Old bedfellows: ethics and obstetrics and gynecology.
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Delivery of Health Care↗
Biomedical subjects
R C Park
Publications and source records attributed to R C Park.
Presidential address. The Society of Gynecologic Oncologists--present and future.
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Gynecology↗
Determinants of survival of patients with epithelial ovarian carcinoma following whole abdomen irradiation (WAR).
In an attempt to identify those parameters which represent predictors of clinical outcome, a retrospective review of patients with epithelial ovarian carcinoma who were primarily treated with whole abdominal irradiation (WAR) following staging laparotomy was performed. Complete records with extensive long-term follow-up were available on 102 patients treated from 1962 through 1974. Histopathologic review excluded 18 patients with lesions of low malignant potential. Of the remaining 84 cases there were 12 Stage I (14%), 23 Stage II (27%), 45 Stage III (54%), and 4 Stage IV (5%). Measure of completeness of surgical resection was expressed as the largest diameter of residual gross tumor. Following primary surgical debulking Stages II and III patients, 24 patients had no gross residual disease, 24 patients had less than 2 cm of residual disease, and 20 patients had greater than 2 cm of residual disease. For Stages II and III patients together, 5- and 10-year actuarial survivals were: No gross residual, 69% and 59%; less than 2 cm, 48% and 42%; and greater than 2 cm, 15% and 10%. The technique of administration of WAR did not appear to influence survival. The results of this review support the concept that in selecting WAR for primary treatment of ovarian carcinoma, completeness of cytoreductive surgery should be considered. These data justify a prospective randomized study in patients with minimal residual disease following staging laparotomy comparing WAR with current first-line combination chemotherapy.
Abdomen↗
Evaluation of the scalene lymph nodes in primary and recurrent cervical carcinoma.
Open biopsy of the left scalene lymph nodes has been utilized to identify distant spread of cervical carcinoma in selected groups of patients who do not have other clinical evidence of disseminated disease. Twenty-one patients with primary cervical carcinoma and histologically proven para-aortic lymph node metastases and 10 patients with centrally recurrent tumors underwent scalene lymph node biopsy at Walter Reed Army Medical Center or the Naval Hospital, Bethesda, Maryland, between July 1, 1979 and June 30, 1985. All patients undergoing scalene node biopsy had clinically negative physical examinations. There were no surgical complications. All 31 biopsies were negative for metastatic tumor. Combined with previously reported data from this institution, 3 of 28 patients (11%) with primary cervical carcinoma and involved para-aortic nodes, and 6 of 35 patients (17%) with centrally recurrent disease had subclinical scalene node metastases. Patients with clinically suspicious scalene lymphadenopathy had fine needle aspiration cytology performed to document metastatic disease. The success of this technique has eliminated the need for open biopsy in these patients. Scalene node biopsy provides valuable prognostic information in patients with cervical cancer who have positive para-aortic lymph nodes. It also obviates surgical exploration in some patients felt to have resectable recurrent disease who actually have subclinical distant spread.
Adenocarcinoma↗
Prognostic factors associated with radical hysterectomy failure.
Two hundred seventy-five patients who underwent radical hysterectomy and pelvic lymphadenectomy for FIGO stage IB carcinoma of the cervix between 1961 and 1982 were retrospectively analyzed to identify specific risk factors associated with treatment failure. Patients were classified as high or low risk on the basis of tumor spread to pelvic lymph nodes or surgical margins. Thirty-eight patients had tumor involvement of pelvic nodes or surgical margins. Despite postoperative whole pelvis radiation therapy in 88% of patients, 13 (34.2%) developed recurrence. All patients with involved nodes or margins who recurred died of disease. Patients with pelvic lymph node or surgical margin involvement clearly constitute a high risk group and should be considered candidates for some form of adjuvant therapy. Two hundred thirty-seven patients had negative nodes and clear surgical margins. There were 18 recurrences (7.6%) in this group. Pathologic specimens were reviewed to evaluate additional histologic criteria which might identify those patients at greatest risk for tumor recurrence in this low risk group. Patients whose tumors contained vascular-lymphatic space invasion or adenomatous histologic components recurred more frequently than patients whose tumors did not (P less than 0.05). Eighty-three percent of low risk patients who recurred had tumors with at least one of these features. Degree of differentiation and depth of invasion did not correlate with risk of recurrence. Prospective randomized trials are needed to determine the effectiveness of postoperative adjuvant therapy for patients at risk for recurrent disease.
