Prognostic value of persistent cancer cells in vaginal smears of patients with cervical carcinoma treated by radiotherapy

In an attempt to improve the therapeutic scheme in cervical carcinoma a clinical research program involving 100 patients with stages 1 and 2 of cervical carcinoma was started. All patients underwent radiation treatment only. In the series 32 patients were state 1 and 68 stage 2. About 1/2 had undifferentiated squamous epithelioma and the others moderately differentiated epthelioma. Radiotherapy consisted of intracavity radium of 5000 mg-hr. and an external telecobalt irradiation up to 4000 rad tumor dose through 4 portals. During and after radiotherapy patients were followed by clinical examiniations and vaginal smears. Months after beginning of treatment another cervical punch biopsy was done. The 3 year recovery rate was 97% of stage 1 but only 75% of stage 2 patients. Recovery seemed better in well differentiated epithelioma and in cases treated first with external radiation. There were 13 deaths from recurrent disease within 5 to 35 months after begining of treatment. Punch biopsies performed 4 months after beginning of treatment revealed carcinomatous tissue in the cervical area of only 2 of these 13 patients. In all 87 survivors, abnormal cells disappeared from vaginal smears by 7 weeks. In the 13 fatal cases, abnormal cells persisted for 7 weeks or beyond. In 5 of the 13 fatal cases, tumor cells in the vaginal smears persisted throughout the remainder of the patients' lives. Other follow-up methods seemed inefficient cases. Well defined vaginal cytology seemed of most prognostic value. The radioresistent group could be submitted to complementary surgical treatment to improve the prognosis.     

Contraception with an injectable progestin. A study of its use in postpartum women

100 patients received 150 mg of depo-medroxyprogesterone acetate (DMPA) supplied as Depo-Provera, between Days 1 and 5 postpartum and then at 3-month intervals. Vaginal cytologic smears and endometrial biopsies were obtained 6 weeks and 3 months after the first injection and then 3 months following each subsequent injection during a 1 year study period. Of the 100 patients, 82 received at least 1 subsequent injection. Of these 22 received injections 1-4 weeks late. At the end of 1 year 43 patients had continued the treatments and 31 continued longer. 24 stopped for medical reasons, mostly irregular vaginal bleeding. Others had moved away or lacked transportation to the hospital. By the end of the year 77% of the patients were amenorrheic. About as many lost as gained weight. Of 275 endometrial biopsies obtained from 86 patients none showed a secretory type of endometrium. 6 weeks after first injection 44% of biopsies showed a minimally proliferative type of endometrium. Later this type of reaction became less frequent and more showed a quiescent type. At 1 year 40% of biopsies showed an atrophic endometrium. In 241 vaginal smears both the mean and median karyopyknotic indices were low. Resumption of spontaneous ovulation occurred at prolonged and unpredictable intervals after stopping therapy. Pregnancy occurred in 6 women, a failure rate of .51% per 100 woman-years of use.     

Primary invasive vaginal carcinoma.

A review of primary vaginal carcinoma treated at the Medical University of South Carolina from January 1970 through December 1989 included 76 squamous carcinomas, 12 adenocarcinomas, and 3 undifferentiated carcinomas. Staging was done according to the system of the International Federal of Gynecology and Obstetrics as modified by Perez et al. Stages I, II, III, and IV included 25, 39, 15, and 12 patients, respectively. Corrected 5-year survival rates were 73% for stage I, 39% for stage II, 38% for stage III, and 25% for stage IV. Sixteen percent of patients had received prior pelvic radiation. Invasive cervical cancer preceded vaginal cancer in 21% of patients. Detection of cancer was accomplished by routine cytologic testing in 17% of patients, palpation of an asymptomatic mass in 10% of patients, or palpation of a symptomatic mass in 72% of patients. Eighty-seven percent of patients were treated with radiation therapy. Survival curves of patients grouped by stage and other potential prognostic factors were compared. Lower stage (p less than 0.01), younger age (p less than 0.02), and no symptoms at detection (p less than 0.01) were statistically significant favorable prognostic factors. Histologic type, extent of vaginal involvement, vaginal location, prior radiation therapy, prior cervical cancer, and prior hysterectomy are factors that did not significantly affect survival.     

