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Carcinoma of the cervix uteri during pregnancy
Carcinoma of the cervix uteri during pregnancy A study
of the combined
antibiotic,
and
a long-acting
in situ carcinoma
EDWARD
P.
WELDON
K.
.4LEX
VARGA,
JOHN
E.
PHILIP
progestin
JONES,
SCHWINN, BULLOCK,
and
M.D M.D. M.D.
M.D. A.B.
California
entire cervix, and a definite plan for its eradication, as the in situ lesion is always close to the invasive stage and progression to invasion is recognized.’ 0nly during pregnancy is it permissible to delay treatment and not immediately eradicate the lesion. There are three reasons for this difference in a standard treatment plan: ( 1) Study of the lesion by many workers has led to opposing views regarding the biological potential in the pregnant woman. Evidence has been presented that the lesion discovered during pregnancy regresses more frequently than when found in the nonpregnant woman, although this has been challenged.’ (2) The increased hazard of abortion resulting from any treatment or extensive diagnostic procedure, may outweigh the benefit gained by immediate treatment even of a potentially dangerous lesion. (3) A complete study of the endocervix is impossible without interrupting the pregnancy. Therefore, the diagnostic procedures and therapy necessarily must be incomplete until the pregnancy is terminated. In August, 1961, a program of cancer cyto-
T H E u R G E N C Y for treatment of carcinoma of the cervix is so great that the opportunities for long-term study are rare. The in situ stage is an ideal time for observation, especially since it has been reported that carcinoma has regressed as well as progressed at this stage.‘. “. ” The application of substances which would produce regression of the histological changes of Stage 0 squamous carcinoma of the cervix might be an important step in the establishment of its etiology. However, any such study must be conducted within the limitations of “standards of practice” with respect to this disease. These include adequate investigation of the
From the Los Angeles County Hospital, and Defiartments of Obstetrics and Gynecology, and Surgical PathologyUniuel-sity of Southern California, School of Medicine. by a Grant from the United States Health Service, and the State of California, Bureau of Chronic Diseases.
Aided Public
Presented
at the the and Gynecological California, Sept.
Meeting
on dysplasia
a broad-spectrum
M.D.
DUNN, BUELL,
Angeles,
of a trichomonacide,
of the cervix
GOMER
CHARLES
I.or
effect
of
Thirtieth
Pacific
Annual
Coast Obstetrical Society, Yosemite, 18-21, 1963.
285
286
Jones
Fig. into
1. Tissue longitudinal
et al.
June 1, IYtit Am. J. Ohs. & Gyrwr.
pieces for strips.
biopsy
from
anterior
lip
detection in the prenatal clinics of the city and county of Los Angeles was initiated. This provided opportunity to study a continuing group of patients with (1) in situ carcinoma, or (2) dysplasia of the squamous epithelium of the cervix. This report is a summary of the first 2 years of the cytodetection program, and of the attempts to produce regression of the lesions. Sufficient data have been recorded to present definite findings regarding the effectiveness of the first three drugs used. Future studies will show effectiveness of other drugs and give long-term observations on the dysplasia group. Materials
and
methods
Patients in the study were selected on the basis of abnormal smears reported in one of the city or county prenatal clinics. They were usually seen in the second trimester of pregnancy. These patients were treated and observed for a period of 3 to 9 months from the time of the initial smear to the making of definitive diagnosis by conization 3 months post partum. The medications used were a combination of an oral trichomonacide, a broad-spectrum antibiotic, and a long-acting progestational agent given sequentially.
of cervix
before
slicing
The smears were obtained by cervical scraping with a wooden spatula at the junction of endo- and ectocervix. The material was then placed on two slides which v\‘er’c immediately immersed in the standard ether-alcohol solution containing Carbowax. After a 1 hour fixation, the slides were dried and, with triplicate identification, were sent to the Cytology Laboratory of the Los Angeles County General Hospital. One slide from each patient was stained by the Papanicolaou method and the other with acridine-orange for fluorescent interpretation. (These slides were read separately by trained cytotechnicians.) All abnormal slides were rescreened by the chief cytotechnician and these in turn were checked by a pathologist qualified in cytodetection. The comparative results of these slides will be reported later. In this laboratory, slides classed I and II are normal, Class IIIA are suspicious and a repeat smear is requested. All patients having a repeat smear Class IIIA, Class IIIB, IV, or V were referred to the definitive diagnostic clinic. Approximately 80 per cent of the patients were between their fifth to ninth month of gestation with the remaining 20 per cent 4 to 8 weeks post partum when the initial smears were obtained.
Volunlc Number
89 3
Carcinoma
Fig. 2. Microscopic biopsy. In the diagnostic clinic additional smears were taken to confirm the abnormality following which the cervix was stained with Schiller’s solution and multibiopsies obtained from nonstaining areas, all at the first visit. This usually resulted in four pieces of tissue from the posterior lip submitted as one specimen and four pieces from the anterior lip, second specimen (Fig. 1) . The tissue for biopsy was processed as follows: Each piece of tissue was cut into linear slices. The flat sides of these sections were placed on the surface of a glass slide, covered with a few drops of liquid agar, which when hardened allowed the sections to be moved directly to a metal cassette.” This technique assured that the tissue remained in longitudinal strips flat against the surface of the block when the tissue was impregnated with paraffin. Approximately 15 to 20 sections were thus available from each patient’s tissue biopsies (Fig. 2). Selection
of
medication
The selection of the type of treatment was determined by factors known to be of possible importance in the induction of cervical cancer. Our knowledge of these factors is limited to those which have been shown to
of cervix
uteri
slide of tissue of anterior
during
cervical
pregnancy
287
lip processed for
be related to the frequency of the lesion. These are religion, pregnancy, marriage, early socioeconomic status, and pregnancy in life.” Since it is known that progestational agents produce an increase of cytoplasm. and cessation of cell division of the glandular epithelium of endometrium,’ the possibility of a similar effect on the squamous epithelium of the cervix was considered pertinent to the investigation. The association of a low economic status and marriage with carcinoma of the cervix has resulted in much speculation regarding infectious agents (protozoa, bacteria, and viruses). Several studies have been reported relating Trichomonas vaginalis to in situ carcinoma.7-1” Also, regression of the in situ lesion following the use of broad spectrum antibiotics has been reported.3, I1 A combination rather than a single agent was chosen because of skepticism that any of the three would be extremely effective. Therefore, the absence of a definite clinical response after all three had been tried wouId eliminate all in one clinical trial. On the other hand, if a beneficial effect was found. it could easily be analyzed in additional studies.
288
Jones
et al.
Table I. Treatment
plan
Repeat smears and initial biopsies 1. Nitroimidazole-1 tablet p.o, q.i.d. x 3 2. Polymyxin B sulfate, neomycin sulfate, acetarsone vaginal suppository-nightly x 7 3. Hydroxyprogesterone caproate1 : m 1 per week \* 4 If above were given during pregnancy 1 month post partum Hydroxyprogesterone caproate-500 mg. 1 per week x 4 Final smears and biopsies at 2 to 3 months post “arturn
Medication
A trichomonacide (nitroimidazole) was selected which in previous studies was found to be effective in 95 per cent of patients when given orally for three days.” It was begun on the first visit to the special diagnostic clinic when the first biopsies were done --1 tablet four times a day for 3 days for a total dose of 2.1 Gm. of nitroimidazole.” The second medication was a broad-spectrum antibiotic effective as a vaginal suppository, used for 7 days beginning 1 week after the first clinic visit. Each suppository contained 20,000 U. of polymyxin B sulfate, 5 mg. neomycin sulfate, and acetarsone 250 mg. in a base of 1 Gm. of beta lactose.? The third drug, hydroxyprogesterone caproate, shown to have a long-acting progestational effect, was administered beginning 2 weeks after initial biopsy. The drug was given in a dosage of 500 mg. intramuscularly at weekly intervals for 1 wceks.$ One week following the last hormonal injection. smears, and biopsies were repeated. Patients who completed treatment and evaluation before the end of gestation also were treated with a 4 week repeat course of hydroxyprogesterone caproate beginning 1 month post partum. Final biopsies and smears of all patients were taken approximately 2J/2 to 3 months post partum (Table I) If the
*Supplied
by
G.
