- Email: [email protected]
Indications for hysterectomy
INDICATIONS
FOR HY8TEBECTOW
A Panel Discussion MODERATOR: PANELISTS :
CHARLES MCLANE, M.D., NEW YORK, N. Y. NORMAN F. MILLER, M.D., ANN ARBOR, MICH. RICHARD W. TE IJINDE, M.D., BALTIMORE, MD. ALBERT H. ALDRIDGE, M.D., NEW YORK, N. Y.
Carcinoma of the Endometrium and of the Ovaries DR. NORMAN MILLER.---& the beginning of this century hysterectomy was the treatment of choice for carcinoma of the endometrium. Indeed, it was at first the only treatment. About 1925 the idea developed that preliminary irradiation might be of value. There were very good reasons for considering such preliminary therapy. While the operation was successful, the follow-ups, which were few and far between, indicated that the patient didn’t always survive very long. There were recurrences, locally. There were manipulative spread and metastases to the chest and other parts of the body and it was felt that perhaps by irradiation prior to operation these hazards could be reduced. I believe they were reduced. But like everything else, I think the carcinoma of the endometrium situation has changed. Back in those early days carcinoma of the endometrium was in an advanced state when diagnosed. Today we find the diagnosis being made much earlier and I admit that there are many patients today who probably do not need either preoperative x-radiation or preoperative radium irradiation. But, I believe these patients should be individualized. I am firmly convinced that there is no treatment at this time better than irradiation followed by surgery I am familiar with the figures that the for carcinoma of the endometrium. R,adiumhemmet has reported, which I believe are the best in the world for They irradiation alone in the treatment of carcinoma of the endometrium. do not equal those for surgery combined with preoperative radiation. In so far as carcinoma of the ovary is concerned, again we have gone through a cycle There was a time when the only treatment was operation and removal of all the pelvic organs. Then we came to the stage where we considered leaving the uterus so that intracavitary irradiation of the pelvis might be considered along with external irradiation in the hope that the results could be improved. Now most gynecologists have discontinued leaving the uterus for the simple reason that the figures did not show improved results when the uterus was left in. Indeed there are very good reasons why the uterus should be removed. I believe you are familiar with the fact that, in carcinoma of the ovary, involvement of the uterus and the tubes is not uncommon. In some recent studies that have been made, where cytological investigation was carried out, free carcinoma cells were found in the tubes and in the uterine cavity. So I believe that for carcinoma of the ovary we have in the operable cases a clear-cut indication for doing a hysterectomy. In our treatment of carcinoma of the endometrium, we generally supplement or precede the hysterectomy with x-irradiation but I believe there is room *Presented
at a meeting of the New York Obstetrical
534
Society, March
8, 1955.
\ dome Numhrr
i2
i
INDICATIONS FOR HYSTERECTOMY
,5x*
for individualization of patients, principally because many of these patients are reporting for treatment in an earlier stage of the disease. In SO far as cancer of the ovary is concerned this is still a real problem as you all know The major aspect of this problem is not what to take out but how to diagnose it early. Perhaps the discovery that loose cells from ovarian carcinoma may he recovered from the uterus will be a small step leading to earlier diagnosis. which is perhaps the most important factor in obtaining improved results iu the management of carcinoma of the ovary.
Carcinoma of the Cervix DR. RICHARD TE LINDE.-I like to think of the treatment of carcinoma (11 the cervix historically because, I do date back to the previous era when the Wertheim operation was done. I did several of these operations during my residency. By the Wertheim operation I mean the radical operation, doing a salpingo-oophorectomy removing a good part of the upper portion of tht, vagina, and a pelvic lymphadenectomy. There have been some disputes as to just what the Wertheim operation is. As a matter of fact, Wertheim did not always perform the same operation, so there is no wonder there is confusion. In the later years he decided lymph gland dissection was of very little value and many of the operations which he did were of the type we now call a modified Wertheim operation and WC us
536
MILLER,
TE LINDE,
AND
ALDRIDGE
Am. .I. Obst. & Gyner. September. 1956
per cent. In other words, the figures were practically identical for that year but Meigs ’ cases were selected and ours were the run of the mill. The thin woman, the young woman, the good operative risk is also a better irradiation risk. I think I ought to say just one word about the Schauta operation-the radical vaginal hysterectomy. Professor van Bouwdijk Bastiaanse of Amsterdam is one of the chief advocates of that today. In Stage I his five-year salvage is 59 per cent which is considerably lower than the salvage from many of the better irradiation clinics in that group of cases. The operation does not appeal to me although Dr. Van Bouwdijk Bastiaanse is a master of it technically. I believe that that operation has little if any place in the treatment of carcinoma of the cervix. There has been only one controlled study on the relative value of surgical and radioactive technique that I know of. This was done right here in the City of New York by Dr. Howard Taylor and Dr. Twombly in which alternate cases of Stages I and II were operated on and irradiated. What were their five-year results? The salvage in the cases operated upon was 60 per cent and the salvage in the irradiated cases was 68 per cent. So there was a little edge in favor of irradiation. I think almost everybody believes that Stages III and IV should be treated with irradiation. After looking over these figures and trying as hard as 1 can to compare one set of figures with another, this is my present belief regarding t,he treatcarcinoma we do the modiment of cervical cancer: In Stage 0 intraepithelial fied Wertheim operation. This operation is a total hysterectomy but we take a couple of centimeters of parametrium on either side, and catheterize the ureters preoperatively so as to know where they are all the time and thus avoid dissecting them out with resulting fistula formation. We also take about a 2 cm. cuff of vagina. We have been accused of being too radical in treating I feel nothing short of this surgery carcinoma in situ by hysterectomy. should be done provided you are very sure you are dealing with a bona fide case of carcinoma in situ because you never know just how extensive that lesion is until you have the whole specimen to examine. We have many cases in which the lesion extends as high as t,he internal OS and if we had done an amputation of the cervix in many cases we would have left carcinoma in. In fact, we have one case in which the “in situ” replaces the endometrium and goes way up to the fundus of the uterus where it becomes invasive. The reason 1 think a vaginal cuff should be taken-and I think that is the most important deviation from the normal hysterectomy in dealing with carcinoma in situ-is that alt,hough the lesion is superficial it is many times very extensive on the surface of the cervix. We have had one case in which the lesion was found on the cervix and also out in the vaginal vault. You probably all know that Dr. Meigs has reported t,hree cases of recurrence in the vaginal vault after hysterectomy and I am sure his hysterectomy is fully as radical as ours is. We have had no recurrence in the vaginal vault in our in situ cases. If you look at the figures on surgery done by the few experts and those on irradiation, the results are just about the same in Stage I. Before a man undertakes the Wertheim operation for Stage I carcinoma of the cervix he should look himself in the eye and ask himself, “Have I any right to operate on this woman with my operative experience when I can get just as good results by irradiation?” Avoiding surgery will certainly decrease the chances of ureteral injuries which even the best operators have. In fact, I think some of the best operators, who do the most thorough job, have the most ureteral-vaginal fistulas. The more thorough the job of eradicating the cancer, perhaps the more fistulas you will have.
Volume Number
72 3
INDICATIONS
FOR HYSTERECTOMY
3537
As far as Stages II, III, and IV are concerned, in our clinic we feel they should be treated by complete irradiation.
