International Journal of Radiation Oncology*Biology*Physics
Clinical investigation: cervixOperable Stages IB and II cervical carcinomas: a retrospective study comparing preoperative uterovaginal brachytherapy and postoperative radiotherapy
Introduction
The topic of therapeutic modalities remains controversial for cervical carcinomas that are Stage IB and IIA according to the 1995 FIGO staging system (1) and Stage IIB with 1/3 proximal parametrial involvement according to the Gustave Roussy Institut staging system (2). Three treatment strategies are possible: One is primary surgery with either a Class III radical abdominal hysterectomy as described by Piver et al. (3) or, for selected small tumors ≤2 cm in diameter, a Class II modified radical hysterectomy. A bilateral pelvic lymphadenectomy is usually carried out with or without para-aortic lymph node sampling or lymph node dissection 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13. Postoperative radiation therapy (RT) with or without concomitant chemotherapy is generally prescribed for patients with a high risk of local recurrence 11, 12, 13, 14, 15, 16, 17. A second approach is definitive RT combining external beam pelvic RT (EBPRT) and uterovaginal brachytherapy with or without concurrent chemotherapy, depending on prognostic factors 14, 18, 19, 20, 21, 22, 23, 24, 25. The third treatment strategy uses preoperative RT. Preoperative irradiation can be delivered as uterovaginal brachytherapy for small Stage IB and IIA cervical carcinoma with a low risk of lymph node involvement 2, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, or as EBRT followed or not by preoperative uterovaginal brachytherapy with concurrent chemotherapy for bulky (≥4 cm in diameter) Stage IB2, IIA, and IIB with 1/3 proximal parametrial invasion of the cervix 14, 23, 25, 30, 31, 32. Whatever the tumor size, the three above-described treatment strategies obtain comparable tumor control 12, 33, 34, 35, 36. However, the types of severe complications do differ depending on treatment strategy. The preference for one treatment strategy over another depends on patient status and local tumor characteristics.
To better define the role and toxicity of combined modality therapy with RT and surgery and to know whether RT and surgery should be combined at all, we undertook a statistical analysis of the clinical efficacy between adjuvant preoperative uterovaginal brachytherapy and adjuvant postoperative RT in a retrospective series of 414 patients with early operable clinically node-negative carcinoma of the uterine cervix. The chronology and type of adjuvant RT were not randomized; the usual practices of the surgical teams were applied.
Section snippets
Patients/tumor characteristics
Between May 1972 and January 1994, 414 patients with early operable carcinoma of the uterine cervix were referred to the department of radiation oncology at Tenon Hospital for adjuvant RT. The staging procedure included the following: pelvic examination under anesthesia by a surgeon and a radiation oncologist, exo- and endocervical biopsies, routine blood counts, blood chemistry profile, i.v. pyelogram, cystoscopy, and chest X-ray. During the early period of the study, from May 1972 to December
Recurrences and survival
At the time of analysis, first events included 35 isolated pelvic recurrences, 25 isolated distant metastases, 2 isolated para-aortic lymph node metastases, 11 pelvic recurrences with synchronous metastases, and 2 pelvic recurrences with synchronous para-aortic lymph node metastases (Table 3).
The 5- and 10-year probabilities of isolated locoregional recurrences were 8 ± 3% (291) and 10 ± 3% (184), respectively. The 5- and 10-year probabilities of locoregional recurrences with or without
Discussion
In our series of patients with operable cervical carcinoma, many of the following prognostic factors found to influence disease-free survival have been reported in multiple published series: 1995 FIGO staging system 18, 19, 20, 21, 23, 43, tumor size 7, 18, 19, 20, 21, 24, 43, 44, 45, 46, 47 with a cutoff 4 cm to 5 cm in diameter, depending on the series 20, 22, 23, 25, 43, 44, 45, 46, 47, histologic pelvic or para-aortic lymph node involvement 2, 18, 19, 43, 45, 48, 49, the number of positive
Conclusion
Choice of therapeutic modalities and strategy remains controversial for operable Stages I and II cervical carcinoma without clinical pelvic lymph node involvement. In our retrospective comparative study, disease control was not significantly different in patients treated with postoperative radiotherapy as compared with those treated with preoperative uterovaginal brachytherapy. When postoperative external beam pelvic radiotherapy is indicated to increase disease control, the risk of late severe
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