Experimental evidence on promotion of electric and improved biomass cookstoves.

Improved cookstoves (ICS) can deliver "triple wins" by improving household health, local environments, and global climate. Yet their potential is in doubt because of low and slow diffusion, likely because of constraints imposed by differences in culture, geography, institutions, and missing markets. We offer insights about this challenge based on a multiyear, multiphase study with nearly 1,000 households in the Indian Himalayas. In phase I, we combined desk reviews, simulations, and focus groups to diagnose barriers to ICS adoption. In phase II, we implemented a set of pilots to simulate a mature market and designed an intervention that upgraded the supply chain (combining marketing and home delivery), provided rebates and financing to lower income and liquidity constraints, and allowed households a choice among ICS. In phase III, we used findings from these pilots to implement a field experiment to rigorously test whether this combination of upgraded supply and demand promotion stimulates adoption. The experiment showed that, compared with zero purchase in control villages, over half of intervention households bought an ICS, although demand was highly price-sensitive. Demand was at least twice as high for electric stoves relative to biomass ICS. Even among households that received a negligible price discount, the upgraded supply chain alone induced a 28 percentage-point increase in ICS ownership. Although the bundled intervention is resource-intensive, the full costs are lower than the social benefits of ICS promotion. Our findings suggest that market analysis, robust supply chains, and price discounts are critical for ICS diffusion.

Black patients sustain vision loss while White and South Asian patients gain vision following delamination or segmentation surgery for tractional complications associated with proliferative diabetic retinopathy.

PurposeThis retrospective comparative case series aims to determine whether patient ethnicity (White versus South Asian versus Black) is related to the outcome of surgical treatment for traction complications of severe proliferative diabetic retinopathy (PDR).SettingMoorfields Eye Hospital London, UK.MethodsAll patients who underwent vitrectomy with, delamination and/or segmentation for PDR over a 5-year period (2009-2014) were reviewed retrospectively. Patients were divided into White, South Asian or Black groups, and their age, gender, HbA1C and type of diabetes were recorded. A total of 484 patients (253 White, 117 South Asian, 114 Black) were included. Twenty-one patients were excluded due to inadequate documentation.OutcomesLogMAR Visual acuity (converted from Snellen) (VA), was recorded pre-operatively and ~6 months post surgery (range 5-8 months). Surgical outcome was classified according to the type and duration of tamponade required post-operatively.ResultsPre-operative VA and HbA1C values were similar across all three ethnic groups (P=0.64 and 0.569, respectively). Change in VA (mean±SD) was 0.41±0.78, 0.14±0.76 and -0.26±0.57 in White, South Asian and Black patient groups respectively (P<0.001). Multiple regression analysis showed that post-op VA was significantly related to race and pre-op VA only (both P<0.001). The Black patient group were more likely to require silicone oil tamponade (P<0.001) and long-term retention of silicone oil (P<0.001) than the White and South Asian patient groups.ConclusionsThis study demonstrates that Black patients on average lose vision following delamination surgery for traction complications of PDR while White and South Asian patients gain vision. The same group is also at higher risk of retaining silicone more than 6 months after surgery. This difference remains even when corrected for glycaemic control. The higher risk of visual loss and long-term retention of silicone oil in black patients requires further investigation. If these results are confirmed, surgeons should consider their patients' ethnicity before proceeding with surgical treatment of diabetic tractional detachment.

Frequency of HIV-testing and factors associated with multiple lifetime HIV-testing among a rural population of Zambian men.

