Philip J. DiSaia

Management of carcinoma in situ of the vulva

Concern about multicentricity and occult invasion has led authorities to recommend total vulvectomy in the management of carcinoma in situ of the vulva (VCIS). Of these considerations, only occult invasion has sufficient import to contraindicate a more conservative therapeutic approach. VCIS is being diagnosed with increasing frequency in young women for whom the deforming and sexually crippling effects of vulvectomy are especially repugnant. Because of its distinctive success in localizing preinvasive and early invasive squamous neoplasia of the cervix, colposcopy and directed biopsy were employed in evaluating all patients seen in our vulva clinic since 1971. Of 27 consecutive patients considered to have VCIS, 24 were treated either by local excision, skinning vulvectomy, topical 5-fluorouracil (5-FU), or cryosurgery. In no instance was occult invasion missed on pretreatment evaluation, and only one patient has developed a new in-situ lesion following conservative surgical therapy. Topical 5-FU therapy was unsuccessful in six of six cases. These results demonstrate that total vulvectomy for VCIS can be replaced successfully with more conservative operations.

Carcinoembryonic antigen in patients with gynecologic malignancies

The determination of carcinoembryonic antigen (CEA) in plasma has been of much interest currently concomitant with the search for an immunologic diagnosis test. Recent reports have shed some doubt on the specificity of carcinoembryonic antigens for gastrointestinal tract malignancies. This report details the plasma CEA values in 341 patients with varying gynecologic malignancies. These studies have demonstrated that plasma CEA is elevated in close to 50 per cent of patients with invasive gynecologic cancer. The incidence of positive values is appreciably higher in the advanced stages of disease. Of particular interest was that 84 per cent (21 of 25) of the patients with recurrent squamous-cell carcinoma of the cervix had a positive CEA value. Similar results were found in patients with cancer of the vulva, ovary, and endometrium.

Colposcopic evaluation of the abnormal Papanicolaou test in pregnancy

Colposcopy, including colposcopically directed biopsies in selected cases, was employed to evaluate over 300 pregnant patients with abnormal Papanicolaou tests suggestive of mild dysplasia or worse (Class III to V). Over half of the patients had benign disorders determined by colposcopic examination. All cases of invasive disease were diagnosed by colposcopy and biopsy, and the patients were treated accordingly. Only 3 diagnostic conizations were necessary in the antepartum period. The majority of patients with cervical intraepithelial neoplasia were seen post partum, and appropriate therapy was instituted. In the pregnant patient with an abnormal Papanicolaou test, colposcopy has proved to be a reliable and safe method of evaluation and has virtually eliminated the need for conization.

Pelvic celiotomy in the obese patient

We have responded to the challenge of surgery in the overweight patient by promoting it to an area of special interest. These individuals should not be deprived of good medical care although their obesity makes the physicians task more arduous and increases the risk of a poor result. With the use of intensive preoperative preparation, including prophylactic antibiotics and heparinization, a modified operative technique, and an active recovery regimen, a more sanguine view toward the surgical care of obese women can be taken.

Immunocompetence and prognosis in patients with gynecologic cancer

Abstract An increasing amount of evidence now provides a firm basis for the concept that there is significant relationship between immunological capacity and human neoplastic disease. The presence of human tumor-associated antigens and the ability of the immunologically competent host to respond to them is well documented. Recent studies have indicated a correlation between the cell-mediated component of the immune system and clinical prognosis. Furthermore, the delayed cutaneous hypersensitivity reaction as demonstrated by reactivity to common skin antigens and contact allergens, has proved to be an excellent in vivo correlate of cell-mediated immunity. One hundred and twenty-five patients with various gynecologic cancers were studied using a battery of skin-test antigens and a contact allergen. It was found that those patients capable of displaying a normal delayed hypersensitivity reaction to standard skin test antigens and to DNFB (dinitrofluorobenzene) do indeed have a better prognosis, whereas, those who are anergic or who exhibit impaired reactivity experience a poor response to therapy, with an increased incidence of recurrent disease, metastasis, and eventual early death. This study suggests that, while derangement of the immunological defense system is not unequivocally necessary for a cancer to flourish, it does strongly imply a common framework for the progression of the neoplastic process. Thus, this study supports the concept that there is a highly significant relationship between host cellular immunity and clinical course in the patient with a gynecologic cancer.

