Positive Washings Research Articles

Patterns of Early Infectious Complications in Adult Unrelated Cord Blood Transplantation (UCBT). A Single Center Experience.

The major cause of non-relapse transplant related mortality (TRM) in UCBT continues to be infectious, with blood stream infections (BSI) constituting the majority of these events. However, CMV antigenemia and BK virus associated late onset hemorrhagic cystitis (LOHC) are increasingly important causes of morbidity and mortality. We review our single institution experience. We identified 13 patients with hematological malignancies in our database that had undergone UCBT in the period June 2002 - January 2005 and analyzed these data to document the incidence and patterns of infectious complications. The median age was 48 (range 19–62) years. All patients received infectious prophylaxis with Ciprofloxacin, Acyclovir, Voriconazole, Bactrim/nebulized Pentamidine. Eleven patients underwent conditioning with standardized Thiotepa/Busulfan/Cytoxan and GVHD prophylaxis with Tacrolimus/Mycphenalate Mofetil/ATG and the remaining 2 patients received TBI based conditioning. The median total nucleated cell (TNC) was 1.70E+07 and the median CD34 (+) cell count was 8.0E+04. The HLA matches were 4/6 in 9, 5/6 in 3 and 6/6 in 1 patient. All patients engrafted with a median time to neutrophil engraftment (TNE) of 25 (range 16–34) days. Twelve of thirteen patients achieved full donor chimerism at day 30 and 10 of 12 patients with full chimerism at day 100. Five patients developed grade II-IV acute GVHD requiring additional steroid therapy and 1 patient died of steroid refractory GVHD at day 50. Four patients had positive blood cultures at transplant. All patients developed documented bacterial infections: Gram positive in 12 (92%) (VRE in 23%, Steotrophomonas maltophilia in 31%); Gram negative in 8 (61%) (E. cloacae in 15%, Acinobacter spp. in 2 cases). Ten patients were CMV seropositive and 9 of these developed antigenemia requiring Gancyclovir/Foscarnet therapy. Nine patients had documented BK viruria with consequent late onset hemorrhagic cystitis (LOHC) and 5 patients developed BK viremia. There was 1 case of fungal BSI, while 8 patients had documented fungal tongue cultures. Four patients had positive bronchial washings (3 bacterial, 1 C. glabrata). Twelve (92%) patients were alive at day 100. Of note 62% of BSI and all cases of LOHC and CMV antigenemia developed after neutrophil engraftment. In our series of patients, viral infections (CMV, BK virus) were the most significant causes of morbidity. The high rate of BSI, especially after myeloid recovery, argues for a major influence of impaired immune recovery.

Laparoscopic surgery does not increase the positive peritoneal cytology among women with endometrial carcinoma

Objective. The purpose of our study was to find if uterine manipulation at the time of laparoscopic hysterectomy among women with endometrial carcinoma increases the incidence of malignant cells in the peritoneal washings. Material and methods. We conducted a prospective study including women with clinical stage I endometrioid endometrial carcinoma undergoing laparoscopic surgery between 07/01/2000 and 07/01/2004. Surgery on all patients was conducted by the same surgeon using the same technique and instruments. Two sets of peritoneal washings were obtained, one before and one after the insertion of the Pelosi uterine manipulator. The two sets of washings were blindly reviewed by the same cytopathologist for the presence of malignant cells. Correlation was made between the two sets of washings. Results. Forty-two consecutive women (age 46–90, median: 58) were enrolled in the study. The procedure was converted to laparotomy in 3 (7.6%) patients after obtaining the two sets of washings. The preoperative tumor grades were: G1: 22 (52.4%), G2: 12 (28.6%), and G3: 8 (19.0). The incidence of positive peritoneal washings was 14.3%. All patients underwent laparoscopically assisted vaginal hysterectomy with bilateral salpingo-oophorectomy, 30 patients had bilateral pelvic lymphadenectomy, and 5 patients had bilateral pelvic and para-aortic lymphadenectomy. There was perfect agreement between the two sets of washings in all patients (100%, P < .001). No patients had positive washings after the insertion of the uterine manipulator if the washings were negative before the insertion. The surgical stages were: IA: 14 (33.3%), IB: 12 (28.6%), IC: 7 (16.7%), IIA: 1 (2.4%), IIB: 1 (2.4%), IIIA: 4 (9.5%), IIIB: 1 (2.4%), IIIC: 1 (2.4%), and IV: 1 (2.4%). Twenty-nine patients received no postoperative treatment, 2 received chemotherapy, 3 received Megace, and 9 received radiation therapy. Patients were followed-up for 7–56 months (median: 28). Two patients had tumor recurrence, and one patient died secondary to her disease. Two other patients died secondary to other causes. Conclusions. We conclude that uterine manipulation at the time of laparoscopic hysterectomy does not increase the incidence of positive peritoneal cytology among women with endometrial carcinoma.