BACKGROUND: Across sub-Saharan Africa, men's levels of HIV-testing remain inadequate relative to women's. Men are less likely to access anti-retroviral therapy and experience higher levels of morbidity and mortality once initiated on treatment. More frequent HIV-testing by men at continued risk of HIV-infection is required to facilitate earlier diagnosis. This study explored the frequency of HIV-testing among a rural population of men and the factors associated with more frequent HIV-testing. METHODS: We conducted a secondary analysis of a population-based survey in three rural district in Zambia, from February-November, 2013. Households (N = 300) in randomly selected squares from 42 study sites, defined as a health facility and its catchment area, were invited to participate. Individuals in eligible households were invited to complete questionnaires regarding demographics and HIV-testing behaviours. Men were defined as multiple HIV-testers if they reported more than one lifetime test. Upon questionnaire completion, individuals were offered rapid home-based HIV-testing. RESULTS: Of the 2376 men, more than half (61%) reported having ever-tested for HIV. The median number of lifetime tests was 2 (interquartile range = 1-3). Just over half (n = 834; 57%) of ever-testers were defined as multiple-testers. Relative to never-testers, multiple-testers had higher levels of education and were more likely to report an occupation. Among the 719 men linked to a spouse, multiple-testing was higher among men whose spouse reported ever-testing (adjusted prevalence ratio = 3.02 95% CI: 1.37-4.66). Multiple-testing was higher in study sites where anti-retroviral therapy was available at the health facility on the day of a health facility audit. Among ever-testers, education and occupation were positively associated with multiple-testing relative to reporting one lifetime HIV-test. Almost half (49%) of ever-testers accepted the offer of home-based HIV-testing. DISCUSSION: Reported HIV-testing increased among this population of men since a 2011/12 survey. Yet, only 35% of all men reported multiple lifetime HIV-tests. The factors associated with multiple HIV-testing were similar to factors associated with ever-testing for HIV. Men living with HIV were less likely to report multiple HIV-tests and employment and education were associated with multiple-testing. The offer of home-based HIV-testing increased the frequency of HIV-testing among men. CONCLUSION: Although men's levels of ever-testing for HIV have increased, strategies need to increase the lifetime frequency of HIV-testing among men at continued risk of HIV-infection.

Factors associated with HIV-testing and acceptance of an offer of home-based testing by men in rural Zambia.

The objective of this study is to describe HIV-testing among men in rural Lusaka Province, Zambia, using a population-based survey for a cluster-randomized trial. Households (N = 120) were randomly selected from each of the 42 clusters, defined as a health facility catchment area. Individuals aged 15-60 years were invited to complete questionnaires regarding demographics and HIV-testing history. Men testing in the last year were defined as recent-testers. After questionnaire completion adults were offered home-based rapid HIV-testing. Of the 2,828 men, 53 % reported ever-testing and 25 % recently-testing. Factors independently associated with ever- and recent-testing included age 20+ years, secondary/higher education, being married or widowed, a history of TB-treatment and higher socioeconomic position. 53 % of never-testers and 57 % of men who did not report a recent-test accepted home-based HIV-testing. Current HIV-testing approaches are inadequate in this high prevalence setting. Alternative strategies, including self-testing, mobile- or workplace-testing, may be required to complement facility-based services.

Treatment outcomes of multidrug-resistant tuberculosis patients in Gauteng, South Africa.

PURPOSE: Multidrug-resistant tuberculosis (MDR-TB) is associated with lengthy treatment, expensive and potentially toxic regimens, and high rates of treatment failure and death. This study describes the outcomes of 351 MDR-TB patients who started treatment between 2004 and 2007 at the provincial MDR-TB referral hospital in Johannesburg, South Africa, and investigates risk factors associated with death. METHODS: The study involved the assessment of factors associated with treatment outcomes using a retrospective review of patient records, drug-susceptibility data and spoligotyping of isolates. RESULTS: Treatment success (completion/cure) was recorded in 158 (48.8 %) patients, while 65 (20 %) died, 93 (28.7 %) defaulted, 8 (2.5 %) failed treatment, 11(3.1 %) were transferred out to other health facilities and 16 (4.6 %) had no recorded final outcome. The proportion of successful treatment increased significantly over time. Univariable and multivariable analysis (P = 0.05) identified the year of MDR-TB diagnosis and spoligotype-defined families as factors associated with treatment outcome. No associations were found between treatment outcome and human immunodeficiency virus (HIV) status, previous TB and additional MDR resistance to streptomycin or ethambutol. Molecular typing of the strains revealed a diverse group of spoligotypes, with Beijing, LAM4 and H3 making up the largest groups. CONCLUSIONS: This is the first published study to investigate treatment outcomes at this facility and to find a link between genotype and treatment outcome, suggesting that genotype determination could potentially serve as a prognostic factor.

Trends in drug-resistant tuberculosis in a gold-mining workforce in South Africa, 2002-2008.