Adenocarcinoma↗
Right hemicolectomy and ileal resection with primary reanastomosis for irradiation injury of the terminal ileum.
Injury to the small intestine from pelvic irradiation increases in frequency when extended treatment fields are utilized and when radiation therapy follows a major abdominal operation. Recommended surgical correction of such injury has been intestinal bypass to avoid the excessive morbidity and mortality from anastamotic leaks associated with primary resection and anastomosis. Since 1980, eight patients with extensive ileal injury secondary to irradiation have been seen at the Naval Hospital Bethesda, Maryland. All patients had previously undergone an abdominal operation and three patients had irradiation utilizing extended fields. In all cases, right hemicolectomy and extended ileal resection were performed with primary anastamosis of the ileum to the ascending colon or the transverse colon. Operating time averaged 4 1/2 hr utilizing hand closure anastomoses and 2 1/2 hr with stapled anastomoses. All patients received postoperative hyperalimentation and six of eight patients received preoperative hyperalimentation. One operative death occurred in a patient with intestinal perforation who required multiple resections. The remaining seven patients experienced no serious complications and had rapid return of bowel function. Our experience indicates that wide ileal resection with right hemicolectomy and primary reanastomosis is an acceptable alternative to intestinal bypass for the treatment of severe irradiation injury, especially when performed with gastrointestinal stapling devices.
Colectomy↗
Radical hysterectomy and pelvic lymphadenectomy for stage IB carcinoma of the cervix: 21 years experience.
From September 1971 through December 1982, 153 patients with Stage IB carcinoma of the cervix underwent radical hysterectomy and pelvic lymphadenectomy at two of the teaching hospitals of the Uniformed Services University of the Health Sciences. Records were retrospectively analyzed and independent pathologic review was performed. All surgical procedures were performed by fellows or senior residents under the direct supervision of the gynecologic oncology staff of the Walter Reed Army Medical Center or the Naval Hospital, Bethesda, Maryland. In this series, IB carcinoma was defined as squamous carcinoma clinically confined to the cervix with invasion greater than 5 mm from the basement membrane or any adenocarcinoma confined to the cervix. The average age of the patients was 38.3 years. The histologic types were squamous in 72%, adenocarcinoma in 16%, and adenosquamous in 10.5%. The mean operating time was 5 hr and 40 min with an average blood loss of 1800 cc. There were two ureterovaginal and two vesicovaginal fistulae for an overall fistula rate of 2.6%. Actuarial survival for these 153 patients is 84%. This extends the previous series of R. C. Park, W. E. Patow, R. E. Rogers, and E. A. Zimmerman, Obstet. Gynecol. 41, 117-122 (1973) of 122 cases collected from 1961 to September 1971 to 275 cases. In comparing the two time periods, no significant differences were found in operative technique or complications, but there was a change in the incidence of adenocarcinoma and mixed cell types and a difference in survival. A relatively higher incidence of more aggressive tumors may indicate the need for different therapeutic approaches in the future.
Adenocarcinoma↗
Effects of regional ischemia and ventricular pacing on LV dP/dtmax-end-diastolic volume relation.
