Stage I endometrial carcinoma: Treatment of nonoperable patients with intracavitary radiation therapy alone

From 1976 to 1981, 171 patients with stage I endometrial adenocarcinoma (FIGO, 1971) underwent intracavitary radiotherapy alone because of medical contraindications to surgery and external-beam irradiation. The mean age of patients was 71 years, with the majority of patients being in the age group of 70-79 years. The intracavitary therapy consisted of intrauterine insertions of radium implants in three consecutive courses according to the packing method of Heyman. The estimated dose delivered to point A and to point B was 80 and 20 Gy (3500-7000 mg-hr; mean, 5500 mg-hr), respectively. The corrected 5-year survival rate for stage Ia was 76% and for stage Ib 72%. Grade had a profound effect on survival; corrected 5-year survival for G1 was 77%, for G2 68%, and for G3 53%, respectively. The total failure rate was 24% (40/171). Most of the recurrences occurred in the pelvis (35/171): uterus, 22; vagina, 9; rectum, 2; and bladder, 1. One patient had both vaginal and uterine failure and five had distant metastases (four abdominal and one pulmonary). No difference was seen in the failure rates of stage Ia and stage Ib patients. No major complications (necessitating hospital care or delay of treatment) were seen. Our findings suggest that for patients with stage I endometrial cancer who are unfit for surgery, intracavitary low-dose-rate radiation therapy alone is an effective alternative treatment with a low risk of complications.     

A Comparison of Intracavitary versus Interstitial Irradiation in the Treatment of Cervical Cancer

Objective.Management of locally advanced cervical cancer consists primarily of combination external and internal radiation. In order to investigate the impact of intracavitary brachytherapy versus interstitial brachytherapy on local tumor control, survival, and complications, we retrospectively reviewed the concomitant experience of two institutions, each of which practice exclusively one of these radiotherapeutic techniques.Methods.Between 1979 and 1989, 61 patients with bulky stage II, III, or IVA cervical cancer were treated using a combination of teletherapy and intracavitary brachytherapy at one institution, while 70 similar patients were treated with teletherapy and interstitial brachytherapy at another institution. Patients in both groups were similar with respect to age, FIGO stage, tumor size, surgical stage, and histologic subtype. Patients treated with intracavitary therapy received a mean cumulative dose of 7706 cGy to point A and 5523 cGy to point B using standard Fletcher–Suit techniques. Those who received interstitial irradiation were treated with a mean external dose of 5050 cGy and 2 interstitial implants using a transperineal Syed–Neblett template with a mean tumor dose of 2239 and 1,942 cGy with each application, respectively. Patients treated with chemoradiation were excluded from this review.Results.Although initial rates of local control were not different, prolonged 5-year disease-free survival (50% vs 21%,P= 0.01) and improved 5-year local control (61% vs 32%,P=0.01) were observed among patients with stage II disease treated with intracavitary irradiation. No statistical differences in survival could be detected among stage III and IVA patients. Women treated with intracavitary irradiation received a larger dose of brachytherapy than those treated with interstitial therapy (4608 vs 3504 radium milligram hours equivalent,P< 0.0001) because a tandem was only used in 17 (24%) interstitial implants. Major complications occurred in 21% of patients in each group.Conclusion.When a tandem is infrequently used during interstitial brachytherapy, the toxicity is similar to that of intracavitary techniques. However, more relapses are observed among patients with stage II lesions treated with interstitial irradiation.     

