IIIB Squamous Cell Research Articles

Phase III double-blind randomized trial of radiation therapy for stage IIIB cervical cancer in combination with low or high dose Z-100, immunomodulator widely used in Japan

5029 Background: The Specific Substance of Maruyama (SSM) is a well-known immunomodulator that has been used in Japan as an unapproved drug in the treatment of over 240,000 cancer-bearing patients since 1970. Z-100 is the same agent as SSM, used in different concentrations. The aim of this study is to investigate whether Z-100 enhances the efficacy of radiation therapy (RT) for locally advanced cervical cancer of the uterus. Methods: Between 1995 and 1999, 221 (217 evaluable) patients with stage IIIb squamous cell carcinoma of the uterine cervix were randomly assigned to treatment with either 0.2 μg Z-100 (Group L: n=109) or 40 μg Z-100 (Group H: n=108) in a double-blind manner in combination with conventional RT. Z-100 was administered twice a week during the RT, and it was continuously administered every two weeks after RT for as long as possible ≥ 2 years, or until recurrence or progression was noted. The endpoints were tumor response, progression-free survival (PFS) and overall survival (OS). Results: There was no difference in the tumor-regression effect of Z-100 between two groups. The 5-year survival of Group H was 41.5%, (95%CI: 31.7–51.3%), which was equivalent to that of Japanese historical controls treated by RT alone (35–42%), or to the 4-year survival rate of the RT plus hydroxyurea arms of GOG120 study (50%). The 5-year survival of Group L was 58.2% (95% CI: 48.7–67.7%). Compared with Group H, Group L showed a 30% reduction in the death rate (hazard ratio: 0.670 [95% CI: 0.458 - 0.980], log-rank test, p=0.0387). PFS was also significantly improved in favor of Group L (hazard ratio: 0.667 [95% CI: 0.447 - 0.997], p=0.0482). OS and PFS of Group L were equivalent to those of concurrent cisplatin-based chemoradiation arms of the GOG study. Conclusions: It was suggested that RT combined with the immunomodulator Z-100 improved the survival of patients with locally advanced cervical cancer. However, more was not better, suggesting that the dose response to immunomodulators is different from the responses to conventional cytotoxic agents. A randomized placebo controlled trial is under planning. Author Disclosure Employment or Leadership Consultant or Advisory Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Zeria Pharmaceuticals Aventis; Bristol; GlaxoSmithKline; Roche; AstraZeneca; Zeria

Phase III double-blind randomized trial of radiation therapy for stage IIIB cervical cancer in combination with low or high dose Z-100, immunomodulator widely used in Japan

5029 Background: The Specific Substance of Maruyama (SSM) is a well-known immunomodulator that has been used in Japan as an unapproved drug in the treatment of over 240,000 cancer-bearing patients since 1970. Z-100 is the same agent as SSM, used in different concentrations. The aim of this study is to investigate whether Z-100 enhances the efficacy of radiation therapy (RT) for locally advanced cervical cancer of the uterus. Methods: Between 1995 and 1999, 221 (217 evaluable) patients with stage IIIb squamous cell carcinoma of the uterine cervix were randomly assigned to treatment with either 0.2 μg Z-100 (Group L: n=109) or 40 μg Z-100 (Group H: n=108) in a double-blind manner in combination with conventional RT. Z-100 was administered twice a week during the RT, and it was continuously administered every two weeks after RT for as long as possible ≥ 2 years, or until recurrence or progression was noted. The endpoints were tumor response, progression-free survival (PFS) and overall survival (OS). Results: There was no difference in the tumor-regression effect of Z-100 between two groups. The 5-year survival of Group H was 41.5%, (95%CI: 31.7–51.3%), which was equivalent to that of Japanese historical controls treated by RT alone (35–42%), or to the 4-year survival rate of the RT plus hydroxyurea arms of GOG120 study (50%). The 5-year survival of Group L was 58.2% (95% CI: 48.7–67.7%). Compared with Group H, Group L showed a 30% reduction in the death rate (hazard ratio: 0.670 [95% CI: 0.458 - 0.980], log-rank test, p=0.0387). PFS was also significantly improved in favor of Group L (hazard ratio: 0.667 [95% CI: 0.447 - 0.997], p=0.0482). OS and PFS of Group L were equivalent to those of concurrent cisplatin-based chemoradiation arms of the GOG study. Conclusions: It was suggested that RT combined with the immunomodulator Z-100 improved the survival of patients with locally advanced cervical cancer. However, more was not better, suggesting that the dose response to immunomodulators is different from the responses to conventional cytotoxic agents. A randomized placebo controlled trial is under planning. Author Disclosure Employment or Leadership Consultant or Advisory Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Zeria Pharmaceuticals Aventis; Bristol; GlaxoSmithKline; Roche; AstraZeneca; Zeria

