[Melanoma of the vulva. Report of 12 cases]. / Melanome der Vulva. Bericht über 12 Fälle.

The present retrospective study includes 12 patients with melanoma of the vulva who underwent vulvectomy between 1977 and 1987. Six patients were less than 55 and 6 other patients more than 69 years old. Three women of the younger age group survived (31, 44 and 116 months, respectively), whereas three of them died of the tumour. In the patient group of over 69 years of age 4 patients died of the tumour, one patient did not appear for follow-up and one further patient died in the meantime. Nine patients suffered from deeply infiltrating tumours (Clark levels IV and V), 2 patients had a Clark level II tumour, and in one case the Clark level was unknown. Depth of infiltration correlated with the prognosis of disease, i.e. only one patient with deep tumour infiltration, but both patients with Clark level II tumours survived. Therefore, the importance of early diagnosis of melanoma of the vulva should be emphasized, and accurate inspection of the vulva should be indispensable in the course of routine gynaecological examination also in younger women.

[Recurrence of stage I endometrial cancer: effect of prognostic factors on therapeutic results]. / Rezidive des Endometriumkarzinoms im Stadium I: Einfluss von Prognosefaktoren auf das Therapieergebnis.

Endometrial carcinoma is the most common gynaecological invasive cancer. Since its incidence is increasing, more patients will develop recurrent disease. In an attempt to identify possible prognostic factors associated with survival, we reviewed the results of 45 patients treated in our department for recurrent clinical stage I endometrial carcinoma. All patients received primary therapy consisting of surgical resection. 16 patients developed recurrent disease after initial operative treatment and adjuvant radiotherapy. The minimum follow-up of 3 years was available in 43 patients and the actual 3-year survival rate was estimated 42% (median 16 months). Significant prognostic factors were recurrence site--vagina, 51% (17/33 pts) vs extravaginal, 20% (2/10 pts) (p = 0.01), and histological cell type--non-papillary carcinoma, 50% (17/34 pts) vs papillary adenocarcinoma, 22% (2/9 pts) (p = 0.02). Late recurrences have been reported to carry a better prognosis, than those that recur early. In the present study, time of onset did not appear to be a significant factor--recurrence occurs within 24 months, 36% (9/25 pts) vs recurrence appearing after 2 years, 55% (10/18 pts). We suggest, that systemic therapy should be prospectively evaluated in high-risk patients. Selected patients with recurrent disease--cases of non-papillary histological cell type and vaginal recurrence--can be cured by radiotherapy.

[Radiotherapy of primary vaginal carcinoma and effects of histological and clinical factors on the prognosis]. / Die Strahlentherapie des primären Vaginalkarzinoms und der Einfluss histologischer und klinischer Faktoren auf die Prognose.

434 cases of primary vaginal carcinoma were treated from 1950 to 1984 at the Irradiation Department of the University Clinic for Obstetrics and Gynecology, Vienna. The five-year survival rate for various clinical stages is as follows: Stage I 76.7%, stage II 44.5%, stage III 31%, stage IV 18.2%. In this retrospective study 110 patients seen from 1975 to 1984 were reviewed in detail and evaluated with a view toward their clinical and morphological aspects and survival rates. Patients up to the age of 60 have a five-year survival rate of 50%, those over 75 years of age reach only 34.3%. If the carcinoma was discovered in a routine check up the survival rate is 61.1%, whereas in cases with symptoms the rate decreases to 36.9%. Survival differences were also observed for patients with a carcinoma in the upper third of the vagina (61.1%) versus patients with a carcinoma in the lower third (33.3%); for patients with well-differentiated tumours (62.5%) versus patients with grades II and III (41.5% and 34.9%). It can be seen, that with brachytherapy local control of the carcinoma can be achieved with excellent results in early stages. Treatment of patients with more advanced carcinomas should include external beam therapy. The importance of gynecological screening especially for older women is emphasized.

[The significance of primary radiotherapy in gynecological carcinoma. An account of 40 years]. / Die Bedeutung der primären Strahlentherapie bei gynäkologischen Karzinomen. Ein Rechenschaftsbericht über 40 jahre.

