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The safer birthplace
CORRESPONDENCE
The safer birthplace
had pelvic disease of such magnitude that it could not be sterilized by the conventional radiation doses. I know one of the authors, Dr. Nelson, was an early advocate of pretreatment surgical staging for cervical carcinoma. The artide does not state whether or not the patients reported had surgical staging prior to treatment. We have seen cases which fit the criteria for clinical Stages [ and II barrel lesions with involvement of the lower uterine segment as proved by endometrial biopsy. Exploratory operations were performed in fi\'e of these patients prior to therapy. The results of the pretreatment staging laparotomies are as follows: three patients (two, Stage IB: one, Stage IIB) had microswpically positi\ e para-aortic lymph nodes. The pelvi( nodes ou exploration \\TIT l nn. or less in size. The fourth patient had three peh k nodes on the right side that \\ere greater than 2 ern. in size (2.2. 2.5. and :1..1 t·m.), with negative para-aortk nodes from the bifurcation to the' renal vessels. These large nodes wen: selectively remmed and the beds were dipped. On pathologic examination thev were liJund to be almost total!\' replaced by tumor. '!:he remaining patient (dinical Stage IB disease. had negative para-aortic nodes bilaterallv and no clinically suspicious pelvic nodes. Sh<· had a radical hvsterectomy. pelvic lymphadenectom\·, and bilateral para-aortic lymphadenectomy from the bifurcation to the renal vessels. All margins were free of tumor as KelT the 72 lnnph nodes. She is alive and well without evidence of disease II months af!er treatment. The patiems who did not have surgical exploration had disease clinicallv staged as lB. They received .~.000 rads to the whole pch·is plus :1.460 and 5,810 mg. hours of radium. respectively. with the use of tandems and m·oids. The first patient had exploratory operation 16 weeks after tompletion of radiation therapy and \\as t(nmd to have matted para-aortic nodes as high as the renal 1·essels bilaterally. obviously out of the treatment field. During the course of para-aortic radiation a left supraclavicular node which was positive was detected. The other patient developed right ureteral obstruction three months after treatment. On exploration she had persistent right pehic side-wall disease as well as positive para-aortic nodes to the diaphragm. Both patients arc ali,·e \\ ith widespread metastasis eight and I 0 months after therapy and are undergoing chemotherapy. The treatment failure of these two patients is probablv due to two factors: (I) improper staging. wi1b nwt.astatic disease outside the standard pons for
To the Editon: The prevention aspects of all medical practice arc unquestionably the most important. The recent trend in many instances in the United States, in metropolitan as well as rural areas, for home deliveries of infants has been cited frequentlv in the lay press as well as in medical writings. The decn.:ase in infant and maternal morbidity and mortality rates in modern times reflects not only good prenatal and newborn care but also births being carried out with ample facilities in readiness for anv unforeseen emergency during labor and delivery or immediately thereafter. Fetal distress for various reasons. prolapsed umbilical cords, hemorrhage, and infection are grave problems under the best-equipped surroundings. let alone in the home with little or no help. The important point to remember is that today the ven same unsuspected emergencies can arise as in the davs when an infant and/or expectant mother: were cited ;ts "lost in childbirth." Losses will sure!)' occur if we repeat practices proved long ago to be unsound and unsafe for both the unborn inf
Barrel-shaped cervical carcinoma To tlu' Editors: I have read the article by Dr. Lu and associates on barrel-shaped lesions. in the March 15, 1976, issue, of the JoURNAL, on page 596, with great interest. It is apparent from the pathology reports in the article that the patients who died less than a year after thez·apy either had disease out of the treatment field or 216
The safer birthplace
had pelvic disease of such magnitude that it could not be sterilized by the conventional radiation doses. I know one of the authors, Dr. Nelson, was an early advocate of pretreatment surgical staging for cervical carcinoma. The artide does not state whether or not the patients reported had surgical staging prior to treatment. We have seen cases which fit the criteria for clinical Stages [ and II barrel lesions with involvement of the lower uterine segment as proved by endometrial biopsy. Exploratory operations were performed in fi\'e of these patients prior to therapy. The results of the pretreatment staging laparotomies are as follows: three patients (two, Stage IB: one, Stage IIB) had microswpically positi\ e para-aortic lymph nodes. The pelvi( nodes ou exploration \\TIT l nn. or less in size. The fourth patient had three peh k nodes on the right side that \\ere greater than 2 ern. in size (2.2. 2.5. and :1..1 t·m.), with negative para-aortk nodes from the bifurcation to the' renal vessels. These large nodes wen: selectively remmed and the beds were dipped. On pathologic examination thev were liJund to be almost total!\' replaced by tumor. '!:he remaining patient (dinical Stage IB disease. had negative para-aortic nodes bilaterallv and no clinically suspicious pelvic nodes. Sh<· had a radical hvsterectomy. pelvic lymphadenectom\·, and bilateral para-aortic lymphadenectomy from the bifurcation to the renal vessels. All margins were free of tumor as KelT the 72 lnnph nodes. She is alive and well without evidence of disease II months af!er treatment. The patiems who did not have surgical exploration had disease clinicallv staged as lB. They received .~.000 rads to the whole pch·is plus :1.460 and 5,810 mg. hours of radium. respectively. with the use of tandems and m·oids. The first patient had exploratory operation 16 weeks after tompletion of radiation therapy and \\as t(nmd to have matted para-aortic nodes as high as the renal 1·essels bilaterally. obviously out of the treatment field. During the course of para-aortic radiation a left supraclavicular node which was positive was detected. The other patient developed right ureteral obstruction three months after treatment. On exploration she had persistent right pehic side-wall disease as well as positive para-aortic nodes to the diaphragm. Both patients arc ali,·e \\ ith widespread metastasis eight and I 0 months after therapy and are undergoing chemotherapy. The treatment failure of these two patients is probablv due to two factors: (I) improper staging. wi1b nwt.astatic disease outside the standard pons for
To the Editon: The prevention aspects of all medical practice arc unquestionably the most important. The recent trend in many instances in the United States, in metropolitan as well as rural areas, for home deliveries of infants has been cited frequentlv in the lay press as well as in medical writings. The decn.:ase in infant and maternal morbidity and mortality rates in modern times reflects not only good prenatal and newborn care but also births being carried out with ample facilities in readiness for anv unforeseen emergency during labor and delivery or immediately thereafter. Fetal distress for various reasons. prolapsed umbilical cords, hemorrhage, and infection are grave problems under the best-equipped surroundings. let alone in the home with little or no help. The important point to remember is that today the ven same unsuspected emergencies can arise as in the davs when an infant and/or expectant mother: were cited ;ts "lost in childbirth." Losses will sure!)' occur if we repeat practices proved long ago to be unsound and unsafe for both the unborn inf
Barrel-shaped cervical carcinoma To tlu' Editors: I have read the article by Dr. Lu and associates on barrel-shaped lesions. in the March 15, 1976, issue, of the JoURNAL, on page 596, with great interest. It is apparent from the pathology reports in the article that the patients who died less than a year after thez·apy either had disease out of the treatment field or 216