Richard C. Boronow

Risk factors and recurrent patterns in Stage I endometrial cancer

Clinical Stage I carcinoma of the endometrium was evaluated in 222 patients. Twenty-five percent of patients were found to have pathologic findings thought to require postoperative external irradiation; of these, 20 of 57 (35%) had recurrence. During the 36- to 72-month follow-up period, only 14 of 165 (8.3%) treated only with operation (68 patients or 31%) or operation plus intracavitary radium (97 patients or 44%) manifested a recurrence. Furthermore, of all recurrences, 27 of the 34 (79%) were outside the pelvis. In these surgically staged cases, the absence of definable, demonstrable extrauterine disease was associated with a 7% recurrence rate versus a 43% recurrence rate if disease was found anywhere outside the uterus. Recurrence and death were correlated with other prognostic factors, which are outlined in this report.

Adenocarcinoma of the endometrium: its metastatic lymph node potential. A preliminary report.

Abstract Stage I adenocarcinoma of the endometrium has been evaluated prospective in 140 patients in regards to grade, depth of myometrial invasion, uterine size, pelvic and paraaortic lymph node metastasis. Metastasis to the lymph nodes appears to correlate well with other important prognostic factors. When additional cases are added and the total data base further analyzed, we hope to develop treatment protocols that will test optimal individualized management.

Combined therapy as an alternative to exenteration for locally advanced vulvo-vaginal cancer: Rationale and results

Locally advanced vulvo‐vaginal cancer is a difficult therapeutic problem complicated by the fact that it is an uncommon clinical entity. Surgery for the vulvar (external genital) phase of this disease presentation was combined with radiotherapy for the internal genital phase (with adequate overlap of fields to protect surgical margins). The rationale is that this approach treats the cancer and its dual regional spread patterns, while at the same time preserves the bladder and/or rectum, and should be associated with less morbidity and mortality than exenterative surgery, especially in this predominantly geriatric patient population. During the period from 1968–1980, 33 cancers have been treated. There were 26 primary and seven recurrent cases. The apparent advantages of this combined therapeutic approach over exenterative surgery include bladder and/or rectal preservation, low primary mortality, low treatment morbidity, and good results in cancer control.

Therapeutic alternative to primary exenteration for advanced vulvovaginal cancer

Abstract While not a common clinical problem, locally advanced vulvovaginal cancer represents a difficult management problem. Few report more than a limited experience in managing such cases, and current therapy has usually been by two surgical methods: (1) Conventional: this is not truly conservative surgery, but rather involves radical vulvectomy with excision of a segment of the vagina and/or urethra, but visceral preservation. (2) Extended: this involves primary exenteration with en bloc radical vulvectomy, groin dissection, and pelvic node dissection. This has gained prominence in many centers in recent years. For selected cases, a combined radiotherapeutic and surgical approach may be considered a therapeutic alternative to primary exenteration. It theoretically treats the cancer and its regional spread patterns, and at the same time preserves bladder and rectal function. Any therapeutic alternative to primary exenteration must offer theoretical or practical advantages, must recognize and evaluate potential shortcomings, and its efficacy must be validated by clinical results. The apparent advantages of this combined therapeutic approach over primary pelvic exenteration with radical vulvectomy includes: (1) bladder and/or rectal preservation, (2) less primary mortality, (3) less primary operative morbidity. The theoretical disadvantages to this alternative include: (1) potential for local failure at the vulvectomy margin which transects actual or potential areas of cancer extension, even though preoperatively irradiated, (2) potential for the transformation of the cancer to a more virulent form, (3) potential for fistula formation because of surgery in an irradiated field. The rationale for this therapeutic alternative is discussed in detail and the results in a preliminary series of cases are described.

Endometrial adenocarcinoma and the polycystic ovary syndrome

While endometrial adenocarcinoma is the second most common female genital malignancy, only four per cent of the cases occur in women less than 40 years of age. The relative rarity of this disease in young women requires that we be especially attuned to those who are at high risk. This paper presents two case reports of women with polycystic ovarian disease who developed endometrial adenocarcinoma at 24 years of age. The pathophysiology ovarian disease and its relationship to the development of endometrial adenocarcinoma are discussed.

Management of radiation-induced vaginal fistulas☆

Abstract Occasionally an apparently cured patient with gynecologic malignancy is left with major injury secondary to treatment. One of the most vexing of these complications is the radiation-induced vaginal fistula. Fistulas are difficult to correct, sometimes impossible to correct, and a certain futility has been associated with these complications. This report deals with our limited but optimistic experience with the labial fat pad pedicle method of Martius. From October, 1967, through February, 1969, 10 radiation-induced vaginal fistulas have been repaired. Eight have been successful with the first attempt at correction. The technical problems in managing radiation-induced recto- and vesicovaginal fistulas are reviewed, and our method of the Martius procedure is described. A brief survey of other methods is included.

