Sexuality and cancer: conversation comfort zone

Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital (MGH), founded The Kenneth B. Schwartz Center at MGH. The Schwartz Center is a nonprofit organization dedicated to supporting and advancing compassionate health care delivery, which provides hope to the patient, support to caregivers, and encourages the healing process. The center sponsors the Schwartz Center Rounds, a monthly multidisciplinary forum where caregivers reflect on important psychosocial issues faced by patients, their families, and their caregivers, and gain insight and support from fellow staff members. Psychosocial issues profoundly affect patients with cancer. Of the many complexities that make up the psychosocial dynamic, perhaps the medical profession is most uncomfortable with sexuality. Many elements of sexual behavior remain high-profile taboos. A number of diseases and treatments significantly affect sexual function. Male and female sexuality were discussed in two separate rounds with an emphasis on how to begin a dialogue about sexuality without jeopardizing other aspects of the relationship with patients. Three cases were presented. A patient with prostate cancer considering treatment options for early-stage disease and two patients with gynecologic malignancies; one with a colostomy following cytoreductive surgery for ovarian cancer and the other with a failed vaginal reconstruction for recurrent squamous cell carcinoma of the vagina. Staff discussed the wide diversity of response to sexual dysfunction and the difficulties that patients face. A sensitive and informed approach to discussing sexuality can provide effective support. The elements of successful dialogue are presented in the PLISSIT model.     

Value of Posttransplant Antibody Tests in the Evaluation of Patients with Renal Graft Dysfunction

Posttransplant HLA antibodies correlate with C4d positive rejection and decreased graft survival. However, the diagnostic value of various antibody tests in the management of patients presenting with graft dysfunction is uncertain. Whether all or some patients should be tested, how often, what antibodies to test for and how to interpret results in presensitized or transfused patients, are issues still unresolved. We tested for HLA and non-HLA antibodies by flow cytometry assays in 103 consecutive patients with graft dysfunction. The results show that: (1) C4d positive rejection was diagnosed in 75% of patients who developed posttransplant HLA antibodies, but only in 2% in antibody negative patients. (2) The correlation existed for donor specific IgG antibodies but not for IgM or nondonor specific IgG antibodies. (3) Weak antibody reactivity required confirmation by alternative testing as there were false positive results. (4) Posttransplant transfusions did not induce de novo HLA antibodies. (5) Negative antibody results were unlikely to turn positive after several months of follow-up. (6) Antibodies to the angiotensin II type 1 receptor, HLA-DP and MICA did not correlate with C4d+ rejection. We conclude that testing for posttransplant HLA antibodies is critical in narrowing the diagnostic alternatives in patients with graft dysfunction.     

Relationship between 18F-FDG uptake and breast density in women with normal breast tissue.

Breast density affects the mammographic detectability of breast cancer. The study aimed to evaluate the impact of breast density on the (18)F-FDG uptake of normal breast tissue. METHODS: The study population consisted of 45 women (median age, 54 y; age range, 42-77 y). All underwent whole-body (18)F-FDG PET for various indications other than breast cancer, and all underwent mammography within a mean of 6.6 +/- 4.9 mo of PET. On the basis of mammographic findings, breasts were categorized as extremely dense, heterogeneously dense, primarily fatty, or entirely fatty. Regions of interest were drawn on every PET image in which breast tissue was visualized. Average and peak standardized uptake values (SUVs) were calculated for the left and right breasts. RESULTS: Mammography showed that 20 of the 45 women had heterogeneously dense breasts, 1 had extremely dense breasts, 20 had primarily fatty breasts, and 4 had entirely fatty breasts. In dense breasts, the average SUV was 0.39 +/- 0.05 (right breast) and 0.36 +/- 0.07 (left breast) and the peak SUV was 0.93 +/- 0.16 and 0.89 +/- 0.18, respectively. The average and peak SUVs were significantly lower for primarily fatty breasts than for dense breasts (P < 0.01). Peak and average SUVs of entirely fatty breasts also differed significantly from peak and average SUVs of dense and primarily fatty breasts (P < 0.01). The impact of hormonal status on SUV was significant but less than the impact of breast density. No significant relationship between average SUV or peak SUV and age or serum glucose level was observed. CONCLUSION: Breast density and hormonal status affect the uptake of (18)F-FDG. Dense breasts exhibit, on average, significantly higher (18)F-FDG uptake than do nondense breasts. However, the highest peak SUV observed in dense breasts was 1.39, which is well below the SUV of 2.5 commonly used as a cutoff between benign and malignant tissue. Therefore, breast density is unlikely to affect the ability of (18)F-FDG PET to discriminate between benign and malignant breast lesions.     

A Phase I study of continuous infusion doxorubicin and paclitaxel chemotherapy with granulocyte colony-stimulating factor for relapsed epithelial ovarian cancer.