Progestational activity of a new diacetate progesterone derivative

The synthetic progestogen AY-11440 (pregna-4,6-dien-20-one-6-chloro-3, 17-dihydroxydiacetate) was tested at several doses for 3 cycles in 14 postmenopausal women and 7 ovulating women. Data collected included cervical mucus, vaginal smear stained by Papanicolaou's method, and endometrial biopsy stained by several standard methods, all taken on the day after the last pill. Patients and doses were the following: 14 postmenopausal women with vasomotor syndrome who were given 1.25 mg Premarin for 21 days and .1 mg, 1 mg, or 3 mg AY-11440, for the last 10 days of a cycle; and 7 cycling women seeking contraception, given .1, .5, or 1 mg AY-11440 daily from Day 5-25. Cervical musuc was usually negative for ferning. In postmenopausal women, vaginal smears were estrogenic and comparable to normal Cycle Day 12 in those given .1 mg; progestational like Day 20-22 in those given 1 mg; and early progestational like Day 18 in those given 3 mg. Endometria appeared early proliferative at the .1 and 1 mg doses and progestational (Day 22-23) at 3 mg. Among the fertile women vaginal smears ranged from progestational (Day 18 to late progestational (Day 25) and endometria resembled Day 22-24. Although the effects were variable among individuals, generally the effects were dissociated, in the sense that cervical mucus was most sensitive and endometrium was least changed by the drug.     

How frequently need vaginal smears be taken after hysterectomy for cervical intraepithelial neoplasia?

A retrospective longitudinal review identified 341 women who had had a hysterectomy in association with CIN 3, in Tayside Region, during the years 1967-1977; 219 (64%) had completed 10 years of cytology follow-up and of 140 women eligible for 15-year smears 79 (56%) completed the 15-year follow-up. Eight (4%) of the 219 patients developed abnormal cytology, but in six, smears reverted to normal spontaneously. Two patients had persistently abnormal smears and vaginal intraepithelial neoplasia (VAIN) was diagnosed. Only one patient completing 15-year follow-up had an abnormal smear and VAIN later diagnosed. No patient over this 15-year period developed invasive vaginal carcinoma. Sixty vaginal carcinomas were identified during the period 1957-1987 from the gynaecology cancer register; only one was associated with a previous diagnosis of CIN 3 at hysterectomy. With such data we would propose screening 6-monthly during the first post-operative year and then at 2 years. If these smears were normal, the patient could then revert to the normal screening programme.     

Influence of norethynodrel and mestranol upon cervical dysplasia and carcinoma in situ

A 3-year progress investigation of the results of continuing serial cytologic, cytochemical, colposcopic, histologic, and clinical studies i nvolving 782 women is reported. These patients were selected from 60,00 0 women by a cytodiagnostic screening group before medication was given. The drug used was the steroid contraceptive Enovid, a combination of 9.85 mg norethynodrel with .15 mg mestranol. The usual daily dose of Enovid was 2, 5, or 10 mg orally. Tablets were taken in 20 doses from D ay 5 to Day 24 of the menstrual cycles. In some, continuous therapy was given at the same dosage for 60-240 days. Response was not related to dosage. Medication was begun after a cell-diagnosis was made. Frequent periodic examinations were made of cells scraped from the squamo-columnal junction of the cervix. This method was considered much more accurate than smears from the vaginal area. Some were followed for 3-4 years. No case was found in which a lesion progressed to a stage of infiltration. In the 654 women found to have normal cytology, Enovid therapy appeared to have exerted no unfavorable influence. Of the 66 women who had preexisting inflammatory lesions with precancerous tendencies, slight progression was noted in 2 (6%) and remission in 20 (30%). In 42 (64%) no change was found after Enovid medication. Of 60 patients having marked dysplasia of cells or with beginning carcinoma in situ, 3 (5%) showed remission, 15 (25%) showed fluctuation of findings, and 42 (70%) showed unaltered expected progression. Cytochemical investigations included continuing fluorescent microscopic studies to evaluate changing levels of DNA and RNA, glycogen studies, and micropolysaccharide evaluations. It is concluded that Enovid showed no carcinogenic influence even in preexisting premalignant dysplasia or carcinoma in situ of the cervix. However, periodic examinations with cervical cytologic studies are recommended for those under Enovid medication.     

