Roy T. Parker

Effects of long-term estrogen replacement therapy

Two groups of hypoestrogenic women are analyzed by retrospective comparisons. Patients were observed by a single group of physicians for at least five years; 301 patients were treated with replacement estrogen and 309 patients were untreated. Incidence figures for various metabolic diseases present at entry and both during and after estrogen therapy were compared by the usual statistical analysis and by statistical adjustments for certain group differences (Mantel-Haenszel statistic). The long-term administration of estrogen to these relatively young women with hypoestrogenism was associated with significantly lower rates of development of cardiovascular disease, hypertension, osteoporosis, and fractures. Detrimental effects were a higher rate of abnormal uterine bleeding and an increase in the likelihood of developing adenocarcinoma of the endometrium. Effects of estrogen preparation, dosage, method of therapy, duration of therapy, and the addition of synthetic progestins are presented.

Treatment of metastatic trophoblastic disease: Good and poor prognosis

Abstract This study reports results of therapy in 91 patients with metastatic gestational trophoblastic disease treated by physicians of the Southeastern Regional Trophoblastic Disease Center. The 91 patients were grouped into good (79 per cent) or poor (19 per cent) prognostic categories. “Poor prognosis” patients were identified by the presence of an initial pretreatment human chorionic gonadotropin (HCG) titer greater than 100,000 I.U. per 24 hours, duration of disease greater than 4 months, or the documentation of cerebral or hepatic metastases. The patients with “good prognosis” metastatic disease were all treated with systemic single agent chemotherapy with methotrexate or actinomycin D. Seventy of these 71 patients were cured. The poor prognosis patients were treated by two treatment protocols. The earlier group of 7 patients in this category were treated with combination chemotherapy only after resistance to conventional single agent methotrexate and actinomycin D had failed to cure the patient. Only one patient surviced. The later group of 10 patients with “poor prognosis” disease were initially treated with combination chemotherapy and 7 were cured. The roles of hysterectomy with chemotherapy, simultaneous liver and/or hepatic irradiation with chemotherapy, and arterially infused chemotherapy are discussed.

Effects of long-term estrogen replacement therapy: II. Neoplasia☆

Abstract Two groups of hypoestrogenic women are analyzed by retrospective comparison. Patients were observed by a single group of physicians for at least five years—301 patients treated with replacement estrogen and 309 untreated patients. Of each group, 207 women had uteri in situ. Incidence figures for neoplasia (gynecologic, breast, and all sites) were compared between the two groups and with the Third National Cancer Survey, yielding a risk ratio for the development of adenocarcinoma of the endometrium among estrogen-treated women of 3.8 and 9.3, respectively. There was no increase among any other malignancies. The addition of synthetic progestin to estrogen therapy provided significant protection against the likelihood of developing endometrial cancer and did not reduce previously reported metabolic benefits of estrogen treatment. Data pertaining to estrogen use and details of the patients with endometrial carcinoma are presented.

Abdominal sacral colpopexy with Mersilene mesh in the retroperitoneal position in the management of posthysterectomy vaginal vault prolapse and enterocele

During a 12-year study period from 1972 to 1984, 56 patients underwent abdominal sacral colpopexy with retroperitoneal interposition of a suspensory hammock between a prolapsed vaginal vault and the anterior surface of the sacrum. They were followed from 6 months to 12 1/2 years, and constitute the basis of this report. In most patients, a synthetic mesh was the material interposed. Hysterectomy had previously been performed on 53 patients, and in two patients there was congenital absence of the uterus. Indications for abdominal sacral colpopexy, surgical technique, complications, and results of operation are discussed. Seven additional patients underwent this operation after termination of the defined study period.

Operative management of early invasive epidermoid carcinoma of the vulva

The clinical records and surgical specimens of 60 patients with squamous cancers of the vulva less than 2 cm in size (TI) were studied. Fifty-eight patients had stromal invasion 5 mm. or less in depth. Three of the 60 patients (5 per cent) had pelvic lymph node metastases; two of these three showed invasion of vascular channels; the third patients tumor showed cellular anaplasia. In an effort to reduce patient morbidity in radical surgery for vulvar carcinoma, while achieving comparable survival data, an operative approach less radical than radical vulvectomy, inguinal dissections, and/or pelvic lymphadenectomy is proposed for selected patients.