A technique for transplantation of ovarian cortical strips to the forearm

Objective To describe a forearm heterotopic ovarian transplantation technique. Design Case study. Setting Academic medical center. Patient(s) One patient with stage IIIB squamous cell cervical carcinoma and one patient with recurrent benign ovarian cysts. Intervention(s) Preparation of thin ovarian cortical slices and transplantation under the skin of the forearm. Main outcome measure(s) Follicular development and oocyte retrieval; cyclical estradiol (E 2) and progesterone (P 4) production; restoration of serum follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels to reproductive age range. Result(s) Both patients were menopausal immediately after oophorectomy. The first patient developed a dominant follicle 10 weeks after transplantation, and her gonadotropin levels decreased to nonmenopausal levels. Percutaneous aspiration of ovarian follicles yielded a metaphase I (M-I) oocyte that was matured to metaphase II (M-II). The first patient’s graft was functional for at least 21 months. In the second patient, ovarian follicle development was detected 6 months after transplantation, and periodic menstruation occurred thereafter. Spontaneous ovulation was confirmed by a midluteal increase in her P 4 levels. Menstruation and follicle development continued for more than 2 years after the transplant. Conclusion(s) Heterotopic transplantation of ovarian tissue to the forearm is a simple and promising technique to restore ovarian function in women who become menopausal due to chemotherapy, surgery, or radiation.

Intratumoral Sickling in a Patient with Cervix Cancer and Sickle Trait: Effect on Blood Flow and Oxygenation

Background. Sickle trait affects approximately 8% of the black population in the United States and up to 40% of individuals in some parts of tropical Africa, but rarely causes clinically significant illness. This report provides the first conclusive evidence that erythrocytes in patients with sickle trait may sickle in the microvasculature of solid tumors, leading to impaired perfusion and hypoxia.Case. A black woman who was sickle trait positive presented with stage IIIB squamous cell carcinoma of the cervix. A biopsy showed extensive intravascular sickling of erythrocytes. An aspirate of blood obtained directly from the tumor also showed numerous sickled cells. A peripheral blood smear was normal. Direct measurement of oxygen tension using the Eppendorf electrode revealed the tumor to be markedly hypoxic, with 93% of a total of 142 individual oxygen reading <5 mm Hg.Conclusions. Erythrocytes in patients with sickle trait may sickle in the microvasculature of solid tumors and contribute to reduced blood flow and the development of hypoxia. Hypoxia is a strong independent prognostic factor in patients with cervix cancer, and further study is needed to evaluate the impact of intratumoral sickling on long-term outcome.

The effects of p53 status and human papillomavirus infection on the clinical outcome of patients with stage IIIB cervical carcinoma treated with radiation therapy alone.