SETTING AND OBJECTIVE: To describe trends in drug-resistant tuberculosis (TB) in two gold-mining workforces, South Africa, 2002-2008. DESIGN: TB programme data analysis. RESULTS: TB case notification rates decreased between 2002 and 2008 from 4006 to 3018 per 100,000 and from 3192 to 2468/100,000 for Companies A and B, respectively. Human immunodeficiency virus (HIV) prevalence exceeded 80% in TB episodes with known status. The proportion of TB episodes with multidrug-resistant TB (MDR-TB) increased from 6/129 (4.7%) to 17/85 (20.0%) among previously treated cases, and from 4/38 (10.4%) to 7/28 (25.0%) in Companies A and B, respectively (tests for trend, Company A, P < 0.001; Company B, P = 0.304). Case notifications of MDR-TB increased during 2002-2008 from 39.8 to 122.9/100,000/year in Company A and from 7.8 to 96.8/100,000/year in Company B. Coverage of second-line drug susceptibility testing (DST) among MDR-TB episodes was low. Previous treatment exposure was a strong risk factor for MDR-TB (prevalence ratio 8.78, 95%CI 5.94-12.97 in previously treated vs. untreated individuals). CONCLUSION: Despite decreasing TB notifications overall, MDR-TB notifications and proportions of episodes with MDR-TB increased in the larger company. Cure must be ensured in first episodes to prevent acquired resistance. Improved coverage of culture, DST and HIV testing is required to allow treatment to be optimised.

Behaviour change in generalised HIV epidemics: impact of reducing cross-generational sex and delaying age at sexual debut.

BACKGROUND: Sexual behavioural change is essential to prevent HIV infections in Africa and statistical analysis of risk factors at the individual-level may be used to design interventions. The importance of reducing cross-generational sex (young women having sex with older men) and delaying age at first sex on the spread of HIV at the population-level has been presumed but not scientifically investigated and quantified. METHODS: A mathematical model of heterosexual spread of HIV was developed to predict the population-level impact of reducing cross-generational sex and delaying sexual debut. RESULTS: The impact of behaviour change on the spread of HIV is sensitive to the structure and reaction of the sexual network. Reducing cross-generational sex could have little impact on the risk of infection unless it is accompanied by a reduction in the number of risky sexual contacts. Even peer-to-peer sexual mixing can support high endemic levels of HIV. The benefit of delaying sexual debut is comparatively small and is reduced if males continue to prefer young partners or if young women spend more time unmarried. In Manicaland, Zimbabwe, if older men were to use condoms as frequently as young men, the reduction in risk of infection could exceed that generated by a two-year delay in first sex. CONCLUSIONS: At the individual-level avoiding sex with older partners and delaying sexual debut can decrease the risk of infection but at the population-level these interventions may do little to limit the spread of HIV without wider-ranging behavioural changes throughout the sexual network.

HIV infection and reproductive health in teenage women orphaned and made vulnerable by AIDS in Zimbabwe.

AIDS has increased the number of orphans and vulnerable children (OVCs) in sub-Saharan Africa who could suffer detrimental life experiences. We investigated whether OVCs have heightened risks of adverse reproductive health outcomes including HIV infection. Data on HIV infection, sexually transmitted infection (STI) symptoms and pregnancy, and common risk factors were collected for OVCs and non-OVCs in a population survey of 1523 teenage children in eastern Zimbabwe between July 2001 and March 2003. Multivariate logistic regression was used to test for statistical association between OVC status, adverse reproductive health outcomes and suspected risk factors. Amongst women aged 15-18 years, OVCs had higher HIV prevalence than non-OVCs (3.2% versus 0.0%; p = 0.002) and more common experience of STI symptoms (5.9% versus 3.3%; adjusted odds ratio = 1.75, 95% CI 0.80-3.80) and teenage pregnancy (8.3% versus 1.9%; 4.25, 1.58-11.42). OVCs (overall), maternal orphans and young women with an infected parent were more likely to have received no secondary school education and to have started sex and married, which, in turn, were associated with poor reproductive health. Amongst men aged 17-18 years, OVC status was not associated with HIV infection (0.5% versus 0.0%; p = 1.000) or STI symptoms (2.7% versus 1.6%; p = 0.529). No association was found between history of medical injections and HIV risk amongst teenage women and men. High proportions of HIV infections, STIs and pregnancies among teenage girls in eastern Zimbabwe can be attributed to maternal orphanhood and parental HIV. Many of these could be averted through further female secondary school education. Predicted substantial expanded increases in orphanhood could hamper efforts to slow the acquisition of HIV infection in successive generations of young adults, perpetuating the vicious cycle of poverty and disease.