We investigated the effects of coronary artery occlusion and pacing from ventricular sites on the relation of the maximum rate of rise of left ventricular pressure (dP/dtmax) to the end-diastolic volume (VED) in dogs previously instrumented to measure left ventricular pressure and to determine left ventricular volume from three ultrasonically measured dimensions. The dP/dtmax-VED relation was generated by vena caval occlusion and compared with the simultaneously produced end-systolic pressure-end-systolic volume (PES-VES) relation. The dP/dtmax-VED relation was described by a straight line during all conditions. Occlusion of the left circumflex coronary artery produced a rightward shift of the dP/dtmax-VED relation, increasing the volume intercept by 11.3 +/- 5.3 (SD) ml (P less than 0.05). Compared with atrial pacing, the dP/dtmax-VED relation was shifted to the right with the volume intercept increasing by 4.8 +/- 4.4 ml (P less than 0.05) during pacing from the right ventricular free wall, 3.7 +/- 5.0 ml (P less than 0.05) during pacing from the right ventricular apex, and 3.7 +/- 2.4 ml (P less than 0.05) during pacing from the left ventricular free wall. Similar increases were observed in the volume intercepts of the PES-VES relations during coronary occlusion or ventricular pacing. These results are consistent with the predictions of the time-varying elastance model and support its use as a conceptual framework to understand left ventricular performance during isovolumic contraction and at end systole, both in the normal ventricle and the ventricle with regional abnormalities of contraction.
Animals↗
Calyceal rupture with perirenal urinoma in a patient with cervical carcinoma.
A patient is presented with calyceal rupture and perirenal urinoma formation secondary to distal ureteral obstruction by cervical carcinoma. Preoperative diagnosis was established with computed tomography and renal scan. Surgical placement of an indwelling ureteral stent resolved the urinoma. Causes of perirenal urine extravasation and approaches to diagnosis and management are reviewed.
Carcinoma, Squamous Cell↗
End colostomy using the end-to-end anastomosis instrument.
Gastrointestinal stapling instruments have achieved wide-spread application in intestinal surgery. Reported advantages of stapled bowel procedures compared to classic hand-sutured procedures include reduced tissue trauma, shorter operating time, and improved blood supply to the stapled bowel segment. A technique for creation of an end colostomy using the end-to-end anastomosis stapler (EEA instrument) is described. This technique was used in 11 gynecologic oncology patients who required colostomy. Postoperative stomal function was normal in all cases. No patient developed stomal necrosis, peristomal hematoma, or abscess. No delayed complications have been observed. Colostomy creation with the EEA instrument is a safe, simple and rapid procedure. Possible advantages of the stapled colostomy are enhanced blood flow to the stomal site, reduced incidence of peristomal infection, and improved appliance fit.
Adult↗
Clinical patterns of tumor recurrence after radical hysterectomy in stage IB cervical carcinoma.
We reviewed the cases of 31 patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB cervical carcinoma who developed recurrent disease after radical hysterectomy and pelvic lymphadenectomy between 1961 and 1982. The overall incidence of recurrence was 11.3%. Recurrence was significantly more common in patients with adenocarcinoma or adenosquamous carcinoma (17.4%) than in those with pure squamous tumors (9.2%). The median time from operation to recurrence was eight months. The median survival of patients dying of disease was 18 months. Sites of recurrence were categorized as central pelvic in 35% of cases, pelvic sidewall in 39%, and distant in 26%. Patients treated with postoperative pelvic radiotherapy for positive pelvic nodes or surgical margin involvement were more likely to develop distant recurrence. Various therapeutic modalities were used to treat recurrent disease. Twenty-two of 23 patients with central pelvic or sidewall recurrence failed radiation therapy. None of four patients with central recurrence treated by pelvic exenteration survived. No patient treated with chemotherapy survived. Overall survival for patients with recurrence was 3.2%. The dismal prognosis for this group of patients warrants evaluation of alternative treatment modalities.
Adenocarcinoma↗
Alterations in regional myocardial blood flow after nitroprusside and nitroglycerin in patients with and without significant coronary artery disease.