A pilot trial of TAC (paclitaxel, doxorubicin, and carboplatin) chemotherapy with filgastrim (r-metHuG-CSF) support followed by radiotherapy in patients with "high-risk" endometrial cancer

OBJECTIVES: To determine the toxicity, tolerability, and feasibility of delivering combination chemotherapy with subsequent radiation therapy to women with high-risk endometrial cancer and to evaluate the long-term bowel toxicity of this regimen. METHODS: The trial was approved by the Dana Farber/Partners Cancer Care (DFPCC) Institutional Review Board (IRB). Patients with stage 3 or stage 4 endometrial cancer or patients with high-risk histology and any stage disease were prospectively entered. Complete surgical staging and a normal gated blood pool scan were required prior to entry. Patients were treated with three cycles of paclitaxel (160 mg/m(2) ), doxorubicin (45 mg/m(2)) and carboplatin (AUC 5) (TAC) all on day 1 of a 21-day schedule as an outpatient with G-CSF support. At the conclusion of chemotherapy, patients received radiation therapy (4500 cGy to the whole pelvis) commencing within 35 days of the last cycle of chemotherapy. Paraaortic radiation and/or vaginal brachytherapy were allowed at the discretion of the treating radiation oncologist. RESULTS: Twenty patients were entered onto the trial from November 2000 through February 2003. Eighteen patients successfully completed the trial, and two patients came off trial during chemotherapy (both later completed planned radiation therapy). Patients were initially stage 1 (n = 3), stage 3 (n = 14), and stage 4 (n = 3). Papillary serous was the dominant histology with 13 patients. Chemotherapy was given on average within 32 days of surgery (range 11-63 days) and radiation was initiated on average within 14 weeks of surgery (range 10-18 weeks). Chemotherapy was well tolerated, with 57 total cycles delivered of a planned 60 cycles. Two patients required dose modification in two cycles (two patients in cycle 3 secondary to hematologic toxicity). No grade 3 or grade 4 neurotoxicity was reported. There were six episodes of grade 3 short-term toxicity with radiation therapy reported in a single patient. Late radiotherapy toxicity included bowel obstruction requiring laparotomy in two patients and grade 3 constipation in one patient. Late radiation toxicity data are still being collected as follow-up continues. CONCLUSIONS: The TAC chemotherapy regimen is well tolerated and three cycles were delivered successfully with G-CSF support without evidence of the neurotoxicity or cardiac toxicity reported with the cisplatin containing TAP regimen. Standard radiation was deliverable following TAC therapy without excessive toxicity. Further study of this regimen with subsequent radiation therapy is warranted in patients at risk for systemic and regional recurrence of their malignancy.     

Salvage of isolated vaginal recurrences in women with surgical stage I endometrial cancer: a multiinstitutional experience

The objective of this study was to evaluate the treatment outcomes and risk factors of women with surgical stage I endometrial adenocarcinoma who were initially treated with surgery alone and subsequently developed isolated vaginal recurrences. Patients with surgical stage I endometrial adenocarcinoma diagnosed from 1975 to 2002 were identified from tumor registry databases at seven institutions. All patients were treated with surgery alone including a total hysterectomy, bilateral salpingo-oophorectomy, pelvic (+/- para-aortic) lymph node dissection, and peritoneal cytology and did not receive postoperative radiation therapy. Vaginal recurrences were documented histologically. Metastatic disease in the chest and abdomen was excluded by radiologic studies. Overall survival was calculated by the Kaplan-Meier method. Sixty-nine women with surgical stage I endometrial cancer with isolated vaginal recurrences were identified. Of the 69 patients, 10 (15%) were diagnosed with stage IA disease, 43 (62%) were diagnosed with stage IB disease, and 16 (23%) were diagnosed with stage IC disease. Patients diagnosed with grade 1 disease were 22 (32%), grade 2 disease were 26 (38%), and grade 3 disease were 21 (30%). Among women, 81% with isolated vaginal recurrences were salvaged with radiation therapy. The mean time to recurrence was 24 months, and the mean follow-up was 63 months. Among women, 18% died from subsequent recurrent disease. The 5-year overall survival was 75%. The majority of isolated vaginal recurrences in women with surgical stage I endometrial cancer can be successfully salvaged with radiation therapy, further questioning the role of adjuvant therapy for patients with uterine-confined endometrial cancer at the time of initial diagnosis.     

