Vaginal Relapse Research Articles

Vaginectomy: A Minimally Invasive Treatment for Cervical Cancer Vaginal Recurrence

Radiotherapy and/or pelvic exenteration represent the treatment of vaginal recurrence, but the prognosis remains unsatisfactory and with long-term complications. We investigated the possible role of vaginectomy for isolated vaginal relapse (IVR) in cervical cancer (CC). Patients with vaginal CC recurrence were evaluated for surgical treatment consisting in vaginectomy. Data were prospectively collected and analyzed to identify independent prognostic factors. Twenty-nine patients with IVR from CC were enrolled. Early and late complications were observed in 7 (24%) and 6 (21%) patients, respectively. After a median follow-up of 57.5 months (range, 8-100 months), 16 patients (55%) were disease-free. The 5-year overall survival and progression-free survival rates were 70.5% and 59.4%, respectively. In carefully selected patients, vaginectomy may be considered a therapeutic option for IVR. Older patients with long disease-free interval and small recurrences benefit the most from this bladder-sparing surgical technique.

Can primary recurrences in surgical stage I-II uterine papillary serous carcinoma (UPSC) patients be salvaged?

e16503 Background: There is an absence of data in the literature on salvage rates for vaginal, pelvic, and extra-pelvic recurrences for early-stage UPSC patients (pts). The purpose of this study is to determine whether primary recurrences can be salvaged with chemotherapy or radiotherapy. Methods: A retrospective, multi-institution study of pts with stage I-II UPSC diagnosed from 1993–2006. All pts underwent comprehensive surgical staging. Postoperative treatment included either observation (OBS), radiotherapy (RT: brachytherapy, pelvic, abdominal or combo) or ≥ 3 cycles carboplatin/paclitaxel (CT) alone or with RT (CT+RT). Results: We identified 197 stage I-II pts; 44/197 (22.3%) experienced a primary recurrence during a median follow-up of 35 months. Patterns of recurrence analysis revealed that 17 (38.6%) were vaginal/pelvic (V/P) and 27 (61.4%) were extra-pelvic (EP). Multi-site relapses occurred in 13/44 (30%). Pts initially treated with adjuvant CT±RT (n = 108) had a significantly decreased risk of primary recurrence (9.9%) when compared to those patients treated with RT alone (n = 45; 37%) or OBS (n = 43; 35%; p < 0.001). There were no distinguishing risk factors for development of V/P versus EP recurrence. Median time to recurrence after diagnosis was 16 months. The majority of pts (86%) were not salvaged by second line therapy, with a median time from recurrence to death of 8.9 months. However, more pts with isolated vaginal recurrences (5/12 or 42%) were salvaged when compared to those with pelvic or EP recurrences (1/32 or 3.1%; p = 0.004). The 5 pts who are NED after vaginal relapse were treated with CT±RT (n = 3) or RT (n = 2); 80% had not received prior treatment and 20% had received prior CT. To date, more pts with EP recurrence are dead of disease (23/27) than with V/P recurrences (7/17; p = 0.003). Conclusions: Stage I-II USPC pts are more likely to experience an extra-pelvic than vaginal/pelvic primary recurrence, are unlikely to be salvaged and will have a short interval from recurrence to death. The exception is in those with isolated vaginal recurrence, who may be salvaged in select cases. The current best strategy to avoid primary recurrences in this setting is an initial staging surgery followed by adjuvant carboplatin/paclitaxel. No significant financial relationships to disclose.