To evaluate vasodilator-induced redistribution of regional myocardial blood flow, intravenous sodium nitroprusside and nitroglycerin were administered in doses producing matched reductions (15%) in mean arterial pressure at constant heart rate. Anterior left ventricular great cardiac vein blood flow (thermodilution) was measured in 14 patients without angiographic anterior collateral supply. Global coronary sinus blood flow remained constant with both nitroprusside and nitroglycerin administration, despite significant reductions in mean arterial pressure. However, nitroglycerin reduced great vein flow by 25 +/- 17% and nitroprusside by 10 +/- 16% (p less than 0.01). Subgroup analysis indicated that the nitroglycerin-nitroprusside regional blood flow differences were more pronounced in patients without significant left anterior descending coronary artery narrowing. Neither vasodilator produced significant differences in arterial-coronary sinus oxygen or lactate contents, calculated myocardial oxygen consumption, left ventricular dP/dt, or electrocardiographic or clinical signs of myocardial ischemia. Despite qualitatively similar hemodynamic effects, comparisons of vasodilator-induced relative reductions in normally supplied anterior left ventricular regional coronary blood flow suggest a mechanism of the reported beneficial effects of nitroglycerin on potentially ischemic myocardial regions.
Adult↗
Cervical carcinoma found incidentally in a uterus removed for benign indications.
Thirty-five patients with invasive cervical carcinoma discovered in a uterus removed for benign indications were evaluated and treated from 1961 through 1983. Although formal staging was not possible, patients with presumed stage IA disease had a 100% five-year survival rate regardless of the addition of adjuvant therapy. All patients with more advanced disease received radiation therapy. Patients with presumed stage IB disease had a corrected five-year survival rate of 78%, and those with presumed stage IIB disease had a corrected five-year survival rate of 67%. No patient in this series was thought to have disease more advanced than a stage IIB equivalent. The hysterectomy alone may have been adequate therapy for patients with presumed stage IA disease. Adjuvant radiation therapy appears to be effective treatment for patients with presumed stage IB or IIB disease.
Actuarial Analysis↗
Vincristine, dactinomycin, and cyclophosphamide in the treatment of malignant germ cell tumors of the ovary. A Gynecologic Oncology Group Study (a final report).
Seventy-six patients with malignant germ cell tumors of the ovary received vincristine, dactinomycin, and cyclophosphamide (VAC) postoperatively. Fifty-four were treated after removal of all gross disease. The majority of these remain disease-free. Indeed, only 15 (28%) have failed, including 11 of 24 with pure endodermal sinus tumor, 3 of 11 (27%) with mixed germ cell tumor containing endodermal sinus elements, and only 1 of 20 with immature teratoma grade 2 or 3, a patient seen initially with recurrent disease. Postoperative VAC therapy, however, did not appear to be effective in patients with unresectable or incompletely resected germ cell tumors of the ovary. Fifteen of 22 patients (68%) with incompletely resected germ cell tumors failed VAC therapy, including 4 of 7 with pure endodermal sinus tumor, 5 of 5 with mixed germ cell tumors containing endodermal sinus elements, 2 of 2 with embryonal carcinoma, and 4 of 8 with immature teratoma. In failing, patients' median time to progression was 8 months. Dose-limiting toxicity was seen in 30% of the entire group. Combined cisplatin, vinblastine and bleomycin therapy now is being tested in this group of tumors.
Adolescent↗
Effects of pulsed external augmentation of diastolic pressure on coronary and systemic hemodynamics in patients with coronary artery disease.
The purpose of this study was to define the effects of pulsed external diastolic pressure augmentation on coronary and systemic hemodynamics in 14 men with coronary artery disease and normal left ventricular function. Coronary sinus and great vein blood flow (thermodilution) and systemic hemodynamics were measured before, during, and after timed lower extremity compression, augmenting peak diastolic pressure to within 5 mm Hg of systolic pressure. Systolic and diastolic pressure-time indices were calculated from the high-fidelity micromanometer left ventricular-aortic recordings. External counterpulsation increased mean arterial pressure (108 +/- 11 [1 SD] to 114 +/- 12 mm Hg, p less than 0.01) and the diastolic pressure-time index (440 +/- 51 to 498 +/- 82 units, p less than 0.01), with no change in the systolic pressure-time index, absolute coronary sinus, or great cardiac vein blood flow. External diastolic pressure augmentation did not affect heart rate, right heart hemodynamics, cardiac output, or calculated myocardial oxygen consumption. An unanticipated finding was a greater than or equal to 10% reduction in peak systolic pressure during external diastolic pressure augmentation in 8 of 14 patients. Despite minimal changes in absolute myocardial blood flow and oxygen consumption, the increase in the diastolic pressure-time/systolic pressure-time index ratio suggests that subendocardial perfusion may be favorably influenced by diastolic pressure augmentation and may explain the previously reported clinical benefits of external counterpulsation in some patients with ischemic heart disease.
