Lack of effect of tumor size on the prognosis of carcinoma of the uterine cervix stage IB and IIA treated with preoperative irradiation and surgery

doi:10.1016/S0360-3016(99)00217-5

International Journal of Radiation OncologyBiologyPhysics

Volume 45, Issue 3, October 1999, Pages 645-651

https://doi.org/10.1016/S0360-3016(99)00217-5 Get rights and content

Abstract

Purpose: The purpose of this analysis was to evaluate the prognostic significance of cervical tumor size in patients with Stages Ib and IIa carcinoma of the cervix treated with preoperative irradiation and radical or conservative hysterectomy.

Methods and Materials: This study is a retrospective analysis of 177 patients. One hundred forty-one patients had Stage Ib and 36 patients had Stage IIa carcinoma of the cervix. All patients were treated with preoperative irradiation and surgery. Radiation therapy consisted of external pelvic irradiation and intracavitary brachytherapy; total doses ranged from 30 to 60 Gy to the pelvic sidewall and 60 to 70 Gy to point A. Surgery consisting of radical hysterectomy and lymph node dissection or a conservative hysterectomy and lymph node dissection was performed 4 to 6 weeks after completion of irradiation.

Results: The 5-year progression-free survivals were 80% for Stage Ib and 63% for Stage IIa (p = 0.03). The 5-year cumulative pelvic failure rates for Stage Ib were 16% for tumors <3 cm and 9% for tumors >3 cm (p = 0.90). The 5-year cumulative pelvic failure rates for Stage IIa were 22% for tumors <3 cm and 22% for tumors >3 cm (p = 0.75). The corresponding cumulative distant metastasis failure rates at 5 years for Stage Ib were 21% for tumors <3 cm and 21% for tumors >3 cm (p = 0.60). For patients with Stage IIa disease, the 5-year cumulative distant metastasis rates were 33% for tumors <3 cm and 36% for tumors >3 cm (p = 0.70). A multivariate analysis was performed to evaluate prognostic factors for the endpoint of progression-free survival. The variables that were analyzed were patient age, tumor histology, tumor size, clinical stage, point A and pelvic lymph node irradiation dose, and cervical tumor status and pelvic lymph node status at the time of hysterectomy. The variables that were found to be of independent significance for progression-free survival by multivariate analysis were pelvic lymph node irradiation dose (p <0.001), pelvic lymph node status at the time of hysterectomy (p = 0.01), and clinical stage (p = 0.02). Cervical tumor size at the time of diagnosis and the presence of tumor cells in the cervix in the hysterectomy specimen was not an independent prognostic factor by multivariate analysis. The overall severe complication rate was 11% for all patients.

Conclusions: For this population of patients treated with preoperative irradiation and surgery, pelvic lymph node status at the time of hysterectomy and the preoperative irradiation dose to the pelvic lymph nodes are independent predictors of progression-free survival and the development of distant metastasis. The pretreatment cervical tumor size is of less importance for predicting progression-free survival and the development of distant metastasis but clinical stage is an important prognostic variable. These results are in contrast with those of surgery or irradiation alone, in which primary tumor size is a critical prognostic factor for all outcome parameters.

Introduction

Results of therapy for patients with carcinoma of the uterine cervix are most often reported by clinical stage of the tumor. However, in patients treated with radical surgery or irradiation alone size of the primary cervical lesion is of prognostic significance irrespective of the clinical stage of the tumor 1, 2, 3, 4, 5. Additionally, the status of the pelvic and para-aortic lymph nodes is of prognostic significance for survival (6).

The results of radiation therapy alone for patients with clinical Stages Ib and IIa carcinoma of the cervix from the Mallinckrodt Institute of Radiology (7) indicate that the 5-year progression-free survivals for patients with clinical Stage Ib disease are 100% for tumors <1 cm, 93% for 1 to 2 cm, 98% for 2 to 3 cm, 83% for 3 to 4 cm, and 76% for lesions >4 cm. The findings were similar for patients with clinical stage IIa cancer. The 5-year progression-free survivals are 100% for tumors <1 cm, 100% for 1 to 2 cm, 75% for 2 to 3 cm, 66% for 3 to 4 cm, and 61% for >4 cm. Perez et al. (8) reported that for Stage IIb, the pelvic failure rate was 23% for tumors less than 5 cm and 34% for tumors greater than 5 cm. In Stage III, unilateral parametrial involvement was associated with a 32% pelvic failure rate versus 50% for bilateral parametrial extensions. The pelvic lymph node status was not usually histologically confirmed by fine needle aspiration for these patients but lymphangiography was frequently performed. None of the patients underwent surgical staging.

