Bladder or rectal injury following radiation therapy for cervical cancer

A visualization analysis of hotspots and global trends on pelvic floor dysfunction in cervical cancer

BACKGROUND/OBJECTIVE

Cervical cancer is the major cause of cancer-related mortalities in women globally. It constitutes one of the life-threatening conditions for women in developing countries. The popularization of cervical cancer screening and the improvement of treatment levels has caused the mortality rate of cervical cancer to decrease gradually, but pelvic floor dysfunction before and after cervical cancer treatment has become prominent and attracted more and more attention. Bibliometric analysis has been carried out in this research. The main goal of this research is to provide a comprehensive insight into the knowledge structure and global research hotspots about pelvic floor dysfunction in cervical cancer.

METHODS

Literature related to cervical cancer and pelvic floor dysfunction as of May 2023 was searched on the Web of Science Core Collection (WOSCC). The visualization and bibliometric analyses of the number and contents of publications were performed to analyze the temporal trends, spatial distribution, collaborative networks, influential references, keyword co-occurrence, and clustering.

RESULTS

There were 870 publications from 74 countries or regions, with the U.S. publications in a leading position. Since 2020, the number of publications has rapidly increased with the emphasis on the quality of life of cervical cancer patients. Although pelvic floor dysfunction in cervical cancer mainly occurs in developing countries, developed countries have made great contributions to this disease. However, in developing countries such as China and India, the quality of publications needs to be improved. In this field, the studies focused on the sexual dysfunction or urinary incontinence of cervical cancer patients, and the most cited papers discussed the effect of cervical cancer treatment on the sexual activities of females. The frontier keywords were represented by pelvic radiotherapy and risk factors.

CONCLUSION

This study provides an objective and comprehensive analysis of the literature available on pelvic floor dysfunction in cervical cancer and identifies future trends and current hotspots. It can provide a valuable reference for researchers in this field.

Treatment of urethrorectal fistulas caused by radical prostatectomy - two surgical techniques

INTRODUCTION

The repair of complex urethrorectal fistulas, which can be the result of treating prostate cancer with radical prostatectomy, is a big problem in urology and its final result is not always satisfactory. There are no universally accepted methods for repairing such fistulas. In our work we present a retrospective analysis of patients treated for urethrorectal fistulas after previous radical prostatectomy. The methods used were the initial excision and suture of the fistula, or a gracilis muscle flap interposition.

MATERIAL AND METHODS

In the years 2000-2012, four patients were treated because of urethrorectal fistulas after radical prostatectomy. In two patients, open radical prostatectomy had been performed. Two other patients had been operated laparoscopically. Two patients had a primary fistula repair. They were operated using anterior perineal access. Two others were treated with the use of a gracilis muscle flap.

RESULTS

During the follow up, there was no recurrence of fistulas. Medium follow up for the first two patients was 120 and 156 months, and follow up of two other patients was 16 and 23 months. Until now, there were no final postoperative complications.

CONCLUSIONS

Repair of the fistulas requires an individual approach to each case. Excision and suturing of the fistula gives a very good final result, especially when the primary reconstruction is performed. Repair of urethrorectal fistula using a gracilis muscle flap appears to be an excellent option in cases of complex recurrent fistulas. It is also associated with low morbidity in patients and a high success rate.

Gracilis muscle interposition for the treatment of rectourethral, rectovaginal, and pouch-vaginal fistulas: results in 53 patients

BACKGROUND

The aim of this study was to review our experience with gracilis muscle interposition for complex perineal fistulas.

MATERIAL AND METHODS

A retrospective review of all patients who underwent repair of perineal fistula using the gracilis muscle between 1995 and 2007 was undertaken. Patients were divided into 2 groups according to the fistula type by gender: females (rectovaginal and pouch-vaginal) and males (rectourethral).

RESULTS

Gracilis interposition was performed in 53 patients. Seventeen women underwent 19 gracilis interpositions for 15 rectovaginal and 2 pouch-vaginal fistulas; 76% had a mean of (1-4) (mean of 2) prior failed attempt at repair. Eight patients experienced at least one postoperative complication. Two women required a second gracilis interposition. Thirty-three percent of the Crohn's disease-associated fistulas successfully healed; 75% without Crohn's successfully healed.Thirty-six males underwent gracilis interposition for rectourethral fistulas, mainly due to prostate cancer treatment; 13 (36%) had a mean of 1.5 (range 1-3) failed prior repairs. Seventeen patients experienced postoperative complications. The initial success rate in men with rectourethral fistulas was 78%. After successful second procedures in 8 patients, the overall clinical healing rate was 97%.

