The benefit of a special elective gynecologic oncology program for obstetrics and gynecology residents.

OBJECTIVE: To assess the benefit of a special elective gynecologic oncology program for Obstetrics and Gynecology (Ob/Gyn) residents. METHODS: We reviewed our housestaff records from July 1992 to June 1998 and the National Residency Matching Program (NRMP) subspeciality match results for gynecologic oncology from its inception in 1994 to 1999. RESULTS: From July 1992 to June 1998, a total of 146 residents participated in our elective program. Of the 104 candidates who went through our program and subsequently participated in the NRMP, 55 (53%) obtained match positions. After completion of the elective, 42 of the 146 residents (29%) did not participate in the NRMP for gynecologic oncology and therefore were not eligible to obtain match appointments. During the study period, there were 255 other residents in the United States who applied for gynecologic oncology fellowship positions through the NRMP and did not participate in our program. Of these 255 candidates, 137 (54%) matched. CONCLUSION: The percentage of residents who went through our program, participated in the NRMP, and obtained fellowships did not differ significantly from the percentage of residents who matched without participating in the program. However, almost one-third of the residents who went through our program did not participate in the NRMP. The reasons for their lack of participation were not formally evaluated, but are likely related to a personal decision to pursue another carrer pathway, a decision facilitiated by their experience in our program. Therefore, it appears that the main benefits of the program are to help potential candidates decide whether or not to pursue a career in gyencologic oncology and to aid fellowship programs in identifying exceptional candidates for subspecialty training.

An investigation into the behavioural characteristics of orthodontic elastomeric modules.

The object of the study was to investigate the behavioural characteristics of orthodontic elastomeric modules with regard to their effect on frictional resistance and their failure load forces, and involved the use of an experimental laboratory-based study. Six cohorts were assembled employing five types of module and two bracket types. Straight lengths of 0.018 x 0.025-inch stainless steel were pulled through the ligated brackets and frictional resistance was measured using an Instron universal testing machine. Recordings were repeated over a 4-week period, during which time the cohorts were placed in a simulated oral environment. Failure load forces of new and used modules were also recorded, and frictional resistance and failure load forces. Analysis of variance revealed that the Minitwin cohort exhibited significantly higher frictional resistance and that the clear modules demonstrated the lowest levels of friction. Time soaked in a simulated oral environment had a variable effect on frictional resistance. A wide range of failure load forces was seen for the five types of module and all types showed a reduction in failure load force following their soaking in the simulated oral environment. There was variation in performance of the different modules both in friction testing and failure load testing.

Trends in the use of radiation and chemotherapy in the initial management of patients with carcinoma of the uterine cervix.

PURPOSE: The Commission on Cancer of the American College of Surgeons conducts Patient Care Evaluation studies to describe practice patterns and trends in disease management. This report surveys changing strategies in the initial treatment of patients with invasive cancer of the uterine cervix. METHODS AND MATERIALS: Using a standard data collection form designed by a multidisciplinary committee of specialists, cancer registrars at 703 hospitals submitted anonymous data on 11,721 total cervical cancer patients diagnosed in 1984 and 1990. RESULTS: Between the two study years, the use of radiation as all, or a component, of the initial course of therapy declined from 70 to 60.3%, coincident with a 32.3% increase in the use of hysterectomy alone and a 33.7% reduction in the use of radiation alone. The percentage of all patients receiving combined hysterectomy and radiation (preoperative or postoperative) remained virtually unchanged--10.2% in 1984, and 9.3% in 1990. However, women who were treated by hysterectomy in 1990 were less likely to receive radiation as part of their treatment than patients treated by hysterectomy in 1984. Among patients treated by radiation without hysterectomy, the use of intracavitary brachytherapy techniques substantially exceeded interstitial brachytherapy techniques in both study years. Among patients treated by local radiation without hysterectomy, the frequency of adjunctive chemotherapy use increased from 6.9% in 1984 to 24.8% in 1990, with chemotherapy and radiation increasingly administered concurrently rather than sequentially. Although differences based on age, histology, race/ethnicity, and insurance status were observed, these general management trends were seen in all groups. CONCLUSIONS: Changes in the utilization of radiation and surgery may reflect the increasing surgical involvement of gynecologic oncologists in the management of early stage cervical cancer, rather than significant alterations in the demographics of the disease. Although brachytherapy is recognized as an important component of radiation treatment, some patients may not receive the potential benefit of this modality. Despite controversy concerning its efficacy, the use of adjuvant systemic chemotherapy to supplement local treatment modalities appears to be increasing rapidly.

