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Groin dissection versus groin radiation in carcinoma of the vulva
SOCIETY
78 8. The Validity and Significance cinoma. E. E. PARTRIDGE, VAREZ, S-J. SOONG, J. M.
OF GYNECOLOGIC
of Substages
in Advanced Ovarian CarM. S. GELDER, R. D. ALJR., AND L. C. KILGORE, The
B. GUNTER, AUSTIN,
University of Alabama, Birmingham,
Alabama 35233.
No studies to date have evaluated the validity of the new FIG0 substaging of advanced epithehal ovarian cancer or assessed the importance of substage in relation to other elements such as age at diagnosis, aggressive debulking surgery, and second look Iaparotomy. The purpose of this study was to determine the significance of these substages on these factors. 167 patients with stage III ovarian cancer treated between January 1, 1977 and June 30, 1985 were restaged according to the 1988 FIG0 criteria for substaging. Ten patients were stage III-A (6%) 26 were stage III-B (15.6%), and 131 were stage III-C (78.4%). The mean age at diagnosis was 35.5 years for stage III-A, 51 years for stage III-B, and 62 years for stage III-C (P = 0.0001). Survival was significantly influenced by age with a median survival of 2.59 years for patients age ~60 and 1.11 years for those age >60 (P = 0.0001). This survival difference by age group was also significant in each substage. 110 patients had a TAH/S&O as part of their initial debulking surgery (Grp I), initial debulking required some type of bowel resection in 29 patients (Grp II), and 28 patients had ovarian biopsy or partial omentectomy to confirm diagnosis only (Grp III). Median survival of patients in Grp I (2.06 years) was significantly better than patients in Grp II (1.39 years) or Grp III (1.38 years) (P = 0.0003). 90% (9110) of stage III-A patients, 65% (17/26) of stage III-B patients, and 46% (61/131) of stage III-C patients underwent second look laparotomy. Seven of nine (77%) stage III-A, 6/17 (35%) stage III-B, and 14/61 (23%) stage III-C patients had no evidence of disease at the time of second look laparotomy (P = 0.004). Only 29% (4/14) of patients with stage IIIC are alive after negative second look compared to 62% (8/13) of stage III-A/B patients (P = 0.37). Survival was significantly influenced by substage. Median survival for stage III-A patients has not been reached, as 77% of these patients are alive; median survival for III-B patients was 2.29 years and for stage III-C patients was 1.33 years (P =
ONCOLOGISTS-ABSTRACTS site of failure was the pelvis. The overall treatment complication rate was 18%; 7% of the patients experienced major gastrointestinal or urinary complications. While many patients with no residual disease survive, the complication rate seems to be higher than that reported for patients who undergo primary irradiation. Survival for patients with gross residual disease is poor. Despite increasing emphasis on screening, the number of referrals for “cut-through” hysterectomy is not decreasing. Most cases could be avoided by careful adherence to well-established guidelines for cervical cancer detection. 10. Bulky
Stage IB Cervical Carcinoma Managed by Primary Radical Hysterectomy followed by Tailored Radiotherapy. J. D. B~oss, M. L. BERMAN, J. MUKHERJEE, A. MANETTA, D. EMMA, M. A. RETTENMAIER, AND P. J. DISAIA, University of California, Irvine,
California 92668. The management of bulky stage IB cervical carcinoma remains controversial The present study reports the outcome of 84 women treated by radical hysterectomy, in which the surgical specimen revealed a lesion measured to be 4.0 cm or greater in size following formalin fixation. Preoperatively, 89% of these patients were suspected of having cervical lesions greater than 4.0 cm in size based on pelvic examination. Of the 84 women, 42 (50%) received postoperative radiotherapy based on additional surgical findings beyond tumor size suggesting a high risk for pelvic recurrence including lymph node metastasis parametrial spread and compromised margins. Despite the bulky nature of these lesions, major operative and early postoperative complication rates were low (6%). Delayed complications including fistulae and bowel obstructions occurred in only 2.4% of patients treated with surgery alone and in 14.2% of women treated with combined therapy. Corrected 5-year survival in this series was 70.4% (75.6% in the surgery only group and 65.0% in the surgery plus radiotherapy group). Recurrence and mortality rates were related to lesion size with the majority of recurrences and deaths occurring in women with lesions measuring 6.0 cm or greater. Comparison of these data utilizing primary radical hysterectomy followed by tailored radiotherapy with previously published data on similar groups of patients treated with either radiation therapy alone or with radiation therapy followed by simple hysterectomy suggests equal to improved survival and simple morbidity with the primary surgical approach. 11. Groin
9. Simple Hysterectomy in the Presence of Invasive Cervical Cancer. ROMAN, M. MORRIS, P. EIFEL, T. BURKE, M. FOLLEN MITCHELL, GERSHENSON, AND J. T. WHARTON. University of Texas M. D.