Benign Conditions of the Uterus or Adnexa DR. ALBERT H. ALDRIDGK-Hysterectomy by either the abdominal or vaginal route is now the treatment of choice for a variety of benign gynecological conditions. W ithin the past few years the risks of these operative procedures have been reduced to a low level by (1) improved surgical techniques, (2) better anesthesia, (3) modern routines to prepare patients for operation, (4) facilities for adequate replacement of blood loss, and (5) development of effective means to prevent and to treat infections. This has led to modifications in indications for hysterectomy and to an increase in the percentage of complete hysterectomies which until recent years were considered by some gyntcologists to be unnecessarily radical. Gynecologists have accepted the advantages of complete hysterectomy whenever there are indications to remove the uterine corpus. They are convinced that the results of hysterectomy are on the whole better than those from irradiation therapy. Partial hysterectomy and irradiation therapy are now reserved for a few patients who are poor surgical risks and for those in whom unusual technical problems are encountered. The incidence of vaginal hysterectomy has increased in all gynecological clinics. Many women who consult a gynecologist have symptoms and conditions which constitute definite and acceptable indications for this procedure. Others have troublesome symptoms which can be promptly and positively relieved by hysterectomy but they have little ‘evidence of any abnormalities of the pelvic organs. Their symptoms may or may not respond to more conservative therapeutic or surgical procedures. Some have had prolonged treatment before they consult a gynecologist. They are anxious for prompt and permanent relief from their symptoms. In these days, many patients need assurance that they do not have cancer and that the treatment which is recommended will prevent development of pelvic cancer in t,he future. The decision as to whether a woman’s uterus should be removed must be based not only upon her symptoms and the condition of her pelvic organs but also upon her age, marital status, and the importance of retaining her menstrual and childbearing functions. Hysterectomy is‘indicated for the following benign pelvic conditions in women a.t or near the menopause and for t,hose who have conditions which cannot be adequately treated by more conservative methods : 1. Uterine fibromyomas, which show signs and symptoms of active growth or degeneration and those which cause excessive uterine bleeding and/or This includes regrowth of symptoms of pressure on the pelvic structures. fibroids after previous myomectomy. 2. Uterine adenomyosis which is diffuse and extensive enough to cause pelvic pain, abnormal uterine bleeding, and severe dysmenorrhea. 3. Uterine fibrosis an,4 vascular sclerosis which produce physical changes in the uterine musculature and symptoms which are difficult to differentiate before operation from those due to adenomyosis. In fact both conditions are found frequently in the same uterus. I realize that there is a difference of opinion regarding uterine fibrosis and vascular sclerosis, that is, whether there are such conditions. At the Woman’s Hospital we have accepted these diagnoses which are made by our Pathologist, Dr. Leon Motyloff, who was trained by the late Professor Robert Meyer and has had much experience in gynecological pathology.
538
MILLER,
TE LINDE,
AND
ALI)RIDGE
4. Endometriosis which is extensive enough to necessitate removal of b,oth tubes and ovaries for relief of pelvic symptoms. 5. Pelvic inflammatory disease including pelvic tuberculosis which has failed to respond to palliative therapy and is extensive enough to necessitate removal of both tubes and ovaries for relief of pelvic symptoms. 6. Functional uterine bleeding which cannot be controlled by a suitable hygienic routine, adequate endocrine therapy, psychotherapy, and repeated curettage of the uterus. 7. Recurrent or persistent uterine Dleedino after irradiation therapy for benign uterine conditions. 8. Severe dysmenorrhea which has failed to respond to all other types of treatment. 9. Ov#arian cysts or benign tumors which necessitate complete removal of both ovaries. 10. Uterine prolapse if the uterus is abnormal or the prolapse is extensive or complete. 11. At times for the following obstetrical complications : (a) uncontrolled hemorrhage from uterine atony ; (b) ruptured uterus; (c) premature separation of the placenta ; (d) placenta accreta ; (e) fibroids which are extensive and often degenerated ; and (f) hydatidiform mole if tests for chorionie gonadotropin continue to be positive or if they become positive after being negative provided the uterus has been carefully and completely emptied. Hysterectomy is contraindicated for the following benign pelvic conditions in patients for whom it is important to preserve the menstrual and/or childbearing functions and for some women who are poor surgical risks: 1. Uterine fibromyomas which are asymptomatic or can be adequately treated by myomectomy. 2. Uterine adenomyosis which is diffuse and is not causing enough symptoms to justify removal of the uterus or is localized and can be excised for relief of symptoms. 3. Endometriosis which requires surgery and is localized so that it can be removed or destroyed, leaving one normal tube and a part of one ovary. 4. Pelvic inflamm’atory disease which requires surgery if one functioning tube and at least a part of one ovary can be retained. 5. Functional uterine bleeding unless it has failed to respond to a suitable hygienic routine, adequate endocrine therapy, psychotherapy, and repeated curettage. 6. Benign ovarian cysts and tumors which can be resected in such a way as to leave at least a part of one ovary and a normal tube. 7. Normal uteri which are partially prolapsed. 8. Sterilization of a patient rather than by tubal ligation if the uterus is relatively normal.
Discussion PRESIDENT McLANE.-The rest of the program we thought we would devote to questions. The various members of this panel have had to talk up to this point on specific topics. I would like to have some questions from the floor directed to specific individuals to produce further discussion of this matter of hysterectomy.
DR. J. EDWARD HAmA.-What are the indications dysmenorrhea is present? I would like Dr. Aldridge
for hysterectomy to expand a little
when more.
DR. ALumDoE.--It is assumed that Dr. Hall’s question refers to dysmenorrhea in women who have relatively normal pelvic organs. In such circum-
Volume
72
Number 1
INDICATIONS
FOR HYS’l’ERECTOM\T
:i3!)
stances menstrual pain can usually be adequat,ely controlled or relieved by antispasmodic or pain-relieving drugs, hormone therapy, psychotherapy, and/ or various gynecological procedures such as cervical dilatation, uterine curettage, operations for retroversion, and resections of the presacral nerve. Severe dysmenorrhea may or may not be relieved after childbirth. Every gynecologist knows that abnormal mental and emotional states are important factors in the causation and exaggeration of menstrual pain. Effective psychotherapy is difficult to arrange and at best fails often to produce results. Hysterectomy during the childbearing years to relieve dysmenorrhea is rarely indicated and should never be considered until all types of therapy outlined above have been tried. If they fail, removal of the uterus in occasiona. cases offers the only means by which woman can bc relieved of prolonged severe dysmenorrhea and can be restored to normal physical and emotional health. Whenever a surgeon is forced to resort to hysterectomy for relief of disabling menstrual pain, he must usually acknowledge a measure of defeat in that the patient has probably not had an opportunity to get complete benefit from other types of treatment and especially from psychotherapy. DR. CLAIR E. FOLSOME.-I for adenomyosis Z
was going to ask what the c,linical criteria
arr
DR. MILLER.-I have heard several terms used here this evening which disturb me a litt,le. One is fibrosis uteri, and I understand there is no such entity. Otto Schwarz, you may recall, stndied that, problem. In differential staining of t,hese enlarged uteri, the amount of connective tissue does not appear to be excessive except in approximately 10 per cent of the patients suffe?*ing from what has been called from a clinical standpoint fibrosis uteri. The other term that bothers me in differential diagnosis is adenomyosis uteri. It, is a difficult clinical diagnosis to make in its less advanced form, The only criteria I have for making this diagnosis are two: one is ahnormal bleeding or spotting and it does not have to be excessive, and the see:1 a.m frank to admit thn.t I ond is enlargement and firmness of the uterus. caannot prove the diagnosis until I have the specimen. DR. TE LINDE.---Adenomyosis of a certain degree is a common lesion. When Roger Scott and I studied our external enclomctriosis we went over all the cases of internal endometriosis too. We found there were just as many internal as external recorded in our laboratory but most of the cases of adenomyosis were asymptomatic and of minor degree. The major lesion of real dif. fuse adenomyosis of the uterus is not a very common lesion. The diagnosis is extremely difYicult to make with certainty and, frankly, I operate for the symptoms. If the patient has sufficiently excessive menstruation and if her dysmenorrhea is sufficiently bad 1 suspect the diagnosis and operate but sometimes I do not find it. If you combine these symptoms with a symmetrical enlargement of the uterus you have something to make O~IV suspicious of adenomyosis. DR. JOHN A. EIELLY.-I cation of in situ carcinoma
should like to ask Dr. Te Linde what is his class%. of the cervix?