Korpuskarzinom / Zervixkarzinom

Malignant uterine tumours can affect the corpus or the cervix. The endometrial carcinoma with its different histological subtypes counts for most of the malignomas of the uterine body. But the rare category of uterine sarcomas (carcinosarcomas, leiomyosarcomas as well as endometrial stromal sarcomas) also belongs to this group. Cervical cancer presents an own entitity, regarding both histology and therapeutic options. Endometrial cancer is the most common genital malignoma in Northern Europe and North America. Histologically, the endometrial cancer can be subdivided in two groups: type I is hormonal sensitive and well differentiated, type II represents an undifferenciated aggressive tumour with poor prognosis. In general, the patient is elderly. Due to the main symptom - abnormal vaginal bleeding - endometrial cancer is detected in an early stage in about 75% of all patients. First choice in therapy is stage related surgery. Follow-up schemes have not proved yet to improve survival, therefore clear guidelines are missing. National and international groups recommend regular follow-up visits to detect the early vaginal vault relapse which is curable. Cervical cancer is mainly a squamous cell carcinoma and oncogenic Human Papilloma Virus (HPV) associated. Surgery is only indicated up to stage IIA, advanced stages should be treated by radio-chemotherapy. Several studies have shown that follow-up visits can improve survival rates. Intention is the detection of the curable local relapse.

Lymphovascular space invasion does not predict vaginal relapses in stage I endometrioid adenocarcinoma of the endometrium

This study was conducted to determine whether, in a pure population of patients with International Federation of Gynecology and Obstetrics stage I endometrioid endometrial (S1EE) carcinoma that is confined to the uterus and without lymph node metastases, the presence of lymphovascular space invasion (LVSI) is positively associated with vaginal relapses. Pathologic reports for all S1EE diagnosed in a hysterectomy specimen during a 9-year period (1997-2005) were reviewed. Cases with LVSI were selected and immunohistochemical staining for CD34, factor VIII-related antigen and pancytokeratin were performed on the relevant slides for confirmation. Various established prognostic/predictive clinicopathologic parameters were documented for the whole cohort and were correlated with the presence or absence of LVSI. One-way analysis of variance with Bonferroni correction and Fisher exact/chi(2) tests were used in the respective comparisons of continuous and categoric variables among the different groups. A total of 345 patients were diagnosed with S1EE during this period. The mean patient age for the cohort was 61.9 (+/-12.2) years (range, 28-89 years) and median follow-up was 80 months. Among these 345 patients, LVSI was present in 52 (15%), representing 1 (0.8%) of 121 stage 1A, 23 (14.5%) of 159 stage 1B, and 28 (43%) of 65 stage 1C cases (P < .001). Pelvic and/or para-aortic lymph node dissection was performed in 216 cases, and none had positive lymph nodes. We noted that LVSI correlated significantly with nuclear grade, with LVSI being present in 48% (10/21), 18% (32/175), and 5% (7/140) of cases with nuclear grades 3, 2, and 1 cases, respectively (P < .001). It was also more likely to be present in cases with architectural grades 2 and 3 (35/105) than grade 1 (16/234) (P < .01). Vaginal recurrences occurred in 2 (3.8%) of 52 patients with LVSI and 8 (2.7%) of 293 patients without LVSI (P = .65). In addition, on univariate analysis, LVSI did not correlate significantly with patient age, body mass index (using 50-year and 30 body mass index thresholds, respectively), or diabetic status. We conclude that LVSI is seen in approximately 15% of S1EE, and correlates with established prognostic parameters such as the level of myometrial invasion (substage), nuclear grade, and architectural grade. However, LVSI does not denote an increased likelihood of vaginal recurrences in S1EE. The presence of LVSI should not, in of itself, alter clinical staging, or trigger unnecessary therapeutic intervention.

