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Aspects in the treatment of vulvar and cervical carcinoma
ASPECTS
IN THE TREATMENT OF VULVAR CERVICAL CARCINOMA”
GRACE C. DONNELLY, (From
the
Radkm
Clinic,
M.D., WITH W. A. Q. BAULD,
Royal Obstetrics
Victoria Jfoxtleal and Gynecolo{fy,
Afatekty McGill
3!I.l).,
Hospital 77wivcrsity)
AND
MONTREAL,
rind
Qw:.
the Department
o]
F
ROM a recent survey of female pelvic malignancies treated in this Clinic: from 1926 to 1945, inclusive, we have selected three groups as being of some interest. These are carcinoma of the vulva, carcinoma occurring in the cervical stump, and selected cases of carcinoma of the cervix treated by radiation and surgery.
There have been 40 cases of carcinoma. of the vulva as compared to 664 cases of carcinoma of the cervix, 177 cases of carcinoma of the uterus, and 185 ot carcinoma of the ovary. This is a somewhat greater incidence than that of Graves and Mezerl from the Free Hospital for Women in Boston, who reported 66 cases of carcinoma of the vulva in 51 years from 1890 to 1941, as compared to 1,668 cases of carcinoma of the cervix, 475 cases of carcinoma of the uterus, and 179 of carcinoma of the ovary. The age corresponds to that found in other clinics?’ i.e., the youngest patient was 40 years of age and the oldest 80 years, with the average age 61 years. I.
TABI,E _--___--z.
IJOCATIOX
LABIA L’NILATERAL
RILATER.4L
CI,ITURIS INVOLVED
CLITORIS CAXCFR
OF TIIE
VuLr.m
IXSION -_____ FOPKCIIRTTE ONI,Y
KARTHOLIN GLANn
MALIGNAN
ENTlRE vc I .\‘A
The location also was similar to that found elsewhere. The labia were involved in 28 cases; 23 times it was a unilateral lesion and 5 times it was bilateral. The labia minora or labia majora were involved an equal number of times. There were two cases of adenocarcinoma with the site of origin the Bartholin gland. In one case, t,he lesion was confined to the fourchette. In four cases, the rare diagnosis of true clitoris carcinoma was made. In five others, the lesion on the anterior part of the labia involved the clitoris. In two cases, the whole vulva, including the urethra and clitoris, were so involved in the tumor that the site of origin could not be determined. There were three cases diagnosed as leucoplakis with malignant changes. The symptoms were not remarkable. Pain and pruritus were complained of most frequently, bleeding and dysuria occurred in some cases, and leucorrhea less often. The gross lesion appeared as a tumor mass twice as often as in the form oi an ulcer; i.e., in 22 cases there was a mass and in 11 cases the lesion was an ulcer. Of the forty patients, thirty-six received all of their treatment in this Clinic, three had received treatment elsewhere before coming here! two were untreated. I,imited,
*This study Walkerville.
was
aided Ontario.
by
a*Fellowship
grant
494
from
John
Wyeth
&
Brother
(Canada)
Volume 56 Number J
VULVAR
AND
CERVICAL TABLE
PRURlTUS
PAIN
495
,
II
BLEEDING
15
13
CARCINOMA
DYSURIA
8
WUCORRIIEA
5
2
The treatment of this disease is, and has been, a difficult problem. In the early years, radium and x-ray were used with distressing results, the patient suffered extreme pain, and the vulva did not heal. One of these patients is interesting from the point of view of the curative value of radiation therapy. She was treated by surgical excision of the vulva followed by radium to the vulva and groins. The follow-up notes state that the vulva had not healed ten years later but the patient was living and well for fifteen years. The variations in treatment, with five and more years of survival in the different cases, were as follows : TABLE
III.
METHODS
OF TREATMENT
TO
1940
YEARS
NO. OF CASES
TREATMENT
Radium X-ray to Radium Surgical Coagulation Coagulation Diathermic Diathermic Surgical Surgical Surgical Diathermic Diathermic Untreated
AND
to vulva and groins vulva and groins + surgical excision + x-ray excision + radium to vulva and groins of the vulva of the vulva + radium excision of growth + radium vulvectomy + radium to groins vulvectomy + x-ray excision of growth vulvectomy excision of growth vulvectomy
OF SURVIVAL YEARS 5
: 1 1 3 2
OF SURVIVAL 10
1 1
1
; 1
1
1 1
;
i 1
1’
15
1
;
2
In the remaining 10 cases, treated in the last five years to 1945, diathermy excision of the growth was done in two and a diathermy vulvectomy in eight cases. TABLE
IV.
COMPARISON
OF REPORTED
FIVE-YEAR
NO. OF CASES
Royal Victoria Montreal Maternity Massachusetts Free Hospital for Women (Graves & Mezer) Fred 5. Taussige Cases Tauasig treated by vulvectomy and Basset gland dissection
Hospital
30 54
101 41
SURVIVAL NO. OF SURVIVALS
RATES
1:
PER CENT SURVIVALS 23.33 2.7.7.
