On the logarithmic relationship between NO2 concentration and the distance from a highroad.

Measurements of nitrogen dioxide (NO2) concentrations, performed with passive diffusion samplers in gradients from a highway in South-west Sweden, were used to test the assumption that the NO2 concentration contributed by the highway varies with the logarithm of the distance from the highway. The five data sets used corroborated the hypothesis, and it was shown that all data could be accommodated to a common relationship with high correlation (R2=0.95) using the concentration of 10 m away from the highroad as the reference. The data were also well in accordance with a recently published study from Canada, although the slope of the relationship between the NO2 concentration contributed by a highway and the logarithm of the distance was somewhat stronger for the Swedish data compared to the Canadian. The regression slope is likely to be sensitive to wind speed, atmospheric stability, surface roughness and the background ozone concentrations of the area.

The prognostic importance of p53, bcl-2, and bax in early stage epithelial ovarian carcinoma treated with adjuvant chemotherapy.

Epithelial ovarian cancer is one of the major causes of death among women. The increasing knowledge about molecular events involved in the early stages of ovarian tumorigenesis may provide the basis for management in the future. In a series of 109 patients with epithelial carcinomas in FIGO stages IA-IIC, a number of clinicopathologic prognostic factors (age, FIGO stage, histopathologic type, and tumor grade) were studied in relation to the biologic factors p53, bcl-2, and bax, which are important regulators of apoptosis. Immunohistochemical techniques were used. All the patients received adjuvant chemotherapy after the primary surgery. Univariate analysis showed that expression of p53 was significantly associated with tumor grade (P = 0.014), probability of persistent disease (P = 0.016), and cancer-specific survival rate (P = 0.007). Positive bcl-2 staining was associated with endometrioid tumor subtype (P = 0.029) and a favorable tumor grade distribution (P = 0.034), but not with the survival status. The combined p53-bcl-2 expression was related to histopathologic subtype (P = 0.032), tumor grade (P = 0.011), persistent disease (P = 0.014), and risk of dying due to the disease (P = 0.039). The bax status was not a prognostic factor, but the combined p53-bax expression showed an association with FIGO stage (P = 0.014), tumor grade (P = 0.034), persistent disease (P = 0.006), and risk of dying due to the disease (P = 0.039). The combined bcl-2-bax expression was related to histopathologic subtype (P = 0.045) and tumor grade (P = 0.022). In a multivariate Cox analysis, tumor grade (P = 0.014), and p53 status (P = 0.020) were independent and significant prognostic factors with regard to the cancer-specific survival rate.

Ovarian cancer in young women in Sweden, 1989-1991.

The present study is an evaluation of the symptoms and gynecological status, at the time of seeking medical advice, among women of reproductive age diagnosed with ovarian malignancies. The study was based on the medical records of all women in Sweden between 15 and 40 years of age who were diagnosed with ovarian malignancies during a 3-year period (1989-1991). The study focused on the diagnosis and panorama of symptoms. These data were compared to the records of more than 10,000 women in this age group during the same period of time who underwent surgery for ovarian changes that resulted in benign diagnoses. The 152 cases of ovarian cancer included only 1 patient who was without symptoms, had normal pelvic status upon manual examination, and a sonographically diagnosed simple cyst. These data support the conclusion that the majority of young women with ovarian cancer have symptoms and/or clinically detectable adnexal masses at the time when medical advice is sought. These studies suggest that diagnosis of ovarian cancer is unlikely in young healthy women lacking subjective symptoms and an adnexal mass upon pelvic examination. In conclusion, programs for the management of simple cysts and development of noninvasive diagnostic methods for ovarian changes found in patients in the reproductive age group are needed in order to reduce the number of patients subjected to operative intervention.

In vitro determination of cytotoxic drug response in ovarian carcinoma using the fluorometric microculture cytotoxicity assay (FMCA).