The Department of Gynecological Radiotherapy of the University of Vienna is headed since 40 years by Prof. Dr. Karl Weghaupt. In this time about 25,000 cancer cases were treated, 12,000 of them by radiation alone. Local therapy was performed by conventional Radium-226 irradiation, which has to be replaced by remote afterloading technique. Therapy modalities have not been changed and therefore an extraordinary high number of cases is available for 5 year survival rates. Results of new radiologic techniques will have to be compared to these fundamental data. Due to radioprotective regulations replacement of Radium-226 is necessary but there will not take place any change in treatment politics in cases of vulvar carcinoma.

[Value of irradiation alone of generally inoperable endometrial cancer with high dose rate iridium 192]. / Zum Wert der alleinigen Bestrahlung des allgemein inoperablen Endometriumkarzinoms mittels High-Dose-Rate-Iridium-192.

Surgery should be an integral part of the management of the patient suffering from endometrial cancer. Only patients with severe internal diseases should be treated with radiation therapy alone. Although radiation therapy alone can cure endometrial cancer, the survival figures are poorer than for the operation. At the University of Vienna (1st Department of Gynaecology), 267 patients with endometrial cancer were treated by radiation therapy alone (Afterloading iridium192 technique). 5-year survival (life table method) for all patients was 65.2%. In stage I, 5-year survival was 66.9%, and in stage II 46.7%, respectively. For up to 69 years of age the survival was 76.6%, for 70 years and more 61.8%, for grading I 78.8%, for grading II and III only 55.4%, respectively. With radium226 technique, the survival rate was only 56%, while 65.2% were reached with the Iridium technique. All differences are significant. External irradiation (cobalt60) was employed as combined treatment in only 9.4% of the cases. Intrauterine and intravaginal applications were performed without anaesthesia and the hospitalisation time was only one day per week. The relapse rate in stage I/b was 14.8% and in stage II 30%, respectively. Therefore, the dose of intracavitary treatment should be changed and external irradiation used more often.

Benefit of external irradiation in pathologic stage I endometrial carcinoma: a prospective clinical trial of 605 patients who received postoperative vaginal irradiation and additional pelvic irradiation in the presence of unfavorable prognostic factors.

Six hundred and five cases of endometrial carcinoma, pathologic stage I, without definable extrauterine disease were initially treated with total abdominal hysterectomy and bilateral salpingo-oophorectomy, followed by high-dose-rate iridium-192 irradiation of the vagina. External irradiation of the pelvis was performed only for patients with poor prognostic factors. Five-year survival was calculated by the product-limit method of Kaplan and Meier. Three hundred and forty-eight patients with tumor invasion of the inner third, of any tumor grade, received postoperative vaginal irradiation only. Twenty-eight patients with grade 1 tumor invasion of the middle third received vaginal irradiation only. One hundred and six patients with grade 2 or 3 tumor and infiltration of the middle third received vaginal and external irradiation of the pelvis. One hundred and twenty-three patients with deep muscle invasion of the external third of the myometrium received vaginal and pelvic irradiation. Differences in survival figures were not significant. Survival of the treatment group with good prognosis who received vaginal irradiation alone (91%) was similar to that of the group with poor prognosis who received additional pelvic irradiation (87.7%). Despite the unfavorable situation of patients with poor prognostic factors, treatment results after additional external irradiation were relatively equal to the results for patients with good prognostic factors who had not received external irradiation. Therefore, the benefit of external irradiation in patients with stage I endometrial carcinoma with unfavorable prognostic factors seems evident.

[Effect of inguinal lymph node irradiation on the treatment result of vulvar cancer with different risk factors]. / Zum Einfluss der inguinalen Lymphknotenbestrahlung auf das Behandlungsergebnis beim Vulvakarzinom mit unterschiedlichen Risikofaktoren.