32 24
32.0 58.5
-
In our cases, there has been no therapy directed to-the inguinal glands at the initial treatment, except in four cases where the glands clinically were involved at that time. A number of cases, however, have shown metastases at a later date and these were treated as follows : Recurrences in the vulva itself have not been numerous. One occurred after vulvectomy and three after other forms of therapy. As the above figures show, diathermic vulvectomy has been the preferred treatment in recent years. The chief difficulty is that healing is slow. The only other complications recorded have been induration in the scar in one case, and, in another, the urethra healed over and required dilatation.
In the past two years, i.e., since the period covered by this report, x-radia tion to the vulva has been used again in a number of cases by a new technique with what, would appear to be good results and without the complication OSthe old method. Carcinoma occurring in the cervical stump after subtotal hyst,erectomp is of interest in the prevention of cancer but a sbump cancer is also of considerable importance from the aspect, of t,reatment. after the uterine body is rcmoved, the cervical canal is often too short to hold a. radium tandem satisfmtorily. Also, in the surgical procedure, the bladder is usually sutured over tIlti t,op of the rervix making it more vulnerable to the radiation. For this reason. all cervical stumps which have been treated for carcinoma are included in this group of 48 rases. .~~. TOTAIJ NO. CASES _
~-..-_~
48
UTERINE CARCINOMA IN STUMP 5
CERVICAL ChRCINOhIA IN STmIP 43
--
ASSOClATED WIT11 PREGSANCY -3
- ~..__--.--
---
TRUE
CERVICAL STUMP CARCINOMA
28
The uterine carcinoma occurring in the stump is probably of most interest from the point of view of treatment of fundal cancer. However, the apparently good result in the surgical removal of stumps in two instances after the use of radiation is of significance. Three of these patients had had their hysterectomies in this hospital. One patient was treated with radium and fourteen days later a subtotal hysterec.tom.v and bilateral salpingo-oophorectomy was done. There was nothing in the record to indicate why a subtotal hysterectomy was the procedure of choice. She received radium on three later occasions, making a total of 6,160 mg. hr. This patient lived three years. In one of the other two patients, the cervix was clinically healthy, but, at. operation, the infiltration around the internal OSwas such that the cervix could not be removed. Three years later the cervical stump was treated with radium. And, six months after that, she was thought to have rectal metastases, so a colostomy was done. Eleven yea,rs later the patient was well and the colostomy was closed. At operation, the second patient had a uterine myoma and extensive malignancy in the broad ligaments and bladder. She was treated postoperatively wit,11 radium and x-ray but died eight months later. The two remaining patients had hysterectomies elsewhere. Carcinoma of the fundus was found on pathologic examination and they were referred here for treatment of the stump. One patient was given radium. The other patient had x-ray and then the cervix was removed. The first patient was well ten years later and the second one six months later. The three cases associated with pregnancy have to do more with the special problem of pregnancy in cancer of the cervix. There was extensive spread of the carcinoma in all of them. In two cases Porro-cesarean sections were done
YULVAR
AND
CERVICAL
497
CARCIiYOMA
One of these patients was well two years and followed by radiation therapy. died in three and one-half years. The other patient received radiation before and after operation and died’in four months. Most clinics” count t,heir t,rue stump cancers as those appearing two years or more after subtotal hysterectomy ; otherwise, the cervical carcinoma is presumed to have been present at the time of hysterectomy. Our twent,y-eight cases were so counted, which means that in twelve paGents (exclusive of the three pregnancy cases) ca.rcinoma of the cervix was present, at t,he time of operation. Of these twelve, six of the subtotal hysterectomies were done in this clinic and six were done elsewhere, with the patients coming here later either by referral or because of subsequent symptoms. In eight of the cases, t,he lesion evidently was not apparent before operation. In four cases before 1935, the cancer was found at the time of operation; three.of these were our own and on one operation report the statement was made that a rim of cervix was left for radium treatment postoperatively. Another case was probably handled this way for the same reason, and, in the third, the tumor growth was too extensive to remove the cervix. This is also the likely explanation in the fourth case. This patient was referred from another ho?+ pita1 soon after operation when a very extensive neoplasm had been found. Seven patients were treated with radium plus x-ray and five with radium only. Two patients wete living and well at five years and one at fifteen J-ears. TABLE
VII.
TK~E REPORTED
STCMP IWII)EWE
CARCINOMA --
Meigs (all clinics) George V. S. Smith and Richard Dresser4 Lewis C. Scheffey, Wm. J. Thudium, David M. Farrell5 B. 2. Cashmans Royal Victoria Montreal Maternity Hospital
CASES CARCINOMA CERVIX
CASES CERVICAL STUMP CARCINOMA
1111
58
3 to 5.2
293
14
4.7
150 664
4 28
2.66 4.21
PERCENTAGE
4
”
__
There have been 2,273 subtotal hysterectomies in this twenty-year period and, with this figure, we have estimated the incidence of carcinoma of t,he cervix to subtotal hysterectomies. It is a somewhat higher incidence than Meigs’* 0.73 per cent with 13 cases of cervical stump cancer and 1,771 subtotal hysterectomies from 1900 to 1933. He also counted these stump cancers as those appearing at, least. a year after hysterectomy. TABLE VIII. TRI-E STI:MP CARCI~;O~IA I~CIUENCE TO SUBTOTAI, HYSTE~(~TOMP ____ NO. OF SUBTOTAL NO. OF CERVlCAT, STUMP CARCIKoIIA HYSTERECTOMIES
( Meigs
’)
2,273 I,77 1
28 13
PERCENTAGE
1.2 0.73
--
The youngest patient in our series t,o develop carcinoma in the cervical stump two or more years after subtotal hysterectomy was 23 years of age. There were two patients of 70 years and one of 69 years. The average age in the group of 28 cases was 51 years.