Radical vaginal trachelectomy and pelvic lymphadenectomy for preservation of fertility in early cervical carcinoma

OBJECTIVE: The aim of this study was to examine our experience with radical vaginal trachelectomy in women with early cervical cancers who desire to maintain fertility. METHODS: Women who underwent radical vaginal trachelectomy with pelvic lymphadenectomy over a 6-year period are the basis of this report. Subjects were selected for this treatment on the basis of favorable cervical tumors and a desire to maintain fertility. All subjects were informed that this therapy did not represent standard treatment for early stage cervical cancer. Obstetrical and oncologic outcomes were evaluated. RESULTS: Twenty-one women underwent this procedure. The median age was 30 years (range 23-41); 14 were nulligravid and 16 were nulliparous. Mean tumor diameter was 1.1 cm (range 0.3-3.0). Mean operative time was 318 min, with a mean blood loss of 293 cc, and average hospital stay was 3 days. Three patients had transient neuropathy postoperatively. No patient required laparotomy. Two patients had completion of radical vaginal hysterectomy for an inability to clear the cancer with trachelectomy and 1 had postoperative radiation for high-risk features on final pathology. With an average follow-up of 31.5 months, there have been no recurrences. Three women have become pregnant: 1 woman delivered twins at 24 weeks, 1 woman delivered a singleton at term, and 1 patient had rupture of membranes and chorioamnionitis at 20 weeks gestation. CONCLUSIONS: Radical vaginal trachelectomy with pelvic lymphadenectomy permits preservation of fertility in selected patients. To date, with more than 150 cases reported in the literature, recurrence rates are comparable to those seen with radical hysterectomy.     

Liquid-based cytology for the postirradiation surveillance of women with gynecologic malignancies

OBJECTIVE: To determine the performance of liquid-based cytology using ThinPrep in the postirradiation surveillance of women with gynecologic malignancies. METHODS: Patients with endometrial and cervical cancer treated with primary or adjuvant radiotherapy between 2000 and 2002 were identified. Details regarding tumor characteristics, treatment, and cytologic and histologic results were abstracted. Binomial variables were compared with the chi-square test. The performance characteristics of liquid-based cytology were evaluated. RESULTS: A total of 302 liquid-based cytologic samples from 121 women were evaluated. Overall, 294 (97.4%) of the specimens were adequate for interpretation and 132 (44.9%) were within normal limits. Benign cellular changes, including benign radiation changes, were identified in 141 (47.6%). Atypical squamous cells (ASCUS) were found in 15 (5.1%), recurrent dysplasia in 4 (1.3%), and recurrent carcinoma in 2 (0.7%). Follow-up of the 15 ASCUS smears revealed 13 (86.7%) normal smears and 2 cases of squamous intraepithelial lesions. Benign findings were noted in three of the four smears with SIL. The sensitivity for the detection of SIL was 33%, the specificity 99%, and the positive predictive value (PPV) 25%. Of the 4 patients with local recurrences, 2 were detected by cytology. The sensitivity for the detection of recurrent carcinoma was 50%, with a specificity and PPV of 100%. CONCLUSIONS: ThinPrep for the surveillance of women with gynecologic malignancies treated with radiotherapy is associated with a high rate of satisfactory samples and a low rate of equivocal and ASCUS cytology.     

Radiation-induced benign glandular cells in posthysterectomy smears: a cytomorphologic and clinical analysis

In this retrospective study, we aimed to investigate the frequency and cytomorphologic characteristics of benign glandular cells (BGCs) in hysterectomized individuals. We also discussed the possible effect of radiation therapy on these cells. We reviewed our cytopathology archive material through a 5.5-year period and found 1460 posthysterectomy vaginal smears. Of these, 508 smears were from patients who had undergone hysterectomy for a gynecological malignancy. Review of this vaginal cytology material revealed 17 posthysterectomy patients whose smears contained BGCs. We obtained detailed clinical information in 16 of these. In addition to routine Papanicolaou staining, mucicarmine stain was also used to demonstrate cytoplasmic mucin in some cases. All the patients had a history of gynecological malignancy and had radiation therapy. Glandular cells appeared singly or in rows and honeycomb groups and did not show cytologic atypia. We concluded that radiation might give rise to a metaplastic process in which basal cells of squamous epithelium of the vagina transform into glandular cells. Most probably this process is independent of radiation dosage and period and is irreversible. We also propose that the possibility of encountering glandular cells in posthysterectomy smears is higher than expected, if the mucin stains have been used for the microscopic examination.     