DR. TE LINDE.-I will try to answer this question as briefly as I can but I would like to have a few minutes to defend my views. There seems to be some question as to whether Dr. Galvin and I in our original publication went overboard in talking about invasion in the 72 of 108 cases which we had. I am perfectly willing to admit that the term “invasion” was ill chosen as it was interpreted. In ‘i2 of the 108 there was carcinoma beneath
540
MILLER, TE LINJ)E, AND XLI~R11)GE
Am. J. Obst. & Gym. September, 1956
the surface. I mean these epithelial cells which had all the characteristics of malignancy on the surface invaded glands and in some instances invaded the stroma. When it invades glands, even though those glands are way up in the endocervix, we still call it carcinoma in situ. I think there is agreement by most of the people who are workin g with it that they are willing still to call it carcinoma in situ, when the glands are invaded without true stromal invasion. But I agree that there have been a tremendous amount of misunderstanding and a tremendous amount of misinterpretation on the part of pathologists. Many sections that are sent to me from pathologists with a diagnosis of carcinoma in situ, have only a mild degree of what we would call basal-cell hyperactivity. According to our views there must be an involvement of the full thickness of the epithelium by these abnormal cells to justify a diagnosis of carcinoma in situ. I do not think that carcinoma in situ is invasive cancer of the cervix and we do not include these cases in our statistics of invasive cancer. As to the matter of treatment lesser than hysterectomy, I could show you many, many sections in which if we had amputated the cervix we would have cut right through carcinoma in situ. Dr. Paul Young reports that he had 42 cases that he treated with something less than a total hysterectomy and, of those 42 cases, 14 subsequently required further treatment for carcinoma of So I think when you are dealing with something which is POthe cervix. tentially malignant and you have a chance to strike it, you should strike it. I do not mean that all cases of carcinoma in situ become invasive cancer but I do mean that many cases of invasive cancer are preceded by carcinoma in situ. Of 723 cases of advanced cancer that we were treating in our clinic we had biopsies from one to 19 years before on 13 cases. We went back and restudied Therefore we had 12 cases with epithose 13 cases. One had no epithelium. thelium and in 11 of the 12 we found carcinoma in situ. In the few cases in which we operate for invasive cervical cancer we do We do it on the cases of Stage I and some the typical Wertheim operation. Stage II that fail to respond to irradiation or have local recurrences in the cervix. I did not say that I thought that Stage Ill’s and Stage IV’s were not suitI say almost everyone agrees that that is the only treatable for irradiation. ment that there is for them and that we treat’ them that way, but I do not think they are as amenable to radiation naturally as Stages I and II.
DR. OSCARGLASSMAN.-I would like to ask Dr. Miller about carcinoma of the endometrium. He says in some of these cases he gives radiation preoperatively. I would like to ask him whether in the cases which do not receive preoperative radiation he always gives postoperative radiation Z DR. MILLER.-We do not use postoperative radiation in cases of carcinoma of the endometrium, nor do we use irradiation either pre- or postoperatively when we operate for carcinoma of the cervix. It seems to me if we are going to learn something about how to treat some of t,hese diseases we should not be mixing our treatments unless we have a specific and clear-cut indication for so doing. When we use it preoperatively, as in carcinoma of the endometrium, we feel that we are accomplishing certain specific things. One, we are giving the cancer cells a good stiff jolt. We hope thereby to minimize manipulative Second, we formerly thought that maybe spread at the time of operation. we could do something to the lymphatics such as seal them off, but we have long since learned that we dilate some and seal others. We have discovered, too, that we reduced the vascularity by preoperative radiation, if we waited a reasonable length of time and we think six weeks is ,about right. The fourth thing we expect from preopera.tive irradiation in carcinoma of the endometrium
Volume
i?
Number3
INDICATIONS
FOR HYSTERECTOMY
541
is to reduce vaginal recurrence. W e think we accomplish this. The final and most important reason for preoperative irradiation of course is the improvement of the end result. W e believe we do achieve better and longer survival. In our series of cases of carcinoma of the endometrium treated by prc?operative x-ray, then operation we have 87.5 per cent five-year survivals. I know there are others who report 90 per cent but some of these series are sma,ll in number. It is going to take years before we will know positive11 which plan is best and the question may never be answered because if wt keep on diagnosing these cases earlier we may gradually discard supplement.al t,hernpy. There is only one question that 1)~. TE LINDE.--I agree with Dr. Miller. I might ask him. How do you differentiate between those to whom you give preoperative radiation and those to whom you do not 2 I find this distinction difficult, so we routinely use preoperative irradiation. I could entirely agrrc with him on what he says about vaginal recurrences. I have not seen a vaginal recurrence in any of the cases to which we have given preoperative intra ctavitary irradiation. L)R. Mn,r,E:a.--In my desire to be brief 1 mav have cut a few Corners. :I report,ed to y.ou on our five-year survival rates. S>nce we published that report we have individualized our patients to a greater degree and our criteria for, whether or not we shall use preoperative irradiation are three in number: Ii the uterus is not enlarged, if the duration of the symptoms is limited 1~1 a short time, and if the histological picture is t,hat of a Grade I or a Grade I I carcinoma, W C today may go ahead directly with surgery. Put we still SV(’ mostly advanced cases in the sense that. the symptoms have been present, for more than six months, so most of our patients with endometrial carcinomas art” given preoperative irradiation, customaril)- s-irradiation. L)R. %LFH W . (:Ause.---May 1 ask a question about benign tumors? 1 would like to ask Dr. Te Lindc when he ~oulcl choose hyst,erectomy o~(‘1 myomectomy. IIR. TE: I,INm:.--In our Negro ward in Baltimore, it is a very rare thing to do a myomectomy for the reason that in a tremendous percentage there is already sterilization by salpingitis. In private practice, on the other hand. I do a reasona,ble number of myomectomies. I do not rush in whenever I find myomas ljresent in a woman who wants to ha,vtl babies. These patients a.rcl given a thorough trial to get pregnant, worked up completely from the sterilit?; standpoint, but if there are myomas the size of golf balls, and the patient has remained sterile after a good t.rial to become pregnant, I think myomec On the other hand, if I see a tomy is just,ifiable in the treatment of sterility. young woman who has recently been married and who has a good-sized fibroitl and I believe that the presence of the myoma is likely to interferr with thtb course of pregnancy I think a myomectomy is indicated at once. QUESTIOP;
: Is hysterectomy ever indicated primarily
for sterilization?
r)R. ALDRIDGE.--It is assumed that this question refers to a woman in whom the uterus and menstrual functions are normal. In such circumstances hysterectomy is definitely contraindicated for sterilization or to satisfy a woman who is tired of menstruating. Unnecessary removal of the uterus in a young woman may lead to physical and emotional symptoms which are troublesomr for both the patient and the surgeon.