There is considerable interest. in the r~elationship bet,wcen ovarian function and carcinoma of the cervix. From our own records and records obtained from the doctors and hospifals who had treated the patients previously, we found thal eleven patients, or 39 per cent of t,hc twenty-eight patients, had had bilateral oophorectomy at the time of subtotal hysterect,omy. The importance of amputation or cauterization of the cervix ilk the yrevention of cancer is frequently stressed. Four patirnts were definitely stated to have had one of these procedures at some time. In addition, cauterization from above was most likelv done at the time of subtotal hysterectomy in our OWH patients, as this was a routine procedure in this clinic. The classification of carcinoma of the cervix into stages lwed in ihis clinic* is as follows : Stage I-Single lesion limited lo the cervix canal or portjo. Stage II-General involvement. of tho cervix. No spread beyond. Stage Ill-Spread to fornices and/or parametrium. Stage IV--Frozen pelvis. T’aginal and distant nletastases. Fistulac. .-STAGE
TABLE _--.I
X.
TRUE
STUMP STAGE
CARCWOMA CASESRY STAGES ---.--~-.. --_.___--_. II STAGE III
13
0 METHODS
OF DISEASE - __I___-----..~ STAGE
13
OF TREATMENT
X0.
Radium Radium + x raj Cauterization + radium Surgical removal -~~---.----.-.----._.--------NO. OF CASES 13 _.--.-- --l___l__.-_l
-
OF CASES
l-1 1t’ I 1
FIVE-YEAIC
--____
IV
2
SURVIVAL
.--.-.._
LIVING FIVE YEARS 2
-_--
--_ SCRVIVAL RATE
.---.
15 per cent
--.-
--.
Up to 1940 there were thirteen patients, of whom two survived for five years, a 15 per cent salvage. One qf these was a Stage III in a woman of 70, twenty years postoperative, who was keated with x-ray and radium. The other was a Stage II in a patient, of 54, eleven pears postoperat,ive, treated with radium and x-ray. Thou h surgical treatment for carcinoma of the cervix has not been practiced in t?Iis Clinic, there has been a small group for whom the procedure of radiation followed by surgery has been used. An effort has been made to limit this method of therapy to cases of Stages I and IT, though a number of Stage III are included. Each case therefore has been particularly selected for this form of treatment, and, though the general procedure has been the same, there has been variation in the detail of treatment.
~$g,‘f
VULVAR
AND
CERVICAL
CARCINOMA
499
There have been thirty-seven of these cases with an average age of 43.6 years. The youngest patient was 24 and the oldest 62 years old. Three cases were diagnosed as adenocarcinoma of the cervix, the other thirty-four were squamous-cell carcinomas. TABLE ---__
STAGE 12
-__
XI.
CARCKOMA
OF TI-IE CERVIX-SELECTED
I
GROUP
BY STAGES
STAGE II 13
STAQE III 12
There were twenty-five patients of the thirty-seven in Stages I and II, or t,wenty-five patients who clinically and grossly had a localized tumor. The majority. of patients were treated by radium and panhysterectomy, i.e., removal of the uterus with total removal of the cervix and bilateral salpingooophorectomy. The upper vagina was left and there was no dissection or extirpation of glands or other pelvic structures. There was, however, considerable variation from this method in some cases as can be seen from the following table : TABLE
XII.
TREATMENT
OF SELECTED
GROUP
BY RADIATION
FOLLOWED
BY SURGERY
Radium -I. x-ray + panhysterectomy Radium + panhysterectomy X-ray + panhysterectomy Radium + total hysterectomy Radium and amputation of cervix Cauterization of cervix + radium + panhysterectomy Conization of cervix + x-ray + panhysterectomy Radium + total hysterectomy and left salpingo-oophorectomy TABLE l-10
DAYS 5
XIII.
TIME
6 WEEKS 2
INTERVAL
BETWEEN
3 MONTHS 10
RADIATION
6 MONTHS 9
3 20 2 3 5 2 i
AND SURGERY 1 YEAR 3
2 YEARS 3
*
In most cases, the surgical procedure followed the radiation within a sixmonth period, and there was no record of undue difficulty due to radiation effect on the tissues, which agrees with the opinion expressed by other operators.” The follow-up shows that, of nine deaths, the cause of death was considered to be the disease in five cases, one patient six months later, the others two, three, five, and nine years later. One woman died ten years later of a cerebral accident, and one of drowning. PATIENTS
TABLE XIV. LIVING FIVE,
5 YEARS
SELECTED GROUP TEN, AND FIFTEEN
10 YEARS
YEARS 15 YEARS
FIVE-YEAR NO. OF CASES -____--. 24
-
SURVIVAL RATE LIVING AT FIVE YEARS 18 .-
There was one death due to peritonitis in intestinal obstruction in a Stage I case. Both immediate postoperative complications. The late complications, or poor results in most frequently of course in the Stage III group
PERCENTAQE 75.0
a Stage III case, and one to these conditions developed as the follow-up period, occurred with some in-Stage II.
