Biomedical subjects
Publications and source records attributed to K C Podratz.
Two hundred eighteen patients underwent urinary diversion: 156 with ileal and 62 with sigmoid conduits. There were no significant differences between the two groups regarding frequency of conduit morbidity or patient survival. The ileal conduit is preferred for urinary diversion with anterior exenteration, whereas the sigmoid conduit is preferable for urinary diversion with total exenteration.
Thirty-five patients with advanced ovarian cancer have received, as salvage therapy, irradiation consisting of 30 Gy to the entire abdominal contents with partial liver/kidney shielding and boosts to 42 and 51 Gy for the paraaortic/diaphragmatic and pelvic regions, respectively. These patients had received 6 to 25 cycles (median, 11 cycles) of prior combination chemotherapy (included cisplatin in 30), with "second-look" laparotomy performed in 33; 24 (68%) had three or more laparotomies. Acute gastrointestinal toxicity was generally mild. Significant hematologic toxicity (leukocytes less than 2000/mm3; or platelets less than 100,000/mm3) was seen in 19 (54%); platelet suppression occurred in 18 of these 19. Nine patients failed to complete the prescribed course of therapy; in seven, this was secondary to hematologic toxicity. Amount of prior chemotherapy and advanced age correlated with degree of hematologic toxicity. Five patients without evidence of disease (laparotomy confirmed) have developed treatment-related bowel obstruction. No other chronic toxicity of clinical significance has been observed. Seven patients have developed bowel obstruction associated with progressive neoplasm. Irradiation was well tolerated symptomatically, but hematologic toxicity associated with prior chemotherapy prevented its completion in 20% of patients. Clinical manifestations of radiation bowel toxicity have been moderate to date and should be interpreted in the context of the aggressive combined modality program.
From 1977 through 1982, 135 patients with ovarian cancer, having a mean age of 53.7 years and no clinical evidence of disease after approximately 1 year of treatment, underwent a "second-look" laparotomy. Of the 135 patients, 58 (43%) had histologic confirmation of disease at the second-look procedure. Persistent disease was positively correlated with the original stage and negatively correlated with the extent of the original reductive surgery. The original histologic grade or cellular subtype did not significantly influence the findings at reexploration. Patient survival, as judged by percentage of patients alive 3 years after the second-look laparotomy, was dependent on the following surgical/pathologic parameters: tumor size at reexploration, peritoneal cytologic features, residual tumor after reexploration, and histologic grade.
Among 187 women with stage III and IV ovarian carcinoma who participated in this comparative clinical trial, 181 were eligible for analysis. Of these patients, 89 received monthly treatment with CP [cyclophosphamide (1 g/m2) plus cisplatin (60 mg/m2)] and 92 received monthly treatment with HCAP [hexamethylmelamine (150 mg/m2/day X 7), cyclophosphamide (400 mg/m2), doxorubicin (30 mg/m2), and cisplatin (60 mg/m2)]. All treatments were administered iv on Day 1 of each monthly treatment cycle, except for hexamethylmelamine, which was administered orally on Days 2-8. With a median follow-up time of 30 months, survival curves for the two treatment groups were almost identical, as were their times to progression [estimated median survival, 24.6 months (Kaplan-Meier)]. Patient characteristics which significantly influenced survival were age, degree of histologic differentiation, extent of residual disease, stage of disease, and histologic type. Results of posttreatment laparotomies have been equal for the two treatment groups. Toxic effects of the two regimens have been similar, except for more frequent, more severe, and earlier neurotoxicity among patients treated with HCAP. Of the two regimens, CP has the better therapeutic index.
Progestational agents induced an objective response in 11.2% of 155 patients with advanced primary or recurrent endometrial carcinoma. Response rates decreased with decreasing tumor differentiation from 40% with Broders grade 1 lesions to 17.5, 2.4, and 0%, respectively, with grades 2, 3, and 4. 17 alpha-Hydroxyprogesterone caproate (Delalutin), 6,17 alpha-dimethyl-6-dehydroprogesterone (Colprone), and 6-methyl-6-dehydroprogesterone acetate (Megace) were the progestogens used; there was no significant advantage for any one agent. Overall, survival after initiation of hormone therapy was 40% at one year, 19% at two years, and 8% at five years. Survival was highly dependent on the degree of tissue differentiation (P less than .001) and was influenced significantly by the estimated tumor volume at the start of therapy (P less than .01) and by the time interval from primary treatment to the beginning of hormone therapy (P less than .01).
Pelvic exenteration or extensive abdominoperineal resections, in combination with radiation therapy, may result in difficulties with healing of the wound in the perineum. In addition, the reconstruction of a functional vagina is rendered difficult. At the Mayo Clinic between February 1980 and October 1981, eight patients underwent vaginal reconstruction with use of bilateral gracilis myocutaneous flaps. Although complications were experienced, the procedure resulted in healed wounds in all patients. Patient satisfaction with respect to sexual function was variable. Reconstruction of the vagina and closure of the extensive defect after pelvic exenteration by using gracilis myocutaneous flaps seems to be a worthwhile and appropriate procedure.