CONCLUSION

The gracilis muscle transposition is a safe and effective method of treating complex perianal fistulas.

Minimizing urinary bladder radiation dose during brachytherapy for carcinoma of the cervix using balloon inflation technique

PURPOSE

Radiotherapy is effective in treating cancer of the cervix. However, its success is associated with significant morbidity of the urinary bladder. This study has been designed to reduce the radiotherapy dose from the brachytherapy component of cervical cancer treatment to the urinary bladder to minimize radiation-induced morbidity.

MATERIALS AND METHODS

By inflating the balloon of a Foley catheter at the anterior fornix region, attempts were made to displace the urinary bladder in patients undergoing gynecological intracavitary brachytherapy. The radiation dose to the urinary bladder was then studied in 12 insertions without and 31 insertions with balloon inflation.

RESULTS

The increase in the distance from the intrauterine tandem source to a reference point in the base of the bladder and the resultant decrease in the radiation dose have been determined. A highly significant reduction in the radiation dose with an increase in distance between the source applicator and bladder base were achieved (p < 0.01 in both cases).

CONCLUSION

A significant reduction in radiation dose to the bladder base can be achieved by the technique described in this study. A three-dimensional plan generated using CT images can demonstrate the drawback of ICRU-38 bladder reference point. The technique is simple consistent and reproducible within an acceptable range.

Rectovaginal fistula

Rectovaginal fistulas present a distressing problem for the patient and a challenge for the treating physician. Successful management must take into consideration the etiology of the fistula and the health of both the rectum and the patient. Obstetrical fistulas can be treated successfully by local approaches transanally or transvaginally. Episioproctotomy may be considered if there is an associated sphincter defect. Crohn's related fistulas usually require proctectomy if the rectum is severely involved. Local repair can be considered in instances where the rectum is relatively healthy and local sepsis has been controlled. Radiation-induced fistulas may be secondary to cancer recurrence, which must be excluded. If the patient is not a candidate for a radical resectional approach, fecal diversion alone should be performed.

The effect of nonmalignant systemic disease on tolerance to radiation therapy

PURPOSE

Some patients with nonmalignant systemic diseases, like collagen vascular disease (CVD), hypertension, diabetes mellitus, and inflammatory bowel disease (IBD), tolerate radiation therapy poorly. Although the mechanisms of each of these disease processes are different, they share a common microvessel pathology that is potentially exacerbated by radiotherapy. This article reviews and evaluates available data examining the effects of these benign disease processes on radiation tolerance.

METHODS

We conducted a thorough review of the Anglo-American medical literature from 1960 to 2001 on the effects of radiotherapy on CVD, hypertension, diabetes mellitus, and IBD.

RESULTS

Fifteen studies were identified that examined the effects of radiation therapy for cancer in patients with CVDs. Thirteen of 15 studies documented greater occurrences of acute and late toxicities (range 7%-100%). Higher rates of complications were noted especially for nonrheumatoid arthritis CVDs. Nine studies evaluated the effects of hypertension and diabetes on radiation tolerance. All nine studies documented higher rates of late toxicities than in a "control" group (range 34%-100%). When patients had both diabetes and hypertension, the risk of late toxicities was even higher. Six studies examined radiation tolerance of patients with IBD irradiated to the abdomen and pelvis. Five of these six studies showed greater occurrences of acute and late toxicities for patients with IBD, even with precautionary measures like reduced fraction size and volume and patient immobilization (13%-29%).

CONCLUSION

The majority of published studies documented lower radiation tolerance for patients who have CVD, diabetes mellitus, hypertension, and IBD. This may reflect a publication bias, as the majority of these studies are retrospective with small numbers of patients and use different scoring scales for complications. These factors may contribute to an overestimation of true radiation-induced morbidity. Although the paucity of data makes precise estimates difficult, a subset of patients, in particular, those with active CVD, IBD, or a combination of uncontrolled hypertension with type I diabetes, is likely to be at higher risk. Future prospective trials need to document these disease entities when reporting treatment-related complications and also must monitor toxicities associated with quiescent versus active IBD and CVD, type I versus type II diabetes, and levels of hypertension (controlled versus uncontrolled) matched for radiation-specific treatment sites, field size, fractionation, and total dose.

High-dose-rate brachytherapy in the treatment of uterine cervix cancer. Analysis of dose effectiveness and late complications

PURPOSE

This retrospective analysis aims to report results of patients with cervix cancer treated by external beam radiotherapy (EBR) and high-dose-rate (HDR) brachytherapy.