500
_._--.__.__.._.._ .. _..- -__“.__ -.-.-.-._.__..--. .- _._._-.____.-.. ..__._. -.._.._-...__-_ -_-. ._-- __.---..-.~_1_‘-~“_~::51~~:. .ILZLL-T’. ..:..._-_ ._.-.--.._... Ilecurrerw
Itwt:tl $1 I-ivtuw Ih!c torrrgiual fi~td:~
-
..--
Ycsicow~in:~l tirt uh \Tcrtel)ral - __-__._ metwrtaaw
I St:qe 111 ill li monrhs. I St:qc III I Kltl$y’ I I. I Shfr I I I in I wat 1 Ptnp Ill. irl ‘fi mbnths. l’:tticnl \‘CilPS without further trwtment. I St:gy ‘I II ill ii nmntlis. I- _.___ $1.iige II _. iv.-----6 m011tl1s.__..-.-...--_. _ . ..--...
in 2 yars. liviitg
._._- ----
lit’tcvtl
--. .--.
.-
living and well I*‘ourfwn patients out of thinly-sewn. or 37.7 iwr writ, wrc This ten--car survival figure compares favourahl) ten years after t.reatmcnt. with reported fire-ya r survival rat es for wwinolna of t hc cervix. indicating Ihat late rccwre~lccs may be eliniinatctl 1)~ this nwthotl ol’ treatment. its outlinctl al~ovc?.wrc i’w~ and 0~ In addition, t.he known rewrwnws. curred carlg. Probably thcsc cases H’I.W actually nwre widc~sprcad than est.imated at the time of treatment. Whether the two fistulae and WC wctnl wicturo were clue to radirltion cffeect or to sur’gerv it is difficult, to sa>-, but. it. is unlikely ihat. any were causetl by spread of the di&asc. Summary
and Conclusions
2. Treatment of tho inguinal glands, either by surgery as recommen~lecl Iby Taussig, 01‘ I)y s-l’ny 11s is IlOw lwin g tlonc i,n this Clinic. would appear to IW important in the initial treattnent ol’ (c;lrGnonla of the Tulsa. 3. The rqwted incidence is ,for true stump cancer only. If all CHSCSa I*(! iricludcd, the figure is raised considerably. In our own figarcs, the incidence to cases of carcinoma of the cervix would lw 6.02 per cent. and to nutnbcr OF suhtotal hysterytomies woul~l be 1.75 per cent. 4. At the same linw, most of the true? stump caasesowurred so long after subtotal hysterectoqv~ that the diagnosis of a hwlthy wrvix at the time of operat ion must ha-c: been wlwct.. 5. Thirty-nine per cent. of twenty-eight palients with trut! stump carcinonnl were known to hart had bilateral oophorcctotny with the subtotal hystercctony,~ and! t.herefore! could rtlasonably bc considcrcd to IlilVP had no ovarian tissue a! the t.inic! the carcinoma dewloped. This fairlp large perccntagc does not. support. the t hcwry that carcinoma OI the cervix is reliItcY1 to ovarian stimulation. 6. There were no Stage I casts of true cervical stump carcinoma, and tbc majority were in Stages III and IV. Though it is usual to have manypatients in the more advanced stages, these figures also suggest that the patient ma! dewlop a false sc’nsc of security following operation and he more prone to disregard subsequent synptoms. 7 * 1;\7lCll’” IlilS ShtVtl tht his “curt rate with radical operation aftcl . radiwn was twice what T obtained after radiutn alone in Stages ‘I and .[I (Sch1nit.z). ”
\‘olume Number
56 3
VULVAR
AND
CERVICAL
CARCINOMA
501
Our survival rate has been greatly improved by a similar technique. This group includes Stage III. In addition, the radical pelvic operation has not been done in any case. If ten-year survivals are considered to be cured cases, the cure rate is also higher in these cases, i.e., 41.6 per cent.
References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Graves, 5. C., and Mezer, Jacob: AM. J. OBST. & GYNEC. 43: 1016-1021, 1946. Taussig, Fred J.: Am J. OBST. & GYNEC. 40: 764-779, 1940. Meins. J. V.: New Enaland J. Med. 230: 577. 1944. Srnizhi George V. S., and Dresser, Richard: ‘AM. J. OBST. & GYNEC. 50: 1, 1945. Scheffey, Lewis C., Thudium, Wm. J., and Farrell, David M.: AM. J. OBST. & GYNEC. 43: ‘941-954, 1942. Cashman, B. Z.: AM. J. OBST. & GYNEC. 41: 216-224, 1941. Meigs, J. V.: Tumors of the Female Pelvic Organs, New York, 1934, The Macmillan Company. Taussig, Fred J.: 1943. J. Mt. Sinai Hosp. 10: 172-175, May-June, Meigs, Joe V.: AK J. OBST. & GYNEC. 49: 542, 1945. Lynch, Frank W.: Am. J. Surg. 48: 249-254, 1940.
