The bulky 6-cm barrel-shaped lesion of the cervix: primary surgery and postoperative chemoradiation.

OBJECTIVE: The purpose of this report is to detail what appears to be the largest reported experience of primary radical hysterectomy for bulky barrel-shaped cervical cancers of 6 cm or greater in diameter, followed in all instances by radiation therapy and chemotherapy. METHODS: Twenty-two unselected cases were operated primarily. One had unresectable aortic node disease. Twenty-one were treated with intent to cure. All patients received extended field radiation therapy beginning 4 weeks after surgery. All patients also received infusion chemotherapy during weeks 1, 4, and 7 of their radiation therapy. Initially, 5-FU was the drug of choice; more recently, Platinol has been employed. RESULTS: The Berkson-Gage relative survival of the total 22 cases was 71.3%. For the 21 cases treated with intent to cure, the survival was 75.4%. Complications were minimal. CONCLUSION: The experienced pelvic surgeon can accomplish this exercise with a high degree of safety; and this multimodality approach is offered as another therapeutic alternative for these high-risk patients.

Death of the Papanicolaou smear? A tale of three reasons.

The Papanicolaou smear is arguably the most cost-effective cancer screening test ever devised. Yet future availability of this low-cost test is seriously threatened by increasing litigation, huge awards, and the implied linkage between "error" and "negligence." The expectation of a 0 error standard, even for a screening test, is central in the current medical-legal climate. Three reasons for this escalating problem will be explored, as follows: (1) substandard laboratories; (2) misunderstanding of the Papanicolaou smear by the media, the public, the legal profession, and physicians, compounded by the "greed factor"; (3) an "acceptable error rate" in quality laboratories for Papanicolaou smear screening. I will explore the future of the Papanicolaou smear and will make specific recommendations for all obstetricians-gynecologists.

Endometrial cancer and surgical staging: a personal assessment.

In 1998, FIGO introduced a new staging system for endometrial cancer that is now surgical rather than clinical. The addition of extensive lymph node surgery, either formal lymphadenectomy or liberal sampling of the pelvic and aortic lymph nodes, represents the most significant and controversial component of this system. The yield of metastatic nodes is relatively low. The controversy surrounding this staging system are reviewed and some practical options considered.

Should whole pelvic radiation therapy become past history? A case for the routine use of extended field therapy and multimodality therapy.

Total pelvis radiation therapy as refined over the past 40 years has impacted positively on gynecologic cancer management. Improved overall results on a worldwide basis reflect a broader application of contemporary radiation treatment plans. Individual clinical stages of disease and subsets have not seen improvement in several decades. Currently available techniques for the safe application of extended field radiation therapy strongly support its routine use. Concomitant continuous infusion chemotherapy (CCIC) with radiation therapy (RT) should be strongly considered. Primary radical surgery is employed in our hands prior to extended RT and CCIC for most Stage I and II cases.

Advances in diagnosis, staging, and management of cervical and endometrial cancer, stages I and II.

The majority of patients with low stage cervical and endometrial cancer are cured. Results obtained in the past only in the categorical cancer centers are currently being achieved more broadly. This reflects the work of formally trained gynecologic oncologists often in collaboration with formally trained radiation therapists distributing themselves in a horizontal fashion to more and more university medical centers, teaching hospitals, and quality tertiary hospitals in the private sector. The formalization of training in gynecologic oncology has been pivotal in this development. This group of physicians, working with physicians in other disciplines, have impacted significantly on patient care and have provided many clinical and pathologic studies to better define favorable low stage cases and poor prognosis cases. The need to explore the use of currently available modalities in a variety of different combinations and to define and develop new techniques to apply to these poor prognosis subsets of disease represent areas of progress and challenge.

Combined therapy as an alternative to exenteration for locally advanced vulvovaginal cancer. II. Results, complications, and dosimetric and surgical considerations.