L. D. An-
derson Cancer Center, Houston, Texas 77030. Between the years 1973 and 1987,148 patients who underwent simple hysterectomy in the presence of invasive cancer of the cervix were evaluated. Two patients had microinvasive squamous carcinoma; in neither patient was the hysterectomy performed as a planned procedure for this diagnosis. The remaining 146 patients all had either an adenocarcinoma or a squamous carcinoma exhibiting greater than 3 mm of stromal invasion. Reasons for inappropriate hysterectomy were: inadequate evaluation of an abnormal Papanicolaou smear or biopsy (21%), deliberate hysterectomy for cancer of the cervix (ll%), failure to perform an indicated conization (12%) no Papanicolaou smear (7%), conization margins positive or not evaluated (7%), and pathology misread (5%). Thirty-one percent of the patients had normal or inflammatory Papanicolaou smears and normal cervical examinations. Although 93% of this latter group complained of abnormal bleeding, 78% did not have endocervical or endometrial sampling preoperatively. Radiation therapy was given to 122 patients after hysterectomy. Five-year survivals for patients with and without gross residual disease (excluding microinvasive cancers) were 39 and 75%, respectively (P = O.ooOS). The most common
Dissection versus F. STEHMAN, B. BUNDY,
Groin
Radiation
in Carcinoma of the Vulva. M. VARIA, Indiana
J. BELL, J. ROBERTS, AND University, Indianapolis, Indiana; Gynecologic Buffalo, New York; Columbus Cancer Council, University of Alabama, Birmingham, Alabama; North Carolina, Chapel Hill, North Carolina.
Oncology Group, Columbus, Ohio; and University of
Fifty-eight patients with squamous carcinoma of the vulva and nonsuspicious (N,-,) groin nodes were randomized to receive either groin dissection or groin irradiation, each in conjunction with radical vulvectomy. Radiation consisted of a dose of 5000 cGy given in daily 200cGy fractions to a depth of 3 cm below the anterior skin surface. The objective of this study was to determine if groin irradiation was superior to and less morbid than groin dissection. The study was closed prematurely when interim monitoring revealed an excess number of groin relapses on the groin irradiation regimen. Metastatic involvement of the groin nodes was projected to occur in 24% of patients based on previous GOG experience. On the groin dissection arm, there were 5/23 (21.7%) patients with positive groin nodes, none of whom relapsed in the groin. There were 5 groin relapses among the 26 (19.2%) patients on the groin irradiation regimen. Radiation to the intact groins is significantly inferior for groin control (P = 0.02) and survival (P = 0.04, log-rank test) to groin dissection in patients with squamous carcinoma of the vulva and No-, nodes.
78 8. The Validity and Significance cinoma. E. E. PARTRIDGE, VAREZ, S-J. SOONG, J. M.
OF GYNECOLOGIC
of Substages
in Advanced Ovarian CarM. S. GELDER, R. D. ALJR., AND L. C. KILGORE, The
B. GUNTER, AUSTIN,
University of Alabama, Birmingham,
Alabama 35233.
No studies to date have evaluated the validity of the new FIG0 substaging of advanced epithehal ovarian cancer or assessed the importance of substage in relation to other elements such as age at diagnosis, aggressive debulking surgery, and second look Iaparotomy. The purpose of this study was to determine the significance of these substages on these factors. 167 patients with stage III ovarian cancer treated between January 1, 1977 and June 30, 1985 were restaged according to the 1988 FIG0 criteria for substaging. Ten patients were stage III-A (6%) 26 were stage III-B (15.6%), and 131 were stage III-C (78.4%). The mean age at diagnosis was 35.5 years for stage III-A, 51 years for stage III-B, and 62 years for stage III-C (P = 0.0001). Survival was significantly influenced by age with a median survival of 2.59 years for patients age ~60 and 1.11 years for those age >60 (P = 0.0001). This survival difference by age group was also significant in each substage. 110 patients had a TAH/S&O as part of their initial debulking surgery (Grp I), initial debulking required some type of bowel resection in 29 patients (Grp II), and 28 patients had ovarian biopsy or partial omentectomy to confirm diagnosis only (Grp III). Median survival of patients in Grp I (2.06 years) was significantly better than patients in Grp II (1.39 years) or Grp III (1.38 years) (P = 0.0003). 90% (9110) of stage III-A patients, 65% (17/26) of stage III-B patients, and 46% (61/131) of stage III-C patients underwent second look laparotomy. Seven of nine (77%) stage III-A, 6/17 (35%) stage III-B, and 14/61 (23%) stage III-C patients had no evidence of disease at the time of second look laparotomy (P = 0.004). Only 29% (4/14) of patients with stage IIIC are alive after negative second look compared to 62% (8/13) of stage III-A/B patients (P = 0.37). Survival was significantly influenced by substage. Median survival for stage III-A patients has not been reached, as 77% of these patients are alive; median survival for III-B patients was 2.29 years and for stage III-C patients was 1.33 years (P =
