R A D I O T H E R A P Y IN E P I T H E L I O M A OF CERVIX 203

R E S U L T S OF R A D I O T H E R A P Y ( C U R I E T H E R A P Y A N D R O E N T G E N - T H E R A P Y ) IN I24 EPITHELIOMA C A S E S OF S T U M P OF THE CERVIX,

T R E A T E D F R O M I919 TO I944 AT THE CURIE F O U N D A T I O N

BY JULIETTE BAUD, FONDATION CURIE, PARIS

CURE of carcinoma of the cervix by radiotherapy is often considered more difficult when it develops on the s tump after a subtotal hysterectomy performed for a non-cancerous gyn~ecological disease. This is at tr ibuted to the impossibil i ty of introducing a radium sound of normal length, which would irradiate the pelvis from the uterus. The aim of this work is to compare the results obtained among patients treated by radiations from 1919 to i944 at the Curie Foundation, either for epitheliomas of the s tump of the cervix, or for ordinary epitheliomas of the cervix.

Among the 2688 epitheliomas of the uterine cervix treated during this period, i24 (4.6 per cent) developed on stumps. In these i24 patients the uterus had been removed from one to thir ty-eight years before on account of the following non-cancerous affections : fibromyoma, 6o cases ; salpingitis or pelvic inflammation, 48 cases ; ovarian cyst, 6 cases ; hysterectomy after Caesarean operation, I case ; h~ematocele, 3 cases ; war injury, I case.

In 3 cases the patients had been operated on io, 12, and 14 years before for a non-specific t raumatic bleeding. In 2 cases only it was impossible to ascertain the reason for operations carried out 6 and I I years before.

The length of the period of freedom from gyn~ecological symptoms between the operation and the development of the epithelioma varied from i to 38 years (i year in 2 cases, 2 years in 8 cases, 3 years in 4 cases, 4 years in 6 cases, 5 years in 7 cases, 6 years in 6 cases, 7 years in io cases, 8 years in 7 cases, 9 years in 4 cases, IO years in 5 cases, i i years in 5 cases, i2 years in 7 cases, 13 years in 3 cases, 14 years in 4 cases, 15 years in 2 cases, 16 years in 7 cases, 17 years in 3 cases, i8 years in 2 cases, 2o years in 3 cases, 2i years in 5 cases, 22 years in 3 cases, 23 years in 5 cases, 24 years in i case, 25 years in 2 cases, 26 years in 2 cases, 27 years in 2 cases, 28 years in i case, 29 years in 2 cases, 32 years in 3 cases, 33 years in i case, 37 years in i case, 38 years in i case).

T O sum up, the symptomless period lasted from 4 to 38 years in i io cases. As to the 14 cases where it lasted only from I to 3 years, it was possible to ensure that no sign of cancer had been present at the t ime of the surgical intervention.

AETIOLOGY OF EPITHELIOMAS OF THE CERVIX STUMP The aetiology of epitheliomas of the cervix s tump does not seem to be different from that of

cancer of the cervix in the intact uterus. The relative frequency of their occurrence after surgery is not easy to establish, because patients who are operated upon for noncancerous diseases are not usually followed up very long by the surgeon. The surgical t rauma probably plays no part in the later development of cancer. I t is difficult to appreciate the part played by hormonal disorders, as in most cases it is difficult to obtain accurate surgical records, especially after a long t ime has elapsed. In particular, we do not know whether the ovaries were left or removed. The clinical stories of 60 patients operated for f ibromyoma did not differ from those of 48 patients who were operated for salpingitis or subpelvic inflammation. Amongst our i24 patients, there were 2 who showed signs of cervical infection before the development of the epithelioma, and in only I was an important purulent discharge at ' the cervical ostium the first sign of cancer.

The interval between the first actual symptom of cancer and the first consultation varied from 3 months to 3 years, but more often from 3 months to i year, as for epithelioma of the cervix generally.

204 J O U R N A L O F T H E F A C U L T Y O F R A D I O L O G I S T S

In the intact uterus the age of the patient at the first ~ indication of carcinoma of the cervix was, in most of the cases, 4 ° to 5 ° years. For carcinoma of the stump the age was greater. Among our 124 patients, 4 ° were between 4 ° and 50, 6o were between 50 and 60, 15 were more than 60, and 5 were under 4 ° (4 of these had been operated for salpingitis 6, 7, io, and i8 years before, and i had had a hysterectomy for ectopic gestation).

In these i24 patients, it appears that t h e n u m b e r s of exophytic and ulcerative types is the same. The starting point of the proliferation and the relative proport ion of the different histological varieties were the same in the epithelioma of the stump as in cancer of the cervix generally.

The classification of our I24 patients was made according to the recommendations of the United Nations Society : 25 patients (20 per cent) Stage I, 59 patients (47"5 per cent) Stage I I , 33 patients (26. 5 per cent) Stage I I I , 7 patients (5.6 per cent) Stage IV.

