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Choriocarcinoma
volume 85
number 7
April 1, 1963
American Journal of
Obstetrics and Gynecology
(.
OBSTETRICS
Choriocarcinoma Absolute 5 year survival rates of 122 patients treated by hysterectomy
JOHN I. BREWER, M.D. ROY T. SMITH, M.D. GEORGE B. PRATT, M.D. Chicago, Illinois
.
IT HAs been asserted that chemotherapy is more effective than surgical procedures in the treatment of choriocarcinoma. 1 A comparison between these two modalities is difficult since the surgical data includes those patients subjected to various procedures that are not considered adequate for cure, such as curettage, biopsies, or abdominal exploration alone. More suitable for comparison are the results attained by hysterectomy, especially in those patients with metastatic disease at the time of operation since the report on chemotherapy deals only with patients who had metastasis when treatment was instituted. The purpose of this presentation is to re-
port the absolute 5 year results obtained by hysterectomy, the results in patients with and without metastasis at the time of operation, and the length of survival of the patients. Material
In the Albert Mathieu Chorionepithelioma Registry* of the American Association of Obstetricians and Gynecologists maintained in the Department of Obstetrics and Gynecology of Northwestern University Medical School, there are case records of and pathologic material from 122 patients with choriocarcinoma treated by hysterectomy 5 or more years ago (treated prior to Dec. 31, 1956; data gathered as of Jan. 1, 1962). This group is subdivided into 52 patients who had
From the Albert Mathieu Chorionepithelioma Registry and the Department of Obstetrics and Gynecology, Northwestern University Medical School and Passavant Memorial Hospital.
*Maintained by an annual grant from the Obstetrical and Gynecological Assembly of Southern California.
841
842
Brewer, Smith, and Pratt
Am.
and 70 who did not have metastatic disease at the time of operation. Metastatic disease was said to exist at the time of hysterectomy if it could be demonstrated by roentgen examination or by histologic examination of biopsy material. Since these two methods often fail to reveal a lesion in an inaccessible tissue or organ, it is quite probable that metastases were present but were undetected in some patients at the time of hysterectomy. The diagnosis of choriocarcinoma in each patient must be firmly established to make the data meaningful. The five-member national committee of the Registry that studies each case has attained a good degree of diagnostic accuracy~ through the experience of viewing 690 specimens of diseases of the trophoblast during a period of many years. It is therefore believed that the diagnosis of choriocarcinoma in each of the 122 patients has been accurately made. None of the patients received methotrexate or vincaleukoblastine. Forty-eight patients received either radiation, nitrogen mustard, thio-TEPA, testosterone, diethylstilbestrol, or combinations of these agents in addition to hysterectomy. Since it was apparent that such adjunctive therapy did not alter the results, they are included in the study group. Results and comments
Five-year survival rates. The absolute 5 year rates of survival without evidence of disease for the entire group was 31.9 per cent; for the subgroup of patients who did not have demonstrable metastasis at the time of hysterectomy 41.4 per cent; and for
:\prii 1, 1963 & Gynec.
J, Obsr.
the subgroup of patients who had demonstrable metastasis at the time of hvsterectomy, 19.2 per cent (Table I). The data dealing with results in patient' who had metastatic disease at the time of hysterectomy are not entirely comparable to those reported by Hertz and associates, 1 but are as nearly comparable as is possible to gather at this and probably any other time. Some of the differences are: the extent of disease may not be similar; the interval between the time of diagnosis and the institution of definitive therapy may not be thf' same in patients of each group; in the hysterectomy group some patients were excluded because the procedure was not completed even though attempted; in the chemotherapy group some of the patients had hysterectomies performed either before or during the period of treatment. Utili;;:ing chemotherapeutic agents, chiefly methotrexate, Hertz and co-workers 1 reported 48 per cent complete remissions in 44 patients who had choriocarcinoma with metastasis when treatment was begun. The report gives the rates for periods from Y2 year to 5 years, but Hertz has indicated 3 that another 2 years can be added to these statistics as those patients in complete remissions have continued in that state since the accumulation of the data, Oct. 31, 1960. This would indicate that in all probability the 5 year complete remission rate in patients with metastasis at the time chemotherapy is instituted should be approximately 48 per cent. This is superior to the 5 year "cure" rate of 19.2 per cent in similar patients treated by hysterectomy. Forty of the 70 patients who did not have '!'
Table I. Absolute 5 year survival rates* No. of Patients Patients treated by hysterectomy
122
"" Known to be living without disease
Known to be dead
Lost to follow-up
39 (31.9%)
74 (60.7%)
9 ( 7.4%)
No demonstrable metastasis at time of hysterectomy
70 (57.4%)
29 (41.4%)
34 (48.6%)
7 (10.0%)
Demonstrable metastasis at time of hysterectomy
52 ( 42.6%)
10 ( 19.2%)
40 (76.9%)
2 ( 3.9
*Data collected as of Jan. I, 1962; hysterectomies performed on or before Dec. 31, 1956.
~
Volume 85 Number 7
.