Pattern of failure and value of follow-up procedures in endometrial and cervical cancer patients

Objective The aim of this study was to evaluate the outcome benefit of follow-up protocols for patients with recurrent endometrial and cervical cancer. Methods A retrospective review on patients primarily treated at the Division of Gynecologic Oncology, University of Brescia, was performed. We focused our attention on recurrent patients and we evaluated the pattern of relapse and the presence of symptoms or signs of disease at recurrence and evidence of disease on routine follow-up test or visits. Results The vast majority of recurrences occurred within the first 3 years after primary treatment (78% and 87% in endometrial and cervical cancers, respectively). A better overall survival from relapse was observed when vaginal relapse was compared to other sites in endometrial cancer patients and when pelvic recurrence was compared to distant sites in cervical cancer cases. Recurrent endometrial and cervical cancer patients were symptomatic in 52% and 65% of cases, respectively. Among asymptomatic recurrent endometrial cancer cases, pelvic examination, abdominal or pelvic ultrasound and CT could detect 92% of relapses, while the vast majority of cervical cancer relapses could be diagnosed by pelvic examination and/or CT (85%). Conclusion Endometrial cancer patients showed a significantly better prognosis when the recurrence was detected during follow-up visits, thus supporting the real advantage of our surveillance programs, while no statistically significant differences were found in survival of cervical cancer patients between the symptomatic and the asymptomatic group.

Role of lymphadenectomy and pelvic radiotherapy in patients with clinical FIGO stage I endometrial adenocarcinoma: an analysis of 208 patients

Two hundred and eight patients with a clinical stage I endometrial carcinoma were studied (164 fulfilled the inclusion criteria). High risk was defined as nonendometrioid, or endometrioid tumors grade 3 (G3), or G2 with any or G1 with deep (>1/2) myometrial infiltration. The low-risk group consisted of the remaining patients. Surgical staging in the high-risk group included pelvic lymphadenectomy with para-aortic lymphadenectomy in selected cases. Twelve percent of the high-risk patients had nodal metastasis. Patients with low-risk (group A, n = 85) and high-risk disease confined to the uterus (group B, n = 57) did not receive adjuvant radiotherapy. Patients with nodal metastases (group C, n = 10) received postoperative irradiation. The total recurrence rate of the entire population was 12.5%, and the actuarial overall survival, disease-specific survival, and disease-free survival were 90%, 94%, and 88%, respectively. All patients with only vaginal relapse (n = 9) were cured locally with salvage radiotherapy until the date of analysis. The pelvic relapse rate was low as only one patient of group B recurred in the pelvis. In conclusion, lymphadenectomy remains indicated to better select patients at high risk of pelvic recurrence that may benefit from postoperative radiotherapy.

Predictors of vaginal relapse in stage I endometrial cancer

Objective To identify factors predictive of vaginal relapse in stage I endometrial cancer, thereby potentially facilitating the selection of patients who may benefit from vaginal brachytherapy. Methods The study population included 632 patients with stage I endometrial cancer managed with hysterectomy at our institution between 1984 and 1996. Median follow-up was 73 months; 122 patients (19%) received adjuvant radiotherapy. Results Overall, 2.9% of the stage I cohort developed vaginal relapse at 5 years. Vaginal relapse was observed in 1.7% of patients who received radiotherapy and in 3.0% of those whose treatment did not include radiotherapy ( P = 0.36). Cox regression analysis (including radiotherapy) identified only grade 3 differentiation (hazard ratio = 3.83, P = 0.007) as an independent predictor of vaginal relapse. Patients with a low-grade tumor had a 5-year vaginal relapse rate of 2%, compared with 7% for those with a grade 3 tumor. When only patients who did not receive adjuvant radiotherapy were considered, both grade 3 tumor and lymphovascular invasion were significant predictors of vaginal relapse ( P < 0.05). When neither variable was present, 2% of patients experienced vaginal relapse at 5 years, compared with 11% when either 1 was present ( P < 0.001). Depth of myometrial invasion was not a significant predictor of vaginal recurrence. Conclusion Histologic grade 3 tumor and lymphovascular invasion were the cogent predictors of vaginal relapse in our population. The cost and morbidity of vaginal brachytherapy should be balanced against the potential risk of vaginal relapse in this group of patients.

109 Clinical outcome of re-irradiated patients for isolated vaginal relapse for cervix cancer

109 Clinical outcome of re-irradiated patients for isolated vaginal relapse for cervix cancer

Fractionated stereotactic radiotherapy boost for gynecologic tumors: An alternative to brachytherapy?