ONCOLOGISTS-ABSTRACTS site of failure was the pelvis. The overall treatment complication rate was 18%; 7% of the patients experienced major gastrointestinal or urinary complications. While many patients with no residual disease survive, the complication rate seems to be higher than that reported for patients who undergo primary irradiation. Survival for patients with gross residual disease is poor. Despite increasing emphasis on screening, the number of referrals for “cut-through” hysterectomy is not decreasing. Most cases could be avoided by careful adherence to well-established guidelines for cervical cancer detection. 10. Bulky
Stage IB Cervical Carcinoma Managed by Primary Radical Hysterectomy followed by Tailored Radiotherapy. J. D. B~oss, M. L. BERMAN, J. MUKHERJEE, A. MANETTA, D. EMMA, M. A. RETTENMAIER, AND P. J. DISAIA, University of California, Irvine,
California 92668. The management of bulky stage IB cervical carcinoma remains controversial The present study reports the outcome of 84 women treated by radical hysterectomy, in which the surgical specimen revealed a lesion measured to be 4.0 cm or greater in size following formalin fixation. Preoperatively, 89% of these patients were suspected of having cervical lesions greater than 4.0 cm in size based on pelvic examination. Of the 84 women, 42 (50%) received postoperative radiotherapy based on additional surgical findings beyond tumor size suggesting a high risk for pelvic recurrence including lymph node metastasis parametrial spread and compromised margins. Despite the bulky nature of these lesions, major operative and early postoperative complication rates were low (6%). Delayed complications including fistulae and bowel obstructions occurred in only 2.4% of patients treated with surgery alone and in 14.2% of women treated with combined therapy. Corrected 5-year survival in this series was 70.4% (75.6% in the surgery only group and 65.0% in the surgery plus radiotherapy group). Recurrence and mortality rates were related to lesion size with the majority of recurrences and deaths occurring in women with lesions measuring 6.0 cm or greater. Comparison of these data utilizing primary radical hysterectomy followed by tailored radiotherapy with previously published data on similar groups of patients treated with either radiation therapy alone or with radiation therapy followed by simple hysterectomy suggests equal to improved survival and simple morbidity with the primary surgical approach. 11. Groin
9. Simple Hysterectomy in the Presence of Invasive Cervical Cancer. ROMAN, M. MORRIS, P. EIFEL, T. BURKE, M. FOLLEN MITCHELL, GERSHENSON, AND J. T. WHARTON. University of Texas M. D.
L. D. An-
derson Cancer Center, Houston, Texas 77030. Between the years 1973 and 1987,148 patients who underwent simple hysterectomy in the presence of invasive cancer of the cervix were evaluated. Two patients had microinvasive squamous carcinoma; in neither patient was the hysterectomy performed as a planned procedure for this diagnosis. The remaining 146 patients all had either an adenocarcinoma or a squamous carcinoma exhibiting greater than 3 mm of stromal invasion. Reasons for inappropriate hysterectomy were: inadequate evaluation of an abnormal Papanicolaou smear or biopsy (21%), deliberate hysterectomy for cancer of the cervix (ll%), failure to perform an indicated conization (12%) no Papanicolaou smear (7%), conization margins positive or not evaluated (7%), and pathology misread (5%). Thirty-one percent of the patients had normal or inflammatory Papanicolaou smears and normal cervical examinations. Although 93% of this latter group complained of abnormal bleeding, 78% did not have endocervical or endometrial sampling preoperatively. Radiation therapy was given to 122 patients after hysterectomy. Five-year survivals for patients with and without gross residual disease (excluding microinvasive cancers) were 39 and 75%, respectively (P = O.ooOS). The most common
Dissection versus F. STEHMAN, B. BUNDY,
Groin
Radiation
in Carcinoma of the Vulva. M. VARIA, Indiana
J. BELL, J. ROBERTS, AND University, Indianapolis, Indiana; Gynecologic Buffalo, New York; Columbus Cancer Council, University of Alabama, Birmingham, Alabama; North Carolina, Chapel Hill, North Carolina.
Oncology Group, Columbus, Ohio; and University of
Fifty-eight patients with squamous carcinoma of the vulva and nonsuspicious (N,-,) groin nodes were randomized to receive either groin dissection or groin irradiation, each in conjunction with radical vulvectomy. Radiation consisted of a dose of 5000 cGy given in daily 200cGy fractions to a depth of 3 cm below the anterior skin surface. The objective of this study was to determine if groin irradiation was superior to and less morbid than groin dissection. The study was closed prematurely when interim monitoring revealed an excess number of groin relapses on the groin irradiation regimen. Metastatic involvement of the groin nodes was projected to occur in 24% of patients based on previous GOG experience. On the groin dissection arm, there were 5/23 (21.7%) patients with positive groin nodes, none of whom relapsed in the groin. There were 5 groin relapses among the 26 (19.2%) patients on the groin irradiation regimen. Radiation to the intact groins is significantly inferior for groin control (P = 0.02) and survival (P = 0.04, log-rank test) to groin dissection in patients with squamous carcinoma of the vulva and No-, nodes.