IN THE TREATMENT OF VULVAR CERVICAL CARCINOMA”
GRACE C. DONNELLY, (From
the
Radkm
Clinic,
M.D., WITH W. A. Q. BAULD,
Royal Obstetrics
Victoria Jfoxtleal and Gynecolo{fy,
Afatekty McGill
3!I.l).,
Hospital 77wivcrsity)
AND
MONTREAL,
rind
Qw:.
the Department
o]
F
ROM a recent survey of female pelvic malignancies treated in this Clinic: from 1926 to 1945, inclusive, we have selected three groups as being of some interest. These are carcinoma of the vulva, carcinoma occurring in the cervical stump, and selected cases of carcinoma of the cervix treated by radiation and surgery.
There have been 40 cases of carcinoma. of the vulva as compared to 664 cases of carcinoma of the cervix, 177 cases of carcinoma of the uterus, and 185 ot carcinoma of the ovary. This is a somewhat greater incidence than that of Graves and Mezerl from the Free Hospital for Women in Boston, who reported 66 cases of carcinoma of the vulva in 51 years from 1890 to 1941, as compared to 1,668 cases of carcinoma of the cervix, 475 cases of carcinoma of the uterus, and 179 of carcinoma of the ovary. The age corresponds to that found in other clinics?’ i.e., the youngest patient was 40 years of age and the oldest 80 years, with the average age 61 years. I.
TABI,E _--___--z.
IJOCATIOX
LABIA L’NILATERAL
RILATER.4L
CI,ITURIS INVOLVED
CLITORIS CAXCFR
OF TIIE
VuLr.m
IXSION -_____ FOPKCIIRTTE ONI,Y
KARTHOLIN GLANn
MALIGNAN
ENTlRE vc I .\‘A
The location also was similar to that found elsewhere. The labia were involved in 28 cases; 23 times it was a unilateral lesion and 5 times it was bilateral. The labia minora or labia majora were involved an equal number of times. There were two cases of adenocarcinoma with the site of origin the Bartholin gland. In one case, t,he lesion was confined to the fourchette. In four cases, the rare diagnosis of true clitoris carcinoma was made. In five others, the lesion on the anterior part of the labia involved the clitoris. In two cases, the whole vulva, including the urethra and clitoris, were so involved in the tumor that the site of origin could not be determined. There were three cases diagnosed as leucoplakis with malignant changes. The symptoms were not remarkable. Pain and pruritus were complained of most frequently, bleeding and dysuria occurred in some cases, and leucorrhea less often. The gross lesion appeared as a tumor mass twice as often as in the form oi an ulcer; i.e., in 22 cases there was a mass and in 11 cases the lesion was an ulcer. Of the forty patients, thirty-six received all of their treatment in this Clinic, three had received treatment elsewhere before coming here! two were untreated. I,imited,
*This study Walkerville.
was
aided Ontario.
by
a*Fellowship
grant
494
from
John
Wyeth
&
Brother
(Canada)
Volume 56 Number J
VULVAR
AND
CERVICAL TABLE
PRURlTUS
PAIN
495
,
II
BLEEDING
15
13
CARCINOMA
DYSURIA
8
WUCORRIIEA
5
2
The treatment of this disease is, and has been, a difficult problem. In the early years, radium and x-ray were used with distressing results, the patient suffered extreme pain, and the vulva did not heal. One of these patients is interesting from the point of view of the curative value of radiation therapy. She was treated by surgical excision of the vulva followed by radium to the vulva and groins. The follow-up notes state that the vulva had not healed ten years later but the patient was living and well for fifteen years. The variations in treatment, with five and more years of survival in the different cases, were as follows : TABLE
III.
METHODS
OF TREATMENT
TO
1940
YEARS
NO. OF CASES
TREATMENT
Radium X-ray to Radium Surgical Coagulation Coagulation Diathermic Diathermic Surgical Surgical Surgical Diathermic Diathermic Untreated
AND
to vulva and groins vulva and groins + surgical excision + x-ray excision + radium to vulva and groins of the vulva of the vulva + radium excision of growth + radium vulvectomy + radium to groins vulvectomy + x-ray excision of growth vulvectomy excision of growth vulvectomy
OF SURVIVAL YEARS 5
: 1 1 3 2
OF SURVIVAL 10
1 1
1
; 1
1
1 1
;
i 1
1’
15
1
;
2
In the remaining 10 cases, treated in the last five years to 1945, diathermy excision of the growth was done in two and a diathermy vulvectomy in eight cases. TABLE
IV.
COMPARISON
OF REPORTED
FIVE-YEAR
NO. OF CASES
Royal Victoria Montreal Maternity Massachusetts Free Hospital for Women (Graves & Mezer) Fred 5. Taussige Cases Tauasig treated by vulvectomy and Basset gland dissection
Hospital
30 54
101 41
SURVIVAL NO. OF SURVIVALS
RATES
1:
PER CENT SURVIVALS 23.33 2.7.7.