Patterns of uptake of treatment for self reported sexually transmitted infection symptoms in rural Zimbabwe.

OBJECTIVES: To determine the extent of self reported symptoms perceived to be related to sexually transmitted infections and the patterns of subsequent treatment seeking behaviour in a predominantly rural population of Zimbabwe. METHODS: A population based survey of 4331 men and 5149 women was conducted in rural Zimbabwe during 1998-2000. Structured confidential interviews collected data on self reported sexually transmitted infection symptoms, treatment seeking behaviour, sociodemographic characteristics, and sexual behaviour. RESULTS: 25% of men aged 17-54 years report experiencing genital sores and 25% of men report experiencing urethral discharge; 30% of women aged 15-44 years report experiencing vaginal discharge. The lifetime number of sexual partners, age, and years of sexual activity were all significant predictors of symptoms for both men and women (all p values <0.001). 92% of men and 62% of women had sought treatment for their symptoms in the past year (p value <0.001). Men and women were equally likely to have sought treatment at a local hospital or clinic, but women were much less likely than men to have sought treatment at a different hospital or clinic. Among those who had sought treatment, men sought treatment faster than women and were more likely to report being "very satisfied" with their treatment than women. CONCLUSIONS: The gender differences in treatment seeking are of major concern for control efforts and further work on determining the reasons for these should be a priority. This would inform the likely impact of both increasing availability of local services and further reducing the stigma faced by those wishing to access such services.

Autologous heat shock protein-peptide complexes for vaccination against cancer: from bench to bedside.

Random mutations in cancer cells generate unique antigens in each patient's tumour, warranting a personalized treatment approach. Autologous heat shock protein-peptide complexes (HSPPCs) produced from a patient's cancer tissue provide such a personalized approach without the need to identify the unique antigens contained in the individual vaccine. HSPPCs elicit adaptive and innate immune responses and have been tested in a variety of animal models and different human cancers. Currently, there are more than 150 medical centres worldwide enrolling cancer patients in randomized, controlled Phase III clinical trials testing autologous HSPPCs vaccines. This review summarizes the key steps involved in the translation of HSPPCs--from basic science to advanced clinical investigation.

Quality of life improvement in treatment of psoriasis with intermittent short course cyclosporin (Neoral).

Due to concern over long term safety of continuous treatment with cyclosporin, the aim of this 1-year study was to assess the effect of intermittent therapy with cyclosporin (Neoral) on the quality of life of patients suffering from chronic plaque psoriasis. A total of 41 patients with chronic plaque psoriasis (26 male, mean age: 36 years, range: 18-61; duration of psoriasis 17 years, range: 2-31) entered a 9-centre open study in which cyclosporin was taken as an initial dose of 5 mg/kg/daily for a maximum of 12 weeks for up to three cycles. Each patient completed a psoriasis specific QOL measure (Psoriasis Disability Index, PDI) at the beginning and end of each treatment cycle and at the end of study. Clinical parameters including Psoriasis Area and Severity Index (PASI) were measured. The PDI scores showed a significant improvement (p < 0.01) between the beginning and end of all three treatment cycles. The various clinical assessments for each treatment period also showed significant improvement (p < 0.001) for all three cycles. When comparing the last follow-up value to baseline there was a clear indication of relapse, but these scores were still significantly better than at baseline (p < 0.01). Notably, the mean PASI score improved by more than 50% (p < 0.001) between first baseline and end of the study. These findings indicate that a short course of intermittent therapy with cyclosporin in microemulsion formulation, used at starting doses of 5 mg/kg/day, improves QOL of patients with chronic plaque psoriasis. Once again, the applicability and validity of the PDI as a useful QOL tool has been demonstrated.

Randomized, placebo-controlled trial of dietary supplementation of alpha-tocopherol on mutagen sensitivity levels in melanoma patients: a pilot trial.