The National Cancer Data Base report on endometrial carcinoma in African-American women.

BACKGROUND: Although the incidence of uterine carcinoma is lower among African-American women compared with white women, the mortality rates are higher for African-American patients. This report is part of an ongoing series on gynecologic malignancies in African-American women. METHODS: Hospital registry reports collected by the National Cancer Data Base were used to describe some of the differences in case presentation and management characteristics of endometrial carcinoma in these two groups. The cases represented 52,307 Non-Hispanic white and 3226 African-American women diagnosed with primary carcinoma of the endometrium between 1988-1994. RESULTS: More African-American patients were diagnosed with less favorable histologies than white patients, at more advanced stages of disease, and with less tumor differentiation. Income had no effect on stage or grade. African-American patients were treated less often for their tumor at every stage of diagnosis compared with white women. Income generally had no effect on whether treatment was provided, but limited income was associated with a lack of treatment in African-American patients with American Joint Committee on Cancer Stage IV tumors. African-American women were less frequently treated surgically and, among surgically treated patients at advanced stages of disease, they received adjuvant radiotherapy less often and chemotherapy more often than white patients. Five-year survival was poorer for African-American women, even for patients with the more favorable Stage I adenocarcinoma who were treated surgically. CONCLUSIONS: All patients, regardless of race, should be treated appropriately as dictated by medical and prognostic factors and not by race. Although no screening methods currently exist for endometrial carcinoma, the development of procedures for identifying patients at risk for the prognostic factors that lead to a poor outcome should be a primary focus.

Noninvasive fluorescence detection of hepatic and renal function.

A noninvasive in vivo fluorescence detection scheme was employed to continuously monitor exogenous dye clearance from the vasculature. Differentiation between normal and impaired physiological function in a rat model was demonstrated for both liver and kidney. A fiber optic transmitted light from source to ear; a second fiber optic positioned near the ear transmitted the fluorescent light to a detector system. Two model dye systems were employed in this initial study. Indocyanine green, known to be exclusively cleared from the blood stream by the liver, was excited in vivo with laser light at 780 nm. The fluorescence signal was detected at 830 nm. A characteristic clearance curve of normal hepatic function was obtained. After a partial hepatectomy of the liver, the clearance curve was extended in time, as would be expected from reduced hepatic function. In addition, fluorescein labeled poly-D-lysine, a small polymer predominantly cleared from the blood stream by the kidney, was excited in vivo with laser light at 488 nm. The fluorescence signal was detected at 518 nm. A characteristic clearance curve of normal renal function was obtained. After a bilateral ligation of the kidneys, the clearance curve remained elevated and constant, indicating little if any clearance. Thus, the feasibility of a new noninvasive method for physiological function assessment was established. © 1998 Society of Photo-Optical Instrumentation Engineers.

The National Cancer Data Base report on malignant epithelial ovarian carcinoma in African-American women.

