C. Allen Stringer

Radical wide excision and selective inguinal node dissection for squamous cell carcinoma of the vulva

Abstract Limited resection of some vulvar cancers may provide cure rates equivalent to those obtained with radical vulvectomy and bilateral inguinal node dissection. Rapid recovery, fewer complications, and better functional result have been described as advantages to less extensive procedures. Since 1978, 32 patients with invasive squamous cell cancer of the vulva (depth > 1 mm) and clinically negative inguinal lymph nodes underwent radical wide excisions as primary therapy. Mean age at diagnosis was 61 years. Seventeen patients had T1 and 15 had T2 tumors. Resection of the primary lesion was tailored to lesion location and size, and dissection was carried to the deep perineal fascia. Twenty-two patients had unilateral superficial inguinal lymph node dissections, five with midline lesions had bilateral superficial dissections, and five had node samplings which included deep inguinal nodes. Depth of invasion ranged from 1.5 to 13.0 mm. Mean largest lesion dimension was 23 mm. Five-year lifetable survival for the entire group was 84%. Univariate analysis of potential prognostic variables showed no significant recurrence or survival differences for patient age ( P = 0.56), symptom duration ( P = 0.57), FIGO stage ( P = 0.67), tumor grade ( P = 0.20), tumor location ( P = 0.26), depth of invasion ( P = 0.56), or resection margin status ( P = 0.63). Thirty-one percent of patients had perioperative complications, and 16% developed delayed complications. Mean hospital stay was 10 days. Three patients (10%) developed new or recurrent vulvar disease and underwent additional therapy. None have died of disease, although one is alive with persistent tumor. Radical wide excision and selective inguinal lymphadenectomy constitute a reasonable alternative to radical vulvectomy with bilateral inguinal node dissections for squamous tumors clinically limited to the vulva. Outcome may not be strongly influenced by lesion size or depth of invasion.

Recurrent cervical carcinoma after radical hysterectomy

The characteristics of recurrent carcinoma following radical hysterectomy and pelvic lymphadenectomy for cervical carcinoma are not well known. Disease recurrence was noted in 27 of 249 patients (11%) with stage IB cervical carcinoma who were treated with a primary surgical approach between January 1962 and December 1984. Fourteen recurrences (52%) occurred within 1 year of surgery, and 24 (89%) within 2 years. Patients with pelvic node metastases or adenocarcinoma had a significantly higher recurrence rate than did patients with negative nodes (33% vs 8%) or with squamous carcinoma (22% vs 8%). Seventeen patients (63%) had disease recurrence in the pelvis or vulva and 12 of these patients had recurrences within 1 year. Eight patients developed asymptomatic pelvic or vulvar recurrences, and all were diagnosed within 1 year. Ten patients (37%) developed recurrences outside the pelvis and 8 of these experienced recurrence after 1 year. Successful treatment after recurrence was independent of clinical or histopathologic parameters except site of recurrence. Eight of 15 patients (53%) who were treated with irradiation for a recurrence in the pelvis or vulva are free of disease 10 to 126 months (median, 48 months) after recurrence. Since irradiation can aid in salvaging patients with recurrent cervical carcinoma confined to the pelvis following radical surgery, clinical vigilance for this site of recurrence is emphasized.

Treatment of malignant nondysgerminomatous germ cell tumors of the ovary with vincristine, dactinomycin, and cyclophosphamide

Eighty patients with malignant nondysgerminomatous germ cell tumors of the ovary were treated with the combination of vincristine, dactinomycin, and cyclophosphamide (VAC) at The University of Texas M. D. Anderson Hospital and Tumor Institute. All patients underwent initial surgery: biopsy alone in 3 patients, unilateral salpingo‐oophorectomy in 48 patients, and bilateral salpingo‐oophorectomy with or without hysterectomy in 29 patients. Sixty‐six patients received VAC as primary postoperative therapy; 46 patients (70%) achieved a sustained remission. VAC produced sustained remission in 86% of patients with Stage I, 57% of patients with Stage II, 50% of patients with Stage III, and no patients with Stage IV disease. For patients with Stage I disease, survival rates did not differ among histologic groups, but in advanced disease, patients with immature teratoma did significantly better than the others. Four of the 20 patients who failed primary VAC therapy were salvaged with other therapies, and 8 of 14 treated with VAC after relapse or failure of other treatments were salvaged. Although VAC produces excellent results with very acceptable toxicity in patients with Stage I disease and advanced immature teratoma, survival of patients with other advanced histologic types has been disappointing. The authors are therefore treating this latter group with alternative therapy such as vinblastine, bleomycin, and cisplatin with the goal of achieving improved efficacy.

Gracilis myocutaneous vaginal reconstruction concurrent with total pelvic exenteration

The gracilis myocutaneous vaginal reconstruction is commonly performed in patients undergoing a total pelvic exenteration. This retrospective review compares the operative and perioperative morbidity in 107 patients who underwent reconstruction with that in 44 patients who did not have reconstruction. With incorporation of the reconstructive procedure, there were no increases in operating time, blood loss, or length of hospitalization. Before 1980, 65% of patients experienced prolapse of the neovagina; in 25% it was severe. The frequency of prolapse has since been decreased to 16% (6% severe) because of several modifications to the initial technique. Modifications have included using smaller flaps, anchoring the neovagina to the levator and retropubic fascia, and, when necessary for mobilization, ligating the neurovascular pedicle. With these modifications, 66% of patients also remained free of wound breakdown or necrosis. The frequency of severe necrosis has decreased from 24% to 13%. The anatomic result of the vaginal reconstructions appears to have been enhanced by these changes in technique.