The fluorometric microculture cytotoxicity assay (FMCA), a short-term in vitro assay based on the concept of total tumor cell kill, was used for testing the cytotoxic drug sensitivity of tumor cells from patients with ovarian carcinoma. A total of 125 fresh specimens was obtained, 98 (78%) of which were analyzed successfully. Data from 45 patients were available for clinical correlations. The FMCA appeared to yield clinically relevant cytotoxic drug sensitivity data for ovarian carcinoma as indicated by a comparison with tumor samples obtained from patients with non-Hodgkin's lymphoma or kidney carcinoma. Considering the most active single agent in vitro actually given in vivo, and using the median drug activity among all ovarian carcinoma samples as a cut-off, the sensitivity of the assay and its specificity were 75 and 52%, respectively. Cross-resistance in vitro was frequently observed between standard drugs but not between standard drugs and Taxol. Ten percent of the specimens showed an extreme resistance for at least 4 of 6 of the drugs investigated.

Mechanisms of escape from CD8+ T-cell clones specific for the HER-2/neu proto-oncogene expressed in ovarian carcinomas: related and unrelated to decreased MHC class 1 expression.

We have developed an in vitro model to study mechanisms by which ovarian tumor cells that over-express the HER-2/neu proto-oncogene escape recognition by TCD8+. Nine tumor-specific, HLA A2-restricted TCD8+ clones were isolated from 2 ovarian tumor-specific TCD8+ lines derived from tumor-infiltrating or -associated lymphocytes. Of these, 2 clones recognized the previously defined HER-2/neu epitope E75 (a.a. 369-377) and one recognized the C85 epitope (a.a. 971-979), whereas the specificity of the remaining 6 clones was unknown. Three different tumor escape variants (EVC8, EVC22 and EVC36) were produced by co-culturing an ovarian tumor line over-expressing HER-2/neu with these autologous TCD8+ clones. Cell surface expression of HLA A2 was markedly decreased on all 3 escape variants, relative to the parental tumor line, while no significant decrease in their expression of the HER-2/neu, ICAM-1 or LFA-3 molecules was found. There was a correlation between the level of tumor-specific recognition and HLA A2 expression among the tumor clones isolated from 2 of the escape variants (EVC8 and EVC36). In contrast, high HLA A2-expressing tumor clones isolated from the EVC22 variant, or EVC22 which had regained high HLA A2 expression through IFN-gamma treatment, were not recognized by the HER-2/neu-specific TCD8+ clone C-22. No mutations were found in the cDNA or the genomic DNA derived from the PCR product corresponding to a 496 bp fragment including the region coding for the E75 epitope of the HER2/neu gene in the EVC22 variant. Collectively, this in vitro model underlines the importance of decreased expression of the HLA restriction element for escape from tumor-specific TCD8+ but also demonstrates that additional mechanisms exist.

Excretion of ketobemidone in human breast milk.

The excretion of ketobemidone into human breast milk was investigated in three women who obtained ketobemidone as postoperative pain relief after Cesarean section and two women premedicated with 5 mg of ketobemidone before currettage after delivery. The highest observed concentration of ketobemidone in breast milk was 36 ng/ml three hours after administration, and 4-7 hours after administration the concentration was 3-5 fold that in maternal plasma. It could be estimated that the newborn will be exposed to less than 2 micrograms of ketobemidone during the first 24 hours.

Complications after radiotherapy and radical hysterectomy in early-stage cervical carcinoma.

OBJECTIVE: To evaluate the overall complications, major as well as minor, in patients treated for early-stage cervical carcinoma as related to treatment parameters. METHODS: In this retrospective study, 167 consecutive patients with early-stage cervical carcinoma treated with preoperative radiotherapy and radical hysterectomy were investigated. Clinical data were collected from the medical files. RESULTS: Transient or permanent complications appeared in up to half of all patients. Seven percent exhibited intraoperative complications and 35% suffered from early postoperative urinary tract problems; most frequently urinary tract infection. After one year, the urinary tract complications dominated; voidance difficulties and incontinence being most common. Gastrointestinal complications occurred in 15% of patients. Lymphedema appeared during the first year in 21% of the patients but several of the mild or moderate cases improved after the first year. The relative risk of lymphedema was increased with shorter duration of surgery, extensive preoperative irradiation to the bladder and after external postoperative irradiation. Some form of late sequelae remained in every fifth patient, and every fourth patient, aged 24-44 years, periodically suffered from vasomotor symptoms despite estrogen replacement therapy. CONCLUSION: The complications after radiotherapy and radical hysterectomy in early stage cervical carcinoma suggest that attempts should be made to evaluate effective treatments designed to minimize risk to the patients.

