Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
After total thyroidectomy it is presumed that the uptake visualised in the thyroid bed is due to generic 250 mg mysoline overnight delivery treatment naive residual thyroid tissue buy mysoline on line symptoms zoloft overdose. In the midline order generic mysoline pills medicine xyzal, the uptake is due to residual pyramidal lobe and/or thyroid cells in the distal thyroglossal duct and that immediately above the upper poles is due to residual tissue of the extension of the upper pole. As long as there is no pathological evidence of extracapsular or extra-thyroidal extension of the thyroid cancer seen on histology, these areas of radioiodine uptake can be presumed to be normal tissue. However, if there is evidence of extracapsular or extra-thyroidal extension and there is uptake in that portion of the thyroid bed, then it can be presumed that this could have residual thyroid cancer and should be treated for the same. The presence of residual thyroid cancer is more obvious when there is an incomplete surgery for removal of the primary cancer in biopsy proven inoperable cancers and in recurrent invasive cancer in thyroid bed. Ablation of residual normal thyroid the ablation of residual normal thyroid tissue although a widely practiced procedure remains controversial [11. It is because no randomized control trial is yet published in this field and there are many difficulties to realize this goal also in near future [11. The 131 131 proponents for the use of I have shown evidence to suggest that I destroys residual tissue and microscopic thyroid cancer which is difficult to detect clinically. Secondly, its use greatly simplifies the follow-up evaluation for secondaries especially using serum thyroglobulin as a tumour marker. In the presence of large remnant thyroid tissue, secondaries may remain undetected for long periods of time. Papillary carcinoma of the thyroid tends to be bilateral, microscopically multicentric, metastasises to regional lymph nodes and has a higher incidence of persistent or recurrent disease. Both papillary and follicular cancers have a tendency to be invasive and locally infiltrate and this leads to a high probability for recurrence. This feature of invasiveness is often missed on histology if not looked for carefully. In a retrospective analysis of 1599 patients with differentiated thyroid 131 cancer, it was observed that I therapy was the single most important prognostic indicator by 131 Cox proportional hazards regression model for prolonging disease free survival [11. The incidence of 131 recurrence was reduced by 50% in the low risk given I for ablation of residual tissue. Even the incidence of pulmonary metastases was reduced by more than 50% when subtotal 131 thyroidectomy was supplemented by I treatment. Another large study of 1578 patients 111 131 reported from 13 Canadian hospitals where I or external irradiation was employed for ablation of residual thyroid tissue, local disease in those with residual microscopic papillary cancer was controlled in 82-90% of patients as compared to 26% of those on T4 suppression 131 alone [11. Similarly survival at 20 years was 90% in patients treated with I or external irradiation while it was 40% when only surgery was performed. Strong support for use of 131 extensive initial surgery and post-operative I in papillary carcinoma with a tumour size more than 1 cm, showed a decreased risk of recurrence and death. Radioiodine ablation prolongs life expectancy of patients who were apparently disease free after surgical treatment for thyroid cancer [11. It was estimated that even the modest increase in the life expectancy shown was comparable to the absolute gain obtained by accepted medical interventions like screening mammography and lowering cholesterol levels in the blood. Nevertheless, there are reservations expressed by some physicians who have shown no benefit arising from treatment 131 with I of low risk group patients [11. Tumour recurrence, especially papillary cancer recurrence in regional lymph nodes is not associated with a fatal outcome. However, one should take local recurrence as a warning for adverse outcome which may precede or accompany distant metastases. A report in an International symposium in which 160 surgeons, endocrinologists, pathologists and nuclear medicine physicians participated, suggested a total thyroidectomy with post-operative thyroid remnant ablation, for most differentiated thyroid cancer regardless of patients age. Hemithyroidectomy was recommended for papillary cancer confined to one lobe or with ipsilateral nodes and follicular cancer confined to one lobe with minimal tumour capsular invasion. In another study of internationally recognized experts, total thyroidectomy was advised by 60% for papillary and 74% for follicular. Radioiodine for thyroid remnant ablation was recommended by 81% of respondents for papillary carcinoma and by 97% for follicular cancer [11. In a recent meta-analysis of published literature on remnant ablation, Sawka, et al. Methods of ablation of residual/remnant thyroid tissue the ablation of residual thyroid tissue can be achieved in three ways viz. The proponents of high dose ablation 131 suggest that higher doses may actually be considered as a I adjuvant radiotherapy for occult 131 metastases not detected on diagnostic I imaging studies [11. It was also suggested that, with low dose therapy where ablation rate is not as high, multiple small doses require multiple periods of hypothyroidism which is an inefficient, costly 112 approach that requires significant time investment on the patients part. In fact, evidence suggests that sublethal radiation doses to the thyroid cells may decrease the biological half life of subsequent radioiodine doses, thereby decreasing the effectiveness of therapy. The doses of radioiodine needed for ablation of normal thyroid tissue with high radioiodine uptakes are generally higher and these are more difficult to ablate. A common variation is to adjust the amount of radioiodine based on the location of the cancer; 3. An overall analysis of Radiation Medicine Centre experience in treating 579 residual thyroid tissue (Table 11. The proponents of initial high dose I ablation argue that low doses are less effective for ablation of the micrometastases that are not visualized in post-therapy whole body scan, which at later date may result in higher local as well as distal recurrence rate. Calculated dose ablation the third approach is that of ablation based on radiation dose delivered rather than empirical administration of a fixed amount or varying amounts of radioiodine.
