported to highlight a very malignant course of PSTT that was associated with a live-born male infant.

A comparison of staging systems for squamous cell carcinoma of the vulva

A review of 172 patients with squamous cell cancer of the vulva treated at the University of Michigan Medical Center from 1975-1989 was performed to compare the 1988 FIGO Staging System to the 1970 FIGO Staging System. The stage distribution according to the 1970 FIGO Staging System was stage I, 65; stage II, 44; stage III, 50; and stage IV, 13. The cumulative 5-year survival under the old system was stage I, 94%; stage II, 91%; stage III, 36%; and stage IV, 26%. The distribution changed under the 1988 FIGO system to stage I, 58; stage II, 36; stage III, 49; stage IVA, 16; and stage IVB, 13. The cumulative survival also changed to stage I, 94%; stage II, 89%; stage III, 71%; stage IVA, 19%; and stage IVB, 8%. The new FIGO stage distribution shifted for the worse due to the influence of positive lymph nodes found at the time of surgery. The survival was then analyzed for death from all causes. This was markedly decreased when compared to the cumulative corrected survival. This relates to the high number of other primary malignancies and the age of the patients. Among these 172 patients, other primary malignancies included squamous cell cancer of the cervix (11), squamous cell cancer of the vagina (2), endometrial cancer (3), squamous cell cancer of the lung (2), colon cancer (3), and others (6). An additional 5 patients died from myocardial infarction within 2 years of diagnosis. The new 1988 FIGO Staging System provides for better discrimination of survival between stages than the 1970 FIGO Staging System.

The prognosis and management of cervical cancer associated with pregnancy

OBJECTIVE

We sought to evaluate the prognosis of patients with stage IB cervical cancer related to pregnancy.

METHODS

We reviewed 53 patients from the University of Michigan diagnosed with cervical cancer related to pregnancy between 1960-1989. Patients with stage IB disease were compared with a control group less than 46 years old to determine whether pregnancy influenced survival.

RESULTS

The mean age of the patients was 30.5 years (range 22-45). The number of patients treated by 5-year periods decreased from a high of 17 during 1965-1969 to a low of three during 1985-1989. The following cell types and stages were treated: squamous cell stages IA (four), IB (35), and IIB (six); adenocarcinoma stages IB (five) and IIB (two); and small-cell stage IIB (one). The 35 patients with stage IB disease had a cumulative 5-year survival of 83%. Positive lymph nodes were present in eight of 24 patients. There was no significant difference in 5-year survival according to the time of therapy (P = .45): Ten second-trimester patients had 90% survival, five third-trimester patients had 75% survival, and 20 postpartum patients had 75% survival. Eighteen of 21 patients treated by radical hysterectomy survived: three of four treated at term, five of five treated in the second trimester, and ten of 12 treated postpartum. Seven of 12 patients treated by radiation therapy survived: one of one treated at term, five of six treated in the second trimester, and one of five treated postpartum. When we compared these patients with 170 nonpregnant women less than 46 years old with stage IB squamous cell cancer, pregnancy did not adversely influence survival (P = .13).

CONCLUSIONS

The number of patients diagnosed with invasive cervical cancer related to pregnancy has decreased. Survival is not altered by pregnancy for stage IB disease.

Continuous infusion of low-dose 5-fluorouracil and radiation therapy for poor-prognosis squamous cell carcinoma of the uterine cervix

Ten patients with squamous cell carcinoma of the cervix metastatic to periaortic lymph nodes were treated with external-beam radiation therapy and synchronous infusion of intravenous 5-fluorouracil (5-FU) chemotherapy at doses of 350 mg/m2/day. The overall response rate was 90% with four complete responses (CR) and five partial responses (PR). The median duration of response was 11.8 months for CRs and 3.6 months for PRs. Toxicity was tolerable, with gastrointestinal symptoms and myelosuppression being noted most frequently. No patient experienced life-threatening toxicity. Median survival was 7.6 months, with only one patient being alive and free of disease at 2 years. In this pilot study we were unable to demonstrate a beneficial effect of continuous infusion of low doses of 5-FU chemotherapy concurrent with radiation therapy when compared to conventional radiotherapy in patients with advanced squamous cell carcinoma of the cervix.

Rapid growth of leiomyoma in patient receiving tamoxifen

A 49-year-old patient with breast cancer had a leiomyoma that rapidly enlarged shortly after she started therapy with tamoxifen. Exploratory laparotomy was necessary to confirm the diagnosis. The rapid growth may have resulted from the estrogen agonist properties of tamoxifen or alternatively by ovarian stimulation resulting in endogenous estrogen production.