Similar results are reported for patients treated with a radical hysterectomy and lymph node dissection. Surgical results can also be correlated to tumor size. Piver and Chung (5) reported the 5-year survivals for women treated with a radical hysterectomy and lymph node dissection. The survivals for women with Stage Ib tumors were 84% for tumors <1 cm, 90% for 2 to 3 cm, 66% for 4 to 5 cm, and 60% for tumors >6 cm. For those patients with Stage IIa disease the survivals are 82% for tumors <1 cm, 72% for 2 to 3 cm, 38% for 4 to 5 cm, and 41% for >6 cm. Evaluation of survival by pelvic lymph node status indicated that the patients with Stage Ib disease and negative lymph nodes had a 91% survival. Survival for those with positive lymph nodes ranges from 56% to 75% depending on the number of positive lymph nodes. Patients with Stage IIa disease and negative lymph nodes had a 67% survival compared to 17 to 33% for those with positive lymph nodes.

Preoperative irradiation and surgery has been used to treat patients with bulky and barrel-shaped cervical lesions greater than 5 to 6 cm in diameter. However, this current study is a retrospective analysis of the effect of tumor size for patients with Stages Ib and IIa cervical cancer treated with a range of doses of radiation therapy followed by surgery as part of two prospective studies to evaluate the therapeutic efficacy of these two treatment modalities 9, 10. Therefore, the patient population for this current study included both patients with small, nonbulky cervical cancers and patients with large, barrel-shaped tumors (greater than 5 to 6 cm).

The present report analyzes the results of patients treated with a combination of irradiation and surgery for invasive carcinoma of the cervix. The purpose of this analysis was to evaluate the prognostic significance of cervical tumor size in patients with Stages Ib and IIa carcinoma of the cervix treated with preoperative irradiation and radical or conservative hysterectomy.

Section snippets

Methods and materials

This study includes 177 patients with the diagnosis of Stages Ib and IIa carcinoma of the uterine cervix who were treated with preoperative irradiation and surgery at Washington University Medical Center, St. Louis, Missouri. Therapy was initiated between 1959 and 1989, inclusive. All patients have been followed for a minimum of 5 years; median follow-up was 11 years and maximum 23 years. Cervical biopsies were obtained in all patients. Patients were evaluated by medical history and a physical

Results

The progression-free survivals for all patients by clinical stage are shown in Fig. 1; the 5- and 10-year survivals were 80% and 78% for Stage Ib and 63% and 57% for Stage IIa (p = 0.03). Figure 2 shows that the 5- and 10-year cumulative pelvic failure estimates for patients with Stage Ib disease and tumors less than 3 cm in diameter were 16%. The 5- and 10-year rates were 9% and 13% for patients with Stage Ib disease and tumors greater than 3 cm in diameter. There was no statistically

Discussion

It is generally accepted that the outcome of patients with carcinoma of the uterine cervix is affected by several tumor-related variables, which include tumor size, histology, and clinical stage. Other known prognostic factors that are tumor-related, but generally not known or accurately evaluated in patients undergoing radiotherapy for their disease, are lymph–vascular space invasion, lymph node involvement, and number of lymph nodes that are involved with tumor. Because there are inherent

Conclusion

The data from this study demonstrate that if the prognostic significance of primary tumor size is eliminated, and clinical stage is accounted for, the most significant prognostic factors for progression-free survival and the development of distant metastasis are the status of the lymph nodes at the time of surgery and the preoperative pelvic lymph node irradiation dose. The implication of this finding is that when patients are treated with radiation therapy alone, a sufficient irradiation dose

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Cited by (23)