We evaluated the effects of vitamin E (dl-alpha-tocopherol) on mutagen sensitivity levels in a randomized placebo-controlled pilot trial. In brief, a dietary supplement of 1000 mg/day vitamin E or a placebo was randomly administered for 3 months to melanoma outpatients clinically free of the disease. Plasma vitamin E and mutagen sensitivity levels were measured at baseline and at the end of the trial after 3 months. At baseline, we found no significant differences in plasma vitamin E and mutagen sensitivity levels between the two groups. We also measured dietary intake at baseline and found dietary vitamin E to be a poor predictor of plasma levels of vitamin E. After 3 months of supplementation, we found that plasma levels of alpha-tocopherol increased significantly (P = 0.0005) in the vitamin E compared to the placebo group. We also found a non-significant, but consistent decrease in plasma gamma-tocopherol concentrations in the vitamin E supplemented compared to the placebo group. We did not find any significant difference between the vitamin E and placebo groups in mutagen sensitivity levels either at baseline or after 3 months of supplementation. We conclude that short term vitamin E supplementation, although it causes increased blood levels of alpha-tocopherol, does not provide protection against bleomycin-induced chromosome damage.

Resection of the sciatic, peroneal, or tibial nerves: assessment of functional status.

BACKGROUND: Lower-extremity tumors are often treated by amputation rather than limb-sparing excision that sacrifices the sciatic nerve or a branch. This study assessed the functional outcome of major nerve sacrifice during limb-sparing resections for lower-extremity soft tissue sarcoma. METHODS: Patients who underwent division of the sciatic, tibial, or peroneal nerve(s) during limb-sparing sarcoma surgery (January 1982 through June 2000) were identified. Eleven surviving patients evaluated their pre- and postoperative functional status by self-administered questionnaire (six sciatic, two tibial, and three peroneal nerve divisions). RESULTS: Eighteen patients (10 male, 8 female; 14-84 years old) had nine primary and nine locally recurrent tumors. Tumors were high (16) or low grade (two). Five patients died of disease and two died of other causes. Median overall survival was 50 months. One of 11 reported increased pain. Eight had new phantom sensations with a median intensity of 4.5 (1 = least; 10 = most). All patients used an ankle brace to walk after a sciatic (four) or peroneal (one) division. Walking ability and distance after surgery was unchanged (nine), improved (one), and worsened (one). Standing improved in 7 of 11 patients. Proprioception in the affected extremity was retained in six. The median postoperative leg functional score was 8 (1 = worst; 10 = best). No patient developed foot ulcers. One patient underwent amputation for recurrence. All patients preferred their status over having an amputation. CONCLUSIONS: Objectively and subjectively, division of the major lower-extremity nerves causes acceptable functional deficits in most patients. Resection of affected sciatic nerve (branches) during limb-sparing tumor surgery is an excellent alternative to amputation.

Is there a role for incomplete resection in the management of retroperitoneal liposarcomas?

Complete surgical resection is the most effective modality for the treatment of retroperitoneal sarcomas. Previous studies of all types of retroperitoneal sarcomas have not shown a survival benefit of incomplete resection over no resection. Because death often occurs as a result of local progression in retroperitoneal liposarcomas (RPLS), it is possible that incomplete resection may be beneficial in this histologic type. In this study we have sought to determine the clinical outcomes in patients with incompletely resected and unresected RPLS with the aim of defining patients who may benefit from palliative resection. From a prospective clinical database 55 patients with incompletely resected (n = 43) or unresected (n = 12) RPLS were identified between 1982 and 1999. Statistical analyses were performed using the log-rank test and Kaplan-Meier estimates with disease-specific survival as the primary end point. Variables studied included age, gender, recurrent versus primary disease, tumor grade, and tumor size. The patient population consisted of 34 men and 21 women with a mean age of 61 +/- 14 (SD) years. The median time to death was 10 months (range 1 to 83 months) with a median followup of 12 months (range 1 to 60 months) for survivors. Partial resection was an independent factor for increased survival as compared with exploration or biopsy only (median survival 26 versus 4 months, p < 0.0001). Of patients who received incomplete resections, locally recurrent presentation (n = 19) versus primary disease (n = 24) was a negative prognostic variable (median survival 17 versus 46 months, p = 0.009). Successful palliation of symptoms was achieved in 24 of 32 patients (75%) with preoperative symptoms. In select patients with unresectable RPLS, incomplete surgical resection can provide prolongation in survival and successful symptom palliation. Most likely to benefit are those patients presenting with primary tumors, suggesting that surgical resection should be attempted in the majority of patients.

Community health worker performance in the management of multiple childhood illnesses: Siaya District, Kenya, 1997-2001.

