John H. Ford

Results and complications of operative staging in cervical cancer: Experience of the Gynecologic Oncology Group

Abstract A multiinstitutional study by the Gynecologic Oncology Group (GOG) has confirmed that clinical staging often is inaccurate in determining the extent of disease in patients with cervical cancer. The finding of positive paraaortic nodes in 29% of patients with Stage II, III, and IV tumors supports this conclusion. In this series, the incidence of paraaortic nodal metastases could not be correlated with the histologic grade of the tumors . With positive paraaortic nodes, conventional treatment limited to the pelvis can be expected to fail, but it is still not clear how many patients can be salvaged by treatment to extended paraaortic radiation fields . Longer periods of follow-up in patients whose treatment plans were based on surgical staging information will be required.

Exploratory celiotomy for surgical staging of cervical cancer

Abstract Exploratory celiotomy has been evaluated for surgical staging of cervical cancer prior to therapy. In an 18 month period, 70 of 82 patients with untreated cervical cancer were explored abdominally prior to definitive treatment. Exploration revealed that clinical staging was inaccurate in 38.6 per cent of patients studied. Fourteen and three tenths per cent of the patients had aortic lymph node metastasis. Surgical staging modified therapy considerably whether primary therapy was by radical operation or radiation. This approach to cervical cancer hopefully will improve the over-all 5 year survival rate.

Radical hysterectomy and pelvic lymphadenectomy for the management of early invasive cancer of the cervix

Abstract In recent years there has been an increasing awareness that radical hysterectomy and pelvic lymphadenectomy can play an important role in the management of early invasive cervical cancer. The present report presents 224 patients with early cervical cancer managed by radical hysterectomy and pelvic lymphadenectomy in a gynecologic oncology training program at the University of Miami School of Medicine. Our operative mortality is 0.89% and our primary fistula rate is 1.3%. The survival rate as calculated by the life table method is 87%. A review of the recent literature as to the management of early cervical cancer both by radical hysterectomy and pelvic lymphadenectomy and by radical radiotherapy is presented. We have shown that not only does radical hysterectomy and pelvic lymphadenectomy have definite advantages for most patients with early invasive cancer of the cervix, but that such procedures can be carried out in a gynecologic oncology training program with a minimum morbidity and mortality.

Diagnosis and management of microinvasive (stage IA) carcinoma of the uterine cervix

One hundred and sixty‐two cases of Stage IA microinvasive carcinoma of the cervix are presented. These patients represent the combined experience at the University of Miami School of Medicine, Miami, Florida, and Downstate Medical Center, Brooklyn, New York. The criteria used in both institutions are 1) penetration of invasive carcinoma beneath the basement membrane of less than 1 mm and 2) absence of invasion of blood vessel or lymphatic spaces. All tissue specimens have been measured accurately by use of calibrated optics. The literature has been reviewed for criteria of diagnosis of microinvasive cancer, as well as methods of management. Our method of accurately determining depth of penetration is described and the evolution of microinvasive cancer is presented in a series of photomicrographs in which measurements are accurate to 0.1 mm. In the literature, when depth of penetration of up to 5 mm is used as criterion for microinvasive carcinoma, the incidence of nodal metastasis may be as high as 3.5%. Since, in our combined institutions, the mortality rate with radical hysterectomy is less than 1% and the incidence of ureterovaginal fistulas is 1.2%, we conclude that simple hysterectomy is not adequate therapy for lesions with stromal invasion to a depth of 5 mm.

Carcinoma of the cervix and pregnancy

Abstract All patients with cervical cancer diagnosed during pregnancy at Jackson Memorial Hospital, the University of Miami School of Medicine, from 1960–1970 have been reviewed. There are 122 patients in this group; 99 had carcinoma in situ and 23 had invasive cancer. The prevalence rate for carcinoma in situ during pregnancy, was 0.192% and for invasive carcinoma, 0.046%. Of the patients, 95% had a Class III or higher Papanicolaou smear which led to the diagnosis. This is a young population in that the mean age was 29.6 years. Therapy for Stage 0 carcinoma and Stage IA (microinvasive) carcinoma was total hysterectomy, whereas radical hysterectomy with pelvic lymphadenectomy was recommended for Stage IB/IIAcarcinoma of the cervix. Radiotherapy was utilized for more advanced disease or in patients with contraindications to surgery. The importance of adequate follow-up is emphasized in that six patients with carcinoma in situ during pregnancy were found to have invasive carcinoma at a later date and two patients with invasive carcinoma had progression of their disease when treatment was delayed. The survival rate with radical operation during pregnancy for Stage IB and IIA carcinoma has been 90% in 10 patients followed nearly 3 years or longer. An additional four patients had radical operation in the follow-up period and all four are clinically free of recurrent cancer at the present time. Major complications were high in those patients treated with primary radiotherapy, and of the five patients who were so treated, four have died, one with recurrent carcinoma and the other three from complications of radiotherapy. An additional three patients were treated with primary radiotherapy during the intrapartum period. In this group two have died of recurrent cancer while one remains clinically free of cancer.

