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Curietherapy of operable cancer of the cervix
848
THE AMERICAN
JOURNAL
OF OBSTETRICS AND QYNECOLOCrY
There is an appreciable improvement in the local and general condition and usually an increase in body weight. Where a diagnosis of tuberculous peritonitis is certain, no other therapy is indicated. Where necessary, the treatment may be undertaken subsequent to a conservative exploratory operation. LITTLE. fistulae.
Reym~, H. V. James: Technic and Results in the Treatment of Car&mma of the Uterine Cervix at “Radiumhemmet” Stockholm. The Journal of Obstetrics and Gynaecology of the British Empire, 1924, xxxi, 1. In eight years previous to 1922 five hundred and five cases of carcinoma of the cervix were treated by radium unaccompanied by efforts at surgical removal. Previous to 1918 about 91.2 per cent of cases were inoperable or of the borderline type. Since 1918 the inoperable and borderline cases constitute only 68.4 per cent of the material. Nineteen per cent of cases were forty years of age or less (a highly malignant group). Twenty per cent of all cases, 16.6 per cent of the inoperable eases and 40 per cent of the operable cases treated previous to 1919 were alive five years later. All deaths occurring are considered as due to cancer. As a rule two or three applications of radium are given in five weeks, time, Radium is placed both in the uterus (average total dose 2220 to 2640 mg.) and in the vagina (average dose 4500 mg.) The radium is filtered through 3 to 4 mm, of lead. All operative interference such as cauterization, excochleation and frequent biopsy is absolutely contraindicated. Treatment is never repeated in the first six months. Only one application is made if there is a recurrence at this time. If there is a local recurrence and the growth is operable, hysterectomy is done. Roentgen irradiation is used in conjunction with radium treatment if there are extensive glandular metastases, in the presence of recurrence in the parametria or where severe pain follows radium treatment. Local recurrence, if it occurs, takes place usually within one year. Metastasis may follow years of apparently good health. In the absence of palpable recurrences, pain, anemia and fever usually indicate cancer tissue somewhere in the pelvis. Rectal complications following radium are usually due to an overdose and manifest themselves in tenesmus and hemorrhage about six months after treatment. The bladder is more resistant to an overdose than the rectum. There is a primary mortality of 1.19 per cent associated with the use of radium. Five of the author’s patients died of general peritonitis and sepsis and one of pulmonary embolism. Changes in technic, larger doses over shorter periods, less frequent and meddlesome treatment and the accumulation of experience, are factors in the improved results seen year by year. H. W. SRUTT~~.
Gage& J.: So&%5
Curietherapy of Operable Canoer of the Cervix. d’Obst&rique et de GynBcologie, 1924, xiii, 22.
Bulletin
de la
Gagey reports 14 cases of cancer of the cervix which were operable but which were treated by radium alone during the years 1919 and 1920. He believes that after a lapse of three years or more, recurrence is unlikely. Information concerning 10 of these patients was obtained in January, 1924, and 9 of the 10 were found to be alive and well. The tenth had died, seven months after radium treatment, of extension of the carcinoma into the parametrium and the rectum. In this group the number of spinal cell carcinomata which were cured equaled the number of basal cell carcinomata. In all the casea relatively small doses were used (about 20 millicuries with primary filtration of only $$ mm. of platinum). The only ease where more filtration was used was the one which had the recurrence which ended in death. In one patient treated by the above technic there was reetitutio ad integrum, for the patient later became pregnant and carried to term.