OBJECTIVES: To characterize community health worker (CHW) performance using an algorithm for managing common childhood illnesses in Siaya District, Kenya, we conducted CHW evaluations in 1998, 1999, and 2001. METHODS: Randomly selected CHWs were observed managing sick outpatient and inpatient children at a hospital, and their management was compared with that of an expert clinician who used the algorithm. RESULTS: One hundred, 108, and 114 CHWs participated in the evaluations in 1998, 1999, and 2001, respectively. The proportions of children treated "adequately" (with an antibiotic, antimalarial, oral rehydration solution, or referral, depending on the child's disease classifications) were 57.8%, 35.5%, and 38.9%, respectively, for children with a severe classification and 27.7%, 77.3%, and 74.3%, respectively, for children with a moderate (but not severe) classification. CHWs adequately treated 90.5% of malaria cases (the most commonly encountered classification). CHWs often made mistakes assessing symptoms, classifying illnesses, and prescribing correct doses of medications. CONCLUSIONS: Deficiencies were found in the management of sick children by CHWs, although care was not consistently poor. Key reasons for the deficiencies appear to be guideline complexity and inadequate clinical supervision; other possible causes are discussed.

Soft tissue sarcomas of the groin: diagnosis, management, and prognosis.

BACKGROUND: Sott tissue sarcomas (STS) of the groin may present a difficult problem because or misdiagnosis as groin hernia and proximity to major neurovascular structures. We evaluated our management and survival in a large cohort of patients. STUDY DESIGN: Patients treated between July 1, 1982 and July 1, 1998 with primary or recurrent STS of the groin were included. Groin sarcomas were defined as those tumors within 5 cm of the inguinal crease. Patient, tumor, clinical, and survival data were analyzed using a log rank test and Cox regression. RESULTS: We treated and followed 88 patients with STS of the groin. The median age was 52 years (range 16 to 86 years) and 55 patients (63%) were male. Disease-specific survival was 72% at 5 years. Tumors tended to be larger than 5 cm (52%), deep (72%), and high-grade (60%). Unfavorable prognostic factors for disease-specific survival were high grade (p < 0.001), neurovascular invasion (p < 0.001), positive margin (p < 0.01), deep depth (p < 0.01), and selection for adjuvant therapy (p < 0.005). Multivariate analysis indicated age greater than 50 years (p < 0.05), high grade (p < 0.001), neurovascular invasion (p < 0.001), and positive microscopic margins (p < 0.001). Fourteen patients (16%) were diagnosed with STS at hernia operation then went on to a definitive operation with no impact on survival. Seventeen patients (19%) had involvement of a major vessel or nerve, and 5 of these ultimately required amputations, 3 for local recurrence. CONCLUSIONS: High grade, neurovascular invasion, and positive microscopic margins are associated with poor outcomes. The biology of these tumors is similar to other extremity STS, and similar principles of management apply. Even with neurovascular involvement, most patients with primary groin STS do not require amputation.

Adult perineal sarcomas.

BACKGROUND AND OBJECTIVES: Primary perineal sarcoma in adults is a rare disease that has only been documented to occur in isolated case reports. METHODS: To better characterize and define the natural history of perineal sarcoma in adults (> or = 18 years), we reviewed our experience with treatment of perineal sarcoma between 1982 and 1999 (nine cases). RESULTS: Epithelioid sarcoma (n = 4) was the most common histologic subtype. Seven cases (78%) were histologically high grade, and lesions were most commonly < 5 cm. All patients were treated with wide local excision. External beam radiation was the most commonly used form of adjuvant therapy (n = 6). Recurrences were noted in five patients, and the recurrences were most commonly local (60%). Median time to first recurrence was 21 months. Six of nine patients are alive with a median follow-up of 54 months. Three died of recurrent/metastatic disease at 16, 51, and 54 months after initial surgery. CONCLUSIONS: Aggressive therapy and follow-up beginning with wide excision can be associated with long-term survival in adults with primary perineal sarcoma.

Gastrointestinal stromal tumors and leiomyosarcoma of the abdomen and retroperitoneum: a clinical comparison.