32 24
32.0 58.5
-
In our cases, there has been no therapy directed to-the inguinal glands at the initial treatment, except in four cases where the glands clinically were involved at that time. A number of cases, however, have shown metastases at a later date and these were treated as follows : Recurrences in the vulva itself have not been numerous. One occurred after vulvectomy and three after other forms of therapy. As the above figures show, diathermic vulvectomy has been the preferred treatment in recent years. The chief difficulty is that healing is slow. The only other complications recorded have been induration in the scar in one case, and, in another, the urethra healed over and required dilatation.
In the past two years, i.e., since the period covered by this report, x-radia tion to the vulva has been used again in a number of cases by a new technique with what, would appear to be good results and without the complication OSthe old method. Carcinoma occurring in the cervical stump after subtotal hyst,erectomp is of interest in the prevention of cancer but a sbump cancer is also of considerable importance from the aspect, of t,reatment. after the uterine body is rcmoved, the cervical canal is often too short to hold a. radium tandem satisfmtorily. Also, in the surgical procedure, the bladder is usually sutured over tIlti t,op of the rervix making it more vulnerable to the radiation. For this reason. all cervical stumps which have been treated for carcinoma are included in this group of 48 rases. .~~. TOTAIJ NO. CASES _
~-..-_~
48
UTERINE CARCINOMA IN STUMP 5
CERVICAL ChRCINOhIA IN STmIP 43
--
ASSOClATED WIT11 PREGSANCY -3
- ~..__--.--
---
TRUE
CERVICAL STUMP CARCINOMA
28
The uterine carcinoma occurring in the stump is probably of most interest from the point of view of treatment of fundal cancer. However, the apparently good result in the surgical removal of stumps in two instances after the use of radiation is of significance. Three of these patients had had their hysterectomies in this hospital. One patient was treated with radium and fourteen days later a subtotal hysterec.tom.v and bilateral salpingo-oophorectomy was done. There was nothing in the record to indicate why a subtotal hysterectomy was the procedure of choice. She received radium on three later occasions, making a total of 6,160 mg. hr. This patient lived three years. In one of the other two patients, the cervix was clinically healthy, but, at. operation, the infiltration around the internal OSwas such that the cervix could not be removed. Three years later the cervical stump was treated with radium. And, six months after that, she was thought to have rectal metastases, so a colostomy was done. Eleven yea,rs later the patient was well and the colostomy was closed. At operation, the second patient had a uterine myoma and extensive malignancy in the broad ligaments and bladder. She was treated postoperatively wit,11 radium and x-ray but died eight months later. The two remaining patients had hysterectomies elsewhere. Carcinoma of the fundus was found on pathologic examination and they were referred here for treatment of the stump. One patient was given radium. The other patient had x-ray and then the cervix was removed. The first patient was well ten years later and the second one six months later. The three cases associated with pregnancy have to do more with the special problem of pregnancy in cancer of the cervix. There was extensive spread of the carcinoma in all of them. In two cases Porro-cesarean sections were done
YULVAR
AND
CERVICAL
497
CARCIiYOMA
One of these patients was well two years and followed by radiation therapy. died in three and one-half years. The other patient received radiation before and after operation and died’in four months. Most clinics” count t,heir t,rue stump cancers as those appearing two years or more after subtotal hysterectomy ; otherwise, the cervical carcinoma is presumed to have been present at the time of hysterectomy. Our twent,y-eight cases were so counted, which means that in twelve paGents (exclusive of the three pregnancy cases) ca.rcinoma of the cervix was present, at t,he time of operation. Of these twelve, six of the subtotal hysterectomies were done in this clinic and six were done elsewhere, with the patients coming here later either by referral or because of subsequent symptoms. In eight of the cases, t,he lesion evidently was not apparent before operation. In four cases before 1935, the cancer was found at the time of operation; three.of these were our own and on one operation report the statement was made that a rim of cervix was left for radium treatment postoperatively. Another case was probably handled this way for the same reason, and, in the third, the tumor growth was too extensive to remove the cervix. This is also the likely explanation in the fourth case. This patient was referred from another ho?+ pita1 soon after operation when a very extensive neoplasm had been found. Seven patients were treated with radium plus x-ray and five with radium only. Two patients wete living and well at five years and one at fifteen J-ears. TABLE
VII.
TK~E REPORTED
STCMP IWII)EWE
CARCINOMA --
Meigs (all clinics) George V. S. Smith and Richard Dresser4 Lewis C. Scheffey, Wm. J. Thudium, David M. Farrell5 B. 2. Cashmans Royal Victoria Montreal Maternity Hospital
CASES CARCINOMA CERVIX
CASES CERVICAL STUMP CARCINOMA
1111
58
3 to 5.2
293
14
4.7
150 664
4 28
2.66 4.21
PERCENTAGE
4
”
__
There have been 2,273 subtotal hysterectomies in this twenty-year period and, with this figure, we have estimated the incidence of carcinoma of t,he cervix to subtotal hysterectomies. It is a somewhat higher incidence than Meigs’* 0.73 per cent with 13 cases of cervical stump cancer and 1,771 subtotal hysterectomies from 1900 to 1933. He also counted these stump cancers as those appearing at, least. a year after hysterectomy. TABLE VIII. TRI-E STI:MP CARCI~;O~IA I~CIUENCE TO SUBTOTAI, HYSTE~(~TOMP ____ NO. OF SUBTOTAL NO. OF CERVlCAT, STUMP CARCIKoIIA HYSTERECTOMIES
( Meigs
’)
2,273 I,77 1
28 13
PERCENTAGE
1.2 0.73
--
The youngest patient in our series t,o develop carcinoma in the cervical stump two or more years after subtotal hysterectomy was 23 years of age. There were two patients of 70 years and one of 69 years. The average age in the group of 28 cases was 51 years.