BACKGROUND: Epithelial ovarian carcinoma is the fifth most common cause of cancer death among African-American women. Although the incidence rate of ovarian carcinoma for whites is higher than that for African Americans, the relative survival rate for African Americans is poorer. METHODS: Data were cases submitted to the National Cancer Data Base for invasive epithelial tumors of the ovary diagnosed between 1985-1988 and 1990-1993. African-American women with epithelial ovarian carcinoma were compared with non-Hispanic white women with the same disease. The groups of white women with which African-American women were compared were classified as "White-same facility" and "White-other facility." "White-same facility" were white patients from hospitals that contributed a substantial proportion of African-American patients. "White-other facility" were white patients from hospitals that contributed few or no African-American patients. No patient had a history of prior cancer. RESULTS: African-American women with advanced invasive epithelial ovarian carcinoma were less often treated with combined surgery and chemotherapy and more often treated with chemotherapy only. African-American women were twice as likely as white women not to receive appropriate treatment. African-American women had poorer survival rates than white women from the same or different hospitals, regardless of income. Among staged cases, African-American women were more often diagnosed with Stage IV disease than either group of white women. CONCLUSIONS: The current study findings show that African-American women with advanced epithelial ovarian carcinoma received less aggressive treatment than white women and had a poorer prognosis.

Regression of uterine low-grade smooth-muscle tumors metastatic to the lung after oophorectomy.

BACKGROUND: Metastatic uterine low-grade smooth-muscle tumors may present with pulmonary symptoms and radiographic lung abnormalities consistent with metastatic neoplasms. Ovarian hormone stimulation of these smooth-muscle tumors has been suggested, but the role of surgical or medical oophorectomy has not been established in patients with metastatic disease. CASES: Two women with histologically confirmed uterine low-grade smooth-muscle tumors metastatic to the lung had progressive and complete tumor regression after oophorectomy and no further therapy. CONCLUSION: Some uterine low-grade smooth-muscle tumors metastatic to the lung regress after oophorectomy. Removing ovarian hormone stimulation may result in complete tumor regression without the need for further therapy.

Management of high-risk gestational trophoblastic disease--the Memorial Hospital experience.

Thirty-two patients with high-risk gestational trophoblastic disease (GTD), defined as metastases to the brain or liver (regardless of hCG level or duration of disease) or prior unsuccessful chemotherapy are reviewed. In this classification, an antecedent term pregnancy is not considered to be an independent high-risk factor. Initial chemotherapy in 15 (46.8%) patients consisted of methotrexate, actinomycin D, and chlorambucil (MAC), actinomycin D alone in seven (21.8%), etoposide, methotrexate, actinomycin D, cytoxan on covin (EMACO) EMACO in three (9.4%), ITMA (hydroxyurea, vincristine, methotrexate, folinic acid, cyclophosphamide, actinomycin D, adriamycin, and melphalan) in three (9.4%). The remaining patients were treated with actinomycin D and 6-mercaptopurine (1), CHAMOCA (1), carboplatin and Taxol (1), and methotrexate (1). All patients with brain metastases were treated with cranial radiotherapy. Overall complete remission was achieved in 14 of 32 (43.7%) patients. Five of 9 (55.5%) patients whose disease followed a term pregnancy survived compared to nine of 23 (39.1%) patients whose disease followed other types of pregnancies. The data analyzed according to the clinical classification of 'high-risk' indicates that an overall survival rate of 70% was achieved. The Memorial Hospital classification therefore identifies patients who need primary chemotherapy more aggressive than MAC and similar to the WHO scoring system is a better predictor of survival than the clinical classification.

Diagnostic assessments in patients with invasive cancer of the cervix: a national patterns of care study of the American College of Surgeons.

Using a standard collection form designed by a multidisciplinary committee of specialists, cancer registrars at 703 hospitals submitted anonymous data on 11,721 patients with cervical cancer diagnosed during 2 study years, 1984 and 1990. Information concerning the initial use of diagnostic assessments was analyzed with respect to the potential influences of clinical stage, patient age, race/ethnicity, insurance status, and modalities of therapy employed. Estimates of the yield of diagnostic information for each test were correlated with clinical stage and patient age. Judged by the number of procedures performed, the intensity of pretreatment assessment declined between 1984 and 1990. Substantially increased use of the newer body imaging modalities (computerized axial tomography and magnetic resonance imaging) with high probabilities of revealing abnormalities attributed to cancer, balanced major declines in utilization of procedures historically important in staging and assessment (cystoscopy, proctoscopy, barium enema, excretory urography (intravenous pyelogram), bone scintography, and lymphangiography). Race/ethnicity and insurance status had no discernible independent impact on the intensity of diagnostic evaluation. Patients with more advanced clinical stages underwent more extensive testing, as did patients treated initially with radiation compared to surgery. Periodic review of assessment strategies would seem prudent to avoid widening discrepancies between sanctioned staging formalisms with endorsed and authorized appraisals and actual clinical practice.

