Alexander Brunschwig

Necropsy findings in patients with carcinoma of the cervix

Abstract In a review of 65 necropsies of patients who had carcinoma of the cervix, the following salient features appear deserving of emphasis: 1. 1. Cancer of the cervix tends to spread primarily via the lymphatics, the periaortic nodes being first involved outside the pelvis in most instances. 2. 2. Half of the patients died from various causes other than wide dissemination of the disease since necropsy revealed no gross evidence of neoplasm outside the pelvis in this group. 3. 3. Uremia was the immediate cause of death in 27.7 per cent of the series, and ureteral obstruction of varying degrees was present in 63 per cent of the cases. 4. 4. Infection, principally as peritonitis, pelvic abscess, and septicemia in varying combinations appeared to be the immediate cause of death in 38 per cent of the series. Thus uremia and infection together were the immediate causes of death in 66 per cent of the series, not widespread malignant disease. 5. 5. Aside from eradication or restraint of the neoplasm, preservation of urinary tract function and avoidance of infection appear to be the principal problems to be dealt with for the prolongation of life in patients with cancer of the cervix.

Effect of leukocytes on transplantability of human cancer

In patients with nonresectable cancer quantitated suspensions of cells from their own tumor were transplanted subcutaneously in serial dilutions and observed for growth. In parallel were implants of tumor cells mixed with the patients own leukocytes. Comparison revealed an inhibition of tumor cell growth by the admixed leukocytes in half of the 41 patients who were suitable for evaluation. In 21 of these patients there was a third parallel series of autotransplants of tumor cells mixed with autologous plasma. The plasma inhibited tumor cell growth in only 7, and only in patients whose leukocytes were also inhibitory. In 9 patients there was a row of transplants consisting of autologous cancer cells mixed with homologous leukocytes from a healthy donor. Results in this group showed no consistent pattern. Similar suspensions of tumor cells, with and without admixed leukocytes, were homotransplanted subcutaneously to patients with advanced cancer. Only 9 of these studies gave evaluatable homograft nodules but 7 of them showed evidence of inhibition of the implanted cancer cells by the leukocytes of the cancer donor. The studies are not sufficient in number to be statistically significant, but they suggest that the leukocytes (? lymphocytes) of cancer patients have a specific inhibitory effect on the growth of the cancer cells of that individual.

A proposed classification for cases of cancer of the cervix treated by surgery

Abstract A classification is presented to catalogue patients with carcinoma of the cervix who receive radical hysterectomy and pelvic lymph node excision or some type of pelvic exenteration operation. The need for such a classification is presented.

Operative management of patients previously operated upon for a benign lesion with cervical cancer as a surprise finding

Abstract From 1947 to January, 1960, 213 patients were referred to The Memorial-James Ewing Hospitals for treatment of inadequately excised invasive cancer of the cervix. A survey of the literature revealed that little had been written about this problem. In reviewing the charts of the 213 patients, it was evident that prior to doing a hysterectomy for benign disease, cancer of the cervix must be ruled out, and if it is present, appropriate definitive primary therapy must be carried out. Papanicolaou smears should be mandatory on admission to the hospital. When the patient is anesthetized, an examination under anesthesia and a dilatation and curettage represent the height of professional integrity. Having run into the problem of unsuspected cancer of the cervix, reliance on the use of a “little x-ray therapy” postoperatively results in calamity for the patient. However, faced with the problem, gloom must be dispelled, and rather than compromise the possibility of cure by inadequate and time-consuming radiation, it appears from the review that operation provides the most comprehensive therapy in the shortest period of time. Of 213 patients treated, 37 (32.2 per cent) lived 5 or more years.

The rationale for radical panhysterectomy and pelvic node excision in carcinoma of the corpus uteri; clinical and pathological data on the mode of spread of endometrial carcinoma.

Abstract A discussion based upon surgical experience and pathologic study in the treatment of adenocarcinoma of the endometrium in 74 patients is presented to emphasize the following points: 1. Endometrial carcinoma of the corpus uteri may spread in similar fashion to epidermoid carcinoma of the cervix, i.e., invasion of parametria, bladder, rectum, and metastasis to pelvic lymph nodes, progressively, before spread to extrapelvic sites occurs. 2. Local direct spread to bladder and pelvic colon may occur prior to metastasis to pelvic nodes. 3. It appears that simple total hysterectomy for endometrial carcinoma does not represent the maximal surgical effort possible for endometrial carcinoma. 4. When the patients condition permits, a radical panhysterectomy with pelvic lymph node excision is indicated. The mortality can be held to a minimum. In patients who are not good risks a Wertheim type of radical hysterectomy should be performed. 5. In advanced and/or recurrent cases of endometrial carcinoma some type of exenteration operation may still offer the patient a chance for long survival. 6. Consideration of pelvic lymph nodes in the surgical treatment of endometrial carcinoma is consistent with the modern principles of cancer surgery. There is no reason to assume that the surgery of endometrial cancer should constitute a sole exception to this principle.