There is considerable interest. in the r~elationship bet,wcen ovarian function and carcinoma of the cervix. From our own records and records obtained from the doctors and hospifals who had treated the patients previously, we found thal eleven patients, or 39 per cent of t,hc twenty-eight patients, had had bilateral oophorectomy at the time of subtotal hysterect,omy. The importance of amputation or cauterization of the cervix ilk the yrevention of cancer is frequently stressed. Four patirnts were definitely stated to have had one of these procedures at some time. In addition, cauterization from above was most likelv done at the time of subtotal hysterectomy in our OWH patients, as this was a routine procedure in this clinic. The classification of carcinoma of the cervix into stages lwed in ihis clinic* is as follows : Stage I-Single lesion limited lo the cervix canal or portjo. Stage II-General involvement. of tho cervix. No spread beyond. Stage Ill-Spread to fornices and/or parametrium. Stage IV--Frozen pelvis. T’aginal and distant nletastases. Fistulac. .-STAGE
TABLE _--.I
X.
TRUE
STUMP STAGE
CARCWOMA CASESRY STAGES ---.--~-.. --_.___--_. II STAGE III
13
0 METHODS
OF DISEASE - __I___-----..~ STAGE
13
OF TREATMENT
X0.
Radium Radium + x raj Cauterization + radium Surgical removal -~~---.----.-.----._.--------NO. OF CASES 13 _.--.-- --l___l__.-_l
-
OF CASES
l-1 1t’ I 1
FIVE-YEAIC
--____
IV
2
SURVIVAL
.--.-.._
LIVING FIVE YEARS 2
-_--
--_ SCRVIVAL RATE
.---.
15 per cent
--.-
--.
Up to 1940 there were thirteen patients, of whom two survived for five years, a 15 per cent salvage. One qf these was a Stage III in a woman of 70, twenty years postoperative, who was keated with x-ray and radium. The other was a Stage II in a patient, of 54, eleven pears postoperat,ive, treated with radium and x-ray. Thou h surgical treatment for carcinoma of the cervix has not been practiced in t?Iis Clinic, there has been a small group for whom the procedure of radiation followed by surgery has been used. An effort has been made to limit this method of therapy to cases of Stages I and IT, though a number of Stage III are included. Each case therefore has been particularly selected for this form of treatment, and, though the general procedure has been the same, there has been variation in the detail of treatment.
~$g,‘f
VULVAR
AND
CERVICAL
CARCINOMA
499
There have been thirty-seven of these cases with an average age of 43.6 years. The youngest patient was 24 and the oldest 62 years old. Three cases were diagnosed as adenocarcinoma of the cervix, the other thirty-four were squamous-cell carcinomas. TABLE ---__
STAGE 12
-__
XI.
CARCKOMA
OF TI-IE CERVIX-SELECTED
I
GROUP
BY STAGES
STAGE II 13
STAQE III 12
There were twenty-five patients of the thirty-seven in Stages I and II, or t,wenty-five patients who clinically and grossly had a localized tumor. The majority. of patients were treated by radium and panhysterectomy, i.e., removal of the uterus with total removal of the cervix and bilateral salpingooophorectomy. The upper vagina was left and there was no dissection or extirpation of glands or other pelvic structures. There was, however, considerable variation from this method in some cases as can be seen from the following table : TABLE
XII.
TREATMENT
OF SELECTED
GROUP
BY RADIATION
FOLLOWED
BY SURGERY
Radium -I. x-ray + panhysterectomy Radium + panhysterectomy X-ray + panhysterectomy Radium + total hysterectomy Radium and amputation of cervix Cauterization of cervix + radium + panhysterectomy Conization of cervix + x-ray + panhysterectomy Radium + total hysterectomy and left salpingo-oophorectomy TABLE l-10
DAYS 5
XIII.
TIME
6 WEEKS 2
INTERVAL
BETWEEN
3 MONTHS 10
RADIATION
6 MONTHS 9
3 20 2 3 5 2 i
AND SURGERY 1 YEAR 3
2 YEARS 3
*
In most cases, the surgical procedure followed the radiation within a sixmonth period, and there was no record of undue difficulty due to radiation effect on the tissues, which agrees with the opinion expressed by other operators.” The follow-up shows that, of nine deaths, the cause of death was considered to be the disease in five cases, one patient six months later, the others two, three, five, and nine years later. One woman died ten years later of a cerebral accident, and one of drowning. PATIENTS
TABLE XIV. LIVING FIVE,
5 YEARS
SELECTED GROUP TEN, AND FIFTEEN
10 YEARS
YEARS 15 YEARS
FIVE-YEAR NO. OF CASES -____--. 24
-
SURVIVAL RATE LIVING AT FIVE YEARS 18 .-
There was one death due to peritonitis in intestinal obstruction in a Stage I case. Both immediate postoperative complications. The late complications, or poor results in most frequently of course in the Stage III group
PERCENTAQE 75.0
a Stage III case, and one to these conditions developed as the follow-up period, occurred with some in-Stage II.