D.
tSupplird by Butloughs vaginal wppositorirs.
Sea&
& Co. Wrllcome
as Flagyl. & Co.
as Neospotin
Papanicolaou smears had never been greater than Class IIIB and biopsies failed to reveal anything more extensive than dysplasia, the patient studied remained in the group to IX followed by repeat cytologic study at 6 month intervals without conization. Control
groups
The active drugs and their inert counterparts were labeled by the chief pharmacist. All patients coming to the clinic were assigned to two treatment groups, A or H. in matching pairs before any definitive diagnostic studies (one of the pair to be the control and receive inert medication). It was felt that a delay in the initiation of treatment until biopsy diagnoses rnight not leave tirne for completion of the treatment befort* the final evaluation at 3 months post partum. ‘When statistical analysis w-as compiled. howe\,er. patients in Group A were matched in pairs with patients in Group B on the basis of the tissue result at first biopsy, and without knowledge of results of the diagnosis post parturn. Thus, the first carcinoma in situ patient in Group A is paired with the first carcinoma in situ patient in Group B: thr first dysplasia patient in Group .4 with thr first dysplasia patient in 1%. ‘I‘he CXJIn~~l~tc' protocols of patients also contain age ancl duration of gestation at time of first discnostic smear. The gestation grouping lvas based on a study by Reagan and associates’,’ who showed in a
‘I’hc information listed is from approsimately 25,000 women screened. In this group there werr 2.5 per cent who had abnormal smears requiring further study and in situ carcinoma was found in about .3 per crnt of the total. There have been 84 patients
Carcinoma
ANALYSIS
CARCINOMA
I
uteri
during
pregnancy
289
matched pairs, whose initial Papanicolaou smears were Classes IIIB, IV, and V. The statistical evaluation of the first two groupings is by the method of sequential analysis using a restricted design.‘-’ This type of comparison usually allows the acceptance or rejection of a hypothesis with a smaller number of patients than that required by conventional methods of estimating sample size. Our hypothesis for both groups was that in 10 per cent of the patients the lesion might spontaneously regress and that a total of 50 per cent of the experimental group would show regression with treatment. A change of this order would be decisive and the treatment used could be considered therapeutic for cervical lesions bordering on carcinoma.
with a diagnosis of in situ carcinoma who have had a final evaluation following conization or hysterectomy. There have been 90 patients with dysplasia whose final evaluation was by multiple biopsies. An analysis of the results of treatment of the in situ and dysplasia groups described, and the final estimation of the progression or regression of the disease in the entire in situ group will be presented. Three groupings are presented in the treatment results: (1 ) comparison of final biopsies and conization of matched pairs, whose initial biopsies were in situ carcinoma; (21 comparison of final biopsies of matched pairs, whose initial biopsies were dysplasia; and (3 ) comparison of final Papanicolaou smears in
SEQUENTIAL
of cervix
OF TEN IN
SITU
PAIRS
BUT
OF CASES
WITH
ORIGINAL?Y
UNLIKE
FINAL
DIAGNOSED
AS
DIAGNOSIS*
DECISION:
Difference Treatment
in
favor
of
-A
No
Significant Difference
15
Treatment
B
10
pairs
pl
pai
rs
n
Member
improves
=
J
Member
improves
=m
with
one
member
w; th
members
Figs. 3 and 4. Restricted sequential designs improvement in treatment group compared improvement in a placebo group (see text). = .05; power of test 1-p = .95 ; 6 = .90.
of
X (Drug) (Control)
improved pairs
al ike
(nqt
charted)
to detect at least 50 per cent to an expected 10 per cent a sided significance test 2 (I
290
Jones
SEQUENTIAL DIAGNO
et at.
ANALYSIS SE ‘D AS
OF FOURTEEN
DYSPLASIA
BUT
PAIRS WITH
OF CASES
UNLIKE
ORIGINALLY
FINAL
DIAGNOSIS*
DECISION: Difference Treatment
in
favor
of
A
Difference
15
Treatment
B
A Member
improves
=
X (Drug)
B Member
improves
=
l
14
pai
rs
with
one
member
22
pai
rs
with
members
(Control)
improved of
pei
rs
el ike
(not
charted)
Fig. 4.
Comparison of the 10 to 50 per cent level for in situ carcinoma and dysplasia is shown in Figs. 3 and 4. It should be noted that in these sequential charts only the unlike pairs are plotted, i.e., pairs in which one member only improved. In the in situ group there were 21 pairs in which both members were alike on the first and last biopsies. There were 10 pairs in which one member improved. Fig. 3 shows that when the latter group is plotted (A member directed above the ordinate and B member directed below the ordinate) improvement to the 50 per cent level did not take place within the closed graph pattern (22 members were not charted because some pair mates were not finally evaluated, while others had failed to complete the treatment plan). Similarly, with dysplasias there were 22 pairs alike on first and last biopsies, and 14
pairs where one member improved. Again. improvement did not approach the 50 per cent level of regression when plotted (Fig. 4), but to date there have been insufficient pairs for a final opinion. It does appear that the drugs produced improvement in an occasional patient. The comparison of the initial Papanicolaou smear IIIB and the final Papanicolaou smear in the two treatment groups is shown in Table II. It is readily seen that the two groups (treatment and control) are similar both when the tissue diagnosis is in situ carcinoma and when the tissue diagnosis is dysplasia. Furthermore, there is a suggestion of a gradual improvement in the total dysplasia group that is similar in both the treatment and control group. The concomitant phase of this study was to determine (1) whether the lesion in situ
Carcinoma
Table II. Comparison report
in treatment
Total Biopsy dysplasia Final Papanicolaou I or II IIIA IIIB
-
Total
A (treated)
B (control)
4 5 7 - 3 19
4 6 8 - 0 18
uteri
7 1 - 0 8
8 3 0
Biobsies
on
? Microinvasive ? Microinvasive
first
carcinoma in pregnancy remains post partum and (2 ) whether the lesion progresses or regresses rapidly. The comparison of tissue diagnosis by biopsy versus final tissue diagnosis by conization in all the patients who have been followed beyond 3 months post partum gives a fairly clear answer to these questions. Table III shows that most of the in situ lesions remain. The diagnosis of a slight advancement of the lesions in a few instances suggests slight progression. Only after continued clinical experience and restudy of the tissue in continuity may this progression be determined. There are approximately 38 per cent of patients showing lessening of the lesion (Table III) but in 22 per cent of these the change is in the brief interval of 3 weeks between last biopsy and cone (Table IV). This finding would suggest that all of these changes and some of the remaining 16 per cent are caused by inflammation or removal of the lesion rather than a true spontaneous regression. It seems obvious that in situ carcinoma rarely regresses spontaneously.
pregnancy
291
of diagnoses by in 83 cases proved
to
/ No. of cme~ 40
In situ In situ Dysplasia Chronic cervicitis In situ
Dysplasia
11
during
I c onization
In situ ? Microinvasive In situ In situ
report
*All patients with IIIB Papanicolaou or higher .rmear and diagnosis of carcinoma in situ by biopsy.
cervix
Table III. Comparison biopsy and conization have in situ carcinoma
of Papanicolaou and control groups*
Finn1 Papanicolaou report I or II IIIA IIIB None or unsatisfactory
of
2(: (38per 12 1 cent ) * 4 (5per cent)t 2x
Microinvasive ? Microinvasive
2
(There were 8 other cases of invasion on first biopsy) “38 per cent in situ removed by biopsies regressed; however, 22 per cent of these last biopsy and conk&on or hysterectomy wading of tissue). t5 pex cent of suspected by distinctly :Micxoinvasion calcinoma with
or spontaneously changed between (initial routine
lesions coned because abnormal smears.
is defined in this a focus of questionable
of
malignancy
series as in situ superficial invasion.
