Middle Meningeal Artery Embolization for the Management of Chronic Subdural Hematomas: A New-Old Treatment.

Chronic subdural hematoma (cSDH) is defined as a subdural collection of blood on CT imaging that tends to persist and gradually increase in volume over time, with components that are hypodense or isodense compared to the brain. There are no proven guidelines for the management of patients with cSDH. Surgical approaches included burr hole, twist drill hole, and craniotomy-based evacuations. Outcomes after surgical removal is generally favorable, but cSDH tends to recur after the initial evacuation.Middle meningeal artery (MMA) embolization has been gaining increasing popularity among the treatments of cSDH. This is largely due to a growing population of patients with cSDH who are refractory to other treatments or in patients who present with multiple comorbidities or who are taking antiplatelet and anticoagulant medications. The goal of middle meningeal artery (MMA) embolization is to devascularize subdural membranes associated with SDH so that the balance between continued leakage and reabsorption is shifted toward reabsorption.We discuss our clinical and technical approach to cSDH treated with perioperative embolization of the MMA.

Posterior Circulation Endovascular Thrombectomy for Large-Vessel Occlusion: Predictors of Favorable Clinical Outcome and Analysis of First-Pass Effect.

BACKGROUND AND PURPOSE: Successful vessel recanalization in posterior circulation large-vessel occlusion is considered crucial, though the evidence of clinical usefulness, compared with the anterior circulation, is not still determined. The aim of this study was to evaluate predictors of favorable clinical outcome and to analyze the effect of first-pass thrombectomy. MATERIALS AND METHODS: A retrospective, multicenter, observational study was conducted in 10 high-volume stroke centers in Europe, including the period from January 2016 to July 2019. Only patients with an acute basilar artery occlusion or a single, dominant vertebral artery occlusion ("functional" basilar artery occlusion) who had a 3-month mRS were included. Clinical, procedural, and radiologic data were evaluated, and the association between these parameters and both the functional outcome and the first-pass effect was assessed. RESULTS: A total of 191 patients were included. A lower baseline NIHSS score (adjusted OR, 0.77; 95% CI, 0.61-0.96; P = .025) and higher baseline MR imaging posterior circulation ASPECTS (adjusted OR, 3.01; 95% CI, 1.03-8.76; P = .043) were predictors of better outcomes. The use of large-bore catheters (adjusted OR, 2.25; 95% CI, 1.08-4.67; P = .030) was a positive predictor of successful reperfusion at first-pass, while the use of a combined technique was a negative predictor (adjusted OR, 0.26; 95% CI, 0.09-0.76; P = .014). CONCLUSIONS: The analysis of our retrospective series demonstrates that a lower baseline NIHSS score and a higher MR imaging posterior circulation ASPECTS were predictors of good clinical outcome. The use of large-bore catheters was a positive predictor of first-pass modified TICI 2b/3; the use of a combined technique was a negative predictor.

Is subareolar intraoperative biopsy still necessary to predict nipple involvement?

OBJECTIVE: To predict the occult tumor involvement of nipple-areola complex (NAC) using preoperative MR imaging and to investigate whether the intraoperative histopathological examination of the subareolar tissue is still necessary. PATIENTS AND METHODS: Out of 712 patients submitted to nipple-sparing mastectomy (NSM) between 2014 and 2019, we selected 188 patients who underwent preoperative breast MRI. Breast MRI and intraoperative histopathological examination of the subareolar tissue were performed to predict NAC involvement at permanent pathology. All parameters were correlated with final pathological NAC assessment by univariate and multivariate analysis. RESULTS: Forty-three patients (22.9%) had tumor involvement of the NAC. At univariate analysis, non-mass enhancement type (p = 0.009), multifocality/multicentricity (p = 0.002), median tumor size (p < 0.001), median tumor-NAC distance measured by MRI (p < 0.001), tumor-NAC distance ≤ 10 mm (p < 0.001) and tumor-NAC distance ≤ 20 mm (p < 0.001), and lymphovascular invasion (p = 0.001) were significantly correlated with NAC involvement. At multivariate analysis, only tumor-NAC distance ≤ 10 mm retained statistical significance. The sensitivity and specificity of MRI tumor-NAC distance ≤ 10 mm were 79.1% and 97.2% and those of intraoperative pathologic assessment were 74,4% and 100%, respectively. CONCLUSIONS: Tumor-NAC distance is the only reliable MRI characteristic that can predict NAC involvement in breast cancer patients. Although several cut-offs showed promising performances, intraoperative pathologic assessment is still mandatory.