500
_._--.__.__.._.._ .. _..- -__“.__ -.-.-.-._.__..--. .- _._._-.____.-.. ..__._. -.._.._-...__-_ -_-. ._-- __.---..-.~_1_‘-~“_~::51~~:. .ILZLL-T’. ..:..._-_ ._.-.--.._... Ilecurrerw
Itwt:tl $1 I-ivtuw Ih!c torrrgiual fi~td:~
-
..--
Ycsicow~in:~l tirt uh \Tcrtel)ral - __-__._ metwrtaaw
I St:qe 111 ill li monrhs. I St:qc III I Kltl$y’ I I. I Shfr I I I in I wat 1 Ptnp Ill. irl ‘fi mbnths. l’:tticnl \‘CilPS without further trwtment. I St:gy ‘I II ill ii nmntlis. I- _.___ $1.iige II _. iv.-----6 m011tl1s.__..-.-...--_. _ . ..--...
in 2 yars. liviitg
._._- ----
lit’tcvtl
--. .--.
.-
living and well I*‘ourfwn patients out of thinly-sewn. or 37.7 iwr writ, wrc This ten--car survival figure compares favourahl) ten years after t.reatmcnt. with reported fire-ya r survival rat es for wwinolna of t hc cervix. indicating Ihat late rccwre~lccs may be eliniinatctl 1)~ this nwthotl ol’ treatment. its outlinctl al~ovc?.wrc i’w~ and 0~ In addition, t.he known rewrwnws. curred carlg. Probably thcsc cases H’I.W actually nwre widc~sprcad than est.imated at the time of treatment. Whether the two fistulae and WC wctnl wicturo were clue to radirltion cffeect or to sur’gerv it is difficult, to sa>-, but. it. is unlikely ihat. any were causetl by spread of the di&asc. Summary
and Conclusions
2. Treatment of tho inguinal glands, either by surgery as recommen~lecl Iby Taussig, 01‘ I)y s-l’ny 11s is IlOw lwin g tlonc i,n this Clinic. would appear to IW important in the initial treattnent ol’ (c;lrGnonla of the Tulsa. 3. The rqwted incidence is ,for true stump cancer only. If all CHSCSa I*(! iricludcd, the figure is raised considerably. In our own figarcs, the incidence to cases of carcinoma of the cervix would lw 6.02 per cent. and to nutnbcr OF suhtotal hysterytomies woul~l be 1.75 per cent. 4. At the same linw, most of the true? stump caasesowurred so long after subtotal hysterectoqv~ that the diagnosis of a hwlthy wrvix at the time of operat ion must ha-c: been wlwct.. 5. Thirty-nine per cent. of twenty-eight palients with trut! stump carcinonnl were known to hart had bilateral oophorcctotny with the subtotal hystercctony,~ and! t.herefore! could rtlasonably bc considcrcd to IlilVP had no ovarian tissue a! the t.inic! the carcinoma dewloped. This fairlp large perccntagc does not. support. the t hcwry that carcinoma OI the cervix is reliItcY1 to ovarian stimulation. 6. There were no Stage I casts of true cervical stump carcinoma, and tbc majority were in Stages III and IV. Though it is usual to have manypatients in the more advanced stages, these figures also suggest that the patient ma! dewlop a false sc’nsc of security following operation and he more prone to disregard subsequent synptoms. 7 * 1;\7lCll’” IlilS ShtVtl tht his “curt rate with radical operation aftcl . radiwn was twice what T obtained after radiutn alone in Stages ‘I and .[I (Sch1nit.z). ”
\‘olume Number
56 3
VULVAR
AND
CERVICAL
CARCINOMA
501
Our survival rate has been greatly improved by a similar technique. This group includes Stage III. In addition, the radical pelvic operation has not been done in any case. If ten-year survivals are considered to be cured cases, the cure rate is also higher in these cases, i.e., 41.6 per cent.
References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Graves, 5. C., and Mezer, Jacob: AM. J. OBST. & GYNEC. 43: 1016-1021, 1946. Taussig, Fred J.: Am J. OBST. & GYNEC. 40: 764-779, 1940. Meins. J. V.: New Enaland J. Med. 230: 577. 1944. Srnizhi George V. S., and Dresser, Richard: ‘AM. J. OBST. & GYNEC. 50: 1, 1945. Scheffey, Lewis C., Thudium, Wm. J., and Farrell, David M.: AM. J. OBST. & GYNEC. 43: ‘941-954, 1942. Cashman, B. Z.: AM. J. OBST. & GYNEC. 41: 216-224, 1941. Meigs, J. V.: Tumors of the Female Pelvic Organs, New York, 1934, The Macmillan Company. Taussig, Fred J.: 1943. J. Mt. Sinai Hosp. 10: 172-175, May-June, Meigs, Joe V.: AK J. OBST. & GYNEC. 49: 542, 1945. Lynch, Frank W.: Am. J. Surg. 48: 249-254, 1940.