Surgical treatment of patients with stages IB and IIA carcinoma of the cervix and palpably positive pelvic lymph nodes.

Review of the records of all patients undergoing radical hysterectomy for cervical cancer at our institution between 1956 and 1985 revealed 121 patients with stage IB or IIA lesions and metastasis to pelvic lymph nodes. A uniform part of our surgical practice is to record the findings from visual and palpatory examinations of the intra-abdominal and retroperitoneal structures at the beginning of the operative report. This information was available for 117 of 121 patients. Of these 117 patients, 51 (44%) had pelvic lymph nodes palpably involved with metastatic malignant disease at the time of exploration. The Kaplan-Meier estimate of 5-year disease-free survival for this group was 40% (median follow-up of disease-free patients was 20.5 years). Adjuvant pelvic radiotherapy was received by 29 of the 51 patients. The remaining 22 patients received no adjuvant treatment. Information on the sites of recurrence was available for 30 of 32 patients who had recurrence. The site of first recurrence included an extrapelvic component in 22 of the 30 (73%). Disease-free survival rates for these patients reflect the advanced nature of their tumors. In light of our experience and our current understanding of the relationship between radiotherapy dose, tumor volume, and efficacy, we regard the assertion that primary radiotherapy is preferable to surgery in this population to be counterintuitive, and we await with interest data demonstrating that disease-free survival with approaches that involve leaving macroscopic tumor on the pelvic sidewall is superior to that noted above.

Identification of a low-risk subset of patients with stage IB invasive squamous cancer of the cervix possibly suited to less radical surgical treatment.

Because of the well-documented morbidity of radical hysterectomy, it would appear desirable to isolate a subset of patients at low risk of parametrial spread or disease recurrence who might thereby be candidates for less radical surgical therapy. To this end, the records of all patients undergoing radical hysterectomy for cervical carcinoma at our institution between 1956 and 1985 were reviewed. Of the 387 patients treated for squamous carcinoma clinically confined to the cervix, 83 (21.4%) had tumors with depth of invasion greater than 3 mm (stage IB) but volume of tumor less than or equal to that of a sphere 2 cm in diameter (4.19 cm3) and no tumor in angiolymphatic spaces. Of the 83 patients, none had parametrial nodal metastasis. Median follow-up of this subgroup was 9.8 years, and the Kaplan-Meier estimate of 5-year disease-free survival was 97.6% (95% confidence interval, 94.3-100%). We consider patients in the subset described above to be candidates for modified radical hysterectomy and pelvic lymphadenectomy, with a decrease in morbidity associated with the less radical dissection, a low risk of failure to excise occult parametrial tumor, and the expectation of an excellent chance of long-term disease-free survival.

Mucous membrane plasmacytosis of the upper aerodigestive tract. A clinicopathologic study.

We report 9 patients with an unusual plasma cell proliferative disorder of the upper aerodigestive tract. Six patients were men and three, women. The age at presentation ranged from 40 to 67 years with a mean of 54 years. Symptoms at presentation included dysphonia, dysphagia, difficulty breathing, and oral pain. These plasma cell lesions typically produced a cobblestone or warty appearance of the upper aerodigestive tract mucosa including the larynx, pharynx, palate, lips, mouth, tongue, and trachea in varying combination of multiple sites in each patient. Histologically, all lesions were characterized by psoriasiform epithelial hyperplasia with dyskeratosis and dense subepithelial plasmacytosis. Plasma cells were mature but so expansive and diffuse in infiltration as to suggest extramedullary plasmacytoma. Immunohistochemistry for kappa and lambda light chain showed polyclonal immunoglobulin content in all cases examined. Microbial cultures and Warthin-Starry stains were negative for organisms. A variety of treatments including antibiotic therapy, corticosteroid administration, and surgical resection were unsuccessful. In two patients, the process required tracheostomy. This disorder has not been previously described with the exception of a single reported case, which is included in this series. The etiology, pathogenesis, and successful management of mucous membrane plasmacytosis remain unknown.

Long-term survival and sequelae after surgical management of invasive cervical carcinoma diagnosed at the time of simple hysterectomy.

From 1956 to 1988, 27 women (median age, 60 years) found to have occult invasive carcinoma of the cervix at total hysterectomy underwent radical reoperation consisting of radical parametriectomy, upper vaginectomy, and pelvic lymphadenectomy. Residual disease was present at reexploration in 4 (15%) of the 27 patients: in the pelvic lymph nodes in 2, in the parametrium in 1, and in the vagina and a para-aortic node in 1. All patients were followed a minimum of 18 months; there were no deaths within 3 months of operation. However, 2 (7%) of the 27 patients developed ureterovaginal fistulas. Recurrent disease was observed in 6 (22%) of the patients: 2 had successful salvage procedures, and 4 died of disease, all within 4 years of reoperation. Recurrence correlated with the presence of residual disease at reoperation and with nonsquamous histologic findings. At a median follow-up of 8.4 years, 23 of the 27 patients were alive and disease-free. The 5-year absolute survival estimate (Kaplan-Meier) was 82%. Radical reoperation can be performed safely in selected patients who have early-stage invasive carcinoma of the cervix at the time of total hysterectomy with the expectation of an acceptable rate of long-term disease-free survival.

Wertheim hysterectomy in the geriatric population.

A series of 38 patients 65 years of age or older who underwent Wertheim hysterectomy for primary treatment of stages IB and IIA (FIGO) carcinoma of the cervix is reported. There were no ureteral fistulas and no perioperative mortality, but 4 of the patients required reoperation. A control population of 320 patients less than age 65 was identified who had been treated in the same fashion and who resembled the older group in regard to stage, histologic features, grade, and incidence of pelvic nodal metastasis. Transfusion requirements and incidence of postoperative lower extremity edema were similar between groups. Febrile morbidity was less frequent in the geriatric group (P = 0.03) but postoperative small bowel obstruction (P = 0.01), bladder dysfunction (P = 0.06), and pulmonary emboli were more frequent (P = 0.11). Five-year cancer-specific Kaplan-Meier survival estimates were 84 and 85% for the geriatric and younger patient populations, respectively.