Henry Clay Frick

Vulvar intraepithelial Neoplasia (severe atypia and carcinoma in situ). A clinicopathologic analysis of 41 cases

Forty‐one cases of vulvar intraepithelial neoplasia (VIN) were analyzed clinicopathologically with emphasis on the changes in age‐specific incidence rates, coexisting condylomata, coexisting koilocytotic atypia, subsequent invasive carcinoma and response to therapy. The number of cases referred to in the interval from 1975 to 1982 was 26 compared with 15 in the interval from 1966 to 1974. In addition, the percentage of patients in each group younger than 45 years of age was 66% after 1975 versus 33% prior to 1975. The yearly incidence of patients older than 45 years of age remained constant. The association of condyloma or marked koilocytosis in the neoplastic epithelium per se correlated with a younger mean age (31.1 and 31.8 years, respectively) than the absence of condyloma or marked koilocytosis (45.5 years and 47.5 years, respectively). Carcinoma developed in five patients (10.2%), and the mean age of the group was 55 years. Four of the five developed carcinoma within 3 years of diagnosis of the VIN. The incidence of persistence of the VIN lesion or recurrence following local excision was 22% over a mean following of 6.1 years. Spontaneous regressions were not reported in this patient population. Vulvar intraepithelial neoplasia appears to be a disease of multiple etiology which affects at least two populations. The younger patients are associated with papilloma‐virus infection, and have a low risk of progression to cancer. The older patients have a variable history of condylomata, and a higher risk of developing invasive cancers of the anogenital region. The most important risk factor from the clinicopathologic standpoint appears to be age.

Uterine sarcomas: A clinicopathologic study, 1965–1981

Forty-six cases diagnosed as uterine sarcoma from 1965 to 1981 were analyzed. Using mitotic count, 7 of 21 leiomyosarcomas (LMS) were redesignated leiomyomas and all are NED. The actuarial survival rates for the 38 considered sarcomas were 55 and 27% at 2 and 5 years. (The 22 patients eligible for 5-year follow-up had a 27% absolute survival, with 3 of 22 NED.) Fourteen LMS patients had a superior 5-year actuarial survival (42%) than 18 malignant mixed mesodermal (MMM) patients (15%), but the difference disappears when only patients under 70 are considered. Stage and age were the most important prognostic indicators. Complete surgical resection was essential for long-term survival. Six resected patients given adjuvant chemotherapy (mostly VAC) had an improved actuarial survival (61 vs 15% for the 23 resected patients not receiving chemotherapy). Seventy percent of 23 recurrences occurred within 2 years and average survival post-recurrence was 7.6 months. Survival post-recurrence for 8 patients was not improved by chemotherapy. Seventy-eight percent of recurrences had a distal component, with lung being the most common site.

Critical points of failure in the therapy of cancer of the cervix: A reappraisal

Abstract All patients admitted to the Columbia-Presbyterian Medical Center and the Francis Delafield Hospital from January 1, 1955, to December 31, 1964, with recurrent carcinoma of the cervix have been studied in regard to initial staging, histologic type, age, pretreatment pyelogram, and initial therapy. The pattern of recurrence has been classified according to Munnell and Bonneys 1 system, and the results of treatment have been analyzed. Of the 134 patients with recurrence, 54 could be treated for cure, the remaining 80 patients receiving only supportive or palliative therapy. Fourteen of the 54 patients (25.9 per cent) treated for cure, or 10.4 per cent of the entire 134 patients, survived more than 5 years after treatment of the recurrence. Central recurrences are most amenable to therapy; peripheral pelvic and metastatic recurrences, least amenable. Back pain, sciatic pain, weight loss, and obstructive uropathy are grave prognostic signs. The proper method of treating a recurrence depends on the pattern of recurrence and the type of therapy previously employed. Since the most common sites of recurrence are the parametria, uterosacral ligaments, rectum, and bladder, it is evident that methods of primary therapy should be re-examied with respect to their effectiveness in destroying all of the cancer at the periphery of the treated fields.

Malignant mixed tumor of the vagina probably arising in mesonephric rests

An exceedingly rare tumor arising in the upper lateral vagina is described histologically, histochemically, and ultrastructurally. It is compared to the lesion reported by Okagaki et al. which is considered to represent the same type of tumor. Comparison with synovial sarcomas indicates that the lesion is similar, but the reasons why it should not be so classified are discussed. Evidence is presented for the origin of these tumors in mesonephric rests (Gartners duct).

The efficacy of chemotherapeutic agents in the management of disseminated gynecologic cancer

Abstract 1. 1. The results of chemotherapy in 206 patients with disseminated gynecologic cancer have been reviewed. 2. 2. About 15 per cent of the patients with advanced ovarian cancer treated by alkylating agents showed an objective response that lasted at least 6 months. 3. 3. There was also an objective response in 3 out of 10 patients with disseminated endometrial cancers treated by massive doses of progestational drugs for 3 or more months. 4. 4. There was, however, no evidence that the drugs used increased the total life expectancy of the patient.

