High dose irradiation to biopsy confirmed aortic node metastases from carcinoma of the uterine cervix

Twenty-one women with biopsy proven aortic node metastases from previously untreated carcinoma of the uterine cervix were treated with high dose irradiation to the pelvis and para-aortic areas. The majority received 6000 rads to the pelvis and para-aortic nodes by split course therapy plus 2500 rads by intracavitary radium to point A; 57.1% sustained severe complications to the stomach, small intestine or colon. Only 14.2% are surviving over 2 years free of recurrence. Though approximately 40% of women with Stages III and IV cervical cancer will have metastases to the para-aortic nodes, to date there is no satisfactory therapy that results in a significant number of such women surviving free of recurrent cervical cancer.     

High-dose rate intracavitary irradiation for carcinoma of the uterine cervix. The adverse effect of treatment prolongation

AIM: To investigate the adverse effect of treatment prolongation on the local control and survival of the cervical carcinoma of the uterus. PATIENTS AND METHOD: Two hundred and sixteen patients with stage IIB and III cervical carcinoma treated with a combination of external radiation and high-dose rate (HDR) intracavitary irradiation between 1978 and 1989 were retrospectively studied. A multivariate analysis was used to determine the effect of treatment time on local control and survival. RESULTS: Overall treatment time was the most highly significant factors for local control in the multivariate analysis (p = 0.0005). The 5-year cumulative relapse rates were significantly different with the treatment times 35 to 42 days: 9% versus 43 to 49 days: 19% versus 50 to 62 days: 42% (p = 0.001). The second most significant parameter was stage classification (p = 0.02). Concerning relapse-free survival, stage classification (p = 0.0001), overall treatment time (p = 0.0035) and hemoglobin level (p = 0.0174) were the 3 most important prognostic factors, although there was no relationship between treatment time and late complications. CONCLUSION: These results suggest that prolongation of treatment time is associated with decreased local control and survival in patients treated with external radiation and HDR intracavitary irradiation.     

The prevention of carcinoma of the cervix

Circulating blood volume, cardiac index, heart rate, and ejection rate were measured in patients with angina pectoris. The controls and the patients were divided in sub-groups of those under 45 and over 45 years of age. The investigation was carried out using the isotope method. A significant difference was observed in the value of intravascular blood volume at rest between the controls and patients with ischaemic heart disease unrelated to anginal attack. The blood volume was 5.6 litre in the control group and 6.4 litre in patients with ischaemic heart disease. Exercise tests produced further increases during attack in the blood volume of angina patients. A significant increase of blood volume after moderate exercise was also observed in patients under 45 with ischaemic heart disease but without angina. It is suggested that the increase of intravascular blood volume plays a part in the pathogenesis of angina pectoris.     

Outcome of obstructive uropathy after pelvic irradiation in patients with carcinoma of the uterine cervix

A prospective, randomized study was performed to assess the effectiveness of postoperative closed suction drainage. One hundred and twelve consecutive procedures involving autologous iliac-crest bone graft were performed, from December 29, 1992, to July 1, 1993, following a traumatic injury of the spine in 108 patients. Sixty of the sites from which the bone graft had been obtained were drained with a single large Hemovac device. The drains were maintained for two to five days postoperatively. The remaining fifty-two incisions were closed without a drainage device. All patients were evaluated clinically for problems with wound-healing. The incisions were considered to be healed when they had been asymptomatic for one year. Of eleven patients who had problems with wound-healing, six had been managed with a drain and five had not. The findings of this study do not support the routine use of drainage at the donor sites of iliac-crest bone grafts.     