Influence of exploratory celiotomy on the management of carcinoma of the cervix. A preliminary report.

The policy of treating patients with Stages IB and IIA carcinoma of the cervix by radical hysterectomy and pelvic lymphadenectomy led to the initiation of laparotomy staging of carcinoma of the cervix in 1970. Two‐hundred twenty patients were subjected to surgical staging at which time bilateral aortic lymphadenectomies and biopsies of perirectal and perivesical spaces were done. If these were negative, radical hysterectomy and pelvic lymphadenectomy were performed in patients with surgical Stage IB and IIA. Para‐aortic node involvement was seen in 7%, 14%, 18%, and 19% in patients with Stages IB, IIA, IIB, and IIIB, respectively, in the context of the surgical material being heavily weighed in favor of early stage disease. The methods of management in these patients were designed according to the findings at exploratory celiotomy. Twenty‐one patients were found to have positive para‐aortic nodes and received en bloc pelvis and para‐aortic irradiation. Four patients are alive and well at 63,23,20, and 19 months, respectively. One patient is alive with disease at 18 months. Two died from other causes at 34 and three months. There was no difference in the survival of the two groups of patients among 75 with negative para‐aortic nodes, who received either pelvic irradiation alone or pelvic and para‐aortic irradiation on the basis of possible presence of subclinical disease not dissected at the time of surgery.

Parenteral hyperalimentation in gynecologic oncology patients.

Abstract Parenteral hyperalimentation has been introduced as an adjunct in the care and management of the patient with gynecologic cancer. Our indications for parenteral hyperalimentation and results of therapy are presented. The complications of this form of therapy are reviewed and measures to prevent complications are suggested. In selected patients, with proper monitoring, parenteral hyperalimentation may prove to be a lifesaving measure.

Selective therapy for early cancer of the cervix: I. Surgically explored nonresected cases

Abstract During 1967–1976, 337 new cases of cancer of the cervix, stages IB and IIA, were treated in our Institution. Radical hysterectomy with pelvic lymphadenectomy was the preferred mode of therapy. It was used in 254 patients. In 36, radical hysterectomy was selectively abandoned as therapy after surgical exploration where greater extension of disease was found than clinically suspected, and in one patient surgical therapy was not done because of coexisting cancer of the breast. One patient had primary pelvic exenteration and 36 were treated by radiation therapy. The extension of disease in these patients is analyzed by a modified Meigs-Brunschwig surgical and pathologic classification. The 3-year survival following other therapy was 50% among 24 patients. The most favorable mode of spread was paracervical extension without involvement of pelvic or periaortic lymph nodes. The most devastating was metastases to periaortic nodes. Only one out of seven patients was alive at 3 years. The complication rate with radiation therapy following surgical exploration was low.

Surgical management of invasive carcinoma of the vulva utilizing a lower abdominal midline incision

Abstract An approach to radical vulvectomy and bilateral lymphadenectomy utilizing a lower abdominal midline incision is presented. Nineteen patients were operated on for invasive vulvar carcinoma utilizing this technique, while fifteen patients were operated on with the more traditional transverse incision for groin dissection. When evaluated by intraoperative and postoperative parameters, the two techniques gave roughly identical results. The midline approach can be particularly valuable in those situations where celiotomy is to be performed at the time of radical vulvectomy.

Survival of patients with positive aortic nodes in clinical stage I and IIA carcinoma of cervix

Fifty-five patients with histologically confirmed Stage II adenocarcinoma of the corpus uteri were treated with combined radiation therapy and surgery and followed for 2 to 10 years. The overall survival at 5 and 10 years is 75% and 56% respectively; the age adjusted survival is 93%.and 73% respectively. Disease free survival is 88% at 2 years and 83% at both 5 and ID years. Although 10 patients (18%) failed treatment, each local pelvic recurrence was accompanied by dissemination elsewhere. Histological grade and extent of involvement of the uterine cervix at time of examination under anesthesia are statistically significant prognostic factors. Age, depth of uterine sounding, and depth of myometrial invasion by tumor were not of prognostic value. We conclude that combined pre-operative external beam and intracavitary radiation with total abdominal hysterectomy and bilateral salpingo-oophorectomy is the preferred treatment for stage II endometrial carcinoma because of the excellent survival and low morbidity. Furthermore, both histologic grade and extent of cervical involvement predict the natural history of stage II disease.