Arterio-enteric fistula following pelvic radiation: A case report

Abstract Two cases of arterial perforation into the small bowel are reported. Etiology was not determined in one case, but surgical trauma leading to localized infection in the irradiated tissue seemed responsible in the other. After the initial episode of hemorrhage, there was a symptom-free interval before its reappearance and vascular collapse. This is believed to be due to the distensibility of the large bowel. The site of arterial perforation was determined pre-operatively in one case by selective arteriography. Review of the recent literature relevant to transcatheter arterial embolization suggests that it may have potential in management of the arterio-enteric fistula as an alternative to or an aid in surgical correction by stabilizing the patient in a favorable condition.

A comparison of two radiation therapy-treatment plans for carcinoma of the cervix: II. Complications and survival rates

One hundred and one cases of cervical cancer were randomized by a card selection system into two treatment groups. Group A patients (48) were treated according to the radiotherapy plans used at the University of Mississippi Medical Center. Group B patients (53) were treated according to the radiotherapy plan used at the M.D. Anderson Hospital and Tumor Insitute. The purpose was to evaluate these two different therapy programs in terms of survival, complications, and physician radiation exposure. The latter has been reported. Life-table techniques revealed an over-all five-year survival rate of 68.6 per cent in Group A and 86.7 per cent in Group B (statistically significant to P = 0.05). Over-all radiation complication rates were similar although there were four radiation-induced vaginal fistulas in Group A and one in Group B. Our institution has converted to the treatment plan represented in Group B.

Should whole pelvic radiation therapy become past history? A case for the routine use of extended field therapy and multimodality therapy

Total pelvis radiation therapy as refined over the past 40 years has impacted positively on gynecologic cancer management. Improved overall results on a worldwide basis reflect a broader application of contemporary radiation treatment plans. Individual clinical stages of disease and subsets have not seen improvement in several decades. Currently available techniques for the safe application of extended field radiation therapy strongly support its routine use. Concomitant continuous infusion chemotherapy (CCIC) with radiation therapy (RT) should be strongly considered. Primary radical surgery is employed in our hands prior to extended RT and CCIC for most Stage I and II cases.

INSIGHTS IN PARA-AORTIC RADIATION THERAPY FOR ENDOMETRIAL CARCINOMA

It was believed in past decades that if patients with gynecologic malignancies had metastatic disease in the periaortic (PA) nodes, cure was all but impossible, and it was indicative of concomitant systemic spread. Or if one did treat the PA nodes, the required radiation dose would produce an unacceptable risk of severe complications. These perceptions began to abate somewhat with observations gleaned from various small studies demonstrating that selected subsets of patients with metastatic disease in the PA nodes could benefit, in terms of survival and local control, if extended field irradiation therapy was given (2, 12, 13). On the presumption that carcinoma of the uterine cervix spreads in a reasonably predictable manner, first to the pelvic nodes and then to the PA nodes, it was hypothesized that effective treatment could be directed prophylactically to the PA nodes. This hypothesis was proposed by Rotman et al. in 1979 and later confirmed by the prospective randomized trial of the RTOG in 1990 (14, 15). Although such information regarding cervical cancer was forthcoming, considerably less information was available regarding endometrial cancer. The incidence of PA nodes in the endometrial carcinoma was first studied in a relatively systematic way by the Gynecologic Oncology Group. Their Pilot Study One was envisioned by Boronow and Morrow, with subsequent collaboration from DiSaia and Creasman (7) early in the 1970s (7). This project was prompted, in part, by the impressive report from Oxford, England who reported their experience with pelvic lymph node metastasis in Stage I cancer of the endometrium (11). It was of great interest that in their series, one-third of the patients achieved cure when postoperative external beam treatment was directed to the pelvis only, and when metastatic pelvic nodes had been resected. The GOG Pilot Study suggested the predictive role that pelvic node dissection could provide (3). If pelvic nodes were negative, only 2% of patients were found to have aortic node metastasis; conversely, if pelvic node metastasis were found, about two-thirds of the patients had positive PA nodes. This surgical pathologic data meshed impressively with the Oxford clinical experience (i.e., one-third with positive pelvic nodes were salvaged with pelvic RT, but two-thirds were not-and the GOG study suggested that these two-thirds likely had aortic spread).