Discordance Between Serum Level and Tissue Immunohistochemical Staining of CA125 in Endometrioid Adenocarcinoma of the Uterine Corpus

This study was designed to correlate tissue expression of CA125 with the corresponding serum value in endometrial cancer. The records of 52 endometrioid adenocarcinomas diagnosed were reviewed. Serum CA125 levels were examined before definitive surgery, and 20 U/ml was used as the cutoff value. Immunohistochemical staining for CA125 was assessed according to the ImmunoReactive Score. Statistical analyzes were performed to identify independent factor for high serum CA125 levels, including CA125 staining and the conventional pathologic features. Elevated serum CA125 levels were found in 15 of 52 patients (29%) (range, 0.1-172.1; mean 22.6 U/ml). The frequency of positive CA125 tissue staining (35/52, 67%) tended to be higher than that of elevated serum levels (p = 0.046). Fifteen patients with elevated serum CA125 levels statistically differed from the remaining 37 patients with normal serum CA125 level with respect to International Federation of Gynecology and Obstetrics (FIGO) stage (p = 0.027) and lymph node metastasis (p = 0.024), and tended to have positive washing cytology (p = 0.052). In multivariate analysis, elevated serum CA125 significantly correlated only with FIGO stage III, but not with tumor size or CA125 tissue staining. Intrauterine tumor may not be the main source of serum CA125 in endometrial cancer, and elevated serum level is closely related to the presence of disseminated cancer cells in the peritoneal cavity.

Clinical features and prognosis of double primary carcinoma of uterine corpus and the ovary

To investigate the clinical features, treatment and prognosis of patients with double primary carcinoma of uterine corpus and ovary. The clinical features, operation findings, treatment and prognosis of 36 patients with double primary carcinoma of uterine corpus diagnosed and treated in the last 20 years, 25 with typical endometrial adenocarcinoma and endometrioid carcinoma of the ovary (group A) 11 with non-endometrioid carcinoma in uterine corpus and/or ovary (group B) were respectively analyzed. There was no significant difference in survival rate between the group A and group B. The 1, 3, and 5-year survival rates of these 36 patients were 89%, 83%, and 75% respectively, all equal to those of the patients with stage I ovarian cancer. The pelvic and abdominal involvement, histologic grade, positive abdominal washing and myometrial invasion were proven to be statistically significant indicators of the poor prognosis (all P < 0.05). Radiotherapy seemed to be useful for improving the survival. The prognosis of double primary carcinoma of uterine corpus and ovary is rather good. It is necessary to distinguish double primary carcinoma of uterine corpus and ovary from stage II ovarian cancer and stage III endometrial carcinoma.

Upstaging based solely on positive peritoneal washing does not affect outcome in endometrial cancer

Surgical staging of endometrial carcinoma includes the collection of peritoneal washings in the abdomen and pelvis. A positive finding upstages patients to International Federation of Gynecology and Obstetrics stage IIIA. However, the prognostic significance of such an upstaging, and thus the justification for the routine performance of this procedure, is unclear. This 5-year retrospective study was conducted to determine the frequency and prognostic significance of upstaging of endometrial carcinoma based solely on positive washings. The cohort for the study was collected by review of pathology reports of all washings that were performed prior to hysterectomies for suspected endometrial carcinomas over a 5-year period (01/1995–12/1999). Cases with positive cytology were selected if there was no grossly apparent intraperitoneal disease, no histologic evidence of extra-uterine tumor and the cases would otherwise have been considered stage I or II (case group). An age-matched control group was selected of stage I and II patients with the same histologic subtypes and negative washings (n=19). Of 220 endometrial carcinomas, peritoneal washing cytology was abnormal in 19 (8.6%) and was solely responsible for upstaging only 10 patients (4.5% of all cases, eight—endometrioid, one–serous, one–mixed; nine stage IA or IB and one stage IIB). Adjuvant therapy was administered in 90% of the case group and 74% of the control group. After a median follow-up of 51 months (case group) and 63 months (control group), we found only a single patient with progression of disease (recurrence, metastases or death) in the control group. It is concluded that abnormal cytology without other evidence of extrauterine disease leads to upstaging of a minority of endometrial carcinoma patients (4.5%), but does not appear to affect their overall outcome. Although this is a small single site study, it raises questions about the value of this procedure in patients with endometrial cancer.