The clinical data from 101 patients with invasive squamous cell cancers of the vulva with less than 10 mm stromal invasion in depth, treated between 1972 and 1983, were studied. 43 of these patients underwent merely a radical vulvectomy, the remaining 58 patients underwent a combination therapy of vulvectomy and irradiation of inguinal lymph nodes. Although the majority of risk factors, like clinically suspicious nodes, stromal invasion of more than 5 mm, tumour expansion of more than 2 cm and clitoral location, occurred more frequently (p<0,001) in the combination therapy group. There was no statistical significance in the five-year survival rate between our two therapy groups (88,4% versus 79,3%). In stage I and II cases inguinal relapses occurred in the group with vulvectomy alone in 9.3%, in the group with adjuvant external irradiation of the inguinal fields in 2.6%. We believe, the data presented show the important role of radiotherapy of inguinal nodes in the curative management of vulvar cancer.

[Risk factors in stage I squamous cell epithelial cancer of the vulva and their effect on results of therapy]. / Risikofaktoren beim Plattenepithelkarzinom der Vulva im Stadium I und ihr Einfluss auf das Therapieergebnis.

A total of 113 cases of carcinoma of the vulva, stage I, were retrospectively (1972-1983) evaluated with respect to the clinical and morphological findings. 14 of the patients developed a recurrence. The five-year period survival rate was 84.9% and the corrected survival rate was 92.5%. 79 of these patients underwent radical vulvectomy only. The other 34 patients received combination therapy of vulvectomy and irradiation of the inguinal lymph nodes. Our surgical technique of using the warm knife and open-wound technique in combination with radiotherapy applied only to the inguinal lymph nodes gives excellent results without the complications associated with aggressive surgery.

[The value of postoperative irradiation in endometrial cancer of pathohistologic stage I]. / Zum Wert der postoperativen Bestrahlung beim Endometriumkarzinom im pathohistologischen Stadium I.

In a prospective therapeutic study, 571 cases of endometrial cancer in pathological stage I were treated initially with total hysterectomy and received 6 weeks after surgery double high-dose-rate iridium 192 irradiation of the vagina (afterloading technique). The single dose was 700 cGY (at 2 cm distance from the applicator axis). Postoperative treatment planning was based on the prognosticators of depth of myometrial invasion and tumor grading with subtypes. External irradiation was prescribed only for patients with poor prognostic factors (Cobalt-60,5600 cGY on the pelvis wall, 30 fractions). At the time of this report, the patients had been followed up for 6 to 96 months after their original therapy. Survival was calculated by the life table method. 327 cases with slight tumor infiltration, independent of the tumor morphology, received postoperative vaginal irradiation only. Survival rate was 90.6%. 27 cases with tumor infiltration of the middle third of the myometrium and grade 1 tumors, received also only vaginal irradiation. Survival rate was 100%. 101 cases with tumor infiltration of the middle third of the myometrium and grade 2 and 3 tumors, received vaginal irradiation plus external irradiation. Survival rate was 89.9%. 116 cases with tumor infiltration of the external third of the mymetrium and any tumor grade, received vaginal irradiation plus also external irradiation. In these patients with poor prognosis, the survival rate was 85%. Differences between groups are not significant. Considering the treatment group with good prognosis and the group with poorer prognosis and the additional external irradiation, the survival figures were quite similar (90.6% and 87.9% respectively). In spite of the unfavorable situation of patients with poor prognosticators, treatment results after the additional external irradiation were rather similar to those cases with good prognosticators and without external irradiation. The value of external irradiation in cases of endometrial cancer in stage I with unfavorable prognosticators seems to be quite clear. This therapy improvement was all the better, because side effects of external irradiation were low (0.2% rectovaginal fistulas) and in case of irradiation of the vagina only, no severe side effects occurred. Relapse rate for the treatment group with good prognosis and vaginal irradiation only was 0.6% (2 from 354) and for the group with poor prognosis and additional external irradiation 2.8% (6 from 217) respectively.

[Results of electrosurgical vulvectomy with postoperative irradiation of the inguinal lymph nodes in vulvar cancer]. / Ergebnisse der elektrochirurgischen Vulvektomie mit postoperativer Bestrahlung der Inguinallymphknoten beim Vulvakarzinom.