Another series of 10 cases was followed in which operation was performed soon after radium therapy. In these cases instead of the Wertheim operation, a total hysterectomy was performed because the author believes that if recurrences do take place they are usually found in situ rather than out in the broad ligaments. Of these 10 patients who were operated upon during 1920, eight were followed. Three of the latter had died soon after operation and one other patient died in 1923 of metastases. The results for the patients treated by hysterectomy were therefore much inferior to those treated by radium alone. The problem, however, is complex, for in three of the cases operated on after radium application active cancer cells were found. Judging from these results, the author is tempted to treat operative cancer of the cervix by radium alone. Since, however, radium treatment a few weeks before operation does not render the operation more di&ult and since the radium always sterilizes the uterus, one should combine radium therapy with operation; for some patients were saved who could not have been cured by radium alone. The author gives this as his opinion despite the unfavorable results whieh he had from such a procedure. J. P. GREENEILL
Smith, Wm. Sidney: Gynfsologic Conditiexx3Treated With IE&d.iumAlone or CombinedWith Surgery. Surgery, Gynecology and Obstetrics, 1925, xl, 598. Radium, heavily screened with one millimeter of platinum and two millimeters of rubber and used within the uterus in 1200 to 2400 mg. doses, even with repeated administrations, causes no untoward effect on bladder and rectum and produces very little troublesome leucorrhea. The temperature reactions occasionally seen are more likely due to a fresh invasion by organisms started by the curetting and blocked drainage than to radium. Radium alone is an excellent treatment for chronic metritis and small fibroids at the menopause age, curing most of the cases with one 1200 mg. dose, but even a 2400 mg. dose will not always control the bleeding indefinitely in all patients. Plastic operations on cervix and perineum may be performed with excellent results at the same time that radium is applied to the interior of the uterus. For advanced cases of cancer of the cervix and corpus, radium, as a palliative measure, gives more relief than any other treatment at our command. In early cervical cases, the cautery operation and radium at the same session, with or without x-ray treatment later, give results which are 80 valuable that the combination should be thoughtfully considered as a possible standard method of treatment. WM. C?. HENSXE. Cheval:
Vesicovaginal Fistula Occurring 48 ITours After Radium Application.
Bruxelles
Mddical,
1925, v, 5.
Patient, 44 years old, had severe hemorrhages. Examination showed carcinoma of the cervix the size of a hen’s egg, with slight broad ligament involvement. Cystoseopy showed bladder irregularity and congestion but no neoplastic growth or ulceration. The patient received 10800 millicuries’ of radiation in the region of each broad ligament, over a period of five days, and 21600 millicuries in the vagina, over a period of nine days. In each case the radium was filtered by 1.5 mm. of brass, 0.2 of aluminum, and 2 mm. of rubber while the vaginal radium had an additional titer of 1 cm. of gauze. On the second day following the beginning of radiation a vesicovaginal fistula developed. Three weeks later a panhysterectomy was done, and two weeks following this an attempt was made to close the fistula, which failed. Three months later the vagina was closed, and a rectovesieal fistula made; however, there was still some drainage of urine below the urethra. Twenty months later the patient had shown no signs of recurrence.
THE AMERICAN
JOURNAL
OF OBSTETRICS AND QYNECOLOCrY
There is an appreciable improvement in the local and general condition and usually an increase in body weight. Where a diagnosis of tuberculous peritonitis is certain, no other therapy is indicated. Where necessary, the treatment may be undertaken subsequent to a conservative exploratory operation. LITTLE. fistulae.
Reym~, H. V. James: Technic and Results in the Treatment of Car&mma of the Uterine Cervix at “Radiumhemmet” Stockholm. The Journal of Obstetrics and Gynaecology of the British Empire, 1924, xxxi, 1. In eight years previous to 1922 five hundred and five cases of carcinoma of the cervix were treated by radium unaccompanied by efforts at surgical removal. Previous to 1918 about 91.2 per cent of cases were inoperable or of the borderline type. Since 1918 the inoperable and borderline cases constitute only 68.4 per cent of the material. Nineteen per cent of cases were forty years of age or less (a highly malignant group). Twenty per cent of all cases, 16.6 per cent of the inoperable eases and 40 per cent of the operable cases treated previous to 1919 were alive five years later. All deaths occurring are considered as due to cancer. As a rule two or three applications of radium are given in five weeks, time, Radium is placed both in the uterus (average total dose 2220 to 2640 mg.) and in the vagina (average dose 4500 mg.) The radium is filtered through 3 to 4 mm, of lead. All operative interference such as cauterization, excochleation and frequent biopsy is absolutely contraindicated. Treatment is never repeated in the first six months. Only one application is made if there is a recurrence at this time. If there is a local recurrence and the growth is operable, hysterectomy is done. Roentgen irradiation is used in conjunction with radium treatment if there are extensive glandular metastases, in the presence of recurrence in the parametria or where severe pain follows radium treatment. Local recurrence, if it occurs, takes place usually within one year. Metastasis may follow years of apparently good health. In the absence of palpable recurrences, pain, anemia and fever usually indicate cancer tissue somewhere in the pelvis. Rectal complications following radium are usually due to an overdose and manifest themselves in tenesmus and hemorrhage about six months after treatment. The bladder is more resistant to an overdose than the rectum. There is a primary mortality of 1.19 per cent associated with the use of radium. Five of the author’s patients died of general peritonitis and sepsis and one of pulmonary embolism. Changes in technic, larger doses over shorter periods, less frequent and meddlesome treatment and the accumulation of experience, are factors in the improved results seen year by year. H. W. SRUTT~~.