Does fluid hysteroscopy increase the stage or worsen the prognosis in patients with endometrial cancer?: A randomized controlled trial

Objective: To determine whether fluid hysteroscopic directed biopsies, in patients with endometrial cancer upstages the tumor and worsens the prognosis. Study design: Between January 1996 and September 2001, a total of 62 consecutive patients with endometrial cancer, treated at our institution, were randomized 3:2 to have or not to have a fluid hysteroscopic biopsy just prior to surgery. A total of 38 patients underwent a hysteroscopy after the induction of anesthesia. All patients had pelvic washings performed, followed by a hysterectomy, bilateral salpingooforectomy and pelvic +/− para-aortic lymph node dissections. Only stages I and II endometrioid type tumors or stage IIIa, secondary to positive pelvic washings, were included in the study. Eight patients in the hysteroscopy group and four patients in the control group were excluded for various reasons. Patients received post-operative radiation therapy depending on the surgical–pathological risk factors. The median follow up was 34 months. Fisher’s Exact Test was performed to compare differences between the hysteroscopic ( n=30) and the control ( n=20) groups. Results: We found three patients (10%) with positive washings in the hysteroscopic group compared to one (5%) among the controls ( P=0.64), with a statistical power of <20%. If the differences would persist, we would need 588 patients in each arm to obtain a power of 80%, and reach definitive conclusions. The Odds Ratio (OR) of performing a hysteroscopy and upstaging the tumor in this study was: 2.1 95% CI (0.20–21.09). Prognostic variables were compared between both groups and no differences were observed. All patients but one (dead due to intercurrent disease), were alive and with no evidence of disease at the completion of the study. Conclusions: Fluid hysteroscopy and directed biopsies may have a small risk of upstaging early endometrial cancers, but does not seem to influence prognosis.

Does diagnostic hysteroscopy in patients with stage I endometrial carcinoma cause positive peritoneal washings?

Objectives. Previous studies have shown that positive peritoneal washings may adversely affect cancer survival rates and that hysteroscopy is associated with a higher risk of positive washings in patients with endometrial carcinoma. Our aim was to assess if diagnostic hysteroscopy increases the risk of positive peritoneal washings in patients with endometrial cancer and affects the prognosis after surgery. Study design. Retrospective cohort study. The medical records of 50 consecutive patients with endometrial carcinoma, diagnosed with hysteroscopy and tissue sampling and treated by abdominal hysterectomy with bilateral salpingo-oophorectomy and peritoneal washings were reviewed. Results. Of the 43 patients with endometrial carcinoma FIGO stage I, none had positive peritoneal washings (95%CI: 0–8.2%). The mean interval between hysteroscopy and surgery was 33.5 days. The 5-year disease-specific survival rate was 91.8%, the 5-year recurrence-free survival rate was 85.4%. Conclusion. Diagnostic hysteroscopy had no adverse effect on the incidence of positive peritoneal washings or on prognosis in stage I endometrial cancer patients.

Malignant mixed müllerian tumors of the uterus: Analysis of patterns of failure, prognostic factors, and treatment outcome