Endometrial cancer stage II: 190 cases with different preoperative irradiation

In a retrospective study, the 5-year survival in 190 patients with endometrial adenocarcinoma stage II was evaluated in relation to different preoperative radiotherapy techniques. In one group, group A, 111 patients received low dose rate radium to the cervix region and in a second group, group B, 79 patients received high dose rate 60Co treatment using the after-loading technique. Both groups received intracavitary radium using the standard Heyman technique. There were no statistically significant differences in survival, after correction for intercurrent disease, between the two groups. The overall 5-year survival corrected by intercurrent disease was 79% for group A and 80% for group B. The histological grade survival in group A was 94% in grade 1, 83% in grade 2, and 60% in grade 3 and in group B, 100% in grade 1, 80% in grade 2, and 59% in grade 3. A correlation was found between histological grade, uterine sound, and survival in both groups. Only in grade 3 was deep infiltration found to have a worse prognosis. No metastasis in regional lymph nodes was found, but distant metastasis was a problem in grade 3. A significant overrepresentation of nullipara could be found among the 190 patients and was pronounced for grade 1. Our results indicate that vaginal radium application can be replaced by high dose rate 60Co in the treatment of stage II endometrial adenocarcinoma, with no decrease in the 5-year survival rate.     

Effect of radiotherapeutic technique on local control in primary vaginal carcinoma

A retrospective analysis of 73 patients treated for primary vaginal carcinoma with radiation therapy was performed to evaluate the effect of radiotherapeutic technique on local control. Local control was achieved in five of 22 patients (23%) treated with pelvic external beam therapy alone, three of four patients (75%) treated with intracavitary cylinder or Bloedorn applicator alone, and 30 of 47 patients (64%) treated with combination of external beam and brachytherapy. Radiation therapy complications requiring hospitalization occurred in six patients (8%). A statistically significant difference in local control was achieved only when patients receiving external beam and brachytherapy were compared with patients receiving external beam therapy alone ( P < 0.005). Total mid-tumor dose was defined as the sum of midplane tumor dose from external beam therapy, mid-tumor dose from interstitial radium needles, and the vaginal surface dose from intracavitary radium systems. Total mid-tumor doses ranged from 16 to 121.7 Gy. Only two of 16 patients receiving less than 55 Gy total mid-tumor dose achieved local control. As a result, dividing doses of 45, 55, 65 and 75 Gy produced a statistically significant superior local control rate in the patients receiving the higher dose ( P < 0.01). None of the 16 patients receiving less than 55 Gy total mid-tumor dose had received brachytherapy. We conclude that the combination of external beam therapy and brachytherapy is essential to achieve optimal control of primary vaginal carcinoma.     

High dose rate intracavitary brachytherapy for recurrent or residual lesions in the vaginal cuff: Results in post-hysterectomy patients with carcinoma of the cervix

Abstract. Ogino I, Kitamura T, Okamoto N, Nakayama H, Matsubara S. High dose rate intracavitary brachytherapy for recurrent or residual lesions in the vaginal cuff: results in post-hysterectomy patients with carcinoma of the cervix.
The purpose of this study was to assess the long-term survival, disease control, and complication rates of high dose rate intracavitary brachytherapy (HDR-ICR) alone or combined with external beam irradiation (HDR-ICR + EBRT) in patients with pathologically involved or close surgical margin in the vagina (Group 1) and recurrent lesions in the vaginal cuff (Group 2) following hysterectomy for cervical carcinoma. In Group 1, 10 patients received HDR-ICR only, and 11 patients received HDR-ICR + EBRT with or without paravaginal shielding. In Group 2, 8 patients received HDR-ICR only, and 11 patients received HDR-ICR + EBRT with or without paravaginal shielding. The HDR-ICR dose per fraction planned at the Apical Vaginal Point was 5–6 Gy per week. In Group 1, the 5-year absolute survival rates (AS), disease-free survival rates (DFS), and vaginal control rates (VC) were 81.0%, 76.2%, and 100%, respectively. The 5-year AS was lower in patients with parametrial infiltration or adenocarcinoma. In Group 2, the 5-year AS, DFS, and VC were 73.3%, 77.4% and 88.8%, respectively. The 5-year AS was lower when tumors were larger than 3 cm or infiltrated. Late complications occurred in 10 patients. In all but one patient, the complications were acceptable. All patients with cystitis, ileus, or leg edema received EBRT + HDR-ICR.
We recommend a treatment regimen of 25–30 Gy of HDR-ICR alone for Group 1 patients without pathologically high risk of recurrence or Group 2 patients with superficial recurrent lesions, and a treatment regime of 50 Gy whole pelvis EBRT combined with 10–15 Gy HDR-ICR for Group 1 patients with pathologically high risk of recurrence or Group 2 patients with infiltrated recurrent lesions.     

