CASE HISTORY

Sent to radiotherapy department with a diagnosis of carcinoma of the cervix, stage II, (confirmed by biopsy), following a 7 months' history of increasing vaginal bloodstained discharge. She had one normal pregnancy in her twenties, the monopause had started 2 years before this admission to hospital. Additional recent symptoms were constipation, nocturnal frequency, slight urinary incontinence, and a loss in weight of 7lbs in 2 months. On examination her general condition appeared good, but in fact she was anaemic, Hb 60%. The cervix was replaced by a proliferative friable growth, which bled profusely when touched. There was induration in the anterior and posterior formix on both sides. She was treated by a combination of 3 successive radium insertions and deep Xray therapy calculated to give a total irradiation of 9000 r units to point A (2cm above and 2 cm lateral to the external os) and 6000 r to point B (3 cm internal to point A). The radium insertions were done on 12.12.50 and 19.12.50 and 2.1.51. She was given a blood transfusion of 2 pints of packed red cells on 29.12.50. Examination in January 1951 showed a good general condition, though she was still anaemic (Hb 69%). There was a total clinical regression of the cervical growth; the posterior lip of the cervix was markedly indurated. Follow up in March 1951 showed nil abnormal apart from slight thickening of the cervix, all discharge had ceased; there was no bleeding on examination. Biopsies had been taken: (A) on 12.12.50 (pre-radiation), S50/2622; (B) on 19.12.50 (at time of 2nd radium insertion, S50/2680) and (C) on 2.1.51 (at time of 3rd radium insertion S.51/12). (A) shows an anaplastic squamous cell carcinoma very rich in mitoses; in (B) the tumour cells are larger, many nucei are bizarre, mitoses are still present and a very occasional cell shows commencing keratinisation. (C) consists of fibroid cervix cells in which can be seen an islet of anaplastic squamous cancer cells. These section were examined which reported as follows: (A) mitosing cells, 10% Resting 81%, Differentiating 0, Degenerating 6%. (B) Mitosing 1%, resting 74%, differentiating 3%, degenerating 22%. (C) 1 focus of visible cells. Comment: "The cell counts indicate a partial response of the tumour tissue to radiotherapy. Histological prognosis: Unfavourable. The patient was readmitted in June 1951 complaining of lower abdominal pain since April. Examination: general condition good, fixed tender mass in right pelvic wall, small ulcer in vaginal vault, blood stained mucoid discharge. Biopsy of the ulcer (D), G51/391, shows an anaplastic squamous cell carcinoma rich in mitoses. There was no clinical or radiological evidence of distant metastases, the blood urea was 25mgm per 100ml, Hb 92% and on 4.7.51. A pelvic exenteration was performed, i.e. (1) Removal of bladder, uterus, vagina, rectum and anus, together wth associated pelvic lymph-nodes; (2) Bi-lateral transplantation of the ureters into the sigmoid colon; (3) Abdominal wet colostomy, discharging urine and faeces. Specimen (E) G51/464. The postoperative course was complicated by anuria on days 1 to 5 and ileus with vomiting on days 1 to 10. These were overcome with the help of electrolyte and fluid replacement therapy. She was fed mostly intravenous and intragastric drip. The colostomy eventually worked well and both faeces and urine were passed. On day 13 the patient had a haematomosis. The blood urea, which had risen to 144 on the 7th postoperative day and fallen to 92 on the 14th, began to rise again. It was 138 on the 19th postoperative day and 274 on the 23rd day, when the patient died of peripheral circulatory failure.

PATHOLOGY

Sagittal section through pelvic exenteration operation specimen, consisting of right half of bladder, uterus and rectum, and of right tubes and ovary. The front of the specimen shows an almost total loss of cervix which is replaced by a raw roughened brown pigmented area extending upwards into the pouch of Douglas and forwards to abut upon but not involve the right ureter. The fimbrial end of the right tube is swollen.