It has been suggested that the p53 tumor suppressor gene regulates the radiosensitivity in human malignancies after irradiation; however, in cervical carcinoma, the role of the p53 gene is still unclear because of inactivation of functional p53 by infection with human papillomavirus (HPV). The objective of this study was to clarify the effects of p53 status and HPV infection on the clinical outcome of patients with cervical carcinoma after undergoing radiation therapy. Fifty-two patients with International Federation of Gynecology and Obstetrics Stage IIIB squamous cell carcinoma of the cervix who received radiation therapy alone were reviewed. The combination of external beam irradiation therapy and three sessions of intracavity brachytherapy irradiation was performed for all patients. Genomic DNA extracted from paraffin embedded tissues was examined for HPV types 16, 18 and 33 by the polymerase chain reaction (PCR) method and for p53 status by PCR-single-strand conformation polymorphism (PCR-SSCP) technique. The effects of HPV infection, p53 status, and other parameters on clinical outcome were investigated by univariate analysis. HPV-DNA was detected in 40 patients (76.9%), and 14 patients (26.9%) had mutations of the p53 gene in the study. There was a significant correlation between the existence of HPV and p53 status (P < 0.001). Mutations of the p53 gene were detected in 6 of 12 patients (50%) who had local recurrent tumors, whereas p53 were wild type in 32 of 40 patients (80%) who achieved local control. The p53 mutation had a significant correlations with local tumor recurrence. Furthermore, p53 status caused statistical significant differences in the curves of the recurrence free survival rate and local control rate as determined by the log rank test (P = 0.02 and P = 0.03, respectively). Conversely, no obvious correlation with any clinical outcome for patients with cervical carcinoma was found concerning HPV infection. It is possible that the p53 gene may be used as a predictive factor in radiation therapy for patients with Stage IIIB squamous cell carcinoma of the cervix.

Mutational analysis of nm23-H1 gene in human lung cancer by polymerase chain reaction-single strand conformation polymorphism

To investigate the mutation of nm23 gene and its correlation with development , progression and metastasis of human lung cancer. Polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP) was employed for mutational analysis of the five exons of nm23-H1 gene in 45 surgically resected lung cancer and 7 normal pulmonary tissues. In the examined DNA samples of pulmonary tissues , no homozygous loss of allele of nm23-H1 gene was observed. SSCP analysis revealed altered mobility of single stranded DNA of nm23-H1 exon 1 in one case of stage IIIB squamous cell pulmonary carcinoma with mediastinal lymphnode metastasis and malignant pleural effusion. The frequency of nm23-H1 gene mutation in its coding region is rare in lung cancer. Mutation of nm23-H1 gene might play a role in the progression and metastasis of lung cancer.

Detection of apoptosis and expression of apoptosis-associated proteins as early predictors of prognosis after irradiation therapy in stage IIIb uterine cervical cancer.

We investigated the proportion of apoptotic cells and the expression of apoptosis‐associated proteins after the delivery of the first week of irradiation for stage IIIb uterine cervical cancer. Thirty patients with stage IIIb squamous cell carcinoma of the uterine cervix who received only irradiation therapy were registered in this study. Specimens were obtained before irradiation therapy and at the end of the first week of irradiation. The apoptotic index (AI) of each tissue specimen was calculated by counting the apoptotic cells and expressed as a percentage. Immunohistochemical evaluation for apoptosis‐related proteins, p53, Bcl‐2, Bax, caspase‐1 and caspase‐3 was also performed. The AI was 0.8±0.9% (mean±SD) before irradiation and 1.7±1.3% at the end of the first week of irradiation. We observed that the patients who survived more than 5 years had AI levels of 2.1±1.3% at the end of their first week of therapy. This rate was significantly higher than the rate of 1.1±0.8% (P=0.02) of the patients who died within 5 years. When the cut‐off value of the AI was set at 1.7%, the sensitivity, specificity, positive predictive value, and negative predictive value for the prediction of patients' prognosis after irradiation therapy were 73.4%, 72.4%, 82.4%, and 61.5%, respectively. In 17 of the AI‐positive cases, expressions of Bax (P=0.006), caspase‐1 (P=0.045), and caspase‐3 (P=0.013) at the end of the first week were significantly higher than before irradiation. The proportion of apoptotic cells and the expression of apoptosis‐associated proteins, Bax, caspase‐1, and caspase‐3, at the end of the first week of irradiation could be useful predictors of the prognosis in stage IIIb squamous cell carcinoma of the uterine cervix treated by irradiation therapy.