Radical surgical management of cancer of the colon spread to tissues and organs beyond the colon

THE RESULTS Of surgical t rea tment of cancer of the colon are bet ter than those achieved by surgery of cancer of any other abdomina l organ with the except ion of the uterus. Extensive experience dur ing the past several decades has led to the evolvement of technics for wide resection of various segments of the colon that are now more or less s tandardized depend ing u p o n which segment is involved. No good purpose can be served by presenting ano ther series of patients who underwen t one or more of the general ly established procedures and recording the results obtained. Almost all imaginable technics have been employed and ei ther discarded or con t inued in some form or another . My purpose is to present some thoughts about cancer in man and to refer to cancer of the colon as evidence for the

Intestinal fistulas following pelvic exenteration

Abstract Intestinal fistulas occurring as a post-operative complication after pelvic exenteration have been noted in 87 cases from a total of 640 exenteration procedures. The time of onset of these fistulas has been found to fall into two rather well-defined groups, namely, those in the immediate potsoperative period and those occurring later. The latter group is noted to be associated with a high incidence of recurrent cancer. It is shown that preoperative radiation treatment significantly increases the incidence of such fistulas, and further important etiologic factors include ileus, obstruction and abscess, or infection. Evaluation of the treatment of these fistulas would indicate the advisability of early surgical intervention as opposed to an expectant policy.

Radical vaginal operation (Schauta) for carcinoma of the cervix.

I N THE first decades of this century considerable interest existed in the radical vaginal hysterectomy for cancer of the cervix, especially in the Central European clinics. Schauta’s name is associated with this procedure which was offered as a substitute for Wertheim’s abdominal hysterect0my.l The advantages set forth in favor of the radical vaginal operation were : (a) decreased morbidity, (b) decreased mortality, (c) “cure rates” comparable to or even greater than those obtained with the then more formidable abdominal operation. With the advent of radiation therapy for cancer of the cervix, the operative treatment waned considerably in a number of countries, and was in fact regarded as practically obsolete in most centers in the United States, England, France, Scandinavian and other western European countries, as well as in Latin America. Adler? continued to support the operation, eventually combining it with local insertion of radium capsules; NavratilS in Graz was also a proponent of it for a period since the last World War. Subodh Mitra4 of Calcutta continues to report series of patients subjected to this operation, contending that in his patients and under his working conditions the lowered operative risk and mortality justify the procedure. Bastiaanse5 in Holland is also a proponent of the operation. In Italy, Ingiullae has reported his experience with the Amreich modification of the Schauta procedure. Recent communications in the Austrian literature indicate continued employment of the operation. It is of interest no note that the surgical treatment of cancer of the cervix has been pushed so far into the background in this country that many are not at all acquainted with the operation and most American gynecological texts published in recent years do not even mention the operation. The outstanding disadvantage of the radical vaginal operation for cancer of the cervix is the failure to reach and excise the pelvic lymph nodes and fatty tissues of the obturator and external iliac regions. Some of the hypogastric nodes and surrounding fatty tissues can be reached. Thus it is admittedly an operation of limited extent. On the other hand, it does not subject the patient to the physiologic strain that obtains with radical panhysterectomy and pelvic lymph node excision and therefore should be accompanied by less morbidity and less mortality. In the pursuance of a surgical program for attack upon cancer of the cervix in the Memorial Hospital,7 certain patients were deemed poor operative

Carcinoma of the bowel

Abstract The leading causes of maternal death for the country as a whole are toxemia, infection, and hemorrhage. However, in the better staffed and equipped hospitals these causes are decreasing and others are increasing; among the latter is malignant neoplastic disease. The opportunity presents itself to report upon a patient with cancer of the bowel treated by preoperative radiation therapy, an abdominal-perineal resection followed 8 years later by normal pregnancy terminated by cesarean section. The problem of the diagnosis of malignancy in the young age group as well as the management of bowel carcinoma complieatillg pregnancy is diseusud. Since, the ovaries received sufficient radiation therapy to result in amenorrhea for 8 years, the problem of radiation as it affects the ovary, future progeny, and relationship to genetics is considered.

Studies in human physiology incident to extended surgery for cancer

The author reviews his clinical‐surgical experiences of more than 30 years, devoted in large measure to the extension of radical surgery in attack upon advanced cancer; he points out that in a variety of situations the extended radical surgery produces anatomo‐physiological alterations in human beings which permit of general physiological observations apart from the cancer problem. Specific examples are cited. He points out that advances in knowledge of human physiology can be made in patients who have extended radical operations for cancer. He expresses a hope that these possibilities will always be borne in mind by surgeons who constantly are performing extended radical surgery for cancer.