METHODS AND MATERIALS

From September 1992 to December 1996, 138 patients with FIGO Stages II and III and mean age of 56 years were treated. Median EBR to the whole pelvis was 45 Gy in 25 fractions. Parametrial boost was performed in 93% of patients, with a median dose of 14.4 Gy. Brachytherapy with HDR was performed during EBR or following its completion with a dose of 24 Gy in four weekly fractions of 6 Gy to point A. Median overall treatment time was of 60 days. Patient age, tumor stage, and overall treatment time were variables analyzed for survival and local control. Cumulative biologic effective dose (BED) at rectal and bladder reference points were correlated with late complications in these organs and dose of EBR at parametrium was correlated with small bowel complications.

RESULTS

Median follow-up time was 38 months. Overall survival, disease-free survival, and local control at 5 years was 53.7%, 52.7%, and 62%, respectively. By multivariate and univariate analysis, overall treatment time up to 50 days was the only statistically significant adverse variable for overall survival (p = 0.003) and actuarial local control (p = 0.008). The 5-year actuarial incidence of rectal, bladder, and small bowel late complications was 16%, 11%, and 14%, respectively. Patients treated with cumulative BED at rectum points above 110 Gy(3) and at bladder point above 125 Gy(3) had a higher but not statistically significant 5-year actuarial rate of complications at these organs (18% vs. 12%, p = 0.49 and 17% vs. 9%, p = 0.20, respectively). Patients who received parametrial doses larger than 59 Gy had a higher 5-year actuarial rate of complications in the small bowel; however, this was not statistically significant (19% vs. 10%, p = 0.260).

CONCLUSION

This series suggests that 45 Gy to the whole pelvis combined with four fractions of 6 Gy to point A with HDR brachytherapy is an effective and safe fractionation schedule in the treatment of Stages II and III cervix cancer if realized up to 50 days. To decrease the small bowel complications, we decreased the superior border of the parametrial fields to the S2-S3 level and the total dose to 54 Gy.

High incidence of severe urologic complications following radiotherapy for cervical cancer in Japanese women

BACKGROUND

Good results have been obtained with radiation therapy for cervical cancer, but many patients suffer radiation-induced complications of adjacent organs. Some authors have reported that about 10% of patients treated with radiotherapy experience radiation-induced complications. We have previously reported that the incidence of spontaneous rupture of the urinary bladder is high in Japan but extremely low in the United States and Europe. In this study, we examined whether incidence or type of radiation-induced complications differs between Japan and the United States and Europe.

METHODS

A retrospective study was performed to determine the incidence among Japanese women of severe complications requiring surgical intervention following radiotherapy for cervical cancer. A total of 271 patients were treated at Kobe City General Hospital using external-beam therapy from December 1981 to March 1989. In 232 external-beam therapy was combined with high-dose-rate intracavitary brachytherapy with a remotely controlled afterloading system (RALS). The incidence and type of radiation-induced complications of the urinary tract, rectum, and intestine were determined following exclusion of 74 patients with evidence of disease recurrence or progression.

RESULTS

A total of 16 patients (8.1%) had urologic complications that required surgical intervention following irradiation, while a total of 26 patients (13.2%) had complications of the rectum or intestine that required surgical intervention following irradiation. Urologic complications occurred significantly later than those of the rectum and intestine (6.4 and 2.2 years, respectively) (P < 0.0001). The overall incidence of severe complications was comparatively higher than reported in the United States and Europe. The incidence of spontaneous rupture of the urinary bladder was particularly high (2.0%) in Japan.

CONCLUSIONS

The incidence of severe complications following radiotherapy is comparatively higher in Japan than in the United States and Europe. In particular, spontaneous rupture of the urinary bladder is common in Japan. This might be due to the use of high-dose-rate brachytherapy. Since brachytherapy is currently being used for prostate cancer, urologists and radiologists must consider the possibility of a high incidence of such severe complications, especially when using high-dose-rate brachytherapy.