PurposeTo determine the survival outcomes, prognostic factors, and patterns of failure in patients with malignant mixed Müllerian tumor (MMMT) of the uterus. Methods and materialsBetween 1954 and 1998, 300 patients with clinical Stage I–III MMMT of the uterus were treated with curative intent at The University of Texas M. D. Anderson Cancer Center. Their hospital records were reviewed to obtain patient and tumor characteristics; details of surgery, radiotherapy (RT), and chemotherapy; and long-term outcome. Surviving patients were followed for a median of 109 months (range 15–138). Survival rates were calculated using the Kaplan-Meier method, with differences assessed by log–rank tests. ResultsOf the 300 patients, 113 (38%) were treated with surgery alone, 160 (53%) with surgery plus adjuvant EBRT or ICRT, and 27 (9%) with RT alone. Forty-eight patients received adjuvant chemotherapy. At 5 years, the overall rates of survival and cause-specific survival were 31% and 33%, respectively. Women who were postmenopausal or had a history of prior pelvic RT, pain at presentation, clinical Stage II-III disease, uterine enlargement (≥12 weeks), or an abnormal Papanicolaou smear finding had a significantly poorer prognosis than the other patients in the series. Of the 273 patients who underwent surgery, those who had positive abdominal washings, uterine length >10 cm, or extrauterine spread of disease to the cervix, adnexa, or peritoneum had a significantly worse prognosis than the other patients. Factors found on multivariate analysis to have an independent adverse influence on cause-specific survival included postmenopausal status (p = 0.0007, relative risk [RR] 3.3), uterine length >10 cm (p = 0.0001, RR 2.2), cervical involvement (p = 0.002, RR 1.8), and peritoneal involvement (p = 0.0001, RR 4.3). At 5 years, the rates of pelvic and distant disease recurrence for the entire group of 300 patients were 38% and 57%, respectively. The most common site of distant recurrence was the peritoneal cavity. Patients treated with pelvic RT had a lower rate of pelvic recurrence than patients treated with surgery alone (28% vs. 48%, p = 0.0002), but the overall survival rates (36% vs. 27%, p = 0.10) and distant metastasis rates (57% vs. 54%, p = 0.96) were not significantly different. However, patients treated with pelvic RT had a longer mean time to any distant relapse (17.3 vs. 7.0 months, p = 0.001) than patients treated with surgery alone. The use of adjuvant chemotherapy did not correlate with the survival rate or rate of distant metastasis. ConclusionAdjuvant pelvic RT decreased the risk of pelvic recurrence and may delay the appearance of distant metastases after hysterectomy for MMMT. However, the survival rates remain poor because of a high rate of distant recurrence. As more effective systemic chemotherapy is developed to control microscopic distant disease, the role of RT in controlling locoregional disease in the pelvis and abdomen may become more important. Future research should consider programs that integrate surgery, RT, and chemotherapy to maximize the probability of cure.

Infecciones respiratorias por metapneumovirus en lactantes hospitalizados

AntecedentesEl metapneumovirus humano es un virus de reciente descripción al que se atribuyen infecciones respiratorias que afectan fundamentalmente a la población infantil.ObjetivosConocer la incidencia de infecciones por metapneumovirus en lactantes hospitalizados, así como sus características clínicas y la posible presencia de coinfecciones con otros agentes virales.Pacientes y métodosEstudio prospectivo realizado de septiembre a junio de 2003 en todos los niños menores de 2 años ingresados en la Unidad de Lactantes del Hospital Severo Ochoa de Leganés (Madrid), por infección respiratoria. La detección de agentes virales se realizó mediante recogida de aspirado nasofaríngeo y realización de inmunofluorescencia directa y/o reacción en cadena de la polimerasa-transcripción inversa (RT-PCR). Descripción de las características clínicas y epidemiológicas de los procesos respiratorios de los pacientes con detección positiva para metapneumovirus humano.ResultadosIngresaron 200 lactantes con patología respiratoria durante el período mencionado, de los cuales en 18 se detectó infección por metapneumovirus humano (9% de los pacientes). El metapneumovirus humano supuso un 13,8% de los aislamientos virales positivos. El 100 % de estos niños ingresaron en marzo-abril. La edad media fue de 6,7 ± 6,1 meses. El 38,8 % desarrolló una bronquiolitis y en el 55,5 % se objetivó un episodio recurrente de sibilancias. El 55,5 % de los niños precisó oxigenoterapia durante el ingreso. Se encontraron coinfecciones con otros agentes virales en el 33,3 % de estos pacientes.ConclusionesEl metapneumovirus humano es un agente viral muy frecuente en los lactantes afectados de enfermedad respiratoria, causando fundamentalmente bronquiolitis y episodios recurrentes de sibilancias. Es más frecuente en primavera y tiene una alta tendencia a la coinfección con otros virus.