DR. F'ALK.-At the time of a complete abdominal hysterectomy in a woman 35 years of age or older who has children, would you leave ovaries moderately involved by endometriosis if they had caused no symptoms?
MILLER, TE LINI)I:, AND ALDRIDQE
542
:\nr. J. Ohs. & Gynec. September, 195/i
DR. ALDRIDGE.-The best treatment for endometriosis is to stop the production of ovarian hormones. We have convincing evidence that ovarian function continues after complete abdominal hysterectomy. Endometriosis involving ovaries may progress after the uterus has been removed and require another operation for relief of symptoms. The only purpose in conservative treatment of ovarian endometriosis is to preserve the menstrual and childbearing functions. At the time of hysterectomy it seems logical to remove ovaries moderately involved by endometriosis even though they have caused no preoperative symptoms. DR. TE LINDE.-I think there is a situation that falls in between the extremes that Dr. Aldridge talked about and I think that is what Dr. Falk had in mind. In a woman in her mid-thirties for example, who has had all the children she wants or has been sterile, has a completely destroyed ovary on one side and a bit of endometriosis in the other ovary, I would remove the destroyed ovary, resect a part of the other ovary, and do a total hysterectomy. Her chances of being comfortable would be greater than if the uterus were left in and yet she would not be thrown into the menopause. I can give you our figures. In the cases in which we were “totally conservative, ” I mean the group in which we saved the uterus as well as one tube and ovary so that childbearing was at least theoretically possible, 12.2 per cent, and in those cases in which we were semiconservative, that is, did a hysterectomy but saved at least some ovarian tissue, 4.4 per cent required further surgery.
QUESTION: It is my impression that Dr. Te Linde leans favorably toward the use of radium in carcinoma of the cervix. I would like to ask him what is his feeling about intracavitary radiation for the treatment of fibromyomas. DR. TE LINDE.-I think radium has a place in the treatment of fibromas. Here is a typical example : a woman, 45 to 46 years old, with a small bleeding fibroid. She has been previously curetted, and carcinoma of endometrium ruled out. The cervix has been hiopsied and carcinoma of the cervix excluded. She continues to bleed. That individual to me is a good candidate for int,racavitary radiation. Sometimes I give such a patient a choice. If she is prejudiced against irradiation I’ll do a vaginal hysterectomy. If the woman says, “I don’t mind having radium and hate to be tied up for a few weeks, I want to do this the quickest possible way,” I have no objection to irradiation. On the whole the results are very good. The same thing applies to functional bleeding. When functional bleeding recurs to the extent that definitive treatment is indicated, intracavitary radiation in people near the menopause is very good. I do object, however, to doing a hysterectomy, vaginal or abdominal, for functional bleeding at the first offense without a curettage and a study of the endometrium.
you consider postmenopausal bleeding an indication if uterine curettings are negat,ive for malignancy?
QUESTION.-DO
hysterectomy
for
DR. ALDRIDGE.-uh?rine curettage is not always a satisfactory or reliable diagnostic procedure for a woman who has postmenopausal bleeding and uterine fibroids. This is especially true if the fibroids are of the submucous variety producing an irregular uterine cavity. The incidence of endometrial carcinoma in such patients is about 50 per cent. It is probably wise to treat such patients with hysterectomy or irradiation. It is now generally agreed that hysterectomy produces better results than irradiation and that it is the treatment of choice for good-risk patients. Physical studies of some patients who have postmenopausal bleeding will show obesity, diabetes, vascular hypertension, and degenerative disease which
Volume72
Number.I
INT)lCATIONS
FOR H YBTERECTOM’;
radium may make them poor surgical risks. For these patients, intracavitary produce excellent results if the fibroids are not too large. If the fibroids arc’ large it may be necessary to accept a calculated surgical risk and to remove the uterus. DR. LOCKE L. MACKENZIE.-I would like to ask Dr. Te Linde a question. Does he believe that basal-cell hyperactivity is a precancerous lesion? DR. TN: LINDE.-That is the hardest question we have been asked tonight, the hardest one for me even to attempt to answer and we do not know thth final answer but this I can say. Basal-cell hyperactivity is frequently found is in the neighborhood of true carcinoma in situ. Basal-cell hyperactivity frequently found around the periphery of true invasive cancer. It is a red flag. When we find it we rebiopsy and we keep that patient under observation for several months but do not make a final diagnosis until the histologic4 findings meet our criteria for carcinoma in situ. On the other hand, we have had some cases of basal-cell hyperactivit: that we have followed for several years and rebiopsied and we have never found it again. So I think we have to consider it a warning, at least temporarily, and possibly a reversible condition. PRESIDENT McLANE.--The hour is getting late. Dr. Miller would like I(> say a few words in closing on some of the larger problems in gynecology. DR. MILLER.-I am making a plea on behalf of gynecology of the future. As you have listened here tonight you have heard a variety of answers to some of today’s gynecological problems. These replies recalled for me a little star, I heard this summer in Europe about the alumnus who came back to his medical school after an absence of 25 years. He went in to see one of his professors whom he liked and as he walked into the office the professor came in; threw some blue books on the table and as he did so a piece of paper fluttered to the floor. The alumnus picked up the paper and looked at it. He noticed there were typed examination questions on it and he perused them. He begall to recollect that they were exactly the same questions the professor hati asked his class. He commented to the professor on this observation, where upon the professor said, “Yes, the questions are the same but, the answers arch different. ” As time goes on our answers change. I mention this because there are many young gynecologists and obstetzi. cians in this room. The answers of today may have to be changed tomorrow. all of which permits me to raise what 1 believe to be a pertinent questiott. What is the future of gynecology 1 I believe the answer to this question dovalves upon each and every one of us who pract,ices this specialty. It is up to every one of us to see that the frontiers of our specaialty are broadened. We have spent a whole evening on the subject of hysterectomy. Wt. might well do so because it is an important aspect of our work. But hystrrgectomy is only one aspect of gynecology. It seems to me that we as a groul) have narrow sights, that it is time for us to raise our sights. There art’ many t,hings that need to be done. We still do not know how to tb, a really good myomectomy and avoid trouble. In all CilSeS of ectopic pregnancy we take out the tube. Perhaps we c~ould learn how to preserve it. In so-called dysfunctional bleeding we remove the uterus but there may be nothing at all wrong with the uterus. We remove the uterus because we still t3~1 not know how to get at the real fault. We should be working to find the facetors truly responsible. How much time have we spent on the removal ot fibroids ? A great deal, yet is it not about. time we spent. a little effort, I ryill>: to figure out why some of these things occur i! Gynecology has a future but its scope and character will depend a great deal upon our own efforts and the lifting of our sights !