Endometrial cancer: a comparative analysis of the therapeutic results and causes of failure after treatment by radiation combined with surgery or radiation therapy alone

The present study involved 215 endometrial carcinoma patients. Ninety-nine were treated by combined irradiation and surgery (preoperative external irradiation and intracavitary insertion followed by total hysterectomy and lymphadenectomy). Radiotherapy alone was used with 116 patients i.e. whole pelvis external irradiation and Heyman radium packing (40 patients) or afterloading techniques with Fletcher-Suit-Delclos applicators and cesium (76-patients). The 5-year NED survival rate was 78.7% in the combined therapy group and 44% in the exclusive radiotherapy group. The locoregional recurrence rates were 10% in the combined group and 28% in the exclusive radiotherapy group. These results are discussed in relation to data in the literature and to biases introduced due to patient selection in this nonrandomized study. Five-year survival rates, locoregional recurrence rates and sites of failures are analyzed according to the different treatments. Modifications of the external irradiation and intracavitary techniques allowed us to obtain better results and fewer complications.     

Radiotherapy in Early Ovarian Cancer

Radiation therapy is an effective curative treatment modality in early ovarian cancer. A combination of the independent prognostic factors of grade, stage, and residual disease defines an "intermediate" risk group whose probability of long-term disease-free survival from abdomino-pelvic radiation therapy (APRT) is between 62 and 91%. This group in which abdomino-pelvic radiotherapy is recommended as the sole postoperative treatment is mainly constituted from patients with Stage II disease of all grades with no residuum or less than 2 cm residuum in the pelvis and selected optimal Stage III patients with low grade tumors. No therapy has been shown to benefit patients with Stage I grade 2 or 3 tumors, although relapse risks of 30% justify postoperative treatment in this group. APRT significantly reduced relapse risk in patients with Stages I and II disease, where tumors were densely adherent. The late toxicity of APRT is acceptable. When the abdominal dose is restricted to a total of 25 Gy and the pelvic dose to 45 Gy serious complications occur in less than 4% of patients. ³²P, widely utilized in early-stage disease, has not been shown to be beneficial compared to cisplatin in a study of the Norwegian Radium Hospital. Its dosimetry precludes effective dosing of tumor at a depth of more than 1 to 2 mm from the peritoneal surface and of the retroperitoneal nodes. Its use should be abandoned. APRT is an effective antitumor modality in ovarian cancer and cannot be discarded. Further studies of this modality are justified. Its future exploitation lies in manipulations to increase the therapeutic ratio by either altered radiotherapy fractionation schemes and/or potential combination with radiation sensitizers.     

Carcinoma of the cervical stump

This review is a retrospective analysis of 263 patients with carcinoma of the cervical stump treated at The University of Texas M. D. Anderson Hospital and Tumor Institute between 1963 and 1975. Symptomatology, stage distribution, and histology of carcinoma of the cervical stump showed no significant differences from cervical carcinoma of the intact uterus. Depending on the tumor stage, tumor volume, and distorted anatomy, treatment consisted of various combinations of intracavitary radium and transvaginal and external radiation. The 5-year survival was 100% in stage 0, 91% in stage I, 77% in stage II, 46% in stage III, and 37% in stage IV. The results achieved are similar to those in cervical cancer of the intact uterus. The complication rate was 30% and there were 9 (3.7%) deaths related to radiation complications.     