The significance of arterial chemotherapy for multiple hepatic metastases from colorectal carcinoma

Controversy persists with regard to the diagnosis and treatment of the acute scrotum in children. The differential diagnosis includes torsion of the testis, torsion of one of the appendices testis and epididymo-orchitis. Clinical differentiation is notoriously difficult and our policy has been to explore the scrotum of all who present with signs of an acute scrotum. The medical records of 199 boys aged less than 13 years who presented with an acute scrotum at Red Cross War Memorial Children's Hospital in Cape Town during the period 1970-1996 were retrospectively reviewed. Diagnosis was made clinically in all cases. Sixty-two boys (31%) were found on exploration to have torsion of the testis (mean age 6.3 years), the left side being affecting 2.5 times more frequently than the right (1 neonate had bilateral torsion), 62 (31%) had torsion of testicular appendages and 56 (28%) had epididymo-orchitis. Nineteen were grouped separately and 13 (6.5%) of these were treated conservatively. Boys needing an orchidectomy (N = 38) for testicular torsion presented three times later than those who did not (48 v. 16.5 hours). Successful conservation of the testis was directly related to the time interval of symptom development and surgical derotation. Boys with torsion of a testicular appendage presented later (mean 51 hours) and were older (mean 10 years) than boys in the other two groups. Those with epididymo-orchitis were younger (mean 3.3 years) and 40% were younger than 1 year. Only in one-third was there any clinical supportive evidence of the diagnosis. Surgical complications were infrequent. We advocate expedient surgical exploration and derotation with contralateral orchidopexy, since clinical differentiation between torsion of the testis, testicular appendages and epididymo-orchitis is inexact, even with highly specialised investigation such as Doppler ultrasound and radionuclide scanning, which may not be widely available, may delay definitive treatment and suggest a lack of urgency where time is of the essence.     

The management and natural history of severe dysplasia and carcinoma in situ of the uterine cervix

From 1951 to 1972, a total of 631 cases of invasive carcinoma of the cervix were diagnosed in Frederiksberg, Copenhagen, Denmark. Treatment was either by surgery or radiotherapy, a combination of both being rarely used. The crude five-year survival rates were 99 per cent in stage Ia, 79 per cent in stage Ib, 67 per cent in stage IIa, 45 per cent in stage IIb, 23 per cent in stage III, 5 per cent in stage IV and 63 per cent for all stages. The relative survival rates were respectively 100 per cent, 81 per cent, 73 per cent, 48 per cent, 26 per cent, 5 per cent and 66 per cent. Radical hysterectomy were found more effective than radiotherapy in stage Ib carcinoma of the cervix. This difference was not explained by age but other factors possibly playing a role are considered. The combination of surgery and radiotherapy is discussed and only seems indicated for patients with stage Ib carcinoma and lymph node metastases.     

Microinvasive carcinoma of the cervix

3-Deacetoxy-7-(alpha-amino-1-cyclohexenylacetoamido) cephalosporanic acid (SCE-100) was compared to cephalexin with respect to absorption, tissue distribution, and urinary and biliary excretion in mice, rats, rabbits and dogs. The absorption of SCE-100 after oral administration is generally slower than that of cephalexin, but its disappearance from blood and tissues is delayed. The concentration of SCE-100 in the liver is distinctly higher than that of cephalexin. These properties of SCE-100 are most clearly manifested in rats. There is no significant difference in urinary excretion of the two cephalosporins in rabbits and dogs, while in rabbits, biliary excretion of SCE-100 is more intensive than that of cephalexin.     

Preoperative irradiation therapy and radical hysterectomy: prognostic value of tumor regression after initial irradiation of squamous cell carcinoma of the cervix

