Biomedical subjects

R E Bristow

Publications and source records attributed to R E Bristow.

At least 19 recordsLinked to original sources

PubMed2001

The role of cytoreductive surgery in the management of stage IV uterine papillary serous carcinoma.

OBJECTIVE: The aim of this study was to evaluate the survival impact of cytoreductive surgery and other prognostic determinants in patients with Stage IV uterine papillary serous carcinoma (UPSC). METHODS: All patients with FIGO Stage IV UPSC diagnosed between January 1, 1989 and December 31, 1998 were identified from tumor registry databases. Individual patient data were collected retrospectively. Survival analysis and comparisons were performed using the method of Kaplan and Meier, the log-rank test, and the Cox proportional hazards regression model. Predictors of surgical outcome were evaluated using the log-rank test. RESULTS: Thirty-one patients underwent primary cytoreductive surgery for Stage IV UPSC (median age, 65 years). The median survival for all patients was 14.4 months. Optimal cytoreduction was defined as residual disease < or =1 cm in maximal diameter. The only significant predictor of a suboptimal surgical outcome was the presence of disease in three or more anatomic regions. Overall, 16 of 31 patients (51.6%) completed primary surgery with optimal disease status. Optimal cytoreduction was associated with a median survival of 26.2 months, compared with 9.6 months for patients left with suboptimal residual disease (P < 0.001). At 24 months, 57.1% of optimally cytoreduced patients were still alive, compared with just 6.7% of patients left with suboptimal disease. Furthermore, patients with only microscopic residual tumor had a significantly longer median survival (30.4 months) than both patients with 0.1- to 1.0-cm residual disease (20.5 months) and those left with suboptimal disease (P = 0.004). Postoperative platinum-based chemotherapy was associated with a median survival of 17.1 months, compared with 9.5 months without such therapy (P = 0.018). Patients receiving the combination of platinum + paclitaxel had a median survival rate of 29.1 months versus 14.4 months for patients receiving platinum + cyclophosphamide +/- doxorubicin (P = 0.054). On multivariate analysis, the only statistically significant predictor of survival was the cytoreductive surgical outcome. CONCLUSIONS: The strongest predictor of overall survival for patients with Stage IV UPSC was the amount of residual disease following surgery. Recommended management for this group of patients should consist of maximal surgical cytoreduction followed by platinum-based chemotherapy, preferably in combination with paclitaxel.

Adult↗

PubMed2001

Extended surgical staging for uterine papillary serous carcinoma: survival outcome of locoregional (Stage I-III) disease.

OBJECTIVE: The aim of this study was to evaluate survival outcome in patients with locoregional uterine papillary serous carcinoma (UPSC) after extended surgical staging (ESS). METHODS: All patients diagnosed with FIGO Stage I-III UPSC undergoing ESS (vertical incision, peritoneal cytology, TAH/BSO, omental biopsy, lymph node sampling, peritoneal biopsy) between 1/1/89 and 12/31/98 were identified retrospectively from the tumor registry database. Pathologic features predictive of regional extrauterine spread were evaluated using the log-rank test. The Kaplan-Meier method was used to generate survival curves, and median survival determinations were compared using the log-rank test or the proportional hazards regression model. RESULTS: Twenty-six patients with locoregional UPSC were identified: FIGO Stage I (n = 11), Stage II (n = 7), and Stage III (n = 8). The median age at diagnosis was 66 years. Preoperative endometrial pathology correctly identified the presence of UPSC in 76.9% of cases. The only pathologic feature found to be predictive of regional extrauterine spread (Stage III) was myometrial invasion > or =50% (P = 0.028). Adjuvant radiation therapy (RT) was administered to 6/18 patients with Stage I/II disease and 5/8 patients with Stage III disease. Platinum-based chemotherapy was administered to 5 patients with Stage III disease. All recurrences of Stage I/II disease were located within the pelvis (16.7%). For Stage III disease, all recurrences occurred at distant sites (42.9%). The median follow-up time for surviving patients was 39.0 months (mean = 45.0 months). For all patients, the overall 5-year survival rate was 61.2%. According to FIGO stage, the overall 5-year survival rates were Stage I, 81.8%; Stage II, 64.3%; and Stage III, 31.3%. No significant differences were detected in the risk of death by stage, although there was a trend toward worse survival with Stage III disease: Stage I hazard ratio [HR] = 1.00, Stage II HR = 1.68, 95% confidence interval [CI] = 0.23-12.03, Stage III HR = 3.63, 95% CI = 0.65-20.12. CONCLUSIONS: Patients with locoregional UPSC following ESS have a more favorable prognosis than previously thought. The additional information provided by ESS facilitates the selection of adjuvant therapy. Whole pelvic RT is recommended for patients with Stage I/II disease. Pathologic Stage III disease portends a significant risk of distant recurrence. For these patients, administration of adjuvant chemotherapy should be considered in addition to directed RT.