Radiological Diagnosis Radiography has limited diagnostic value in the diagnosis of gastric cancer discount mysoline 250 mg on-line symptoms upper respiratory infection. Although better studies (using state-of-the-art techniques performed by practiced technicians) suggest a high sensitivity of x-rays (80?95%) 250mg mysoline sale medications causing pancreatitis, there are limitations order 250 mg mysoline with mastercard medicine synonym. Upper gastrointestinal series may show thickened or enlarged gastric folds, filling defects that correspond to a mass or ulcer, or may demonstrate a failure of the stomach to distend normally to air and instilled barium (Figure 11). These contrast studies do not aid in accurate disease staging and do not allow differentiation of benign from malignant lesions. The ability to distinguish carcinoma from lymphoma is crucial to provide therapy in a timely fashion. Transabdominal ultrasonography may be useful in providing information about metastatic disease, particularly that which affects the liver. Endoscopic Diagnosis Endoscopy provides the most specific and sensitive means of diagnosis of gastric cancers. Gastrointestinal endoscopy allows the physician to visualize and biopsy the mucosa of the esophagus, stomach, duodenum, and most of the jejunum (Figure 13). During these procedures, the patient is situated in the left lateral position and may be administered a topical anesthetic to help prevent gagging. The endoscope (a thin, flexible, lighted tube) is passed through the mouth and pharynx and into the esophagus. It transmits an image of the esophagus, stomach, and duodenum to a monitor visible to the physician. Air may be introduced into the stomach through the scope to expand the folds of tissue and enhance examination (Figure 14). Endoscopy facilitates accurate visualization, histological confirmation and typing. Tumor staging, localization and extent of tumor, and associated local complications may also be established during the procedure (Figure 15). Biopsy leads to correct diagnosis in virtually 100% of cases when at least 7 specimens are obtained. The increasing use of endoscopy has resulted in detection of early gastric cancer, which is amenable to endoscopic therapy. Survival in patients with gastric cancer is largely dependent upon the tumor stage and histological type at the time of initial diagnosis. Correct staging is critical to determining appropriate treatment and course of action. Endoscopic ultrasound accurately delineates the depth of tumor invasion through the layers of the gastric wall and lymph node involvement. The tip of the echoendoscope is advanced into the stomach, air is aspirated, and water is injected. Endoscopy also plays a critical role in the diagnosis of patients with gastric lymphoma. It can provide a visual diagnosis in many patients and may also identify associated lesions (H. Gross endoscopic appearance has led to diagnosis in the majority of patients with high sensitivity. However, noninvasive studies and endoscopy may understage primary gastric lymphoma compared to surgery. Staging the most significant prognostic factor is depth of tumor invasion at the time of diagnosis. The five-year survival rate for patients without nodal involvement is about 40%, and is only 10% for those with metastatic disease. These figures are unchanged over the past several decades despite advances in medical and surgical therapy. Regional lymph nodes (N): Include the perigastric nodes along the lesser and greater curvatures, and the nodes along the left gastric, common hepatic, splenic, and celiac arteries. N0 = no regional lymph node metastasis N1 = metastasis to 1?6 regional lymph nodes N2 = metastasis in 7?15 regional lymph nodes N3 = metastasis in more than 15 regional lymph nodes Distant metastasis (M): M0 = no distant metastasis M1 = distant metastasis Worse prognoses are associated with tumors of the cardia, shorter duration of symptoms prior to diagnosis, tumor unresectability, and poorly differentiated histology. Studies are underway to correlate genetic abnormalities found in tumors to overall prognosis. One of the most important prognostic factors in gastric cancer is the depth of infiltration. Laparoscopic Staging Adenocarcinoma of the stomach may grow by direct extension into adjacent organs such as the colon, liver, pancreas and spleen. Distant metastases to the lung, as well as to the lymph nodes of the celiac axis, greater and lesser omentum, and retroperitoneal space, may occur. Laparoscopy has been demonstrated to be a sensitive method for establishing a definitive diagnosis of liver and other abdominal metastases in the presence of gastric adenocarcinoma. Abdominal lavage with cytologic examination increases the sensitivity of laparoscopy. Surgical resection entails the removal of the primary tumor and regional lymph nodes with resection margins free of tumor. Surgical Therapy the prognosis following surgical resection depends on the stage at presentation. Early tumors confined to the stomach lining have higher cure rates than cases in which disease has already spread to distant sites or regional lymph nodes. These improvements can be attributed mainly to an increase in early detection rates. The type of surgery performed depends on the extent and location of tumor; therefore, preoperative evaluation is critical.