Immunologic response in gynecologic malignancy·as demonstrated by the delayed hypersensitivity reaction: Clinical correlations

The cell-mediated immune response, as demonstrated by cutaneous delayed hypersensitivity, has been reported to correlate well with the clinical course in a variety of neoplastic diseases. To facilitate evaluation of cellular immunity in patients with gynecologic cancer, an immunologic index has been devised which incorporates the cutaneous reaction to standard antigens, 1-nitro,2,4-difluorobenzene, and croton oil. Thirty-six patients with invasive cervical cancer, 19 patients with cervical dysplasia or carcinoma in situ, and 77 patients with dermatologic disorders were tested. Results reported here indicate a highly significant relationship between host cellular immunity and the clinical course of the patient with a gynecologic neoplasm.

Seven-drug polychemotherapy in the treatment of advanced and recurrent squamous carcinoma of the female genital tract

Single-agent chemotherapy of advanced and recurrent squamous carcinoma of the female genital tract has been largely ineffective. Combination-drug therapy which has augmented the efficacy of chemotherapy in numerous solid and nonsolid human tumors is usually attended by a degree of toxicity that has discouraged its use against malignancies exhibiting a poor response to single agents. A seven-drug regimen consisting of cyclophosphamide, 5-fluorouracil, actinomycin D, vincristine, cytosine arabinoside, methotrexate, and bleomycin administered during a 24 hour period at 4 week intervals was selected for clinical trial against squamous malignancies of the female genitalia because of its proved broad-spectrum activity among solid tumors and its low incidence of serious toxicity. Severe bone marrow depression occurred during only two of 98 drug cycles involving 23 patients. An objective tumor response was observed in nine of 18 evaluable patients. This regimen appears to be useful in the palliative management of squamous carcinoma of the female genital tract.

Impact of cephalosporin prophylaxis on conization-vaginal hysterectomy morbidity☆

A prospective, randomized, double-blind evaluation of Loridine-Keflex prophylaxis in a homogeneous group of 32 patients undergoing sequential cervical conization and vaginal hysterectomy is reported. There was no infectious or febrile morbidity in the 18 oatuebts receuvubg abtubuitucs, Morbidity occurred in six of 14 patients receiving placebos (P is less than 0.05). Antibiotic prophylaxis and conization-hysterectomy morbidity are discussed.

Gravlee Jet Washer effectiveness as performed by obstetric/gynecologic paramedical personnel

Abstract The Gravlee Jet Washer has proved to be a safe and reliable technique for obtaining cell and tissue specimens for the detection of adenocarcinoma of the endometrium. The procedure was performed on a series of 141 patients by obstetric/gynecologic paramedical personnel with a success rate of 92.2 per cent. There were 11 cases of adenocarcinoma diagnosed during the study, and 9 of these were either diagnosed or detected by the jet wash. Cervical canal stenosis prevented performance of the technique in the 2 failures. The jet wash was ineffective in detecting uterine sarcomas. The diagnostic scheme was completed in from 5 to 7 minutes in almost all patients. Only a few patients required additional physician attendance during the procedure. Patient cost was therefore reduced, physician time was minimal, and the procedure was well accepted by the patients.

Cell aggregates — A new in vitro model system of tumor growth

Abstract A number of human malignancies have been grown by monolayer tissue culture techniques for the study of cell kinetics and in the assessment of various cancericidal modalities. The discrepancy here for the clinician is that when these results are correlated with the in vivo situation there is little similarity between a monolayer culture and a three-dimensional in vivo growth. Our model system of cell aggregate tissue culture growth more closely approximates the in vivo situation of a malignant tissue. Three tissue culture lines, one derived from squamous cell carcinoma of the cervix, a second from endometrial carcinoma, and a third from rhabdomyosarcoma of the vagina have been grown as cell aggregates in rotation culture. These aggregates which range in size from 1 to 2 ml at maximum diameter present an in vitro model which resembles more closely malignant tissue. Preliminary experimentation is now underway in which these aggregates are subjected to various cancericidal influences such as radiation therapy and various chemotherapeutic agents.