Aged↗

PubMed2001

Complete surgical cytoreduction of advanced ovarian carcinoma using the argon beam coagulator.

OBJECTIVE: The aim of this study was to evaluate the utility of the argon beam coagulator (ABC) in achieving optimal (< or =1 cm) disease status and facilitating the conversion of optimal but visible disease (0.1-1.0 cm) to microscopic residual disease (complete cytoreduction) among patients with advanced ovarian carcinoma. METHODS: All patients undergoing their primary attempt at surgical cytoreduction for Stage IIIB-IV epithelial ovarian carcinoma between October 1, 1997 and June 30, 2000 were identified from the tumor registry database. Data were abstracted retrospectively and included: the size/location of precytoreduction disease, surgical procedures performed, the anatomic regions in which the ABC was used for cytoreduction, the size/location of residual tumor, and the date of last follow-up and disease status. Survival curves were generated using the Kaplan-Meier method, and statistical comparisons were performed using the chi(2) test, Fisher's exact test, log rank test, and multivariate logistic regression. RESULTS: Forty-five patients were identified (FIGO Stage IIIB = 8, Stage IIIC = 29, Stage IV = 8). Overall, optimal cytoreduction was achieved in 84.4% of patients; 60.0% had only microscopic residual and 24.4% had residual disease 0.1-1.0 cm. The ABC was used to facilitate cytoreduction in 31 patients. Optimal disease status was achieved in 93.6% of cases in which the ABC was used compared with 64.3% for non-ABC cases (P < 0.023). ABC use was also associated with a higher rate of complete cytoreduction (74.2%) compared with non-ABC cases (28.6%, P < 0.004). Among patients left with optimal disease (< or =1 cm), conversion to only microscopic residual was achieved in 79.3% of cases using the ABC and 44.4% of cases without ABC use (P < 0.044). The ABC was associated with a statistically significantly higher rate of complete cytoreduction for disease located in the lesser sac/gastrocolic ligament (90.9% vs 14.3%), abdominal peritoneum (95.5% vs 50.0%), bowel mesentery (80.0% vs 0), and pelvis (89.3% vs 50.0%). Multivariate analysis revealed that use of the ABC (P = 0.006) and disease in three or fewer anatomic regions (P = 0.014) were independent predictors of a microscopic residual surgical outcome. Complete cytoreduction was associated with a significant advantage in median progression-free survival (22.2 months) compared with patients with optimal but visible (0.1-1.0 cm) residual disease (12.3 months) and those with suboptimal (>1.0 cm) residual disease (6.3 months, P < 0.001). Among ABC cases, the mean estimated blood loss was 527 ml, and major postoperative complications occurred in 9.7% of patients. CONCLUSIONS: The ABC is a useful adjunct to conventional tumor reductive techniques and appears to significantly increase the feasibility of achieving both optimal disease status and complete cytoreduction of all visible tumor in patients with macroscopic metastatic ovarian carcinoma.

Adolescent↗

PubMed2001

Ablation of metastatic ovarian carcinoma with the argon beam coagulator: pathologic analysis of tumor destruction.