Surgery in endometrial cancer: Age,route, and operability rate in 854 Stage I and II fresh consecutive cases: 1955–1976

Among the 641 fresh consecutive endometrial cancers treated at the Ia Clinica Ostetrica e Ginecologica of the University of Milan during the 15-year period beginning with 1955, no distinction was made between Stages I and II, owing to the inadequacy of the surgical specimens and to the relatively high proportion (29%) of radiotherapy as sole treatment. Operability rate for Stage I–II (606 cases) is 71%, as compared with 45% for Stages III and IV (35 cases); hospital mortality was 1.4%. Histologic differentiation of the tumor, vaginal recurrence, and operability rate all are inversely proportional to the age of the patients, so that 5-year actuarial survival rates fall from 88.2% (patients under 45) to 79.6% (patients over 65). The 178 patients treated with radiotherapy only show a statistically significant reduction in 5-year actuarial survival rate as compared with the 436 patients who underwent surgical or radiosurgical treatment (50.1 vs 85.3%); within the latter group 5-year actuarial survival rate is better following the vaginal (90%) than the abdominal (83.9%) route. In the period 1970–1976, characterized by more rational evaluation of tumor virulence and of patient resistance and by strict follow-up, operability rate was 94.2%, with a 5-year actuarial survival rate of 90.1 and 77.9% at Stages I and II, respectively; isolated vaginal recurrences were 0.5 and 5.1% at Stages I and II, respectively. The importance of surgery is stressed, with particular regard to the selective use of the vaginal route in poor-risk patients. Bilateral salpingo-oophorectomy is significant in the determination of the cure rate. The usefulness of preoperative intracavitary radium, postoperative external irradiation, and adjuvant progestins is not proved by the present paper and needs further study.     

Dosimetric factors predicting severe radiation-induced bowel complications in patients with cervical cancer: combined effect of external parametrial dose and cumulative rectal dose

OBJECTIVE: The purpose of this study was to analyze dosimetric factors of radiation-induced severe bowel complications among patients with cervical cancer. METHODS: We reviewed 297 patients of stage IB-IVA cervical cancer managed by curative-intent radiotherapy from May 1993 through December 1997. Whole-pelvic irradiation of external beam radiation therapy (EBRT) (34.2-48.6 Gy/19-27 fractions) was delivered to all patients. Two hundred and three patients received additional bilateral parametrial boost (3.6-18 Gy/2-10 fractions). High dose-rate (HDR) intracavitary brachytherapy (ICBT), 16-24 Gy/5 fractions to Point A, was given after external irradiation. Cumulative rectal biologically effective dose (CRBED) at rectal reference point was determined by summation of EBRT and ICBT component. RESULTS: The 5-year incidences of Grade 3-4 enterocolitis and proctitis were 10% and 7%, respectively. Both complications were associated with external parametrial dose (PMD) and CRBED. Interaction of CRBED and PMD was noted in multivariate analysis of enterocolitis (P < 0.001) and proctitis (P < 0.001). In CRBED > or = 100 Gy(3) group, PMD was an independent factor in enterocolitis (P = 0.010) and proctitis (P = 0.039). In PMD > or = 54 Gy group, CRBED was an independent factor in enterocolitis (P = 0.003) and proctitis (P = 0.036). Patients with both PMD > or = 54 Gy and CRBED > or = 100 Gy(3) had higher incidence of 5-year enterocolitis (26%) (P < 0.001) and proctitis (17%) (P < 0.001) than other dose groups. CONCLUSION: Radiation-induced severe bowel complications are association on both high PMD and high CRBED. We do not suggest both external PMD > or = 54 Gy and CRBED > or = 100 Gy(3) for treatment of cervical cancer due to unacceptably high incidence of severe bowel complications.     

