Ruth M. Graham

The cytologic method in the diagnosis of cancer.

TO MAKE a balanced judgment is always difficult. It is a human failing to see things either black or white and, often with insufficient evidence, to render an immediate and final decision either fo...

Cytologic prognosis in cancer of the cervix

T I-I E treatment of cancer of the cervix at present falls into two disciplines-surgery and radiotherapy. There are vocal and vigorous advocates of both methods of therapy. It has been difficult to show a clear advantage to either treatment. Brunschwig and Daniel1 report a 54.6 per cent five-year salvage rate in 348 cases treated by radical operation during the years from 1947 to 1952. The five-year salvage rate on 892 cases of cancer of the cervix treated by radiotherapy alone at the Koswell Park Memorial Institute during the same period of time was 53.7 per cent. These figures arc almost identical. Obviously, both methods are effective and both salvage about half the cases. The important cluestion to be answered is “Are radiation and operation saving the same patients or are they savin,g different patients?” If they are the same then there is little hope for a major improvement in the cure rate from this disease cxcept by earlier diagnosis. However, if the patients saved by operation are different from those saved by radiotherapy we may be able to make a substantial improvement in survival figures. Attempts to divide cases of cancer of the cervix into those with a good prognosis and those with a poor prognosis have been attempted for a long time. The most successful method of dividing ‘them is the clinical staging of the disease according to its gross

THE VALUE OF THE VAGINAL SMEAR TO THE GYNAECOLOGIST

I FEEL honoured to have been asked to give the John Shields Fairbairn lecture here at the Royal College of Obstetricians and Gynaecologists. The cytologic diagnosis of cancer is based upon the fact that cells are constantly being shed from epithelial surfaces. This is true of normal epithelium and equally so of the abnormal epithelium harbouring a cancer. There is some evidence that cells may actually desquamate at a faster rate from the surface of a malignant growth than from normal epithelium. Coman (1944) has described a method whereby he can measure the cohesive force between cells. It takes ten times as much force to separate the cells of the normal squamous epithelium of the cervix as to separate the cells in a squamous carcinoma of the cervix. The major technical problem is one of collecting an adequate, representative sample of these desquamated cells. In the vagina a good specimen may be obtained by aspirating the secretion in the posterior fornix with a blunt glass pipette which has a capillary opening. The secretion is then blown on a marked glass slide and fixed immediately in a solution of half ethyl alcohol and half ethyl ether. There are many other techniques which have been used. The secretion on the cervix may be aspirated directly, or, if desired, the cervix may be scraped with Ayre’s (1947) wooden spatula and the cells obtained put on a glass slide. The endocervix or endometrium may be aspirated directly with the use of a cannula. We have preferred the aspiration of the

Spent Radon Seeds: I. Late Effects

SPENT RADON seeds are generally regarded Sas being inert. Actually, they continue to emit measurable radiation for many years. We have had several patients recently with a late complication or recurrence following treatment of cancer of the cervix with radon seeds. The possibility of a connection between the residual radiation and the complications cannot be ignored. The unique properties of radon were recognized and led to the use of this agent almost from the beginning of radiotherapy. Its popularity was understandable, for it gives the same radiations as radium but decays with a half-life of 3.8 days and so may be permanently implanted. It seemed ideal for a number of situations. Radon seeds have been implanted in and about untold thousands of cancers. The results have been satisfactory and there has been no reason to believe that patients treated in this way are any more prone to late complications than those given other forms of radiotherapy. It is well known that radon degenerates into radium C, D, ...

CANCER OF THE UTERINE CERVIX. HARVARD STUDY, 1954 THROUGH 1956.

Abstract A series of 207 consecutive, clinic patients with primary cancer of the cervix were observed in a 28 month period in a group of hospitals associated with Harvard Medical School. The patients were evaluated uniformly by the same staff. The treatment was selected according to the vaginal cytology (SR and RR). Radical hysterectomy and regional lymphadenectomy was performed upon all patients with small Stage I lesions and a low SR. Radiotherapy (Stockholm method) was given to the other patients. Those with a low SR being irradiated also received alpha tocopherol or testosterone propionate in an effort to improve their response. Patients who achieved a good RR after the first radium application or at 1,000 r full pelvis x-ray were treated with radiation alone. Those who failed to achieve a good RR underwent a radical hysterectomy and regional lymphadenectomy if possible. A 55 per cent 5 year salvage was obtained. While that is a respectable result, it is not as good as was expected.

A Prescreening Device for Cancer of the Uterus

A prescreening device for cancer of the uterus was based on the slower sedimentation rate of cells from a vaginal aspirate in the presence of cancer than in its absence. The apparatus recorded the increase in light transmission through the test tube as the cells fell. This mechanical examination of the rate of fall of vaginal and cervical cells did not diagnose cancer, but it identified the normal specimens free of cancer or infections. The negative specimens comprised the bulk of diagnostic material. There was a small increase in false-negative rate compared with the false-negative rate in standard cytologic tests, but this was counterbalanced by the increase in the number of specimens examined.

Prospects for improving the cure rate in cancer of the cervix

15(18%) In recent years some progress has been made in the therapy of patients with can cer of the uterine cervix. These improve ments lie in the rational selection of treat ment and in better treatment itself. Unfortunately, no form of manage ment is infallible, and indeed the best rarely cures more than half of any un selected series. The patient in whom it is impossible to remove the tumor com pletely at the time of radical surgery might better have been treated with radiation, and the apparently early lesion that recurs locally in a few months after irradiation perhaps should have been excised. This retrospective type of reasoning receives some support from the SENSITIZATIONRE SPONSE (sR) observed in the vaginal smear.2 Some patients with cancer of the cervix show a characteristic change in the non malignant cells of the vaginal smear. This consists of a dense, finely vacuolated cyto plasm in the basal cells. The frequency of