Clinical-practice recommendations for the management of bowel obstruction in patients with end-stage cancer.

The paper highlights a series of questions that doctors need to consider when faced with end-stage cancer patients with bowel obstruction: Is the patient fit for surgery? Is there a place for stenting? Is it necessary to use a venting nasogastric tube (NGT) in inoperable patients? What drugs are indicated for symptom control, what is the proper route for their administration and which can be administered in association? When should a venting gastrostomy be considered? What is the role of total parenteral nutrition (TPN) and parenteral hydration (PH)? A working group was established to review issues relating to bowel obstruction in end-stage cancer and to make recommendations for management. A steering group was established by the (multidisciplinary) Board of Directors of the European Association for Palliative Care (EAPC) to select members of the expert panel, who were required to have specific clinical and research interests relating to the topic and to have published significant papers on advanced cancer patients in the last 5 years, or to have particular clinical expertise that is recognised internationally. The final constitution of this group was approved by the Board of the EAPC. This Working Group was made up of English, French and Italian physicians involved in the field of palliative care for advanced and terminal cancer patients; and of English, American and Italian surgeons who also specialized in artificial nutrition (Dr. Bozzetti) and a professor of health economics. We applied a systematic review methodology that showed the relative lack of RCTs in this area and the importance of retrospective and clinical reports from different authors in different countries. The brief was to review published data but also to provide clinical opinion where data were lacking. The recommendations reflect specialist clinical practice in the countries represented. Each member of the group was allocated a specific question and briefed to review the literature and produce a position paper on the indications, advantages and disadvantages of each symptomatic treatment. The position papers were circulated and then debated at a meeting held in Athens and attended by all panel members. The group reviewed all the available data, discussed the evidence and discussed what practical recommendations could be derived from it. An initial outline of the results of the review and recommendations was produced. Where there were gaps in the evidence, consensus was achieved by debate. Only unanimous conclusions have been incorporated. Subsequently the recommendations were drawn together by Carla Ripamonti (Chairperson) and Robert Twycross (Co-Chair) and refined with input from all panel members. The recommendations have been endorsed by the Board of Directors of the EAPC. It was concluded that surgery should not be undertaken routinely in patients with poor prognostic criteria, such as intra-abdominal carcinomatosis, poor performance status and massive ascites. A nasogastric tube should be used only as a temporary measure. Medical measures such as analgesics, anti-secretory drugs and anti-emetics should be used alone or in combination to relieve symptoms. A venting gastrostomy should be considered if drugs fail to reduce vomiting to an acceptable level. TPN should be considered only for patients who may die of starvation rather than from tumour spread. PH is sometimes indicated to correct nausea, whereas regular mouth care is the treatment of choice for dry mouth. A collaborative approach involving both surgeons and physicians can offer patients an individualized and appropriate symptom management plan.

Radical hysterectomy: current management guidelines.

Over the past 11 years (January 1985 through December 1996) the senior authors (B.F.H. and H.B.K.) have performed 205 radical hysterectomies. The most notable trend observed was a marked decrease in length of stay from 12.8 days to 3.5 days. Contributing factors include use of the Maylard incision, placement of suprapubic Foley catheters, discontinuation of drains, early oral feeding, admission to the hospital on the day of surgery, and initiation of a critical care pathway. All criteria for short-stay radical hysterectomy were established by 1994. With continued modification of surgical technique and use of the critical care pathway, short stay has become our standard of care for radical hysterectomy. Complications are minimal, with neither long-term morbidity nor mortality associated with the short stay. In addition, significant cost savings occur, which benefits the patient, hospital, and the health care system.

Witzel gastrostomy in gynecologic surgery.

Tube gastrostomy is a well-accepted procedure for gastrointestinal decompression and the relief of small bowel obstruction. The Witzel technique was used in 123 patients undergoing pelvic-abdominal surgery for known or suspected gynecologic malignancy or for clinical bowel obstruction. For 115 patients, the tube remained in place from 3 to 18 days (mean, 8 days). Eight patients were discharged from the hospital with the tube in place, and these functioned successfully from 43 to 136 days. Sixteen patients (13%) had complications, but there was neither long-term morbidity nor mortality associated with the tube. Witzel gastrostomy, using a Foley catheter, is easily learned, inexpensive, and has an acceptable complication rate. When the need for long-term gastrointestinal decompression is anticipated, Witzel gastrostomy is preferred to nasogastric tube suctioning to facilitate patient care and comfort.