Mature results of a pilot study of pelvic radiotherapy with concurrent continuous infusion intra-arterial 5-FU for stage IIIB-IVA squamous cell carcinoma of the cervix

Purpose: To evaluate the long-term results of continuous infusion intra-arterial 5-fluorouracil (CI IA 5-FU) given with concurrent pelvic radiotherapy (RT) for FIGO stage IIIB–IVA carcinoma of the cervix. Methods and Materials: Between 1965 and 1974, 27 patients with extensive FIGO Stage IIIB (22 patients) or Stage IVA (5 patients) squamous cell carcinoma of the cervix were treated with CI IA 5-FU and RT. Twenty-one patients (78%) had bilateral pelvic wall involvement, 25 (93%) had massive tumors (≥8 cm in diameter), 7 (27%) had involvement of the lower one-third of the vagina, and 15 (56%) presented with hydronephrosis. All patients underwent routine clinical staging, transperitoneal para-aortic lymph node dissection, and bilateral hypogastric artery catheter placement. 5-FU was continuously infused at a dose rate of 10 mg/kg/day on Days 1–15 of RT. The median dose of 5-FU was 376 mg/m 2/day (range 270–692). All patients received concurrent pelvic RT to a median dose of 50 Gy at 2.0 Gy per fraction. Only 4 patients received intracavitary RT. The median follow-up of surviving patients was 190 months. Results: The overall 5-year survival rate was 37%. For the 22 patients with FIGO Stage IIIB disease, the 5-year survival rate was 41%. The survival rate for 18 patients treated with only external beam radiation and chemotherapy for Stage IIIB disease was 33%. Four of 10 patients treated with only 50 Gy of external beam radiation and CI IA 5-FU were long-term survivors. Acute complications, including hematologic toxicity and skin reactions, were severe, with 1 death from neutropenic sepsis. Severe late complications were only observed in patients treated with ≥ 60 Gy of external beam radiation. Conclusions: While this series is small, the fact that 4 patients with massive Stage IIIB tumors survived after a total radiation dose of only 50 Gy suggests that RT with CI IA 5-FU deserves further study. Modifications in dose, technique, and route of administration should reduce toxicity, and the addition of intracavitary RT should improve the local effectiveness of combined treatment.

Irradiation with or without misonidazole for patients with stages IIIb and IVa carcinoma of the cervix: final results of RTOG 80-05

Purpose: The purpose of this study was to evaluate tumor response, progression-free survival, local tumor control, patterns of relapse, and toxicity in patients with Stages IIIb and IVa squamous cell carcinoma of the uterine cervix treated with irradiation or irradiation and misonidazole. This is a report of the final results of the study.Methods: This study was a prospective randomized Phase III trial performed by the Radiation Therapy Oncology Group (RTOG). Between August 1980 and November 1984, 120 patients with Stages IIIb and IVa squamous cell carcinoma of the cervix were randomized to receive either standard irradiation or standard irradiation and misonidazole. Irradiation consisted of 46 Gy to the pelvis plus a 10 Gy parametrial boost followed by intracavitary brachytherapy or external irradiation boost to the primary tumor. Misonidazole was administered at 400 mg/m2 daily, 2–4 h before irradiation. Patients in the 2 treatment groups were evenly distributed by stage, Karnofsky Performance Status, and positive para-aortic lymph nodes.Results: Sixty-one patients were treated with irradiation alone, and 59 patients received irradiation and misonidazole. Complete response in the pelvis occurred in 44 (75%) of those treated with irradiation and in 38 (64%) of those treated with irradiation and misonidazole. The progression-free survivals were 22% at 5 years for the control group, and 29% at 5 years for the misonidazole group. At the time of last follow-up, 18 patients in the control arm were free of disease, and in the experimental arm, 19 were free of disease. The patterns of failure for those treated with irradiation alone were local-only in 9 patients, distant-only in 8 patients, and local and distant in 11 patients. The patterns of failure for those receiving irradiation and misonidazole were local-only in 3 patients, distant-only in 8 patients, and local and distant in 8 patients. The maximum toxicity experienced per patient was grade 3 in 18%, grade 4 in 8%, and no grade 5 toxicity for those treated with irradiation alone compared to 8%, 2%, and 2%, respectively, for the experimental arm.Conclusion: There were no statistically significant differences in pelvic response, disease-free survivals, patterns of failure, or toxicity for the irradiation alone group or for the irradiation and misonidazole group as administered in this study for patients with Stages IIIb and IVa squamous cell carcinoma of the uterine cervix.