Significance of comprehensive surgical staging in noninvasive papillary serous carcinoma of the endometrium

Objective To evaluate the biological behavior of noninvasive papillary serous carcinoma of the endometrium. Methods From 1990 to 2001, all women with noninvasive uterine papillary serous carcinoma (UPSC) at three Southern California hospitals were identified from tumor registry databases. Data for analysis were collected from hospital charts, office records, and tumor registry files. Results Of the 100 patients diagnosed with UPSC, 16 had noninvasive lesions. Twelve underwent a comprehensive surgical staging procedure with omental resection. Six of these 12 women were found to have disease beyond the uterine corpus, including 4 with adnexal involvement, 3 with omental disease, 2 with cervical extension, 1 with pelvic lymph node involvement, and 3 with positive washings. Three women were found to have positive cytology and metastases in more than one location. Of the 12 patients, 1 of the 6 with stage IA disease had distant recurrence and 4 of the 6 with stage II–IV disease recurred. Of the remaining 4 patients who underwent a staging procedure without pathologic omental assessment, 1 was found to have cervical extension. In these 4 women, 1 with stage IA disease recurred. Conclusion The typical patterns of spread and prognostic factors for endometrioid carcinoma of the uterus do not apply to UPSC. In our series, omental assessment was necessary to detect the 25% of patients with stage IVB disease due to omental involvement. Thus, women with noninvasive UPSC should undergo a comprehensive staging procedure including omental sampling to determine the extent of disease.

Value of Urethral Wash Cytology in the Retained Male Urethra After Radical Cystoprostatectomy

We determined the outcome in patients who underwent urethrectomy after cystectomy followed by routine urethral wash cytology versus those not followed by urethral wash cytology who presented with bleeding or urethral discharge. We retrospectively evaluated the outcome in post-cystectomy urethrectomy cases at our institution from 1994 to 2000. A total of 24 patients with a median age of 70.5 years underwent urethrectomy after cystectomy, including 17 due to asymptomatic, positive urethral wash cytology (group 1) and 7 who were not followed by urethral wash and presented with bleeding/urethral discharge (group 2). Median time from cystectomy to urethrectomy was 11.4 months (range 6.7 to 67.1). Median followup after cystectomy and urethrectomy was 37 and 27.7 months, respectively. Urethrectomy pathological evaluation showed pTis disease in cases 12 (50%), pT0 in 9 (37.5%) and pT1 in 3 (12.5%). Cystectomy pathology was organ confined (pT0, pTis and pT1-pT2b disease) in 12 cases (50%), nonorgan confined (pT3a-pT4) in 6 (25%) and pT any N1 in 5 (21%). Cystectomy pathology was unknown in 1 case. At the most recent followup there was no evidence of disease in 14 patients (58%), 5 (21%) were alive with disease, 3 (12.5%) were dead of disease, 1 (4%) was dead of other causes and disease status was unknown in 1 (4%). There was no statistical difference in survival in groups 1 and 2 when controlling for original bladder tumor stage. Cox regression analysis revealed that cystectomy pathology was the only statistically significant parameter of disease-free survival (p = 0.011), while urethrectomy pathology and followup method (urethral washing versus no washing) were not significant. There were no perioperative or postoperative complications and no patients died. There was no significant survival difference in patients followed and not followed with urethral washing. Longer followup and increased patient numbers are needed to determine the significance of these findings.

Transitional cell carcinoma of the renal pelvis the diagnostic role of pelvic washings.

One hundred renal pelvic washings were reviewed blindly for 12 cytologic features. Of 52 washings with tissue confirmation, the cytologic diagnosis suggestive of or positive for transitional cell carcinoma (TCC) was made in 36 cases; 11 were negative, and 5 were unsatisfactory. Of 36 positive washings, histology confirmed the TCC diagnosis in 35 but revealed only reactive changes in 1. Of 11 negative washings, 9 were histologically negative for TCC, and 2 were positive for high-grade TCC. Among 48 washings without tissue confirmation, 33 were negative for TCC or showed reactive changes, 12 were negative for high-grade dysplasia or malignancy, but low-grade TCC could not be ruled out, 1 was suggestive of malignancy, and 2 were unsatisfactory. Clinical follow-up revealed no TCC. Predictive cytologic features of high-grade TCC were high nuclear/cytoplasmic ratio, isolated cells, anisonucleosis, nuclear hyperchromasia, and coarse chromatin; for low-grade they were presence of more than 5 papillary groups, cellular overlapping, anisonucleosis, and hyperchromasia. The sensitivity and specificity for the cytologic diagnosis were 89% and 97% for high-grade TCC and 100% and 78% for low-grade TCC, respectively. Renal pelvic washings can be used to accurately diagnose TCC of the renal pelvis. The positive predictive value for high-grade TCC is 93%, but for low-grade tumors it is 43%.

