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The increase in gynecologic surgery for groups of risk patients, who, heretofore, have been considered as inoperable, forces us to systematize our procedures by estimating the surgical risk. The general surgical risk was high in 158 patients (10%). None of these patients died as a result of surgery. Suggestions were made, based on our own experience, for the extent of preoperative diagnostics, and for the form of the classification and estimation of risks. The improved possibilities for surgery can be extended to high-risk groups only when the existing risks are correctly estimated.

Metrium seen from 1969 to 1973 are reported. These results were compared to the results of treatment of carcinoma of the endometrium at the same institution between 1944 and 1960. There was a considerable increase of the mean age of the patients. Consequently the operability was reduced to 74.3%. The necessity to resort to primary radiotherapy rose to 25.7%. Diseases of old age were contra-indications to operative treatment. In cases generally fit for operation the contra-indications to vaginal surgery increased. Vaginal hysterectomy was therefore only employed in 78.5% of the operations. An individualization of the treatment of carcinoma of the endometrium is recommended. Continually good or improved results of the treatment are expected by individualization in the group of patients which already showed impaired health by age or concomittant diseases.

Lymphocyte preparations obtained from peripheral blood of 36 healthy pregnancy women during the last 4 weeks of gestation were tested for various cell surface markers (E-, EA- EAC-rosettes, surface Ig positive cells). 29 healthy, non-pregnant age matched women served as controls. The cell surface marker analysis did not show significantly different results in the two groups tested except diminished percentages of EA-rosettes in the pregnancy group. EA-rosettes-forming cells (Fc-receptor positive cells) are known to the effectors of spontaneous and antibody dependent lymphocytotoxicity. Therefore, slightly depressed lymphocytotoxicity may be expected during late pregnancy.

A review is presented on 520 patients who had biopsies of the breast which did not show cancer between 1972-1974. These patients are compared to 304 patients whose biopsies definitely showed cancer of the breast and 520 patients who came to the hospital because of well defined gynaecological disease such as uterine fibroids or uterine prolapse. Comparison of these groups regarding age, past history, indications for the biopsy showed that patients with a biopsy without proof of cancer are difficult to follow for diagnosis. Follow-up on these patients is difficult, however, it is important since up to 4% of these patients with previous negative biopsies later have cancer of the breast. A decrease of biopsies in favor of non-surgical diagnosis of breast lesions can only be recommended under optimal conditions. Under other circumstances the risk of cancer of the breast is high enough to justify a liberal indication for breast biopsies.

The management of 63 carcinomas in situ of the breast is reviewed. These 63 carcinomas in situ occurred among 575 carcinomas of the breast from 1969 to 1973. The treatment consisted of simple mastectomy. In cases of early invasion the axilla was explored by palpation of the adipose tissue for enlarged lymph nodes. None were found and no extirpation of the axillary nodes was carried out. Of 59 patients with carcinoma in situ of the breast, 3 later had a local recurrence. Two patients later died of distant metastases. In view of these inadequate results of simple mastectomy it is recommended that a modified radical mastectomy should also be done in all cases of carcinoma in situ of the breast.

The results of treatment of carcinoma in situ of the uterine cervix in 380 patients seen between January 1, 1966 and December 31, 1973 are reported. There were 134 women age 40 or less. There were 246 patients age 40 or older. In 334 patients a total hysterectomy with removal of a vaginal cuff was carried out (87.9%). A large therapeutic cone biopsy was done in 46 patients (12.1%). In the 334 patients treated by hysterectomy, 2 recurrent carcinomas in situ of the vaginal vault were observed (0.6%). In 16 of the cases treated by conization later suspicious colposcopic and/or cytologic findings made hysterectomy necessary. In 5 of these cases a recurrent carcinoma in situ was likely. The postoperative morbidity after total hysterectomy was low. There was no postoperative death. The total vaginal hysterectomy with removal of a vaginal cuff is recommended as treatment for carcinoma in situ of the uterine cervix in order to avoid the diagnostic difficulties in the follow-up after treatment by conization and because of the low recurrence rate after hysterectomy. Conservative treatment should only be employed in patients who desire later child bearing. tthe psychological stresses of the continually required follow-up examinations after conization should not be underestimated.

The results of diminution mammoplasties are reported. From 1972 to 1974, 70 diminution mammoplasties according to Strömbeck were carried out. Indication for the operation was hypertrophy of the breasts with side effects of morbid value. In 47 patients side effects of the body posture were the leading indication. In 23 patients, psychosocial problems were the indication. Only patients with side effects of morbid value were considered to be sufficiently motivated to tolerate the total stress of the operation and the possible post-operative complications. The technical problems of the operation and the post-operative complications are described. 43 patients were followed up at least one year after the operation. In 36 patients the pre-operative complaints were alleviated by the operation. In 7 patients there was improvement. No patient had continuing pre-operative complaints. The mentally depressed and physically and psychologically in their relationship to their environment handicapped patients became usually more satisfied by the operation. Diminution mammoplasties are recommended for the operative treatment of hypertrophy of the breast with side effects of morbid value.

The operative treatment of high risk patients is of increasing importance in gynaecology. The preoperative preventive treatment of latent general problems is an important tool in the prevention of intraoperative and postoperative complications. The experience of the department for gynaecology in Hanover, Germany, during 1976 is reported. Among 1583 major operations 158 were carried out on patients in the risk class III. Guidelines are described for the preventive treatment of cardiac, bronchopulmonary, hypertensive and diabetic risks. The importance of obesity and advanced age is discussed in our cases.

Between 1966 and 1969, 494 patients with carcinoma of the uterine cervix stages I a to IV were admitted in our hospital for primary treatment. In 420 of these patients with carcinoma of the cervix stage I b to IV, complete results of bilateral pretreatment pelvic lymphography are available. The correlation between the results of the lymphographies, the choice of the operative treatment and the cure rates in these 420 cases are reported. All the correlations between the results of the pretreatment lymphography and the prognosis are described. A positive lymphography was in our series of high prognostic value. A plea is therefore made to include the results of the pretreatment lymphography into the classification of carcinoma of the cervix. Classification of the carcinoma of the cervix into the TNM categories is desirable. Our series is reported in these TNM categories. The advantages of such classification are described. The morbid entity of carcinoma of the cervix becomes more transparent to the observer and the choice of operative therapy becomes easier. The prognosis is more clearly established. The proposals of the TNM committee of the UICC for the classification of carcinoma of the cervix according to the TNM categories and the staging according to these categories are discussed critically.

Intravenously administered IgG anti-D permits a prophylatic rhesus sensitization. The size of the dose of immunoglobulin is adapted to the fetomaternal blood transfusion. The procedure is highly reliable in individual cases. The results acquired from a large control group, however, are not significantly better than the results obtained by other authors with intramuscular administration of IgG anti-D. Of the 1216 rh-negative mothers who were given follow-up checks, 1208 showed no active D-antibody formation as late as 7 months postpartum. An active D-antibody formation was found in 8 rh-negative mothers up to 14 days postpartum. These were anamnestic reactions. In 212 second pregnancies with a rh-postive child, 2 rh-negative mothers were sensitized in the rhesus system. The cause of this failure is thought to be the fact that the intravenously administered IgG anti-D did not gain access to the noncirculating D-positive erythrocytes in the pertioneal cavity of the mother.