FIGO IIIB squamous cell carcinoma of the cervix: an analysis of prognostic factors emphasizing the balance between external beam and intracavitary radiation therapy

Purpose: To define patient, tumor, and treatment factors that influence the outcome of patients with FIGO Stage IIIB squamous cell carcinoma of the intact uterine cervix.Methods and Materials: The records of 1,096 patients treated with radiation therapy between 1960 and 1993 for FIGO Stage IIIB squamous cell carcinoma of the intact uterine cervix were reviewed retrospectively. Of these, 983 (90%) were treated with curative intent and 113 were treated only to achieve palliation of symptoms. Of 907 patients who completed the intended curative treatment, 641 (71%) were treated with a combination of external beam irradiation (EBRT) and intracavitary irradiation (ICRT) and 266 (29%) were treated with EBRT only. The median duration of treatment for these 907 patients was 51 days. Between 1966 and 1980, only 52% of patients who completed treatment with curative intent received ICRT, compared with 92% of patients treated during 1981–1993, an increase that reflects an evolution in the philosophy of treatment for advanced tumors. In general, the intensity of ICRT correlated inversely with the dose of EBRT to the central pelvis. Median follow-up of surviving patients was 134 months.Results: For 983 patients treated with initial curative intent, disease-specific survival (DSS) was significantly worse for those who were < 40 years old, had experienced more than a 10% weight loss, or had a hemoglobin level < 10 g/dl before or during radiation therapy. Tumor factors that correlated with a relatively poor DSS were bilateral pelvic wall involvement, clinical tumor diameter ≥ 8 cm, hydronephrosis, lower vaginal involvement, and evidence of lymph node metastases on lymphangiogram (p < 0.01 in all cases). For the 907 patients who completed treatment with curative intent, 641 who had ICRT had a DSS of 45% at 5 years, compared with 24% for those treated with EBRT alone (p < 0.0001). Those who received > 52 Gy of EBRT to the central pelvis had DSS rates of 27–34%, compared with 53% for patients treated with lower doses of EBRT to the central pelvis and more intensive ICRT (p < 0.0001). At 5 years, the actuarial risk of major complications was also greater for patients treated with > 52 Gy of EBRT to the central pelvis (57–68%), compared with those who had 48–52 Gy (28%) and those who had ≤ 47 Gy of EBRT to the central pelvis (15%) (p < 0.0001). Outcome was also compared for four time periods during which different treatment policies were in place for patients with Stage IIIB disease. The highest DSS (51%) and lowest actuarial complication rate (17%) were achieved during the most recent period (1981–1993) when modest doses of EBRT were combined with relatively intensive ICRT (p < 0.01 for both comparisons).Conclusion: Aggressive use of ICRT, carefully balanced with pelvic EBRT, is necessary to achieve the best ratio between tumor control and complications for patients with FIGO Stage IIIB carcinoma of the cervix. In our experience, the highest DSS rates and the lowest complication rates were achieved with a combination of 40–45 Gy of EBRT combined with ICRT.

Extended Field Radiation and Cisplatin for Stage IIB and IIIB Cervical Carcinoma

Objective.The aim of this study was to investigate local regional control, survival, and morbidity in patients with FIGO IIB and IIIB squamous cell carcinoma of the cervix treated with primary extended field (prophylactic paraaoratic radiation) radiation and weekly cisplatin.Methods.Sixty-seven patients (44 IIB and 23 IIIB) with carcinoma of the cervix received cisplatin at 1 mg/kg (up to 60 mg) weekly and extended field radiation therapy including the paraaortic nodes and brachytherapy.Results.After the scheduled therapy 94.1% of the patients were complete responders. Seventy-five percent are alive without evidence of disease with a mean follow-up of 47.5 months.Conclusion.This study confirms the ability to give concomitant weekly cisplatin and prophylactic paraaortic radiation with minimal morbidity. The encouraging Kaplan–Meier survival of 75% and only eight pelvic failures warrants further investigation.

