Conrad G. Collins

Suppurative pelvic thrombophlebitis: A study of 202 cases in which the disease was treated by ligation of the vena cava and ovarian vein☆

Abstract Suppurative pelvic thrombophlebitis has been a disease of intense interest on the Tulane Unit at Charity Hospital of Louisiana at New Orleans since 1911. Various combinations of pelvic vein ligations were utilized without too much improvement in mortality rate until ligation of the normal venous return from the uterus (i.e., the vena cava and ovarian vein) was effected. Our experience regarding early and late results in 202 cases of ligation of the vena cava and ovarian vessels is recorded.

Malignant tumors involving the vulva

Abstract Of the 37 cases seen by us, operation was not recommended in 3 patients because of metastatic lesions to bone or lung found on routine x-ray study of the skeleton and lungs. Needless to say, such studies are essential in all cases of malignancy. In 2 cases considered resectable as a result of clinical and x-ray studies, at the time of operation, unexpected metastases were found to involve the psoas muscle or other retroperitoneal soft tissues and precluded any possibility of extensive resection, including eviscerectomy. One patient refused surgery. All, except one patient in whom resection was attempted only one week ago, failed to survive more than four months (Table VII). 7 . Foolow-up. Total cases, 37 Refused surgery 1 Died in 1 month No therapy, surgery not advised due to 3 Died, 4 months, 2 months, metastasis to bone or lung 1 month, respectively Surgery attempted, not completed due to 2 (1) Died 1 month distant metastasis, nonresectable (1) Living 1 week Resectable, surgery completed 31 Of the 31 cases subjected to surgery, 4 had only radical vulvectomy. Radical pelvic gland dissection was not advised in these patients as multiple microscopic sections from the removed vulva showed the lesion to be intraepithelial in the sections studied. This is in keeping with our established policy in the study of malignancies of the vulva. When enough material of this type has been accumulated and followed for a sufficient period of time we will be able to state whether or not radical vulvectomy is sufficient in the management of intraepithelial carcinoma of the vulva so diagnosed by multiple sections from the resected vulva. Two patients with invasive carcinoma had radical vulvectomy but refused gland dissection. The follow-up on these cases of carcinoma of the vulva having had radical vulvectomy only is listed in Table VIII. 8 . Follow-up. Resectable, surgery completed, 31 Radical vulvectomy, refused gland dissection 2 No recurrence (1) 38 months (2) 6 months Radical vulvectomy, gland dissection not advised 4 No recurrence Intraepithelial carcinoma (1) 14 months (1) 16 months (1) 16 months (1) Dead ∗ Radical vulvectomy and radical gland dissection 25 ∗ Died fifteen days postoperatively from mural thrombus. Radical vulvectomy and radical pelvic gland dissection were performed on 25 cases. Additional procedures thought necessary to produce arrest or cure of the disease were carried out in 4 of these patients. The results are listed in Tables IX and X. It is to be noted that only one patient failed to survive operation. This patient died two weeks following radical vulvectomy from pulmonary embolism as a result of a mural thrombus. It is of interest that this patient had intraepithelial carcinoma and vulvectomy was the only procedure advised or carried out. None of the patients subjected to more extensive resection failed to survive the procedure. We believe that radiation therapy has no place in the treatment of vulvar lesions, including malignancy. In this series therapy was wholly surgical. Radiation therapy was not advised or used either preoperatively or postoperatively by us. In a few cases in the series radiation had been used elsewhere to benign or malignant vulvar lesions without improvement and only resulted in delay in surgical therapy. We think that improvement in five-year cure rates in malignancy of the vulva will be brought about only by prophylactic measures as previously described and utilization of more extensive surgery in cases of established vulvar malignancy. Modern anesthesia, blood transfusion, and antibiotics allow for extension of surgical attack with a very low operative mortality. 9 . Follow-up. Radical vulvectomy and radical gland dissection, 25 Radical vulvectomy and radical gland 2.1 2 Dead ∗ dissection only 1 Living 19 months. Recurrence 18 Living, no recurrence Under 6 months 6 months-1 year 3 1 year-2 years 2 2 years-3 years 3 3 years-4 years 4 4 years-5 years 4 Radical vulvectomy and radical gland 4 All living No recurrence dissection plus other procedures (1) 24 months (1) 20 months (1) 21 months (1) 54 months ∗ (1) Carcinomatosis 9 months postoperatively. (1) Carcinoma of ovary 15 months postoperatively. 10 . Follow-up. Radical vulvectomy and radical gland dissection plus added procedures, 4 Added Procedures A. Removal of Pouparts ligaments, segments of external oblique fascia and fascia lata No recurrence 54 months B. Vaginal hysterectomy and vaginectomy No recurrence 24 months C. Removal of bladder, urethra, uterus, tubes, ovaries, vagina, ligation of right external iliac vein (anterior eviscerectomy) No recurrence 21 months D. Removal of bladder, urethra, vagina, tubes, ovaries, uterus, rectum, anus, transplantation of ureters into signoid, midline colostomy (total eviscerectomy) No recurrence 20 months

Intraepithelial carcinoma of the vulva

Abstract The clinical data and the management of 41 cases of intraepithelial carcinoma of the vulva during a 23 year period are presented. The rationale for an extensive surgical approach is discussed. We found a 7.3 per cent recurrence rate and a 25 per cent second primary malignancy rate in our series. The establishment of a special clinic for the management of vulvar disease, we feel, has greatly increased the diagnostic yield in early lesions. A lifetime follow-up is advocated in these patients following treatment.

Early repair of vesicovaginal fistula

Abstract Thirty-eight patients with vesicovaginal fistula were treated within 60 days of diagnosis of the fistula (acute fistula). The fistulas resulted from obstetrical injuries, surgical procedures, and irradiation and operation for cancer. The majority of the patients were treated within 30 days. This is possible with the use of cortisone as an anti-inflammatory agent. We believe it is no longer necessary for the patient with vesicovaginal fistula to wait six months before attempting repair. With the exception of the use of cortisone preoperatively, the surgical technique employed and the postoperative care, with stress on the importance of maintenance of excellent catheter drainage, are the same basic principles advocated by most authorities. Over two thirds of the patients treated were cured within two weeks after diagnosis.

Intraepithelial cancer of the vulva

Abstract Establishment of a vulvar disease clinic on our service has dramatically increased the diagnostic acumen of the resident staff. In addition during the last 5 years 34 per cent of vulvar cancers diagnosed have been in the intraepithelial stage. More intensive and frequent use of biopsy of the vulva is advocated. Extensive vulvectomy is sufficient for the therapy of intraepithelial cancer. Lymphadenectomy is not necessary for the cure of noninvasive cancer. Eponyms have no place in predicating therapy, as all types of intraepithelial cancer have invasive potential.

Multicentric squamous cell carcinomas of the lower female genital tract. Eleven cases with epidermoid carcinoma of both vulva and cervix.

Abstract Eleven of 105 cases of epidermoid carcinoma of the vulva have also shown epidermoid carcinoma of the cervix. One out of 4 showed cervical carcinoma when the vulvar lesion was of Bowens type. It is questioned, however, whether the continuing emergence of neoplasia, in an adequately treated patient, is a significant problem.