Meningeal carcinomatosis from solid tumors: clinical analysis of 42 cases.

From January 1984 to June 1990, we observed 42 patients with meningeal carcinomatosis, 20 men and 22 women, aged 21 to 80 years (median age, 53 years). The two most common primary malignancies were lung cancer (50%) and breast cancer (31%). Sixty-four per cent was adenocarcinoma. On the first lumbar puncture, 86% had malignant cells in the cerebrospinal fluid. The findings of brain computed tomography were hydrocephalus (62%), contrast enhancement in the cerebral sulci or basal cisterns (31%), concomitant parenchymal metastases (15%) and normal scan (18%). In five out of seven cases, myelography showed irregular filling defects over the spinal cord or cauda equina. Treatment results were evaluated in 24 patients. Eight received radiation therapy (RT) alone, and 16 had combined therapy with RT plus intrathecal methotrexate (IT MTX). Of the patients who received RT alone, only one patient with lung carcinoma was stabilized clinically. Of the cases receiving combined therapy, seven improved clinically. Six of these were patients with breast carcinoma who received IT MTX via Ommaya reservoir. The latter had a median survival of 23 weeks. The follow-up period of the entire group of patients ranged from one day to 50 weeks. The median survival was four weeks. Based on this study, combined therapy with RT and IT MTX is indicated for breast carcinoma with meningeal carcinomatosis, but the therapeutic effects are uncertain for lung carcinoma and other malignancies.     

Clinical evaluation of follow-up methods and results of atypical glandular cells of undetermined significance (AGUS) detected on cervicovaginal Pap smears.

OBJECTIVES: The aim of this study was to evaluate the efficacy of the follow-up methods and results of atypical glandular cells of undetermined significance (AGUS) detected on cervicovaginal Pap smears. METHODS: From May 1991 to December 1996, we have performed 407, 451 cervicovaginal Pap smears, of which 326 patients were identified as AGUS. Of the 326 patients, 268 patients were followed by repeat Pap smears, colposcopy, cone biopsy, or endometrial curettage. RESULTS: The incidence of AGUS on Pap smears is approximately 0.08%. The mean age of the patients was 43 years (range 22-79 years). The most common complaint was abnormal vaginal bleeding. The gross findings of the cervix were normal to mild erosion. The following past histories of patients could affect the AGUS results on Pap smear: 30 had cone biopsy, 21 had Pap smears on pregnancy and within 8 weeks after delivery or evacuation, 3 were on hormonal replacement therapy, 2 had intrauterine devices for contraception, and 5 were undergoing follow-up after treatment of cervical cancer. The benign lesions detected during follow-up periods were 6 microglandular hyperplasia of the cervix, 5 atypical squamous metaplasia of the cervix, 2 cervical endometriosis, 2 tubal metaplasia, 10 cervical myoma, 11 cervical polyps, 9 endometrial polyps, 3 uterine myoma, 1 pelvic endometriosis, 1 ovarian endometriosis, and 4 uterine adenomyosis. The premalignant or malignant lesions of the cervix were 4 low-grade squamous intraepithelial lesions, 24 high-grade squamous intraepithelial lesions, 8 glandular atypia/dysplasia, 5 adenocarcinoma in situ, 3 microinvasive adenocarcinoma, and 4 invasive adenocarcinoma. The neoplastic lesions of the uterus were 6 endometrial hyperplasia, 11 endometrial adenocarcinoma, 1 malignant mixed Müllerian tumor, and 1 metastatic endometrial adenocarcinoma. Sixty-seven (25%) of 268 patients followed up were identified as having clinically significant lesions of the cervix or uterus. The detection rates of abnormal lesions were 3.1% with repeated Pap smears (3/98), 28.4% with colposcopic-directed biopsy (31/109), 63.6% with cone biopsy (35/55), and 29.7% with endometrial curettage (19/64). CONCLUSION: AGUS on Pap smears showed various benign and malignant lesions of the cervix or uterus. The clinicians must communicate with the pathologists regarding the patient's clinical information as well as the origin of the atypical glandular cells in Pap smears. We recommend that patients with AGUS on Pap smear should undergo immediate intensive diagnostic studies, including colposcopic-directed biopsy with endocervical curettage or cone biopsy, to detect cervical lesions and endometrial curettage to detect endometrial lesions.     