Results of treatment in stage IIB squamous cell carcinoma of the uterine cervix: comparison between two and one intracavitary insertion

To compare the results of treatment in stage IIB squamous cell carcinoma of the uterine cervix of two treatment regimens, two radium insertions vs one insertion, a prospective randomized study was carried out at Ramathibodi Hospital from 1 January 1983 to 31 December 1986, and the results were evaluated at the end of March 1991. The patients in treatment I (90 cases) received 40-41.4 Gy whole pelvic external irradiation and two intracavitary radium insertions, while patients in treatment II (53 cases) received 50.0-50.4 Gy and one intracavitary insertion. Both groups received the same total dose at point A, about 85-90 Gy. At 4 and 5 years, by the Kaplan-Meier survival curve, the disease-free survivals were 76 and 76% vs 79 and 79%, respectively, in treatment I and treatment II, which showed no significant difference by the log-rank test. Both groups had comparable serious complication rates, 0% vs 1.9%, respectively. However, grade I complications in treatment II, 35.8%, were higher than those in treatment I, 17.8% (P less than 0.01). Therefore, we concluded that treatment II provided the same disease-free survival and a very low rate of serious complications. To replace treatment I, the dose at the rectum and urinary bladder should be maintained with caution.

The late occurrence of urinary tract damage in patients successfully treated by radiotherapy for cervical carcinoma

Urinary tract complications apparently resulting from radiation therapy for carcinoma of the cervix can occur as long as 30 years after cessation of such treatment. Patients generally present with urinary incontinence and often are treated by standard operative methods that usually are unsuccessful. Incontinence is related to bladder fibrosis, urethral nonfunction and vesicovaginal fistuLa formation, and may be accompanied by bilateral ureteral obstruction. Of 11 patients with late complications of radiotherapy 4 had upper tract deterioration, 4 had vesicovaginal fistulas, 5 had an incompetent urethra aNd 9 had a fibrotic, noncompliant areflexive bladder. Treatment was aimed at providing adequate low pressure storage capacity and consisted of augmentation cystoplasty in 5 patients, repair of the fistula in 4 and correction of urethral dysfunction in 5. Women who complain of incontinence and/or irritable bladder symptoms with a history of radiotherapy for cervical carcinoma should be evaluated for fistuLa formation, urethral incompetence, and detrusor areflexia and fibrosis before treatment is done.

The influence of initial hemoglobin and blood pressure levels on results of radiation therapy for carcinoma of the prostate

A group of 914 patients with carcinoma of the prostate treated by definitive radiotherapy at Stanford between 1956 and 1985 was studied. Of these, the initial hemoglobin level was recorded in 656 cases and the initial blood pressure in 760 cases. End-points studied in actuarial analyses were survival, disease-specific survival, local control, freedom from distant relapse, and occurrence of late intestinal complications. Although the anemic group (Hb less than 13.5 g/dl) was correlated negatively with survival (p = 0.02), there was no correlation with disease-specific survival or local control. The conclusion was that anemia per se did not affect the outcome of radiation therapy. A pulse pressure greater than or equal to 60 mm Hg was significantly correlated with worse survival (p = 0.01) and local control (p = 0.04), but no correlation was found between systolic and diastolic blood pressure and the end-points measured. Neither anemia nor hypertension were significantly correlated with late intestinal complications.

Carcinoma of the cervix: analysis of bladder and rectal radiation dose and complications

From April 1969 through December 1980, 527 patients with epidermoid carcinoma of the cervix received radical radiation therapy at North Carolina Memorial Hospital (NCMH). The treatment was designed to deliver a combined dose (external beam plus intracavitary) of 7000-8000 cGy to Point A and 5000-6500 cGy to the pelvic lymph nodes depending upon the stage of the disease. The maximum dose to the bladder and to the rectum were calculated from the orthogonal intracavitary placement films with contrast material in these organs. Thirty-three cases of cystitis and fifty-eight cases of proctitis were recorded. The mean bladder dose for the group of patients with cystitis was higher, 6661 +/- 1309 cGy, than that for the patients without cystitis, 6298 +/- 1305 cGy, p = .19. The risk of cystitis increased as a function of bladder dose ranging from 3% for patients receiving less than or equal to 5000 cGy to the bladder to 12% for patients receiving greater than or equal to 8001 cGy to the bladder. A similar correlation was also found for rectal dose and proctitis. The mean rectal dose for the group of patients with proctitis was higher, 6907 +/- 981 cGy, than that for the patients without proctitis, 6381 +/- 1290 cGy, p = .003. The risk of proctitis increased as a function of rectal dose ranging from 2% for patients receiving less than or equal to 5000 cGy to the rectum to 18% for patients receiving greater than or equal to 8001 cGy to the rectum. A study of the severity of the cystitis as a function of bladder dose revealed a relationship between bladder dose and the severity of the complication (Grade I cystitis = 6600 +/- 1318 cGy vs Grade III cystitis = 6856 +/- 853 cGy). A dose-response relationship was found between the rectal dose and the severity of the complication (Grade I proctitis = 6810 +/- 906 cGy vs Grade III proctitis = 6997 +/- 1137 cGy). This relationship was statistically significant, p = .003. While there was no difference in the frequency of cystitis as a function of dose to the whole pelvis, the risk of proctitis did increase with increasing doses of external beam to the whole pelvis. It ranged from 3% for patients who received 2000 cGy or less to the whole pelvis to 14% for patients who received greater than 4000 cGy to the whole pelvis, p = .02.