A brachytherapy (BT) boost to the vaginal vault is considered standard treatment for many endometrial or cervical cancers. We aimed to challenge this treatment standard by using stereotactic radiotherapy (SRT) with a linac-based micromultileaf collimator technique. Since January 2002, 16 patients with either endometrial (9) or cervical (7) cancer have been treated with a final boost to the areas at higher risk for relapse. In 14 patients, the target volume included the vaginal vault, the upper vagina, the parametria, or (if not operated) the uterus (clinical target volume [CTV]). In 2 patients with local relapse, the CTV was the tumor in the vaginal stump. Margins of 6-10 mm were added to the CTV to define the planning target volume (PTV). Hypofractionated dynamic-arc or intensity-modulated radiotherapy techniques were used. Postoperative treatment was delivered in 12 patients (2 x 7 Gy to the PTV with a 4-7-day interval between fractions). In the 4 nonoperated patients, a dose of 4 Gy/fraction in 5 fractions with 2 to 3 days' interval was delivered. Patients were immobilized in a customized vacuum body cast and optimally repositioned with an infrared-guided system developed for extracranial SRT. To further optimize daily repositioning and target immobilization, an inflated rectal balloon was used during each treatment fraction. In 10 patients, CT resimulation was performed before the last boost fraction to assess for repositioning reproducibility via CT-to-CT registration and to estimate PTV safety margins around the CTV. Finally, a comparative treatment planning study between BT and SRT was performed in 2 patients with an operated endometrial Stage I cancer. No patient developed severe acute urinary or low-intestinal toxicity. No patient developed urinary late effects (>6 months). One patient with a vaginal relapse previously irradiated to the pelvic region presented with Grade 3 rectal bleeding 18 months after retreatment. A second patient known to suffer from irritable bowel syndrome presented with Grade 1 abdominal pain after treatment. The estimated PTV margins around the CTV were 9-10 mm with infrared marker registration. External SRT succeeded in improving dose homogeneity to the PTV and in reducing the maximum dose to the rectum, when compared to BT. These results suggest that the use of external SRT to deliver a final boost to the areas at higher risk for relapse in endometrial or cervical cancer is feasible, well tolerated, and may well be considered an acceptable alternative to BT.

Survival after relapse in patients with endometrial cancer: results from a randomized trial☆

Objective The aim of this study was to determine the rates of local control and survival after relapse in patients with stage I endometrial cancer treated in the multicenter randomized PORTEC trial. Methods The PORTEC trial included 715 patients with stage 1 endometrial cancer, either grade 1 or 2 with deep (>50%) myometrial invasion or grade 2 or 3 with <50% invasion. In all cases an abdominal hysterectomy was performed, without lymphadenectomy. After surgery, patients were randomized to receive pelvic RT (46 Gy) or no further treatment. Results The analysis was done by intention-to-treat. A total of 714 patients were evaluated. At a median follow-up of 73 months, 8-year actuarial locoregional recurrence rates were 4% in the RT group and 15% in the control group ( P < 0.0001). The 8-year actuarial overall survival rates were 71 (RT group) and 77% (control group, P = 0.18). Eight-year rates of distant metastases were 10 and 6% ( P = 0.20). The majority of the locoregional relapses were located in the vagina, mainly in the vaginal vault. Of the 39 patients with isolated vaginal relapse, 35 (87%) were treated with curative intent, usually with external RT and brachytherapy, and surgery in some. A complete remission (CR) was obtained in 31 of the 35 patients (89%), and 24 patients (77%) were still in CR after further follow-up. Five patients subsequently developed distant metastases, and 2 had a second vaginal recurrence. The 3-year survival after first relapse was 51% for patients in the control group and 19% in the RT group ( P = 0.004). The 3-year survival after vaginal relapse was 73%, in contrast to 8 and 14% after pelvic and distant relapse ( P < 0.001). At 5 years, the survival after vaginal relapse was 65% in the control group compared to 43% in the RT group. Conclusion Survival after relapse was significantly better in the patient group without previous RT. Treatment for vaginal relapse was effective, with 89% CR and 65% 5-year survival in the control group, while there was no difference in survival between patients with pelvicrelapse and those with distant metastases. As pelvic RT was shown to improve locoregional control significantly, but without a survival benefit, its use should be limited to those patients at sufficiently high risk (15% or over) for recurrence in order to maximize local control and relapse-free survival.

