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One hundred thirty-four patients with bulky and barrel-shaped cervix cancers were treated with preoperative radiation to 40-45 Gy, intracavitary therapy using Cs-137 or Cf-252 and extrafascial total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAHBSO) 4-6 weeks after radiotherapy. Outcome of therapy was traced for patients with residual tumor (positive) in the hysterectomy specimen and those who had no residual tumor (negative) in the specimens. All specimens were studied by a set protocol to carefully evaluate the TAHBSO specimen for gross or residual tumor. Ninety-two percent of the patients with negative specimens survived 5 years, but this dropped to 71% if the specimen was positive. These findings were observed in both the Cs-137- and Cf-252-treated patients. Patients with negative specimens failed mainly in distant sites, whereas those with positive specimens failed locally and distantly. Patient survival was less in patients with positive specimens. There was no difference in outcomes for adenocarcinoma and squamous cell carcinomas. The specimen histological findings have predictive value in patients treated with preoperative radiation and surgery.

Seventy-four patients with Stage II endometrial cancer were treated by a combination of preoperative radiation therapy followed by extrafascial hysterectomy, bilateral salpingo-oophorectomy, and paraaortic lymph node sampling at the University of Kentucky Medical Center from 1967 to 1988. All patients had histologically confirmed endometrial cancer with involvement of the endocervix. The cell types and numbers of the tumors treated were as follows: adenocarcinoma, 58; adenoacanthoma, six; adenosquamous carcinoma, nine; and clear cell carcinoma, one. Preoperative radiation consisted of 4500 cGy external therapy followed by one intracavitary implant providing an additional 2000 cGy to point A. Surgery was done 4 to 6 weeks after completion of radiation therapy. Five patients (7.1%) had paraaortic lymph node metastases. Four were treated with extended-field radiation therapy and one with platinum-based combination chemotherapy. After treatment, the patients were followed at regular intervals from 2 to 22 years (mean, 5.4 years). Eleven patients (15%) had recurrent cancer, with the vagina and upper abdomen being the most common sites of spread. The estimated 5-year and 10-year disease-free survival rates of these patients are 88% and 76%, respectively. Cell type, depth of myometrial invasion, and lymph node status were the most important prognostic variables in the patients evaluated. These data confirm that the combination of preoperative radiation therapy and surgery produces excellent long-term survival in patients with Stage II endometrial cancer.

Ultrasonography was performed prior to operation upon 60 patients with tumors of the ovary. This procedure was accurate in differentiating tumors of the ovary from other types of tumors of the pelvis in more than 90 per cent of the patients. Likewise, a determination between benign and malignant lesions of the ovary could be reliably made on the basis of ultrasonic patterns. These findings suggest that ultrasonography should be performed on all patients suspected of having a tumor of the ovary.

Surgical specimens from 111 patients with Stage I endometrial cancer were reviewed for the presence of lymph-vascular space invasion by tumor cells. Lymph-vascular space invasion was noted in 16 cases, and occurred most frequently in poorly differentiated tumors with deep myometrial penetration. Tumor recurrence developed in 44% of patients whose tumors demonstrated lymph-vascular space invasion as opposed to only 2% of patients without this finding (p less than 0.001). Of seven patients with lymph-vascular space invasion who experienced tumor recurrence, five developed extra-pelvic metastases. Discriminant function analysis of these data revealed a statistically significant correlation between lymph-vascular space invasion and tumor recurrence, independent of histologic differentiation of myometrial penetration. These findings suggest that lymph-vascular space invasion by tumor cells is an important prognostic variable in Stage I endometrial cancer which should be considered in treatment planning.

From November 1973 to May 1986, 50 patients with Stage I epithelial ovarian cancer were treated at the University of Kentucky Medical Center (Lexington, KY) with oral Alkeran (melphalan) chemotherapy after primary surgery. Twenty-two patients had Grade 1 tumors, 23 patients had Grade 2 tumors, and five patients had Grade 3 tumors. Patients with ovarian tumors of borderline malignancy were excluded from this study. Twenty-eight patients received from six to 11 courses of chemotherapy and 22 patients completed 12 courses of chemotherapy. Chemotherapy was well tolerated and no patient died of chemotherapy-related complications. Thirty-eight patients underwent second-look laparotomy died of disease 41 months after diagnosis and one patient died with no evidence of disease 6 months after treatment. The actuarial survival of the total group of patients was 98% at 2 years and 94% at 5 years. Fewer than 12 months of chemotherapy may be necessary to obtain long-term survival in these patients.

A trial of Cf-252 for the radiotherapy of primary or recurrent corpus adenocarcinoma was carried out at the University of Kentucky. The patients with primary tumors were of advanced age, poor general medical condition, and had multiple chronic medical illness, poorly differentiated tumors and/or metastatic Stage IVB disease. Fourteen patients with primary tumors were treated and all achieved complete local tumor control. The five year actuarial disease-free survival rate by the Kaplan-Meier method was 100% for Stage I-III disease, although 36% died of other, usually medical, causes. For eight patients treated with recurrent tumors, long term tumor control was 40% four year actuarial disease survival. Local control was 100% for vault recurrences of 3 cm diameter size, but only 6/8 (75%) cleared their pelvic tumors completely. Those that did not had tumors of massive size, distant metastatic disease and adenosquamous or poorly-differentiated (G3) pattern. One additional cut across, infected tumor was controlled for 26 months. Corpus carcinoma was highly sensitive to Cf-252 neutron radiation therapy.

Carcinoembryonic antigen (CEA) levels in plasma and the immunocytochemical detection of tumor CEA were studied in patients with endometrial adenocarcinoma treated at the University of Kentucky Medical Center from 1973 to 1976. The incidence of CEA elevation in a group of 60 patients varied directly with uterine size, histologic differentiation, and stage of disease. Immunoperoxidase staining for CEA was performed on 42 specimens, and four were positive, indicating a tissue concentration of CEA of at least 5 microng per gram. Following operation, CEA levels returned to normal within eight weeks in all but two patients, both of whom were later shown to have persistent or recurrent cancer. These data suggest that serial plasma CEA determinations may be useful in predicting occult recurrence of endometrial cancer in patients in whom the plasma or tumor initially contains elevated concentrations of this antigen.

Pelvic lymph nodes from 80 patients with primary invasive cervical cancer undergoing radical hysterectomy and pelvic lymphadenectomy were evaluated morphologically. Six to 25 (mean 14) lymph nodes from each patient were examined histologically and classified as follows: lymphocyte preominant, germinal center predominant, unstimulated, or lymphocyte depleted. Tumors were classified according to their primary cell type: large cell non-keratinizing, keratinizing squamous cell, small cell, and adenocarcinoma. There was no direct relationship between lymph node morphology and patient age, lesion size, or tumor cell type. A lymphocyte predominant nodal pattern was associated with a statistically significant decrease in lymph node metastases, and tumor recurrence, and an increase in patient survival. In contrast, patients with a lymphocyte depleted nodal pattern had a high incidence of metastatic disease and tumor recurrence, and a decreased survival. Patients with lymph nodes showing an unstimulated or germinal center predominant pattern had an intermediate incidence of nodal metastases and tumor recurrence. These findings suggest that regional lymph nodal morphology may be of prognostic significance in patients with invasive carcinoma of the uterine cervix.