Paul B. Heller

Surgical pathologic spread patterns of endometrial cancer: A gynecologic oncology group study

The surgical pathologic features of 621 patients with Stage I carcinoma of the endometrium are presented. All patients were treated with primary surgery consisting of total abdominal hysterectomy, bilateral salpingo‐oophorectomy, selective pelvic and paraaortic lymphadenectomy and peritoneal cytology. An appreciable number of patients (144—22%) with Stage I cancers have disease outside of the uterus (lymph node metastasis, adenexal disease, intraperitoneal spread and/or malignant cells in peritoneal washings). Multiple prognostic factors particularly grade and depth of invasion are related to extrauterine disease. This study adds credence to the primary surgical approach with individualized postoperative therapy as indicated.

Extraperitoneal versus transperitoneal selective paraaortic lymphadenectomy in the pretreatment surgical staging of advanced cervical carcinoma (A Gynecologic Oncology Group study)

Abstract Two-hundred and eighty-eight patients with predominately stage IIB or IIIB cervical carcinoma underwent pretreatment surgical staging including selective paraaortic lymphadenectomy (SPAL), followed by pelvic irradiation with or without paraaortic irradiation (RT). Four patients were excluded from analysis (two received no RT and two were insufficiently documented). Of the remaining 284 patients, 128 underwent extraperitoneal (EP) SPAL and 156 transperitoneal (TP) SPAL procedures. Age, race, and stage (clinical and surgical), cell type, paraaortic nodal status, and peritoneal cytology findings were similar in both groups. Complications presumed to arise from operative staging were infection, which was similar for both groups, and vascular injury, which was higher in the TP group, although not statistically significant. Complications subsequent to RT fell into two categories: local—pelvic necrosis, vesicovaginal and rectovaginal fistulas, proctitis, etc., and regional—enterovaginal fistula, bowel obstruction, enteritis, bowel perforation, etc. The frequency of local complications was similar for both EP and TP patients. Utilizing univariant analysis, among regional complications, both bowel obstruction and nonobstructive enteric injuries were observed significantly more often in TP patients than in EP patients (11.5% vs 3.9%, P = 0.03, for both types). Multivariant analysis confirmed these observations. This report supports the conclusions that in advanced cervical carcinoma (1) EP- and TP-SPAL are of similar sensitivity in detecting nodal spread, (2) no significant differences in the frequency of surgical complications could be detected between EP- and TP-SPAL groups, and (3) TP-SPAL is associated with a higher frequency of certain postirradiation regional enteric complications.

Prognostic factors associated with radical hysterectomy failure

Two hundred seventy-five patients who underwent radical hysterectomy and pelvic lymphadenectomy for FIGO stage IB carcinoma of the cervix between 1961 and 1982 were retrospectively analyzed to identify specific risk factors associated with treatment failure. Patients were classified as high or low risk on the basis of tumor spread to pelvic lymph nodes or surgical margins. Thirty-eight patients had tumor involvement of pelvic nodes or surgical margins. Despite postoperative whole pelvis radiation therapy in 88% of patients, 13 (34.2%) developed recurrence. All patients with involved nodes or margins who recurred died of disease. Patients with pelvic lymph node or surgical margin involvement clearly constitute a high risk group and should be considered candidates for some form of adjuvant therapy. Two hundred thirty-seven patients had negative nodes and clear surgical margins. There were 18 recurrences (7.6%) in this group. Pathologic specimens were reviewed to evaluate additional histologic criteria which might identify those patients at greatest risk for tumor recurrence in this low risk group. Patients whose tumors contained vascular-lymphatic space invasion or adenomatous histologic components recurred more frequently than patients whose tumors did not (P less than 0.05). Eighty-three percent of low risk patients who recurred had tumors with at least one of these features. Degree of differentiation and depth of invasion did not correlate with risk of recurrence. Prospective randomized trials are needed to determine the effectiveness of postoperative adjuvant therapy for patients at risk for recurrent disease.

Radical hysterectomy and pelvic lymphadenectomy for Stage IB carcinoma of the cervix: 21 years experience

From September 1971 through December 1982, 153 patients with Stage IB carcinoma of the cervix underwent radical hysterectomy and pelvic lymphadenectomy at two of the teaching hospitals of the Uniformed Services University of the Health Sciences. Records were retrospectively analyzed and independent pathologic review was performed. All surgical procedures were performed by fellows or senior residents under the direct supervision of the gynecologic oncology staff of the Walter Reed Army Medical Center or the Naval Hospital, Bethesda, Maryland. In this series, IB carcinoma was defined as squamous carcinoma clinically confined to the cervix with invasion greater than 5 mm from the basement membrane or any adenocarcinoma confined to the cervix. The average age of the patients was 38.3 years. The histologic types were squamous in 72%, adenocarcinoma in 16%, and adenosquamous in 10.5%. The mean operating time was 5 hr and 40 min with an average blood loss of 1800 cc. There were two ureterovaginal and two vesicovaginal fistulae for an overall fistula rate of 2.6%. Actuarial survival for these 153 patients is 84%. This extends the previous series of R. C. Park, W. E. Patow, R. E. Rogers, and E. A. Zimmerman, Obstet. Gynecol. 41, 117-122 (1973) of 122 cases collected from 1961 to September 1971 to 275 cases. In comparing the two time periods, no significant differences were found in operative technique or complications, but there was a change in the incidence of adenocarcinoma and mixed cell types and a difference in survival. A relatively higher incidence of more aggressive tumors may indicate the need for different therapeutic approaches in the future.