Table IV. Comparison
of diagnoses between last biopsy and conization (biopsy 3 weeks before conization) La5t
biopsy
Coniration
1 No. of cases
In situ
In situ
38
In situ In situ
Dysplasia
12
Chronic cervicitis
6 I
In situ
? Microinvasive
2
? Microinvasive
Microinvasive
2
In situ
on previous
In situ
Dysplasia
Dysplasia
Dysplasia
Chronic cervicitis
5
Dysplasia Chronic cervicitis
2 1
Chronic
cervicitis cervicitis
cent) *
biopsy
Dysplasia
Chronic
(22per
5 5
Comment
Our comments will be about (1) the controllable variables in this clinical study and (2) the malignant potential of these lesions. In conducting the present study, it was necessary to separate the ordinary clinical ap-
Prez,iou.r Dysplasia Chronic *Regression inflammatory
Papanicolaou cervicitis (22 per reaction.
IIIB, In situ
IV,
or V 5
Chronic cervicitis cent)
due
to
1 removal
by
biopsy
or
292
Jones et al.
preach to in situ carcinoma from a study diagnosis of carcinoma in situ. The clinical pathologist ordinarily feels obliged to assemble information relative to the patient’s age, number of children, desire for pregnancy, and degree of abnormality of the Papanicolaou smear as he evaluates the tissue for biopsy. In the present study the records of the slides were kept in a separate file from that of the biopsy material. Each slide was read separately without any comparison to any previous slide. This independence must be closely guarded to avoid undue v,ariation in the interpretation of slides. The coding of slides may vary from one laboratory to another, but within one laboratory accuracy must be maintained within the agreed code. For example, most in situ carcinomas in out laboratory will have a Class IIIR reading, whereas in another laboratory most of the slides may be read IV or V.‘” The biopsy tissues also must initially be read independent of the cytologic slides and of any additional studies of cells and tissue from the same patient. Final m-evaluation and reinterpretation may be of value, but for statistical evaluation the unprejudiced initial impression is mandatory. The difference of interpretation between severe dysplasia and in situ carcinoma by eminent authorities in other reports”’ (and on review of our material) raises the question of “what. if any, correlation can be made between these two diagnoses?” “What is the relative biologic or malignant potential of these lesions?” Some years ago, in heterologous tissue transplantation, Greene showed that there may be little or no correlation between ‘the degree of anaplasia observed in histologic sections with the biologic malignant potential of a given tumor.” It is also a wellknown fact that tumors may show extreme maturation, but possess the inherent ability to invade and metastasize widely. So, too, out interpretation of individua1 cells as to whether they are dysplastic or malignant may havt little relationship to the actual behavior of the tissue in viv*o in any one individual. Chromosome studies of different in situ car-
cinomas have in fact shown the number of somatic chromosomes to vary considcrably,l’, I!) Furthermore, exfoliative cytology reveals nothing about the host’s stromal bed and its resistance or acceptance of epithelial cells, which after all may be just as important in the malignant process as the epitheIium itself. Thus even though there is a standard of practice which is followed. it should be admitted that the clinical behavior of in situ carcinoma mav have little resemblance to the behavior of invasive cancer.‘: WC have shown that the dr~rgs used did not causr regression of in situ carcinoma ot dysplasia in 50 per cent of instances as was postulated. However, we cannot exclude thf* possibility that these lesions might have brerl influenced or might change to a considerable degree--even regress-if the ljatients had been studied for a longer period of time. Reagan has shown that dysplasias found in patients during pregnancy did not begin to regress until 6 months post parturn.” Indeed, our cytologic study would snggcst there is a beginning change or regression, not inHIrenced by treatment, appearing in the esfoliative cells, but not yet appearing in the biopsy material. Perhaps with more erperience this change will be clarified. Meanwhile, we remain fearful of the mali,gnant potential of these lesions and realize that \ve possess no true understanding of what ljromotes progression or regression of these IPsions. We trust that continued study by these . . In vrvo methods will lead to a better understanding of precancerous as well as cancerous lesions. Summary
1. An in vivo study has been started of patients with in situ carcinoma and dysplasia found during pregnancy to discern whether these lesions can be reversed by chemical substances. 2. The first clinical trial with a trichomonacide ,given orally. a broad-spectrum antibiotic used vaginally, and a long-acting progesterone given intermuscularly (in sequential order) failed to produce regression in 50 per cent of cases within the time limit
Carcinoma
described. There was a suggestive change in some of the dysplasias. 3. This group of cases demonstrates that
of cervix
uteri
during
pregnancy
293
the lesions found during pregnancy are similar to those found at other times and the majority persist if not treated or removed.
REFERENCES
Fluhmann, C. F.: The Cervix Uteri and Its Diseases, Philadelphia, 1961, W. B. Saunders Company. & GYNEC. 72: 2. Peterson, 0. : AM. J. OBST. 1063, 1956. F. W., Foote, F. W., 3. Koss, L. G.: Stewart, Jordan, M. J., Bader, G. M., and Day, E.: Cancer 16: 1160, 1963. 4. Slate, T. A., and Merritt, J. W., Jenny, J.. and Wyss, H. J.: Proc. First International Congress of Exfoliative Cytology 1: 128, 1961. 5. Shaekelford, R. I., and Jones, J. L.: Am. J. Clin. Path. 34: 397, 1959. 6 Jones, E. G., Macdonald, I., and Breslaw, L.: AM. J. OBST. & GYNEC. 76: 1, 1958. M., Lonser, E., Nichols, E. E., 7. Simeckova, and Rubinstein, I. N.: Obst. & Gynec. 20: 410, 1962. W. H., Green, S., Hanburger, F., 8. Frishman, Kasdar, S. C., Nieburgs, F., McInnis, G., and Paud, E. R.: Cancer 7: 729, 1954. 9. Patten, Jr., S. F., Hughes, C. P., and Reagan, J. W.: Acta cytol. 7: 187, 1963. 10. Koss. L. G., and Wolinska, W. J.: Cancer 12: 1171, 1959. 1.
11. 12. 13.
14.
15. 16. 17. 18.
19.
Ayre, J. E.: Antibiotics and Chemotherapy 1: 339, 1951. Jones, E. G., Biddle, M., Browell, B., and Varga, A.: West. J. Surg. 70: 258, 1962. Reagan, J. W., Bell, B. A., Newman, J. L.. Scott, R. B., and Patten, S. F.: Acta cytol 5: 17, 1961. Armitage, P.: Sequential Medical Trials, Oxford, England, 1960, Scientific Publishers Limited. McLennan, M. T., and McLennan, C. E.: California Med. 99: 1, 1963. Siegler, E. E.: Cancer 9: 463, 1956. Greene, H. S. N.: Cancer 5: 24, 1952. Moricard, R., and Cartier, R.: Ciba Foundation Study Group No. 3, Boston. 1959, Little, Brown & Company. Spriggs, A. I., Buddington, M. M., and Clarke. C. M.: Carcinoma In Situ of Cervix Uteri: Soma Cytogenic Observations, Lancet 1: 1383, 1962.
1770 N. Orange Grove Pomona, California
Auenue
Discussion DR. PURVIS L. MARTIN, San Diego, California. In this large, statistically controlled study Dr. Jones has made at least two significant advances in the medical field of cytology. He has screened the largest single series of pregnant women yet to be reported. He has also used cytology in the
search for basic factors underlying
the etiology
and growth of cancer. The detection of 100 curable cervical cancers, which were screened out of 25 thousand essentially indigent pregnant women, is in itself a significant achievement. This report should receive wide attention and should establish, once and for all, the true worth of taking a routine Papanicolaou smear during pregnancy as a part of good prenatal care.
