E.Mark Beckman

Uterine arteriovenous malformation successfully embolized with a liquid polymer, isobutyl 2-cyanoacrylate

A uterine arteriovenous malformation was diagnosed angiographically in a 27-year-old woman presenting with recurrent menometrorrhagia. Bilateral hypogastric artery embolization with a liquid polymer, isobutyl 2-cyanoacrylate (Bucrylate), resulted in subsequent normal menses. Bucrylate offers a number of advantages over other agents previously used to embolize uterine arteriovenous malformations.

Congenital arteriovenous malformation of the female pelvis: A gynecologic perspective

Nine female patients with the rare congenital arteriovenous malformation of the pelvis were treated at New York University Medical Center in the past 8 years. The patients varied significantly in the anatomic location of the arteriovenous malformation, clinical presentation, and natural course of disease. A gynecologic perspective on the management of this condition is presented, which ranges from a conservative approach with preservation of childbearing potential to extensive pelvic surgery. The important role of modern interventional radiology technology and the multidisciplinary approach are stressed. The unpredictable course of disease after any intervention should be emphasized in planning the management of pelvic arteriovenous malformation.

Analysis of multiple prognostic factors in patients with stage IB cervical cancer: Age as a major determinant

To evaluate the prognostic importance of age in patients with Stage IB cervical cancer we reviewed the results of 131 patients treated between 1974 and 1985. Patients ranged in age from 25 to 87 (mean 48) and were followed for a median of 65 months. One hundred twenty-five patients had complete follow-up information for survival analysis. Patients were divided into two groups; Group A comprising 43 patients less than or equal to age 40 and Group B comprising 88 patients greater than age 40. Both Group A and Group B patients were comparable with respect to all covariables studied. The 5-year actuarial survival for the 125 patients studied was 80%, whereas that for Group A (42 patients) and Group B (83 patients) was 54% and 91%, respectively (p = .0001). The 5-year survival for 100 surgical patients was 79% and that for Group A (36 patients) and Group B (64 patients) was 53% and 90%, respectively (p = .0001). The 5-year survival for 25 patients treated with curative RT was 65% and that for Group A (six patients) and Group B (19 patients) was 42% and 90%, respectively (p = .005). Eighteen patients were treated with adjuvant RT following surgery and their 5-year survival was 69% with three out of nine Group A and nine out of nine Group B patients alive at 65 months (p = .004). In 18 patients with pelvic nodal involvement, the 5-year survival was 48% compared to 84% in patients with negative nodes (p = .007). The difference in survival at 5 years between Group A (nine patients) and Group B (nine patients) with positive nodes was 25% and 75%, respectively. Finally, there was an increase in both local and distant failure in Group A patients. Our data illustrate that age has a profound influence on survival in women with Stage IB cervical cancer independent of potentially confounding variables.

Colposcopy and the management of cervical intraepithelial neoplasia.

Abstract The accuracy of the colposcopically directed punch biopsy and its value in the management of cervical intraepithelial neoplasia (C.I.N.) was evaluated among 272 consecutive patients with abnormal Pap smears who were followed in a cervical dysplasia clinic (Bellevue Hospital, New York University Medical Center). The authors conclude that many unnecessary surgical operations were eliminated with this technique. One hundred and eighty-five patients (68%) underwent a colposcopically directed punch biopsy, usually followed by endocervical curettage. Only 22 patients (8%) had subsequent surgical conizations and 11 patients (4%) underwent hysterectomies. All cases diagnosed as mild or moderate dysplasia were treated by cryocauterization. For the cases with severe dysplasia or C.I.N. the treatment was individualized. Surgical conization or hysterectomy was performed in those cases with additional indications such as uterine prolapse, desire for sterilization, or advanced age. To minimize the risk of a later invasive carcinoma, a continuous follow-up with colposcopy and cytology is necessary.

Epithelial carcinoma of the ovary in the reproductive years: Clinical and morphological characterization

In the 10-year interval from 1972 through 1981, 247 patients were treated for epithelial ovarian carcinoma at New York University Medical Center. Of this group, 31 patients (12.6%) were below age 40, and this group had distinctive features favoring longer survival. Of these patients 12 (38.7%) had borderline tumors, compared to 9 of 216 patients (4.2%) over 40 years of age (P less than 0.001). Stage I disease and well differentiated lesions were also common in the younger group. Early symptomatology and frequent gynecologic examinations during the childbearing years may also contribute to early detection of these tumors. The median survival in this group (7 years) was better than that reported for all ages. After careful evaluation, conservative surgical management can be considered for patients with Stage Ia disease which is either borderline or grade 1 carcinoma.

Early Osseous Metastasis of Stage 1 Endometrial Carcinoma: Report of a Case

Abstract Osseous metastasis of endometrial carcinoma is rare and is usually seen in advanced disease. A case of early metastasis to the femur following radical hysterectomy for a stage 1 cancer is presented with a review of the literature.

