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One hundred and eighty-seven patients with stages I, II and III optimal (metastatic lesions of less than 3 centimeters) epithelial carcinoma of the ovaries were evaluated preoperatively and had standardized exploration and biopsy. The protocol called for examination and biopsy of the peritoneum, diaphragm, omentum, pelvic and para-aortic lymph nodes and aspiration of ascites or peritoneal washings for cytologic examination. Of those patients with metastases to the omentum, the clinical impression did not correlate with pathologic findings in 45 per cent. The findings were similar for diaphragmatic lymph nodes (50 per cent), pelvic lymph nodes (71 per cent) and para-aortic lymph nodes (96 per cent). Nine of 97 patients clinically thought to have stage I disease had the stage elevated to II and III based on pathologic findings. Similarly, 15 patients thought to have stage II were found to have stage III based on histopathologic findings. There were 74 complications in 54 patients, with 29 having at least one complication. Surgical exploration for early stage carcinoma of the ovary should include biopsy of the retroperitoneal pelvic and para-aortic lymph nodes, excision of the infracolic omentum, biopsies of pelvic and abdominal peritoneum, including the right diaphragm, and peritoneal cytologic studies.

Intestinal fistulas and obstruction are the most common and most serious complication of pelvic exenteration for gynecologic cancer. In a series of 58 patients, early intestinal fistulas developed in seven and late fistulas in 13 of the patients. Early fistulas are more commonly secondary to surgical trauma or technical errors and were noted to occur more frequently in patients who had previously undergone irradiation. Late fistulas are usually associated with intestinal obstruction and with a high incidence of recurrent malignant growth. The management of choice for intestinal fistulas following pelvic exenteration appears to be prompt surgical intervention with bypass procedures in preference to intestinal resections. Although several technical modifications have been applied to the exenterative operation with a trend toward a decrease in early obstruction and fistula formation rate, additional technical efforts will be necessary if these problems are to be solved.

Considerable controversy exists in the role of scalene lymph node biopsy in the pretreatment assessment of patients with carcinoma of the cervix uteri. Scalene lymph node biopsy was carried out on ten patients having advanced carcinoma of the cervix uteri with documented para-aortic nodal involvement. Metastatic carcinoma was found in the scalene lymph nodes in five of ten patients. These preliminary findings suggest that excision of scalene lymph nodes should be carried out prior to the institution of therapy in all patients with carcinoma of the cervix uteri which is metastatic to the para-aortic lymph nodes.

During a 12 year period, 102 patients with invasive epidermoid carcinoma of the vulva were treated at the University of Iowa Hospitals and Clinic. The over-all corrected three year survival rate was 65.5 per cent, or 67 of 102 patients. Those treated by radical vulvectomy and bilateral dissection of groin nodes had a three year survival rate of 76.9 per cent, or 40 of 52 patients, while those treated by radiotherapy had a survival rate of 10 per cent, or two of 20 patients. Those with Stage I disease lesions, less than 1 centimeter in diameter, had an excellent survival rate whether they were treated by vulvectomy only or by radical vulvectomy with groin node dissection. Our experience in this selected group of patients would indicate that a degree of individualization in the treatment of early invasive lesions of the vulva can give most satisfactory results.