Clinical data on 669 patients with invasive squamous cell carcinoma of the vulva were seen between 1952 and 1982. All of these patients were available for 5-year evaluation. The crude survival for these patients was 62%, and the "cleaned" 5-year survival for 585 patients was 70%. All patients were treated with radical vulvectomy using the warm knife and open-wound technique. Treatment of the regional lymph nodes was performed by irradiation alone. This simple surgical technique in combination with radiotherapy applied only to the inguinal lymph nodes gives an excellent result without the complications associated with aggressive surgery.

[Postoperative irradiation of carcinoma of the corpus uteri using the iridium afterloading technic]. / Die postoperative Bestrahlung des Carcinoma corporis uteri mit der Iridium-Afterloading-Technik.

From 1981 to 1986 a prospective study was conducted of University of Vienna, 1st gynecology department, for 708 patients with operated and postoperatively irradiated endometrial cancer. These patients were treated by total hysterectomy, bilateral salpingo-oophorectomy and postoperative vaginal irradiation with high-dose-afterloading (iridium 192). A percutaneous irradiation (cobalt 60) was done in stage I cases only when myometrial infiltration was deep. Highly differentiated tumors with infiltration of the first and second third of the myometrium were treated by vaginal irradiation alone. Poorly differentiated tumors (G2, G3) with infiltration of the second and third third of the myometrium were treated by vaginal and percutaneous irradiation. A group of 125 cases with good prognosis (infiltration 1/3, G1) and with postoperative vaginal irradiation alone had the same five-year-survival of 83% as a group of 152 cases with bad prognosis (infiltration 2/3 and 3/3, G2 or G3) treated by vaginal and percutaneous irradiation. This result shows clearly the importance of additional irradiation of the pelvis in cases with bad prognosis factors. The incidence of radiation side effect in all 708 cases was: cystitis 4.6%, proctitis 5.2%, vaginal or rectal ulcers 1.4% and fistulas 0.2%. Cases with vaginal irradiation alone and with the optimal intravaginal fraction dose of 700 cGy (twice) had the lowest level of side effects: cystitis 3.8%, proctitis 2.1%, vaginal necrosis 0.7%, no further severe complications. None of the patients with postoperative vaginal irradiation alone had a vaginal recurrence. The incidence of recurrences in 708 patients was 1.6%. All recurrence cases in stage I (0.7%) had bad prognosis factors and were treated with vaginal and percutaneous irradiation. It is concluded that primary surgery of endometrial cancer should be followed by postoperative vaginal radiation. It appears that the remote afterloading treatment for vaginal radiation produces minimally complications and gives complete protection from radiation exposure to the medical staff. With additional external radiation in high-risk cases the same good result can be achieved as in cases with low-risk and vaginal radiation alone.

[Treatment of inoperable endometrial carcinoma with intracavitary high-dose rate iridium irradiation]. / Die Behandlung des inoperablen Endometriumkarzinoms mittels intrakavitärer High-dose-rate-Iridium-Bestrahlung.

Surgery should be an integral part of the management of the patient with endometrial cancer. Only patients with severe medical conditions should be treated with radiation therapy alone. Although radiation therapy alone often can cure endometrial cancer, five-year-survival figures are poorer than for operation. At the University of Vienna, I. Department of Gynecology, 198 patients with endometrial cancer were treated by radiation therapy alone. Using the afterloading-iridium-192-technique, the three-year-survival-rate was 76%, five-year-survival 60%. A comparable group of 185 cases treated by intracavitary radium-226 had five-year-survival of only 40% (p less than 0.001). With afterloading high-dose irradiation younger patients had five-year-survival of 75%, older patients (70 years and more) 51%; when tumor grading was one survival figures reached 76%, with tumor grading 2 and 3 only 41%. Severe radiation side effects did not occur with the optimal intrauterine single dose of 850 cGy (four times) and 700 cGy intravaginal (once), nor could any severe complications be observed when the total rectal dose did not exceed 500 cGy. In only 8% of the cases the treatment was combined with external irradiation (Cobalt-60). Intrauterine and intravaginal applications were performed without anaesthesia and the hospitalisation time was very short.

The electrosurgical operation of vulvar carcinoma with postoperative irradiation of inguinal lymph nodes.