INTRODUCTION: The present study was undertaken to define the clinical differences between leiomyosarcomas (LMS) occurring within the abdomen and retroperitoneum and gastrointestinal stromal tumors (GIST). METHODS: It was a retrospective, single-institution review of patients treated for intra-abdominal and retroperitoneal GIST and LMS from July 1, 1982 through August 1, 1999. RESULTS: A total of 561 patients, 239 with GIST and 322 with LMS, were identified. Patients with GIST were older, with a median age of 58 years versus 54 years in the LMS group (P < .01). The majority of patients with GIST were male (58%), whereas 68% of LMS patients (excluding gender-specific sites) were female (P < .01). The 5-year disease-specific survival for GIST and LMS were 28% and 29%, respectively. The presentation status and ability to achieve a complete surgical resection were the main independent predictors of outcome for both GIST and LMS. Local and distant recurrence was common in both. The pattern of distant recurrence differed: 50% of all first-site GIST recurrences involved the liver, whereas 30% of all LMS first-site recurrences involved the lungs. CONCLUSIONS: Although the two patient populations appear to be distinct, their clinical courses are similar. The pattern of distant spread follows the known patterns of hematogenous dissemination. Complete surgical resection is the cornerstone of treatment for primary GIST and LMS and in selected patients with local and distant recurrence.

Early recurrence after lymphatic mapping and sentinel node biopsy in patients with primary extremity melanoma: a comparison with elective lymph node dissection.

INTRODUCTION: Although sentinel node biopsy with completion lymphadenectomy in node-positive patients (SLND) has been widely adopted in the management of patients with early stage melanoma, reports detailing the outcome of patients after SLND are limited. To address this issue, we analyzed our experience with SLND and provided a comparison to patients treated with elective lymph node dissection (ELND). METHODS: All patients who underwent SLND (1991-1998) and ELND (1974-1994) were identified from single institution melanoma databases. RESULTS: A total of 152 and 329 patients with early-stage melanoma of the extremity underwent SLND and ELND, respectively. Nodal metastases were present in 44 of 329 ELND patients (13%) and in 31 of 152 SLND patients (20%). Early relapse-free and disease-specific survivals were similar for the entire population, although in patients at higher risk for recurrence (age >50 years, thickness >3.0 mm), there was an increased rate of relapse in the SLND group (P = .04). Among all sites of early recurrences, locoregional sites were more common in patients undergoing SLND (72%) compared with ELND (39%, P < .01). SLN-negative patients with nodal recurrence had evidence of metastases on retrospective enhanced pathologic analysis in four of seven cases. CONCLUSIONS: Although overall relapse-free and disease-specific survivals are similar, there is a higher rate of relapse in a subset of SLND node-negative patients who are at high risk for nodal metastases. ELND and SLNB should not be thought of as equivalent approaches until studies with longer follow-up are available.

Characterization of molecular abnormalities in human fibroblastic neoplasms: a model for genotype-phenotype association in soft tissue tumors.

Desmoid tumors and fibrosarcomas (FS) are part of a wide spectrum of disordered fibroblastic growth that display striking clinical and phenotypic differences. This study was designed to characterize molecular abnormalities that are associated with these differences and to determine their clinical relevance. A cohort of 24 desmoid tumors and 25 low-grade (LG) and 14 high-grade (HG) FS that were clinically and pathologically well characterized was analyzed for alterations in expression of Ki-67, Bcl-2, retinoblastoma gene product (pRB), and p53 by immunohistochemistry. LG-FS and HG-FS showed abnormal expression of Ki-67 (32 versus 86%), Bcl-2 (48 versus 57%), and pRB (56 versus 93%). In contrast, desmoid tumors showed a normal phenotype with these markers. p53 overexpression was identified in 20% of LG-FS and in 29% of HG-FS cases but only in 4% of desmoid tumors. There was an increasing trend in the proportion of abnormal expression of Ki-67, Bcl-2, pRB, and p53 with the increase of tumor aggressiveness from desmoid tumors to LG-FS to HG-FS. The molecular differences between tumor entities were highly statistically significant (P < 0.01). Significant associations between abnormal expression of pRB and recurrence-free survival of LG-FS patients (P = 0.05) and between Ki-67 overexpression and recurrence-free survival for tumors of >5 cm were observed (P = 0.02). The demonstrated differences of molecular alterations in HG-FS, LG-FS, and desmoids appear to be related to biological aggressiveness of such tumors, and they might be useful to differentiate between histologically similar cases of desmoid tumors and LG-FS. pRB and Ki-67 status may be useful to predict recurrence in certain subsets of patients.