FOR HY8TEBECTOW
A Panel Discussion MODERATOR: PANELISTS :
CHARLES MCLANE, M.D., NEW YORK, N. Y. NORMAN F. MILLER, M.D., ANN ARBOR, MICH. RICHARD W. TE IJINDE, M.D., BALTIMORE, MD. ALBERT H. ALDRIDGE, M.D., NEW YORK, N. Y.
Carcinoma of the Endometrium and of the Ovaries DR. NORMAN MILLER.---& the beginning of this century hysterectomy was the treatment of choice for carcinoma of the endometrium. Indeed, it was at first the only treatment. About 1925 the idea developed that preliminary irradiation might be of value. There were very good reasons for considering such preliminary therapy. While the operation was successful, the follow-ups, which were few and far between, indicated that the patient didn’t always survive very long. There were recurrences, locally. There were manipulative spread and metastases to the chest and other parts of the body and it was felt that perhaps by irradiation prior to operation these hazards could be reduced. I believe they were reduced. But like everything else, I think the carcinoma of the endometrium situation has changed. Back in those early days carcinoma of the endometrium was in an advanced state when diagnosed. Today we find the diagnosis being made much earlier and I admit that there are many patients today who probably do not need either preoperative x-radiation or preoperative radium irradiation. But, I believe these patients should be individualized. I am firmly convinced that there is no treatment at this time better than irradiation followed by surgery I am familiar with the figures that the for carcinoma of the endometrium. R,adiumhemmet has reported, which I believe are the best in the world for They irradiation alone in the treatment of carcinoma of the endometrium. do not equal those for surgery combined with preoperative radiation. In so far as carcinoma of the ovary is concerned, again we have gone through a cycle There was a time when the only treatment was operation and removal of all the pelvic organs. Then we came to the stage where we considered leaving the uterus so that intracavitary irradiation of the pelvis might be considered along with external irradiation in the hope that the results could be improved. Now most gynecologists have discontinued leaving the uterus for the simple reason that the figures did not show improved results when the uterus was left in. Indeed there are very good reasons why the uterus should be removed. I believe you are familiar with the fact that, in carcinoma of the ovary, involvement of the uterus and the tubes is not uncommon. In some recent studies that have been made, where cytological investigation was carried out, free carcinoma cells were found in the tubes and in the uterine cavity. So I believe that for carcinoma of the ovary we have in the operable cases a clear-cut indication for doing a hysterectomy. In our treatment of carcinoma of the endometrium, we generally supplement or precede the hysterectomy with x-irradiation but I believe there is room *Presented
at a meeting of the New York Obstetrical
534
Society, March
8, 1955.
\ dome Numhrr
i2
i
INDICATIONS FOR HYSTERECTOMY
,5x*
for individualization of patients, principally because many of these patients are reporting for treatment in an earlier stage of the disease. In SO far as cancer of the ovary is concerned this is still a real problem as you all know The major aspect of this problem is not what to take out but how to diagnose it early. Perhaps the discovery that loose cells from ovarian carcinoma may he recovered from the uterus will be a small step leading to earlier diagnosis. which is perhaps the most important factor in obtaining improved results iu the management of carcinoma of the ovary.
Carcinoma of the Cervix DR. RICHARD TE LINDE.-I like to think of the treatment of carcinoma (11 the cervix historically because, I do date back to the previous era when the Wertheim operation was done. I did several of these operations during my residency. By the Wertheim operation I mean the radical operation, doing a salpingo-oophorectomy removing a good part of the upper portion of tht, vagina, and a pelvic lymphadenectomy. There have been some disputes as to just what the Wertheim operation is. As a matter of fact, Wertheim did not always perform the same operation, so there is no wonder there is confusion. In the later years he decided lymph gland dissection was of very little value and many of the operations which he did were of the type we now call a modified Wertheim operation and WC us
536
MILLER,
TE LINDE,
AND
ALDRIDGE
Am. .I. Obst. & Gyner. September. 1956
per cent. In other words, the figures were practically identical for that year but Meigs ’ cases were selected and ours were the run of the mill. The thin woman, the young woman, the good operative risk is also a better irradiation risk. I think I ought to say just one word about the Schauta operation-the radical vaginal hysterectomy. Professor van Bouwdijk Bastiaanse of Amsterdam is one of the chief advocates of that today. In Stage I his five-year salvage is 59 per cent which is considerably lower than the salvage from many of the better irradiation clinics in that group of cases. The operation does not appeal to me although Dr. Van Bouwdijk Bastiaanse is a master of it technically. I believe that that operation has little if any place in the treatment of carcinoma of the cervix. There has been only one controlled study on the relative value of surgical and radioactive technique that I know of. This was done right here in the City of New York by Dr. Howard Taylor and Dr. Twombly in which alternate cases of Stages I and II were operated on and irradiated. What were their five-year results? The salvage in the cases operated upon was 60 per cent and the salvage in the irradiated cases was 68 per cent. So there was a little edge in favor of irradiation. I think almost everybody believes that Stages III and IV should be treated with irradiation. After looking over these figures and trying as hard as 1 can to compare one set of figures with another, this is my present belief regarding t,he treatcarcinoma we do the modiment of cervical cancer: In Stage 0 intraepithelial fied Wertheim operation. This operation is a total hysterectomy but we take a couple of centimeters of parametrium on either side, and catheterize the ureters preoperatively so as to know where they are all the time and thus avoid dissecting them out with resulting fistula formation. We also take about a 2 cm. cuff of vagina. We have been accused of being too radical in treating I feel nothing short of this surgery carcinoma in situ by hysterectomy. should be done provided you are very sure you are dealing with a bona fide case of carcinoma in situ because you never know just how extensive that lesion is until you have the whole specimen to examine. We have many cases in which the lesion extends as high as t,he internal OS and if we had done an amputation of the cervix in many cases we would have left carcinoma in. In fact, we have one case in which the “in situ” replaces the endometrium and goes way up to the fundus of the uterus where it becomes invasive. The reason 1 think a vaginal cuff should be taken-and I think that is the most important deviation from the normal hysterectomy in dealing with carcinoma in situ-is that alt,hough the lesion is superficial it is many times very extensive on the surface of the cervix. We have had one case in which the lesion was found on the cervix and also out in the vaginal vault. You probably all know that Dr. Meigs has reported t,hree cases of recurrence in the vaginal vault after hysterectomy and I am sure his hysterectomy is fully as radical as ours is. We have had no recurrence in the vaginal vault in our in situ cases. If you look at the figures on surgery done by the few experts and those on irradiation, the results are just about the same in Stage I. Before a man undertakes the Wertheim operation for Stage I carcinoma of the cervix he should look himself in the eye and ask himself, “Have I any right to operate on this woman with my operative experience when I can get just as good results by irradiation?” Avoiding surgery will certainly decrease the chances of ureteral injuries which even the best operators have. In fact, I think some of the best operators, who do the most thorough job, have the most ureteral-vaginal fistulas. The more thorough the job of eradicating the cancer, perhaps the more fistulas you will have.
Volume Number
72 3
INDICATIONS
FOR HYSTERECTOMY
3537
As far as Stages II, III, and IV are concerned, in our clinic we feel they should be treated by complete irradiation.