Strange
as it may seem, taking
panicolaou smears during versal practice. Less than
routine
Pa-
pregnancy is not uni5 years ago practicing
cytologists,
in our area at least, held that cyto-
logical smears in pregnancy should not he taken because of a wide margin of error in reading them and because of the presumed reversibility of the lesions that were found. In an opinion survey of members of the San Diego County Medical Society, in 1961, while more than 90 per cent of physicians favored routine use of Papanicolaou smears, less than 25 per cent favored their routine use in pregnancy. Even today, California’s Medicare plan for defraying the costs of obstetrical care for military depen-
dents will pay for a variety of laboratory tests in the name of good prenatal care, but will not pay
for a Papanicolaou smear. the other hand, it is now our conviction that by omitting smears during pregnancy the medical profession is missing a golden opportunity to control cervical cancer. Every mass On
294
Jones
et
al.
screening program has fallen short of its total population goal because of difficulties in motivating women to see doctors. The majority of in situ cancers are believed to remain quiescent for many years during the time in a woman‘s life whrn she is most likely to become pregnant. (Two-thirds of our “Gynob” series of 933 early cancers occurred before age forty.) Experienced cytologists and screeners can no\\ reco,gnizc~ cellular aberrations of pregnancy and distinguish thrm from atypias of cancer. It follows that if all physicians wyre to obtain cervical smears on all their obstetrical patients, most women would eventually get scrcrned at an a,qe which is most important to them. Pregnancy screening alone should go a long way toward controlling cer\rical cancer. Every physician whose practice includrq the rarr of pregnant Womrn should be convinced of the value of pregnancy smrars, and hct should not miss this opportunity to educate each young wnman to a lifr-lon,q habit of seeking an annual Papanicolaou smrar. In his other major advance, as we sre it, Dr. Jones has opened “p a fascinating avenue in cytolo,~y, tlsing the study nf exfoliated human cells in a search for factors influencing the rtiology and growth of crrvical cancer. By careful. double blind study hc has convincingly ruled nut his first three rtiologiral suspects. Trichomonas hag long bcrn known to produce aberrations in rxfoliatrd rrlls. Brcausc of this, an etiologiral relationship to cr:rvic.al cancer has been suspected. and brcal~se of it many cervices havcl been damaged by conization that followed Trirhomonas-induced Class III cytology reports. Slate, Merritt, and Kennedy, from a study of material in our laboratory, could establish no rclation betwrcn Trichomonas and cervical cancer in situ. Dr. Jones in this study failed to affect the growth of in situ cancer by using an effcctivc trichomonacide. R<*lativc steroid starvation \vas another logical suspect. In a parallel observation wt‘ havta noted that the rather abrupt menopausal stcrtrid deprivation coincides with a drcrraw in frequrnry of in situ cancer. but an increase in invasive cervical cancer. Large doses of progesterone here failed to influence thr growth of cervical cancer but the way is paved for thr testing of other agents. It is heartening to find that in this project govcrnmcnt subsidy was used where it belongs. for research and in the care of indigent patients. The results of this magnificent screening project in pregnancy should become widely known. Cy-
tology appears to be a practical tool for investigative cancer research. DR. C. F. FLUHMANN, San Francisco, (:alifornia. The most significant conclusion \vhi<.h must be reached from the data presented I,)- L)r. Jones is that the various lesions diagnosrd as carcinoma in situ of the cervix uteri during pregnancy persisted and ivere still recogniLablc as such after the termination uf gestation. This evidence lends support to the concept that carcinoma in situ as such exists Tvhethrr the pa~iet~t is prrgnant or not, and if she is pregnant cliagnosis and treatment must bc conducted without delay. The possibility that early invasi\~~~ disease may also be present remains as a constatll thrrat. It is most unfortunate that there is a belief amonS many obstetricians that during prf’g:nanry certain histologic changes may occItr ill the cervix uteri which are of a hrnign charac-trl and mrrrly simulate carcinoma in situ. Thesr, changes arr said to result from endocrine srimulation and rrgress spontaneously in the l,ostpartal period. This is incorrect and a persistcncc, of such ideas may lead to tragic dt,lays in rhr diagnosis of early cancer. Vaginal smears must l)e an csscntial part of el’ery prenatal cxnmination, and when they arc reported as positivtx they must be rPpeatrd and adrqllatr diagnostic. procedures carried out in spite nf thr existin pregnancy. DR. KARL SCHAUPP, JR., San Francisco, California. I was a little confllsed 1,) the statistical graph and had some trouble interpreting what it meant at this first sight. A certain perccntagts of carcinoma in situ will regress spontaneoltsly, Ijut I do not know the actual figure. It has hccn variously reported between 60 to 70 per cent Tu 20 to 30 per cent. I would like to knot%? what your opinion is. The same per cent would rcCgress follnwinq pregnancy. I rlsportrd two raw\ IO the San Francisco Gynecological Societythat \vcrc diagnosed during pregnancy hut the lesions 1atc.r rcgrcassed spontaneously. DR. 1’1:. DOUGLAS MARSH.W.,” \;ictoria, British Colllrnbia, Canada. In British Columbia th(. cervical smear program is carrird out as a servicr, frer of rharge, by the British Columbia Division of the Canadian Cancer Foundation. Last year more than 100,000 smears wprc rc’ported upon. If more of ollr (:ommissions
“By
invitation.
Carcinoma
adopted the routine smears in pregnancy, we could project a study such as the one we have heard this morning and, I think, make an important contribution to the subject. One would think that if the changes in the cervix during pregnancy, that is, dysplasia or carcinoma in situ, were due to the pregnancy per se, one would find a large number of false positive smears in a series such as this. I do not think that this has bren the case and I belieIre that these changes are unrelated to pregnancy and do not disappear spontaneously post partum. The diagnosis of carcinoma in situ can only be made on the basis of an adequate cone biopsy, adequately scrutinized. If one believes the diagnosis is important, one should get on with it regardless of the pregnancy. There is, naturally, some fear and reluctance that by doing a cone biopsy during pregnancy one may interrupt a pregnancy for the simple purpose of diagnosing a dysplasia. However, on the basis of two previous positive smears, I think the diagnosis must be made and the distinction between a benign and a malignant lesion clarified. I believe the cone biopsy should be very carefully done. It is not a procedure that one would entrust to a junior. One can take a good centimeter cone with the knife, almost to the internal OS, without undue difficulty. I have had no problem with bleeding and have not yet interrupted a pregnancy. DR. CLDYE VON DER AHE," Beverly Hills, California. Last year I presented a paper before the Society on the study of approximately 1,800 unmarried pregnant women. During that time in our studies we did routine Papanicolaou smears. In the very young group we had absolutely no positive smears whatsoever. As a matter of fact, in the whole group we had only one positive smear.
*By
invitation.
of
cervix
uteri
during
pregnancy
We were impressed, however, with the percentage of Trichomonas that was found these vaginal smears, well over 90 per Therefore, I would like to ask Dr. Jones the basis of his figures whether or not he that the routine Papanicolaou smear in the young girl, that is, from 12 years up to really justified? DR. JONES, (Closing). At the inception
295
high in cent. on feels ver) 18 is
oi
this study we anticipated many abnormal smears caused by pregnancy reactions alone. But wc found no severe changes caused by pregnancy which will be confused with malignancy. We were assured by several investigators before we began the present study that the use of selected biopsies, repeat Papanicolaou smears. and colposcopy rather than conization would bc an adequate and accurate way of diagnosis during pregnancy. When one examines 30 to 81) good tissue slices from selected sites, it is not surprising that the biopsy method of diagnosis is very accurate. These lesions found in the pregnant patients are smaller or earlier than the ones found in our other clinic patients. Residual in situ carcinoma after conization was found in only 3 out of 50 hysterectomy specimens in the present study, whereas in the other patients about 30 per cent of the hysterectomy specimens have residual in situ areas. The largest group of in situ carcinoma is in the 20 to 30 age group, because most of the women seen are in that age group. The youngest patient with a distinctly abnormal smear, but not proved to have in situ carcinoma, was aged 15 in the third month of her first pregnancy. The youngest patient with proved in situ carcinoma was aged 19. We believe that a cytoIogic smear is in order from the time of the first pregnancy and thereafter.
of the combined
antibiotic,
and
a long-acting
in situ carcinoma
EDWARD
P.