A Enteroclysis showing a large mysoline 250 mg generic in treatment 1, nonobstructing purchase mysoline 250mg mastercard medications 3605, largely excavated mass order mysoline master card medications names and uses, displacing adjacent barium-filled loops of intestine. Springer,Berlin Hei appear as large cavity filled with barium and it may be delberg New York,pp 399?428 7. Miettinen M,Lasota (2001) Gastrointestinal stromal tumors difficult to identity the connection between the small definition, clinical, histological, immunohistochemical, and intestine and the cavity (Fig. It can accurately demonstrate (2003) Gastrointestinal stromal tumors: radiologic features the size,shape and extent of the lesion,and it can depict with pathologic correlation. Radiology 126: 379?385 associated with higher survival rates,despite metastases 17. Z0 Other lymphoid leukemia not having achieved remission achieved remission, failed remission C91. For these neoplasm related disease, there should be the B20 code followed by the specific malignancy code. Prior to 1950, it was the most common cause of cancer death in men, and the third leading cause of cancer death in women in the U. Mortality from gastric cancer in the United States has declined, perhaps due to dietary changes. This cancer is twice as common in men than women, twice as common in blacks than whites, and more common with advancing age. Gastric cancer is also seen in higher rates in Latin America, Northern Europe and the Far East. Fortunately, dedicated research into its pathogenesis and identification of new risk factors, treatment, and advanced endoscopic techniques have led to earlier detection of gastric cancer. Recognition that Helicobacter pylori infection causes most gastric ulcers has revolutionized the approach to gastric cancer today. The intestinal-type is the end-result of an inflammatory process that progresses from chronic gastritis to atrophic gastritis and finally to intestinal metaplasia and dysplasia. This type is more common among elderly men, unlike the diffuse type, which is more prevalent among women and in individuals under the age of 50. The diffuse-type, characterized by the development of linitis plastica, is associated with an unfavorable prognosis because the diagnosis is often delayed until the disease is quite advanced. Adenocarcinoma Adenocarcinomas arising from gastric epithelium are the most common malignancies of the stomach (90% of cases). Malignancies arising from connective tissue (sarcoma) and from lymphatics (lymphoma) are less common. Adenocarcinomas (Figures 2 and 3) are most often found in the gastric cardia (31%), followed by the antrum (26%), and body of the stomach (14%). A, Endoscopic image of an ulcerating adenocarcinoma; B, ulcerating adenocarcinoma. A type of adenocarcinoma that diffusely infiltrates the stomach wall, linitis plastica (Figure 4), accounts for the remaining 10%. Histologically, these malignancies may be divided into well-differentiated and poorly differentiated types, depending on the degree of gland formation and ability to secrete mucus. Most tumors are heterogeneous in histological appearance; therefore, classification is made by noting the predominant structures. Thus, well-differentiated tubular and poorly differentiated signet-ring cell carcinoma make up the majority of tumors. Early Gastric Cancer Early gastric cancers, where tumor cells are confined to the mucosa (the most superficial layer of the stomach), have been identified in Japan where there is active screening of patients at high-risk for gastric cancer. In these patients, early gastric cancer may appear as a subtle lesion, usually less than 2 cm in diameter. The identification of early gastric cancer is important because it is potentially amenable to endoscopic therapy and accompanied by an excellent prognosis (Figure 5). Hereditary (Familial) Gastric Cancer the term, familial gastric cancer, has been used to describe families in which several members under the age of 40 have had the diffuse type of gastric cancer. These lymphomas usually have a favorable clinical course, but may undergo high-grade transformation. Symptoms Most patients are asymptomatic in early stages of gastric cancer and have advanced disease by the time of presentation. In a review of