Cytotoxic drug sensitivity testing of tumor cells from patients with ovarian carcinoma using the fluorometric microculture cytotoxicity assay (FMCA).

The automated fluorometric microculture cytotoxicity assay (FMCA) is based on the measurement of fluorescence generated from cellular hydrolysis of fluorescein diacetate (FDA) to fluorescein by viable cells after a 72-hr culture period in microtiter plates. The FMCA was adopted for chemosensitivity testing of tumor cells from patients with ovarian carcinoma. Thirty-seven samples of solid tumors and malignant effusions were obtained from 35 patients at diagnosis or relapse. Tumor cells from solid samples and effusions were prepared by enzymatic digestion and centrifugation, respectively, followed by Percoll or Ficoll purification. The fluorescence was proportional to the number of cells/well and considerably higher in tumor cells than in contaminating normal cells. The effect of up to 19 cytotoxic drugs was successfully assessed in 70% of the samples and there was a good correlation between drug sensitivity data reported by the FMCA and the DiSC assay performed in parallel. The overall drug sensitivity pattern in vitro corresponded well to the clinical experience. The effect of cisplatin varied considerably between patients and resistance was found also in cases not previously exposed to cytotoxic drugs. The FMCA is a rapid and simple method that seems to report clinically relevant cytotoxic drug sensitivity data in ovarian carcinomas. In the future, this method may contribute to optimizing chemotherapy by assisting in individualized drug selection and new drug development.

Prognostic factors and relapse patterns in early-stage cervical carcinoma after brachytherapy and radical hysterectomy.

Patients with cervical carcinoma FIGO stage IB and IIA (n = 167) treated with brachytherapy, radical hysterectomy, and pelvic lymphadenectomy at the University Hospital of Uppsala were evaluated, and a multivariate analysis was performed to reveal clinical and histopathological variables of predictive value of recurrence. The 5-year survival rate was 90%. Nineteen patients developed recurrent disease (11%), 15 of whom died. Patient age, clinical stage, type, and histologic grade of tumor did not indicate an increased risk of recurrence. However, multiparity (3 children or more; relative risk, RR = 4.6), lymph node metastases (RR = 6.4), tumor size (RR = 5.1), and residual carcinoma in the hysterectomy specimen (RR = 3.4) were important predictive indicators of recurrence. The median interval from initial treatment to the diagnosis of recurrence was 15 months. The majority of recurrences occurred during the first 2 years after treatment (74%) and most of them had symptoms (84%). Only three patients with recurrence were diagnosed within our surveillance program. The data suggest that surveillance for recurrence can be made more cost efficient with a more individualized follow-up during the first 2 years after treatment, concentrating on the patients with high-risk factors such as large tumors, residual carcinoma after irradiation therapy, and/or lymph node metastases.

Immunohistochemical identification of receptors for epidermal growth factor in tumor endothelium may be affected by cross-reactivity to blood group A antigen.