Adult↗
Whole abdominal and pelvic irradiation in patients with minimal disease at second-look surgical reassessment for ovarian carcinoma.
Aggressive cytoreductive surgery followed by combination chemotherapy for stage III ovarian carcinoma has resulted in a significant percentage of complete clinical responses. However, 30-50% of patients with no clinical evidence of disease are found to have residual carcinoma at second-look surgical reassessment. Because recent reports have indicated a high degree of effectiveness utilizing abdominal and pelvic irradiation as primary therapy for ovarian carcinoma with small residual disease, the authors treated eight patients found to have residual disease of less than 1 cm at second-look reassessment with either open field or split field abdominal and pelvic irradiation. All eight patients had initially undergone aggressive cytoreductive surgery and seven of the eight patients had received multidrug chemotherapy. Patients were treated either at the National Cancer Institute or the Naval Hospital Bethesda both with and without intraperitoneal radiation sensitizers. Fifty percent of the patients required early termination of therapy due to myelosuppression. All eight patients have recurred and three have died. Six of the eight patients have required major surgical procedures for gastrointestinal complications. Based on this experience, we cannot advocate this form of therapy in patients with minimal residual ovarian carcinoma following second-look surgical reassessment.
Abdomen↗
Heart of the athlete.
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Adaptation, Physiological↗
Effect of alteration of left ventricular activation sequence on the left ventricular end-systolic pressure-volume relation in closed-chest dogs.
We investigated the effect of pacing from the atrium and various ventricular sites on the left ventricular end-systolic pressure-volume relation following autonomic blockade in a total of 10 dogs chronically instrumented to measure left ventricular pressure and determine left ventricular volume from three ultrasonic endocardial dimensions. During ventricular pacing, left ventricular end-diastolic volume, stroke volume, and end-systolic pressure were decreased, while the end-systolic volume was relatively unchanged. Left ventricular end-systolic pressure-volume relations were generated by vena caval occlusions during pacing at a constant rate from the left atria, and the epicardium of the right ventricular free wall, right ventricular apex, and left ventricular free wall. The left ventricular end-systolic pressure-volume relations were described by straight lines for each site (r greater than 0.96 and SEE less than 2.9 mm Hg in all but one instance). Compared to atrial pacing, the left ventricular end-systolic pressure-volume relations were shifted (P less than 0.001) to the right during pacing from ventricular sites. During atrial pacing, the volume intercept of the left ventricular end-systolic pressure-volume relation was 16.0 +/- 7.2 ml (mean +/- SD), and increased to 18.7 +/- 7.8 ml (P less than 0.05) during pacing from the right ventricular free wall, to 19.6 +/- 7.7 ml (P less than 0.05) during pacing from the right ventricular apex, and to 20.0 +/- 7.5 ml (P less than 0.05) during pacing from the left ventricular free wall. These volume intercepts correlated roughly with the extent of dyssynchronous activation as estimated by the QRS duration (r = 0.59 to 0.93) and the time for left ventricular endocardial activation (r = 0.92 and 0.95). During ventricular pacing, the slope of the left ventricular end-systolic pressure-volume relation changed only slightly. Similar results were obtained during pacing from right ventricular endocardial sites. We conclude that alterations of the normal activation sequence produced by ventricular pacing depress left ventricular pumping function independent of loading conditions, as indicated by a rightward shift of the left ventricular end-systolic pressure-volume relation. The extent of this shift appears to be in proportion to the degree of dyssynchronous activation. The decreased stroke volume during ventricular pacing is due both to a decreased end-diastolic volume (decreased preload) and the rightward shift of the end-systolic pressure-volume relation (decreased pump function).
Animals↗