In surgical gynecology the concept of radicality has long been closely associated with the surgical treatment of cervical cancer. Wilhelm Alexander Freund reported on the abdominal extirpation of a carcinomatous uterus in Breslau (now Wroclaw, Poland) in 1878 [1]. His contemporaries and pupils immediately recognized that any hope of therapeutic success would require shifting the plane of resection laterally into the parametrial tissue in order to totally remove disease that had exceded the confines of the uterus [2]. Freund and his pupils also removed bulky, grossly positive lymph nodes. Emil Ries, who went from Strasbourg to the Postgraduate Medical School in Chicago, is the father of modern lymphadenectomy. In an almost prophetic presentation in Frankfurt, Germany, in March 1895, Ries laid out the theoretical basis for a systematic lymphadenectomy with removal of grossly normal node-bearing tissue [3]. He performed dissections in cadavers and dogs and postulated a therapeutic effect before actually having done such an operation in a patient. In 1897 Ries described his surgical technique in two patients [4]. He showed that grossly normal nodes could already contain cancer deposits and also pointed out that removing the lymphatic fatty tissue made it easier to remove the parametria. Notably, he dissected out the ureter all the way to the bladder, permitting him to resect a large part of the connective tissue around the uterus. In a postscript to his second publication, Ries went to some lengths to show that he gave Clarke’s chief Howard Kelly, and thus presumably Clark himself, the idea for the lymphadenectomy component of his radical operation [4]. Ries laid the groundwork for integrating lymphadenectomy with an extended hysterectomy to a truly radical operation. Later Joe Vincent Meigs [5] and Ernst Navratil built upon and carried out this same strategy. It was Ernst Wertheim’s accomplishment to systematically develop, apply, tabulate, and analyze what he called ‘‘The extended abdominal operation for carcinoma colli uteri.’’ His landmark monograph in 1911 demonstrated that it was possible to cure locally advanced cervical carcinoma with surgery [6]. He also showed that the abdominal approach was not inferior to the vaginal approach, as advocated by Friedrich Schauta, with regard to surgical complications and therapeutic results. Wertheim considered the ‘‘possibility of resecting a large extent of the parametrium and in advanced cases to isolate the severely fused organs’’ a particular advantage of the abdominal approach. Wertheim followed a systematic surgical plan and noted that dissecting out the ureters does not in itself constitute a radical operation (Fig. 1). The idea of gynecologic oncology did not yet exist when I began my gynecologic training on the recommendation of Isidor Amreich at the department in Graz chaired by Ernst Navratil in 1954. Nonetheless, cancer treatment was a major challenge at large central hospitals, demanding large material and physical resources. The central problem of gynecologic cancer surgery was still cervical cancer. Before the effects of screening and early detection methods had come into full effect, most of the patients we saw had very advanced disease. But the problem was not only the relative frequency of the disease. It was also the treatment, particularly surgery. Radiation therapy was reserved for locally or medically inoperable patients. If the carcinoma had not yet advanced to and become fixed at the pelvic wall, the goal of treatment was radical surgical excision. Even the radiation therapists, aware of their own modest results, referred patients they still considered operable to the gynecologic surgeons. Navratil was a pupil of the Schauta school, which was continued by von Peham and Amreich [7], but in Vienna he also became familiar with Wertheim’s department. Navratil’s early passion was vaginal surgery, and many noted gynecologic surgeons of the day came to Graz to see his technique of radical vaginal hysterectomy. I remember him performing his 1000th Schauta procedure in the early 1960s. I believe that Meigs, who visited our department in 1956, converted Navratil to the abdominal approach to cervical cancer. Meigs [5] had improved Wertheim’s technique by integrating it with Latzko’s anatomic approach [8] and an uncompromising pelvic lymphadenectomy. In a way, he was retracing Emil Ries’s footsteps. In 1954 surgical radicality focused on excision of the parametrial tissue and a large as possible vaginal cuff. Surgeons prided themselves on photographs of their surgical specimens with the parametrial tissue spread out and the vaginal cuff opened. In those days the histologic diagnosis of a biopsy GYNECOLOGIC ONCOLOGY 70, 172–175 (1998) ARTICLE NO. GO985069
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Feb 1, 2001
Henry T Lynch + 1
Open Access