WELDON
K.
.4LEX
VARGA,
JOHN
E.
PHILIP
progestin
JONES,
SCHWINN, BULLOCK,
and
M.D M.D. M.D.
M.D. A.B.
California
entire cervix, and a definite plan for its eradication, as the in situ lesion is always close to the invasive stage and progression to invasion is recognized.’ 0nly during pregnancy is it permissible to delay treatment and not immediately eradicate the lesion. There are three reasons for this difference in a standard treatment plan: ( 1) Study of the lesion by many workers has led to opposing views regarding the biological potential in the pregnant woman. Evidence has been presented that the lesion discovered during pregnancy regresses more frequently than when found in the nonpregnant woman, although this has been challenged.’ (2) The increased hazard of abortion resulting from any treatment or extensive diagnostic procedure, may outweigh the benefit gained by immediate treatment even of a potentially dangerous lesion. (3) A complete study of the endocervix is impossible without interrupting the pregnancy. Therefore, the diagnostic procedures and therapy necessarily must be incomplete until the pregnancy is terminated. In August, 1961, a program of cancer cyto-
T H E u R G E N C Y for treatment of carcinoma of the cervix is so great that the opportunities for long-term study are rare. The in situ stage is an ideal time for observation, especially since it has been reported that carcinoma has regressed as well as progressed at this stage.‘. “. ” The application of substances which would produce regression of the histological changes of Stage 0 squamous carcinoma of the cervix might be an important step in the establishment of its etiology. However, any such study must be conducted within the limitations of “standards of practice” with respect to this disease. These include adequate investigation of the
From the Los Angeles County Hospital, and Defiartments of Obstetrics and Gynecology, and Surgical PathologyUniuel-sity of Southern California, School of Medicine. by a Grant from the United States Health Service, and the State of California, Bureau of Chronic Diseases.
Aided Public
Presented
at the the and Gynecological California, Sept.
Meeting
on dysplasia
a broad-spectrum
M.D.
DUNN, BUELL,
Angeles,
of a trichomonacide,
of the cervix
GOMER
CHARLES
I.or
effect
of
Thirtieth
Pacific
Annual
Coast Obstetrical Society, Yosemite, 18-21, 1963.
285
286
Jones
Fig. into
1. Tissue longitudinal
et al.
June 1, IYtit Am. J. Ohs. & Gyrwr.
pieces for strips.
biopsy
from
anterior
lip
detection in the prenatal clinics of the city and county of Los Angeles was initiated. This provided opportunity to study a continuing group of patients with (1) in situ carcinoma, or (2) dysplasia of the squamous epithelium of the cervix. This report is a summary of the first 2 years of the cytodetection program, and of the attempts to produce regression of the lesions. Sufficient data have been recorded to present definite findings regarding the effectiveness of the first three drugs used. Future studies will show effectiveness of other drugs and give long-term observations on the dysplasia group. Materials
and
methods
Patients in the study were selected on the basis of abnormal smears reported in one of the city or county prenatal clinics. They were usually seen in the second trimester of pregnancy. These patients were treated and observed for a period of 3 to 9 months from the time of the initial smear to the making of definitive diagnosis by conization 3 months post partum. The medications used were a combination of an oral trichomonacide, a broad-spectrum antibiotic, and a long-acting progestational agent given sequentially.
of cervix
before
slicing
The smears were obtained by cervical scraping with a wooden spatula at the junction of endo- and ectocervix. The material was then placed on two slides which v\‘er’c immediately immersed in the standard ether-alcohol solution containing Carbowax. After a 1 hour fixation, the slides were dried and, with triplicate identification, were sent to the Cytology Laboratory of the Los Angeles County General Hospital. One slide from each patient was stained by the Papanicolaou method and the other with acridine-orange for fluorescent interpretation. (These slides were read separately by trained cytotechnicians.) All abnormal slides were rescreened by the chief cytotechnician and these in turn were checked by a pathologist qualified in cytodetection. The comparative results of these slides will be reported later. In this laboratory, slides classed I and II are normal, Class IIIA are suspicious and a repeat smear is requested. All patients having a repeat smear Class IIIA, Class IIIB, IV, or V were referred to the definitive diagnostic clinic. Approximately 80 per cent of the patients were between their fifth to ninth month of gestation with the remaining 20 per cent 4 to 8 weeks post partum when the initial smears were obtained.
Volunlc Number
89 3
Carcinoma
Fig. 2. Microscopic biopsy. In the diagnostic clinic additional smears were taken to confirm the abnormality following which the cervix was stained with Schiller’s solution and multibiopsies obtained from nonstaining areas, all at the first visit. This usually resulted in four pieces of tissue from the posterior lip submitted as one specimen and four pieces from the anterior lip, second specimen (Fig. 1) . The tissue for biopsy was processed as follows: Each piece of tissue was cut into linear slices. The flat sides of these sections were placed on the surface of a glass slide, covered with a few drops of liquid agar, which when hardened allowed the sections to be moved directly to a metal cassette.” This technique assured that the tissue remained in longitudinal strips flat against the surface of the block when the tissue was impregnated with paraffin. Approximately 15 to 20 sections were thus available from each patient’s tissue biopsies (Fig. 2). Selection
of
medication
The selection of the type of treatment was determined by factors known to be of possible importance in the induction of cervical cancer. Our knowledge of these factors is limited to those which have been shown to
of cervix
uteri
slide of tissue of anterior
during
cervical
pregnancy
287
lip processed for
be related to the frequency of the lesion. These are religion, pregnancy, marriage, early socioeconomic status, and pregnancy in life.” Since it is known that progestational agents produce an increase of cytoplasm. and cessation of cell division of the glandular epithelium of endometrium,’ the possibility of a similar effect on the squamous epithelium of the cervix was considered pertinent to the investigation. The association of a low economic status and marriage with carcinoma of the cervix has resulted in much speculation regarding infectious agents (protozoa, bacteria, and viruses). Several studies have been reported relating Trichomonas vaginalis to in situ carcinoma.7-1” Also, regression of the in situ lesion following the use of broad spectrum antibiotics has been reported.3, I1 A combination rather than a single agent was chosen because of skepticism that any of the three would be extremely effective. Therefore, the absence of a definite clinical response after all three had been tried wouId eliminate all in one clinical trial. On the other hand, if a beneficial effect was found. it could easily be analyzed in additional studies.
288
Jones
et al.
Table I. Treatment
plan
Repeat smears and initial biopsies 1. Nitroimidazole-1 tablet p.o, q.i.d. x 3 2. Polymyxin B sulfate, neomycin sulfate, acetarsone vaginal suppository-nightly x 7 3. Hydroxyprogesterone caproate1 : m 1 per week \* 4 If above were given during pregnancy 1 month post partum Hydroxyprogesterone caproate-500 mg. 1 per week x 4 Final smears and biopsies at 2 to 3 months post “arturn
Medication
A trichomonacide (nitroimidazole) was selected which in previous studies was found to be effective in 95 per cent of patients when given orally for three days.” It was begun on the first visit to the special diagnostic clinic when the first biopsies were done --1 tablet four times a day for 3 days for a total dose of 2.1 Gm. of nitroimidazole.” The second medication was a broad-spectrum antibiotic effective as a vaginal suppository, used for 7 days beginning 1 week after the first clinic visit. Each suppository contained 20,000 U. of polymyxin B sulfate, 5 mg. neomycin sulfate, and acetarsone 250 mg. in a base of 1 Gm. of beta lactose.? The third drug, hydroxyprogesterone caproate, shown to have a long-acting progestational effect, was administered beginning 2 weeks after initial biopsy. The drug was given in a dosage of 500 mg. intramuscularly at weekly intervals for 1 wceks.$ One week following the last hormonal injection. smears, and biopsies were repeated. Patients who completed treatment and evaluation before the end of gestation also were treated with a 4 week repeat course of hydroxyprogesterone caproate beginning 1 month post partum. Final biopsies and smears of all patients were taken approximately 2J/2 to 3 months post partum (Table I) If the
*Supplied
by
G.