Hysterectomy in invasive cervical cancer: a national patterns of care study of the American College of Surgeons.

BACKGROUND: As the use of Papanicolaou cytologic screening became widespread in the United States of America, there was a shift toward diagnosis of earlier clinical stages in patients with carcinoma of the cervix. This increase in early stage disease has also resulted in increased use of surgery as the primary treatment. Thus, it seems appropriate to investigate the role of hysterectomy in the modern treatment of patients with invasive carcinoma of the cervix, including survival rates and the role of the gynecologic oncologist. STUDY DESIGN: Approximately 1,800 hospitals were sent invitations to submit data on a standard collection form designed by a multidisciplinary committee of specialists. Cancer registrars at 703 hospitals submitted anonymous data on 11,721 patients with carcinoma of the cervix who were diagnosed or treated, or both, in 1984 and 1990. RESULTS: There were 6,570 (56.1 percent) women who had major operations. An operation with curative intent, either total hysterectomy (TAH) or radical type II or III hysterectomy with pelvic node dissection PND (RHPND), was carried out in 5,105 (43.6 percent) women, constituting 38.9 percent of the patients in 1984, and 48.2 percent of the patients in 1990. Overall (both years), 66.5 percent of patients had squamous cell carcinomas and 21.1 percent had adenocarcinomas. The type of operation performed was judged appropriate in 95.6 percent of the patients who underwent RHPND, but in only 80.0 percent of the patients who underwent TAH. Gynecologic oncologists performed 46.8 percent of the hysterectomies in 1984, and 63.8 percent in 1990. Recurrence and long-term survival data are available for the 1984 patients; five-year survival rates for women who underwent TAH (n = 1,013) and RHPND (n = 1,279) were 89 and 85 percent, respectively. A RHPND with negative nodes resulted in a 90 percent five-year survival rate (n = 916) as compared to 70 percent in those with positive nodes (n = 194). CONCLUSIONS: The use of hysterectomy as definitive therapy increased markedly from 1984 to 1990 and was associated with low complication and high five-year survival rates. Gynecologic oncologists now perform the majority of hysterectomies for this type of carcinoma, with general gynecologists playing a lesser role than in the earlier study year. Guidelines should be developed for the use of TAH in patients with invasive carcinoma of the cervix.

Laparotomy to complete staging of presumed early ovarian cancer.

OBJECTIVE: To assess the findings and complications of laparotomies for completely staging presumed early-stage ovarian cancer in patients who initial surgery was inadequate. METHODS: Records of 45 patients surgically restaged at our institution, after having been incompletely staged elsewhere, were reviewed for original operative reports, pathologic diagnoses, restaging procedures, operative results, and perioperative complications. RESULTS: Initial clinical staging was IA, 28; IB, three; IC, 12; IIA, one; IIB, one. Histologic distribution was as follows: invasive epithelial, 19 (42%); borderline epithelial, 16 (36%); germ cell tumor, seven (16%) had their disease reclassified to a more advanced stage. Of patients with borderline ovarian tumors, two, initially staged as IA, were restaged to IB and IC, and one was restaged from IIB to IIIA. Three patients with invasive epithelial adenocarcinoma were reclassified to a higher stage: one, with a presumed stage IC, poorly differentiated adenocarcinoma, to IIIB; one, with a stage IC, grade 2 mucinous cystadenocarcinoma, to IIIA; and a third, with a IIA, poorly differentiated adenocarcinoma, to IIIC. A patient with granulosa cell tumor, initially stages as IC, was restaged to IIB. Fifteen patients (33%) had complications after restaging surgery. Seven (16%) patients undergoing restaging laparotomy for presumed early ovarian cancer were reclassified to a higher stage, resulting in alteration of treatment for only on patient. In 18 patients with invasive cancer, the second operation confirmed the presence of low-risk stage IA/B disease, allowing adjuvant chemotherapy to be withheld. CONCLUSION: Although restaging laparotomies provide important prognostic information with minimal morbidity, they provide little benefit to those patients already requiring chemotherapy based on the original operative findings.