Choriocarcinoma 843
Table II . Length of survival of 122 patients with choriocarcinoma Time in months
,.,
Result Living Dead Lost to follow-up Total
••
•
3
6
12
24
36
48
60
85 33 4 122
70 48 4 122
53 65 4 122
45 72 5 122
43 72 7 122
39 74 9 122
39 74 9 122
demonstrable metastasis at the time of hysterectomy developed metastatic lesions subsequent to the procedure. Of these 40, 34 are known to be dead of the disease; 4 are known to be living and free of disease; and 2 have been lost to follow-up. Considering the latter 2 as dead, in accordance with accepted methods of reporting, the mortality rate in the patients who developed metastasis subsequent to hysterectomy is 90 per cent. It is quite apparent that hysterectomy was not adequate treatment in this particular group, of patients and it is quite probable that chemotherapy (if it had been available at the time) would have salvaged some patients of this group. Length of survival. The prevalent concept that most fatalities occur during the first 2 years is supported by the findings in these 122 patients treated by hysterectomy (Table II). Only 2 patients of the known 74 fatalities are known to have died after the end of the second postoperative year. Neither of the 2 had demonstrable metastasis when the hysterectomy was performed but both died with extensive metastatic disease during the fourth year. All of the 40 deaths in the group of 52 patients who had metastasis at the time of
31.9% 68.1%
hysterectomy occurred during the first 18 months postoperatively. Thirty-two of the 34 deaths in the group of 70 patients without demonstrable metastasis at the time of hysterectomy occurred during the first 24 months. Summary
The absolute 5 year rate of survival without evidence of disease in 122 patients with choriocarcinoma treated by hysterectomy is 31.9 per cent; in the 70 patients without metastasis at the time of hysterectomy it is 41.4 per cent; and in the 52 patients with metastasis at the time of hysterectomy it is 19.2 per cent. The latter rate of 19.2 per cent is much less favorable than the projected rate of 48 per cent attained in similar patients treated with chemotherapeutic agents as reported by Hertz and associates. 1 In these patients treated by hysterectomy, 72 of the 74 known deaths occurred during the first 2 years. REFERENCES
1. Hertz, Roy, Lewis, J., Jr., and Lipsett, M. B.: AM.
J.
2. Brewer,
R. W.:
0BST.
&
82: 631, 1961.
GYNEC.
J.
1., Rinehart,
AM.
0BST.
J.
&
J. J.,
and Dunbar,
GYNEC.
81: 574, 1961.
3. Hertz, Roy: Personal communication.
number 7
April 1, 1963
American Journal of
Obstetrics and Gynecology
(.
OBSTETRICS
Choriocarcinoma Absolute 5 year survival rates of 122 patients treated by hysterectomy
JOHN I. BREWER, M.D. ROY T. SMITH, M.D. GEORGE B. PRATT, M.D. Chicago, Illinois
.
IT HAs been asserted that chemotherapy is more effective than surgical procedures in the treatment of choriocarcinoma. 1 A comparison between these two modalities is difficult since the surgical data includes those patients subjected to various procedures that are not considered adequate for cure, such as curettage, biopsies, or abdominal exploration alone. More suitable for comparison are the results attained by hysterectomy, especially in those patients with metastatic disease at the time of operation since the report on chemotherapy deals only with patients who had metastasis when treatment was instituted. The purpose of this presentation is to re-
port the absolute 5 year results obtained by hysterectomy, the results in patients with and without metastasis at the time of operation, and the length of survival of the patients. Material
In the Albert Mathieu Chorionepithelioma Registry* of the American Association of Obstetricians and Gynecologists maintained in the Department of Obstetrics and Gynecology of Northwestern University Medical School, there are case records of and pathologic material from 122 patients with choriocarcinoma treated by hysterectomy 5 or more years ago (treated prior to Dec. 31, 1956; data gathered as of Jan. 1, 1962). This group is subdivided into 52 patients who had
From the Albert Mathieu Chorionepithelioma Registry and the Department of Obstetrics and Gynecology, Northwestern University Medical School and Passavant Memorial Hospital.
*Maintained by an annual grant from the Obstetrical and Gynecological Assembly of Southern California.
841
842
Brewer, Smith, and Pratt
Am.
and 70 who did not have metastatic disease at the time of operation. Metastatic disease was said to exist at the time of hysterectomy if it could be demonstrated by roentgen examination or by histologic examination of biopsy material. Since these two methods often fail to reveal a lesion in an inaccessible tissue or organ, it is quite probable that metastases were present but were undetected in some patients at the time of hysterectomy. The diagnosis of choriocarcinoma in each patient must be firmly established to make the data meaningful. The five-member national committee of the Registry that studies each case has attained a good degree of diagnostic accuracy~ through the experience of viewing 690 specimens of diseases of the trophoblast during a period of many years. It is therefore believed that the diagnosis of choriocarcinoma in each of the 122 patients has been accurately made. None of the patients received methotrexate or vincaleukoblastine. Forty-eight patients received either radiation, nitrogen mustard, thio-TEPA, testosterone, diethylstilbestrol, or combinations of these agents in addition to hysterectomy. Since it was apparent that such adjunctive therapy did not alter the results, they are included in the study group. Results and comments
Five-year survival rates. The absolute 5 year rates of survival without evidence of disease for the entire group was 31.9 per cent; for the subgroup of patients who did not have demonstrable metastasis at the time of hysterectomy 41.4 per cent; and for
:\prii 1, 1963 & Gynec.