Analysis of vaginal recurrences in stage I endometrial adenocarcinoma

OBJECTIVE: To determine the risk of vaginal recurrence in Stage 1 endometrial cancer and treatment morbidity associated with different therapeutic approaches MATERIAL AND METHODS: Between 1995 and 2005, 341 patients with clinical Stage I endometrial cancer were treated at Istanbul Medical Faculty. One hundred and forty-four women were included in this study as the follow-ups and records were complete. The patients with no myometrial invasion received no further therapy following hysterectomy. When there was superficial myometrial invasion postoperative vaginal vault radiation was used, and if deep myometrial invasion was present, external pelvic radiation was given. RESULTS: Overall 5-year survival rate for all patients with Stage I disease was 80%. Nine patients (6.25%) developed recurrent disease, three of whom had vaginal recurrences. All three vaginal recurrences were small and diagnosed at routine follow-up exam within 51 months of primary therapy. CONCLUSION: This selective treatment protocol for patients with Stage I endometrial cancer avoided radiation entirely in 38% of the patients while achieving a very low rate of vaginal recurrence and good overall survival.     

Hormonal therapy for the management of grade 1 endometrial adenocarcinoma: a literature review

OBJECTIVE: We reviewed reported cases of grade 1 endometrial adenocarcinoma that were conservatively managed with hormonal therapy in an effort to identify the most effective treatment regimen. METHODS: We searched MEDLINE and other databases for English-language articles describing patients with grade 1 endometrial adenocarcinoma who were treated with hormonal therapy. The search included articles published between January 1966 and December 2003. The following key words were used: endometrial cancer, uterine cancer, adenocarcinoma, hormones, progesterone, medroxyprogesterone acetate, megestrol acetate, conservative therapy, fertility, and female. A total of 79 articles were found. Studies were excluded for the following reasons: advanced stage, metastatic or recurrent disease, progestin use after radiation, chemotherapy, or surgery, concurrent with radiation therapy or chemotherapy, administration of progestin other than orally or intramuscularly, tumor confined to a polyp, grade 2 or 3 disease, undocumented grade, nonendometrioid histology, progestin use in conjunction with ovarian wedge resection or other hormones, and hyperplasia. Our study ultimately included 81 patients in 27 articles. RESULTS: Sixty-two patients (76%) responded to treatment. The median time to response was 12 weeks (range, 4-60 weeks). Fifteen patients (24%) who initially responded to treatment recurred. The median time to recurrence was 19 months (range, 6-44 months). Ten (67%) of the patients with recurrence ultimately underwent total abdominal hysterectomy. Residual endometrial carcinoma was found in six patients (60%). Nineteen patients never responded. Twenty patients were able to become pregnant at least once after completing treatment. The median follow-up was 36 weeks (range, 0 weeks-30 years). No patients died of their disease. CONCLUSION: The majority of patients reported with well-differentiated endometrial adenocarcinoma who undergo conservative treatment with a progestational agent respond to treatment. When an initial response is not achieved or when disease recurs, carcinoma extending beyond the uterus is rare.     

The role of colposcopy in the evaluation of abnormal vaginal vault smears

Colposcopy was used to evaluate 101 patients with abnormal vaginal vault smears. Forty-five patients were seen because of atypical smears, 53 because of suspicious cytology, and the remaining three because of malignant-type cells present. The colposcopic features of the lesions seen enabled a prediction within one histological degree of the underlying pathology in 97 patients (96%). One patient was diagnosed as having invasive carcinoma, 41 patients had carcinoma in situ, and a further 23 patients were found to have severe dysplasia. Further tissue examination in the 23 patients treated by vaginectomy failed to reveal any unsuspected invasive carcinoma. The results obtained indicate that colposcopy and directed biopsy are useful, accurate methods for the evaluation of patients with abnormal cytology following hysterectomy.     