Consistent chromosome abnormalities in squamous cell carcinoma of the vulva

Six squamous cell carcinomas of the vulva (SCV) were karyotyped in short-term culture and in early passages as established cell lines. Each tumor was cytogenetically distinct, contained multiple chromosome rearrangements, and was karyotypically stable in culture. Heterogeneity within individual tumors was manifested by the presence of more than one clonal population, but the clones within each tumor were closely related to one another. Seven consistent chromosome abnormalities found in five of the six tumors were: losses of 3p14-cen, 8pter-p11, 22q13.1-q13.2, and the short arm of the inactive X; chromosome gains involving 3q25-qter and 11q21; and rearrangement breakpoints at 5cen-q12. Ten additional chromosome changes were observed in four of the six SCVs, and together, 22 changes occurred in at least three of the tumors. Two specific losses, 10q23-q25 and 18q22-q23, were present in all four tumors that exhibited biologically aggressive behavior in vivo, but these losses were not found in the tumors of the two long-term survivors. These findings indicate that: 1) SCVs are genetically complex, but homogeneous; 2) loss of 18q22-q23 and loss of 10q23-q25 may be associated with a poor prognosis; and 3) development and progression of SCV appear to result from cumulative effects of altered gene dosage at multiple, consistent loci.

The effects of early removal of indwelling urinary catheter after radical hysterectomy

Radical hysterectomy has long been a primary mode of therapy for selected gynecologic malignancies. The lower urinary tract is an area associated with complications following this procedure. Lack of satisfactory reflex micturition and urinary retention, diminished bladder sensation, infection, and fistula formation are common adverse sequelae. Prolonged indwelling catheterization is a cornerstone of postoperative management after radical hysterectomy. An alternative regimen consisting of early postoperative catheter removal, with a strict voiding schedule, and intermittent self-catheterization (ISC) for postvoid residuals (PVR) was prospectively investigated. Intermittent self-catheterization was initiated only if the PVR 12 hr after catheter removal was greater than 75 ml. Twenty-six patients who underwent radical hysterectomy were studied. Catheters were removed between the fifth and ninth postoperative day. Eighteen patients (69%) had PVRs less than 75 ml at 12 hr and were successfully managed with a strict voiding schedule only. Eight patients (31%) had 12-hr PVRs greater than 75 ml and were managed with a strict voiding schedule and ISC until the PVR was less than 75 ml for two consecutive voids. These patients were evaluated with fluorourodynamics and none had an abnormal study. Compared to 25 historical control patients, study group median indwelling catheter duration was less (6.0 days compared to 30.0 days) with no increase in postoperative complications. On the basis of these data, early removal of indwelling urinary catheters after radical hysterectomy appears to be an acceptable alternative to long-term catheterization.

Squamous cell carcinoma of the vulva: prognostic factors influencing survival

One hundred seventy-two cases of patients with squamous cell cancer of the vulva treated at the University of Michigan Medical Center from 1975 to 1988 are reported. The mean age was 66 years with a range of 21 to 101 years. The distribution by stage included Stage I, 65; Stage II, 44; Stage III, 50; and Stage IV, 13 patients. Groin node dissections performed on 145 patients showed negative nodes, 58%; unilateral positive nodes, 28%; and bilateral positive nodes, 14%. The distribution of patients with positive nodes was influenced by stage: Stage I, 14%; Stage II, 23%; Stage III, 72%; Stage IV, 92%. The overall cumulative 5-year survival was 71% and this was significantly influenced by stage of disease: Stage I, 94%; Stage II, 91%; Stage III, 36%; Stage IV, 26%. Stages I/II and III/IV were combined for analysis. In Stages I/II, survival was significantly influenced by tumor grade while size, patient age, and lymph node status did not influence survival. In Stage III/IV, survival was significantly influenced by tumor size, node status, and number of positive nodes while grade, patient age, and tumor location did not influence survival. Squamous cell cancer of the vulva is effectively treated with radical surgery but advanced-stage disease with regional metastases significantly alters survival.