Benign Conditions of the Uterus or Adnexa DR. ALBERT H. ALDRIDGK-Hysterectomy by either the abdominal or vaginal route is now the treatment of choice for a variety of benign gynecological conditions. W ithin the past few years the risks of these operative procedures have been reduced to a low level by (1) improved surgical techniques, (2) better anesthesia, (3) modern routines to prepare patients for operation, (4) facilities for adequate replacement of blood loss, and (5) development of effective means to prevent and to treat infections. This has led to modifications in indications for hysterectomy and to an increase in the percentage of complete hysterectomies which until recent years were considered by some gyntcologists to be unnecessarily radical. Gynecologists have accepted the advantages of complete hysterectomy whenever there are indications to remove the uterine corpus. They are convinced that the results of hysterectomy are on the whole better than those from irradiation therapy. Partial hysterectomy and irradiation therapy are now reserved for a few patients who are poor surgical risks and for those in whom unusual technical problems are encountered. The incidence of vaginal hysterectomy has increased in all gynecological clinics. Many women who consult a gynecologist have symptoms and conditions which constitute definite and acceptable indications for this procedure. Others have troublesome symptoms which can be promptly and positively relieved by hysterectomy but they have little ‘evidence of any abnormalities of the pelvic organs. Their symptoms may or may not respond to more conservative therapeutic or surgical procedures. Some have had prolonged treatment before they consult a gynecologist. They are anxious for prompt and permanent relief from their symptoms. In these days, many patients need assurance that they do not have cancer and that the treatment which is recommended will prevent development of pelvic cancer in t,he future. The decision as to whether a woman’s uterus should be removed must be based not only upon her symptoms and the condition of her pelvic organs but also upon her age, marital status, and the importance of retaining her menstrual and childbearing functions. Hysterectomy is‘indicated for the following benign pelvic conditions in women a.t or near the menopause and for t,hose who have conditions which cannot be adequately treated by more conservative methods : 1. Uterine fibromyomas, which show signs and symptoms of active growth or degeneration and those which cause excessive uterine bleeding and/or This includes regrowth of symptoms of pressure on the pelvic structures. fibroids after previous myomectomy. 2. Uterine adenomyosis which is diffuse and extensive enough to cause pelvic pain, abnormal uterine bleeding, and severe dysmenorrhea. 3. Uterine fibrosis an,4 vascular sclerosis which produce physical changes in the uterine musculature and symptoms which are difficult to differentiate before operation from those due to adenomyosis. In fact both conditions are found frequently in the same uterus. I realize that there is a difference of opinion regarding uterine fibrosis and vascular sclerosis, that is, whether there are such conditions. At the Woman’s Hospital we have accepted these diagnoses which are made by our Pathologist, Dr. Leon Motyloff, who was trained by the late Professor Robert Meyer and has had much experience in gynecological pathology.
538
MILLER,
TE LINDE,
AND
ALI)RIDGE
4. Endometriosis which is extensive enough to necessitate removal of b,oth tubes and ovaries for relief of pelvic symptoms. 5. Pelvic inflammatory disease including pelvic tuberculosis which has failed to respond to palliative therapy and is extensive enough to necessitate removal of both tubes and ovaries for relief of pelvic symptoms. 6. Functional uterine bleeding which cannot be controlled by a suitable hygienic routine, adequate endocrine therapy, psychotherapy, and repeated curettage of the uterus. 7. Recurrent or persistent uterine Dleedino after irradiation therapy for benign uterine conditions. 8. Severe dysmenorrhea which has failed to respond to all other types of treatment. 9. Ov#arian cysts or benign tumors which necessitate complete removal of both ovaries. 10. Uterine prolapse if the uterus is abnormal or the prolapse is extensive or complete. 11. At times for the following obstetrical complications : (a) uncontrolled hemorrhage from uterine atony ; (b) ruptured uterus; (c) premature separation of the placenta ; (d) placenta accreta ; (e) fibroids which are extensive and often degenerated ; and (f) hydatidiform mole if tests for chorionie gonadotropin continue to be positive or if they become positive after being negative provided the uterus has been carefully and completely emptied. Hysterectomy is contraindicated for the following benign pelvic conditions in patients for whom it is important to preserve the menstrual and/or childbearing functions and for some women who are poor surgical risks: 1. Uterine fibromyomas which are asymptomatic or can be adequately treated by myomectomy. 2. Uterine adenomyosis which is diffuse and is not causing enough symptoms to justify removal of the uterus or is localized and can be excised for relief of symptoms. 3. Endometriosis which requires surgery and is localized so that it can be removed or destroyed, leaving one normal tube and a part of one ovary. 4. Pelvic inflamm’atory disease which requires surgery if one functioning tube and at least a part of one ovary can be retained. 5. Functional uterine bleeding unless it has failed to respond to a suitable hygienic routine, adequate endocrine therapy, psychotherapy, and repeated curettage. 6. Benign ovarian cysts and tumors which can be resected in such a way as to leave at least a part of one ovary and a normal tube. 7. Normal uteri which are partially prolapsed. 8. Sterilization of a patient rather than by tubal ligation if the uterus is relatively normal.
Discussion PRESIDENT McLANE.-The rest of the program we thought we would devote to questions. The various members of this panel have had to talk up to this point on specific topics. I would like to have some questions from the floor directed to specific individuals to produce further discussion of this matter of hysterectomy.
DR. J. EDWARD HAmA.-What are the indications dysmenorrhea is present? I would like Dr. Aldridge
for hysterectomy to expand a little
when more.
DR. ALumDoE.--It is assumed that Dr. Hall’s question refers to dysmenorrhea in women who have relatively normal pelvic organs. In such circum-
Volume
72
Number 1
INDICATIONS
FOR HYS’l’ERECTOM\T
:i3!)
stances menstrual pain can usually be adequat,ely controlled or relieved by antispasmodic or pain-relieving drugs, hormone therapy, psychotherapy, and/ or various gynecological procedures such as cervical dilatation, uterine curettage, operations for retroversion, and resections of the presacral nerve. Severe dysmenorrhea may or may not be relieved after childbirth. Every gynecologist knows that abnormal mental and emotional states are important factors in the causation and exaggeration of menstrual pain. Effective psychotherapy is difficult to arrange and at best fails often to produce results. Hysterectomy during the childbearing years to relieve dysmenorrhea is rarely indicated and should never be considered until all types of therapy outlined above have been tried. If they fail, removal of the uterus in occasiona. cases offers the only means by which woman can bc relieved of prolonged severe dysmenorrhea and can be restored to normal physical and emotional health. Whenever a surgeon is forced to resort to hysterectomy for relief of disabling menstrual pain, he must usually acknowledge a measure of defeat in that the patient has probably not had an opportunity to get complete benefit from other types of treatment and especially from psychotherapy. DR. CLAIR E. FOLSOME.-I for adenomyosis Z
was going to ask what the c,linical criteria
arr
DR. MILLER.-I have heard several terms used here this evening which disturb me a litt,le. One is fibrosis uteri, and I understand there is no such entity. Otto Schwarz, you may recall, stndied that, problem. In differential staining of t,hese enlarged uteri, the amount of connective tissue does not appear to be excessive except in approximately 10 per cent of the patients suffe?*ing from what has been called from a clinical standpoint fibrosis uteri. The other term that bothers me in differential diagnosis is adenomyosis uteri. It, is a difficult clinical diagnosis to make in its less advanced form, The only criteria I have for making this diagnosis are two: one is ahnormal bleeding or spotting and it does not have to be excessive, and the see:1 a.m frank to admit thn.t I ond is enlargement and firmness of the uterus. caannot prove the diagnosis until I have the specimen. DR. TE LINDE.---Adenomyosis of a certain degree is a common lesion. When Roger Scott and I studied our external enclomctriosis we went over all the cases of internal endometriosis too. We found there were just as many internal as external recorded in our laboratory but most of the cases of adenomyosis were asymptomatic and of minor degree. The major lesion of real dif. fuse adenomyosis of the uterus is not a very common lesion. The diagnosis is extremely difYicult to make with certainty and, frankly, I operate for the symptoms. If the patient has sufficiently excessive menstruation and if her dysmenorrhea is sufficiently bad 1 suspect the diagnosis and operate but sometimes I do not find it. If you combine these symptoms with a symmetrical enlargement of the uterus you have something to make O~IV suspicious of adenomyosis. DR. JOHN A. EIELLY.-I cation of in situ carcinoma
should like to ask Dr. Te Linde what is his class%. of the cervix?