Loop electrosurgical excision procedures for cervical dysplasia: experience in a community hospital.

OBJECTIVE: The study was undertaken to evaluate the use of the loop electrosurgical excision procedure as an outpatient hospital or surgicenter procedure. STUDY DESIGN: The records of 358 patients treated for cervical intraepithelial neoplasia at a large community hospital over a 1-year period were reviewed. RESULTS: The specimens obtained by loop electrosurgical excision procedure and laser cone excision were comparable in size but smaller than those by means of cold-knife conization. Seventy-two percent of loop electrosurgical excision procedure specimens consisted of two to eight tissue fragments (mean 3.4). In addition, 48% of the loop electrosurgical excision procedure specimens and 38% of laser cones had moderate or severe thermal artifacts. Fragmentation and cautery damage precluded orientation of tissue and evaluation of margins in 19% of the cases. CONCLUSIONS: The advent of the loop electrosurgical excision procedure has shifted the management of cervical intraepithelial neoplasia from the office to the outpatient surgery centers. This negates and, in fact, reverses the advantage of loop electrosurgical excision procedure over other methods in regard to cost and convenience through evaluating and treating a patient with cervical intraepithelial neoplasia in one office visit. Loop electrosurgical excision procedures provide specimens that are inferior compared with cold-knife cones; therefore the role of loop electrosurgical excision procedure for the management of cervical intraepithelial neoplasia outside the office appears limited.

Treatment failure of genital condylomata acuminata in women: role of the male sexual partner.

The male sexual partners of women with genital condylomata acuminata are thought to be carriers of human papillomaviruses. It is therefore often recommended that both sexual partners be treated. We studied 360 women with genital warts to test the hypothesis that when the male partners of women with condylomata acuminata are treated, the treatment failure rate decreases. The male sexual partners of 180 of these women were examined and, if indicated, treated (treatment group). The 180 remaining male sexual partners were neither examined nor treated (control group). One hundred twenty-two (68%) men in the treatment group had human papillomavirus-associated lesions. The treatment failure rate of women was 16.7% in the treatment group and 18.9% in the control group. The difference is not statistically significant (p greater than 0.05). The results of this study do not support the hypothesis that the treatment failure rate of women with condylomata acuminata decreases if their male sexual partners are also treated.

Chronic ulcerations following topical therapy with 5-fluorouracil for vaginal human papillomavirus-associated lesions.

Applied topically to the vagina, 5-fluorouracil (5-FU) cream is an effective therapy for human papillomavirus (HPV)-associated lesions of the vagina including condylomata acuminata and vaginal intraepithelial neoplasia. Although the acute side effects of 5-FU therapy are well recognized, long-term sequelae of intravaginal 5-FU use have not been described in detail in the literature. To assess the incidence and clinical course of 5-FU-related vaginal mucosal alterations, we studied 220 patients who underwent 5-FU therapy for HPV-associated lesions of the vagina. Eighteen women (8.2%) had epithelial ulcers 6 months after completion of the 5-FU treatment. The incidence of ulcers was higher in women who used 5-FU for longer than 10 weeks compared with those who used it for 10 weeks or less (9.6 versus 5.7%; P = .05). All but one of the mucosal defects were in the vaginal fornices and/or the periphery of the ectocervix. The ulcers were mostly singular and measured 0.5-7 cm in greatest diameter. Fourteen patients (77.8%) had symptoms related to the ulcers including a serosanguineous or watery discharge (55.6%), postcoital spotting or bleeding (44.4%), irregular bleeding unrelated to intercourse (16.7%), and pain (5.6%). Spontaneous healing of the ulcers was protracted. Office methods of therapy including estrogen creams and cauterizing agents failed to accelerate healing as compared with untreated patients. Excision of the ulcer and primary closure of the wound was curative in all four cases in which it was used. We conclude that topical 5-FU therapy may lead to troublesome chronic mucosal ulcers that tend to persist despite conservative treatment attempts.

Treatment of genital condylomata with topical 5-fluorouracil.

Use of topical 5-FU is indicated for therapy-resistant condylomata and for extensive untreated vulvar condylomata. It may be the treatment of choice for extensive or therapy-resistant vaginal condylomata. Applications of 5-FU once weekly to the vagina and twice weekly to the vulva for 10 weeks appear to be as effective as continued regimens but are better tolerated. Perhaps the greatest value of 5-FU lies in periodic application for prevention of recurrences of condylomata removed by surgical methods.

The Maylard incision in gynecologic surgery.