Outcome of early stage cervical cancer patients treated according to a radiosurgical approach: Clinical results and prognostic factors
2017, Gynecologic Oncology
Citation Excerpt :
The rationale of this debated option is to optimize the local control and to potentially decrease the need for postoperative EBRT because of adverse histological findings on hysterectomy specimen. Although no randomized trial has demonstrated the benefit of a preoperative brachytherapy in patients with an early stage cervical cancer, retrospective reports have examined the clinical outcome of patients treated according to this radiosurgical modality and shown high local control rates and a satisfactory toxicity profile [6–14]. Our retrospective experience of preoperative brachytherapy as part of a multimodal strategy is reported.
To report clinical results of a multimodal strategy based on preoperative brachytherapy followed with surgery in early stage cervical cancer.
The outcome of consecutive patients receiving brachytherapy in our Institution for an early stage IB1-IIA1 invasive cervical cancer with risk factors (lymphovascular embols and/or tumor > 2 cm) between 2000 and 2013 was analyzed. The treatment consisted of preoperative low dose or pulse dose-rate utero-vaginal brachytherapy followed, 6–8 weeks later, by a radical hysterectomy/bilateral salpingo-oophorectomy plus pelvic ± para-aortic lymph node dissection. A postoperative chemoradiation was delivered in patients with histological evidence of lymph nodes metastases.
182 patients were identified. Histological examination of hysterectomy specimen showed the presence of a tumor residuum in 55 patients (30.2%). One patient (0.5%) had residual tumor cells in the parametria. With a median follow-up of 5.3 years, 14 patients (7.7%) presented tumor relapse, including three (1.6%) local relapses. Five-year disease-free survival (DFS) rate was 93.6% (95%CI: 91.6–95.6%). In log-rank analysis, presence of pelvic nodal metastases at time of lymphadenectomy (p = 0.001) and tumor size ≥ 3 cm (p = 0.003) correlated with a poorer DFS. Presence of a tumor residuum on hysterectomy specimen correlated with a higher risk of pelvic or para-aortic failure (p = 0.035). A time interval > 10 weeks between brachytherapy and surgery correlated with a higher risk of failure outside the pelvis (p = 0.003). Significant postoperative complications were reported in 16 patients (8.8%). All delayed toxicities were mild to moderate.
A preoperative brachytherapy is a safe and effective option in early stage cervical cancer.
Preoperative image-guided brachytherapy in early stage cervical cancers
2016, Radiotherapy and Oncology
To examine the clinical results of a preoperative image-guided pulse-dose-rate brachytherapy (PDR-BT) in early stage cervical cancer.
We examined the outcome of consecutive patients with early stage cervical cancer undergoing preoperative image-guided PDR-BT between 2004 and 2013 because of risk factors (lymphovascular embols and/or tumour > 2 cm). The objective was to deliver 60 Gy to 100% of the intermediate risk clinical target volume. Brachytherapy was followed, 6–8 weeks later, by a radical hysterectomy/bilateral salpingo-oophorectomy plus pelvic +/− para-aortic lymph node dissection. Patients with positive lymph nodes had postoperative chemoradiation.
77 patients met the above criteria of preoperative PDR-BT. On hysterectomy specimen, 54 (70.1%) presented a complete histological response. Four (5.2%) had a tumour residuum ⩾ 1 cm. Median follow-up was 46.8 months. 5-Year disease-free survival (DFS) rate was 84.4%. Only one local recurrence was observed. The presence of lymph nodal metastases, a tumour size > 3 cm and a brachytherapy/surgery time interval ⩾ 9 weeks correlated with a poorer DFS. Six postoperative complications were encountered (7.8%). Total reference air kerma correlated with late vaginal toxicity (p = 0.02).
A preoperative image-guided PDR-BT was safe and effective. Predictive factors for survival and toxicity were evidenced.
Interstitial preoperative high-dose-rate brachytherapy for early stage cervical cancer: Dose-volume histogram parameters, pathologic response and early clinical outcome
2013, Brachytherapy
Citation Excerpt :
However, HDR regimen remains the unique brachytherapy procedure, which enables a treatment in a nonshielded room leading to greater patient quality of life (possible family visits and no sensation of loneliness) (27). We obtained a high rate of complete pathologic response despite an EQD2 of 47 Gyαβ10, which could be judged insufficient compared with the standard dose of 60 Gy classically delivered through LDR brachytherapy (13–17). The rational of this specific HDRB protocol derived from interstitial HDRB was used for partial breast irradiation.
To analyze dose–volume histogram parameters and pathologic response after preoperative high-dose-rate brachytherapy (HDRB) for high-risk early stage cervical cancers (ESCCs).
From June 2007 to December 2011, 32 patients with a histologically proven invasive cervical cancer with high risk of local recurrence (size >2 cm, adenocarcinoma type, perineural and/or lymphovascular invasion) underwent a preoperative HDRB, which delivered a total dose of 39 Gy in nine fractions over 5 days. All the patients underwent hysterectomy after HDRB.
With a median clinical target volume of 50 cc (minimum–maximum, 42–74), the median V₁₀₀ was 49 cc (minimum–maximum, 42–50). Median D₉₀ was 45 Gy (equivalent dose at 2 Gy per fraction, 56 Gy_αβ10). Median D_2cc was 34 Gy, 31 Gy, 28 Gy, and 38 Gy_αβ3 for bladder, rectum, sigmoid, and vagina, respectively. Twenty-eight patients (88.5%) achieved a complete histologic response after surgery, whereas for the 4 remaining patients, residual tumor cells (3 patients) and gross residual disease (1 patient) were observed in the pathologic specimen. With a median followup of 24 months (minimum–maximum, 5–48), no local recurrence was observed; 1 patient died of intercurrent cause. Early toxicity occurred within the 30 days after HDRB (Common Terminology Criteria for Adverse Events v3.0) was G1 diarrhea for 15 patients (47%) and G1 urinary frequency or urgency for 13 patients (40.6%). No G2–G3 toxicities were noticed.