over 18,000 patients, the most common presenting symptoms included weight loss and abdominal pain. Epigastric fullness, nausea, loss of appetite, dyspepsia, and mild gastric discomfort may also occur. Dysphagia may be a prominent symptom for patients with tumors in the cardia or gastroesophageal junction. In patients with pyloric tumors and tumors located in the antrum, vomiting and gastric outlet obstruction may occur. Unusual presentations may include acute appendicitis, musculoskeletal pain, and the sudden appearance of seborrheic keratosis and freckles, accompanied by pruritis and dermatomyositis. Abdominal pain occurs in most patients with gastric lymphoma; however, symptoms may vary from those suggesting peptic ulcer disease to advanced gastric cancer. Gastric lymphoma is more often found in younger females when compared to the incidence of gastric cancer. The size, shape, and position may vary with posture and with content because it is distensible and on a free mesentery. It can fill much of the upper abdomen when distended with food and may descend into the lower abdomen or pelvis upon standing. The duodenum extends from the pylorus to the ligament of Treitz in a sharp curve that almost completes a circle. It is so named because it is about equal in length to the breadth of 12 fingers, or about 25 cm. The stomach and duodenum are closely related in function and in pathogenesis and manifestation of disease.
Revised Optimal Radiotherapy Utilisation Tree for Rectal Cancer Page | 386 Table 1: Rectal Cancer mysoline 250mg for sale treatment pancreatitis. Hence the changes in proportions are due to quality mysoline 250mg medications prednisone the mistakes being picked up and not due to mysoline 250 mg with mastercard treatment quad strain any change in indications or epidemiological data. Optimal Utilisation Tree for Concurrent Chemo-Radiation Page | 392 Table 3: Rectal Cancer. Indications for concurrent chemoradiotherapy levels and sources of evidence Outcome Clinical scenario Level of References Proportion of all Rectal cancer no. Clinical Practice Guidelines for the prevention, early detection and management of colorectal cancer. Marked improvements in survival of patients with rectal cancer in the Netherlands following changes in therapy, 1989 2006. Estimation of an optimal radiotherapy utilization rate for gastrointestinal carcinoma: a review of the evidence. Anal sphincter conservation for patients with adenocarcinoma of the distal rectum: long-term results of radiation therapy oncology group protocol 89-02. Carcinoma of the rectum: 508 patients with failure analysis and implication for adjuvant therapy. The guidelines reviewed were those published from July 2003 (when the previous radiotherapy utilisation study was completed) to April 2012. One additional indication for radiotherapy has been added to the model of optimal utilisation based on updated guideline recommendations (1;2;6), i. There is controversy between guidelines regarding whether or not post-operative adjuvant radiotherapy with concurrent chemotherapy is recommended for resectable gastric cancer. The Japanese and European guidelines recommend chemotherapy but not chemo-radiotherapy in this situation (6;7). The Cancer Care Ontario guidelines recommend either postoperative chemo-radiotherapy or perioperative chemotherapy (3). A British surgical guideline states that adjuvant chemo-radiotherapy should be considered in patients at high risk of recurrence who have not received neoadjuvant therapy (4). In the absence of any current evidence that either treatment approach is superior, in this review we have assigned equal importance to both the treatment options. Changes to Epidemiological Data the epidemiological data in the stomach cancer radiotherapy utilisation tree have been reviewed to see if more recent data are available through extensive electronic searches using the key words stomach cancer, radiotherapy, palliative radiotherapy, epidemiology stomach cancer, incidence, stomach cancer stage, resection rates, bleeding, metastases, brain metastases, bone metastases, skeletal metastases in various combinations. This has been applied particularly to the early branches in the tree for which national or state level data on cancer incidence rates and stages are