Intra- and inter-observer variability in intracranial aneurysm segmentation: comparison between CT angiography (semi-automated segmentation software stroke VCAR) and digital subtraction angiography (3D rotational angiography).

PURPOSE: To compare size and morphologic features of three-dimensional aneurysm models, obtained with a semi-automated segmentation software (Stroke VCAR, GE, USA) from cerebral CT angiography (CTA) data, to three-dimensional aneurysm models obtained with digital subtraction angiography (DSA, with 3D rotational angiography acquisition-3DRA), considered as the reference standard. METHODS: In this retrospective study, we reviewed 132 patients, with a total number of 137 intracranial aneurysm, who underwent CTA and subsequent DSA examination, supplemented with 3DRA. We compared neck length, short axis and long axis measured on 3DRA model to the same variables measured on 3D-CTA model by two blinded readers and to the automatic software dimensions. Therefore, statistics analysis assessed intra-observer and inter-observer variability and differences between patients with or without subarachnoid hemorrhage (SAH). RESULTS: There were no significant differences in short-axis and long-axis measurements between 3D angiographic and 3D-CTA models, while comparison of neck lengths revealed a statistically significant difference, which tended to be greater for smaller neck lengths (partial volume effect and "kissing vessels" artifact). There were significant differences between manual and automatic data measured for the same three variables, and the presence of SAH did not affect aneurysm 3D reconstruction. Inter-observer agreement resulted moderate for neck length and substantial for short axis and long axis. CONCLUSION: The examined 3D-CTA segmentation system is a reproducible procedure for aneurysm morphologic characterization and, in particular, for assessment of aneurysm sac dimensions, but considerable carefulness is required in neck length interpretation.

Determination of malondialdehyde, acrolein and four other products of lipid peroxidation in edible oils by Gas-Diffusion Microextraction combined with Dispersive Liquid-Liquid Microextraction.

A new and sensitive analytical method for the simultaneous determination of secondary lipid peroxidation aldehydes has been successfully developed and validated. Malondialdehyde, acrolein, formaldehyde, acetaldehyde, propanal, and pentanal were extracted and derivatized using 2,4-dinitrophenylhydrazine (DNPH) by gas-diffusion microextraction (GDME) combined with dispersive liquid-liquid microextraction (DLLME) for gas chromatography-mass spectrometry (GC-MS) analysis. The experimental conditions have been optimized by experimental designs. The analytical method validation, in accordance to the Food and Drug Administration (FDA) guidance, provided good results in terms of linearity with r2≥0.9974, in the range from 0.15 or 0.3 µg·g-1 to 3 µg·g-1. Limits of detection and limits of quantification were 0.05 or 0.10 and 0.15 or 0.3 µg·g-1, respectively. Precision was tested as a relative standard deviation (RSD≤ 9.5%) and recoveries were between 95% and 110%. The method was applied in the characterization of aldehydes in forty-eight edible oil samples; with the highest concentration found in pomace olive oil for malondialdehyde at 6.64 µg·g-1.

Occurrence and exposure of 3-monochloropropanediol diesters in edible oils and oil-based foodstuffs from the Spanish market.

During the industrial refining process of edible oils and the manufacture of oil-based foodstuff, contaminants such as 3-monochloropropanediol (3-MCPD) fatty acid diesters can be produced. One hundred samples of different edible oils and related fatty food purchased from local Spanish markets were analyzed to evaluate the occurrence of these contaminants. Data of seven 3-MCPD diesters together with corresponding total 3-MCPD equivalents are presented. The procedure is based on a modified QuEChERS protocol followed by LC-MS/MS analysis. Extra virgin olive oil (EVOO) and unrefined oils did not contain detectable levels of the target analytes. The highest levels of 3-MCPD diesters were found in palm oils, for 1,2-Dilinoleoyl-3-chloropropanediol (LILI) and 1-2-Bispalmitoyl-3-chloropropanediol (PAPA) with concentrations close to 10 mg kg-1 and in the lipid fraction of margarines (8.09, 3.77 and 3.72 mg kg-1 for LILI, PAPA and 1-Oleoyl-2-linoleoyl-3-chloropropanediol (OLLI), respectively).