OBJECTIVE: To investigate the role of tumor persistence in patients submitted to irradiation therapy and radical hysterectomy. DESIGN: A retrospective analysis of prognostic factors. LOCATION: Hospital A.C. Camargo, S?o Paulo, Brazil, a private non-profitmaking foundation and tertiary referral centre. PATIENTS: A total of 629 cases of invasive squamous cell carcinoma of the cervix were studied. Criteria for inclusion in the study were: confirmed histological diagnosis of squamous cell carcinoma and no previous treatment (except for preoperative radiotherapy carried out at the Hospital A.C. Camargo itself). At the end of the follow-up period, 410 patients (65%) had no evidence of disease and 219 (34.8%) had died because of the tumor. INTERVENTION: The patients were submitted to radical surgery and radiation therapy, separately or in combination between 1953 and 1982. MAIN OUTCOMES MEASURES: Multivariate analysis of the different variables was performed according to the Cox regression method. RESULTS: The variables of prognostic value were, in decreasing order of importance: the decade of patient admission (p = 0.0001), the modality of therapy employed (p = 0.0005), the presence of residual tumor in the surgical specimens (p = 0.0055) and the clinical stage of the disease (p = 0.0575). CONCLUSION: Radiation therapy controlled a considerable number of local tumors and pelvic lymph nodes but not all of them in every patient. There is a specific group of patients for whom radical surgery is necessary to achieve control of the disease.     

A new surgical instrument for diathermic conization of the uterine cervix

The most frequent craniofaciosynostoses, Crouzon, Apert and Pfeiffer syndromes, are due to mutations of genes coding for FGF growth factor receptors (FGFR). The Twist gene has been recently implicated in Saethre-Chotzen syndrome. The current confusion concerning phenotypegenotype correlation is starting to be clarified by the increasing number of cases in which the mutations have been identified and the clinical classification will need to be revised in the light of the results of molecular genetics.     

Aggressive surgical management of fibrolamellar hepatocellular carcinoma in puberty

OBJECTIVE: To assess the importance of monitoring sputum conversion as an early treatment indicator of treatment success. METHODS: Retrospective analysis of sputum conversion in a cohort of 'cured' tuberculosis patients. RESULTS: Of 65 (95%) patients whose sputum converted in the third month of treatment, 62 were cured; only 21 of 35 (60%) patients whose sputum was still positive at the end of three months of treatment were ultimately cured. CONCLUSION: Sputum conversion during the third month of treatment is an important predictor of treatment success; failure to convert predicts treatment failure.     

Sweat gland carcinoma. Current concepts of surgical management

In three new cases of sweat gland carcinoma that we observed within recent years, the sites were the axilla, back, and arm. Axillary lymph node dissections were performed in two of the patients and the nodes were normal. Preoperative diagnoses were hydroadenitis, squamous cell carcinoma of the skin, and pyogenic granuloma. In one patient who was followed up for four years, there has been no recurrence; the follow-up period for the other two has been short. Sweat gland carcinoma is an uncommon neoplasm that occurs mostly in the older age groups. It may be very slow growing and is extremely difficult to diagnose preoperatively. Lymph node metastases are frequent and overall survival is poor. Prognosis is related to histologic cell type and presence or absence of lymph node metastases. Treatment by wide local excision of the lesion and primary regional node dissection is recommended.     

Results of radical surgical procedures after radiation for treatment of invasive carcinoma of the uterine cervix in a private practice

An analysis is made of the results of treatment of 96 women with carcinoma of the cervix, Stages IB and II, in a private practice. All 96 women were treated preoperatively with uterine intracavitary radium, followed 6 weeks later by Wertheim hysterectomy with pelvic lymphadenectomy. If malignant tumor was present in the lateral pelvic lymph nodes, external radiation was given postoperatively. The over-all survival rates were: Stage IB, 88% and 84% at 5 and 10 years; Stage II, 72% and 62% at 5 and 10 years. Regardless of the clinical stage, the highest survival rates were found in those patients who had no malignancy in the lateral pelvic lymph nodes and no residual cervical carcinoma. The lowest survival rates were found in those patients who had both residual cervical carcinoma and lymph node metastases.     