available. Any changes to the hierarchical quality of the epidemiological data have been noted (Table 2). This rate is much lower than the incidence in East Asian countries such as China and Japan where gastric cancer is a leading cause of cancer deaths (13). In the original 2003 optimal utilisation model for gastric cancer, the proportion of gastric cancer patients presenting with metastatic disease varied from 17-29%; sensitivity analysis was conducted due to the above variation in epidemiological data between published sources (15;16). A population-based study of gastric cancer in the Netherlands between 1990 and 2007 reported that 48. This showed that out of 13,929 patients with gastric adenocarcinoma with adequate information available, 5588 patients (40. In the original 2003 model of optimal radiotherapy utilisation for gastric cancer, the proportion of patients with stage T1N0M0 who developed distant relapse following surgery could not be identified since there was no published data. There are recent published reports on the outcomes of laparoscopic gastrectomy for early gastric cancer. Incidence of metastases to bone or brain in metastatic gastric cancer As noted in the original study, since metastases to bone or brain are rare, it is difficult to identify data for these branches in the utilisation tree. A comparison of two chemotherapy regimens in the treatment of metastatic gastric cancer reported that in their series of 70 patients with metastatic gastric cancer, 2 patients had bone metastases and no patients had brain metastases (21). This data has been used in the utilisation tree since no other data could be identified. Incidence of symptomatic primary requiring palliative radiotherapy An extensive review of the literature revealed several recent retrospective case series on the palliative treatment of advanced gastric cancer with radiotherapy (22-25). All of the published papers described the patients in their case series and details of radiotherapy treatment given but none mentioned the incidence of patients receiving palliative radiotherapy as a proportion of all gastric cancer or as a proportion of all patients with metastatic disease. Extensive searches were conducted to determine the incidence of symptoms such as bleeding and obstruction in advanced gastric cancer, but no data were identified for these parameters either. The site of radiotherapy treatment is not known, but since metastases to brain and bone are rare in gastric cancer, it has been assumed that most of these patients would have received palliative radiotherapy for their primary cancer. We acknowledge that using actual utilisation data in the model is a limitation; however the actual utilisation data has been used in the revised model of optimal utilisation only because no other data could be identified. Page | 400 Estimation of the Optimal Radiotherapy Utilisation Rate Based on the best available evidence and the most recent epidemiological data, radiotherapy is recommended in 27% of all gastric cancer patients in Australia (Table 1 and Figure 1) in the revised optimal radiotherapy utilisation model. Since this utilisation rate is based on a controversial indication for radiotherapy, sensitivity analysis has been conducted (see below). The previous optimal radiotherapy rate for gastric cancer derived in 2003 was 68% (varying in sensitivity analysis between 58 and 68% due to variation in epidemiological data on stage proportions). Concurrent Chemoradiotherapy in Gastric Cancer the indications for radiotherapy for gastric cancer were reviewed to identify indications where radiotherapy is recommended in conjunction with concurrent chemotherapy as the first treatment. In the model of optimal utilisation for concurrent chemoradiotherapy, 20% of all gastric cancer patients should receive concurrent radiotherapy with chemotherapy (Figure 2 and Table 3). Since this utilisation rate is based on a controversial indication for concurrent chemo-radiotherapy, sensitivity analysis has been conducted (see below). In the sensitivity analysis, the optimal radiotherapy utilisation rate varied from 7. Revised Optimal Radiotherapy Utilisation Tree for Gastric Cancer Page | 402 Table 1: Gastric Cancer.
Buy generic mysoline 250 mg. ECG basics 10/10 - The QT Interval.