In vitro growth of tumor cells may provide a way of testing the effectiveness of chemotherapeutic agents in the treatment of cancer. In 1980 and 1981, operations for gynecologic malignancy were performed on 610 Mayo Clinic patients, and malignant tissue and fluids were obtained from 204 cancers that involved the vulva, uterus, fallopian tubes, and ovaries. These yielded 76 clonogenic stem-cell preparations; and various chemotherapeutic agents were tested against these 76 tumors on soft agar. Considered in this study were the overall process of culturing the samples of tumors and, especially, the data from the preparations that showed sufficient growth of tumor cells for testing. Our guiding concerns were the usefulness of this method to gynecologists and the possible benefits to patients.
During the time interval 1950 through 1980, 48 patients having a mean age of 60.2 years were treated primarily for melanoma of the vulva. In all but one patient, a surgical therapeutic approach was selected, including 40 modified Basset procedures and 23 pelvic lymphadenectomies. The 5-year survival rate of the eligible population was 54%. Although surgical staging according to the classification established by the International Federation of Gynecology and Obstetrics (FIGO) was of minimal value, microstaging, using Clark's and Breslow's stratifications for assessing dermal penetration, was of prognostic significance. Ten-year survival rates associated with Clark's level II, III, IV, and V tumors were 100, 83, 65, and 23%, respectively. Histologic growth patterns (5-year survival rates of 71 and 38% for superficial spreading and nodular melanomas, respectively) and groin nodal metastasis were cogent prognostic factors and indirectly were related to depth of local tumor invasion. Likewise, assessment of treatment failures demonstrated a positive correlation between recurrences (specifically at distant sites) and Clark's level of melanocytic penetration. Because of the unacceptably high (32%) local treatment failure rate despite radical vulvar resection, treatment modifications for vulvar melanoma are imperative.
The treatment of 224 patients with invasive squamous cell carcinoma of the vulva over a 20-year interval at the Mayo Clinic resulted in an overall survival rate of 75%, compared with 89% for age-matched controls. For patients with stage I disease, 5-year survival was 90%; for those with stages II, III, and IV, it was 81, 68, and 20%, respectively. A precipitous decline in survival rates was noted when metastases to regional nodes were encountered, when lesion size was more than 3 cm, and when histologic dedifferentiation exceeded grade 2. Incorrect clinical staging efforts were observed in 25% of the cases, so the necessity for surgical staging was apparent.
Continuous follow-up of 224 patients treated for primary invasive squamous cell carcinoma of the vulva in a 20-year period (1955 to 1975) at the Mayo Clinic resulted in the detection of recurrent (or persistent) neoplasia in 59 (26%). Rates of treatment failure increased with advancing stage of disease-from 14% for Stage I to 71% for Stage IV. The rate of local vulvar recurrence was 18%, which was about three times greater than the recurrence rates for the groin, pelvis, and distant sites. However, the 1- and 5-year survival rates of 73% and 50%, respectively, after vulvar recurrence were in sharp contrast to the corresponding rates of 34% and 10% for regional or distant recurrence. When 35 patients with central vulvar extension of disease were evaluated, groups at excessive risk for treatment failure (lesions 4 cm or larger inguinal node involvement, or both) were identified and modifications in conventional therapy applicable to these groups were considered.
The presence of severe ketoacidosis in the absence of hyperglycemia and glucosuria is reported in a young pregnant chronic alcohol abuser. The clinical presentation included an arterial pH of 7.15, a base deficit of 23 mEq/liter, a bicarbonate of less than 10 m Eq/liter, larger serum and urinary ketone levels, and hyperpnea with Kussmual-type respiration. Corrective therapy consisted of rapid fluid, electrolyte, bicarbonate, and glucose replacement with insulin supplementation. The ability of the fetus to tolerate the maternal metabolic derangements of "alcoholic ketoacidosis" as well as the stress of uterine contractions is discussed and contrasted with diabetic ketoacidosis.
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Aggressive angiomyxoma (AA) was first described in 1983, and fewer than 150 cases have been reported in the world medical literature. These tumors are benign, locally infiltrative mesenchymal neoplasms with a predilection for the female pelvis and perineum and a tendency to recur. The size of AAs at presentation varies considerably; however, these tumors often achieve large dimensions before becoming clinically symptomatic. Surgical excision remains the mainstay of treatment, but whether clear, tumor-free surgical margins are necessary is controversial. We report a cohort of six patients treated surgically during the past 20 years for primary or recurrent AA. Treatment, surgical margin status, estrogen and progesterone receptor status, and outcomes are reviewed.