The investigation of chronic constipation for surgical management

Organic solvents, such as ethanol or dimethyl sulphoxide (DMSO), have been used in liquid embolic agents. To investigate the effects of these solvents on the cerebral blood vessels and cerebral tissue, we subjected Wistar rats weighing 250-300 g to internal carotid artery infusion of 0.2 ml diluted ethanol (10%, 40% or 70%) or anhydrous DMSO (100%). Some rats were sacrificed 5 min after the infusion and the remainder at 10 days. Rats injected with ethanol at high concentration or DMSO showed extensive exudation of Evans blue at the site of injection 5 min after infusion, together with full-thickness necrosis of the wall of vessels and swelling of brain cells. In contrast, rats injected with 10% or 40% ethanol solution showed necrosis of only the intimal layer and partial necrosis of the medial layer and no brain swelling was observed. These findings suggest that ethanol at low concentration can be used as a relatively safe solvent for liquid embolic substances.     

Abdominal radical trachelectomy: a new surgical technique for the conservative management of cervical carcinoma

Traditionally radical hysterectomy has formed the mainstay of treatment for early stage cervical carcinoma. More recently radical trachelectomy and laparoscopic lymphadenectomy have been introduced to allow preservation of fertility. We present a new approach to fertility-sparing surgery, namely abdominal radical trachelectomy. The technique is similar to a standard radical hysterectomy and lymphadenectomy. In our technique the ovarian vessels are not ligated and, following lymphadenectomy and skeletonisation of the uterine arteries, the cervix, parametrium and vaginal cuff are excised. The residuum of the cervix is then sutured to the vagina and the uterine ateries re-anastomosed.     

The use of pelvic arteriography in assessing carcinoma of the cervix

Twenty-nine patients underwent pelvic arteriography as a part of their pre-radical-hysterectomy evaluation for cervical carcinoma. False-positive studies were as common as false-negative studies, not only in the assessment of tumor extension locally, but also in determining the presence of pelvic lymph node involvement. Twenty-one patients underwent preoperative irradiation, but the lack of correlation was similar in 8 patients who were treated by primary radical surgery a few days after arteriography. The clinical estimate of tumor extension corresponded more closely to the pathologic findings than pelvic arteriography.     

The long-term course of carcinoma in situ of the uterine cervix

The malignant potential of carcinoma in situ (CIS) of the uterine cervix has been the subject of great controversy. Despite refinements and additions to knowledge in this area, few reports on the long-term course of the disease have appeared in the past decade. Recent developments in diagnostic and therapeutic techniques coupled with changes in the patient population with this disease have prompted renewed interest in conservative management. Results of long-term observation of a group of patients followed initially without ablative therapy are reported. The data indicate that CIS of the uterine cervix is not the inevitably progressive disease that it has been considered to be. Unequivocal invasive cancer develops in only a small percentage of cases and can be controlled, if not cured, by current therapeutic modalities. The intraepithelial lesion, however, tends to persist despite conization, and eventually requires ablative therapy in most cases. Conservative procedures should be regarded as temporizing, at least until their long-term benefits can be recorded.     

Neuroendocrine differentiated carcinoma of the uterine cervix

Cervical neuroendocrine carcinomas (CNC) are rare tumors. The term includes the cervical carcinoid, the small cell (oat-cell) carcinoma and the primitive neuroectodermal tumor (PNET). Between 1979 and 1993 eight CNC out of 788 cervical carcinomas were identified by conventional light microscopy and immunohistochemistry. Three tumors were small cell carcinomas with positive staining for NSE (6/8 tumors) and chromogranin A (2/8). In one case a PNET was diagnosed by identifying rosette like structures and negative immunohistochemistry for neuroendocrine markers. Two patients (including PNET) died of disease 3.1 (1.3 to 4.8) years after diagnosis. The others showed no evidence of disease after a mean follow up to 4.4 years. Three of them got pelvic radiation postoperatively. Four tumors showed foci of squamous cell carcinoma [3] and adenocarcinoma [2]. There is no evidence, that these foci influence the prognosis on CNC. Therefore, it is important to recognize the neuroendocrine component, as this type of carcinoma requires special therapeutic considerations. The authors favour the metaplastic origin of CNC from a multipotent (endocervical) stem cell.