Hugh R. K. Barber

TREATMENT AND RESULTS OF RECURRENT CANCER OF CORPUS UTERI IN PATIENTS RECEIVING ANTERIOR AND TOTAL PELVIC EXENTERATION 1947--1963.

In cases of cancer corpus uteri in New York state, 30% of these patients have recurrent or persistent disease. The authors question whether further therapy, in the form of exenteration, should be offered to these patients. Of 36 patients receiving pelvic exenteration 5 or more years ago, seven received their initial treatment less than 1 year prior to treatment for recurrence and none survived more than 15 months. Of the 29 patients who were free of disease for at least 1 year after initial treatment and before receiving exenteration for recurrence, five lived 5 or more years. It is concluded that there is a limited place for pelvic exenteration in the treatment of recurrent endometrial cancer.

Incidence of carcinoma in the retained ovary

Abstract 1. 1. Among 624 cases of ovarian cancer in this series, 55 arose in patients who had previous pelvic laparotomy for a benign lesion and in whom there was preservation of the ovaries. Thus, if oophorectomy had been performed previously in these patients, cancer would have been prevented in 8.8 per cent of patients with ovarian cancer seen in this institution from September 1947 through December 1960. In 35 per cent of the patients pelvic laparotomy had been performed five years or less prior to the diagnosis of ovarian cancer. 2. 2. The five year cure rate among the fifty-five patients with cancer in retained ovaries was 18 per cent (ten patients); five of the ten patients lived over five years but eventually died of the disease. 3. 3. Among thirty-four patients who had pelvic laparotomy after the age of forty in whom one or both ovaries were left in situ and in whom carcinoma eventually developed, only two were subsequently cured. Among twenty-one patients whose laparotomy with retention of ovaries was performed when they were less than forty years old, three survived five years after operation for ovarian cancer. 4. 4. The evidence presented herein may be interpreted as justification for bilateral oophorectomy in all patients forty years of age or older receiving pelvic laparotomy for benign lesions as a prophylactic measure for ovarian cancer, when one considers only those women in whom this form of cancer is destined to develop. 5. 5. There is little justification for preserving an ovary at any age if there are atrophic changes in the ovaries, vaginal cytologic studies indicating significant estrogen deficiency, and evidence of arteriosclerosis when the abdomen is open. 6. 6. The peak incidence of ovarian cancer is in patients between forty-five and fifty-five years of age. 7. 7. The prognosis appears to be more favorable in patients below forty years of age and less favorable in those over forty years of age. 8. 8. If there is any doubt as to the status of the ovaries during laparotomy for any condition in patients over forty years of age, it is advisable to remove the ovaries and institute substitution therapy if needed. (Ovaries should be excised at the time of laparotomy for cancer of the gastrointestinal tract.) 9. 10. If for any sound reason ovaries are to be preserved in patients over forty years of age, they should be bisected and biopsied prior to retention.

Antigenic and morphologic properties of ovarian carcinoma

Abstract The application of virologic and immunologic methods to the study of human tumors recently has made significant progress. However, ovarian carcinoma has received thus far little attention in sharp contrast to its clinical importance. As part of a multilateral study of ovarian carcinoma comprising 68 cases, tumors representing all four major histologic types have been explanted in tissue cultures, examined under the electron microscope, and used in immunologic assays. The ultrastructure was characterized by nuclear and nucleolar pleomorphism which correlated well with the degree of malignancy and tumor grading. Cytoplasmic organelles and intercellular junctions were abundant and fairly well differentiated even in ovarian carcinoma of higher grade and stage. Active processes of synthesis and secretion taking place in most of these tumors were suggested by the presence of a richly granular endoplasmic reticulum, dilated cisternae, and numerous secretory granules. All tumors were cultured in vitro and their morphology in light and electron microscopy was compared to that of the original tumors. They displayed a consistent pattern of growth after several months in vitro and numerous subcultures, which led to the conclusion that ovarian tumor cells in culture have preserved most of their salient features and are representative of the original tumors from which they have been derived. The immunologic studies included cytotoxicity assays using the patients own serum and were indicative for the presence of specific humoral antibodies. In other studies a specific antiserum was prepared in a heterologous system then concentrated, purified, and fractionated. Immunofluorescence and immunodiffusion assays revealed a high degree of specificity for this antiserum.

The postmenopausal palpable ovary syndrome.

The time has come to reevaluate our clinical approach to ovarian pathology. Although carcinoma of the endometrium is still the most prevalent cancer of the female reproductive system, ovarian carcinoma has become the leading killer of women who die from gynecologic malignancy. With the present state of diagnostic development, diagnosis of an ovarian tumor is a matter of chance rather than a scientific discovery. By the time it is diagnosed, ovarian cancer in more than 70 to 80% of the patients has spread beyond the ovary. The hard fact remains that a pelvic mass found during a pelvic examination is the only practical and consistent clinical method available to us to detect an ovarian tumor. Certain functional or dysontogenetic tumors with hormone activity are the exception. However, there are only a few such tumors compared to the number of epithelial tumors, which comprise the main group of killers.