The results of treatment in the department of 607 patients with invasive squamous cell carcinoma of the vulva between 1952 and 1980 is described and analyzed. The absolute 5-year cure rate in these patients was 60.3%. Particular attention was given to lymph node status (TNM system) in the analysis of the last 141 patients treated. The absolute 5-year survival rate was 67% for the N0-N1 patients and 43% for the N2-N3 patients. Patients were treated uniformly by means of electrosurgical operation and postactinic irradiation of the inguinal lymph nodes. Operative lymphadenectomy was performed only in 5% of cases when the diameter of inguinal lymph nodes was greater than 2 cm. This simple surgical technique, in combination with irradiation of inguinal lymph nodes, gives excellent results and avoids the complications associated with inguinofemoral lymphadenectomy. Owing to its combination of electrosurgical operation of the vulva and irradiation of the inguinal regions as a standard procedure, the treatment involves extremely low strain on the patient and is almost free of complications. This seems to be particularly important as the results of our treatment are not less satisfactory than those of more aggressive procedures.

The influence of nicotine abuse and diabetes mellitus on the results of primary irradiation in the treatment of carcinoma of the cervix.

References in the literature to the frequent occurrence of cervix carcinoma accompanied by nicotine abuse led us to investigate the effects of cigarette smoking on the results of treatment in primary irradiation of cervix carcinoma. As not only nicotine abuse but also diabetes mellitus can lead to angiopathy, we also investigated the influence of diabetes mellitus on the results of treatment. Of 410 nonsmokers with carcinoma of the cervix in Stages I and II, 260 (63.4%) reached the 5-year limit, but only 62 of 115 smokers survived (53.9%). In Stages III and IV there were significantly less favorable rates of cure in patients with nicotine abuse. Of 626 nonsmokers with cervix carcinoma in Stages III and IV, 212 survived (33.9%); but of 153 smokers, only 31 (20.1%) could be cured (P less than 0.01). The frequency of side effects of primary irradiation was distinctly higher in smokers than in nonsmokers. Reversible complications occurred in 17.5% of the smokers and 15.5% of the nonsmokers. Severe irreversible changes occurred in 28% of the smokers versus 15.2% of the comparative group of nonsmokers (P less than 0.01). The injuries caused by smoking not only reduce the biologic effectiveness of ionizing radiation but also increase the rate of side effects due to the deficient capacity for regeneration of the tissue surrounding the tumor. With diabetes as a complication, however, no significant changes in frequency of side effects were noted. Five-year survival in diabetic patients was affected in Stage I and II, but not in the advanced stages.

[Prognosis of primary radiotherapy of cervix cancer in younger females]. / Zur Prognose der primären Strahlentherapie des Zervixkarzinoms bei jüngeren Frauen.

Between 1970 and 1979 202 women of 40 years of age or younger were treated for invasive cervical cancer at the 1st Department of Obstetrics and Gynaecology of the University of Vienna. 77 patients received primary irradiation therapy (radium and cobalt-60), 125 underwent surgery. These cases were compared with 1586 patients of all ages who received primary radiation therapy. Of the women under 40 receiving only radiation therapy, the survivors were divided into the following categories: stage I:84.6% of 13 cases stage II:69.2% of 13 cases stage III:35.1% of 37 cases stage IV: 0% of 14 cases. The survival rate for all age groups receiving primary radiation therapy was: stage I:76.0% of 225 cases stage II:52.9% of 429 cases stage III:42.9% of 801 cases stage IV:11.4% of 131 cases. There was no significant difference in the 5-year survival rate between the older and younger women. However, a more promising trend for the younger women receiving primary radiation therapy may be expected. The younger women were observed to have irreversible complications (fistulas) at a rate of 7.7%, whereas the rate of comparable patients receiving radiation therapy was 0.6%. The younger women having stage III and IV cancer were found to develop fistulas at a rate of 17.6%, while both groups together had a rate of only 3.2%. Hence, primary radiation therapy for younger women must be considered as involving a relatively high rate of complications. For younger women with stage I cancer the survival rate after radical surgery was 88.8% (98 cases), after radiation therapy 84.6.(ABSTRACT TRUNCATED AT 250 WORDS)

[Does radiosterilization of the vagina occur through therapeutic radiation dosages?]. / Gibt es eine Radiosterilisation der Vagina durch therapeutische Strahlendosen?