Treatment of resistant gestational choriocarcinoma with taxol: a report of two cases.

Two patients with resistant gestational choriocarcinoma were treated w with Taxol after extensive prior chemotherapy including EMACO and platinum-based salvage chemotherapy. Both patients showed significant responses to Taxol. One patient relapsed in the brain and liver after treatment and died. Taxol was combined with carboplatin in the other patient who achieved sustained clinical and hormonal remission after craniotomy and excision of resistant disease in the brain.

Cervical carcinoma and pregnancy. A national patterns of care study of the American College of Surgeons.

BACKGROUND: The American College of Surgeons conducted a national patient care and evaluation study of invasive cervical carcinoma in pregnant patients. METHODS: Invasive cervical carcinoma was diagnosed in 161 patients who were pregnant at the time of diagnosis. A long term study of 78 patients diagnosed in 1984 was compared with a short term study of 83 patients diagnosed in 1990. RESULTS: The mean age of the patients was 31.8 years. Clinical stages were: IA (29%); IB (54%); IIA (6%); IIB (4%); IIIA (0%); IIIB (3%); IV (1%; AND IVB 3%). Thirty-one percent of patient were diagnosed in the first trimester, 34% in the second, and 35% in the third. A tumor size of 4 cm or larger in diameter was found in 36% of the patients diagnosed in the first trimester, 40% of the patients diagnosed in the second, and 38% of the patients diagnosed in the third. Patients were treated with surgery alone (86), radiotherapy alone (30), or with combination therapy (45). The overall 5-year survival rate for patients diagnosed in 1984 was 82%. In this group, the 5-year survival rate for patients diagnosed in the first trimester was 94.6%, in the second, 76.9%, and in the third, 68.9%. Comparing the two time periods, surgical therapy was performed more often by gynecologic oncologists in 1990 (69% vs. 42%), and a greater percentage of patients were diagnosed with a tumor size of 4 cm or larger in diameter (43% vs. 26%) as well as with stage IIB-IVB disease (15% vs. 6.7%). CONCLUSIONS: The prognosis of pregnant patients with invasive cervical carcinoma is similar to that for nonpregnant patients. The significant number of patients diagnosed in the second and third trimesters and the frequent finding of large tumors in all trimesters emphasize the need for patient education and early prenatal evaluation, including cervical cytology and biopsy of any clinically abnormal cervix.

Patterns of care for invasive cervical cancer. Results of a national survey of 1984 and 1990.

BACKGROUND: The American College of Surgeons conducted a national patient care and evaluation study of invasive cervical cancer to measure any changes in patterns of care for the years 1984 and 1990. METHODS: Hospitals with cancer programs were invited to submit data on up to 25 consecutive patients with newly diagnosed invasive cervical cancer for each of the two study years. Data were obtained from 684 hospitals on 5904 patients diagnosed in 1984 and from 700 hospitals on 5817 patients diagnosed in 1990. A long term study of patients diagnosed in 1984 was compared with a short term study of patients diagnosed in 1990. Survival data were described only for patients diagnosed in 1984. RESULTS: Of a total of 11,721 patients, 59.4% were diagnosed and treated at the reporting institution in 1984 and 54.8% in 1990. The remaining patients were referred for treatment after diagnosis elsewhere. The diagnosis was established by cervical biopsy for 69.8% of patients, by conization alone for 9.3%, and by both procedures for 11.8%. The histopathologic diagnoses were squamous cell carcinoma (79.8%), adenocarcinoma (15.8%), and other (4.4%). The stage distributions were as follows: IA, 15.9%; IB, 36.8%; IIA, 8.2%; IIB, 15.5%; IIIA, 2.5%; IIIB, 13.3%; IVA, 2.6%; and IVB, 5.2%. The stage was listed as unknown for 20.3% of patients. Patients were treated with surgery alone (29.2%), radiation alone (40.7%), chemotherapy alone (0.7%), or combination therapy (21.5%), and 7.9% received no treatment at the reporting institution. The overall survival for patients diagnosed in 1984 was 68.3%. Survival by stage in this group was as follows: IA, 93.7%; IB, 80.0%; IIA, 67.2%; IIB, 64.7%; III, 37.9%; and IV, 11.3%. CONCLUSIONS: These data indicate that invasive cervical cancer is highly curable when diagnosed early. During the 5-year period, stage distributions were similar, the use of extended hysterectomy increased, and gynecologic oncologists were more often the primary surgeons. The use of radiation alone decreased.