D.
tSupplird by Butloughs vaginal wppositorirs.
Sea&
& Co. Wrllcome
as Flagyl. & Co.
as Neospotin
Papanicolaou smears had never been greater than Class IIIB and biopsies failed to reveal anything more extensive than dysplasia, the patient studied remained in the group to IX followed by repeat cytologic study at 6 month intervals without conization. Control
groups
The active drugs and their inert counterparts were labeled by the chief pharmacist. All patients coming to the clinic were assigned to two treatment groups, A or H. in matching pairs before any definitive diagnostic studies (one of the pair to be the control and receive inert medication). It was felt that a delay in the initiation of treatment until biopsy diagnoses rnight not leave tirne for completion of the treatment befort* the final evaluation at 3 months post partum. ‘When statistical analysis w-as compiled. howe\,er. patients in Group A were matched in pairs with patients in Group B on the basis of the tissue result at first biopsy, and without knowledge of results of the diagnosis post parturn. Thus, the first carcinoma in situ patient in Group A is paired with the first carcinoma in situ patient in Group B: thr first dysplasia patient in Group .4 with thr first dysplasia patient in 1%. ‘I‘he CXJIn~~l~tc' protocols of patients also contain age ancl duration of gestation at time of first discnostic smear. The gestation grouping lvas based on a study by Reagan and associates’,’ who showed in a
‘I’hc information listed is from approsimately 25,000 women screened. In this group there werr 2.5 per cent who had abnormal smears requiring further study and in situ carcinoma was found in about .3 per crnt of the total. There have been 84 patients
Carcinoma
ANALYSIS
CARCINOMA
I
uteri
during
pregnancy
289
matched pairs, whose initial Papanicolaou smears were Classes IIIB, IV, and V. The statistical evaluation of the first two groupings is by the method of sequential analysis using a restricted design.‘-’ This type of comparison usually allows the acceptance or rejection of a hypothesis with a smaller number of patients than that required by conventional methods of estimating sample size. Our hypothesis for both groups was that in 10 per cent of the patients the lesion might spontaneously regress and that a total of 50 per cent of the experimental group would show regression with treatment. A change of this order would be decisive and the treatment used could be considered therapeutic for cervical lesions bordering on carcinoma.
with a diagnosis of in situ carcinoma who have had a final evaluation following conization or hysterectomy. There have been 90 patients with dysplasia whose final evaluation was by multiple biopsies. An analysis of the results of treatment of the in situ and dysplasia groups described, and the final estimation of the progression or regression of the disease in the entire in situ group will be presented. Three groupings are presented in the treatment results: (1 ) comparison of final biopsies and conization of matched pairs, whose initial biopsies were in situ carcinoma; (21 comparison of final biopsies of matched pairs, whose initial biopsies were dysplasia; and (3 ) comparison of final Papanicolaou smears in
SEQUENTIAL
of cervix
OF TEN IN
SITU
PAIRS
BUT
OF CASES
WITH
ORIGINAL?Y
UNLIKE
FINAL
DIAGNOSED
AS
DIAGNOSIS*
DECISION:
Difference Treatment
in
favor
of
-A
No
Significant Difference
15
Treatment
B
10
pairs
pl
pai
rs
n
Member
improves
=
J
Member
improves
=m
with
one
member
w; th
members
Figs. 3 and 4. Restricted sequential designs improvement in treatment group compared improvement in a placebo group (see text). = .05; power of test 1-p = .95 ; 6 = .90.
of
X (Drug) (Control)
improved pairs
al ike
(nqt
charted)
to detect at least 50 per cent to an expected 10 per cent a sided significance test 2 (I
290
Jones
SEQUENTIAL DIAGNO
et at.
ANALYSIS SE ‘D AS
OF FOURTEEN
DYSPLASIA
BUT
PAIRS WITH
OF CASES
UNLIKE
ORIGINALLY
FINAL
DIAGNOSIS*
DECISION: Difference Treatment
in
favor
of
A
Difference
15
Treatment
B
A Member
improves
=
X (Drug)
B Member
improves
=
l
14
pai
rs
with
one
member
22
pai
rs
with
members
(Control)
improved of
pei
rs
el ike
(not
charted)
Fig. 4.
Comparison of the 10 to 50 per cent level for in situ carcinoma and dysplasia is shown in Figs. 3 and 4. It should be noted that in these sequential charts only the unlike pairs are plotted, i.e., pairs in which one member only improved. In the in situ group there were 21 pairs in which both members were alike on the first and last biopsies. There were 10 pairs in which one member improved. Fig. 3 shows that when the latter group is plotted (A member directed above the ordinate and B member directed below the ordinate) improvement to the 50 per cent level did not take place within the closed graph pattern (22 members were not charted because some pair mates were not finally evaluated, while others had failed to complete the treatment plan). Similarly, with dysplasias there were 22 pairs alike on first and last biopsies, and 14
pairs where one member improved. Again. improvement did not approach the 50 per cent level of regression when plotted (Fig. 4), but to date there have been insufficient pairs for a final opinion. It does appear that the drugs produced improvement in an occasional patient. The comparison of the initial Papanicolaou smear IIIB and the final Papanicolaou smear in the two treatment groups is shown in Table II. It is readily seen that the two groups (treatment and control) are similar both when the tissue diagnosis is in situ carcinoma and when the tissue diagnosis is dysplasia. Furthermore, there is a suggestion of a gradual improvement in the total dysplasia group that is similar in both the treatment and control group. The concomitant phase of this study was to determine (1) whether the lesion in situ
Carcinoma
Table II. Comparison report
in treatment
Total Biopsy dysplasia Final Papanicolaou I or II IIIA IIIB
-
Total
A (treated)
B (control)
4 5 7 - 3 19
4 6 8 - 0 18
uteri
7 1 - 0 8
8 3 0
Biobsies
on
? Microinvasive ? Microinvasive
first
carcinoma in pregnancy remains post partum and (2 ) whether the lesion progresses or regresses rapidly. The comparison of tissue diagnosis by biopsy versus final tissue diagnosis by conization in all the patients who have been followed beyond 3 months post partum gives a fairly clear answer to these questions. Table III shows that most of the in situ lesions remain. The diagnosis of a slight advancement of the lesions in a few instances suggests slight progression. Only after continued clinical experience and restudy of the tissue in continuity may this progression be determined. There are approximately 38 per cent of patients showing lessening of the lesion (Table III) but in 22 per cent of these the change is in the brief interval of 3 weeks between last biopsy and cone (Table IV). This finding would suggest that all of these changes and some of the remaining 16 per cent are caused by inflammation or removal of the lesion rather than a true spontaneous regression. It seems obvious that in situ carcinoma rarely regresses spontaneously.
pregnancy
291
of diagnoses by in 83 cases proved
to
/ No. of cme~ 40
In situ In situ Dysplasia Chronic cervicitis In situ
Dysplasia
11
during
I c onization
In situ ? Microinvasive In situ In situ
report
*All patients with IIIB Papanicolaou or higher .rmear and diagnosis of carcinoma in situ by biopsy.
cervix
Table III. Comparison biopsy and conization have in situ carcinoma
of Papanicolaou and control groups*
Finn1 Papanicolaou report I or II IIIA IIIB None or unsatisfactory
of
2(: (38per 12 1 cent ) * 4 (5per cent)t 2x
Microinvasive ? Microinvasive
2
(There were 8 other cases of invasion on first biopsy) “38 per cent in situ removed by biopsies regressed; however, 22 per cent of these last biopsy and conk&on or hysterectomy wading of tissue). t5 pex cent of suspected by distinctly :Micxoinvasion calcinoma with
or spontaneously changed between (initial routine
lesions coned because abnormal smears.
is defined in this a focus of questionable
of
malignancy
series as in situ superficial invasion.