This shows the same distr ibution as for the whole series of 2688 cases of epithelioma of the cervix treated from i 9 i 9 to 1944, which was as follows : Stage I, 15 per cent ; Stage I I , 45"5 per cent ; Stage I I I , 3 ° per cent ; Stage IV, 9 per cent.

T R E A T M E N T OF THE EPITHELIOMAS O F THE S T U M P OF THE CERVIX

The treatment was the same as for the other epitheliomas of the cervix. Local radiumtherapy was associated with peripelvic X-ray or teleradium therapy in 98 cases. Local rad iumtherapy alone was employed in 15 cases and peripelvic irradiation was the only t reatment in I1 cases.

Peripelvic irradiation was performed in the same Way as for epithelioma of the cervix, with the same modifications from time to time and, in particular, increasing doses since i942. Vaginal radiumtherapy was performed with the usual technique of the Curie Fgundation, using a colpostat with the frequent addit ion of a median cork and, exceptionally, addition of two indepen- dent median corks. The only difference was the absence of intra-uterine radium, except in 28 cases (22"6 per cent), where it was possible to introduce a short radium sound in the cervical canal of the stump.

R E S U L T S OF T R E A T M E N T

The following results were obtained in these 124 epitheliomas of the stump : - - 51 patients (41 per cent) were living in good health from 6 to 22 years after t reatment 3 patients were living but not cured after 5 years ; their survival was of 6, 7, and 9 years

after t reatment 52 were dead of cancer after 6 to 24 months 15 had local and pelvic recurrences after over 2 years, survival from 3 to 41 years 2 were lost to follow-up after 3 years i died of a second cancer (glandular epithelioma of the stomach). The 5-year cure rates for the different stages were as follows : Stage I, 18/25 (72 per cent)

cures ; Stage I I , 26/59 (44 per cent) cures ; Stage I I I , 7/33 (2i per cent) cures. These rates are at least as good as those in the total series of 2688 cases, which were as follows :

38.5 per cent cures for Stages I - I V together, 66. 9 per cerft cures for Stage I, 43 per cent cures for Stage II , 26.I per cent cures for Stage I I I .

Le t us look at the fate of 51 patients cured after over 5 years (July, 195o ) : - - 4 ° are living, cured after 6 to 2o years 5 are dead of intercurrent diseases 6, 7, 9, and 22 years after t reatment 2 had late recurrences developing rapidly after 6 and 13 years 3 are dead of metastases after i I , i2, and 14 years I is dead of a second cancer (breast cancer) after 17 years.

R A D I O T H E R A P Y I N E P I T H E L I O M A O F C E R V I X 205

Results According to M e t h o d o f T r e a t m e n t . - Local Radiumtherapy alone.--There were 15 cases treated by radiumtherapy alone. For 9

of them (3 Stage I, 2 Stage I I , 4 Stage I I I ) it was not possible to introduce a uterine sound in the s tump and irradiation was only Vaginal ; 5/9 (55"5 per cent) cures, from 6 to 17 years after treatment, were obtained. For the 6 other cases (6 Stage I), a short radium sound 3 cm. long was introduced in the cervical canal ; 3/6 (50 per cent) cures from 9 to 19 years after t reatment were obtained.

Radiumtherapy associated with Roentgentherapy.--There were 5o cases treated by local radium- therapy associated with roentgentherapy.

For 43 of them ( io Stage I, 23 Stage II , 9 Stage I I I , i Stage IV) radiumtherapy was only vaginal ; 20/43 (47 per cent) cures were obtained from 6 to 20 years after treatment. Fo r 7 patients ( i Stage I, 6 Stage II) , it was possible to introduce a 3-cm. sound containing a radium tube in the s tump ; 3/7 (43 per cent) cures were obtained, io, IO, and 5 years after.

Radiumtherapy associated with Teleradiumtherapy.--There were 48 cases treated by local radium- therapy associated with teleradiumtherapy. For 33 of them (3 Stage I, 19 Stage I I , io Stage I I I , i Stage IV) the local radium application was only vaginal ; 12/33 (36 per cent) cures, dating from 6 to 22 years, were obtained. For 15 patients it was possible to introduce a 5-cm. sound containing 2 radium tubes in 6 cases, and only i radium tube in 9 cases ; 8/15 (53 per cent) cures dating from IO to 15 years, were obtained.

Roentgentherapy alone.--There were 6 cases treated by roentgentherapy alone (i Stage II , I Stage I I I , 4 Stage IV). No cure was obtained.

Teleradiumtherapy alone.--There were 5 cases treated by te leradiumtherapy alone (i Stage I, 3 Stage I I I , I Stage IV). No cure was obtained.

The main difference between the treatment employed with the 113 patients treated by local radium associated or not with peripelvic irradiation was the possibility or the impossibil i ty of introducing a radium sound in the stump.