Development of a partitioned liquid-liquid extraction- dispersive solid phase extraction procedure followed by liquid chromatography-tandem mass spectrometry for analysis of 3-monochloropropane-1,2-diol diesters in edible oils.

A fast and effective method using a modified QuEChERS (Quick, Easy, Cheap, Effective, Rugged and Safe) approach which includes partitioned liquid-liquid extraction (PLLE) and dispersive solid phase extraction (dSPE) clean-up step for the determination of seven 3-monochloropropane-1,2-diol (3-MCPD) fatty acid diesters in vegetable oils is developed and validated according to the Food and Drug Administration (FDA) guidelines. Due to the complexity of the matrices, combination of silica based sorbents (Silica Strong Anion Exchange (Si-SAX), Supel™ QuE Z-Sep+ (Z-Sep+) and Primary Secondary Amine (PSA) were tested for lipid removal. The effect of several experimental factors on the efficiency of the extraction procedure was studied by a screening design 3422//16 and a response surface Doehlert design. The separation and determination was carried out by liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS). The method provided suitable linearity (r2 > 0.9960), precision (relative standard deviation (RSD) lower than 10%) and accuracy, in terms of recovery. The limits of detection (LOD) and limits of quantification (LOQ) ranged from 10 to 20 µg kg -1 and from 25 to 50 µg kg-1, respectively. The recoveries at three spiking levels of 100, 250, and 500 µg kg-1 were over the range of 71.4-122.9% with RSD lower than 13%. The method was successfully applied in edible oils and fatty food samples. The results provide valuable information to assess the risk of exposure to these foodborne contaminants.

Intussusception in childhood: role of sonography on diagnosis and treatment.

OBJECTIVE: The aim of this study was to determine the role of ultrasound in the diagnosis and treatment of pediatric patients with acute abdominal pain caused by intussusceptions. MATERIALS AND METHODS: We performed a retrospective study of all pediatric patients with acute abdominal pain caused by intussusceptions and that underwent ultrasound examination at the emergency service of the Radiology Department between November 2007 and June 2013. The role of ultrasonography in the diagnosis of intussusceptions has been assessed by comparing the echographic presumptive diagnosis with the final diagnosis of discharge. Its importance in the treatment has been assessed by determining the value of ultrasound findings in the choice of the best treatment. RESULTS: The ultrasound examination was positive in 16/18 patients with a final diagnosis of intussusception. Some sonographic findings seemed to be able to predict the opportunity to resort to non-surgical therapeutic options like hydrostatic or pneumatic reduction of the intestinal segments invaginated. In our casuistry, five children presented characteristics typical of this subgroup and underwent barium enema which provided the reduction of the intestinal segments involved. The future challenge will be to perform non-surgical ultrasound-guided reductions to avoid the exposure of the infants to ionizing radiations. CONCLUSIONS: Ultrasonography is essential not only in the diagnosis, but also it adds important elements in the therapeutic choice and could play in the future an important role in non-surgical reduction of intestinal intussusceptions in pediatric patients.

Relating Water Deficiency to Berry Texture, Skin Cell Wall Composition, and Expression of Remodeling Genes in Two Vitis vinifera L. Varieties.

The cell wall (CW) is a dynamic structure that responds to stress. Water shortage (WS) impacts grapevine berry composition and its sensorial quality. In the present work, berry texture, skin CW composition, and expression of remodeling genes were investigated in two V. vinifera varieties, Touriga Nacional (TN) and Trincadeira (TR), under two water regimes, Full Irrigation (FI) and No Irrigation (NI). The global results allowed an evident separation between both varieties and the water treatments. WS resulted in increased anthocyanin contents in both varieties, reduced amounts in cellulose and lignin at maturation, but an increase in arabinose-containing polysaccharides more tightly bound to the CW in TR. In response to WS, the majority of the CW related genes were down-regulated in a variety dependent pattern. The results support the assumption that WS affects grape berries by stiffening the CW through alteration in pectin structure, supporting its involvement in responses to environmental conditions.

Premenstrual syndrome and beyond: lifestyle, nutrition, and personal facts.