The transverse muscle-splitting Maylard incision was used in 175 gynecologic patients who required pelvic-abdominal surgery. One hundred fifty-three patients (87%) had pelvic malignancy; other indications for operation included uterine myomas, endometriosis, tuboovarian abscess, and benign ovarian cysts. Exposure was excellent: 54% of patients underwent pelvic lymphadenectomy and 17% underwent paraaortic lymphadenectomy. Twelve patients (6.9%) had wound complications, but there was neither long-term morbidity nor mortality associated with the incision. Fifty-six patients (32%) received preoperative or postoperative pelvic radiation therapy with no detrimental effect on wound healing. The Maylard incision is cosmetic, strong, easily learned, and has an acceptable complication rate. Unless a vertical incision is indicated, the Maylard technique is preferred when optimal exposure and accessibility to the pelvis are required.

Does the treatment of genital condylomata in men decrease the treatment failure rate of cervical dysplasia in the female sexual partner?

Three hundred ninety women treated for cervical dysplasia by local tissue ablation were studied retrospectively to test the hypothesis that the treatment failure rate is lower if the male sexual partner is also treated. In 190 cases, the male sexual partner was examined and treated successfully for genital condylomata. Controls were 200 women treated during the same time period and closely matched to the study group regarding age, race, socioeconomic status, histologic grade of dysplasia, distribution of the lesions, and methods of therapy, but the male partner was neither examined nor treated. The treatment failure rate for women whose partners were also treated was not significantly different from that for women whose partners were not treated (6.8 versus 7.5%; P greater than .05), suggesting that treating genital condylomata in men does not affect the failure rate of cervical dysplasia in female sexual partners.

Treatment of extensive vulvar condylomata acuminata with topical 5-fluorouracil.

Forty-nine nonpregnant women with extensive condylomata acuminata of the vulva were studied to evaluate the effectiveness of topical 5-fluorouracil (5-FU) for treating vulvar condylomata and to compare the results of continuous use with periodic use of the medication. Patients using the continuous regimen were instructed to apply 5% 5-FU cream to the vulva each night for 6 weeks or until a brisk inflammatory reaction occurred. The periodic regimen consisted of applying 5-FU cream on 2 consecutive nights per week for 10 week. Thirty-five patients (71%) responded to 5-FU treatment (20 complete responses, 41%; 15 partial responses, 30%). Fourteen patients (29%) did not respond. The response rates observed in 19 patients using the continuous regimen (eight complete responses, five partial responses, and six treatment failures) were not significantly different from the response rates obtained in 30 patients with the periodic regimen (12 complete responses, 10 partial responses, and eight treatment failures; P greater than .05, chi-squared test). The periodic regimen caused fewer side effects than the continuous regimen. I conclude that topical 5-FU is effective for treatment of vulvar condylomata acuminata and that periodic applications are preferable to continuous applications.

Bleomycin, vincristine, and mitomycin C (BOM) as second-line treatment after failure of cis-platinum-based combination chemotherapy for recurrent cervical cancer.

Seventeen patients with recurrent cervical cancer were prospectively treated with a combination of bleomycin, vincristine, and mitomycin C (BOM). All patients had previously failed a cis-platinum-containing combination regimen. There were no complete responses. Four patients had partial responses, six patients had stable disease, and seven patients had no response. The median length of survival for responders was the same as that for nonresponders (5 months). More than 50% of patients experienced significant toxicity. The combination of bleomycin, vincristine, and mitomycin C appears to be ineffective as a second-line chemotherapy regimen against recurrent cervical cancer previously treated with cis-platinum.

Management of intestinal obstruction in ovarian cancer.

Bowel obstruction often is a sign of progression of ovarian carcinoma and is a major cause of death in this disease. Its treatment is still being debated. Options range from long tube decompression of the GI tract to bowel surgery. The authors review the management of bowel obstruction associated with ovarian carcinoma and provide guidelines helpful in selection of patients for surgical or medical management. Practical aspects of patient care are described in detail and the old adage "Never let the sun set or rise on a bowel obstruction" is examined in light of current surgical and medical management techniques.

Management of intestinal obstruction in ovarian cancer.

Bowel obstruction often is a sign of progression of ovarian carcinoma and is a major cause of death in this disease. Its treatment is still being debated. Options range from long tube decompression of the GI tract to bowel surgery. The authors review the management of bowel obstruction associated with ovarian carcinoma and provide guidelines helpful in selection of patients for surgical or medical management. Practical aspects of patient care are described in detail and the old adage "Never let the sun set or rise on a bowel obstruction" is examined in light of current surgical and medical management techniques.