Outcome after salvage radiotherapy (brachytherapy +/− external) in patients with a vaginal recurrence from endometrial carcinomas

Background and purpose: The vagina is the site most commonly affected by loco-regional failure in endometrial carcinoma (EC). The aim of this study was to evaluate the efficacy of vaginal brachytherapy (BT) combined or not with whole pelvic external radiotherapy (RT) for the treatment of patients with vaginal recurrences from endometrial cancer. Patients and methods: Between 1986 and 1999 25 women were treated at the Institut Gustave Roussy (IGR) for a vaginal relapse (VR) from EC. Patient characteristics were as follows: median age 65 years (range 43–84), histologic type: adenocarcinoma (21 patients); endometrioid carcinoma (three patients); adenoacanthoma (one patient); FIGO staging for initial disease: Ia, three; Ib, eight; Ic, four; II, seven; IIIa, two; IVa, one. The initial tumor was treated by surgery alone in 18 patients, or surgery combined with RT and/or BT in seven patients. A VR occurred in a median interval of 21 months (range 2–89); 10/25 (40%) occurred within the first year following initial treatment. The recurrence was exclusively in the vagina in 18 patients and was associated with parametrial and or nodal involvement in seven patients; it was localized in the upper 1/3 of the vagina in nine patients, in the upper 2/3 or the entire vagina in 11 patients or in the lower 1/3 in five patients. The largest tumor diameter ranged from 10 to 70 mm (median: 25 mm). The treatment of the VR included low-dose rate endocavitary BT in all cases: three patients received endocavitary BT alone, or it was associated with external RT in 22 patients or delivered after surgical removal of the lesion in nine patients. Seven patients were submitted to further irradiation combining endocavitary and interstitial BT. Results: Local control was achieved in 23 patients (92%). With a follow-up ranging from 4 to 154 months, 13 patients have died (ten due to metastasis, two of intercurrent disease and two due to local tumor progression) and ten patients are alive and disease free. The 3-year actuarial survival was 48%. Late radiation-related sequelae were observed in nine patients (mucous necrosis in one patient, moderate sclerosis in six patients) in an interval varying between 8 and 45 months. The majority of recurrences occurred in patients who had not previously received irradiation, which emphasizes the role of systematic prophylatic post-operative vaginal BT. Extra-vaginal extension ( P<0.001), the tumor size ( P<0.03) and the stage of initial disease ( P<0.01) appeared to have a significant impact on the prognosis. Conclusion: BT combined with external RT is an efficient treatment for VR from EC even in previously irradiated patients. Poor survival remains related to metastatic dissemination.

An investigation into the pathogenesis of vulvo-vaginal candidosis

Objective: To monitor yeasts isolated from women during and between episodes of recurrent vulvo-vaginal candidosis (VVC) to determine whether vaginal relapse or re-infection occurred. Methods: Women presenting at the genitourinary...