Gage& J.: So&%5
Curietherapy of Operable Canoer of the Cervix. d’Obst&rique et de GynBcologie, 1924, xiii, 22.
Bulletin
de la
Gagey reports 14 cases of cancer of the cervix which were operable but which were treated by radium alone during the years 1919 and 1920. He believes that after a lapse of three years or more, recurrence is unlikely. Information concerning 10 of these patients was obtained in January, 1924, and 9 of the 10 were found to be alive and well. The tenth had died, seven months after radium treatment, of extension of the carcinoma into the parametrium and the rectum. In this group the number of spinal cell carcinomata which were cured equaled the number of basal cell carcinomata. In all the casea relatively small doses were used (about 20 millicuries with primary filtration of only $$ mm. of platinum). The only ease where more filtration was used was the one which had the recurrence which ended in death. In one patient treated by the above technic there was reetitutio ad integrum, for the patient later became pregnant and carried to term.
Another series of 10 cases was followed in which operation was performed soon after radium therapy. In these cases instead of the Wertheim operation, a total hysterectomy was performed because the author believes that if recurrences do take place they are usually found in situ rather than out in the broad ligaments. Of these 10 patients who were operated upon during 1920, eight were followed. Three of the latter had died soon after operation and one other patient died in 1923 of metastases. The results for the patients treated by hysterectomy were therefore much inferior to those treated by radium alone. The problem, however, is complex, for in three of the cases operated on after radium application active cancer cells were found. Judging from these results, the author is tempted to treat operative cancer of the cervix by radium alone. Since, however, radium treatment a few weeks before operation does not render the operation more di&ult and since the radium always sterilizes the uterus, one should combine radium therapy with operation; for some patients were saved who could not have been cured by radium alone. The author gives this as his opinion despite the unfavorable results whieh he had from such a procedure. J. P. GREENEILL
Smith, Wm. Sidney: Gynfsologic Conditiexx3Treated With IE&d.iumAlone or CombinedWith Surgery. Surgery, Gynecology and Obstetrics, 1925, xl, 598. Radium, heavily screened with one millimeter of platinum and two millimeters of rubber and used within the uterus in 1200 to 2400 mg. doses, even with repeated administrations, causes no untoward effect on bladder and rectum and produces very little troublesome leucorrhea. The temperature reactions occasionally seen are more likely due to a fresh invasion by organisms started by the curetting and blocked drainage than to radium. Radium alone is an excellent treatment for chronic metritis and small fibroids at the menopause age, curing most of the cases with one 1200 mg. dose, but even a 2400 mg. dose will not always control the bleeding indefinitely in all patients. Plastic operations on cervix and perineum may be performed with excellent results at the same time that radium is applied to the interior of the uterus. For advanced cases of cancer of the cervix and corpus, radium, as a palliative measure, gives more relief than any other treatment at our command. In early cervical cases, the cautery operation and radium at the same session, with or without x-ray treatment later, give results which are 80 valuable that the combination should be thoughtfully considered as a possible standard method of treatment. WM. C?. HENSXE. Cheval:
Vesicovaginal Fistula Occurring 48 ITours After Radium Application.
Bruxelles
Mddical,
1925, v, 5.
Patient, 44 years old, had severe hemorrhages. Examination showed carcinoma of the cervix the size of a hen’s egg, with slight broad ligament involvement. Cystoseopy showed bladder irregularity and congestion but no neoplastic growth or ulceration. The patient received 10800 millicuries’ of radiation in the region of each broad ligament, over a period of five days, and 21600 millicuries in the vagina, over a period of nine days. In each case the radium was filtered by 1.5 mm. of brass, 0.2 of aluminum, and 2 mm. of rubber while the vaginal radium had an additional titer of 1 cm. of gauze. On the second day following the beginning of radiation a vesicovaginal fistula developed. Three weeks later a panhysterectomy was done, and two weeks following this an attempt was made to close the fistula, which failed. Three months later the vagina was closed, and a rectovesieal fistula made; however, there was still some drainage of urine below the urethra. Twenty months later the patient had shown no signs of recurrence.