OBJECTIVE: The aim of this study was to characterize the histopathologic effects of electrosurgical tumor destruction of metastatic ovarian carcinoma using the argon beam coagulator (ABC) and evaluate the depth of tissue damage produced by a range of power settings and tissue interaction times. METHODS: Epithelial ovarian carcinoma tumor specimens (1 cm(3)) were harvested intraoperatively. Following surgical excision, electrosurgical destruction of tumor was effected using the ABC at three power settings (60, 80, and 100 W) and three tissue interaction time intervals (1, 3, and 5 s), yielding nine experimental groups of 16 samples each (n = 144). Samples were formalin-fixed, cross-sectioned, stained with hematoxylin and eosin, and examined microscopically for histologic characteristics and depth of tissue destruction. RESULTS: Microscopic evaluation revealed that the total depth of destruction (TDD) produced by the ABC was composed of three distinct zones of tissue injury: vaporization, carbonized eschar (ESC), and coagulative necrosis (NEC). For each power setting, the mean TDD increased in a linear fashion as the interaction time interval increased from 1 to 5 s (60 W, 1.71 to 2.43 mm; 80 W, 2.24 to 3.69 mm; 100 W, 3.21 to 5.58 mm). By regression analysis, both power setting and tissue interaction time were independently associated with increasing TDD, with power having the strongest effect. At all power settings and interaction time intervals, the incremental change in TDD was primarily a function of the degree of tissue vaporization, which increased from 0.59 mm at 60 W (1 s) to 3.22 mm at 100 W (5 s). For all experimental groups, the ratio of NEC/ESC was highly consistent, ranging from 1.03 to 1.33 (P > 0.05, Bonferroni multiple comparisons procedure), and demonstrated that for each resulting ESC, an equivalent or greater degree of underlying NEC was also present. CONCLUSIONS: The destruction of ovarian carcinoma tumor tissue produced by the ABC is dependent upon both power setting and tissue interaction time. Increasing depth of destruction is due predominantly to a deeper level of tissue vaporization. The NEC/ESC ratio provides a reliable means of estimating the true depth of tumor destruction produced by the ABC and may contribute to increased safety and efficacy of electrosurgical cytoreduction of using this technique.

Epithelial Cells↗

PubMed2001

Impact of increasing Papanicolaou test sensitivity and compliance: a modeled cost and outcomes analysis.

OBJECTIVE: To model the impact of increasing screening compliance or implementing liquid-based cytology in populations with known compliance patterns and risk profiles on rates of detection of cervical precancers. METHODS: An adaptation of a time-varying Markov model was used to follow a theoretic cohort of 100,000 women from age 20 through age 80. Separate analyses of all women, white, and black women were completed using three compliance rates (self-reported, Healthy People 2000, and Healthy People 2010 compliance) and two Papanicolaou test sensitivities (conventional Papanicolaou smear and liquid-based cytology). RESULTS: All populations benefited from both increased compliance and liquid-based cytology use. Increasing compliance to Healthy People 2010 goals resulted in 23%, 21.7%, and 17% reductions in cervical cancer incidence for all women, white, and black women, respectively. Substituting liquid-based cytology for traditional Papanicolaou smear collection and processing with no change in compliance resulted in 32%, 32%, and 33% reductions in cervical cancer incidence for the same three subpopulations. In addition, cost-effectiveness of the liquid-based technology indirectly related to the risk profile of the population: for black women, the cost-effectiveness ratio was $10,335 per life year saved, whereas for white women, the ratio was $17,967 per life year saved. CONCLUSION: Using liquid-based cytology in all populations would be cost-effective in improving outcomes from cervical cancer. In high-risk populations, this new technology may represent the most cost-effective approach to improve cervical cancer outcomes.

Adult↗

PubMed2001

Management of pelvic hemorrhage.

Massive pelvic hemorrhage is a potential complication in any patient undergoing obstetric or gynecologic surgery. This article reviews the management of pelvic hemorrhage in obstetrics and gynecology, briefly discussing the blood supply to the pelvis and the physiology of normal coagulation and focusing on the causes and treatment of specific vascular injuries incurred during pelvic surgery.

Female↗

PubMed2001

Adenocarcinoma in situ and early invasive adenocarcinoma of the uterine cervix.

As data continue to accumulate, the clinical characteristics of preinvasive and early invasive glandular cervical neoplasia are becoming progressively better defined. Cytologic screening for these lesions is imprecise; however, modifications to current classification systems may improve the overall accuracy. All glandular abnormalities on the Papanicolaou smear, nevertheless, require judicious evaluation and careful follow-up. Cervical conization is the most definitive means of diagnosing adenocarcinoma in situ (ACIS). Because ACIS has been thought to represent a multifocal process, with negative conization margins having limited predictive value, conservative management protocols have been difficult to endorse. Several large studies now indicate that the surgical margin status may be a more reliable indicator of true disease clearance than previously thought. For young patients desiring to maintain reproductive capacity, ACIS appears to be safely managed by cold-knife conization combined with diligent surveillance. Early invasive adenocarcinoma of the uterine cervix is associated with an excellent prognosis, and recent data suggest that radical surgery may be unnecessary.