Is there really a difference in survival of women with squamous cell carcinoma, adenocarcinoma, and adenosquamous cell carcinoma of the cervix?

BACKGROUND: The authors' aim was to assess whether there is a difference in biologic behavior and survival in comparing adenocarcinoma (AdCA), squamous cell carcinoma (SCC), and adenosquamous carcinoma (Ad/SC) of the cervix. METHODS: Cancer registrars at 703 hospitals submitted anonymous data on 11,157 patients with cervical cancer diagnosed and/or treated in 1984 and 1990 for a Patient Care Evaluation Study of the American College of Surgeons. Among these patients, 9351 (83.8%) had SCC; 1405 (12.6%), AdCA; and 401 (3.6%), Ad/SC cancers. There were no significant changes in percentages of the different histologic types between the study years 1984 and 1990, nor was the patient distribution different regarding age, race/ethnicity, and socioeconomic background for each histologic group. Furthermore, the distribution of patients who had had a hysterectomy did not change between 1984 and 1990. RESULTS: A larger percent of patients with SCC (63.8%) than those with Ad/SC (59.8%) or AdCA (50.2%) had tumors larger than 3 cm at greatest dimension. Early stage patients (IA, IB, IIA) often were treated by hysterectomy alone (45.5%) or combined with radiation (21.1%). The remaining patients (21.9%) received radiation alone. Of the patients with clinical stage I disease, 7.6% of Ad/CA patients, 15.5% of Ad/SC patients and 12.6% of SCC patients had positive nodes. Although patients with SCC had higher survival rates for all four clinical stages (I-IV), the differences were only significant for Stage II patients. Patients with clinical stage IB SCC and AdCA treated by surgery alone were found to have significantly better survival rates (93.1% and 94.6% at 5 years, respectively) than women treated by either radiation alone or a combination of surgery and radiation (P < 0.001, both histologic comparisons). For women with Ad/SC tumors, however, the 5-year survival rate was 87.3% for those receiving combined treatment compared with those receiving surgery alone (69.2%) or radiation alone (79.2%). However, these survival curves were not significantly different (P = 0.496). One hundred six patients with positive nodes were available for analysis. The 5-year survival rate of patients with SCC and positive nodes was 76.1%. Surprisingly, patients with Ad/SC and positive nodes had the highest 5-year survival rate (85.7%), whereas, women with AdCA and positive nodes had a sharply reduced 5-year survival rate (33.3%). The curves were significantly different (P < 0.01). For patients with clinical stage I, the risk factors for age, tumor size, nodal status, histologic features, and treatment were analyzed with Cox's multivariate regression. In this analysis, subset IB, greater tumor size, age 80 or older, and positive nodal status were each independently significant for poorer survival. Patients who were treated by surgery alone had a significantly better survival than patients who had other types of treatment or no treatment. Histologic characteristics had no significant effect on survival. In the analysis of patients with pathologic stage I disease, those with SCC had significantly poorer survival and those with Ad/SC had significantly better survival than patients with Ad/CA. Positive nodes had no significant independent effect on survival. In another analysis, tissue type was not found to be an important factor in recurrence time. CONCLUSIONS: 1. Ad/CA and Ad/SC tumors were found to represent 12.6% and 3.6%, respectively, of a large series (N = 11,157) of cervical cancers diagnosed in 1984 and 1990 and reported to the Commission on Cancer of the American College of Surgeons. 2. Two thirds of women with early clinical stage disease (IA, IB, IIA) had hysterectomy as all or part of their primary therapy. 3. No significant differences were found in 5-year survival among the three tissue types in any clinical stage except American Joint Committee on Cancer stage II.