Early stage uterine papillary serous carcinoma of the endometrium

BACKGROUND Uterine papillary serous carcinoma (UPSC) is an aggressive subtype of endometrial cancer, behaving like ovarian epithelial cancers and having a predilection for transperitoneal relapse. Within this subtype of uterine cancers, predictors of outcome and the role of adjuvant therapies have not been firmly established, to the authors' knowledge.. METHODS Between 1985–1995, 78 patients who had International Federation of Gynecology and Obstetrics (FIGO) Stage I, II, or IIIa UPSC (based on positive washings only) were seen at the British Columbia Cancer Agency. During this time, the authors had a policy of offering adjuvant pelvic, paraaortic and whole-abdominal radiotherapy (WART) to these patients. Fifty-eight patients received adjuvant WART, and 20 received lesser or no adjuvant therapy. The authors undertook a retrospective analysis of pathology with quantification of the percentage of papillary serous component (% PSC) and p53 expression. Pathology was retrieved and reviewed on 62 patients; p53 staining was performed on blocks from the hysterectomy specimen in 46 cases. Pathologic parameters, stage, and adjuvant therapy were correlated with clinical outcome in a multivariate analysis. RESULTS Median follow-up was 52 months (3–139 mos) and the 5-year disease-specific survival rate was 66.2%. The 58 patients who received adjuvant WART had a significantly better 5-year disease-specific survival than those 20 patients who did not, 74.9% versus 41.3% (P = 0.04). Multivariate analysis showed that % PSC and p53 were not significant predictors of outcome for early stage UPSC. Of the factors examined, only FIGO stage and WART significantly predicted improved outcome (P = 0.02 and 0.04, respectively). CONCLUSIONS The current study demonstrated a significant difference in the outcomes of patients who had FIGO Stage I compared with Stage II UPSC. In the current series of patients, the authors were not able to predict outcome based on % PSC or p53 expression. The current study results with WART were promising, and WART merits further study. Cancer 2001;91:752–7. © 2001 American Cancer Society.

Peritoneal cytology: impact on disease-free survival in clinical stage I endometrioid adenocarcinoma of the uterus

The prognostic significance of positive peritoneal cytology in endometrial carcinoma has led to the incorporation of peritoneal cytology into the current FIGO staging system. While cytology was shown to be prognostically relevant in patients with stage II and III disease, conflicting data exists about its significance in patients who would have been stage I but were classified as stage III solely and exclusively on the basis of positive peritoneal cytology (clinical stage I). Analysis was based on the data of 369 consecutive patients with clinical stage I endometrioid adenocarcinoma of the endometrium. Standard treatment consisted of an abdominal total hysterectomy, bilateral salpingo-oophorectomy with or without pelvic lymph node dissection. Peritoneal cytology was obtained at laparotomy by peritoneal washing of the pouch of Douglas and was considered positive if malignant cells could be detected regardless of the number of malignant cells present. Disease-free survival (DFS) was considered the primary statistical endpoint. In 13/369 (3.5%) patients, positive peritoneal cytology was found. The median follow-up was 29 months and 15 recurrences occurred. Peritoneal cytology was independent of the depth of myometrial invasion and the grade of tumour differentiation. Patients with negative washings had a DFS of 96% at 36 months compared with 67% for patients with positive washings (log-rank P<0.001). The presence of positive peritoneal cytology in patients with clinically stage I endometrioid adenocarcinoma of the endometrium is considered an adverse prognostic factor.