Table IV. Comparison
of diagnoses between last biopsy and conization (biopsy 3 weeks before conization) La5t
biopsy
Coniration
1 No. of cases
In situ
In situ
38
In situ In situ
Dysplasia
12
Chronic cervicitis
6 I
In situ
? Microinvasive
2
? Microinvasive
Microinvasive
2
In situ
on previous
In situ
Dysplasia
Dysplasia
Dysplasia
Chronic cervicitis
5
Dysplasia Chronic cervicitis
2 1
Chronic
cervicitis cervicitis
cent) *
biopsy
Dysplasia
Chronic
(22per
5 5
Comment
Our comments will be about (1) the controllable variables in this clinical study and (2) the malignant potential of these lesions. In conducting the present study, it was necessary to separate the ordinary clinical ap-
Prez,iou.r Dysplasia Chronic *Regression inflammatory
Papanicolaou cervicitis (22 per reaction.
IIIB, In situ
IV,
or V 5
Chronic cervicitis cent)
due
to
1 removal
by
biopsy
or
292
Jones et al.
preach to in situ carcinoma from a study diagnosis of carcinoma in situ. The clinical pathologist ordinarily feels obliged to assemble information relative to the patient’s age, number of children, desire for pregnancy, and degree of abnormality of the Papanicolaou smear as he evaluates the tissue for biopsy. In the present study the records of the slides were kept in a separate file from that of the biopsy material. Each slide was read separately without any comparison to any previous slide. This independence must be closely guarded to avoid undue v,ariation in the interpretation of slides. The coding of slides may vary from one laboratory to another, but within one laboratory accuracy must be maintained within the agreed code. For example, most in situ carcinomas in out laboratory will have a Class IIIR reading, whereas in another laboratory most of the slides may be read IV or V.‘” The biopsy tissues also must initially be read independent of the cytologic slides and of any additional studies of cells and tissue from the same patient. Final m-evaluation and reinterpretation may be of value, but for statistical evaluation the unprejudiced initial impression is mandatory. The difference of interpretation between severe dysplasia and in situ carcinoma by eminent authorities in other reports”’ (and on review of our material) raises the question of “what. if any, correlation can be made between these two diagnoses?” “What is the relative biologic or malignant potential of these lesions?” Some years ago, in heterologous tissue transplantation, Greene showed that there may be little or no correlation between ‘the degree of anaplasia observed in histologic sections with the biologic malignant potential of a given tumor.” It is also a wellknown fact that tumors may show extreme maturation, but possess the inherent ability to invade and metastasize widely. So, too, out interpretation of individua1 cells as to whether they are dysplastic or malignant may havt little relationship to the actual behavior of the tissue in viv*o in any one individual. Chromosome studies of different in situ car-
cinomas have in fact shown the number of somatic chromosomes to vary considcrably,l’, I!) Furthermore, exfoliative cytology reveals nothing about the host’s stromal bed and its resistance or acceptance of epithelial cells, which after all may be just as important in the malignant process as the epitheIium itself. Thus even though there is a standard of practice which is followed. it should be admitted that the clinical behavior of in situ carcinoma mav have little resemblance to the behavior of invasive cancer.‘: WC have shown that the dr~rgs used did not causr regression of in situ carcinoma ot dysplasia in 50 per cent of instances as was postulated. However, we cannot exclude thf* possibility that these lesions might have brerl influenced or might change to a considerable degree--even regress-if the ljatients had been studied for a longer period of time. Reagan has shown that dysplasias found in patients during pregnancy did not begin to regress until 6 months post parturn.” Indeed, our cytologic study would snggcst there is a beginning change or regression, not inHIrenced by treatment, appearing in the esfoliative cells, but not yet appearing in the biopsy material. Perhaps with more erperience this change will be clarified. Meanwhile, we remain fearful of the mali,gnant potential of these lesions and realize that \ve possess no true understanding of what ljromotes progression or regression of these IPsions. We trust that continued study by these . . In vrvo methods will lead to a better understanding of precancerous as well as cancerous lesions. Summary
1. An in vivo study has been started of patients with in situ carcinoma and dysplasia found during pregnancy to discern whether these lesions can be reversed by chemical substances. 2. The first clinical trial with a trichomonacide ,given orally. a broad-spectrum antibiotic used vaginally, and a long-acting progesterone given intermuscularly (in sequential order) failed to produce regression in 50 per cent of cases within the time limit
Carcinoma
described. There was a suggestive change in some of the dysplasias. 3. This group of cases demonstrates that
of cervix
uteri
during
pregnancy
293
the lesions found during pregnancy are similar to those found at other times and the majority persist if not treated or removed.
REFERENCES
Fluhmann, C. F.: The Cervix Uteri and Its Diseases, Philadelphia, 1961, W. B. Saunders Company. & GYNEC. 72: 2. Peterson, 0. : AM. J. OBST. 1063, 1956. F. W., Foote, F. W., 3. Koss, L. G.: Stewart, Jordan, M. J., Bader, G. M., and Day, E.: Cancer 16: 1160, 1963. 4. Slate, T. A., and Merritt, J. W., Jenny, J.. and Wyss, H. J.: Proc. First International Congress of Exfoliative Cytology 1: 128, 1961. 5. Shaekelford, R. I., and Jones, J. L.: Am. J. Clin. Path. 34: 397, 1959. 6 Jones, E. G., Macdonald, I., and Breslaw, L.: AM. J. OBST. & GYNEC. 76: 1, 1958. M., Lonser, E., Nichols, E. E., 7. Simeckova, and Rubinstein, I. N.: Obst. & Gynec. 20: 410, 1962. W. H., Green, S., Hanburger, F., 8. Frishman, Kasdar, S. C., Nieburgs, F., McInnis, G., and Paud, E. R.: Cancer 7: 729, 1954. 9. Patten, Jr., S. F., Hughes, C. P., and Reagan, J. W.: Acta cytol. 7: 187, 1963. 10. Koss. L. G., and Wolinska, W. J.: Cancer 12: 1171, 1959. 1.
11. 12. 13.
14.
15. 16. 17. 18.
19.
Ayre, J. E.: Antibiotics and Chemotherapy 1: 339, 1951. Jones, E. G., Biddle, M., Browell, B., and Varga, A.: West. J. Surg. 70: 258, 1962. Reagan, J. W., Bell, B. A., Newman, J. L.. Scott, R. B., and Patten, S. F.: Acta cytol 5: 17, 1961. Armitage, P.: Sequential Medical Trials, Oxford, England, 1960, Scientific Publishers Limited. McLennan, M. T., and McLennan, C. E.: California Med. 99: 1, 1963. Siegler, E. E.: Cancer 9: 463, 1956. Greene, H. S. N.: Cancer 5: 24, 1952. Moricard, R., and Cartier, R.: Ciba Foundation Study Group No. 3, Boston. 1959, Little, Brown & Company. Spriggs, A. I., Buddington, M. M., and Clarke. C. M.: Carcinoma In Situ of Cervix Uteri: Soma Cytogenic Observations, Lancet 1: 1383, 1962.
1770 N. Orange Grove Pomona, California
Auenue
Discussion DR. PURVIS L. MARTIN, San Diego, California. In this large, statistically controlled study Dr. Jones has made at least two significant advances in the medical field of cytology. He has screened the largest single series of pregnant women yet to be reported. He has also used cytology in the
search for basic factors underlying
the etiology
and growth of cancer. The detection of 100 curable cervical cancers, which were screened out of 25 thousand essentially indigent pregnant women, is in itself a significant achievement. This report should receive wide attention and should establish, once and for all, the true worth of taking a routine Papanicolaou smear during pregnancy as a part of good prenatal care.
