Evaluation of radiotherapy

Corresponde nce Evaluation of Radiotherapy To lhe Editor: As a radiologist, I am in the habit of realling many journals in allied fiellls, a practice in which I sometimes find myself woefully in arrears. It is thus that I have but recently read the article by Speert and Peightal entitled, ''An Evaluation of Adjunctive Radiotherapy in the Surgical Treatment of Endometrial Carcinoma,'' which appeared in the September, 1948, issue of the JoURNAL. The conclusion drawn in this article serves only further to becloud the issue of the procedure of choice in the treatment of corpus carcinoma. I therefore feel constrained to write this letter in an effort to clear the field. In this article, the authors divide corpus carcinoma into three stages on a histologic basis: early, where the carcinoma is limited to the endometrium or where invasion of the myometrium is minimal; intermediate, where not more than half the thickness of the uterine wall is invaded; advanced, where more than hal£ the thickness of the myometrium is involveu. The five-year determinate (i.e., based on the traced l.'ases) survival rate on the basis of these stages is then given in their Table VI as follows: EARLY

Hysterectomy Hysterectomy plus x-ray, (with or without ra-

INTERMEDIATE

NO. OF CASES

PER CENT

33

85

7

71

24

79

ADVANCED

PER CENT

NO. OF CASES

PER CENT

25 7

52 57

14

29

H

57

3

67

2

NO. OF CASES

dim:~)

Hysterectomy plus ralliurn (with or without x-ray)

u

Since, as seen from this table, there is no apparent benefit from either preoperative ra· dium or postoperative x-ray in the early stage, the authors conclude that hysterectomy alone is the procedure of choice in corpus carcinoma, except that in the advanced stage an advantage seems to result from postoperative x-ray. It is to this error in conclusion that I wish to draw attention. Since the division into stages is on a histologic basis, hysterectomy alone as the proeedure of choice can be a
711

71~

( 'ORRERPONDEN( 'E

Am.

J, Obst.

& Gynec. 1\1arcb, I9SO

TABLE A. -

TOTAL NO. OF CASES 58

~-

Hysterectomy Hysterectomy plus x-ray, (with or without radium) Hysterectomy plus radium, (with or without x-ray)

]-1-

EARLY PLUS INTERMEDIATE NO. OF CASES SURVIVING PER CENT FIVEFIVE YEARS YEAR SURVIVAL 41 (28+13) 70.6 64.3 9 (5+4)

27

21 (19+2)

77.7

I

It i~ seen from this table that there is a significant difference in the end result in the group in which hysterectomy alone is employed from that in the group treated by radium plus hy~tere~tomy, ani! that this difference favors the use of preoperative radium in certain groups of patients. It is probable, from the histologic specifications of the authors, that these groups eorrespond to the clinioal Groups I and II as described by Healy and Brown ( 1939). Although the figures in the authors' Table VI haYe been employetl to illustrate the application of their end results to the clinical problem, ther~> is a question as to the validity of the results arrived at in Table A. This is due to the fact that, in adding the number of cases in Table VI one obtains a total of 129, while the sum of the authors' subtotals in the last line of Table VI is only 121 and the total of determinate cases in their Table I is aho 121. A reeheck of thE' figures in Table VI woulcl therefore f-eem exsential. A. J. FLAXMA~, M.D. 546 SURF STREET CHICAGO 14, ILLIKOIS .JAXVAHY

4, 1950

Reply by Dr. Speert To thr Editor:

.llr. Flaxman has raiseu three points, all of which can be clarified by reference to our paper. J<'irst, he questions the practicality, from the standpoint of therapy, of :i classification of endometrial carcinoma based on pathologic examination of the excised uterus. Since we failed to demonstrate any benefit from preoperative radium, our initial procedure of choice is hysterectomy, regardless of the extent of uterine invasion. This factor, and the histologic grade of the tumor, may indicate the tlesirability of postoperative roentgen therapy, but it is ~caJ'(•ely necesRary to make a decision on this point before hysterectomy is performed. 'rumor classification based on pathologic examination is more significant than one based on clinical estimation of uterine size, since the latter is so often affected hy coincident myomas. Seconrl, Dr. l''laxman haH regrouped om data into his Table A, which he believes shows a ''significant 1lifference'' in favor of preoperative radium. The difference is 7.1 per cent in terms of ea.ses with fiye-year survival. Simple statistical treatment of the data in Dr. J<'laxman 's table will show that there is about a 50 per cent probability of a difference as largr as or larger than this oecurring by chance alone. Third, the suggested recheck of the figures in our 'l'able VI has shown them to be correct. Dr. J<'laxman 's arithmetical confusion apparently stems from his failure to note the fol· lowing statement in our paper: ''Since a few patients had both forms of irradiation, there i~ ~orne overlapping between tlw Rerond and third categories.'' HAROLD SPEER'!.', M.D. COLUMBIA-PRESBYTERIAN MEDIC'.\L CENTER NF:w YORK, NEW YoRK .lAK\TARY

11, 1950