Treatment of vaginal intraepithelial neoplasia with laser and topical 5-fluorouracil.

The records of 59 women with grades 2 and 3 vaginal intraepithelial neoplasia were reviewed to define the role of CO2 laser ablation and topical 5-fluorouracil (5-FU) in the treatment of vaginal intraepithelial neoplasia. The patients in each treatment group were comparable in their personal characteristics and in distribution and severity of the lesions. Thirty-one patients used prophylactic 5-FU. Seventy-eight percent of all patients were free of vaginal intraepithelial neoplasia at the first follow-up examination. The results of treatment were not influenced by the grade of the lesion or previous radiation exposure of the patient. Topical 5-FU appeared to be as effective as laser. Periodic applications of 5-FU (once weekly for 10 weeks) were as effective as 5-FU applied in a continuous fashion (three 7-day courses 1 week apart), and caused fewer side effects.

Management of human papillomavirus-associated genital lesions in men.

A total of 155 men with human papillomavirus (HPV)-associated genital lesions were studied to evaluate therapy for obvious and subclinical lesions. The treatment methods were selected according to type, location, size, and number of lesions. Seventy-three percent of all patients were successfully treated by the initial therapy. Eighty men with minimal disease had a significantly lower treatment failure rate than 75 men with multiple lesions (15 versus 40%; P less than .001). The type of lesions (classical condyloma versus other HPV-associated lesions), visibility (obvious condylomata versus subclinical lesions), and location did not significantly influence the cure rate (P greater than .05). Seventy-six percent of treatment failures were evident at the first follow-up examination. After a follow-up time of 1 year, 95% of men with obvious condylomata and 93% of men with subclinical lesions were disease-free. The results indicate that obvious and subclinical HPV-associated lesions in men may be successfully controlled by one or more treatment modalities adapted to the particular needs of the patient.

Whole abdominal radiotherapy following cytoreductive surgery and chemotherapy in ovarian carcinoma.

Persistent or recurrent disease following surgery and chemotherapy in ovarian carcinoma remains a major therapeutic dilemma. Between January 1980 and December 1985, there were 26 patients who had previously undergone cytoreductive surgery and chemotherapy and were treated with external beam radiotherapy. Twenty-one of these patients had been treated with platinum-adriamycin-cytoxan (PAC) regimen and 5 were treated with other combinations. Surgical reevaluation was performed in 21 of the 26 patients and only 4/21 (19%) patients were free of disease. All 26 patients were irradiated with a planned dose of 2500 cGy/100 cGy/day or 2280 cGy/120 cGy/day to the whole abdomen and a final calculated dose to the pelvis of 4500 cGy. Initial evaluation showed a 3-year actuarial survival rate of 51% and a disease-free survival rate of 42%. Follow-up analysis yields survivals of 45 and 35%, respectively. Severe gastrointestinal complications were observed in 3/26 patients and all hematologic complications resolved. Variables of prognostic significance were chemotherapy tolerance, grade, and volume of residual disease. We conclude that a proportion of patients with disease following cytoreductive surgery and chemotherapy may be salvaged with abdominopelvic irradiation.

Combination of laser plus 5-fluorouracil for the treatment of extensive genital condylomata acuminata.

Although laser is effective in the treatment of genital condylomata, patients with extensive lesions frequently require more than one treatment. The present study was undertaken to investigate whether the cure rate achieved by a single laser treatment could be improved by adding topical 5% 5-fluorouracil (5-FU). Twenty patients with extensive genital condylomata were treated with laser alone. Twenty patients comparable to the first group in age, number, size, and distribution of the condylomata were treated by laser and 5-FU. The first application of 5% 5-FU cream was carried out at the end of the laser treatment by the surgeon in the operating room. The patients were instructed to apply 5-FU cream once weekly to the vulva and once every two weeks to the vagina by using an applicator filled to one-third with 5-FU cream. Seven patients (35%) without 5-FU were found to have persistent condylomata at the first follow-up examination eight to 12 weeks after the single laser treatment. Two additional patients were noted to have disease six and nine months after laser treatment. The combination of laser and 5-FU failed in two cases (10%), both identified at the first visit. The difference is statistically significant (P less than .025, chi-square test). Two patients exposed to 5-FU experienced chemical vulvitis. It is concluded that the combination of a single laser treatment and 5-FU has acceptable side effects and results in a higher cure rate than a single laser treatment without 5-FU.