Donald G. C. Clark

A review of second-look laparotomy for ovarian cancer

One hundred twenty-seven patients underwent second-look laparotomies from July 1969 to June 1982. To be included in this report they must have met the following criteria: a documented ovarian neoplasm; previous surgery; adequate chemotherapy for cessation if no disease was found; and no X-ray, chemical, or clinical evidence of disease including an exam under anesthesia. Forty-one percent had residual disease at second-look laparotomy. The original stage and the percentage of tumor debulked at initial surgery were inversely related to the likelihood of finding residual disease. Age, histologic type and grade, and type of chemotherapy did not show a significant relationship with the likelihood of disease persisting. Recurrent tumor was subsequently detected in 16% of patients who had been found to be free of disease at second-look laparotomy. Of thirty stage III and IV patients treated with combinations containing cis-platinum, 10 (33%) had recurrences. This rate of recurrence was significantly greater than the 17.6% recurrence rate in 17 patients with Stage III and IV disease whose chemotherapy consisted of single alkylating agents or with combinations without cis-platinum. Twenty patients underwent a third-look laparotomy after completion of additional chemotherapy. Nine were found to have no residual disease. Two of the nine (22%) subsequently had recurrence of disease. Three of the eleven patients with persistent disease at the time of a third-look laparotomy underwent a fourth-look laparotomy. All were found free of disease and none have recurred. Six (55%) of those with persistent disease at the third-look laparotomy have died despite continued therapy. The ability to successfully treat some patients with persistent disease continues to be a justification for the use of a second-look laparotomy. However, the high rate of recurrence after cessation of treatment following the finding of no residual disease raises the question of whether it is appropriate to discontinue all therapy at this time.

Radiation-induced angiosarcoma

A 47‐year‐old woman presented with an angiosarcoma of the terminal ileum 14 years after receiving adjuvant radiation therapy for ovarian dysgerminoma. Her clinical course is described, and the previously reported cases of radiation‐induced angiosarcoma are reviewed.

Pelvic exenteration for recurrent or persistent gynecologic malignancies: A 10-year review of the Memorial Sloan-Kettering Cancer Center experience (1972–1981)

From January 1, 1972 to December 31, 1981, sixty-five patients underwent pelvic exenteration as treatment for recurrent or persistent gynecologic malignancy at Memorial Sloan-Kettering Cancer Center. Cervical carcinoma was the disease most commonly treated by exenteration. The operative mortality of 9.2% represents an improvement over previous reports from this institution. After routine use of prophylactic minidose heparin, no cases of thrombophlebitis or pulmonary embolus occurred postoperatively. A 5-year survival rate of 23% warrants continued use of exenteration in carefully selected patients. The significant mortality and morbidity associated with pelvic exenteration preclude its use as a palliative procedure.

Pretreatment laparotomy in carcinoma of the cervix.

Abstract In cases of advanced carcinoma of the uterine cervix, control of regional pelvic disease is not always equated with survival. While early disease often does remain localized within the pelvis, more advanced cervical cancers are observed to metastasize to paraaortic nodes and to distant sites. This study reports a surgical protocol designed to define extent of disease in patients having invasive cervical carcinoma prior to administering primary radiation therapy. Three questions have been raised: (1) Which individual patients have disease outside the pelvis? (2) Is it possible to modify therapy to control disease outside the pelvis and thereby influence survival? (3) Are positive paraaortic nodes found at pretreatment laparotomy indicative of systemic spread of disease? This pretreatment laparotomy was done on 127 patients, 31 of whom were found to have positive paraaortic nodes (24.4%). Sixteen patients had metastatic disease within the peritoneal cavity. Standard pelvic radiotherapy was subsequently given, supplemented with a paraaortic field in those cases with positive paraaortic nodes. Survival was not significantly different in patients with or without paraaortic nodal disease. It was further noted that 17 of the 31 patients (54.8%) who had positive paraaortic nodes later had distant metastases (median time 8 months), compared to 2496 (25.0%) with negative nodes having a median time to metastases of 10 months.

Interstitial irradiation in recurrent gynecological cancer

Abstract Ninety-six patients with recurrent gynecological, cancer documented by biopsy underwent interstitial implantation at Memorial Sloan-Kettering Cancer Center during the period of 1957–1976. They are divided into two groups: Group I includes 75 patients with recurrent cervical cancer and Group II includes 21 patients with other recurrent gynecological cancer. In Group 1, 63% (47) had previously received a full course of both external and intracavitary radiation, 22% (17) had surgery and 12% (9) had both sugery and radiation as prior management for their primary disease. In two patients, the prior management was not clearly documented. Symptomatic relief was obtained in 70% of the patients who initially presented with symptoms. Without subsequent treatment, 34 of these 75 (45%) patients were alive and disease-free at one year, 15 (20%) at two years, 12 (16%) at three years, 9 (12%) at four years and 7 (10%) at five years. In Group II, 48% (10) were alive and disease free at one year, 33% (7) at two years, 24% (5) at three years, 19% (4) at four years and 5% (1) at five years.

Patterns of extension as a guide to radiation therapy in the management of ovarian neoplasms in children

Sixteen cases of childhood malignant ovarian neoplasms of varied histology and stages were reviewed with special reference to the patterns of disease extension within the pelvis and abdomen. All patients had initial surgery elsewhere before referral to Memorial Hospital. Two patients had distant metastases (bone and lung). None of the other 14 girls had disease restricted to the pelvis. The first extension in 11 was to sites within the abdominal cavity as well as to the pelvis and in three to the abdomen without pelvic involvement. Total abdominal irradiation would have been required to encompass all known disease‐bearing areas in these 14 girls.