I. Urinary tract fistulas following radical surgical treatment of carcinoma of the cervix (exclusive of exenterations).

Abstract In the performance of radical surgery for cancer of the cervix (exclusive of exenterations), as previously stated, the occurrence of lower urinary tract injury is a hazard that must be expected and accepted. Avoidance of such complications, however, must be constantly kept in mind, and conservatism of the operative attack to obviate urinary tract damage must always be balanced against maintaining radicality in the attack upon cancer. An actual experience based upon 212 consecutive operations envisaging cure of cancer of the cervix (excluding exenterations) is reported. The incidence in this series of postoperative urinary tract fistulas was 23.5 per cent (50 instances). There were 27 ureteral fistulas, an incidence of 12 per cent, and 23 vesical fistulas, an incidence of 11 per cent. There were two deaths attributable to the reparative surgery; an incidence of 4.3 per cent surgical mortality compared with about 1 per cent mortality for the cancer operation itself. Twenty-two of the patients who developed postoperative urinary tract fistulas were living and well, free from cancer five or more years after their original operation (44 per cent five-year survivals among all patients in Stages I, II, III, IV). Of the 28 patients who did not survive, 25 died of cancer in less than five years. Of the 22 patients who survived five years, 11 are classified as “urological cripples” because they have nephrostomies, cutaneous ureterostomies, persistent fistulas, or severe incontinence without “ostomies.” These, however, all seem to be adjusted to their situations and are not invalided (except one). Eleven are living and well without fistulas or incontinence. Since this series has been accumulated the radicality of the panhysterectomy and node dissection has been modified to preserve the periureteral layer of connective tissue and often the mesial leaf of peritoneum attached to the upper two-thirds of the pelvic portion of the ureter. These measures seem to have reduced the incidence of ureteral fistulas, but definite conclusions must await actual tabulations at a later date. This report as presented is intended as a record of experience to serve those who may embark on the surgical treatment of cancer of the cervix and to emphasize the hazard of closely stripping the ureters. Reports recently published of cases in which the dosage of radiation has been increased indicate an incidence of urinary tract fistulas appreciably above that often previously reported for complications of radiation therapy. It is our opinion that while lower urinary tract fistulas are complications encountered in the radical surgical treatment of cancer of the cervix, they do not pose a serious deterrent to such treatment. The problem of urinary fistulas is one that can be coped with. In the development of the modern surgical attack upon cancer of the cervix, it behooves the original operator to become familiar with the fistula problem and while calling upon his urological colleagues for help and advice he should, as time goes on, perfect himself in the reparative surgery necessary and from his own experience develop judgment for the management of these and all other complications which may ensue from the original surgery.

Disseminated carcinoma of the ovary treated by L‐phenylalanine mustard

Forty cases of widely disseminated ovarian cancer were treated with L‐phenylalanine mustard administered by mouth. The diagnosis in all cases was established by biopsy. There were 12 objective responses. A case was classified as showing an objective response if one or more of the following phenomena occurred: (1) 50 % or more decrease in the clinical size of the tumor mass; (2) 50% or more decrease in the size of the tumor on roentgenogram and (3) 50% decrease or complete disappearance of pelvic and pleural effusion. The response lasted 3 to 36 months or more. The authors found no evidence to suggest that the drug prolonged life. Complications from the drug were minimal and in most instances the patients were managed as out‐patients during a large part of their treatment. The effect of phenylalanine mustard on disseminated ovarian cancer was much the same as that of other alkylating agents.

Palliative urinary diversion in patients with advanced carcinoma of the cervix

During a 10‐year period 47 of 222 patients with advanced carcinoma of the cervix admitted to the Francis Delafield Hospital had ureteral obstruction on initial admission. All but 3 of the 47 patients were treated with roentgen rays and/or radium; the exceptions underwent radical surgery. Twelve patients underwent palliative urinary diversion. There was no statistical significant difference in the survival rates of the patients who underwent urinary diversion and those who did not, irrespective of the stage of the disease and whether one or both ureters were involved; however, 8 of the 12 patients who underwent urinary diversion had partial relief of their symptoms. The indications for urinary diversion followed by the authors are ennumerated.

Prognostic significance of ureteral obstruction in carcinoma of the cervix.

Fifty patients with advanced cervical carcinoma were studied to determine the significance of the degree of ureteral obstruction. No correlation could be found between the survival rates and the amount of ureteral obstruction as measured by excretory urography.

Occlusion of the Fallopian tubes with tantalum clips

The Fallopian tubes of 8 animals 3 baboons and 5 rhesus monkeys were occluded with tantalum or silver clips. There was no sloughing or tissue irritation. Upon removal of the clips after 1-7 months tubal patency seemed restored in 1/2 the cases; the rest seemed in the process of recovery. When 2 clips were applied to a tube hydrosalfpinx developed between the blocks indicating closure of that section. The clips were applied with a specially designed stapling instrument introduced through the cul-de-sac with Deckers technique of culdoscopy. Both placing the clips and removal may be done without laparotomy. The procedure may be regarded as a contraceptive measure rather than sterilization.