For the 28 patients to which there was added a radium sound in the stump, together with the colpostat, 14 cures (50 per cent) were obtained. For the 85 patients who had only a vaginal intra- cavitary application, 37 cures (43"5 per cent) were obtained. These figures show that the application

Table /.--COMPARISON OF RATE OF CURE IN THE I24 EPITHELIOMAS OF STUMP OF THE CERVIX AND IN THE TOTAL OF 2688 EPITHELIOMAS OF THE CERVIX TREATED AT THE CURIE FOUNDATION FROM

1919 TO 1944

EP1THEL1OMAS OF STUMP OF THE ORDINARY EPITHELIOMAS OF THE TOTAL OF EPITHELIOMAS OF THE CERVIX--I 24 CERVIX--2564 CERVIX--2688

Stage I 1 8 / 2 5 (72 per cent) 254/381 (66"6 per cent) 272/406 (66'9 per cent) Stage II 26/59 (44 per cent) 5oI/~163 (43 per cent) 527/1222 (43'I per cent) Stage III 7/33 (2i per cent) 2o9/794 (26"4 per cent) 216/827 (26.I per cent) Stage IV 0/7 20/226 (8"8 per cent) 20/233 (8' 5 per cent)

Stages I-IV 51/124 (41 per cent) 984/2564 (38'3 per cent) lO35/2688 (38'5 per cent)

of a radium sound in the cervix canal does not change the results to a great extent, and that vaginal application alone is really effective.

The introduction of a radium sound in the s tump is justifiable only when the cervical canal is patent for at least 3 cm. Moreover, it is necessary that gyn~ecological exploration should reveal the existence of a little median tumour, which can act as a screen for the protection of rectum or bladder. When the cervical canal is shorter, it becomes difficult to maintain the sound in correct

2o6 J O U R N A L O F T H E F A C U L T Y O F R A D I O L O G I S T S

position. Post-radiation accidents should be expected in normal or cancerous tissues at the upper part of the cervical cavity, where the wall may be very thin and easily damaged.

SUM M ARY

I t seems possible to say, for the I2 4 patients observed, that epitheliomas on the stump of the cervix :

(i) Occur and develop in the same conditions as the other epitheliomas of the cervix. (2) May be treated by the usual method of treatment with no change of prognosis resulting

from the impossibility of introducing a radium sound in the cervix canal. (3 ) Are cured in the same proportions as other epitheliomas of the cervix.

BOOK R E V I E W A Text-book of X-ray Diagnosis. By BRITISH AUTHORS. Edited by S. COCHRANE SHANKS, M.D.,

F.R.C.P., F.F.R., Director, X-ray Diagnostic Department, University College Hospital, London ; and PETER KERLEY, M.D., F.R.C.P., F.F.R., D.M.R.E., Director X-ray Department, Westminster Hospital; Radiologist, Royal Chest Hospital, London. Second edition. In four volumes. 5½ × 9¼ in. Volume I, Pp. 434 + xiv, with 439 illustrations. 195o. London : H. K. Lewis

&Co., Ltd. 45 s.

THE second edition of the ' British Authors ', as these volumes have become familiarly known, appears some twelve years after the publication of the first edition. It appears already assured of a warm wel- come from radiologists and from workers in other subjects who have come to rely upon it as one of the most valued and comprehensive radiological text-books in the English language.

In this new edition, the number of volumes has been increased from three to four. Volume I now comprises the Sections of the Skull, Central Nervous System and Eye, which previously formed part of Volume III . This new arrangement has produced a Volume of more manageable size and allows of better arrangement of the subject matter.

The chapters on the skull and central nervous system have again been undertaken by Sir Hugh Cairns and Dr. Jupe. It says much for the skill of the authors that in these chapters hardly any alter- ations have been found necessary from the first edition. In the chapter on ventriculography and encephalography the detail of the technique required for filling the various parts of the ventricular system and at the same time conserving the air within the system might have been described at some- what greater length, as might also the technique of encephalography. With the increase in number of neuro-surgical centres we may hope to see the Radiologist undertaking more and more the conduct of all examinations which do not involve surgical procedures, and it seems, therefore, desirable that in a book of reference such as this more details of technique should be included.

The description of anomalies and diseases of the skull is excellent and most clearly written. The importance of recognizing the minor degrees of basilar invagination is perhaps not fully insisted upon.

A new chapter on cerebral angiography has been added in which the technique and the diagnostic points are clearly set out. Perhaps slightly more emphasis might have been placed on the variations in the normal appearances, and more variations might have been described and illustrated, as it is in these cases the student finds most difficulty.

Dr. Reid has revised the section on the eye in this volume. There is again a valuable and well illustrated chapter by Dr. Worth on the radiology of the teeth and jaws.

The sections on the accessory nasal sinuses and the temporal bone are again contributed by Sir Harold Graharn-Hodgson, who stresses the clinical knowledge which is essential for the proper understanding of the radiological findings. The standard of the irlustrations throughout these sections is excellent.

This volume achieves its object in providing a text-book of first class format with a well-balanced presentation of material. Description throughout is kept simple, and for reading beyond the proper scope of a text-book a comprehensive bibliography is provided at the end of each section.