Early stage uterine papillary serous carcinoma of the endometrium

Uterine papillary serous carcinoma (UPSC) is an aggressive subtype of endometrial cancer, behaving like ovarian epithelial cancers and having a predilection for transperitoneal relapse. Within this subtype of uterine cancers, predictors of outcome and the role of adjuvant therapies have not been firmly established, to the authors' knowledge. Between 1985-1995, 78 patients who had International Federation of Gynecology and Obstetrics (FIGO) Stage I, II, or IIIa UPSC (based on positive washings only) were seen at the British Columbia Cancer Agency. During this time, the authors had a policy of offering adjuvant pelvic, paraaortic and whole-abdominal radiotherapy (WART) to these patients. Fifty-eight patients received adjuvant WART, and 20 received lesser or no adjuvant therapy. The authors undertook a retrospective analysis of pathology with quantification of the percentage of papillary serous component (% PSC) and p53 expression. Pathology was retrieved and reviewed on 62 patients; p53 staining was performed on blocks from the hysterectomy specimen in 46 cases. Pathologic parameters, stage, and adjuvant therapy were correlated with clinical outcome in a multivariate analysis. Median follow-up was 52 months (3-139 mos) and the 5-year disease-specific survival rate was 66.2%. The 58 patients who received adjuvant WART had a significantly better 5-year disease-specific survival than those 20 patients who did not, 74.9% versus 41.3% (P = 0.04). Multivariate analysis showed that % PSC and p53 were not significant predictors of outcome for early stage UPSC. Of the factors examined, only FIGO stage and WART significantly predicted improved outcome (P = 0.02 and 0.04, respectively). The current study demonstrated a significant difference in the outcomes of patients who had FIGO Stage I compared with Stage II UPSC. In the current series of patients, the authors were not able to predict outcome based on % PSC or p53 expression. The current study results with WART were promising, and WART merits further study.

Diagnostic role of fibreoptic bronchoscopy in pulmonary tuberculosis

Fibreoptic bronchoscopy with bronchial aspiration* washings and biopsy was performed in 104 patients suspected clinically and radio logically of having pulmonary tuberculosis diagnostic yield in 9230% (96/104) cases. Diagnostic yield for tuberculosis was in 69.22% (72/104)cases, it includes positive aspiration and washings smear in 38.46%(40/l04) patients,positive mycobacteriai culture alone in 26.92% (28/104) casesandpositive biopsy in 3*84% (4/ 104) patients, Non-tuberculous conditions like pneumonia and bronchogenic carcinoma were diagnosed in 19.23% (20/104) cases and 3.84% (4/104) cases respectively. These results suggest that in areas with high prevalence of tuberculosis, bronchoscopy should be performed for early diagnosis and initiation of therapy in sputum smear-negative cases of pulmonary tuberculosis.

HINGE FLOW IN A BILEAFLET MECHANICAL HEART VALVE (MHV)

The significance of flow structure within the hinge socket of (BMHV) has been reported in recent years. Adverse flow structures, e.g. stagnation, may lead to thromboses in those regions. Computational fluid dynamics (CFD) play a substantial role in exploring the microscopic hinge-flow. CFD investigation of the positive washing flows in the region of a protruded-design hinge is presented. The flow field is modeled as a quarter of the valve channel with one immersed hinge by applying the two symmetry planes of the BMHV. Unstructured grids are generated in the entire flow field with finer cells near the hinge region, including the micro clearance between the leaflet and hinge. The rounded edges of the hinge and leaflet are taken into account on the flow structures for the first time. The valve leaflets fully opens to 87°. A simplified sinusoidal velocity is initially applied at the inlet to mimic the time dependent flow through the valve. The CFD simulation of the pulsatile flow ran on SGI workstation (CRAY Origin 2000) using Fluent 5.05 codes. The CFD results show that complex 3D vortices are formed downstream of the hinges during the acceleration phase, however a partial washing flow is noted to develop near the end of the deceleration phase. This partial washing flow scours the hinge regions and hence avoids stagnation in the hinge regions.

Performance of virus isolation and Directigen Flu A to detect influenza A virus in experimental human infection.