Preoperative HDRB for high-risk ESCCs represents a well-tolerated procedure, which leads to a high rate of postoperative pathologic response. Dose–volume histogram parameters were at least equivalent to those obtained with a low-dose-rate procedure. Long-term results will help to analyze the place of preoperative brachytherapy in the management of high-risk ESCCs.
Change in T2-fat saturation MRI correlates with outcome in cervical cancer patients
2011, International Journal of Radiation Oncology Biology Physics
To compare pretreatment and midtreatment tumor intensity as measured by T2 fat-saturation (T2-FS) MRI and its association with treatment response in cervical cancer patients.
Weekly MRI scans were performed for brachytherapy planning on 23 consecutive patients with clinical Stage IB1 to IIIB cervical cancer treated with definitive chemoradiotherapy. These scans were performed on a 1.5-T clinical scanner using a specialized pelvic coil. Mean signal intensity from T2-FS imaging was calculated for each tumor voxel. Average tumor intensity and tumor volume were recorded pre- and midtreatment (at Weeks 0 and 4). All patients subsequently underwent routine follow-up, including periodic clinical examinations and fluorodeoxyglucose–positron emission tomography imaging.
Mean follow-up for surviving patients was 14.5 months. Mean tumor volume at presentation was 49.6 cc, and mean midtreatment tumor volume was 16.0 cc. There was no correlation between initial tumor volume and pretreatment signal intensity (r = 0.44), nor was there a correlation between pre- or midtreatment tumor volume with disease-free survival (p = 0.18, p = 0.08 respectively.) However, having at least a 30% drop in signal intensity from pretreatment to midtreatment was correlated with having disease resolution on posttreatment fluorodeoxyglucose–positron emission tomography imaging (p = 0.05) and with disease-free survival (p = 0.03.) Estimated disease-free survival at 22 months was 100% for patients with at least a 30% drop in tumor signal intensity compared with 33% for patients above this selected threshold (p = 0.004).
Longitudinal changes in T2-FS tumor intensity during chemoradiation correlated with disease-free survival in cervical cancer patients. Persistently high midtreatment tumor intensities correlated with a high risk of treatment failure, whereas large decreases in tumor intensity correlated with a favorable outcome.
Preoperative Concurrent Radiation Therapy and Chemotherapy for Bulky Stage IB2, IIA, and IIB Carcinoma of the Uterine Cervix With Proximal Parametrial Invasion
2008, International Journal of Radiation Oncology Biology Physics
Citation Excerpt :
In our series, the para-aortic lymph node recurrence rate was relatively high (15% of patients), but always associated with synchronous pelvic recurrence or metastatic failure. Regardless of the treatment modalities, persistent pathologic pelvic or para-aortic lymph node involvement after preoperative RT with or without concurrent CT is considered to be one of the most sensitive prognostic factors (5, 18–20, 36). Extraperitoneal laparoscopic pelvic or para-aortic dissection before receiving concomitant chemotherapy (37–39) could improve selection of the treatment strategy and more accurately adopt the irradiated volume with a low risk of severe radiation-induced complications.
To evaluate toxicity, local tumor control, and survival after preoperative chemoradiation for operable bulky cervical carcinoma.
Between December 1991 and July 2006, 92 patients with operable bulky stage IB2, IIA, and IIB cervical carcinoma without pelvic or para-aortic nodes on pretreatment imaging were treated. Treatment consisted of preoperative external beam pelvic radiation therapy (EBRT) and concomitant chemotherapy (CT) during the first and fourth weeks of radiation combining 5-fluorouracil and cisplatin. The pelvic radiation dose was 40.5 Gy over 4.5 weeks. EBRT was followed by low-dose rate uterovaginal brachytherapy with a total dose of 20 Gy in 62 patients. After a median rest period of 44 days, all patients underwent Class II modified radical hysterectomy with bilateral pelvic lymphadenectomy. Thirty patients who had not received preoperative uterovaginal brachytherapy underwent postoperative low-dose-rate vaginal brachytherapy at a dose of 20 Gy. The mean follow-up was 46 months.
Pathologic residual tumor was observed in 43 patients. After multivariate analysis, additional preoperative uterovaginal brachytherapy was the single significant predictive factor for pathologic complete response rate (p = 0.019). The 2- and 5-year disease-free survival (DFS) rates were 80.4% and 72.2%, respectively. Pathologic residual cervical tumor was the single independent factor decreasing the probability of DFS (p = 0.020). Acute toxicities were moderate. Two severe ureteral complications requiring surgical intervention were observed.
Concomitant chemoradiation followed by surgery for operable bulky stage I-II cervical carcinoma without clinical lymph node involvement can be used with acceptable toxicity. Pathologic complete response increases the probability of DFS.
Preoperative concurrent radiation therapy and chemotherapy for operable bulky carcinomas of uterine cervix stages IB2, IIA, and IIB with proximal parametrial invasion
2004, Cancer/Radiotherapie