AIM: The aim was to study prevalence of menstrual symptoms and their presenting patterns, and to assess nutrition and behaviours correlates. METHODS: The study enrolled 108 women, who were prospectively assessed for menstrual symptoms; a 212 items questionnaire about lifestyle and nutrition was administered. Diagnosis and intensity of symptoms were separately compared for dietary and other factors. The χ2 test or Fisher exact test as required and a multivariate analysis were performed. RESULTS: Seventeen percent of the sample reported no symptoms; core PMD was diagnosed in 14%, and related to symptoms of moderate intensity, to late menarche, irregular, long cycles, dysmenorrhoea, and to lower intake of complex carbohydrates, fibers, calcium; non-cyclical pattern in 27%, and related to symptoms of severe intensity, to young age, unemployed, to poor health, stress, traumatic events, abnormal BMI, to long, heavy menses, to lower intake of fibers, magnesium, vitamin B6, and to higher intake of fat, proteins, sodium, caffeine; variant PMD-premenstrual exacerbation in 42%, and related to symptoms of severe - moderate intensity, to young age, students, unemployed, sedentary work, abnormal BMI, stress, to cycle irregularities, heavy menses, to higher intake of simple sugars and sodium, and to lower intake of calcium, magnesium, and vitamin B6. Regardless of diagnosis, severe intensity of symptoms was associated with young age /students (P<0.001), lower education, unemployed, smoke, sedentary work, poor health, stress, heavy menses (P<0.01), dysmenorrhea, more unfavorable and less favorable nutrients. CONCLUSION: Lifestyle, nutrition, and general health considerations seem to be important issues in the management of menstrual symptoms, prospective symptoms chart being mandatory for diagnosis.

Spontaneous regression of low-grade cervical intraepithelial lesions is positively improved by topical bovine colostrum preparations (GINEDIE®). A multicentre, observational, italian pilot study.

OBJECTIVES: Human papillomavirus (HPV) is the causal agent of cervical cancer. The great majority of abnormal Pap test results - almost 90% - is referrable to either atypical squamous intraepithelial lesion or CIN1. For these lesions, worldwide agreement exists concerning the high rate - ranging from 40% to 70% - of spontaneous regression over a period of 1-5 years. Host's immune response is a key point influencing the natural history of these conditions. Bovine colostrum is a natural agent positively promoting several immune activities against bacterial and viral agents. The aim of this report was to evaluate the potential positive effect of bovine colostrum-containing vaginal tablets administered to CIN1 diagnosed patients in a prospective trial in regards to spontaneous regression rate. PATIENTS AND METHODS: A series of 256 consecutive patients with histologically proven CIN1 recruited in a multicentre, observational, Italian study. Patients have been enrolled in a 24-weeks protocol of treatment and re-tested at the end of the study. Rates of regression have been recorded. RESULTS: Overall regression rate to a negative histology at the end of the 6 month follow up was 75.5%. CONCLUSIONS: Regression to normal histology was observed in a very high rate of cases in a very short period compared to the natural history of these lesions. CIN1 patients could benefit from bovine colostrum topical administration in terms of significantly shortening the regression time.

Predictors of delayed sputum smear and culture conversion among a Portuguese population with pulmonary tuberculosis.

INTRODUCTION: Failure of sputum smear and/or culture conversion after 2 months of tuberculosis (TB) treatment has been considered a predictor of patient infectivity and treatment failure. We aimed to identify the factors associated with delayed sputum smear and culture conversion in patients with pulmonary TB who were given anti-TB treatment. MATERIAL AND METHODS: Retrospective cohort of 136 adult patients with sputum culture-proven pulmonary TB referred to an urban Chest Disease Centre. Socio-demographic, clinical, radiological, microbiological, and therapeutic data were evaluated. RESULTS: The median age was 41.0 (interquartile range [IQR] 18.0) years and 75.0% of patients were male. Delayed sputum smear and culture conversion occurred in 25.4% (30/118) and 27.2% (37/136) of patients, respectively. Multivariate analysis indicated that age ≥ 50 years (odds ratio [OR] 4.4, 95% confidence interval [CI] 1.5-13.3), male gender (OR 10.8, 95% CI 1.3-91.1), and smear grade > 1-9 acid fast bacilli (AFB)/field (3+) (OR 11.7, 95% CI 1.4-100.6) were significantly associated with persistent smear positivity after 2 months of treatment. Bilateral radiological involvement (OR 3.7, 95% CI 1.5-9.0) and colony count > 100 (3+) (OR 5.8, 95% CI 1.2-27.4) were significantly associated with persistent culture positivity. CONCLUSIONS: Delayed sputum smear and culture conversion occurred in about one third of patients. Older age, male gender, and higher bacillary load were independently associated with delayed smear conversion. Bilateral radiological involvement and higher colony count were independently associated with delayed culture conversion.