Adenocarcinoma↗

PubMed2000

A model for predicting surgical outcome in patients with advanced ovarian carcinoma using computed tomography.

BACKGROUND: A reliable model for predicting the outcome of primary cytoreductive surgery may be a useful tool in the clinical management of patients with advanced epithelial ovarian carcinoma. METHODS: Forty-one women with a preoperative computed tomographic (CT) scan of the abdomen and pelvis and a histologic diagnosis of Stage III or IV epithelial ovarian carcinoma following primary surgery performed by one of nine gynecologic oncologists were identified from tumor registry databases. All CT scans were analyzed retrospectively using a panel of 25 radiographic features without knowledge of the operative findings. Patient demographics, surgical findings and outcome, Gynecologic Oncology Group performance status, and pre-operative serum CA125 values were collected from patient medical records. Residual disease measuring < or = 1 cm in maximal diameter was considered an optimal surgical result. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each radiographic feature and clinical characteristic. Based on statistical probability of each factor predicting cytoreductive outcome, 13 radiographic features, in addition to performance status, were selected for inclusion in the final model. Each parameter was assigned a numeric value based on the strength of statistical association, and a total Predictive Index score was tabulated for each patient. Receiver operating characteristic (ROC) curve analysis was used to assess the ability of the model to predict surgical outcome. Statistical significance was evaluated using the Fisher exact test. RESULTS: Twenty of 41 patients (48.8%) underwent optimal cytoreduction to </= 1 cm residual disease. CT features of peritoneal thickening, peritoneal implants (>/= 2 cm), bowel mesentery involvement (>/= 2 cm), suprarenal paraaortic lymph nodes (>/= 1 cm), omental extension (spleen, stomach, or lesser sac), and pelvic sidewall involvement and/or hydroureter were most strongly associated with surgical outcome. Using the Predictive Index scores, a receiver operating characteristic curve was generated with an area under the curve = 0. 969 +/- 0.023. In the final model, a Predictive Index score >/= 4 had the highest overall accuracy at 92.7% and identified patients undergoing suboptimal surgery with a sensitivity of 100% (21/21). The specificity, or ability to identify patients undergoing optimal surgery, was 85.0% (17/20). The PPV of a Predictive Index score >/= 4 was 87.5% (21/24), and the NPV was 100%. The ability of this model to correctly predict surgical outcome was statistically significant (P < 0.001). CONCLUSIONS: In this model, a Predictive Index score >/= 4 demonstrated high sensitivity, specificity, PPV, and NPV, and was highly accurate in identifying patients with advanced epithelial ovarian carcinoma unlikely to undergo optimal primary cytoreductive surgery. The Predictive Index model may have clinical utility in guiding the management of patients with ovarian carcinoma.

Adult↗

PubMed2000

Stage IVB endometrial carcinoma: the role of cytoreductive surgery and determinants of survival.

