Felix N. Rutledge

Pelvic exenteration: Analysis of 296 patients

An analysis of 296 patients who had pelvic exenteration discloses a high risk of postoperative complications and death; however, the safety has been improved by technical modifications for urinary diversion and treatment of the denuded pelvic cavity. Recurrent cancer of the cervix or vagina was the main reason for the operation. Prognostic factors were sought to improve selection of patients who are able to withstand operation, tolerate postoperative complications, and remain free of cancer. The five-year survival rate for 296 patients with various types of cancer calculated by the Berkson-Gage method was 56.5 per cent after death from all causes were deducted, the rate was 42.1 per cent. The five-year survival rate for 196 patients with recurrent carcinoma of the cervix calculated by the Berkson-Gage method was 48.3 per cent; after deaths from all causes were deducted, the rate was 33.8 per cent.

Microinvasive carcinoma of the vulva

Abstract Forty-five patients with invasive squamous carcinoma of the vulva, 2 cm. or less in diameter, were evaluated. Twenty-five of the 45 patients had carcinomas that invaded the stroma to a depth of 5 mm. or less. In this group, categorized as “microinvasive,” none had positive lymph nodes, none developed recurrence, and none died as a result of vulva cancer. The results imply that microinvasive carcinoma of the vulva is a definable stage and that this group may be treated by conservative surgery.

Advances in chemotherapy for gynecologic cancer

Considerable progress is being made in the chemotherapy of some gynecologic cancers. A random study comparing postoperative irradiation therapy with chemotherapy shows the two to be equally effective. Chemotherapy has the advantages of added safety and of being much less expensive for the patient. Postoperative chemotherapeutic treatment with VAC of patients with embryonal carcinoma of the ovary can prevent recurrence of this frequently fatal tumor. In some patients with advanced embryonal carcinoma of the ovary, chemotherapy with VAC may produce permanent remissions. Combined irradiation and chemotherapy with vincristine and actinomycin‐D may be curative for some patients with advanced sarcomas in the pelvis or abdomen. This treatment combination is associated with severe complications; however, some are preventable.

Second trial drugs in ovarian cancer

Abstract Three hundred forty-seven patients received a second trial of chemotherapy for progressing ovarian carcinoma. A complete or partial respond to the second trial of chemotherapy was noted in only 6.1% of patients. No change in the disease was noted in 12.6%, and resistance to second trial chemotherapy with progressing disease was noted in 81.3%.

Carcinoma of the cervix: the effect of age on survival.

Abstract A significant decrease in 5-year survival was found in 265 patients with invasive cervical cancer under the age of 35 compared to 820 over the age of 35 in all stages except Stage I-A and Stage IV. The exact reasons for the differences remain obscure. The greatest number of failures occurred in Stage II-B patients where, despite central control of disease, distant metastases developed. This suggests that the pretreatment evaluation of younger patients, especially those with Stage II-B cancer, should be more aggressive at attempts to detect cancer beyond the usual treatment fields. The poorer prognosis for patients under age 35 could not be explained on the basis of cell type. It was found that patients with large-cell, keratinizing cancers had a somewhat improved survival over patients with large-cell, non-keratinizing cancers.

The treatment for dysgerminoma of the ovary

Thirty‐six patients with pure dysgerminoma of the ovary were treated at the University of Texas System Cancer Center, M. D. Anderson Hospital and Tumor Institute between 1947 and 1974. Twenty‐six of these patients had their initial surgery at the M. D. Anderson Hospital or were referred to the M. D. Anderson Hospital shortly after surgery at another hospital. The remaining 10 were referred after developing a recurrence of their tumor. Five of the 26 patients who were treated initially at the M. D. Anderson Hospital had only a unilateral salpingo‐oophorectomy and are alive and well at the present time. The remaining 31 patients have received postoperative radiotherapy. Ninety‐two percent of the patients receiving initial treatment at M. D. Anderson Hospital, and seventy percent of those referred for treatment after recurrence, are surviving at the present time without evidence of disease. The selection of treatment for the individual patient is discussed.