Induction with basiliximab plus thymoglobulin is effective and safe in old-for-old renal transplantation: six-month results of a prospective clinical study.

Old-for-old renal transplantation is becoming more frequent, but the optimal immunosuppressive regimens for this transplant population are still unclear. The aim of this pilot prospective study was to evaluate the efficacy and safety of the combination of basiliximab with a short course of low-dose thymoglobulin induction therapy among a group of patients receiving kidneys from donors >60 years (OLD), compared with those receiving organs from donors <60 years (YNG). Forty-six consecutive deceased donor kidney transplant patients received induction therapy with a combination of basiliximab (20 mg IV on days 0 and 4) and thymoglobulin (200 mg total dose IV on days 0-3). As maintenance immunosuppression starting on day 4, patients received a low dose of calcineurin inhibitor and steroids. Demographic characteristics at baseline were not significantly different between the 2 groups. At 6 months, patient survival, graft survival, and acute rejection rates were similar between the YNG and OLD groups: 100% and 95%, 96% and 95%, and 8% and 0%, respectively. Patients in the OLD group showed higher serum creatinine concentrations (YNG 1.5 +/- 0.3 vs OLD 1.9 +/- 0.3 mg/dL; P = .0002) but not proteinuria (YNG 0.11 +/- 0.11 vs OLD 0.15 +/- 0.14 g/24 h; P = ns). No significant difference was evident between the 2 groups regarding infectious, hematologic, or posttransplantation lymphoproliferative disorder complications. This study showed that a combination of basiliximab and a short course of low-dose thymoglobulin provided effective and safe immunosuppression, in old-for-old renal transplantation, with good renal function without an increased risk of posttransplantation infectious or hematologic complications.

Diet assessment and the screening for osteoporosis: a survey in a healthy menopause population.

AIM: The aim of this study was to investigate about diet assessment in the screening for osteoporosis. METHODS: In 1,441 women (group A, mean age 53.5 years, mean time from menopause 3.92(+/-4.33)] the number of daily/weekly servings/cups of different foods has been collected. In 71 women (group B, mean age 59 years, mean time from menopause 6 years) diet was assessed through a detailed questionnaire. Demographic and clinical data and dietary habits were related to bone mineral density (BMD) values, using Student t-test and the chi2 test. RESULTS: Group A: borderline/reduced BMD 40%, the percentage increasing with age and the duration of menopause (P<0.001). BMI within normal range 56.28%. BMD values were positively associated with Body Mass Index (BMI, P<0.001), education level (P<0.005), job (P<0.01), oral contraceptives use (P<0.001), negatively with family history of osteoporosis (P<0.05). BMD values showed a positive relation with the number of eggs per week (P<0.05), positive not significant trends were observed with dairy products, vegetables, red and white meat intake. A low/reduced BMD was related to low calcium food intake in less than 50% of the women. Group B: borderline/reduced BMD 55%; BMD showed positive trends, not significant, with daily calcium intake, BMI, physical exercise. Estimated calcium intake less than 700 mg/day was found in 33% of the sample. CONCLUSION: Diet assessment is not useful in the screening for osteoporosis. In women with borderline or reduced BMD, diet assessment helps to detect those at low calcium intake who need calcium supplementation, alone or in combination with other treatments.

Tibolone in the treatment of menopause: compliance, efficacy and safety in a ten year experience.

