Enhanced radiosensitization with interferon-alpha-2b and cisplatin in the treatment of locally advanced cervical carcinoma.

PURPOSE: To evaluate the efficacy and toxicity of interferon-alpha-2b (IFN-alpha) and cisplatin given concomitantly with radiation therapy (RT) in the treatment of locally advanced cervical carcinoma. MATERIALS AND METHODS: Twenty-one patients with stage bulky Ib-IIIb (Ib, 2; IIa, 2; IIb, 8; IIIb, 9) cervical carcinoma were treated with combined IFN-alpha (5 million IU) subcutaneously three times per week and cisplatin (25 mg/m2) i.v. infusion over 2 h weekly for 7 weeks, given concomitantly with RT (4500 cGy of external beam plus 2 brachytherapy procedures). Total radiation doses delivered ranged from 7500 to 9960 cGy (median, 9300 cGy). Follow-up ranged from 16 to 33 months (median, 25 months). RESULTS: The 2-year local control rate was 100%. The only sites of disease recurrence were distant. Freedom from distant metastases, disease-free survival, and overall survival at 2 years was 76%. Late complication rates were high. Grade 4 rectosigmoid, bladder, and small bowel complication rates were 49, 18, and 23% at 2 years. Late toxicity was seen earlier than expected with rectosigmoid complications observed 5 to 11.5 months (median, 8 months) after completion of treatment. CONCLUSION: Combination IFN-alpha and cisplatin produced a marked effect of enhanced radiosensitization as evidenced by 100% local tumor control and high late normal tissue complication rates. Due to the unacceptable late toxicity, its routine clinical use cannot be recommended. Further investigation is needed to determine whether a therapeutic window exists such that the use of lower doses of IFN-alpha, cisplatin, or RT can increase tumor control with more acceptable normal tissue toxicity.

Screening for human immunodeficiency virus in inner city females with abnormal cervical cytology.

OBJECTIVE: This report evaluates the acceptance, results, and predictors of human immunodeficiency virus (HIV) infection in inner city women referred to a colposcopy clinic for abnormal cervical cytology. METHODS: HIV testing results of 1,908 inner city women referred for abnormal cervical cytology were analyzed retrospectively with respect to acceptance, race, ethnicity, Pap smear results, sexually transmitted diseases (STDs), HIV exposures, and final histologic findings. RESULTS: HIV testing was accepted by 50.4% of patients. Women who agreed to screening were significantly more likely to admit exposure to HIV or to be Hispanic, foreign-born, or have a history of multiple STDs. Of those screened, 3.3% were found to be HIV seropositive. Although higher grades of referral Pap smears were noted in the women found to be HIV seropositive, final histologic findings were not different. The only predictors of unknown HIV seropositivity were admitted HIV exposure and external condyloma. CONCLUSIONS: Fifty percent of inner city women of unknown HIV status referred for abnormal cervical cytology will accept HIV serotesting and 3.3% are found to be positive. Most HIV-seropositive women can be detected based on either a history of exposure to HIV or the presence of external condyloma.

The stapled continent ileocecal urinary reservoir in the surgical management of gynecologic malignancy.