OBJECTIVE: The aim of this study was to evaluate the role of cytoreductive surgery and survival determinants in patients with Stage IVB endometrial carcinoma. METHODS: All patients with Stage IVB endometrial carcinoma diagnosed between 1/1/90 and 12/31/98 were identified from tumor registry databases. Individual patient data were collected retrospectively. Survival analyses and comparisons were performed using the Kaplan-Meier method and the log-rank test. The Cox proportional hazards model was used to identify independent variables associated with survival. RESULTS: Sixty-five patients underwent surgery as primary therapy for Stage IVB endometrial carcinoma (median survival 14.8 months). The median age of the population was 65 years (range 29-85 years); 89.2% of patients were postmenopausal, and 21.5% were nulliparous. The most common histologic subtypes were endometrioid (33.8%), serous (32.3%), and mixed (16.9%). Optimal cytoreductive surgery (residual tumor < or =1 cm in maximal diameter) was accomplished in 36 patients (55.4%), while 29 patients (44.6%) were left with >1 cm residual disease. The median survival rate of patients undergoing optimal surgery was 34.3 months, a statistically significant advantage compared to patients with >1 cm residual tumor (11.0 months, P = 0.0001). Among those with optimal surgery, patients with only microscopic residual disease survived significantly longer than patients with optimal but macroscopic residual tumor. Higher performance status, age < or = 58 years, and adjuvant chemotherapy followed by radiation therapy were also significantly associated with superior survival on univariate analysis. On multivariate analysis, residual disease (P = 0.0001), performance status (P = 0.043), and age (P = 0.023) were independent predictors of survival. CONCLUSIONS: The amount of residual disease after cytoreductive surgery, age, and performance status appear to be important determinants of survival in patients with Stage IVB endometrial carcinoma. Maximal cytoreduction should be the goal at the time of primary surgery for advanced disease. For selected patients, combined postoperative chemotherapy and radiation therapy may provide some therapeutic benefit.

Adult↗

PubMed2000

Retrograde seeding of malignant cells during hysteroscopy in presumed early endometrial cancer.

OBJECTIVE: The aim of this study was to determine the effect that preoperative hysteroscopy has on the frequency of positive cytology at the time of definitive surgical management in endometrial cancer. METHODS: Charts of 222 patients with endometrial cancer were reviewed. Patients were divided according to whether (n = 64) or not (n = 158) they had hysteroscopy with saline infusion. Each group was stratified into low or high risk for positive peritoneal cytology. Logistic regression analysis was used to compare the prevalence of positive peritoneal cytology with and without hysteroscopy, before and after the stratification, adjusting for the confounding risk factors. RESULTS: After adjusting for confounding variables there was a statistical difference in the frequency of positive peritoneal cytology in those who had hysteroscopy versus those who did not (odds ratio (OR) = 2.6, 95% confidence interval (CI) = 1.02-6.63, P = 0.05). Even after stratifying patients into a low-risk group (OR = 2.12, 95% CI = 0.13-35.9, P = 0.6) and a high-risk group (OR = 3.46, 95% CI = 1.3-9.12, P = 0.01) the difference in the high-risk group was statistically significant. CONCLUSION: Hysteroscopy seems to affect the prevalence of positive peritoneal cytology, especially in those patients with high-risk cell types. Its use in patients with suspicion of endometrial cancer should be reconsidered.

Aged↗

PubMed2000

Coexistent choriocarcinoma and malignant mixed mesodermal tumor of the uterus.

OBJECTIVE: The purpose of this article is to report a case of coexisting uterine choriocarcinoma and uterine malignant mixed mesodermal tumor (MMMT). The relevant literature is reviewed and possible pathogenesis discussed. METHODS: The clinical course and histopathology of the case were reviewed and a Medline literature search for other cases was performed. RESULTS: The patient's uterine tumor contained syncytiotrophoblastic and cytotrophoblastic cells that stained positively for the beta subunit of human chorionic gonadotrophin consistent with uterine choriocarcinoma. Pathology also revealed a second distinct neoplasm composed of adenocarcinoma admixed with sarcoma, compatible with a uterine MMMT. The patient experienced metastatic choriocarcinoma to her lungs, lymph nodes, and brain. She suffered a complicated clinical course and died 7 months after her initial diagnosis. The literature search revealed that various gynecologic and nongynecologic carcinomas with trophoblastic differentiation have been described, but an association with uterine MMMT has not been previously reported. CONCLUSIONS: Trophoblastic differentiation and choriocarcinoma associated with gynecologic and nongynecologic tumors is rare. We document the presence of uterine MMMT coexisting with uterine choriocarcinoma that followed an aggressive clinical course and review the possible pathogenesis of this lesion.

Adult↗

PubMed2000

Workup of the abnormal Pap test.