Alveolar rhabdomyosarcoma of the female genitalia

Eight cases of alveolar rhabdomyosarcoma of the female genitalia were diagnosed from 1963 to 1983 at The University of Texas M. D. Anderson Hospital. The primary sites were vulva in two, perineum in five, and broad ligament in one patient. When possible, therapy was initiated with local tumor excision (five patients). Surgery was followed by local or regional radiation (six patients) and chemotherapy (seven patients). Of the eight patients, five died within 9 months, one died 27 months after diagnosis, and only two are 5‐year survivors. The aggressive behavior of this tumor is evidenced by autopsy findings of widespread metastases. Metastatic disease to the bone was present in four patients and to the breast in three patients. Local disease was controlled in two patients who died of distant metastases. Current therapy recommendations include excisional surgery, local radiation, and combination chemotherapy. A need for more effective chemotherapeutic programs is evident.

History of the Baylor Charles A. Sammons Cancer Center

The Charles A. Sammons Cancer Center at Baylor University Medical Center (BUMC) in Dallas, Texas, opened in 1976. Unlike freestanding cancer centers, Sammons is an integral part of a large tertiary care hospital whose medical staff is composed of physicians in private practice. Thus, it is “a center within a center.” Multidisciplinary interaction among physicians from different specialties has been the pivotal concept underlying the organization and development of the cancer center. Ongoing cooperative interaction with the hospital and with physicians in various communities is a key objective. The principal goals are to provide patients with personalized, high-quality care and to conduct educational and research programs that advance knowledge in the field. The term cancer refers to more than 100 separate diseases that share the common biologic characteristic of abnormal growth. These malignant cells can, if untreated, spread to other parts of the body and ultimately cause death of the patient. Five percent to 10% of cancers are hereditary; individuals carrying an abnormal gene transmitted in the germline are at very high risk of developing certain malignancies. The vast majority of cancers are not hereditary but develop from mutations in various genes (DNA) due to internal or external agents. Cancer remains a major public health problem in the USA and the most feared diagnosis. In the year 2002, the American Cancer Society estimated that 1,285,000 new cases and 555,500 deaths occurred from these malignant diseases (1). In Texas, 79,700 new cases and 34,500 deaths were anticipated. In other words, 1 in every 4 deaths in the USA is related to cancer; this translates to more than 1500 people dying each day. Nearly one third of cancer deaths are caused by tobacco, especially cigarette smoking. Men have a 1 in 2 lifetime risk of developing cancer, and for women the risk is 1 in 3. The 3 most common cancers in men (prostate, lung, and colon) and women (breast, lung, and colon) account for about 50% of new cases and 50% of cancer deaths. Nearly 80% of all new cancer diagnoses are made in persons aged 55 and older; this figure will increase as our population ages. The overall annual costs for cancer in the USA during 2001 were estimated to be

Secondary cytoreductive surgery for recurrent epithelial ovarian cancer

156.7 billion,

Re-treatment of patients with recurrent epithelial ovarian cancer with cisplatin-based chemotherapy

56.4 billion of which was due to direct medical costs. On the brighter side, over 9 million Americans are alive today who have a history of cancer. Cancer survival was rare in the early part of the 20th century. By the 1990s, more than 40% of cancer patients survived. The mortality rate from cancer in the USA began to decline for the first time during the 1990s and is continuing to fall (2). The 5-year relative survival rate for all cancers is now approximately 62% (1). Better outcomes are due to advances in research and education. Future progress will require ongoing advances in cancer prevention, detection, and treatment.

Postoperative Adjuvant Cisplatin, Doxorubicin, and Cyclophosphamide (PAC) Chemotherapy in Women with High-Risk Endometrial Carcinoma

Pdvic exenteratioa in clear ceil adenocarciaomr of tke vagina and cervix Seuekjian EK; Frey K; Herbst AL Department of Obstetrics and Gynecology, Pritzker School of Medicine, University of Chicago, IL; USA Gynecologic Ontology/34/3 (413-416)/1989/ Pelvic exenteration was performed in 29 of 527 cases of vaginal and cervical clear cell adenocarcinoma (CCA). Exenteration was the initial therapy in 21 cases (1 stage I, 15 stage II, 3 stage III, 1 stage IV, and 1 unknown stage) and was undertaken in 8 cases for central failure after primary radiotherapy. Of the 78 patients with stage II vaginal CCA, the 9 treated with primary exenteration were compared with the 69 who had other modalities of therapy; no significant difference in the survival experience was noted between the two groups. Among the 96 patients with stage II cercical CCA the survival experience was less favorable for those who underwent primary exenteration (n = 5) than for those who were treated with other varieties of therapy (n = 91). Of the 34 patients with central treatment failure, 8 had exenteration and 26 had other forms of therapy. The overall 5and 8-year actuarial survival rates for the exenteration group (100 and 60%) do not differ significantly from those for the nonexcnteration group (71 and 5ar70). Primary exenteration was used more frequently in the 1970s but has been predominantly reserved for the treatment of recurrent disease during the past favorable in cases of vaginal and cervical CCA than in cases of cervical squamous carcinoma.