Vaginalrezidiv nach Primärtherapie des Endometriumkarzinoms im Stadium FIGO I* - Langzeitbeobachtungen der Freiburger Behandlungsjahrgänge 1969 - 1990 -

Objective. To investigate the prevalence of vaginal recurrence, as defined by Perez and Carmel 1982, after endometrial cancer. We wanted to know whether vaginal relapse depends on initial treatment, risk factors such as depth of infiltration, orading and histological subtype. The results of second line therapy after relapse are demonstrated. Materials and Methods: 2521 patients treated for endometrial cancer at a tertiary reference center (Freiburg university women's hospital) between 1970 and 1990 were identified. Of those 1864 patients had FIGO stage I disease. In a retrospective analysis with a mean follow-up of more than 12 years, time to and type of recurrence were studied in relation to initial treatment and high risk factors (rare subtypes, grading 3 and deep myometrial infiltration. Results: 1732 patients were available for follow-up, 0.9% of the patients had a relapse limited to the vagina, in 1% a combined vaginal-pelvic wall relapse was diagnosed. Together 1.9% of the patients suffered a vaginal recurrence. The rate was highest for women, who had undergone surgery only (7.8%) and lowest for those, who had received adjuvant brachytherapy after surgery (0.5%), Myometrial infiltration, high grading and rate histological subtypes have only limited influence on the oc currence of vaginal relapse. These factors appear to be more strongly associated with pelvic wall recurrence and distant metastasis. A restriction of adjuvant brachytherapy to patients presenting with risk factors would miss the larger proportion of patients, who will later develop a relapse. Median survival after therapy for isolated vaginal relapse was 5.7 years, whereas after combined vaginal-pelvic recurrence only 1.6 years. Condusion: Radiotherapy after hysterectomy can limit the rate of vaginal relapse to 1,9%. Secondline therapy of the isolated vaginal recurrence can yield excellent results with a 5-year survival rate of 51.6%, supporting an aggressive therapentic approach in this situation.

124 Outcome of salvage brachytherapy and external irradiation in vaginal local relapses from endometrial cancers

124 Outcome of salvage brachytherapy and external irradiation in vaginal local relapses from endometrial cancers

Karyotyping Of Candida Albicans Isolates Obtained Longitudinally In Women With Recurrent Vulvovaginal Candidiasis

Ten women with recurrent vulvovaginal candidiasis (RVVC) due to Candida albicans were followed for a mean of 35.3 months, and 81 vaginal isolates were evaluated by pulsed-field gel electrophoresis for strain delineation. The initial strain of C. albicans isolated was unique to each patient; in addition, in 8 women, only 1 strain type of C. albicans was identified throughout follow-up. In 1 patient, 3 strains of C. albicans were identified over a 27-month period and in another, 2 strains were recovered over a 30-month period. Two pairs of women shared identical strains of C. albicans. These results confirm the enormous diversity of strain types of C. albicans and demonstrate the persistence of colonization with the same strain over prolonged periods despite therapy. Results also support the concept of recurrent vaginitis being due to vaginal relapse or endogenous reinfection with the identical strain.

Pathogenesis and Epidemiology of Vulvovaginal Candidiasis

In contrast to women with infrequent episodes of candidal vaginitis, women with chronic and recurrent candidal vaginitis do not have recognizable precipitating or causal factors. Analysis of vaginal yeast isolated from women with recurrent candidal vaginitis, although revealing a higher percentage of non-albicans Candida sp., indicates that resistance to imidazoles is not a causal factor, and other fungal virulence factors that could explain the repeated attacks have not been identified. Strain typing of sequential clinical isolates indicates a pattern of vaginal relapse rather than frequent vaginal reinfection, and attempts to reduce attacks by treating sexual partners and suppressing a gastrointestinal tract focus have failed. Recent immunological studies suggest the possibility of an acquired Candida antigen-specific immunological deficiency resulting in uncontrolled vaginal Candida proliferation and hence repeated clinical attacks. In support of the immunological hypothesis is the recent report of normal T lymphocyte suppression of Candida hyphal production.

Simultaneous presentation of carcinoma involving the ovary and the uterine corpus.