Objectif de l'étude. – Évaluation des résultats préliminaires en termes de toxicité, de contrôle tumoral local et de survie après une chimioradiothérapie préopératoire dans les carcinomes du col utérin de gros volume opérables.
Patientes et méthodes. – De décembre 1991 à octobre 2001, 42 patientes atteintes d'un cancer du col utérin de stades IB2 (11 patientes), IIA (15 patientes) et IIB proximal (16 patientes) ont reçu une chimioradiothérapie préopératoire. L'âge médian était de 45 ans (extrêmes : 24–75 ans) et la taille clinique médiane de 5 cm (extrêmes : 4,1–8 cm). La présence de signes radiologiques d'envahissement ganglionnaire pelvien a été observée chez dix patientes. La radiothérapie externe pelvienne a délivré 40,50 Gy en 4,5 semaines et était associée à une chimiothérapie par cisplatine et 5-fluoro-uracile administrée la 1^re et la 4^e semaine de radiothérapie externe pelvienne. Une curiethérapie utérovaginale de bas débit de dose de complément de 20 Gy a été réalisée chez 17 patientes dont l'anatomie était favorable. Après un repos de cinq à six semaines, une hystérectomie élargie non conservatrice de type Piver II avec curage ganglionnaire iliaque bilatéral a été réalisée. Un curage ganglionnaire lombo-aortique a été effectué dans huit cas, il était indemne de tumeur. Vingt et une des 25 patientes qui n'avaient pu bénéficier d'une curiethérapie préopératoire ont reçu une curiethérapie vaginale postopératoire de bas débit de dose de 20 Gy. Le recul médian était de 31 mois (extrêmes : 3–123 mois).
Résultats. – Un résidu tumoral histologique, quelle que soit sa topographie, a été observé dans 23 cas. Parmi les 22 patientes (52 %) ayant un résidu tumoral cervical histologique (< 0,5 cm : 9 patientes ; ≥ 0,5 cm et ≤ 1 cm : 3 patientes ; > 1 cm : 10 patientes), sept avaient reçu une radiothérapie externe pelvienne suivie d'une curiethérapie utérovaginale préopératoire contre 15 traitées par irradiation externe pelvienne préopératoire seule (p = 0,23). Un envahissement ganglionnaire pelvien histologique a été observé dans quatre cas, un résidu tumoral dans la collerette vaginale dans trois cas et paramétrial dans quatre cas. Les taux de survie globale et de survie sans rechute à deux et cinq ans étaient respectivement de 85 et 74 % et de 80 et 71 %. Après analyse multifactorielle, seule la taille du résidu cervical histologique était un facteur indépendant de la survie sans rechute (p = 0,0054). Les taux de contrôle tumoral local et métastatique à cinq ans étaient respectivement de 90 et 83,5 %. La tolérance hématologique au cours de la chimioradiothérapie a été bonne, mais six patientes ont souffert d'une toxicité digestive aiguë de grade 3. Quatre complications sévères tardives ont nécessité une réparation chirurgicale (digestive : 1, urétérale : 3).
Conclusion. – La chimioradiothérapie suivie d'une chirurgie d'exérèse de type Piver II dans les cancers du col utérin de stades I et II de gros volume opérables est faisable avec une toxicité acceptable. Cependant, le taux de contrôle tumoral pourrait être amélioré par l'utilisation plus systématique de la curiethérapie utérovaginale de complément préopératoire.
Purpose. – To evaluate preliminary results in terms of toxicity, local tumour control, and survival after preoperative concomitant chemoradiation for operable bulky cervical carcinomas.
Patients and methods. – Between December 1991 and October 2001, 42 patients (pts) with bulky cervical carcinomas stage IB2 (11 pts), IIA (15 pts), and IIB (16 pts) with 1/3 proximal parametrial invasion. Median age was 45 years (range: 24–75 years) and clinical median cervical tumour size was 5 cm (range: 4.1–8 cm). A clinical pelvic lymph node involvement has been observed in 10 pts. All patients underwent preoperative external beam pelvic radiation therapy (EBPRT) and concomitant chemotherapy during the first and the fourth radiation weeks combining 5-fluorouracil and cisplatin. The pelvic dose was 40.50 Gy over 4.5 weeks. EBPRT was followed by low-dose-rate uterovaginal brachytherapy with a total dose of 20 Gy in 17 pts. After a rest period of 5–6 weeks, all pts underwent class II modified radical hysterectomy with bilateral lymphadenectomy. Para-aortic lymphadenectomy was performed in eight pts without pathologic para-aortic lymph node involvement. Twenty-one of 25 pts who had not received preoperative uterovaginal brachytherapy underwent postoperative low-dose-rate vaginal brachytherapy of 20 Gy. The median follow-up was 31 months (range: 3–123 months).
Results. – Pathologic residual tumour or lymph node involvement was observed in 23 pts. Among the 22 pts with pathologic residual cervical tumour (<0.5 cm: nine pts; ≥0.5 to ≤1 cm: three pts; >1 cm: 10 pts), seven underwent preoperative EBRT followed by uterovaginal brachytherapy vs. 15 treated with preoperative EBRT alone (P = 0.23). Four pts had pathologic lymph node involvement, three pts had vaginal residual tumour, and four pts had pathologic parametrial invasion. The 2- and 5-year overall survival rates were 85% and 74%, respectively. The 2- and 5-year disease-free survival (DFS) rates were 80% and 71%, respectively. After multivariate analysis, the pathologic residual cervical tumour size was the single independent factor decreasing the probability of DFS (P = 0.0054). The 5-year local control rate and metastatic failure rate were 90% and 83.5%, respectively. Haematological effects were moderate. However, six pts had grade 3 acute intestinal toxicity. Four severe late complications requiring surgical intervention were observed (one small bowel complication, three ureteral complications).
Conclusion. – Primary concomitant chemoradiation followed surgery for bulky operable stage I–II cervical carcinomas can be employed with acceptable toxicity. However, systematic preoperative uterovaginal brachytherapy should increase local tumour control.