DR. TE LINDE.-I will try to answer this question as briefly as I can but I would like to have a few minutes to defend my views. There seems to be some question as to whether Dr. Galvin and I in our original publication went overboard in talking about invasion in the 72 of 108 cases which we had. I am perfectly willing to admit that the term “invasion” was ill chosen as it was interpreted. In ‘i2 of the 108 there was carcinoma beneath
540
MILLER, TE LINJ)E, AND XLI~R11)GE
Am. J. Obst. & Gym. September, 1956
the surface. I mean these epithelial cells which had all the characteristics of malignancy on the surface invaded glands and in some instances invaded the stroma. When it invades glands, even though those glands are way up in the endocervix, we still call it carcinoma in situ. I think there is agreement by most of the people who are workin g with it that they are willing still to call it carcinoma in situ, when the glands are invaded without true stromal invasion. But I agree that there have been a tremendous amount of misunderstanding and a tremendous amount of misinterpretation on the part of pathologists. Many sections that are sent to me from pathologists with a diagnosis of carcinoma in situ, have only a mild degree of what we would call basal-cell hyperactivity. According to our views there must be an involvement of the full thickness of the epithelium by these abnormal cells to justify a diagnosis of carcinoma in situ. I do not think that carcinoma in situ is invasive cancer of the cervix and we do not include these cases in our statistics of invasive cancer. As to the matter of treatment lesser than hysterectomy, I could show you many, many sections in which if we had amputated the cervix we would have cut right through carcinoma in situ. Dr. Paul Young reports that he had 42 cases that he treated with something less than a total hysterectomy and, of those 42 cases, 14 subsequently required further treatment for carcinoma of So I think when you are dealing with something which is POthe cervix. tentially malignant and you have a chance to strike it, you should strike it. I do not mean that all cases of carcinoma in situ become invasive cancer but I do mean that many cases of invasive cancer are preceded by carcinoma in situ. Of 723 cases of advanced cancer that we were treating in our clinic we had biopsies from one to 19 years before on 13 cases. We went back and restudied Therefore we had 12 cases with epithose 13 cases. One had no epithelium. thelium and in 11 of the 12 we found carcinoma in situ. In the few cases in which we operate for invasive cervical cancer we do We do it on the cases of Stage I and some the typical Wertheim operation. Stage II that fail to respond to irradiation or have local recurrences in the cervix. I did not say that I thought that Stage Ill’s and Stage IV’s were not suitI say almost everyone agrees that that is the only treatable for irradiation. ment that there is for them and that we treat’ them that way, but I do not think they are as amenable to radiation naturally as Stages I and II.
DR. OSCARGLASSMAN.-I would like to ask Dr. Miller about carcinoma of the endometrium. He says in some of these cases he gives radiation preoperatively. I would like to ask him whether in the cases which do not receive preoperative radiation he always gives postoperative radiation Z DR. MILLER.-We do not use postoperative radiation in cases of carcinoma of the endometrium, nor do we use irradiation either pre- or postoperatively when we operate for carcinoma of the cervix. It seems to me if we are going to learn something about how to treat some of t,hese diseases we should not be mixing our treatments unless we have a specific and clear-cut indication for so doing. When we use it preoperatively, as in carcinoma of the endometrium, we feel that we are accomplishing certain specific things. One, we are giving the cancer cells a good stiff jolt. We hope thereby to minimize manipulative Second, we formerly thought that maybe spread at the time of operation. we could do something to the lymphatics such as seal them off, but we have long since learned that we dilate some and seal others. We have discovered, too, that we reduced the vascularity by preoperative radiation, if we waited a reasonable length of time and we think six weeks is ,about right. The fourth thing we expect from preopera.tive irradiation in carcinoma of the endometrium
Volume
i?
Number3
INDICATIONS
FOR HYSTERECTOMY
541
is to reduce vaginal recurrence. W e think we accomplish this. The final and most important reason for preoperative irradiation of course is the improvement of the end result. W e believe we do achieve better and longer survival. In our series of cases of carcinoma of the endometrium treated by prc?operative x-ray, then operation we have 87.5 per cent five-year survivals. I know there are others who report 90 per cent but some of these series are sma,ll in number. It is going to take years before we will know positive11 which plan is best and the question may never be answered because if wt keep on diagnosing these cases earlier we may gradually discard supplement.al t,hernpy. There is only one question that 1)~. TE LINDE.--I agree with Dr. Miller. I might ask him. How do you differentiate between those to whom you give preoperative radiation and those to whom you do not 2 I find this distinction difficult, so we routinely use preoperative irradiation. I could entirely agrrc with him on what he says about vaginal recurrences. I have not seen a vaginal recurrence in any of the cases to which we have given preoperative intra ctavitary irradiation. L)R. Mn,r,E:a.--In my desire to be brief 1 mav have cut a few Corners. :I report,ed to y.ou on our five-year survival rates. S>nce we published that report we have individualized our patients to a greater degree and our criteria for, whether or not we shall use preoperative irradiation are three in number: Ii the uterus is not enlarged, if the duration of the symptoms is limited 1~1 a short time, and if the histological picture is t,hat of a Grade I or a Grade I I carcinoma, W C today may go ahead directly with surgery. Put we still SV(’ mostly advanced cases in the sense that. the symptoms have been present, for more than six months, so most of our patients with endometrial carcinomas art” given preoperative irradiation, customaril)- s-irradiation. L)R. %LFH W . (:Ause.---May 1 ask a question about benign tumors? 1 would like to ask Dr. Te Lindc when he ~oulcl choose hyst,erectomy o~(‘1 myomectomy. IIR. TE: I,INm:.--In our Negro ward in Baltimore, it is a very rare thing to do a myomectomy for the reason that in a tremendous percentage there is already sterilization by salpingitis. In private practice, on the other hand. I do a reasona,ble number of myomectomies. I do not rush in whenever I find myomas ljresent in a woman who wants to ha,vtl babies. These patients a.rcl given a thorough trial to get pregnant, worked up completely from the sterilit?; standpoint, but if there are myomas the size of golf balls, and the patient has remained sterile after a good t.rial to become pregnant, I think myomec On the other hand, if I see a tomy is just,ifiable in the treatment of sterility. young woman who has recently been married and who has a good-sized fibroitl and I believe that the presence of the myoma is likely to interferr with thtb course of pregnancy I think a myomectomy is indicated at once. QUESTIOP;
: Is hysterectomy ever indicated primarily
for sterilization?
r)R. ALDRIDGE.--It is assumed that this question refers to a woman in whom the uterus and menstrual functions are normal. In such circumstances hysterectomy is definitely contraindicated for sterilization or to satisfy a woman who is tired of menstruating. Unnecessary removal of the uterus in a young woman may lead to physical and emotional symptoms which are troublesomr for both the patient and the surgeon.