Cytologic evaluation of cells obtained from the cervix and vagina was first proposed by Papanicolaou and Traut in the 1940s as a method of detecting cervical cancer and its precursor lesions. Since that time, cervical cytology has proved to be the most efficacious and cost-effective method of cancer screening. By increasing detection of preinvasive and early invasive disease, use of Papanicolaou's (Pap) test has decreased both the incidence and mortality of cervical cancer in areas with well-established screening programs (1). The American Cancer Society has estimated that in the United States, cervical cancer will be diagnosed in 14,900 women and 4500 women will die as a result of this disease during the year 2000. More than 50 million Pap tests are performed annually in the United States, and about 5% of them will be abnormal (2). Consequently, it is incumbent on the practicing primary care physician to be familiar with the clinical significance and natural history of abnormal cervical cytologic diagnoses as well as the available treatment options. This discussion will delineate practical management protocols for the full range of cervical dysplasia commonly encountered in clinical practice.

Adult↗

PubMed2000

The significance of atypical glandular cells on routine cervical cytologic testing in a community-based population.

OBJECTIVES: We sought to determine the follow-up rate of women with glandular atypia on routine Papanicolaou smears in a community-based population and to describe the associated pathologic findings. STUDY DESIGN: Over a 12-month period, all patients with Papanicolaou smears with atypical glandular cells of undetermined significance were reviewed for demographic and clinical characteristics and followed up for a period of 12 to 24 months. RESULTS: Of the 48,890 Papanicolaou smears examined, 141 (0.29%) were diagnosed with atypical glandular cells of undetermined significance. Of these, 22 (17.6%) had no record of any subsequent investigation, and only 64 (51.2%) were monitored with both colposcopy and biopsy. Of the 64 biopsy specimens, 39 (60.9%) were positive for disease. Twenty-six (66.7%) were of squamous origin, with the most advanced lesion being cervical intraepithelial neoplasia 3. An additional patient had a combined cervical intraepithelial neoplasia and adenocarcinoma in situ lesion. Four (10.3%) additional patients had glandular cervical lesions, 2 benign polyps and 2 adenocarcinoma in situ lesions. Seven (17.9%) patients had endometrial lesions (benign polyps, 2 patients; complex atypical endometrial hyperplasia, 1 patient; and endometrial carcinoma, 4 patients). One patient had ovarian cystadenocarcinoma. Postmenopausal women were 5 times more likely to have a glandular lesion. Women with abnormal vaginal bleeding were also more likely to have a glandular lesion. These same patient groups were also more likely to have endometrial disease. CONCLUSION: The incidence of atypical glandular cells of undetermined significance on Papanicolaou smears in this community-based population was 0.29%, which is consistent with estimates from institution-based populations. Nearly 50% of women studied were not followed up with tissue biopsy. Of those with a tissue biopsy, 61% had positive findings, including 5 with cancer. Although postmenopausal status and abnormal vaginal bleeding were associated with endometrial or glandular disease, studies of larger patient populations should be conducted to examine potential risk factors for these conditions.

Adult↗

PubMed2000

Surgical standards in the management of ovarian cancer.

Surgery is the cornerstone of management of epithelial ovarian cancer and has broad applications throughout the clinical course of disease, from initial diagnosis to palliative care. Comprehensive surgical staging is essential for precise prognostic determination and treatment planning for patients with apparent early-stage ovarian cancer. Although randomized trials are lacking, the survival advantage associated with optimal primary cytoreduction has been consistent and reproducible. With increasing radicality of cytoreductive surgical techniques and sophistication of postoperative care, it appears that an "optimal" surgical procedure is that which leaves the patient with no visible residual disease. The survival benefits of cytoreductive surgery are also applicable to women with stage IV ovarian cancer, although the rate of success is somewhat attenuated compared with patients with stage III disease. Recent data also indicate that with appropriate surgical selection criteria, secondary cytoreduction is associated with a significant prolongation of survival for patients with recurrent ovarian cancer. Unfortunately, several recent publications illustrate how the decentralization of health care may have significant ramifications on the ability of women with known or suspected ovarian cancer to avail themselves of the surgical standard of care.

Female↗

PubMed2000

Management of stage I cervical cancer in pregnancy.