High-Dose-Rate Brachytherapy as the Primary Treatment of Medically Inoperable Stage I–II Endometrial Carcinoma

Between 1984 and 1992, 27 patients with clinical stage I–II histologically proven adenocarcinoma of the endometrium who had significant medical risks precluding surgery underwent radiotherapy (RT) as the primary treatment. The median age at diagnosis was 74 years. There were 20 patients (74%) with stage I and 7 patients (26%) with stage II disease. Patients were treated with high-dose-rate brachytherapy (HDRB) alone (19/27) or with a combination of external-beam RT and HDRB (2 stage I; 6 stage II). HDRB was delivered using a cobalt-60 HDR remote afterloading unit, with a median dose of 2000 cGy to point A, in two to three fractions given once a week. All HDRB treatments were performed under spinal anesthesia on an outpatient basis. External-beam irradiation to the pelvis was given using 4- to 6-MV photons and a median dose of 4200 cGy was delivered. In all patients, vaginal bleeding was controlled within a few days after completion of RT. With a median follow-up of 47 months, the 8-year disease-specific survival rate was 76%. Patients with stage I had an 8-year survival rate superior to that of patients with stage II (95% vs 21%,P< 0.001). No complications were experienced during HDRB. Late serious complications were seen in 3 patients (11%). Based on this retrospective review, primary RT with HDRB appears to be an effective and safe treatment for those patients with medically inoperable clinical stage I endometrial carcinoma. Because HDRB is given on an outpatient basis, it is an attractive option for these patients. However, in stage II disease the results of treatment are poor and RT alone should be considered only when the surgical risks are too high.     

Surgery and postoperative radiotherapy in the treatment of stage I endometrial carcinoma

From 1977 to 1985 160 endometrial carcinoma stage I patients were treated with total abdominal hysterectomy and bilateral salpingo-oophorectomy and postoperative irradiation. Hundred-thirty-one patients received postoperative pelvic telecobalt-therapy, total dose 45-50 Gy and 29 patients received postoperative endocavitary curietherapy (Cs137) to the vagina vault, total dose 50 Gy. Median follow-up was 5.6 years (range 3-11 years). Overall actuarial five-years disease-free survival was 89% +/- 2.7. For the group of patients treated with external radiotherapy and group receiving curietherapy 5-years D.F. survival was respectively 88% +/- 2.9 83% +/- 4.7. There is no statistically significant difference in survival time between the two groups (p = 0.688). There were no cases of vaginal recurrence (0%) and 2/160 cases (1.2%) there pelvic relapse. In 2/160 cases (1.2%) distant metastases occurred. Late I II grade effects were found in 15/160 cases (9.3%). Retrospective analysis of results and casuistry lead to the conclusion that radiotherapy must, in cases at risk, follow surgery in the treatment of stage I endometrial carcinoma with the aim of reducing the loco-regional relapses and increasing survival time.     

Concurrent chemoradiotherapy using high-dose-rate intracavitary brachytherapy for uterine cervical cancer

OBJECTIVE: We retrospectively reviewed our experience with concurrent chemoradiotherapy (CCRT) using high-dose-rate intracavitary brachytherapy (HDR-ICBT) to assess its feasibility and efficacy in the treatment of patients with uterine cervical cancer. METHODS: Forty patients with uterine cervical squamous cell carcinoma treated with CCRT using HDR-ICBT were analyzed. The median cervical tumor size assessed by MRI was 63 mm (range: 40-86 mm). Eighteen patients (45%) had enlarged pelvic nodes on MRI (> or =10 mm). Cisplatin (20 mg/m2/day) was concurrently administered with radiotherapy for 5 days at 21-day intervals for a median of three courses (range: 1-5 courses). Thirty-eight (95%) patients received whole pelvic external beam radiotherapy (EBRT) with 40 Gy/20 fractions followed by HDR-ICBT with 18 Gy/3 fractions to point A. Subsequently, additional pelvic EBRT with 10 Gy/5 fractions was delivered with a midline block. The cumulative biological effective dose (BED) at point A of this schedule was 77 Gy10. The median follow-up period for all 40 patients was 37 months (range: 8-71 months). RESULTS: Grade 3/4 leukopenia was the most common acute side effect (83%). The actuarial 3-year pelvic control rate, disease-free survival rate, and overall survival rate were 91%, 67%, and 79%, respectively. Eight (20%) patients suffered late gastrointestinal complications (all grades). No patient suffered radiation cystitis (all grades). Only one patient experienced grade 3 complication (enterocolitis). The actuarial 3-year late complication rate (all grades) was 9% for proctitis and 15% for enterocolitis. CONCLUSION: This preliminary study suggests that CCRT using HDR-ICBT is feasible and efficacious for patients with locoregionally advanced uterine cervical cancer.     