Management of Stage IA carcinoma of the cervix

One hundred fourteen patients with Stage IA carcinoma of the cervix were retrospectively reviewed in regard to depth of invasion, capillary-like space involvement, stromal reaction, status of conization margins, and the incidence of lymph node metastasis. Type of treatment, recurrences, and deaths were also evaluated. Patients with less than 3 mm invasion can be treated conservatively, including conization, if fertility is desired. No lymph node metastasis or recurrence appeared in this group of patients irrespective of type of treatment. Patients with 3 to 5 mm invasion do appear to be at higher risk for recurrence, but conservative therapy may be used in individualized situations. Size of conization and status of surgical margins appear to be important determining factors in regard to conservative therapy. Data in the literature, as well as our experience, although limited, suggest that the status of capillary-like space involvement does not influence lymph node metastasis or recurrence. Invasion of 5 mm or more in depth should be treated as a Stage IB occult lesion.

Intraepithelial (Stage O) cancer of the cervix

Abstract The concepts of the detection, diagnosis, and treatment of intraepithelial cancer in our clinic are presented. The data are based on 485 patients with intraepithelial cancer of the cervix studied during the past 13 years from Jan. 1, 1947, through Dec. 31, 1959.

Cancer of the ovary: Survival studies based upon operative therapy, chemotherapy, and radiotherapy☆☆☆

Abstract The clinical characteristics, therapy, and results are reported on 262 patients who had primary ovarian cancer. Twenty-four per cent were Stage I and serous cystadenocarcinoma was the most frequent diagnosis (55 per cent). Only 30 per cent of patients had total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy. The complete operation enhanced long-term survival in Stage I patients. Forty-four per cent of patients had an objective response to chemotherapy, while 31 per cent had a similar response to radiotherapy. Advanced ovarian cancer was present in 76 per cent of patients. Radiotherapy was given in localized advanced disease, and 73 per cent of patients received palliation. Chemotherapy was used in disseminated disease and provided palliation for 64 per cent of patients. Radiotherapy after operation enhanced the 2 year survival of patients with Stage IV disease. Chemotherapy did not seem to improve the survival of patients. Cumulative survival rates for patients with Stage I disease was 60 per cent at 5 years, and with Stage IV disease it was 20 per cent at 2 years and 6 per cent at five years.