Epithelial Ovarian Carcinoma of Low Malignant Potential

The records of 94 patients with epithelial ovarian carcinoma of low malignant potential were examined. These records were contributed by Walter Reed Army Medical Center, Naval Hospital, Bethesda, MD, and Naval Hospital, Portsmouth, VA. A review of microscopic sections from each of the 94 tumors confirmed that these were lesions of low malignant potential. The tumors occurred in patients of a younger age than that generally described for invasive epithelial ovarian carcinoma. Forty-seven of 94 patients had stage I disease. The corrected five- and ten-year survival rates were 95 and 87%, respectively. Adjunctive postoperative therapy may not influence survival.

The second-look surgical reassessment for epithelial ovarian carcinoma☆

The second-look surgical reassessment is currently being performed on most patients with epithelial ovarian carcinoma after first-line chemotherapy if they are clinically free of disease. Ninety-six patients who underwent such procedures at Walter Reed Army Medical Center and the Naval Hospital, Bethesda, from January 1974 through May 1982 are reviewed. The grade of tumor, stage of disease, and amount of residual tumor remaining after initial surgery are predictive of the findings of the surgical reassessment. While a surgical reassessment is beneficial in evaluating response to therapeutic modalities under protocol investigation, its use should be individualized.

Cervical carcinoma found incidentally in a uterus removed for benign indications.

Thirty-five patients with invasive cervical carcinoma discovered in a uterus removed for benign indications were evaluated and treated from 1961 through 1983. Although formal staging was not possible, patients with presumed stage IA disease had a 100% five-year survival rate regardless of the addition of adjuvant therapy. All patients with more advanced disease received radiation therapy. Patients with presumed stage IB disease had a corrected five-year survival rate of 78%, and those with presumed stage IIB disease had a corrected five-year survival rate of 67%. No patient in this series was thought to have disease more advanced than a stage IIB equivalent. The hysterectomy alone may have been adequate therapy for patients with presumed stage IA disease. Adjuvant radiation therapy appears to be effective treatment for patients with presumed stage IB or IIB disease.

Nonsquamous cancer of the vagina

This report retrospectively analyzes 48 cases of primary vaginal cancer treated at Walter Reed Army Medical Center and the Naval Hospital, Bethesda, from 1962 through 1983. There was an unusually high number of uncommon histologic types. Nine patients had an adenocarcinoma, 5 had a sarcoma, 3 had a melanoma, 2 had an adenosquamous carcinoma, 1 had a lymphoma, and 1 had a carcinoid tumor. The remaining 27 patients had a squamous cell carcinoma. This represents a 43% prevalence of nonsquamous lesions. Nonsquamous cancer of the vagina occurred in patients at an earlier age than squamous cell carcinoma. Presenting symptoms, the location of the tumor within the vagina, and survival rates were similar for both groups. The clinical characteristics and treatment of the patients with nonsquamous tumors are discussed.

Determinants of survival of patients with epithelial ovarian carcinoma following whole abdomen irradiation (WAR)

In an attempt to identify those parameters which represent predictors of clinical outcome, a retrospective review of patients with epithelial ovarian carcinoma who were primarily treated with whole abdominal irradiation (WAR) following staging laparotomy was performed. Complete records with extensive long-term follow-up were available on 102 patients treated from 1962 through 1974. Histopathologic review excluded 18 patients with lesions of low malignant potential. Of the remaining 84 cases there were 12 Stage I (14%), 23 Stage II (27%), 45 Stage III (54%), and 4 Stage IV (5%). Measure of completeness of surgical resection was expressed as the largest diameter of residual gross tumor. Following primary surgical debulking Stages II and III patients, 24 patients had no gross residual disease, 24 patients had less than 2 cm of residual disease, and 20 patients had greater than 2 cm of residual disease. For Stages II and III patients together, 5- and 10-year actuarial survivals were: No gross residual, 69% and 59%; less than 2 cm, 48% and 42%; and greater than 2 cm, 15% and 10%. The technique of administration of WAR did not appear to influence survival. The results of this review support the concept that in selecting WAR for primary treatment of ovarian carcinoma, completeness of cytoreductive surgery should be considered. These data justify a prospective randomized study in patients with minimal residual disease following staging laparotomy comparing WAR with current first-line combination chemotherapy.

Evaluation of the scalene lymph nodes in primary and recurrent cervical carcinoma.

Open biopsy of the left scalene lymph nodes has been utilized to identify distant spread of cervical carcinoma in selected groups of patients who do not have other clinical evidence of disseminated disease. Twenty-one patients with primary cervical carcinoma and histologically proven para-aortic lymph node metastases and 10 patients with centrally recurrent tumors underwent scalene lymph node biopsy at Walter Reed Army Medical Center or the Naval Hospital, Bethesda, Maryland, between July 1, 1979 and June 30, 1985. All patients undergoing scalene node biopsy had clinically negative physical examinations. There were no surgical complications. All 31 biopsies were negative for metastatic tumor. Combined with previously reported data from this institution, 3 of 28 patients (11%) with primary cervical carcinoma and involved para-aortic nodes, and 6 of 35 patients (17%) with centrally recurrent disease had subclinical scalene node metastases. Patients with clinically suspicious scalene lymphadenopathy had fine needle aspiration cytology performed to document metastatic disease. The success of this technique has eliminated the need for open biopsy in these patients. Scalene node biopsy provides valuable prognostic information in patients with cervical cancer who have positive para-aortic lymph nodes. It also obviates surgical exploration in some patients felt to have resectable recurrent disease who actually have subclinical distant spread.