UNLABELLED: Although cervical carcinoma is the most common gynecologic malignancy associated with pregnancy, its occurrence is rare with an incidence of approximately 1 per 1,200 to 10,000 pregnancies. There are inadequate data addressing both the obstetric implications of the diagnostic evaluation and the impact of intervention on maternal and infant outcomes. Certain conclusions and recommendations, however, can be drawn from the available data. Diagnostic evaluation includes cytological screening, colposcopy and if necessary, biopsy, and selective conization. Staging of the pregnant patient is modified to minimize radiation exposure to the developing fetus. The treatment schema for patients with stage I cervical cancer in pregnancy varies with the stage of disease and gestational age at diagnosis. With close surveillance, deliberate delay of therapy to achieve fetal maturity is a reasonable option for patients with microinvasive and early stage IB cervical cancer. Tumor characteristics and maternal survival are not adversely affected by pregnancy. Conversely, cervical cancer does not seem adversely to affect pregnancy. However, timing and type of therapy may have a significant influence on the fate of the fetus. In counseling patients with cervical cancer during pregnancy, many factors must be considered, including the patient's desire for the pregnancy, stage of disease, and gestational age at diagnosis. Pregnant patients with stage I cervical cancer should be fully informed of all possible treatment options and consequences. The care of these patients should be closely coordinated by experts in perinatology and gynecologic oncology. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader will be able to describe the signs and symptoms of cervical cancer during pregnancy and the indications for conization during pregnancy, as well as being able to outline management strategies for the various stages of cervical cancer during pregnancy.

Adult↗

PubMed1999

Altered expression of transforming growth factor-beta ligands and receptors in primary and recurrent ovarian carcinoma.

BACKGROUND: Resistance to the potent growth inhibitory effects of transforming growth factor-beta (TGF-beta) is a characteristic of many malignancies. TGF-beta insensitivity has been attributed to alterations in the number and function of the TGF-beta receptors as well as disturbances of downstream signal transduction. Paradoxically, increased levels of TGF-beta ligand have been demonstrated in several types of malignant tumors. TGF-beta also may play a role in ovarian carcinogenesis; however, the nature of this interaction has yet to be defined completely. METHODS: To explore the potential role of TGF-beta-mediated autocrine and paracrine influences in epithelial ovarian carcinoma, mRNA expression levels of the three TGF-beta ligand isoforms (TGF-beta1, TGF-beta2, and TGF-beta3) and the three TGF-beta receptors (TbetaR-I, T/betaR-II, and TbetaR-III) were examined by Northern blot analysis in both primary and recurrent ovarian carcinoma specimens. Immunohistochemical analysis was performed to localize expression of TbetaR-I and TbetaR-II, whereas the presence of genetic alterations in TbetaR-1 was examined through Southern blot analysis. RESULTS: Compared with normal ovarian tissue, both primary and recurrent ovarian carcinomas demonstrated significant overexpression of the TGF-beta1 and TGF-beta3 mRNA transcripts. TGF-beta2 expression was detectable in 75% of primary and only 53% of recurrent tumor specimens. Alterations also were detected in TbetaR mRNA expression. Expression levels of TbetaR-III were significantly reduced in both primary and recurrent ovarian carcinomas. Furthermore, detectable levels of TbetaR-I and TbetaR-III mRNA transcripts were present in only 47% and 50% of recurrent ovarian tumors, respectively. Immunohistochemical staining demonstrated that TbetaR-I and TbetaR-II expression localized to tumor cells; however, receptor staining in stromal tissue also was detected. Southern blot analysis of TbetaR-I did not reveal any major genetic changes to account for the absence of TbetaR-I expression. CONCLUSIONS: Alterations in expression of TGF-beta ligands and receptors consistently were greater in recurrent ovarian carcinomas compared with primary tumors, and may reflect a phenotype that promotes tumor recurrence or chemoresistance. Together, these data suggest that enhanced expression of TGF-betaI and TGF-beta3, as well as the loss of expression of TbetaR-I and TbetaR-III, contribute to ovarian carcinogenesis and/or tumor progression.

Blotting, Northern↗

PubMed1999

Survival impact of surgical cytoreduction in stage IV epithelial ovarian cancer.