Clinical problems in stage 0 (intraepithelial) cancer of the cervix

Abstract A report is given of 275 patients with intraepithelial (Stage 0) squamous-cell cancer of the cervix or cervical stump, who have had diagnosis and treatment in our clinic during the past eight and one-half years. An attempt is made, by the use of descriptive tables, to place Stage 0 cancer in its proper perspective in the entire problem of malignancies of the female generative tract, as these malignancies are seen by our group. From this small series, we can draw no valid conclusions. This series is simply the basis for consideration of an attempt to formulate how properly to manage the problem of Stage 0 cancer. A review of the clinical material, as shown in the various tables, adds little noteworthy data to those of the 1952 report. Although the figures are not of statistical value, Table I shows that the incidence of intraepithelial cancer in the gynecologic patients was 0.58 per cent and in the obstetric patients the incidence was 0.57 per cent. No significant alterations are found for age (Tables III and IV), for race and economic status, for marital status, or parity (Tables V, VI, and VII). Table VIII shows clearly that Stage 0 cancers were found in cervices and in cervical stumps in which no clinical manifestations of disease were apparent to the examiners. If evidences of disease were present, they were in no way pathognomonic of Stage 0 cancer. A comparison of treatment Tables IX, X, and XI in the original report of 1952 with treatment Tables X and XI in this present report shows among the clinicians of our department a definite trend to vaginal hysterectomy with conservation of the ovaries in our younger age groups. The majority feels that vaginal hysterectomy with removal of an adequate vaginal cuff is the operation of choice. It should be noted in Table X that of 237 gynecologic patients with intraepithelial cancer of the cervix, 57 are being followed with no further definitive treatments than multiple punch biopsies for 7 patients and cold-knife cone biopsies for 50 patients. Discrepancies between the total figures for certain categories in the treatment Table X in this report and those in the treatment Tables IX and X in the original 1952 report are due to elimination from this series of a number of patients treated and followed elsewhere (uncontrolled and lost). Table XI shows that of 38 obstetric patients with intraepithelial cancer of the cervix, 10 have received no more definitive treatments than multiple punch biopsies and 11 no more definitive treatments than cold-knife conizations. The figures in Tables X and XI state a calculated risk we have assumed in following these patients who have not had definitive treatment. Another expression of this assumed risk is found in Table XII which shows that 7 gynecologic patients with Stage 0 cancer of the cervix were permitted to become pregnant one or more times before definitive treatments were given. It is important to note that only one of these 7 patients has continued to show genital smear atypicalities. This patient had multiple biopsies only and not cervical conization. Table XIII gives the data on the 11 patients, in a total of 38 obstetric patients who had Stage 0 cancer, who became pregnant after the diagnosis was established. Of these 11 patients, but 3 at the present time had had definitive operative treatment. Eight patients are being followed. One obese, hypertensive patient died following vaginal hysterectomy. No other significant complications occurred as a result of operations for diagnosis or treatment of Stage 0 cancer. Resuturing of the cervix for hemostasis was done in several patients who continued to bleed following cold-knife conization. Routine soundings control the problem of cervical stenosis. One patient, of the 275 patients, had a depressive psychosis prior to diagnosis and definitive therapy and committed suicide despite psychiatric care. It is not felt that the diagnosis and treatment hastened her action. No patient in this series has developed drug addiction. In the discussion, an effort is made to show some of the problems of Stage 0 cancer as they involve many of the specialists of hospital technical practice as well as those of our own service. A short summary is given of the clinical records of two patients in whom invasive squamous-cell cancer of the vagina was demonstrated years after definitive diagnosis and hysterectomy for intraepithelial cancer of the cervix. These two patients are subjects for many varied speculations. To our knowledge none of the patients who are being followed without definitive treatment has developed invasive squamous-cell cancer of the cervix. The follow-up is an important feature in the study of Stage 0 cancer of the cervix or of the cervical stump. It is essential that all patients whether they have had conservative or definitive treatment be followed with adequate diagnostic techniques. Heavy obligations are assumed by anyone who elects to treat the lesion whether by conservative or definitive therapeutic methods. The “pooling” of data from many clinics must be expedited in order to clarify the confusion which now exists in criteria both for diagnosis and for the methods of treatment. Data are presented on the number of follow-up visits and the duration of the follow-up periods for 60 of 75 patients who have Stage 0 cancer and who have had but multiple punch biopsies and cold-knife cervical conizations. The number of follow-up visits per patient ranges from 1 to 14, totaling 289 for the 60 patients. The duration of the follow-up periods ranged from 2 months to 6 years. No patient in this series who has had definitive treatment for Stage 0 cancer of the cervix continues to show atypicalities in genital smears. Three gynecologic and 2 obstetric patients who had multiple punch biopsies or coldknife cervical conizations of the cervix have persistent cytologic atypiae. The two obstetric patients have recently delivered and 2 of the gynecologic patients desire further pregnancies. The third gynecologic patient is 74 years of age and has severe cardiac disease. It is important that two groups of patients in this series be followed closely for academic as well as for clinical reasons. The first group is comprised of those patients who had microscopic foci of invasion found in tissue specimens subjected to multiple block sectioning. There were 7 of these patients, 6 gynecologic and one obstetric. To date, none of these patients has clinical evidence of invasive cancer. The second group is comprised of those patients who have not yet had definitive treatment. Patient 4 in Table XII is an outstanding example in this category. Faithful in follow-ups and with understanding, she refuses further diagnostic or treatment procedures. The diagnostic multiple punch biopsies were made just four years ago. The patient remains adamant in her intention to have another child. Periodic infertility on the husbands part has increased the difficulty of the situation.

Surgical management of rectovaginal fistulas in Crohn’s disease

An analysis of 15 patients with rectovaginal fistulas complicating Crohns disease, who were managed at Duke Medical Center between 1966 and 1979, is presented. The experience reported suggests that, in carefully selected patients, and with proper timing of operative intervention, the role of primary repair of these fistulas may be more important and yield greater success than is generally maintained in the literature. Selection of the patients, perioperative management, and surgical technique are discussed.