It has been reported that endothelium in malignant glioma stains with a commercial antibody raised against the receptor for epidermal growth factor (EGFr) on A431 cells (clone 29.1). In this report, this antibody was used to study the immunohistochemical expression of EGFr in benign and malignant ovarian, mid-gut carcinoid, and thyroid neoplasms using the avidin-biotin-peroxidase complex technique. Eighteen of the 37 ovarian neoplasms, 4 of the 10 thyroid neoplasms, and 14 of 28 mid-gut carcinoid tumors expressed strong and distinct endothelial staining, whereas staining results of the remaining tumors were negative. The endothelial nature of the staining was verified by staining serial sections with Ulex europaeus agglutinin-I. The staining was independent of that obtained with an antibody raised against a synthetic peptide consisting of residues 985 to 996 from the cytoplasmic domain of EGFr (clone F4). All positive staining occurred in patients determined to be of blood groups A or AB, whereas samples from patients with blood groups B or O were negative. Immunoabsorption of the antibody with centrifuged erythrocytes from a blood group A donor, but not from a blood group B donor, abolished the positive staining. The data indicate that positive staining of tumor endothelium with this antibody is due to cross-reactivity with blood group A antigen. The results obtained challenge the validity of previously performed immunohistochemical studies in which monoclonal antibodies raised against the EGFr of A431 cells have been used, and in which the epitope for the monoclonal antibody has not been determined.

Ethylmorphine O-deethylation cosegregates with the debrisoquin genetic metabolic polymorphism.

The single oral dose kinetics of ethylmorphine and its fractional metabolic clearance by O-dealkylation and N-dealkylation was investigated in five extensive and four poor metabolizers of dextromethorphan. In addition, the urinary metabolic ratios for these pathways (MRO and MRN, respectively) were investigated in a larger group of 27 extensive metabolizers and six poor metabolizers. The mean values for the fractional metabolic clearance by O-dealkylation and the MRO differed significantly between the poor metabolizers and extensive metabolizers without overlap between the values of either of these parameters in the two groups of subjects. In contrast, the corresponding parameters for the N-demethylation did not differ between poor metabolizers and extensive metabolizers. The area under the plasma concentration versus time curve was significantly higher (about three times higher) in the poor metabolizers compared with the extensive metabolizers (p = 0.004). Our data suggest that ethylmorphine is O-deethylated by the cytochrome P4502D6 isozyme inasmuch as both the fractional metabolic clearance by O-dealkylation and the MRO were found to cosegregate with the phenotype for the O-demethylation of dextromethorphan in our group of subjects.

N-demethylation of ethylmorphine in pregnant and non-pregnant women and in men: an evaluation of the effects of sex steroids.

1. The effects of oestrogens, testosterone, progesterone and medroxyprogesterone acetate (MPA) on the rate of N-demethylation of ethylmorphine (EM) to norethylmorphine (NEM) were studied in human adult liver microsomes. 2. N-Demethylase activity was found to be inhibited by progesterone and MPA to a similar extent while oestrogens and testosterone had no or negligible effects. 3. These findings prompted us to measure the N-demethylation of EM in relation to serum progesterone concentration in vivo in three groups of volunteers with large physiological differences in their endogenous levels of progesterone, i.e. i) pregnant women, ii) non-pregnant ovulating women and iii) men. 4. The metabolic ratio (MRP) of EM to NEM in plasma 60 min after dosage and the corresponding ratio in urine sampled for 6 h (MRU,1), measured on two occasions 14 days apart were used to reflect intraindividual variation in the rate of N-demethylation. 5. The average difference in MRP and MRU,1 between the two occasions was similar in all groups. However, the variability in MRP between individuals within a group was significantly higher in ovulating women than in men, but this had no relation to the serum concentrations of progesterone or oestradiol. 6. The cumulative 12 h urinary excretion of EM, NEM and morphine (MO) after hydrolysis with beta-glucuronidase was about 46%. There was no difference in the metabolic ratio of EM to NEM and its conjugate(s) in the urine between the luteal and the follicular phases. Our findings suggest that the menstrual cycle does not influence the rate of N-demethylation of EM.

Selective expression of interleukin 10, interferon gamma, and granulocyte-macrophage colony-stimulating factor in ovarian cancer biopsies.