The role of radical hysterectomy in adenocarcinoma of the endometrium

Abstract A retrospective assessment of treatment results for patients with adenocarcinoma of the endometrium shows little progress for the past 20 yr in management of this disease. These accomplishments may have been affected adversely by the increased number of elderly patients treated within recent years, for the prognosis worsens with advanced age. Likewise, because women are living longer, more enter the age when adenocarcinoma of the endometrium is prevalent, increasing the frequency of this disease. Thus, gynecologic oncologists have become aware that the treatment problem for adenocarcinoma of the endometrium deserves more research for methods to improve survival. The primary lesion is readily curable by hysterectomy. Therefore, it is the metastases which need better therapy. For this purpose, megavoltage irradiation therapy is being used more often to supplement intracavitary radium. However, the role of radical hysterectomy has been reconsidered. A review of the experiences with radical hysterectomy has been summarized from the literature and the conclusions presented.

Clinical studies with adjunctive surgery and irradiation therapy in the treatment of carcinoma of the cervix

The majority of patients with cancer of the cervix are treated adequately by irradiation alone, and surgery is not necessary. A role for operation develops in certain patients with Stage I‐II cancer of the cervix, who are prone to develop central recurrence if treated by irradiation alone. In these patients the primary lesion is massive. The vasculature to the center of these bulky or barrel‐shaped cancers is insufficient, and a population of the cancer cells, perhaps related to anoxia, is more resistant to irradiation. The postirradiation conservative hysterectomy was incorporated into the treatment plan for 212 selected patients and the number of local recurrences was reduced. Incomplete cure of the peripheral component of the disease is another mechanism of treatment failure. This may occur, even though the primary lesion is cured. Patients with cervical cancers greater than 5 cm diameter have a high incidence of node metastasis, regardless of clinical stage. In those patients with positive nodes, the standard portals for external irradiation were expanded to include nodes at higher levels. The site of metastases was established by pretreatment laparotomy and the irradiation portals were then extended to include the involved nodes. Survival rates were not improved, because recurrences were not prevented, and death from treatment complications were high.

Hexamethylmelamine: An evaluation of its role in the treatment of ovarian cancer

Hexamethylmelamine (HMM), NSC 13875, a synthetic agent structurally related to triethylenemelamine, has clinical antitumor activity and a role in the treatment of ovarian cancers of epithelial origin. Fifty-four patients, with International Federation of Gynecology and Obstetrics Stage III or IV carcinomas, previously untreated with chemotherapy or irradiation therapy, were treated with HMM (8 mg/kg/day) as a single agent at the M. D. Anderson Hospital and Tumor Institute in Houston, Texas, between January, 1973, and May, 1976. The response end points analyzed were complete plus partial response rate, duration of remission, and survival time. The complete and partial responses were verified whenever possible by second-look operation. Seventeen patients (31.8%) responded to HMM and three had no evidence of cancer, determined by multiple biopsies at second-look operation. Gastrointestinal, hematologic, and nervous system toxic effects were severe in 10 patients, requiring discontinuation of HMM. This study shows that HMM can induce a complete response and provide an extended disease-free interval without maintenance chemotherapy.

The significance of measurement of human placental lactogen, human chorionic gonadotropin, and carcinoembryonic antigen in patients with ovarian carcinoma

Human placental lactogen (HPL or HCS), the beta subunit of human chorionic gonadotropin (beta-HCG), and carcinoembryonic antigen (CEA) were measured by a specific radioimmunoassay in plasma of 65 patients with ovarian cancer. Fifty-one patients had epithelial tumors, while 14 had germ cell tumors. It was found that 47 patients (72 per cent) had high levels of plasma HPL, 29 patients (45 per cent) had high levels of plasma beta-HCG, and 34 patients (52 per cent) had high levels of plasma CEA, but there was no correlation between these protein marker levels in different patients. Twenty of these patients were studied before and after operation and during chemotherapy and/or radiotherpy. There was no consistent correlation between these marker levels and the course of the disease. These data suggest that measurement of HPL, beta-HCG, and CEA in sera of patients with ovarian cancer is not of value in assessing the clinical status of the patients or in determining the effect of therapy.