Radical hysterectomy versus radiation therapy for stage IB squamous cell cancer of the cervix

Three hundred forty-five patients with Stage IB squamous cell carcinoma of the cervix were treated at the University of Michigan Medical Center from 1970 to 1985. The overall cumulative 5-year survival rate was 89% and the mean age was 44.6 years. In 213 patients undergoing radical hysterectomy the cumulative 5-year survival rate was 92%; 14 patients were explored for radical hysterectomy that was not performed due to high risk features and their survival rate was 50%. Ninety-seven patients underwent radiation therapy as initial treatment and had a 5-year survival rate of 86%. There was no significant difference when radiation therapy was compared with radical hysterectomy (P = 0.098). The survival rates for lesions 3 cm or smaller were 94% for radical hysterectomy and 88% for radiation therapy. When the lesion was larger than 3 cm, the survival rates were 82% with radical surgery and 73% with radiation therapy. Metastatic disease to lymph nodes was present in 26 of the 213 patients undergoing radical hysterectomy. When 1 to 3 nodes were involved 16 of 19 patients survived and when 4 to 10 nodes were involved 3 of 7 patients survived. The addition of radiation therapy did not influence survival. Complications were similar in both treatment groups. Fistulas occurred in 4 of 213 patients undergoing radical hysterectomy and 1 of 111 undergoing radiation. Second surgery for a complication was required in 6 of 213 patients undergoing radical hysterectomy and 7 of 111 undergoing radiation. Survival and complication rates in early stage squamous cell carcinoma of the cervix are equal with either radical surgery or radiation therapy.

Squamous cell cancer of the cervix: prognostic factors related to survival

Seven hundred and fifty-three patients with invasive squamous cell cancer of the cervix treated at the University of Michigan from 1970–1985 are reported. These included stage IA 43, stage IB 345, stage IIA 27, stage IIB 163, stage IIIA 4, stage IIIB 113, stage IVA 32, stage IVB 26. The age ranged from 18 to 92 years with a mean of 49.9 years. Clinical characteristics included: nulliparity 11%, married 93%, obese 41%, hypertensive 37%, diabetes 10%, smoking 50%, bleeding 76%. The cumulative five-year survival for all patients was 67% and this was influenced by the stage of disease: stage IA 98%, stage IB 89%, stage IIA 72%, stage IIB 62%, stage III 37%, stage IVA 14%, stage IVB 4%. Patients with a well-differentiated tumor had an 85% survival rate while those with a poorly differentiated tumor had a 57% survival rate. The probability of metastatic disease to lymph nodes corresponded to the stage of disease; stage I 17%, stage II 55%, stage III 70%, stage IV 81%. When lymph nodes were negative, the survival rate for all patients was 86% while those with positive nodes had a 33% survival rate. Factors which influenced survival in the univariate analysis included stage, node status, tumor grade, age, interval from previous pelvic examination, diabetes. Only stage, node status and tumor grade maintained significance in the multiple proportion hazard analysis.

Stage IB squamous cell cancer of the cervix: clinicopathologic features related to survival

Three hundred forty-five patients with stage IB squamous cell carcinoma of the cervix were treated at the University of Michigan Medical Center from 1970 through 1985. The overall cumulative 5-year survival was 89%. The clinical characteristics included mean age 44.6 years, nulliparity 10%, married 93%, obese 38%, hypertension 32%, diabetes mellitus 5%, smoking 54%, symptoms of bleeding 68%, positive cytologic smear 83%. Lymph nodes were diseased in 45 of 261 (17%) with 26 unilateral (10%) and 19 bilateral (7%). Tumor differentiation showed: grade 1, 112 (33%); grade 2, 144 (42%); grade 3, 86 (25%). Factors that did not influence survival included age, presence or absence of positive cervical cytologic smear, the interval from previous papanicolaou smear, hypertension, smoking history, patient's blood type, and transfusion at radical hysterectomy. In all patients survival was significantly influenced by the following features: tumor classified as well differentiated (95%) or poorly differentiated (82%); tumor size less than 3 cm (91%) or greater than 3 cm (76%); negative lymph nodes (93%) or positive lymph nodes (61%). When three or fewer lymph nodes were involved, the survival was 79% compared with 33% when four or more lymph nodes were involved. In 213 patients undergoing radical hysterectomy the cumulative 5-year survival was significantly influenced by the amount of residual cervical disease: no residual disease, 100%; less than 50% penetration, 96%; greater than 50% penetration, 83%. Involvement of the lower uterine segment reduced survival to 73% compared with 95% when the lower segment was uninvolved. One hundred seventeen patients without angiolymphatic invasion had a 97% cumulative 5-year survival whereas 70 patients without disease in the lymph nodes but with angiolymphatic invasion had an 88% cumulative 5-year survival rate. A Cox model, multiple proportional hazard analysis was performed for all patients, and the factors that influenced survival included tumor grade, tumor size, presence of metastatic disease in the lymph nodes, and diabetes mellitus. In patients undergoing radiation therapy, the tumor grade and size were significant factors in survival. In patients undergoing radical hysterectomy, survival was influenced by the depth of cervical penetration and lower uterine segment involvement whereas the tumor grade, tumor size, patient's age, and removal of ovaries were not significant.