We have introduced a therapeutic alternative to exenteration for locally advanced vulvovaginal cancer using surgery for the vulvar (external genital) phase of this disease presentation, combined with radiotherapy for the internal genital phase (with adequate overlap of fields to protect surgical margins). The rationale is that this approach treats the cancer and its dual regional spread patterns, while at the same time preserving the bladder and/or rectum, and should be associated with less morbidity and mortality than exenterative surgery. This report updates our experience with a total of 48 treated cases (37 primary cases and 11 cases of recurrent disease). Of the 37 primary cases, 20 were FIGO stage III, 4 were FIGO stage IV, and 3 other cases represented "field" cancers involving vulva and/or cervix and/or vagina. Utilizing a Life Table analysis, the 5-year survival for the primary cases was 75.6%. Published FIGO survival for stage III is 32% and for stage IV 10.5%. Life Table analysis projects a 62.6% survival for recurrent cases and an overall 72% 5-year survival for all 48 cases treated. With 48 patients treated, 48 bladders and 48 rectums were at risk for surgical removal had exenteration been employed. One patient had a total pelvic exenteration for local failure, and one had a posterior exenteration for local failure. One bladder and one rectum were lost to permanent diversion because of radiation injury. Thus, 5 of these major viscera were lost of the 96 total, and 91 (94.8%) were retained. Radiation therapy and surgical details have been reviewed relevant to local control and local failure and complications. The continuing evolution of treatment modifications of all modalities will be discussed. The apparent advantages of this combined therapeutic approach over exenterative surgery include high probability of bladder and/or rectal preservation, low primary mortality, low treatment morbidity, and very good results in cancer control.

Risk factors and recurrent patterns in Stage I endometrial cancer.

Clinical Stage I carcinoma of the endometrium was evaluated in 222 patients. Twenty-five percent of patients were found to have pathologic findings thought to require postoperative external irradiation; of these, 20 of 57 (35%) had recurrence. During the 36- to 72-month follow-up period, only 14 of 165 (8.3%) treated only with operation (68 patients or 31%) or operation plus intracavitary radium (97 patients or 44%) manifested a recurrence. Furthermore, of all recurrences, 27 of the 34 (79%) were outside the pelvis. In these surgically staged cases, the absence of definable, demonstrable extrauterine disease was associated with a 7% recurrence rate versus a 43% recurrence rate if disease was found anywhere outside the uterus. Recurrence and death were correlated with other prognostic factors, which are outlined in this report.

Presidential panel. The gynecologic oncologist in academic departments.

Now that the subspecialty of gynecologic oncology is well established within the specialty of obstetrics and gynecology, it seems timely to evaluate the pros and cons, the strengths and weaknesses of such a program as it interrelates with other programs in an academic department. A survey is presented which reflects the beliefs of both members and candidate members of the Society of Gynecologic Oncologists on such issues as gynecologic oncologists as chairmen of departments; teaching demands; time commitments to patient care and research in an academic institution; and surgical privileges for gastro-intestinal and urologic procedures in various hospitals. Financial and budgetary items are also discussed. Perspectives from three different points of view are presented as a discussion of the report of the survey.

Surgical staging in endometrial cancer: clinical-pathologic findings of a prospective study.

The pathologic features of a prospective study of FIGO stage I endometrial cancer is presented. The uterus, tubes, ovaries, and pelvic lymph nodes of 222 cases and aortic nodes of 157 cases have been analyzed. The surgical-pathologic specimen would suggest a negligible risk for lymph node metastasis if: cancer is confined to the endometrium irrespective of grade, invasion is superficial for grades 1 and 2 tumor, the intermediate third of the myometrium is invaded for grade 1 tumor only, and occult disease is not present in the cervix and/or adnexa. Conversely, a substantial risk for lymph node metastasis exists if the surgical-pathologic study identifies superficial myometrial invasion by grade 3 cancer, intermediate myometrial invasion by grade 2 or 3 cancer, deep myometrial invasion by cancer of any grade, vascular space involvement, and extension of tumor to the cervix and/or adnexa.

Combined therapy as an alternative to exenteration for locally advanced vulvo-vaginal cancer: rationale and results.

Locally advanced vulvo-vaginal cancer is a difficult therapeutic problem complicated by the fact that it is an uncommon clinical entity. Surgery for the vulvar (external genital) phase of this disease presentation was combined with radiotherapy for the internal genital phase (with adequate overlap of fields to protect surgical margins). The rationale is that this approach treats the cancer and its dual regional spread patterns, while at the same time preserves the bladder and/or rectum, and should be associated with less morbidity and mortality than exenterative surgery, especially in this predominantly geriatric patient population. During the period from 1968-1980, 33 cancers have been treated. There were 26 primary and seven recurrent cases. The apparent advantages of this combined therapeutic approach over exenterative surgery include bladder and/or rectal preservation, low primary mortality, low treatment morbidity, and good results in cancer control.