不同治疗方法对Ⅰ,Ⅱ期子宫内膜癌治疗后复发,转移及并发 …

目的 研究不同治疗方法对Ⅰ、Ⅱ期子宫内膜癌治疗后复发、转移及并发症的影响。方法 根据不同治疗方法将２０５例Ⅰ、Ⅱ期子宫内膜癌患者分为手术组、术前腔内全量放射治疗（放疗）组、术前腔内非全量放疗组和单纯放疗组４组,对其治疗后揽发、转移及并发症进行分析、比较。结果 手术组、术前腔内全量放疗组、术前腔内非全量放且及单纯放疗组的总复发转移分别为１９．８％、８．１％、２２．２％、３４．６％,其中阴道残断复发率     

Radiotherapy alone for invasive vaginal cancer: outcome with intracavitary high dose rate brachytherapy versus conventional low dose rate brachytherapy

PURPOSE: Our aim was to compare the role of remote afterloaded high-dose-rate brachytherapy (HDRB) with traditional low-dose-rate brachytherapy (LDRB) for patients with invasive primary vaginal carcinoma. METHODS: The study group comprised 190 patients with invasive carcinoma of the vagina. The patients were staged according to the International Federation of Gynecology and Obstetrics (FIGO) staging system. Eighty patients were treated with intracavitary high-dose rate iridium 192 brachytherapy with or without external beam therapy. These patients are compared with a historical group of 110 patients treated with intracavitary low-dose-rate radium 226 or cesium 137 brachytherapy with or without external beam therapy. RESULTS: No significant differences were found for stages, tumor grade or location between the two groups. Crude 5-year survival for all patients was 41% in the former LDRB group, 81% in stage I and 43% in stage II. Overall actuarial 3-year survival and disease-specific survival rates for all patients in the HDRB series were 51% and 66%, respectively. Disease-specific 3-year survival attained 83% in stage I and 66% in stage II. There were no significant differences in local and distant recurrences between the treatment modalities. The comparison of treatments with or without external beam radiation and of complications showed no significant differences between the HDRB and LDRB series. CONCLUSION: With HDRB and its advantages of decreased radiation exposure and patient immobilization and precise positioning, treatment results to be obtained are at least similar to traditional LDRB for primary vaginal cancer.     

Radiation therapy for primary carcinoma of the female urethra: a survey over 25 years

Sixty-two patients with primary carcinoma of the female urethra were treated with a combined radiation therapy (high-dose intracavitary vaginal radium and external beam). Treatment was strictly individualized, but an administered tumor dose of 5500-7000 rad (55-70 Gy) was always attempted. Forty-two patients (67.7%) had tumors of the anterior urethra, and in 20 women (32.3%) the posterior urethra was involved. In 19 patients (30.6%) the clinical diagnosis of lymph node involvement was made. The overall 5-year-survival rate was 64.5%. Patients with anterior urethral carcinoma had a higher 5-year-survival rate (71.4%) than patients with posterior carcinoma (50.0%). The favorable results underline the substantial role of radiation therapy for this malignancy.     