AIM: To assess tibolone compliance, efficacy and safety in everyday clinical practice a non-randomized, prospective, cohort clinical study was carried out. METHODS: One hundred and fifty post-menopausal women aged 48 to 73 years were prescribed tibolone: 72 of them were treated for 36.4 months, 55 terminated treatment after less than 1 year, while 23 never took the tablets after seeking for menopause counseling and having agreed upon the treatment. We examined: endometrial thickness and histology, total cholesterol, triglycerides, fibrinogen, AST, ALT, gamma-gt, and the body weight. RESULTS: Side effects were the main causes of withdrawal (32%), and insufficient therapeutic effect and adverse events for a small number of cases (5.5% and 4.7% respectively), while various causes (fear of cancer, missing tablets, family doctor or other specialist's advice, remission of symptoms) were responsible for terminating treatment after extended periods. Laboratory findings showed a favorable trend; only the (GT showed slightly higher mean values, although within a normal range. On average, weight during treatment increased of 1.5 kg, and endometrial thickness grew of 1.3 mm in a mean time of 34.5 months of observation. An average of 2.3%/year increase of bone mineral density was reported, though bone mass didn't improve in some patients. CONCLUSIONS: Different causes of terminating treatment are related to the length of treatment, side effects being the main reason for early withdrawals, efficacy on symptoms or medical advice or fear of treatment for extended periods of time. Effectiveness on bone mass, safety as resulting from endometrial thickness and laboratory measures are confirmed. It is suggested to enhance follow-up accuracy and reinforce counseling as measures to improve compliance.

[Human papillomavirus of the female genital tract: prevalence in women attending a centre for early cancer detection]. / Il virus del papilloma umano genitale: note sulla prevalenza nell'utenza di un centro per la prevenzione dei tumori femminili.

AIM: The authors study the trend of cytologic human papillomavirus (HPV) detection in the period between 1980 and 2000 in women attending a clinic for genital cancer early detection. METHODS: Routine activity, besides pap smear, is based on clinical evaluation, colposcopy and target biopsy in the presence of a lesion. The cytological trend is compared with that of histologic and clinical findings of HPV lesions on the basis of data prospectively collected. RESULTS: About 5% of cytologic HPV detection is observed in the whole, with a pick of about 11% in the years 1992-1994, and values around 2-3% up to 1991 and after 1995. The finding does not change if the whole pap smear group is considered (46,862) or only the first pap smear per woman (16,810). A similar trend, but with a smaller pick, is observed in histologic findings, not in colposcopic findings. The clinical finding of condylomata is higher in the first period of observation, sloping down through the time intervals considered. Standardization on age or patient's recruiting does not change the evidence. CONCLUSION: The trend of the HPV parameters studied could represent an epidemiological model for HPV infection. The clinical epidemics is followed by a period of HPV cytological pick, which might be followed, at suitable time interval, by more cervical intraepithelial neoplasia/squamous intraepithelial lesions, according to the well known latency between infection and premalignant changes.

Congenital heart malformations associated with dilated cardiomyopathy.

From June 1977 to February 1986 we studied 31 children with dilated cardiomyopathy. Seven patients (22%) aged 8 months to 3 years had associated congenital cardiac lesions--tetralogy of Fallot (3), coarctation of the aorta (2), ventricular septal defect (1) and Ebstein's malformation (1). The diagnosis was confirmed by hemodynamic and angiographic studies in 5 patients and by autopsy in 2. Although different congenital lesions were present, all 7 patients had congestive heart failure, flattening of T-waves or ST-segment depression on the electrocardiogram and significant decrease in the left ventricular shortening fraction as judged by echo. We conclude that the incidence of dilated cardiomyopathy associated with congenital heart malformations is high in our pediatric population. The clinical status of patients appears to be more dependent on the improvement of dilated cardiomyopathy and less dependent upon the underlying congenital heart malformations.

Hexamethylmelamine, adriamycin, and cyclophosphamide (HAC) versus cis-dichlorodiamineplatinum, adriamycin, and cyclophosphamide (PAC) in advanced ovarian cancer: a randomized clinical trial.

After stratification according to diameter of the largest residual tumor, 120 previously untreated ovarian cancer patients were randomized to receive adriamycin and cyclophosphamide in combination with hexamethylmelamine (HAC) or cis-dichlorodiamineplatinum (PAC). The surgical response rates were 66% to HAC and 70% to PAC, with median times to progression of 14 and 22 months and median survival times of 23 and 24 months, respectively. In patients with residual tumor greater than 2 cm the surgical response rates to HAC and PAC were 56% and 63%, with complete response rates of 13% and 21%, respectively. In two of five complete responders to HAC there has still been no progression at 38 and 48 months, with a median response duration of 25 months. Only one of the nine complete responders to PAC has relapsed, at 33 months, while in the eight others response is maintained at follow-up times of 35-64 months. Myelosuppression was generally mild and similar in the two arms. No significant nonhematological toxicity was reported. It is concluded that at a median follow-up time of 36 months HAC is as effective as PAC in terms of response, duration of remission, and survival in previously untreated advanced ovarian cancer.