Total cystectomy at the time of radical pelvic surgery for gynecologic malignancies is not uncommon. Many techniques have been developed for urinary diversion including the continent ileocecal urinary reservoir. Twenty-nine patients underwent construction of a continent ileocecal urinary reservoir during the reconstructive phase of an exenterative procedure or for the relief of urinary tract fistula between 1990 and 1993. All procedures were performed using the mechanical stapling devices using metal staples. The right and proximal transverse colon were mobilized to a length of 24 cm. The ileum was divided 8 cm proximal to the ileocecal valve and plicated using the stapling technique. The colonic segment was opened on its antimesenteric border and the reservoir was created by stapling in a fashion to reapproximate the distal ends to each other. The ureters were stented and implanted without tunneling. A large Malecot drain was placed in all the pouches for irrigation of the colonic mucosa in the postoperative period. The ileal stoma was fixed to the anterior abdominal wall as was the anterior surface of the pouch. Operative time ranged from 50 to 150 min for the pouch construction. All patients underwent retrograde contrast study of the pouch 7-10 days postoperatively to verify lack of anastomatic leaks. After recovery, all patients successfully self-catheterized the pouch three to five times daily without difficulty. Of the 29 patients, 17 (59%) had received prior radiation as part of therapy. All patients remained continent at the end of observation. One developed a fistula to the perineum after intraoperative placement of 125I seeds on the pelvic wall. One patient developed pouch stones; endoscopic evaluation of this pouch revealed no evidence of stones at the staple lines and metabolic workup demonstrated hypocitremia as the etiology for the stones. Mean reservoir volume was 550 ml. Mean follow-up is 15.8 months; 5 have expired due to recurrent disease and 19 (83%) remain alive. Only two patients have been admitted for urosepsis due to reflux pyelonephritis. The stapled continent ileocecal reservoir offers benefits to patients undergoing total cystectomy. Using the mechanical stapling devices decreases the operative time and has not resulted in stone formation or pouch leakage. The complications of the procedure are acceptable.

Advanced abdominal pregnancy complicated by bilateral ureteral obstruction. A case report.

A case of term abdominal pregnancy is reported. The patient was followed throughout pregnancy, but the diagnosis was made only at the time of laparotomy for elective cesarean section. The report exemplifies the ease with which the diagnosis of abdominal pregnancy can be overlooked and stresses the importance of considering this diagnosis in cases of high maternal serum alpha-fetoprotein. The management of the placenta is also discussed. In this case the retained placenta was managed successfully without intervention despite the unusual complication of bilateral ureteral obstruction. Additionally, the biochemical activity of the placenta was assessed by following the progressive decline of serum human chorionic gonadotropin over time.

Phase II trial of etoposide, carboplatin, and ifosfamide as salvage therapy in advanced ovarian carcinoma.

A phase II study combining etoposide with carboplatin and ifosfamide as salvage therapy in advanced ovarian cancer was undertaken. Objective responses were achieved in 37.5% of 16 evaluable patients with a mean progression-free interval of 8.6 months. Stable disease was present in 25% of patients; in 37.5% of patients the disease progressed on salvage. Based on original response to front-line therapy, patients were classified as being platinum-sensitive (group I) or platinum-refractory (group II). Clinical response to salvage therapy was seen in 44.5% of group I patients, but in only 28.6% of group II patients. This difference was not statistically significant. When a more precise definition of platinum sensitivity was applied, clinical responses were seen in 54.5% of group I patients, but no responses were noted among group II patients (p < 0.05). Platinum sensitivity appeared to be an important factor in achieving a response with this regimen. This combination was well tolerated, myelotoxicity being the dose-limiting toxicity encountered. No life-threatening, nonhematologic toxicities were seen. One death occurred secondary to nadir sepsis. The combination of etoposide, carboplatin, and ifosfamide is an active salvage regimen in patients with advanced ovarian carcinoma; however, severe myelotoxicities and inability to produce long-term responses underscore the need for continued trials to find a more durable salvage regimen.

Heterogeneity in restriction patterns of Gardnerella vaginalis isolates from individuals with bacterial vaginosis.

