Robert E. Girtanner

Pelvic exenteration: A 15-year experience in a general metropolitan hospital

Between June, 1966, and June, 1981, 92 pelvic exenterations were performed by gynecologic oncologists at Jackson Memorial Hospital/University of Miami Medical Center. The decrease in postoperative morbidity and mortality and the improved 5-year survival rate probably were related to improvement in hospital facilities and more refined surgical techniques. Urinary and gastrointestinal complications occurred with equal frequency during the period of study and were more common in patients who had received previous radiation therapy. On the basis of our experience, recommendations to decrease gastrointestinal and urinary complications further are presented.

Treatment of advanced cervical cancer by combination of bleomycin and mitomycin-C

A combination of bleomycin and mitomycin‐C, reported as extraordinarily effective in a previous clinical trial, was used to treat 20 patients with advanced cervical cancer. Seven partial remissions (35%) and one complete remission (5%) were observed. Six of the partial remissions were of short duration (less than four months); the only patient with complete remission was still alive without evidence of disease ten months after initiation of chemotherapy. Nonresponders had a mean survival time of 6.6 months and responders 8.0 months. The treatment results confirm some efficacy of the drug regimen, although in our hands it did not live up to the high expectations raised by others.

Gastrointestinal surgery in gynecologic oncology: evaluation of surgical techniques.

In recent years, the use of surgical staples has become popular in all subspecialties of surgery. The advantages proposed have been a decrease in operative time and morbidity. This paper reviews the University of Miami/Jackson Memorial Medical Center, Division of Gynecologic Oncology experience with the use of surgical staples in gastrointestinal surgery on patients with a diagnosis of a gynecologic malignancy. Between January 1, 1979 and July 1, 1985, a total of 152 procedures were done, 81 by stapler and 71 by suture anastomosis. Ninety-one patients had received previous radiation or chemotherapy. The average age of the patients was 52 years. The results show a decrease in operating time, blood loss, and postoperative hospital stay in those patients where the stapler anastomosis was used. The postoperative morbidity and mortality were not increased. Twenty-seven total pelvic exenterations were performed during the period of study and they were evaluated separately. The hospital stay and blood loss as well as the operative time were significantly less using staplers. This report includes a detailed evaluation of the results. From this study, we concluded that surgical staples are a safe alternative in gastrointestinal surgery in patients with a gynecologic malignancy.

Cell kinetics and programmed chemotherapy for gynecologic cancer

The results of current investigation into cellular kinetics of both normal and abnormal human genital tissue have stimulated interest in programming chemotherapeutic drug regimens for the treatment of genital cancer. This report outlines the results of cell kinetic studies of normal and abnormal squamous epithelium of the female genital tract and presents preliminary results of a regimen utilizing methotrexate, hydroxyurea, and vincristine in patients with far-advanced squamous-cell cancer of the vulva, vagina, and cervix. A total of 92 patients have received 444 courses of programmed chemotherapy by either pelvic intra-arterial infusion or systemic administration of the drugs. Our results are presented and the theoretical basis of the research is discussed.

Small bowel complications after supravesical urinary diversion in pelvic exenteration

Between June, 1966, and June, 1984, 102 pelvic exenterations were performed at Jackson Memorial Hospital/University of Miami Medical Center and all patients had some type of supravesical urinary diversion. Of these patients, 23 were reexplored for a gastrointestinal complication and 15 of those had a small bowel complication. Small bowel fistula occurred in 15 instances and 9 patients were reexplored. The fistula associated mortality was 53.3%. All the fistulas occurred in previously radiated patients who had undergone an enteroenteroanastomosis. The recent use of enterocolostomies after the construction of an ileal conduit in 21 patients has not produced any postoperative small bowel fistula, while in 43 patients who underwent enteroenterostomies, 13 fistulas occurred (P less than 0.01). Patients who did not undergo pelvic floor closure had a higher incidence of fistula and small bowel obstruction, while there were no fistulas in patients with previous enterocolostomies, regardless of the pelvic closure.

Fine-needle-aspiration cytology in gynecologic oncology: “Early detection of occult persistent, or recurrent cancer after radiation therapy”☆

Abstract This study discusses the value of fine-needle-aspiration cytology in the early detection of occult carcinoma in patients treated with radiation therapy for gynecologic malignancies. Fifty-eight patients with normal cervical cytology were evaluated with 77 fine-needle aspirations (FNA) starting as early as 3 months after therapy. The results of FNAs added about 30% predictability to the accuracy of diagnosing carcinoma to that of the conventional methods used today like pelvic examination and radiographic studies. Fine-needle aspiration of the pelvis after radiation therapy is an accurate and safe method to sample the parametria, pelvic sidewalls, and other sites of possible recurrence, and may be used as part of the routine follow-up of these patients.

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.

Adenosis and adenocarcinoma of the vagina in young women: A review: Adenosis and adenocarcinoma

Prior to 1971, adenosis and primary adenocarcinoma of the vagina were unusual entities. Since then, a marked increase in both processes has occurred, felt to be related to maternal ingestion of Diethylstibestrol (DES) and other estrogenic compounds during the first trimester, with subsequent abnormalities in female offspring. To date, there are over 170 cases of adenocarcinoma reported, and there may be as many as one million patients with adenosis. Treatment of benign adenosis is somewhat of a controversy but adenocarcinoma is treated with surgery radiation or a combination thereof, depending upon the specifics of the patients. Four patients are presented, one treated surgically and three with radiotherapy, all with complete remission over one to two years. It behooves all phys-cians caring for young women to be aware of these disease processes for the maximum therapeutic benefit to be achieved.

The Swan-Ganz catheter and its application in the gynecologic patient

Swan-Ganz catheters were used in the pre- and postoperative management of 22 gynecologic patients admitted to the Surgical Intensive Care Unit, University of Miami School of Medicine. Primary indications include preoperative assessment of fluid and volume status, evaluation of patients with severe heart disease, and management of multisystem organ failure. Seventeen patients required ventilatory assistance and 15 patients required vasoactive drugs as determined by Swan-Ganz measurements. With a low complication rate and highly reliable cardiopulmonary data, the Swan-Ganz catheter should be considered routinely in the optimal management of the critically ill or high-risk gynecologic patient.

Survival of patients with positive aortic nodes in clinical stage IB and IIA carcinoma of the 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.