DR. F'ALK.-At the time of a complete abdominal hysterectomy in a woman 35 years of age or older who has children, would you leave ovaries moderately involved by endometriosis if they had caused no symptoms?
MILLER, TE LINI)I:, AND ALDRIDQE
542
:\nr. J. Ohs. & Gynec. September, 195/i
DR. ALDRIDGE.-The best treatment for endometriosis is to stop the production of ovarian hormones. We have convincing evidence that ovarian function continues after complete abdominal hysterectomy. Endometriosis involving ovaries may progress after the uterus has been removed and require another operation for relief of symptoms. The only purpose in conservative treatment of ovarian endometriosis is to preserve the menstrual and childbearing functions. At the time of hysterectomy it seems logical to remove ovaries moderately involved by endometriosis even though they have caused no preoperative symptoms. DR. TE LINDE.-I think there is a situation that falls in between the extremes that Dr. Aldridge talked about and I think that is what Dr. Falk had in mind. In a woman in her mid-thirties for example, who has had all the children she wants or has been sterile, has a completely destroyed ovary on one side and a bit of endometriosis in the other ovary, I would remove the destroyed ovary, resect a part of the other ovary, and do a total hysterectomy. Her chances of being comfortable would be greater than if the uterus were left in and yet she would not be thrown into the menopause. I can give you our figures. In the cases in which we were “totally conservative, ” I mean the group in which we saved the uterus as well as one tube and ovary so that childbearing was at least theoretically possible, 12.2 per cent, and in those cases in which we were semiconservative, that is, did a hysterectomy but saved at least some ovarian tissue, 4.4 per cent required further surgery.
QUESTION: It is my impression that Dr. Te Linde leans favorably toward the use of radium in carcinoma of the cervix. I would like to ask him what is his feeling about intracavitary radiation for the treatment of fibromyomas. DR. TE LINDE.-I think radium has a place in the treatment of fibromas. Here is a typical example : a woman, 45 to 46 years old, with a small bleeding fibroid. She has been previously curetted, and carcinoma of endometrium ruled out. The cervix has been hiopsied and carcinoma of the cervix excluded. She continues to bleed. That individual to me is a good candidate for int,racavitary radiation. Sometimes I give such a patient a choice. If she is prejudiced against irradiation I’ll do a vaginal hysterectomy. If the woman says, “I don’t mind having radium and hate to be tied up for a few weeks, I want to do this the quickest possible way,” I have no objection to irradiation. On the whole the results are very good. The same thing applies to functional bleeding. When functional bleeding recurs to the extent that definitive treatment is indicated, intracavitary radiation in people near the menopause is very good. I do object, however, to doing a hysterectomy, vaginal or abdominal, for functional bleeding at the first offense without a curettage and a study of the endometrium.
you consider postmenopausal bleeding an indication if uterine curettings are negat,ive for malignancy?
QUESTION.-DO
hysterectomy
for
DR. ALDRIDGE.-uh?rine curettage is not always a satisfactory or reliable diagnostic procedure for a woman who has postmenopausal bleeding and uterine fibroids. This is especially true if the fibroids are of the submucous variety producing an irregular uterine cavity. The incidence of endometrial carcinoma in such patients is about 50 per cent. It is probably wise to treat such patients with hysterectomy or irradiation. It is now generally agreed that hysterectomy produces better results than irradiation and that it is the treatment of choice for good-risk patients. Physical studies of some patients who have postmenopausal bleeding will show obesity, diabetes, vascular hypertension, and degenerative disease which
Volume72
Number.I
INT)lCATIONS
FOR H YBTERECTOM’;
radium may make them poor surgical risks. For these patients, intracavitary produce excellent results if the fibroids are not too large. If the fibroids arc’ large it may be necessary to accept a calculated surgical risk and to remove the uterus. DR. LOCKE L. MACKENZIE.-I would like to ask Dr. Te Linde a question. Does he believe that basal-cell hyperactivity is a precancerous lesion? DR. TN: LINDE.-That is the hardest question we have been asked tonight, the hardest one for me even to attempt to answer and we do not know thth final answer but this I can say. Basal-cell hyperactivity is frequently found is in the neighborhood of true carcinoma in situ. Basal-cell hyperactivity frequently found around the periphery of true invasive cancer. It is a red flag. When we find it we rebiopsy and we keep that patient under observation for several months but do not make a final diagnosis until the histologic4 findings meet our criteria for carcinoma in situ. On the other hand, we have had some cases of basal-cell hyperactivit: that we have followed for several years and rebiopsied and we have never found it again. So I think we have to consider it a warning, at least temporarily, and possibly a reversible condition. PRESIDENT McLANE.--The hour is getting late. Dr. Miller would like I(> say a few words in closing on some of the larger problems in gynecology. DR. MILLER.-I am making a plea on behalf of gynecology of the future. As you have listened here tonight you have heard a variety of answers to some of today’s gynecological problems. These replies recalled for me a little star, I heard this summer in Europe about the alumnus who came back to his medical school after an absence of 25 years. He went in to see one of his professors whom he liked and as he walked into the office the professor came in; threw some blue books on the table and as he did so a piece of paper fluttered to the floor. The alumnus picked up the paper and looked at it. He noticed there were typed examination questions on it and he perused them. He begall to recollect that they were exactly the same questions the professor hati asked his class. He commented to the professor on this observation, where upon the professor said, “Yes, the questions are the same but, the answers arch different. ” As time goes on our answers change. I mention this because there are many young gynecologists and obstetzi. cians in this room. The answers of today may have to be changed tomorrow. all of which permits me to raise what 1 believe to be a pertinent questiott. What is the future of gynecology 1 I believe the answer to this question dovalves upon each and every one of us who pract,ices this specialty. It is up to every one of us to see that the frontiers of our specaialty are broadened. We have spent a whole evening on the subject of hysterectomy. Wt. might well do so because it is an important aspect of our work. But hystrrgectomy is only one aspect of gynecology. It seems to me that we as a groul) have narrow sights, that it is time for us to raise our sights. There art’ many t,hings that need to be done. We still do not know how to tb, a really good myomectomy and avoid trouble. In all CilSeS of ectopic pregnancy we take out the tube. Perhaps we c~ould learn how to preserve it. In so-called dysfunctional bleeding we remove the uterus but there may be nothing at all wrong with the uterus. We remove the uterus because we still t3~1 not know how to get at the real fault. We should be working to find the facetors truly responsible. How much time have we spent on the removal ot fibroids ? A great deal, yet is it not about. time we spent. a little effort, I ryill>: to figure out why some of these things occur i! Gynecology has a future but its scope and character will depend a great deal upon our own efforts and the lifting of our sights !