Influence of grade, histologic subtype, and timing of radiotherapy on outcome among patients with stage II carcinoma of the endometrium

In 1988, the Federation of International Gynecologic Oncologists (FIGO) adopted a new staging system mandating preradiotherapy surgical staging in endometrial cancer. To evaluate the potential impact of this recommendation on patients with cervical involvement (stage II), an analysis of 184 consecutive patients with clinical or pathologic stage II carcinoma of the endometrium treated with definitive intent at three institutions was performed. Median follow-up time was 5.7 years. Treatment consisted of total abdominal hysterectomy and bilateral salpingo-oophorectomy with preoperative radiation therapy (RT) (54%), postoperative RT (37%), or both (1%); definitive RT (7%); or radical hysterectomy (1%). The median total RT dose for combined intracavitary and external beam or either alone was 70.6 Gy with a range of 32.4-105.0 Gy. The overall 5-year survival rate and disease-free survival (DFS) rate at 5 years were 70 and 79%, respectively. Of patients treated with surgery and adjuvant radiation, 13% (22/168) had infield pelvic failure (PF) and 18% (31/168) had distant metastases (DM). Patterns of failure in patients receiving preoperative and postoperative radiotherapy are presented. Univariate analysis of pretreatment and treatment factors, including histology, grade, clinical stage, extent of cervical involvement, and timing of adjuvant radiation, revealed histology and grade to be significant predictors of DFS, PF, and DM. Clinical stage was a significant predictor of DFS only in univariate analysis. Multivariate analysis found only histology (P less than 0.001) and grade (P = 0.002) to be predictors of DFS. From this review, we conclude that histology and grade are independent predictors of DFS, and more aggressive treatment should be directed at patients with stage II endometrial cancer found to have high grade adenocarcinoma or papillary serous/clear cell histologic variants. The timing of radiotherapy was not an independent predictor of outcome; therefore, preradiotherapy surgical staging should not impact on DFS and should provide surgicopathologic information to tailor treatment and predict prognosis. The FIGO clinical staging system used in this analysis was not an independent predictor of outcome, and future multivariate analyses will be necessary to test the predictive value on outcome of the new 1988 FIGO surgical staging.     

Can treatment of carcinoma of the cervix be individualized?

Assessment of response of cervical cancers to irradiation by the conventional histological method of biopsies done during the course of radiotherapy in 51 Stage I and early stage II patients was discussed. The prediction of response to irradiation was based on the nuclear and cytoplasmic changes in the tumor cells. Two applications of intracavitary radium or external irradiation followed by intracavitary radium were given to the patients. Wertheim hysterectomy was done 4–6 weeks after irradiation in the former and 3–4 weeks after irradiation in the latter. The accuracy of the prediction was correlated with the presence of residual growth in the surgical specimens. The prediction based on biopsies done after intracavitary radium was found to be of significance. If the patient was treated initially by external irradiation, biopsy should only be taken after 5400 rad or on completion of the whole course. Validity of this study was discussed. It was concluded that it is possible to select patients who would respond poorly to irradiation for surgery.     

Direct trocar insertion vs. Verres needle use for laparoscopic sterilization

A randomized, prospective trial was designed to compare direct trocar insertion with prior peritoneal insufflation with a Verres needle for laparoscopic tubal sterilization. Direct trocar insertion resulted in fewer instrument insertions (21.8% vs. 7.8%) and use of smaller volumes of CO2 (2.67 vs. 2.32 L). Direct trocar use resulted in a decrease in operating time from 9 minutes, 40 seconds in the needle group to 7 minutes, 30 seconds in the trocar group. Minor omental injuries occurred in a small percentage of each group, while serious complications occurred once in each group.     

Treatment of primary invasive cervical cancer. Considerations on 997 consecutive cases

From 1965 to 1979 997 consecutive cervical cancer patients were treated at the University of Brescia. Stage I B and II A low risk patients underwent radical surgery, followed by Co60 external pelvic radiation when positive nodes and/or adverse pathological factors on the specimens were encountered. In stage I B the 5-year survival was 95.9% and 82.7% in the two groups and in stage II A 93.3% and 76.5% respectively. Bulky and large tumors were treated by intracavitary radium followed by radical hysterectomy and, if indicated, by Co60 external beam pelvic radiation. All other patients and all stage II B were treated by radiotherapy. The results of primary radical surgery may reflect the favourable preselection of cases. Postoperative radiation teletherapy in case of adverse pathological factors is of benefit to the patients.