Few data exist to assess the sensitivity of different specimen types for viral detection during the course of influenza virus infection. This study assessed the relationships between quantitative influenza A virus replication and antigen detectability by the enzyme immunosorbent assay (EIA) Directigen Flu A in different type of samples during experimental human infection. Fourteen volunteers were inoculated with influenza A virus A/Texas/36/91 (H1N1). Four specimens types were collected in sequence for quantitative isolation in cell culture and antigen testing from days 1 to 8 after inoculation. Seventy-one (63%) of nasopharyngeal wash specimens were culture positive, compared to 51 (46%) of throat gargles, 51 (46%) of nasal swabs, and 27 (24%) of throat swabs. All subjects shed virus in their nasopharyngeal wash at least one day and 86% of subjects had a positive nasopharyngeal wash culture on day 2 after inoculation. The mean viral titers were highest on day 2 post inoculation for all specimen types and averaged 3.6 log10 TCID50/ml for nasal washes, 1.2 log10 TCID50/ml for throat gargles, 1.8 log10 TCID50/ml for the nasopharyngeal swabs, and 0.6 log10 TCID50/ml for the throat swabs. Mean viral titers in the nasal washes were significantly different (P<0.05) compared to other specimen types. The peak of sensitivity of EIA (compared to culture) was the second day after inoculation. Nasopharyngeal and throat swab results were combined for this analysis and considered positive by culture if positive in either or both samples. Thus, on day 2 the number of EIA positive samples relative to the number culture positive was 9/12 (75%) for nasopharyngeal wash specimens, 2/9 (22%) for throat gargles, and 7/11 (64%) for the combined throat and nasal swabs specimens. Nasopharyngeal washes are the most sensitive sample type detecting influenza A virus in adults. For rapid diagnosis the Directigen Flu A is an alternative with a sensitivity compared to culture ranging between 64 and 78% if performed on nasopharyngeal specimens on day two or three after experimental infection in adults. However, if performed on other specimens or later in the course of infection the sensitivity is lower.

Peritoneal Cytology in Uterine Papillary Serous Carcinoma

To highlight the significance of positive peritoneal cytology in uterine papillary serous carcinoma (UPSC). Seventeen consecutive UPSC cases with peritoneal cytology from 1993 to 1997 were reviewed and compared with the original cytologic diagnosis and extent of tumor involvement in tissues. Of the 17 post-menopausal women with UPSC, 11 had early-stage tumors (clinical stage I and II); three cases (27%) with positive peritoneal cytology were upgraded from at least International Federation of Gynecologists and Obstetricians stage IA to IIIA. No change in surgical stage was noted in four of six (67%) advanced cases with positive peritoneal cytology. The review diagnoses of peritoneal cytology did not differ from the original diagnoses. The features of UPSC in peritoneal cytology are those of a high grade malignancy and may be shared by tumors with similar histology from other sites. The malignant features are readily identified, but the site of origin may not be completely ensured. Positive peritoneal cytology upgrades the surgical stage of early-stage UPSC cases and helps with prognostication and treatment. One case with positive washings but without residual tumor probably represented early spread and/or multicentric origin of the tumor.

THE VALUE OF UPPER TRACT CYTOLOGY AFTER TRANSURETHRAL RESECTION OF BLADDER TUMOR IN PATIENTS WITH BLADDER TRANSITIONAL CELL CANCER

Patients with transitional cell carcinoma of the bladder are at risk for concurrent or subsequent cancer of the upper tract. Traditionally disease is monitored by radiography (excretory or retrograde urography). Some elect to sample the upper tract by obtaining urine for cytology. Are the results meaningful when performed in a patient with bladder cancer? We evaluated 27 consecutive patients with transitional cell cancer of the bladder (grade 1 to 3, Ta to T2) with bladder wash for cytology and cystoscopy as well as resection of visible tumor. A 5F ureteral catheter was positioned at each ureteral orifice, flushed with saline and passed into each renal pelvis. Urine was collected for cytology. Of 19 patients (68%) with high grade (grade 3) bladder cancer 13 had a positive bladder wash, including 6 (32%) with tumor cells detected in the urine from the upper tract. Of 8 patients (38%) with low grade (grade 1 to 2) transitional cell cancer 3 had a positive bladder wash and 2 (25%) had a positive upper tract cytology. All patients had a normal upper tract by excretory or retrograde urography. Ureteroscopy was not performed. Given the normal appearance of the upper urinary tract, it is highly unlikely that most, if any, of these patients with bladder cancer have tumor in the upper tract despite tumor cells in urine obtained by retrograde catheterization. Thus, upper tract sampling by a retrograde technique lacks specificity for localizing transitional cell cancer to the upper tract when performed in a patient with bladder cancer.