Treatment of cervical carcinoma employing a template for transperineal interstitial Ir192 brachytherapy

The development of a template technique at this institution for transperineal interstitial-intracavitary brachytherapy employing Ir192 wire has previously been reported. In this paper we report the results of radiation treatment of 84 women with fresh, primary squamous carcinoma of the cervix admitted to the Los Angeles County--University of Southern California Medical Center from April, 1975 to September, 1979 who received at least one transperineal template implant as part of their initial treatment. The 75 evaluable patients were followed 3 to 60 months, with a median of 17 months. Recurrence rates in the pelvic treatment field by clinical (FIGO) stage grouping were 35.7% (5/14) Stage IB;0% (0/8) Stage IIA; 20% (5/25) Stage IIB; 46.2% (12/26) Stage III; and 0% (0/2) Stage IVA. The overall failure rate within the treatment field was 29.3% (22/75). The non-tumor associated rectovaginal and vesicovaginal fistula rate was 14.3% (2/14) in Stage IB; 0% (0/8) in Stage IIA; 16.0% (4/25) in Stage IIB; 15.4% (4/26) in Stage III; and 0% (0/2) in Stage IVA. The non-tumor associated fistula rate for all stages was 13.3% (10/75). Severe or grade III nonfistulous, delayed adverse effects (proctosigmoiditis, cystitis, vault necrosis) occurred in an additional 6 patients. Thus, 21.3% (16/75) of all evaluable patients experienced severe adverse radiation effects during the follow-up period. Pre-radiation staging laparotomy was performed on 31 patients. It had no obvious effect on the pattern or rate of radiation complications. The role of the interstitial-intracavitary template in the treatment of primary cervical carcinoma is discussed.

Tumor regression and histologic clearance after neutron brachytherapy for bulky localized cervical carcinoma

The response of bulky, advanced Stage 1B and early Stage II carcinoma of the cervix to neutron brachytherapy (NT and radiotherapy) was studied using combined NT radiation and extrafascial hysterectomy with histologic evaluation. Scheduling of neutron therapy relative to external beam photon therapy, tumor volume, tumor stage, tumor histology, and clinical tumor clearance were assessed in these studied. NT was easily combined with surgery in this study. Low stage tumors, small tumor volume and "early" neutron implants (scheduled within +/- one week of the start of fractionated radiation) showed more frequent histologic clearance of tumor. Long-term tumor control has been achieved and failures developed distance metastases without pelvic or local recurrence. This experience indicates that NT was effective for tumor clearance and control and represents and promising new modality for localized, advanced tumor therapy.

Time, dose and fractionation factor as an indicator of fibrosis of the abdominopelvic subcutaneous tissue

Ninety-six patients treated with irradiation for epidermoid carcinoma of the uterine cervix were evaluated for the occurrence of subcutaneous tissue fibrosis of the hypogastrium. They were retrospectively stratified according to time, dose and fractionation (TDF) factors of the subcutaneous tissue, total dose delivered and treatment techniques. In our study only the TDF value of the subcutaneous tissue was unequivocally related to the occurrence of fibrosis. The numerical value of the TDF was found to be 110, above which 88.2% of the patients displayed fibrosis.

Intestinal fistula following pelvic exenterative surgery: predisposing causes and treatment

An interest fistula is a life-threatening complication when associated with the treatment of pelvic cancer. Such fistulae arise in 10% of patients treated by the combination of aggressive surgery and radiation therapy. Nineteen such occurrences developing in 245 patients who had pelvic exenterations are used to demonstrate the need for directing immediate attention toward correcting the physiologic and metabolic abnormalities created by the fistulae. Local control of the fistulae is facilitated by techniques for identifying its cause and precise location.