A comparison of adenocarcinoma and squamous cell carcinoma of the cervix

A comparison and survival analysis of 203 patients (21%) with adenocarcinoma and 756 (79%) with squamous cell cancer of the cervix for the time period 1970-1985 is reported. The mean number of new cases of adenocarcinoma (N = 12) remained the same, while squamous cell cases decreased from 57 to 32. The clinical features were compared; oral contraceptive usage, node status, diabetes, and symptoms of bleeding were not related to cell type. Nulliparity was more frequent in patients with adenocarcinoma, whereas obesity and smoking were more frequent in patients with squamous cell cancer. Survival in stage I was significantly influenced by the cell type. Patients with stage I squamous cell disease had a 90% 5-year survival, compared with 60% for adenocarcinoma (P less than .0001). Other features that influenced survival included node status (P = .001), poor differentiation of tumor histology (P = .001), diabetes (P = .001), and Papanicolaou smear interval (P = .001). Patients undergoing radical hysterectomy were analyzed separately, and adenocarcinoma cell type significantly influenced survival (P = .0008). Patients with stage II squamous cell disease had a 62% survival, compared with 47% for adenocarcinoma (P = .01); patients with stage III squamous cell disease had a 36% survival, compared with 8% for adenocarcinoma (P = .002). The percentage of adenocarcinoma has increased because of the decreased number of patients with squamous cell disease. Stage-for-stage survival is significantly decreased for patients with adenocarcinoma as opposed to squamous cell disease.

Characterization of epidermal growth factor receptor in normal and neoplastic human endometrium

Growth factors, including epidermal growth factor (EGF), have been implicated in the growth of several types of cancer. This study compares EGF receptors in normal and neoplastic endometrium. Membrane fractions were isolated from surgical specimens. Radioreceptor assays demonstrated the presence of receptors with a dissociation constant of 0.64 nmol/l in normal endometrium. Affinity cross-linking revealed receptor molecular weight of 150 to 170 kiloDaltons (KD). A survey of samples (n = 37) revealed progressive decrease of EGF receptors in cancers of increasing grade: Grade 1-2 adenocarcinoma decreased 34% from control (n = 6, P less than 0.01), whereas Grade 3 adenocarcinoma decreased 90% (n = 7, P less than 0.01) and sarcoma decreased by 72% (n = 3, P less than 0.01). The dissociation constant and molecular weight of the receptor in neoplastic endometrium did not differ significantly from normal. The inverse relationship with grade suggests receptor alteration or down regulation by hormones and/or growth factors.

Regulation of epidermal growth factor and insulin-like growth factor I receptors by estradiol and progesterone in normal and neoplastic endometrial cell cultures

Growth factors are polypeptides which regulate cell proliferation through binding to specific receptor proteins. Normal and neoplastic human endometrium have been shown to express epidermal growth factor (EGF) and insulin-like growth factor I (IGF-1) receptors. Endometrial cell cultures were used to test modulation of EGF and IGF-1 receptors in response to steroid hormones. Endometrial gland and stroma cells were separated by enzymatic dispersion and were incubated in medium containing estradiol (10, 100, or 1000 pg/ml) or progesterone (1, 10, or 100 ng/ml) followed by radioligand assays. Normal endometrial cultures (n = 6) treated with estradiol demonstrated 40% less EGF binding than control cultures (P less than 0.05), while IGF-1 binding was unaffected. Stromal cells treated identically decreased in only one treatment group. Progesterone treatment stimulated a significant increase in EGF and IGF-1 receptors in gland cultures. Cultures derived from adenocarcinoma (n = 2) demonstrated decreased EGF binding compared with normal endometrium (P less than 0.05). Carcinoma cells treated with progesterone resulted in a dose-dependent increase in EGF binding over control (P less than 0.05). These data illustrate effects of steroid hormones upon growth factor receptors in human endometrium, and suggest involvement of growth factors in the regulation of normal and neoplastic endometrial growth.

Training obstetrics-and-gynecology residents to manage breast disease. Incorporation into a breast care clinic

The American Board of Obstetricians and Gynecologists recently issued a directive that education in breast disease be incorporated into all residency training programs. At the University of Michigan Medical Center, the Comprehensive Breast Care Center (BCC) provides the vehicle for the education and training of residents in the area of breast disease. The department of obstetrics and gynecology is fully integrated and participates actively in the care of patients in the BCC.