Phase IB study of low-dose intraperitoneal recombinant interleukin-2 in patients with refractory advanced ovarian cancer: rationale and preliminary report.

Abstract The biological activity of recombinant Interleukin-2 (rIL-2) administered intraperitoneally (ip) has not been determined and may differ significantly from the maximum tolerated dose (MTD). In this trial, the pharmacokinetics, toxicity, and biologic activity of a single ip dose were studied initially followed a week later by a 5-day ip rIL-2 given for 2 weeks every 28 days. Planned dose escalation was from 2 × 10 3 to 2 × 10 7 U given in 2 liters of D5W. Drug was obtained from the NCI and was administered through an ip port. Four patients received 1 U/ml and four patients received 10 U/ml. Preliminary data demonstrate an increase in the peritoneal fluid mononuclear cell count. Mononuclear cell phenotyping tested in the first eight patients showed a modest increase in Leu 2a +, Leu 15- cells, corresponding to CTL. A similar increase in Leu 19+ cells was also demonstrated (NK cells). Soluble IL-2 receptor was elevated in peritoneal fluid. Cytotoxicity against K562 and Daudi cell lines was not observed at the first two dose levels. Toxicity of treatment was minimal and related to abdominal distention. No objective responses were seen but in one patient we documented a reduction in serum CA-125 levels. The observed biologic response and lack of toxicity is promising and justifies further exploration of this immune-modulating approach.

Phase II study of carboplatin in recurrent ovarian cancer: severe hematologic toxicity in previously treated patients

SummaryCarboplatin (CBDCA) is a second-generation cisplatin analog that has shown activity in early clinical trials. Its spectrum of toxicity is quantitatively and qualitatively different from that of the parent compound. Between November 1984 and September 1986 we conducted a phase II trial of CBDCA in 46 women with epithelial ovarian cancer. All patients had undergone at least one prior chemotherapy regimen; 41 (89%) had previously received cisplatin (mean cumulative dose, 540 mg/m2). The CBDCA dose was based on renal function and was injected i. v. once every 4 weeks. Patients were stratified on the basis of baseline creatinine clearance: those with a baseline creatinine clearance of ≥60 ml/min received 400 mg/m2 CBDCA; those with a creatinine clearance between 30 and 60 ml/min received an initial dose calculated according to a previously published formula [2, 3] that corrected for renal insufficiency and projected nadir platelet counts of 75,000/mm3. Of 41 evaluable patients, 6 (15%) had an objective response [2 complete responses (CRs); 4 partial responses (PRs)]; 5 of the 6 responders had previously responded to cisplatin treatment. No responses were observed in 12 patients who had not responded to prior cisplatin therapy. Significant hematologic toxicity was seen. Of 18 patients with a creatinine clearance of ≥60 ml/min (dose, 400 mg/m2), 6 had nadir platelet counts of <25,000/mm3, 4 with symptomatic bleeding. Of the 21 evaluable patients for whom the dose-modification formula was applied, 10 had nadir platelet counts of <75,000/mm3; 5 had counts of <50,000/mm3. CBDCA has activity even in patients who have previously undergone extensive cisplatin therapy; however, its toxicity is variable and thrombocytopenia is dose-limiting. We did not confirm the ability of the above-mentioned formula to calculate the CBDCA dose and accurately predict the nadir platelet count for all patients. Other factors, such as prior radiotherapy, may also be important in the dosing of CBDCA in pretreated patients.

Clinical management of septic abortion complicated by hypotension

A mortality of 22% is reported for 50 cases of septic abortion complicated by hypotension. Patients were treated by a variety of medical managements, and 44 underwent surgery. 38% were subjected to hysterectomy based on the following indications: 1) unresponsive septic, hypotension, large uterus; 2) intrauterine douche with necrosis; and 3) anuria. Experience with this series indicated the following procedural principles: 1) hourly recording of blood pressure and urinary output; 2) gram-stained smears from cervix; 3) infusion of intravenous fluids and antibiotics geared to combat gram-negative organisms and Clostridium welchii (vasopressor may be required for patients in deep shock); and 4) surgical treatment to remove the source of infection and toxicity. Rationale for clinical management is discussed.

Evaluation of cone biopsy in the management of carcinoma in situ of the cervix

Abstract The success of conization in eradicating carcinoma in situ of the cervix was investigated. Between 1964 and 1973, 115 patients with carcinoma in situ of the cervix on cone biopsy were subsequently treated, within a maximum of 6 wk, by total hysterectomy. Residual significant disease (defined as carcinoma in situ or severe dysplasia) was found in the uterus of 51% of these patients. If in situ carcinoma was present at the surgical margins of resection in the cone biopsy, the incidence of residual significant disease in the uterus was 81%. Absence of in situ carcinoma at the surgical margin of the cone was associated with residual significant disease in the uterus in 31% of cases. This difference is statistically significant ( P