The outcome of radiation therapy in elderly patients with advanced cervical cancer

Objective: To clarify whether radiation therapy is a suitable treatment for elderly patients with advanced squamous cell carcinoma of the uterine cervix. Method: We investigated the outcome of 102 patients with stage IIIb squamous cell carcinoma of the uterine cervix, who underwent radiation therapy alone, by using a multiple regression analysis. Results: All factors investigated were not significant prognostic variables in this study. Five-year survival rates between the two groups, which we have divided for every 5 years of age, showed no differences. Conclusion: Age was not a dependent prognostic factor in the patients with stage IIIb squamous cell carcinoma of the uterine cervix, if the subject underwent complete treatment. This study suggests that radiation therapy is still considered as a reasonable treatment for elderly patients with cervical cancer.

Prognostic Significance of Immunohistochemically Detected p53 Protein Expression in Stage IIIB Squamous Cell Carcinoma of the Uterine Cervix Treated with Radiation Therapy Alone

Immunohistochemical studies were performed to investigate the prognostic significance of p53 protein expression in 46 patients with stage IIIB squamous cell carcinoma of the uterine cervix who were treated with radiation therapy alone. Tumor cells showed p53 protein expression in 29 of 46 patients. The 5-year overall actuarial and cause-specific survival rates for the patients with p53-positive tumor were 52.9 and 70.4%, respectively. The corresponding rates for the patients with p53-negative tumor were 58.2 and 69.0%, respectively. There was no significant difference of local control rates and of distant metastases rates between the two groups. In conclusion, no relationship was observed between radiation treatment outcome and the immunohistochemically detected p53 protein expression in the patients with stage IIIB squamous cell carcinoma of the uterine cervix.

The role of radiation therapy for stage IIIB non-small cell lung cancer: Impact of clinical nodal stage on survival

From 1976 through 1989, 46 patients with stage IIIB non-small cell lung cancer (NSCLC) without malignant effusion were treated with definitive radiation therapy (RT) at Gunma University Hospital. All patients were treated with 10 MV x-rays using antero posterior parallel opposed fields. The total dose ranged from 60 Gy to 70 Gy (mean dose; 66 Gy) with once daily standard fractionation. The actuarial two and five-year survival rates of the entire group were 22% and 10% respectively with a median survival time (MST) of 10 months. The survival of 18 patients with stage NO-2 disease was significantly better than the 28 patients with stage N3 disease (MST 21 versus 9 months;P<0.05). There were no significant differences in survival based on age and sex. However, there was a borderline difference in survival rates between patients with a performance status of 0–1 and those with a status of 2–3 (P=0.06). Three patients with squamous cell carcinoma were alive after 5 years and were without disease progression. No patients with non-squamous cell carcinoma were free of disease after 5 years. These results provide support for the use of definitive RT to manage those patients with limited stage IIIB squamous cell carcinoma not extending to N3 stage.

117 Figo stage IIIB squamous cell carcinoma of the uterine cervix: Natural history, treatment results, and prognostic factors

117 Figo stage IIIB squamous cell carcinoma of the uterine cervix: Natural history, treatment results, and prognostic factors

Squamous Cell Carcinoma of the Cervix Implanting in the Episiotomy Site

The implantation of cervical cancer in an episiotomy scar is very rare. We present such a case in a patient with stage IIIB squamous cell carcinoma of the cervix. The tumor implantation responded only partially to chemotherapy and radiotherapy. Review of the literature revealed six cases of cervical cancer implanting in the episiotomy site. All followed a normal vaginal delivery. Early initial stage, small-size implantation lesion, and early surgical intervention seemed to be good prognostic factors.