Cellular immunologic responsiveness to extracts of ovarian epithelial tumors

Abstract In this study the leukocyte migration-inhibition assay was employed in an attempt to detect cellular immunological responsiveness to a solubilized extract of pooled, epithelially derived ovarian carcinomas. This extract was prepared from fresh, sterile, surgical specimens of serous and mucinous cystadenocarcinomas as per our laboratorys protocol for tissue extractions used in immunodiffusion studies. In six of seven patients having cystadenocarcinomas of the ovary, leukocyte migration inhibition was noted in the presence of the ovarian tumor extract in our tissue culture system when compared to the migration of test leukocytes which were not exposed to the ovarian extract. Leukocytes obtained from patients having nonepithelial ovarian cancers, benign ovarian neoplasms, and other genital tract cancers showed no inhibition of migratory behavior when exposed to the ovarian tumor extract as compared to controls. Cells from normal pregnant and nonpregnant females, as well as male subjects, also showed no inhibitory response when incubated with the ovarian tumor extract. Although the exact nature of the antigenic specificities uniquely associated with ovarian serous and mucinous cystadenocarcinomas is unknown, our data suggest that cellular immune mechanisms may be involved in the host response to cells bearing tumor-specific antigens.

Sex Steroid Receptors

Sex steroid hormone receptors provide the means by which estrogen and progesterone influence their target tissues. Receptor assays have proved clinically useful for the management of breast cancer. Their application to study of the ovary is currently undergoing intensive investigation.

Current status of the treatment of gynecologic cancer by site: ovary.

Cancer of the ovary is the leading cause of death from gynecologic cancer. The constant challenge presented by ovarian cancer is that about 11,000 women die from ovarian cancer each year and the results in 1974 are no better than have been achieved in the previous two decades. Standard practice of treatment for truly invasive common epithelial ovarian cancer includes total hysterectomy, bilateral salpingo‐oophorectomy, appendectomy, omentectomy, and postsurgical insertion of tubes and administration of P32 (if the disease is of limited extent). Although it is occasionally necessary to resect isolated segments of bowel, exenterative or ultraradical surgery in the management of ovarian cancer is not usually chosen because of the natural history of the disease. However, aggressive surgery is indicated not so much because it is curative, but because it potentiates other forms of treatment. All stages I through IV are treated surgically, to remove as much tumor as possible without running a risk of a gastrointestinal or genitourinary fistula. Radiation therapy has been utilized in addition to the surgical therapy in stage IV to control supraclavicular and/or inguinal node involvement. Single agent alkylating chemotherapy is chosen for the treatment of common epithelial ovarian cancers. Combination chemotherapy does not produce better results at this time, except in the treatment of embryonal tumors. The treatment of the common epithelial tumors by stage is outlined. The treatment of germ cell tumors, gonadal stromal tumors, ovarian tumors in childhood, ovarian tumors in pregnancy, as well as tumors not specific for the ovary, will also be discussed.

Uterine cancer (prevention)

Cancer prevention as related to the problem of cervical and endometrial cancer involves a great number of factors that are considered contributory to the development of neoplasms in the uterus. Lifestyles encouraging the development of cervical cancer are different from those encouraging endometrial cancer. Cancer of the cervix is a disease of the inner city. It is seen in those starting intercourse in their teens, having multiple partners, having many children, and coming from the low socioeconomic groups. Semen and herpes virus II may have an adverse effect on immature cells, but there are no hard data to confirm these roles. Cancer of the endometrium is a disease of suburbia. The American Cancer Society estimates that there will be 38,000 new cases of endometrial carcinoma in 1980, making it the most common female genital cancer. Women at highest risk for later carcinoma of the endometrium are those who have obesity, diabetes, infertility, irregular menses and failure of ovulation, adenomatous hyperplasia, and/or prolonged estrogen administration. For both cervical and endometrial cancers, it is possible to identify the high‐risk patient, to detect changes at an early stage, and, by instituting appropriate therapy, to prevent a more serious problem. It is obvious that prevention, detection, and treatment are all closely intertwined. This paper identifies the patient at high risk and makes suggestions for correcting any imbalance that may predipose to the development of invasive cancer. Cancer 47:1126–1132, 1981.

Second Look Operation

Early diagnosis of ovarian cancer is a matter of chance rather than scientific discovery. The same frustration confounds any attempt at detecting early recurrence of disease. Currently, laparoscopic examination and laparotomy are the only means available that have a predictable rate of accuracy. Periodic gynecologic examinations have not been helpful. Cul-de-sac aspiration, cytology, and serum enzyme studies have limited application in the initial diagnosis. Tumor markers, such as CA125, CA15-3, CA19-9, NB/70K, LASA-P, carcinoembryonic antigen, α-fetoprotein, human chorionic gonadotropin, acute phase reactive proteins, complement components, and complement inhibitors, if present, can serve to monitor response to treatment. Ultrasonography is employed to evaluate the position and volume of tumor; and if disease is identified with this technique, ultrasonography is employed to monitor therapy.

Bilateral ovarian dermoids in pregnancy

Abstract 1. 1. An additional case of bilateral ovarian dermoids in pregnancy is reported, bringing the total number of reported cases up to 66. 2. 2. Of the total number of cases reported only 10 cases were treated with conservative ovarian surgery. 3. 3. The present patient treated conservatively has continued to menstruate normally and endometrial biopsy done 6 months post operation revealed secretory endometrium and thereby gives presumptive evidence of ovulation. 4. 4. A plea is made for conservative ovarian surgery and reasons are advanced to support this plea.