Cytoreductive surgery in ovarian carcinoma patients with a documented previously complete surgical response.

Recurrent ovarian cancer after negative findings at second-look laparotomy is common. A retrospective review of 57 patients who developed recurrent tumor after a negative second-look laparotomy was undertaken to evaluate treatment efficacy and prognostic factors. All patients received primary platinum-based chemotherapy. Recurrences occurred in the abdomen or pelvis (40 patients), lymph nodes (7), liver (4), lungs (3), and vagina (3). Recurrent disease was diagnosed at a mean interval of 20 months after second-look surgery. Of the 38 patients who underwent laparotomy for recurrence, 36 (95%) had > 0.5 cm disease. After cytoreductive surgery 14 patients (37%) were left with minimal (< 0.5 cm) residual disease. Intestinal resection or bypass was performed on 10/38 patients (26%) with one requiring a colostomy. There was no operative mortality and one complication (small bowel obstruction). Treatment after recurrence consisted of platinum-based chemotherapy (88%), with the remaining patients receiving irradiation or hormonal therapy. At a mean follow-up from recurrence for the entire group of 20 months, 18/38 (47%) explored patients are alive. All 19 patients who were not explored died with a median survival time from recurrence of 9 months. Patients who underwent a laparotomy and patients with < 0.5 cm residual disease had a significant survival advantage (P < 0.0001). Initial stage, grade, disease-free interval, and disease found at laparotomy did not influence survival. Recurrent ovarian carcinoma after platinum-based chemotherapy is associated with a grave prognosis when the patient is deemed inoperable or when distant metastasis are found. Patients with disease reduced to < 0.5 cm showed a significant survival advantage.

Blood transfusion for radical hysterectomy before and after the discovery of transfusion-related human immunodeficiency virus infection.

OBJECTIVE: To compare the patterns of perioperative blood transfusion in patients undergoing radical hysterectomy in time periods before and after the discovery of transfusion-related human immunodeficiency virus (HIV) infection. METHODS: We reviewed the medical records of all patients who underwent radical hysterectomy and pelvic lymphadenectomy at Memorial Sloan-Kettering Cancer Center during two time periods, an early period (January 1, 1980 through December 31, 1993) and a late period (July 1, 1991 through June 30, 1993). The early period preceded and the late period coincided with the era of increased awareness of transfusion-related HIV infections. RESULTS: One hundred twenty-eight patients underwent radical hysterectomy in the early period and 71 in the late period. In the late period, markedly fewer units of blood were transfused per patient (0.62 versus 3.5). Most patients in the early period received at least one unit (117 of 128, 91%), compared with less than half (31 of 71, 44%) in the late period. For patients who received transfusions, notably fewer received homologous blood during the late (6 of 31, 19%) versus the early period (117 of 117, 100%). Using an unpaired t test and the 95% confidence interval (CI), we found that the patients in the late period had a shorter mean postoperative length of stay (11 versus 14 days, P < .0001, 95% CI +/- 1.3) and were discharged with a significantly lower mean hemoglobin level (9.7 versus 11.4 g/dL, P < .0001, 95% CI +/- 0.35). The mean estimated blood loss was lower in the late period (756 versus 1598 mL). We defined the transfusion index as the number of units transfused per 500 mL of estimated blood loss. The mean transfusion index was significantly lower during the late period (0.38 versus 1.1, P < .001, 95% CI +/- 0.19). CONCLUSIONS: During the perioperative period for radical hysterectomy and pelvic lymphadenectomy, the incidence of blood transfusion at our institution has markedly decreased over the past decade without immediate adverse effects on postoperative recovery. The reasons for this are probably multifactorial. However, the contribution of increased concern about transfusion-related HIV infections must be considered. Preoperative autologous donation can notably decrease the need for homologous transfusion.