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Clinical InvestigationsLack of effect of tumor size on the prognosis of carcinoma of the uterine cervix stage IB and IIA treated with preoperative irradiation and surgery

Abstract

Introduction

Section snippets

Methods and materials

Results

Discussion

Conclusion

The influence of tumor size and morphology on the outcome of patients with FIGO stage IB squamous cell carcinoma of the uterine cervix

Int J Radiat Oncol Biol Phys

Relationship of lesion size to survival in patients with stage IB squamous cell carcinoma of the cervix uteri treated by radiation therapy

Surg Gynecol Obstet

Prognostic factors for risk of recurrence in stages Ib and IIa cervical cancer

Bailleres Clin Obstet Gynaecol

Effect of tumor size on prognosis of carcinoma of uterine cervix treated with irradiation alone

Cancer

Prognostic significance of cervical lesion size and pelvic node metastasis in cervical carcinoma

Obstet Gynecol

Prospective surgical–pathological study of disease-free interval in patients with stage IB squamous cell carcinoma of the cervixA Gynecologic Oncology Group study

Gynecol Oncol

Primary radiotherapy for stage IB or IIA cervical cancer

Monogr Natl Cancer Inst

Tumor size, irradiation dose, and long-term outcome of carcinoma of uterine cervix

Int J Radiat Oncol Biol Phys

Clinical Investigations
Lack of effect of tumor size on the prognosis of carcinoma of the uterine cervix stage IB and IIA treated with preoperative irradiation and surgery