OBJECTIVE: The aim of this study was to evaluate the influence of surgical cytoreduction on survival in patients with Stage IV epithelial ovarian cancer and to determine the survival impact of debulking extrahepatic disease in the subgroup of patients with liver metastasis. METHODS: Medical records were retrospectively reviewed for all women with International Federation of Gynecology and Obstetrics Stage IV ovarian cancer treated between 1/1/82 and 12/31/94. Clinical information abstracted included age at diagnosis, performance status, histologic subtype, tumor grade, Stage IV criteria, ascites volume, predominant peritoneal tumor pattern, surgical procedures performed, hepatic tumor residuum, extrahepatic tumor residuum, and postoperative complications. Optimal surgical status was defined as residual disease </=1 cm. Chemotherapy treatment and follow-up were recorded. Survival analysis and comparisons were performed using the Kaplan-Meier method and the log-rank test. The Cox proportional hazards regression model was used to identify independent variables associated with an improved survival rate. RESULTS: There were 84 women with Stage IV ovarian cancer and complete operative and postoperative information available. Median age at diagnosis was 61 years (range 26-85 years). Performance status was </=2 in 83% of patients (70/84). Papillary serous histology was found in 44/84 patients (52%) and 55 patients (65%) had grade 3 tumors. Thirty-seven of 84 patients (44%) had parenchymal liver metastasis and 32/84 (38%) had malignant pleural effusion. Overall median survival was 18.1 months and was highly correlated with performance status (P = 0.002), predominant peritoneal tumor pattern (P = 0.0002), and the number of chemotherapy regimens received (P = 0.0039). Primary surgical cytoreduction was attempted in all patients and 25/84 (30%) achieved optimal status. Median survival of optimally cytoreduced patients was 38.4 months, compared to 10.3 months for patients with suboptimal residual disease (P = 0.0004). In patients with liver metastasis, optimal extrahepatic cytoreduction was achieved in 46% (17/37). Six of 37 patients (16%) underwent optimal resection of both extrahepatic and hepatic disease and had a median survival of 50.1 months, compared to a median survival of 27.0 months for the 11 patients (30%) with optimal extrahepatic disease but suboptimal residual hepatic tumor. Twenty patients (54%) were left with both suboptimal residual extrahepatic and hepatic disease and had a median survival of 7.6 months (P = 0.0001). Optimal debulking surgery and performance status retained significance as independent predictors of survival on multivariate analysis. CONCLUSIONS: Optimal surgical debulking and performance status appear to be important determinants of survival in patients with Stage IV epithelial ovarian cancer. Even in patients with unresectable liver metastasis, optimal debulking of extrahepatic disease is associated with a significant survival advantage.

Adenocarcinoma↗

PubMed1999

Ethnic differences in patterns of care of stage 1A(1) and stage 1A(2) cervical cancer: a SEER database study.

OBJECTIVE: The aim of this study was to evaluate patterns of care for women with Stage 1A(1) and 1A(2) cervical cancer utilizing the SEER database. METHODS: Review of SEER data from 11 registries from 1990 to 1995 was performed. Data from 2358 women were reviewed and stratified by substage, ethnicity, type of therapy, and age. RESULTS: Three remarkable differences among subgroups were identified. (1) Among women >/=35 years of age, whites were more likely to have Stage 1A(1) cancer than blacks or Hispanics; OR (95% CI) = 1.56 (1. 05, 2.31) and 1.41 (1.04, 1.91), respectively. (2) Patients >/=35 years of age were more likely to undergo hysterectomy than younger patients both for 1A(1) and 1A(2) stages; OR (95% CI) = 2.31 (1.68, 3.19) and 2.78 (2.21, 3.50), respectively, with Mantel-Haenszel test of independence chi(2) = 102.9943, P value < 0.001. (3) Black and Hispanic women >/=35 years of age with 1A(2) disease were less likely to have a hysterectomy than whites. Only 15% of Hispanic patients and 9% of blacks over the age of 35 and with Stage 1A(2) were treated via hysterectomy, compared to 76% of white women. Differences in hysterectomies for <35 years of age, 1A(1) patients approached but did not reach statistical significance: blacks 36% versus Hispanic/whites 59%, P value = 0.07. CONCLUSIONS: Older white women were more likely to have cervical carcinoma diagnosed at an earlier stage (1A(1)) than age-matched blacks or Hispanics. Older patients, across all ethnic groups analyzed, were also more likely to be treated for both Stage 1A(1) and 1A(2) disease via hysterectomy than younger patients. Ethnic differences in the management of women with Stage 1A(2) cervical cancer do exist: older minority women are less likely to have a hysterectomy and more likely to be treated via fertility-sparing, less definitive procedures than whites.

Adult↗