Strange
as it may seem, taking
panicolaou smears during versal practice. Less than
routine
Pa-
pregnancy is not uni5 years ago practicing
cytologists,
in our area at least, held that cyto-
logical smears in pregnancy should not he taken because of a wide margin of error in reading them and because of the presumed reversibility of the lesions that were found. In an opinion survey of members of the San Diego County Medical Society, in 1961, while more than 90 per cent of physicians favored routine use of Papanicolaou smears, less than 25 per cent favored their routine use in pregnancy. Even today, California’s Medicare plan for defraying the costs of obstetrical care for military depen-
dents will pay for a variety of laboratory tests in the name of good prenatal care, but will not pay
for a Papanicolaou smear. the other hand, it is now our conviction that by omitting smears during pregnancy the medical profession is missing a golden opportunity to control cervical cancer. Every mass On
294
Jones
et
al.
screening program has fallen short of its total population goal because of difficulties in motivating women to see doctors. The majority of in situ cancers are believed to remain quiescent for many years during the time in a woman‘s life whrn she is most likely to become pregnant. (Two-thirds of our “Gynob” series of 933 early cancers occurred before age forty.) Experienced cytologists and screeners can no\\ reco,gnizc~ cellular aberrations of pregnancy and distinguish thrm from atypias of cancer. It follows that if all physicians wyre to obtain cervical smears on all their obstetrical patients, most women would eventually get scrcrned at an a,qe which is most important to them. Pregnancy screening alone should go a long way toward controlling cer\rical cancer. Every physician whose practice includrq the rarr of pregnant Womrn should be convinced of the value of pregnancy smrars, and hct should not miss this opportunity to educate each young wnman to a lifr-lon,q habit of seeking an annual Papanicolaou smrar. In his other major advance, as we sre it, Dr. Jones has opened “p a fascinating avenue in cytolo,~y, tlsing the study nf exfoliated human cells in a search for factors influencing the rtiology and growth of crrvical cancer. By careful. double blind study hc has convincingly ruled nut his first three rtiologiral suspects. Trichomonas hag long bcrn known to produce aberrations in rxfoliatrd rrlls. Brcausc of this, an etiologiral relationship to cr:rvic.al cancer has been suspected. and brcal~se of it many cervices havcl been damaged by conization that followed Trirhomonas-induced Class III cytology reports. Slate, Merritt, and Kennedy, from a study of material in our laboratory, could establish no rclation betwrcn Trichomonas and cervical cancer in situ. Dr. Jones in this study failed to affect the growth of in situ cancer by using an effcctivc trichomonacide. R<*lativc steroid starvation \vas another logical suspect. In a parallel observation wt‘ havta noted that the rather abrupt menopausal stcrtrid deprivation coincides with a drcrraw in frequrnry of in situ cancer. but an increase in invasive cervical cancer. Large doses of progesterone here failed to influence thr growth of cervical cancer but the way is paved for thr testing of other agents. It is heartening to find that in this project govcrnmcnt subsidy was used where it belongs. for research and in the care of indigent patients. The results of this magnificent screening project in pregnancy should become widely known. Cy-
tology appears to be a practical tool for investigative cancer research. DR. C. F. FLUHMANN, San Francisco, (:alifornia. The most significant conclusion \vhi<.h must be reached from the data presented I,)- L)r. Jones is that the various lesions diagnosrd as carcinoma in situ of the cervix uteri during pregnancy persisted and ivere still recogniLablc as such after the termination uf gestation. This evidence lends support to the concept that carcinoma in situ as such exists Tvhethrr the pa~iet~t is prrgnant or not, and if she is pregnant cliagnosis and treatment must bc conducted without delay. The possibility that early invasi\~~~ disease may also be present remains as a constatll thrrat. It is most unfortunate that there is a belief amonS many obstetricians that during prf’g:nanry certain histologic changes may occItr ill the cervix uteri which are of a hrnign charac-trl and mrrrly simulate carcinoma in situ. Thesr, changes arr said to result from endocrine srimulation and rrgress spontaneously in the l,ostpartal period. This is incorrect and a persistcncc, of such ideas may lead to tragic dt,lays in rhr diagnosis of early cancer. Vaginal smears must l)e an csscntial part of el’ery prenatal cxnmination, and when they arc reported as positivtx they must be rPpeatrd and adrqllatr diagnostic. procedures carried out in spite nf thr existin pregnancy. DR. KARL SCHAUPP, JR., San Francisco, California. I was a little confllsed 1,) the statistical graph and had some trouble interpreting what it meant at this first sight. A certain perccntagts of carcinoma in situ will regress spontaneoltsly, Ijut I do not know the actual figure. It has hccn variously reported between 60 to 70 per cent Tu 20 to 30 per cent. I would like to knot%? what your opinion is. The same per cent would rcCgress follnwinq pregnancy. I rlsportrd two raw\ IO the San Francisco Gynecological Societythat \vcrc diagnosed during pregnancy hut the lesions 1atc.r rcgrcassed spontaneously. DR. 1’1:. DOUGLAS MARSH.W.,” \;ictoria, British Colllrnbia, Canada. In British Columbia th(. cervical smear program is carrird out as a servicr, frer of rharge, by the British Columbia Division of the Canadian Cancer Foundation. Last year more than 100,000 smears wprc rc’ported upon. If more of ollr (:ommissions
“By
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Carcinoma
adopted the routine smears in pregnancy, we could project a study such as the one we have heard this morning and, I think, make an important contribution to the subject. One would think that if the changes in the cervix during pregnancy, that is, dysplasia or carcinoma in situ, were due to the pregnancy per se, one would find a large number of false positive smears in a series such as this. I do not think that this has bren the case and I belieIre that these changes are unrelated to pregnancy and do not disappear spontaneously post partum. The diagnosis of carcinoma in situ can only be made on the basis of an adequate cone biopsy, adequately scrutinized. If one believes the diagnosis is important, one should get on with it regardless of the pregnancy. There is, naturally, some fear and reluctance that by doing a cone biopsy during pregnancy one may interrupt a pregnancy for the simple purpose of diagnosing a dysplasia. However, on the basis of two previous positive smears, I think the diagnosis must be made and the distinction between a benign and a malignant lesion clarified. I believe the cone biopsy should be very carefully done. It is not a procedure that one would entrust to a junior. One can take a good centimeter cone with the knife, almost to the internal OS, without undue difficulty. I have had no problem with bleeding and have not yet interrupted a pregnancy. DR. CLDYE VON DER AHE," Beverly Hills, California. Last year I presented a paper before the Society on the study of approximately 1,800 unmarried pregnant women. During that time in our studies we did routine Papanicolaou smears. In the very young group we had absolutely no positive smears whatsoever. As a matter of fact, in the whole group we had only one positive smear.
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uteri
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We were impressed, however, with the percentage of Trichomonas that was found these vaginal smears, well over 90 per Therefore, I would like to ask Dr. Jones the basis of his figures whether or not he that the routine Papanicolaou smear in the young girl, that is, from 12 years up to really justified? DR. JONES, (Closing). At the inception
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high in cent. on feels ver) 18 is
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this study we anticipated many abnormal smears caused by pregnancy reactions alone. But wc found no severe changes caused by pregnancy which will be confused with malignancy. We were assured by several investigators before we began the present study that the use of selected biopsies, repeat Papanicolaou smears. and colposcopy rather than conization would bc an adequate and accurate way of diagnosis during pregnancy. When one examines 30 to 81) good tissue slices from selected sites, it is not surprising that the biopsy method of diagnosis is very accurate. These lesions found in the pregnant patients are smaller or earlier than the ones found in our other clinic patients. Residual in situ carcinoma after conization was found in only 3 out of 50 hysterectomy specimens in the present study, whereas in the other patients about 30 per cent of the hysterectomy specimens have residual in situ areas. The largest group of in situ carcinoma is in the 20 to 30 age group, because most of the women seen are in that age group. The youngest patient with a distinctly abnormal smear, but not proved to have in situ carcinoma, was aged 15 in the third month of her first pregnancy. The youngest patient with proved in situ carcinoma was aged 19. We believe that a cytoIogic smear is in order from the time of the first pregnancy and thereafter.