Exposure categories were examined in tertiles generic mysoline 250 mg with visa treatment croup, on the basis of the distribution of hexachlorobenzene concentrations in the controls mysoline 250mg free shipping medicine wheel, and associated odds ratios for breast cancer were calculated by unconditional logistic regression purchase 250mg mysoline medications via peg tube. With the lower exposure category as reference, the odds ratios for breast cancer in the middle and upper exposure categories, adjusted for age, reproductive factors and other potential confounders, were 0. In order to determine any modifying effect of lactation, women were also stratified by history of breastfeeding, excluding 48 nulliparous women. Within the subgroup of 191 women who had ever breastfed, the middle and upper exposure categories for hexachloro benzene were associated with odds ratios of 0. The same files were used to identify 251 potential controls who had had breast-related surgery at the centre in whom benign breast disease was histologically diagnosed, besides fulfilling the same inclusion criteria (age, period and available fat sample) as those applied to cases. Information on major known or suspected risk factors for breast cancer was obtained at personal interviews, and the content of hexachlorobenzene in fat tissue samples was determined by gas chromotography. The cases (mean age, 56 years) were significantly older than controls (mean age, 53 years). The mean concentrations of hexachlorobenzene, adjusted in a multivariate analysis for age and sample lipid composition, were similar for breast cancer cases and benign breast disease controls overall (21 ng/g; standard deviation, 17. Cases and controls also did not differ significantly in the mean concentrations of hexachlorobenzene in adipose tissue when the cases were stratified by estrogen receptor or progesterone status. Quartiles of adipose tissue concentrations of hexachlorobenzene were formed on the basis of the frequency distribution in controls, and a linear logistic regression model was used to adjust for confounders when estimating the exposure?disease relationship. When the lower exposure quartile was used as the standard exposure category (< 12. In addition to infor mation obtained at a personal interview with a standardized questionnaire, 10-mL blood samples were taken. Of 162 blood samples available from cases and 331 available from controls, four (2. Of 824 women eligible for study (under the age of 80, no previous diagnosis of cancer, no breast implants and not too ill) who were all scheduled for excision biopsy of a suspected breast cancer, 663 (80. The majority of the questionnaires, providing information on known and suspected risk factors for breast cancer, were completed before the participants knew their diagnosis. After biopsy, the histological records of study subjects were reviewed: the cases were subjects in whom in-situ or invasive breast cancer was diagnosed and the controls were subjects with no malignancy (but often with some form of benign breast disease). Exposure to organochlorine compounds was examined in four categories, with the cut-point for the upper category at the 85th percentile of the control concentration, and odds ratios were assessed in an unconditional logistic regression analysis. Similar patterns were seen after stratification of study subjects by menopausal status at diagnosis. Of 7224 women initially free of cancer who donated blood to the bank on one or more occasions between 1977 and 1987, 6426 had at least 4 mL of serum remaining in the bank and were included in the study. For each breast cancer case, two controls were selected from among the eligible women, matched to the case on age, benign breast disease diagnosis during the previous 2 years and month and year of blood collection (n = 208). The concentration of hexachlorobenzene was measured by gas chromatography and was corrected for the total lipid content in the sample. Information on clinical status, age, height, weight, menstrual and reproductive histories, smoking, use of medication and family history of breast cancer was obtained by initial self-reporting or medical record review. The case women tended to be better educated than the controls and were more likely to be nulliparous and to have a first-degree relative with a history of breast cancer. The percentages of case and control women with concentrations of hexachlorobenzene at or above the limit of detection of the assay were 98. For use in the risk analysis, the women were stratified into quartiles on the basis of the concentration of hexachlorobenzene per gram of serum lipids relative to the distribution in controls. The relative risk, adjusted for potential con founders, was estimated by conditional logistic regression. When the lower exposure quartile was used as the standard exposure category (0?62 ng/g of serum lipid), the second (63?83 ng/g), third (85?105 ng/g) and upper (106?406 ng/g) quartiles showed relative risks of 2. In summary, the results of the study do not support the hypothesis that women who are exposed to organochloride pesticides are at increased risk for breast cancer. The women, who were identified at departments of gynaecology and gynaecological oncology in the study area, were eligible if they were born in Sweden, had not had a hysterectomy and had never used hormone replacement therapy. Of 396 reported patients, 288 (73%) volun teered to donate blood samples and complete a questionnaire. Subsequently, 134 case women were excluded because they had used hormorne replacement therapy, leaving 154 in the study. Population controls, frequency-matched to the case by 5-year age groups were randomly selected from the population registers of the study area. Of 742 control women selected, 492 (66%) responded to the questionnaire and donated blood samples. After the exclusion of 287 women because of hysterectomy or use of hormone replacement therapy, 205 control women were included in the study. The self-administered questionnaire requested information on weight, height, reproductive history, diet, hormone use, smoking, physical activity and medical history. Serum samples from the study subjects were analysed for their content of hexachlorobenzene and other organochlorine compounds in the lipid fraction by high-resolution gas chro matography. The mean serum concentrations of hexachlorobenzene, unadjusted for any potential confounder, were 70. Exposure categories were exa mined in quartiles on the basis of the distribution of hexachlorobenzene concentrations in the controls, and associated odds ratios for endometrial cancer were calculated by unconditional logistic regression. With the lower exposure category as reference, the odds ratio for endometrial cancer in the second, third and fourth quartiles was 1. The data do not support the hypothesis that the exposure to the organochlorides studied increased the risk for endometrial cancer. The controls were frequency-matched to the cases on age and sex by random digit dialling and random sampling of Health Care Financing Administration lists. A personal interview was conducted in which questions on occupational exposures, tobacco use, diet and medical history were posed, and a blood sample was drawn.