Surgical treatment of the radiation injured bowel

Over the last 10 years, 9 patients treated by surgical procedure for radiation injuries of the bowel were studied with the following conclusions: The damage to the small intestine caused by external irradiation leads to adhesion of the bowel, perforation and postoperative anastomotic dehiscence if the irradiated bowel is used in the anastomosis. Surgical treatment for the small intestine is resection of the damaged loop. In order to determine the extent of the resection it is important that during the operation fibrosis and obstruction of vessels in the submucosa and subserosa is examined by biopsy. On the other hand, rectal ulcer and/or rectovaginal fistula is chiefly caused by intracavitary application plus external irradiation. For these lesion Hartmann operation or colostomy is performed, and the postoperative course is uneventful.

Correlation between retinal and pelvic vascular status: a determinant factor in patients undergoing pelvic irradiation for gynecologic malignancy

The degree of arteriolar sclerosis in pelvic vessels has previously been shown to be related to the incidence of radiation-related enteric and genitourinary injury. Retinal vessel changes were compared to pelvic vascular changes in 48 patients, half of whom were either diabetic or hypertensive. There was an absolute correlation between retinal vessel changes and bowel or cervicovaginal vessel changes in 74% of the cases, and only one patient had a marked (more than one grade) discrepancy between retinal and pelvic vascular status. The findings of this investigation suggest that funduscopic examination of the retina can provide useful information concerning the extent of vascular disease in structures normally present in the field of pelvic irradiation.

Alterations of nutritional status: impact of chemotherapy and radiation therapy

The nutritional status of a cancer patient may be affected by the tumor, the chemotherapy and/or radiation therapy directed against the tumor, and by complications associated with that therapy. Chemotherapy-radiotherapy is not confined exclusively to malignant cell populations; thus, normal tissues may also be affected by the therapy and may contribute to specific nutritional problems. Impaired nutrition due to anorexia, mucositis, nausea, vomiting, and diarrhea may be dependent upon the specific chemotherapeutic agent, dose, or schedule utilized. Similar side effects from radiation therapy depend upon the dose, fractionation, and volume irradiated. When combined modality treatment is given the nutritional consequences may be magnified. Prospective, randomized clinical trials are underway to investigate the efficacy of nutritional support during chemotherapy-radiotherapy on tolerance to treatment, complications from treatment, and response rates to treatment. Preliminary results demonstrate that the administration of total parenteral nutrition is successful in maintaining weight during radiation therapy and chemotherapy, but that weight loss occurs after discontinuation of nutritional support. Thus, long-term evaluation is mandatory to learn the impact of nutritional support on survival, disease-free survival, and complication rates, as well as on the possible prevention of morbidity associated with aggressive chemotherapy-radiation therapy.

Urologic complications of pelvic irradiation

We evaluated 964 patients who had undergone radiation therapy for malignant disease of the pelvic viscera during a 5-year period and who ahd been followed for 5 to 10 years after completion of treatment. Therapy had been given for gynecological tumors in 493 cases, genitourinary tumors in 240 cases, bowel tumors in 172 cases and various other malignant tumors in the pelvis in 59 cases. The incidence of cystitis, hematuria, ureteral obstruction and fistula formation was determined for each group. There were 203 urological complications, an incidence of 21 per cent, but only 25 of these complication (2.5 per cent) could be ascribed to the effects of radiation alone, the remainder being associated with persistent or recurrent tumor. Approximately 20 per cent of the patients had some abnormalities detected in the pre-treatment excretory urogram. The development of urologic complications was related to the radiation dosage and previous bladder operations.

Small cell cancer of the uterine cervix

Forty-one patients with small cell carcinoma of the uterine cervix were evaluated and treated at the University of Kentucky Medical Center from 1962 to 1974. Eighteen patients (44%) developed widespread metastases and died of recurrent cancer within 2 years of therapy. Common sites of metastases included the lung, liver, and bone. There was a significantly lower incidence of lymphoplasmacytic infiltration in small cell cancers than the keratinizing or nonkeratinizing squanmous cell carcinomas of the cervix. In addition, there was a significant increase in the number of unstimulated regional lymph nodes in patients with small cell cancer when compared with the lymph nodes of patients with the other cell types of cervical cancer. These data suggest that small cell cancer of the cervix is a highly aggressive tumor similar to small cell carcinoma of the lung and behaves quite differently from other types of squamous cell carcinoma of the cervix. Radiation therapy was superior to radical surgery in eradicating pelvic disease, but prospective studies need to be undertaken to determine the effect of adjunctive chemotherapy in patients with this rare tumor.

The prognostic significance of carcinoembryonic antigen in the plasma and tumors of patients with endometrial adenocarcinoma

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.