Felix Rutledge

The prognostic value of peritoneal cytology in gynecologic malignant disease

Abstract A study was undertaken to determine if peritoneal cytologic examination at the time of laparotomy could detect nonclinical malignant disease within the peritoneal cavity and thereby be of prognostic value. Between 1961 and 1968, 1,243 cytologic examinations were made of peritoneal specimens obtained from 1,035 patients. Analysis of this material indicates that peritoneal cytologic findings correlate well with prognosis in corpus, ovarian, and cervical malignant lesions. Cytologic examination can detect nonclinical disease spread in early ovarian lesions. In the absence of clinically evident ovarian cancer at the time of “second-look” operation, abnormal cytologic findings may serve as a guide to continuing chemotherapy or changing the mode of therapy. All patients who have gross disease present within the peritoneal cavity at laparotomy do not have malignant cells present in the peritoneal washings. Those patients with normal cytologic findings have a significantly better prognosis than the similar patient with abnormal cytologic findings.

Cancer of the vagina

Abstract Vaginal cancer may not be as uncommon or have as poor a prognosis as was formerly believed. In this series of 101 patients, which included 70 with invasive and 31 with in situ lesions, intravaginal radium, either alone or in combination with external irradiation, was the principal form of therapy. Results show that aggressive treatment is worthwhile in early or moderately advanced disease. The preferred treatment is still unclear, however, and can only be determined by combined experience. Observations are also presented on 23 patients with in situ-like changes developing after radio-therapy for cervical carcinoma. Such changes may or may not represent cancer.

Carcinoma of the vulva

Carcinoma of the vulva is a relatively uncommon malignancy and accounts for 3%–5% of all gynecologic malignancies in the United States. Preservation of function, as well as anatomy, can be paramount in the decision-making process for the treatment of vulvar cancer. Except for diseases with very limited volume and extent that can be treated with surgical excision only, the majority of cases require multidisciplinary management. Radiation therapy plays a major role in the treatment of vulva cancer. Adjuvant radiotherapy is indicated in patients with certain risk factors of locoregional recurrence after surgery. For locally advanced disease or lesions with extension to the midline structures, concurrent chemotherapy +/- surgery is usually the preferred treatment choice.

Cell-mediated immunity to human malignant cells: A brief review and further studies with two gynecologic tumors

Abstract A growing interest in cell-mediated immune response to human malignant tumors is reflected in the recent reports of several investigators. Some of these are briefly reviewed. In addition, evidence is presented that patients with advanced squamous cell carcinoma of the uterine cervix and adenocarcinoma (serous) of the ovary circulate presensitized peripheral blood lymphocytes which in vitro produce a prompt cytotoxic effect on allogenic tumor cells in tissue culture. Lymphocytes from normal donors were cytocidal only after a “learning” period of 48 to 96 hours. The presence of tumor-specific antigens in these two malignancies is suggested. Observations on the interaction of tumor cells and lymphoid cells are described. A “blocking” or enhancing antibody could not be demonstrated in 22 patients studied with progressive disease.

Chemotherapy in the treatment of cancer of the ovary

Most of the ovarian cancer patients referred to The University of Texas M. D. Anderson Hospital and Tumor Institute at Houston are not suitable for either curative operation or irradiation because their cancers are too advanced; however, about one-half profit from chemotherapy with l -phenylalanine mustard and about one-half who are not benefitted by l -PAM, will have regression of their cancers with more intensive chemotherapy of actinomycin-D, 5-fluorouracil, and cyclophosphamide. Such chemotherapy often affords sufficient regression of ovarian cancer to allow resection or irradiation or both, and occasionally causes complete and sustained remissions of such cancers.

Treatment of intraepithelial carcinoma of the vulva by skin excision and graft

Abstract Preliminary observations are presented on the use of skin excision and graft for 10 selected patients with intraepithelial carcinoma of the vulva. These were all patients for whom the deformity resulting from vulvectomy could possibly have been an obstacle to an enjoyable sex life. Because of the danger of obscure invasive carcinoma, however, the operation was limited to those patients with well-defined lesions. The case histories of these 10 patients and of 46 others with intraepithelial vulvar carcinoma were analyzed for pertinent clinical features. In this procedure, the skin was excised to the depth of a layer of loose fibroelastic tissues immediately below the cutis and the excision usually extended around the inside of the labia majora, partially amputated the clitoris, and excised the labia minora, skin of the vestibule, and part of the posterior aspect of the mons. The donor site was the inner aspect of the thigh or, sometimes, the abdomen. Logically, skin excision and graft should be adequate treatment for a comparatively small group of patients. The depth and area of the skin excised should be sufficient for control. A longer period of time is necessary, however, for verification.

Second-look operation in ovarian carcinoma: postchemotherapy.

One hundred and three patients with advanced ovarian cancer underwent a second‐look operation following chemotherapy. Patients should have ten or more courses of chemotherapy before second‐look operation. Those patients with no evidence of disease at the second laparotomy should discontinue their chemotherapy. Patients who continued chemotherapy after the second‐look operation did better than those who were treated with radiation after surgery. Only patients with clinical remission benefit from the second‐look procedure. Advantages of second‐look operations following chemotherapy are discussed.

Chemotherapy of ovarian cancer. New Approaches to Treatment

In an effort to develop a more effective treatment regimen for patients with advanced epithelial cancers of the ovary, patients treated with single agent chemotherapy with an alkylating agent; a three‐drug combination of actino‐mycin D, 5‐fluorouracil, and cyclophosphamide; chemotherapy followed by irradiation, and chemotherapy followed by surgery were compared. Only patients treated with chemotherapy followed by surgery had an improved survival over patients treated with a single alkylating agent.

Lymphocysts; a complication of radical pelvic surgery.

Abstract Lymphocysts developed in 68 of 281 patients following pelvic lymphadenectomy, an incidence of 24 per cent. This is the second report in the American literature of this complication in a large series of cases. The statistical relationship of the incidence of lymphocyst formation to the stage of the carcinoma, preoperative irradiation, and metastases to the regional lymph nodes is presented. No one factor can be isolated as the causative agent at the present time. Methods of diagnosis, prevention, and treatment are discussed. The significance of this problem is reflected in the prolonged postoperative disability that follows this complication.

Malignant gynecologic tumors in children: Current approaches to treatment

Abstract Although at one time malignant gynecologic tumors in pediatric patients were almost always lethal, today, with better understanding of the behavior of these tumors and the use of radical measures, some success can be achieved. Specifically, our experience with 33 patients indicated that: (1) location and treatment with adequate irradiation of the sites of metastatic disease may afford the patient with dysgerminoma of the ovary a chance for cure; (2) intensive chemotherapy used in addition to the indicated surgical procedure may benefit children with embryonal carcinoma of the ovary; (3) children with sarcoma botryoides, once a uniformly fatal disease, may be cured with pelvic exenteration; and (4) the combination of chemotherapy and irradiation for patients with rhabdomyosarcoma of the pelvis may prove to be the most effective treatment.