Silicone Stents in the Management of Inoperable Tracheobronchial Stenoses: Indications and Limitations

Various stent models have been developed for the treatment of inoperable stenoses of the central airways caused by external compression. Increasing use is made of the silicone stents designed by Dumon. We tested their technical feasibility, tolerance, and long-term efficacy in relieving respiratory symptoms in patients referred for endoscopic palliation of malignant disease. All procedures were performed under general anesthesia with the use of the rigid bronchoscope. We inserted 38 stents in 31 patients (median age, 67 years; 25 men and 6 women) whose airways showed residual obstruction of > 50 percent of the lumen after laser resection of endobronchial tumor and/or mechanical dilatation of extrinsic compressions. Stent placement and removal--where necessary--were easy in all patients, but five stents inserted in three patients with short (< or = 2.5 cm) and conical stenoses migrated, necessitating emergency removal. In 27 of the remaining 28 patients, stent tolerance was excellent; 1 proximal tracheal stent (< 1 cm below the vocal cords) had to be removed because of otalgia and dysphagia. One lethal hemoptysis occurred within hours after a repeated laser therapy and removal of an indwelling stent. No other serious complications occurred. Immediate and lasting relief of dyspnea and improvement in performance status (Karnofsky scale, activity index) was achieved in 90 percent (28/31) of patients (p < 0.01). The influence of adjuvant radiotherapy on local tumor recurrence and survival was analyzed in a subgroup of ten patients with stage IIIB squamous cell carcinoma with comparable performance status. Five did not undergo adjuvant radiotherapy (group A) and five did (group B). In group A, four of five stents were occluded by tumor recurrence above or below the stent after a median follow-up of 2 months; in group B, zero of five were occluded (p < 0.05) after 4 months. Median survival was 4 months in group A and 6 months in group B; the difference did not reach significance. The silicone stents designed by Dumon are easily inserted and removed; they are also well tolerated and very efficacious in relieving respiratory symptoms caused by extrinsic airway compression. Short and conical stenoses present limitations for their use due to increased risk of migration. Combined treatment with laser resection, stent insertion, and subsequent radiotherapy is necessary to prevent local tumor recurrence and may improve survival.

Lymphangiography as a staging tool for cervix cancer: Limited value after hip arthroplasty

Lymphangiography (LAG) is often used in the work-up of cervical carcinoma. A patient with a history of bilateral hip arthroplasty, who presented with Stage IIIB squamous cell carcinoma of the cervix, was sent for lymphangiography. The LAG was deemed suboptimal, most likely because of altered lymphatic drainage engendered by the previous orthopaedic procedures. As the American population ages and hip arthroplasty becomes more common, the value of LAG in such patients will need to be reconsidered.

Rapidly progressive squamous cell carcinoma of the cervix coexisting with human immunodeficiency virus infection: Clinical opinion

The acquired immune deficiency syndrome (AIDS) has been characterized by aggressive malignancies and infections with unusual presentations. There is a well-documented association between cervical dysplasia and the development of cervical carcinoma, and more recent evidence of an association between cervical dysplasia and HIV infection. The course of coexistent HIV infection and cervical cancer has not been well described. We report a patient with HIV infection and a stage IIIB squamous cell carcinoma of the cervix who, despite adequate treatment, had rapid disease progression as well as metastasis to an unusual iliopsoas muscle site in association with an abscess. As HIV becomes more prevalent in the female population, an increased frequency of rapidly progressive cervical carcinoma may be forthcoming. Improved life expectancy of HIV-infected patients due to modern medication is anticipated, causing a cervical neoplasm to have a more prominent effect on prognosis. Close surveillance with frequent Pap smears and colposcopies as well as aggressive management of cervical dysplasia and carcinoma in HIV-infected patients is suggested as is thorough patient counseling.

Tumor and treatment factors improving outcome in stage III-B cervix cancer

This report reviews 271 patients with Stage III-B squamous cell cancer of the uterine cervix from three national surveys conducted by the Patterns of Care Study. A progressive increase in local control and survival is seen among the three surveys which parallels a progressive increase in paracentral (point A) dose and use of intracavitary treatment. Multivariate analysis reveals extent of pelvic disease (unilateral sidewall vs. bilateral sidewall vs. lower 1 3 vagina) and use of intracavitary treatment to be the only significant tumor and treatment factors associated with local control and survival. With aggressive radiotherapy, local control rates exceeding 65% and survival of 50% at 4 years can be anticipated at the expense of a small increase in complications.