This study was undertaken to resolve the genetic make up of Gardnerella vaginalis present in bacterial vaginosis (BV). DNA from several G. vaginalis isolates from within and between individual BV patients were compared by BamHI, ClaI and EcoRI restriction endonuclease analysis (REA) followed by a restriction fragment length polymorphism (RFLP) study, utilizing a 5.7-kb BamHI G. vaginalis ATCC14018 DNA probe. Four G. vaginalis isolates from one patient (GVP-062) were composed of 3 different biotypes (biotypes 3, 5 and 8), and while the REA mirrored the biotype, in RFLP studies at least 3 isolates had DNA fragments in common. All of the isolates from 2 other patients (GVP-063 and GVP-072) represented a single biotype (biotype 2), but under REA and in RFLP studies, the isolates GVP-063 differed from GVP-072. An opposite case existed with the isolates GVP-072 (biotype 2) and GVP-065 (biotype 5), which appeared similar under REA and in RFLP studies. Finally, reisolates after 8 weeks (GVP-080) from a BV patient (isolates GVP-065) representing the same biotype (biotype 5) differed under REA and in RFLP studies. Thus, lacking any unique DNA fingerprint, G. vaginalis occurring in BV represents a (genetically) mixed population.

Induction chemotherapy followed by radical surgery in cervical cancer.

To evaluate the therapeutic potential of cytotoxic therapy in patients with squamous cell carcinoma of the cervix, 28 patients with disease clinically localized to the pelvis were treated with chemotherapy followed by radical pelvic surgery. Treatment consisted of cis-platinum 50 mg/m2, mitomycin C 10 mg/m2, vincristine 1.0 mg/m2, and bleomycin 10 U IM given as a course (over 21 days) of induction chemotherapy followed by radical hysterectomy and pelvic and aortic lymphadenectomy in 26 patients and total pelvic exenteration in 2 patients. The stage distribution of the patients in the study was 4 stage IB, 6 stage IIA, 7 stage IIB, 1 stage IIIA, 11 stage IIIB, and 1 stage IVA. Two patients with stage IIIB cancer were found, at the time of laparotomy, to have carcinomatosis and were excluded from the final evaluation in this study. All patients achieved a clinical and histologic response to chemotherapy. There were 35% complete and 65% partial responses. After chemotherapy, at the time of surgery, 4 patients were found to be histologically free of disease, and the incidence of surgically documented nodal disease after chemotherapy was found to be 32%. There was no significant hematologic or pulmonary toxicity. Induction chemotherapy is well tolerated and may be beneficial in the management of some patients with cervical cancer who are at high risk for failure with conventional treatment.

Stented versus nonstented transverse colon conduits: a comparative report.

Postoperative urinary tract complications were evaluated in 75 women who underwent urinary diversion with formation of a transverse colon conduit after radiation for gynecologic cancer. Urinary stents were placed at the ureterocolonic junction in 37 women, while no stents were used in 38 women. Leaks or fistulae developed in 18% of the nonstented group but in only 3% of the stented group (P less than 0.05). Ureteral strictures developed in 18% of the nonstented but in only 8% of the stented group. Pyelonephritis developed in 13% of the nonstented and in 8% of the stented patients. Overall, urinary tract complications developed in 50% of the nonstented and in 16% of the stented group (P less than 0.01). Leaks or strictures developed in 11% of the 75 renal units in the nonstented group but in only 1% of the 72 renal units in the stented group (P less than 0.02). Postoperative leaks or fistulae were associated with further serious complications. Results indicate a significant advantage in employing stents at the ureterocolonic junction in the formation of a transverse colon conduit.

Immunocytochemical assay of estrogen receptors in endometrial carcinoma with monoclonal antibodies. Comparison with biochemical assay.

Specimens of endometrial adenocarcinoma, surgically obtained from 18 women, were analyzed for distribution of estrogen receptors by an immunocytochemical assay, employing monoclonal anti-estrophilin antibodies and the peroxidase-antiperoxidase technique. Results were compared with biochemical receptor analyses, and were in concordance in 83% of them. Marked tumor cell and tissue receptor heterogeneity were apparent with the immunocytochemical method, and a variety of patterns of nuclear staining in positive tissue samples were revealed. These results indicate that the immunohistologic method will provide a number of entirely new variables that may eventually be correlated with both clinical and pathologic features of this malignancy, and may prove to be of value in the prediction of clinical endocrine response.