Changes in immunoglobulin-positive cell populations in the vaginal smear during radiotherapy of cervical cancer and their relation to 5-year survival rate

To study the immunological response of irradiated cervical cancer, vaginal smears were taken from patients with this neoplasm during radiotherapy and stained with fluorescent anti-Igs sera by a direct method. Then, the relationship between the immune response during radiotherapy and a five year cure were discussed. The results obtained were as follows: 1. The mean percentage of the surface IgM-positive cells was 1.9% in normal vaginal smears and 5.8% in cervical cancer. 2. On the changes in the surface IgM-positive cells during radiotherapy, the patients were classified into three groups. Group A: The number of surface IgM-positive cells increased temporarily during radiotherapy. Group B: The number of surface IgM-positive cells decreased gradually during radiotherapy. Group C: The changes in the surface IgM-positive cells were irregular and/or showed little deviation. The five year survival rate for Group A was 81.8% and for Group B was 50.0%. There was significant difference between Group A and Group B in survival rates, and Group A was considered to be an immunoreactive group.     

Guidelines for conservative hysterectomy after irradiation

From September 1, 1954, through December 31, 1969, 155 patients with barrel-shaped endocervical carcinoma were treated with radiation followed by conservative extrafascial hysterectomy 6 weeks later. Thirteen patients developed fistulas involving the vagina and 5 patients developed bowel obstruction with an overall complication rate of a 11.6%. From January 1, 1970 through October 31, 1976, 102 patients were treated in a similar fashion. Only 4 patients developed severe complications. A critical review of the treatment features of the 15 patients who developed vaginal fistulas in both series identified pelvic inflammatory disease, blunt dissection, and excessive vaginal apex doses as contributing factors. The prerequisites for successful therapy without significant complications are absence of pelvic inflammatory changes before initiation of therapy, a conservative external radiation dose with cautious application and loading of the intracavitary system, meticulous surgical technique utilizing sharp dissection, and precautionary measures to avoid infection in the irradiated-operated pelvis during recuperation. Conservative extrafascial hysterectomy is adequate to encompass the disease if the patient has a true expanding endocervical barrel-shaped lesion, providing good protection against central failure.     

Clinical study of primary carcinoma of the fallopian tube: experience with 14 cases

Between 1950 and 1986, 14 cases of primary carcinoma of the fallopian tube were treated and diagnosed at the Cancer Institute Hospital. These cases constituted 0.13% of the total number of gynecologic malignancies at the hospital during the period. The clinical/pathological findings and prognoses were described. Of the 14 cases, the average age was 56.0 years. The most frequent symptom was atypical genital bleeding, seen in 11 cases (79%). Massive watery discharge was seen in four cases (29%). In preoperative cytologic examination of vaginal smears, six cases (43%) were positive for cancer. All cases underwent operation as therapy. Postoperative irradiation, adjuvant chemotherapy, and/or second-or third- look operation was also used. Histopathologically, all materials were found to be adenocarcinoma. Four cases were well differentiated, seven were moderately differentiated, and three were poorly differentiated. Two patients with stage III and IV cancers died of the disease. Nine patients were still alive at the end of this study. The five-year survival rate was 57% (4/7). In stage I cancers, the five-year survival rate was 80% (4/5). The prognosis of stage I cancer patients was estimated as rather good.     

Results of Postoperative Radiation Therapy for Patients with Carcinoma of the Uterine Cervix: Evaluation of Intravaginal Cone Boost with an Electron Beam

Retrospective analysis was carried out from the records of 108 patients with carcinoma of the uterine cervix treated with postoperative external whole pelvic irradiation (EWPI) followed by intravaginal cone boost with an electron beam to the vaginal cuff (IVCB) to evaluate the efficacy of this method. The 5-year cause-specific survival rates were 89% for 89 patients undergoing prophylactic radiation therapy and 56% for 19 patients undergoing salvage radiation therapy (P < 0.001). The 5-year survival rates were 62% for 11 patients with macroscopic residual tumors and 41% for 8 patients with microscopic residual tumors. Of the patients with pelvic lymph node (PLN) involvement, incidences of intrapelvic recurrence, extrapelvic recurrence, and distant metastases were 12, 9, and 3%, respectively. The prognosis for patients without PLN metastasis was significantly better than that for patients with PLN metastasis in the prophylactic radiation therapy group (P < 0.001). Recurrent tumors at the vaginal cuff were observed in only 2 patients in the prophylactic radiation therapy group. Vesicovaginal fistula was observed in 4 patients. Only 1 patient developed Grade 2 rectal complications. No other severe complications were observed. IVCB following EWPI is a safe and effective postoperative radiation therapy technique for patients with cervical cancer.