Myochrysine solution structure and reactivity.

We have determined the framework structure of Myochrysine (disodium gold(I)thiomalate) in the solid state and extremely concentrated aqueous solution, previously. It consists of an open chain polymer with linear gold coordination to two thiolates from the thiomalic acid moieties which bridge between pairs of gold atoms providing an Au-S-Au angle of 95 degrees . The question remained: was this structure relevant to the dilute solutions of drugs administered and the still lower concentrations of gold found in the bodies of patients (typically 1 ppm Au in blood and urine or 5 muM in Au). We have provided an answer to that question using extended X-ray absorption spectroscopy (EXAFS) and capillary zone electrophoresis (CZE). EXAFS studies confirm that the polymeric structure with two sulfur atoms per gold atom persists from molar concentrations down to millimolar concentrations. CZE is able to separate and detect Myochrysine at millimolar levels. More importantly, at micromolar levels Myochrysine solutions exhibit identical CZE behavior to that measured at millimolar levels. Thus, aqueous solutions of the drug remain oligomeric at concentrations commensurate with those found in patient blood and urine.The reactivity of Myochrysine with cyanide, a species especially prevalent in smoking patients, was explored using CZE. Cyanide freely replaces thiomalic acid to form [Au(CN)(2)](-) and thiomalic acid via a mixed ligand intermediate. The overall apparent equilibrium constant (K(app)) for the reaction is 6x10(-4)M(-1). Further reaction of [Au(CN)(2)](-) with a large excess of L, where L is cysteine, N-acetylcysteine, or glutathione, shows that these amino acids readily replace cyanide to form [AuL(2)](-). These species are thus potential metabolites and could possibly be active forms of gold in vivo. That all of these species are readily separated and quantified using CZE demonstrates that capillary electrophoresis is an accessible and powerful tool to add to those used for the study of gold-based antiarthritis drugs.

Late recurrence of clear cell adenocarcinoma of the vagina and cervix: a report of three cases.

Three patients with clear cell adenocarcinomas who developed recurrent disease after a prolonged disease-free interval are presented. The first patient developed a recurrence in the lung 7 years and 3 months after wide local excision and pelvic radiotherapy for clear cell adenocarcinoma of the vagina. She then underwent thoracotomy and chemotherapy and has remained free of disease for more than 13 years after treatment of the recurrence. The second patient with clear cell adenocarcinoma of the vagina developed recurrent disease at the apex of the vagina 5 years after radical hysterectomy, bilateral pelvic lymphadenectomy, and partial vaginectomy. She then underwent exploratory laparotomy, partial vaginectomy, and vaginal irradiation and has been free of disease in follow-up for 6 months. The third patient underwent radical hysterectomy, bilateral pelvic lymphadenectomy, and total vaginectomy for clear cell adenocarcinoma of the cervix that also involved two-thirds of the vagina. Four years and 6 months after this operation, she underwent an exploratory laparotomy, with complete resection of recurrent disease in the abdomen in continuity with a left nephrectomy. Following surgery, she was treated with abdominal and pelvic radiotherapy and chemotherapy and remained clinically free of disease for 1 year, but subsequently developed an unresectable pelvic mass. Despite further chemotherapy, she died 5 years and 10 months after the initial diagnosis.

Cutaneous larva migrans.

The case of cutaneous larva migrans presented here is typical for its mechanism and geographic location of infection, evolution of lesions, and prompt response to treatment. Except for pinworms, helminth infections are rarely thought of in emergency departments away from the areas where the parasites are especially prevalent. The several-day incubation period and modern-day ease of travel should place this illness on one's list of the differential diagnoses of pruritic lesions regardless of the location of practice. This case serves as a reminder that in a mobile society, diseases, as well as patients, can travel.