A Phase I study of paclitaxel and doxorubicin administered as concurrent 96-h continuous i.v. infusion was performed to determine the maximum tolerated dose (MTD), principal toxicities, and pharmacokinetics of this combination in women with relapsed epithelial ovarian cancer. The paclitaxel dose was fixed at 100 mg/m2 (25 mg/m2/day for 4 days). The dose of doxorubicin was escalated from 30 mg/m2 (7.5 mg/m2/day for 4 days) in increments of 10 mg/m2 until dose-limiting toxicity was observed. All patients received granulocyte colony-stimulating factor 5 microg/kg/day prophylactically. Apparent steady-state plasma levels of both drugs were determined in the final cohort of patients treated at the MTD. A total of 17 patients received 52 cycles of therapy. The median age was 58 years, and all patients had previously received one to five different regimens (median, 2) of chemotherapy, including both platinum and paclitaxel. The treatment was tolerated well, with grade 1-2 nausea being the most frequent side effect (73% of cycles). Anemia, neutropenia, thrombocytopenia, and mucositis became dose limiting at the fourth dose level, defining the MTD of doxorubicin in this regimen as 50 mg/m2. There were four partial responses and one complete response in 15 evaluable patients. Apparent steady-state plasma concentrations (mean +/- SD) of paclitaxel and doxorubicin in the three patients treated at the MTD were 33.9 +/- 12.5 nM and 15.7 +/- 1.3 nM, respectively. Paclitaxel and doxorubicin by continuous infusion is a well-tolerated and active chemotherapy regimen for recurrent ovarian cancer.     

An unusual case of heminasal aplasia: proboscis lateralis or cystic teratoma?

Unilateral aplasia of the nose is a rare congenital malformation. It is often associated with other malformations of the facial region, including abnormalities of the eye and lacrimal system, proboscis lateralis, and facial bone malformations. The authors present a case of heminasal aplasia in a 4-year-old boy who underwent surgery immediately after birth because of right-sided proboscis lateralis. A huge hemispheric tumefaction was occupying a large part of the right orbit, medial canthus, and frontonasal region of the face, causing lateroinferior protrusion of the eyeball. The right half of the external nose was aplastic. The patient was operated on by an external approach. The pathohistological findings from the top of tumefaction revealed cystic teratoma. The possible backgrounds for the onset of the tumefaction are discussed in two main directions: the cystic form of the regrowth of the remnants of inadequately excised proboscis lateralis and cystic teratoma of the ethmoidal sinus.     

Fertility-Sparing Options for Early Cervical Cancer: Optimism for Oncologic and Obstetric Outcomes

Purpose of Review

It is well established that in carefully selected patients with early cervical cancer, fertility-sparing procedures are equally safe in terms of recurrence and mortality to the standard treatment with radical hysterectomy. This review highlights the evolution in fertility-sparing management options, with long-term evidence on oncologic and obstetrical outcomes presented.

Recent Findings

The long-term safety of radical vaginal and abdominal trachelectomy is well established. Recently published series also suggest that when patient selection is limited to tumors <2 cm, the oncologic safety for laparoscopic or robotic radical trachelectomy is comparable to the vaginal procedure. Though limited by small numbers and shorter follow-up, favorable outcomes have also been demonstrated for women undergoing conization with tumors <2 cm and neoadjuvant chemotherapy followed by surgical resection for tumors 2–4 cm. Approximately 30 % of women will experience infertility following fertility-sparing treatment, and half of these women can successfully achieve pregnancy with reproductive assistance. Pregnancy can be complicated by premature rupture of membranes, second trimester loss, or preterm delivery. However, most women who achieve pregnancy will reach the third trimester.

Summary

Fertility preservation options are available for women with early stage cervical cancer who wish to preserve their fertility. Radical trachelectomy has equal oncologic safety to radical hysterectomy in selected patients and can be performed by a variety of routes with minimally invasive options providing the best surgical and obstetrical outcomes. Conization has the potential to improve reproductive outcomes even more. For women with tumors 2–4 cm, neoadjuvant chemotherapy is a promising treatment strategy under active investigation.

     

Successful pregnancies in dialysis patients including those suffering from cystinosis and familial Mediterranean fever

For women on maintenance dialysis, pregnancy is still uncommon. The outcome of such pregnancies has improved in recent case series. Here, we report in detail the treatment of five successful pregnancies in dialysis patients from our centre. The present case series also includes the first successful pregnancy of a dialysis patient with underlying familial Mediterranean fever, and of a dialysis patient with cystinosis. We treated all patients with an intensified hemodiafiltration protocol, increased erythropoietin dosages, a generous application of water-soluble vitamins and trace elements in addition to a multidisciplinary clinical management approach with a very low threshold for hospital admission. Specifically, we report treatment of arterial hypertension with respect to changes in dry weight and pharmacological therapy. Mean gestational age at delivery was 32.8+/-3.3 weeks and mean birth weight was 1,765+/-554 g. All mothers and newborns were discharged healthy and in good condition. These modified management guidelines have led to a favourable outcome in all our patients including two patients with familial Mediterranean fever and with cystinosis, and may help to guide therapy in other pregnant dialysis patients.