The endogenous genital flora is a major source of infections of the female genital tract, especially in patients with cervical or endometrial cancer. Until recently the "radiosterilisation of the vagina", respectively a prophylactic and/or therapeutic effect of irradiation (external high voltage as well as intracavitary-radium) concerning infections was postulated in the literature. This theory was disproved in a prospective clinical and bacteriological study covering 48 patients with advanced cervical cancer undergoing primary intracavitary radium-irradiation and 38 patients with inoperable endometrical cancer, undergoing primary Iridium-192-afterloading. Following intracavitary radium for cervical cancer some typical nosocomial pathogens like Streptococcus faecalis, Enterobacter, Klebsiella, Proteus and Pseudomonas were isolated significantly more frequently than before treatment. Likewise, the mean number of aerobic bacterial species increased significantly after irradiation. Also primary Ir-192 (afterloading) irradiation did not alter the frequency of isolation of the resident flora in endometrial cancer patients. Therefore, "radiosterilisation" of the vagina as result of radiotherapy does not exist.

[Afterloading short-term irradiation of the vagina following radical surgery of uterine cancer]. / Die Afterloading-Kurzzeitbestrahlung der Scheide nach Radikaloperation des Korpuskarzinoms.

A report is given of results and complications following postoperative irradiation in endometrial carcinoma via monitored high-dose afterloading therapy (iridium 192). Intravaginal irradiation was performed in all operated cases. In advanced cases or in cases with poor prognosis (deep infiltration of the myometrium, tumour grading 1-2) percutaneous irradiation (cobalt 60) was employed additionally. 327 patients with endometrial carcinoma were treated by postoperative irradiation between 1981 to 1985 and could then be followed up for at least 12 months to 5 years. Evaluation was done with regard to recurrence-free survival rate and side effects. With the postoperative afterloading iridium 192 technique, the 3-year recurrence-free rates were 91% in stage I and 78% in advanced stages. All of the patients in stage I with a control time of 5 years survived. The incidence of radiation side effects in the overall group was: cystitis 4%, proctitis 7% and fistulas 0.6%. No further severe complications occurred with the optimal intravaginal fraction dose of 700 cGy (twice). The afterloading therapy with high dose rates and remote control monitoring reduces the risk of radiation exposure of the medical staff and also places less strain on the patients because of the short-term irradiation. Intravaginal applications were performed without anaesthesia or any drugs, and treatment on an outpatient basis was possible in almost all of the cases.

[Electrosurgical radical operation of vulvar cancer with postoperative irradiation of the inguinal lymph nodes]. / Die elektrochirurgische Radikaloperation des Vulvakarzinoms mit postoperativer Bestrahlung der Inguinallymphknoten.

Clinical data on 607 patients with invasive squamous cell carcinoma of the vulva seen between 1952-1980 are reported. All of these patients were eligible for 5-year evaluation. The crude survival for these patients was 60.3%, and the cleaned 5-year survival for 530 patients was 69% (stage I [n = 158]: 87.3%, stage II [n = 118]: 83%, stage III [n = 182]: 66.5%, stage IV [n = 72]: 12.5%). A series of 141 patients with vulvar squamous cell carcinoma was analysed with regard to treatment of the inguinal lymph nodes. Crude survival for N0-N1 patients was 67%, for N2-N3 cases 43%. All patients were treated with radical vulvectomy using warm knife and open wound technique. Treatment of the regional lymph nodes was performed by irradiation alone. This simple surgical technique in combination with radiotherapy applied only to the inguinal lymph nodes gives an excellent result without complications associated with aggressive surgery. Lymph node dissection was performed in 5% of cases only, if lymph nodes were more than 2 cm. The combination therapy of electrosurgery and irradiation of the inguinal lymph nodes and renunciation of groin dissection gave rise to few complications only. This factor must be interpreted as very important, in particular since our 5-year survival rate compared with other reports was not low and the median age of our patients was very high.