The variable clinical response seen with most cancer immunotherapy suggests that there is a large interindividual variation in immunologic response to tumors. One of the key functional parameters of an immune response is the local production of cytokines. As a method to survey the immune status of tumor-infiltrating cells, we have investigated the constitutive expression of cytokine mRNA in biopsies from epithelial ovarian carcinomas by using a PCR-assisted mRNA amplification assay. Using a set of cytokine-specific primers for 10 different cytokines, we have found selective expression of interleukin 10 (IL-10), granulocyte-macrophage colony-stimulating factor, and interferon gamma mRNA in ovarian tumor tissue as compared to normal ovaries and ovarian tumor cell lines. Such differences could not be explained by the extent of T-cell infiltration, since comparing samples with the same intensity of T-cell receptor (TCR) constant region alpha-chain product from the tumor and normal biopsies demonstrated different cytokine patterns. No IL-2 gene expression was detected in the tumor biopsies. IL-2 mRNA, however, became expressed after stimulation of the tumor-derived cells via the CD3 molecule but not after growth in recombinant IL-2 alone. Using the same methodology, we also analyzed the TCR variable region beta-chain gene repertoire. No restriction or biased expression of these genes was observed.

Laparoscopic cholecystectomy during pregnancy.

Pregnancy is by some considered a contraindication for laparoscopic cholecystectomy. However, no evidence exists to support this opinion. We describe herein a laparoscopic cholecystectomy in a pregnant woman in the 22nd week of gestation with an uneventful postoperative recovery and normal completion of pregnancy. Laparoscopic cholecystectomy can be performed during pregnancy with a slight modification of the operative technique and is less traumatic than open surgery.

The use of obstetric analgesia in Sweden 1983-1986.

The use of obstetric analgesia was investigated in a Swedish population-based prospective study of 335,207 births, which represents almost all women who had vaginal deliveries in Sweden between 1983 and 1986. Lumbar epidural analgesia (EDA) was used in 16%, paracervical block (PCB) in 12%, pethidine or morphine in 49% and pudendal block in 62%. All four types of analgesia were much more commonly used by nulliparae than multiparae. Variables such as maternal age, smoking, nationality, relationship with the infant's father and gestational age had only moderate influence on the rates of different types of analgesia. EDA and PCB were more frequently used in larger than in smaller hospitals and in the daytime than at night. No such differences were found for pethidine or morphine, or pudendal block, which were administered routinely by midwives.

Disposition of morphine-3-glucuronide in the pregnant rhesus monkey.

Morphine-3-glucuronide (M3G) is the major metabolite of morphine and is present in the circulation of persons treated with morphine or abusing heroin. This project was designed to study the kinetics of M3G in the foeto-maternal compartment, since this metabolite may be of relevance for the abstinence syndrome observed in neonates of pregnant abusers. The kinetics of M3G were studied in two non-pregnant and four pregnant Rhesus monkeys. M3G was given as a bolus injection in four of the animals and as a long-term infusion for 12 hr in two animals. M3G passed slowly across the placenta to the foetus and amniotic fluid. After 10 hr of M3G infusion, the foetal plasma M3G concentration was measured in two cases and found to be 37% and 72%, respectively, of the maternal concentration.

Transplacental transfer of morphine in man.

The transplacental transfer of morphine and morphine-3-glucuronide (M3G) was studied in five cases of suspected Rh-isoimmunization. Ultrasound-guided fetal blood sampling from the umbilical vein was carried out as a diagnostic procedure before intrauterine blood transfusion. Morphine was given as a parenteral premedication to the mother at a dose of 0.13-0.20 mg/kg bw. Fetal blood was sampled 5-74 minutes after the morphine administration. These five women were investigated on 14 different occasions. The plasma concentrations of morphine and M3G were measured in blood samples collected simultaneously from mother and fetus. The feto-maternal ratio of morphine was 0.96 at five minutes and remained close to 1.0 in most samples taken later. At 12 minutes the ratio of M3G was less than 0.002 and between 0.2 and 0.6 in the later samples. The feto-maternal plasma ratios of morphine and M3G did not change over the studied period in one woman investigated five times between gestational weeks 26 and 32. This is the first time transplacental transfer of morphine has been quantified in man. Our results demonstrate a rapid transplacental passage and equilibration of morphine between mother and fetus.