J, Obsr.
the subgroup of patients who had demonstrable metastasis at the time of hvsterectomy, 19.2 per cent (Table I). The data dealing with results in patient' who had metastatic disease at the time of hysterectomy are not entirely comparable to those reported by Hertz and associates, 1 but are as nearly comparable as is possible to gather at this and probably any other time. Some of the differences are: the extent of disease may not be similar; the interval between the time of diagnosis and the institution of definitive therapy may not be thf' same in patients of each group; in the hysterectomy group some patients were excluded because the procedure was not completed even though attempted; in the chemotherapy group some of the patients had hysterectomies performed either before or during the period of treatment. Utili;;:ing chemotherapeutic agents, chiefly methotrexate, Hertz and co-workers 1 reported 48 per cent complete remissions in 44 patients who had choriocarcinoma with metastasis when treatment was begun. The report gives the rates for periods from Y2 year to 5 years, but Hertz has indicated 3 that another 2 years can be added to these statistics as those patients in complete remissions have continued in that state since the accumulation of the data, Oct. 31, 1960. This would indicate that in all probability the 5 year complete remission rate in patients with metastasis at the time chemotherapy is instituted should be approximately 48 per cent. This is superior to the 5 year "cure" rate of 19.2 per cent in similar patients treated by hysterectomy. Forty of the 70 patients who did not have '!'
Table I. Absolute 5 year survival rates* No. of Patients Patients treated by hysterectomy
122
"" Known to be living without disease
Known to be dead
Lost to follow-up
39 (31.9%)
74 (60.7%)
9 ( 7.4%)
No demonstrable metastasis at time of hysterectomy
70 (57.4%)
29 (41.4%)
34 (48.6%)
7 (10.0%)
Demonstrable metastasis at time of hysterectomy
52 ( 42.6%)
10 ( 19.2%)
40 (76.9%)
2 ( 3.9
*Data collected as of Jan. I, 1962; hysterectomies performed on or before Dec. 31, 1956.
~
Volume 85 Number 7
.
Choriocarcinoma 843
Table II . Length of survival of 122 patients with choriocarcinoma Time in months
,.,
Result Living Dead Lost to follow-up Total
••
•
3
6
12
24
36
48
60
85 33 4 122
70 48 4 122
53 65 4 122
45 72 5 122
43 72 7 122
39 74 9 122
39 74 9 122
demonstrable metastasis at the time of hysterectomy developed metastatic lesions subsequent to the procedure. Of these 40, 34 are known to be dead of the disease; 4 are known to be living and free of disease; and 2 have been lost to follow-up. Considering the latter 2 as dead, in accordance with accepted methods of reporting, the mortality rate in the patients who developed metastasis subsequent to hysterectomy is 90 per cent. It is quite apparent that hysterectomy was not adequate treatment in this particular group, of patients and it is quite probable that chemotherapy (if it had been available at the time) would have salvaged some patients of this group. Length of survival. The prevalent concept that most fatalities occur during the first 2 years is supported by the findings in these 122 patients treated by hysterectomy (Table II). Only 2 patients of the known 74 fatalities are known to have died after the end of the second postoperative year. Neither of the 2 had demonstrable metastasis when the hysterectomy was performed but both died with extensive metastatic disease during the fourth year. All of the 40 deaths in the group of 52 patients who had metastasis at the time of
31.9% 68.1%
hysterectomy occurred during the first 18 months postoperatively. Thirty-two of the 34 deaths in the group of 70 patients without demonstrable metastasis at the time of hysterectomy occurred during the first 24 months. Summary
The absolute 5 year rate of survival without evidence of disease in 122 patients with choriocarcinoma treated by hysterectomy is 31.9 per cent; in the 70 patients without metastasis at the time of hysterectomy it is 41.4 per cent; and in the 52 patients with metastasis at the time of hysterectomy it is 19.2 per cent. The latter rate of 19.2 per cent is much less favorable than the projected rate of 48 per cent attained in similar patients treated with chemotherapeutic agents as reported by Hertz and associates. 1 In these patients treated by hysterectomy, 72 of the 74 known deaths occurred during the first 2 years. REFERENCES
1. Hertz, Roy, Lewis, J., Jr., and Lipsett, M. B.: AM.
J.
2. Brewer,
R. W.:
0BST.
&
82: 631, 1961.
GYNEC.
J.
1., Rinehart,
AM.
0BST.
J.
&
J. J.,
and Dunbar,
GYNEC.
81: 574, 1961.
3. Hertz, Roy: Personal communication.