Twenty-nine patients had simultaneous malignant epithelial neoplasms of the uterine corpus and ovary. Three groups were defined on the basis of tumor histology: Group A: those with endometrioid carcinoma in both the uterus and ovary; Group B: those with special variants of corpus carcinoma (papillary, clear cell, mucinous) and identical neoplasms in the ovary; and Group C: those whose uterine and ovarian carcinomas were of dissimilar histologic types. Sixteen women had endometrioid carcinoma in both sites. The median age at diagnosis, 41 years, was younger than is usual for corpus or ovarian cancer. For all 16 patients, the grade of the ovarian endometrioid carcinoma was similar to that of the endometrioid carcinoma of the uterine corpus. Seven patients had bilateral ovarian neoplasms. Only one patient had myometrial invasion by the corpus carcinoma. No patient with simultaneous ovarian and uterine endometrioid carcinoma, regardless of grade, has died of cancer although one vaginal relapse was treated successfully. This excellent survival of patients with simultaneous endometrioid carcinomas is better than would be expected for either Stage III adenocarcinoma of the endometrium or Stage II ovarian carcinoma. These simultaneously occurring endometrioid neoplasms of ovary and endometrium are considered to be separate primary tumors. The morphologic reasons for this view and therapeutic implications are discussed. In contrast to the patients with endometrioid carcinoma, the eleven patients with other histologic types of carcinoma in the ovary and corpus were older (median age, 61 years) and more often postmenopausal (90%). These neoplasms were more aggressive, with frequent deep myometrial involvement (63%), tubal involvement (27%), and extension to other pelvic tissues (36%) at the time of initial diagnosis. Six of these 11 patients succumbed to their cancer despite surgical therapy and radiation. The distribution of tumor in some of these patients with nonendometrioid types of carcinoma is suggestive of a single primary with metastases. The therapeutic implications of these findings are discussed.

Diagnostic and therapeutic viewpoints on cervical intraepithelial neoplasia. 10-Year follow-up of a conization material.

In 429 women with the diagnosis of cancer in situ (CIS), we found, during a follow-up time of 10 years, a relapse frequency of 5.3%; conization was the primary treatment in 414 cases, in 13 cases hysterectomy and radiotherapy in 2 cases. We found that the mean age was significantly higher (p less than 0.01) when the primary CIS lesion was localized in the cervix (36.8 +/- 10.5) compared to localization only on the portio (31.3 +/- 8.7). The risk of relapse was significantly higher (p less than 0.05) in patients where the primary cone had the lesion localized in the cervix compared to the patients where the primary cone had the lesion localized only to the portio. We found that the localization of PAD relapses appearing later compared to a high degree (about 65%) with the localization of the primary CIS lesion. Vaginal relapse was, generally speaking, twice as common when the primary CIS lesion was localized in the cervix compared to when it was localized on the portio alone. Alternative treatment methods to the conization operation are discussed and an increased individualization of CIS treatment is emphasized particularly with consideration to age and the localization of the CIS lesion.

Salvage with radiotherapy of postsurgical relapses of endometrial cancer.

From January 1960 to June 1974, 71 patients with a postsurgical relapse of endometrial adenocarcinoma have been referred to the Radiology Institute of the University of Florence. Eleven patients showed hematogenous metastases; the remaining 60 cases showed locoregional relapses and were treated with radiotherapy. Forty-eight patients, whose relapse was localized to the pelvis, vagina, inguinal nodes or perineal scar, were treated with a radical aim (4,500-6,000 rad in 5-6 weeks); the treatment was palliative in 12 cases with abdominal extrapelvic relapse. The therapeutic response was not evaluated in 8 patients lost to follow-up shortly after the treatment. In the cases treated with a radical scope, a complete regression was attained in 22 of 43 (51%); a survival rate of 16 of 43 (37%) was attained at 5 years. In 9 cases treated with a palliative aim, only subjective remission was attained, and no patient was alive one year after the therapy. The most favorable therapeutic response was attained in the vaginal relapses (50% survivors at 5 years) and the cases with a late recurrence (more than 3 years) after the initial surgery. No definite correlation was found between the prognosis of the relapse and the histological grading of the primary tumor.