Laparoscopic surgery in treatment of stage IIb cervical cancer after neoadjuvant chemotherapy. A case report and review of the literature

BACKGROUND: A detailed operative procedure of laparoscopic radical hysterectomy (type III) with pelvic and aortic lymphadenectomy after neoadjuvant chemoterapy in treatment of Stage IIb cervical cancer is described. CASE REPORT: A 50-year-old patient with Stage IIb squamous cell carcinoma of the uterine cervix, who initially was not surgically resectable, received three courses of neoadjuvant chemotherapy that included ifosfamide 5 g/m2, cisplatin 50 mg/m2 and paclitaxel 175 mg/m2 (TIP). Following a partial clinical response to chemotherapy, the patient underwent laparoscopic type III radical hysterectomy with bilateral salpingo-oophorectomy and pelvic and paraaortic lymphadenectomy. The surgical procedure lasted 250 minutes. Blood loss was 310 ml. The patient was discharged on postoperative day 4. The mean length of the resected parametria and paracolpia was 4.1 cm and 2.0 cm, respectively. The number of dissected lymph nodes was 48:29 pelvic and 19 paraaortic nodes. No major intraoperative or postoperative complications occurred. The patient also underwent adjuvant radiation therapy. Follow-up was performed at six months so far. CONCLUSIONS: This experience suggests that such a surgical procedure is safe. Laparoscopic radical hysterectomy potentially allows for decreased perioperative morbidity and blood loss, faster recovery and better cosmetic results. Large studies with long term follow-up are needed to confirm that this approach may be proposed as an alternative to conventional surgery.     

Isolated para-aortic node involvement in stage IB/II cervical carcinoma

The aim of this report was to describe exceptional cases of patients treated for stage Ib and II cervical carcinoma with isolated para-aortic node involvement and to deduce therapeutic implications. Between 1985 and 1998, 491 women with stage IB or II cervical carcinoma underwent radical hysterectomy with systematic pelvic and para-aortic lymphadenectomy. Five patients had para-aortic metastatic nodes but no external iliac, obturator or common iliac node involvement. These five patients had a tumor size >3 cm. According to these cases, in patients with bulky cervical carcinoma systematic complete lymphadenectomy should be performed in order to avoid misdiagnosis of para-aortic node involvement.     

Chemoradiation with adjuvant hysterectomy for stage IB-2 cervical cancer: a 10-year experience

To review outcomes of patients with stage IB-2 cervical carcinoma treated with chemoradiation therapy (CRT) followed by total abdominal hysterectomy (TAH), common iliac and para-aortic lymphadenectomy (PAL). A retrospective review of patients with stage IB-2 cervical cancer treated with CRT followed by TAH/PAL from 1999 to 2009 was performed. Brachytherapy was limited to 1,500–1,800?cGy. Sixty-nine patients were identified. The mean age was 46.7?years, tumor diameter 5.4?cm, and all patients had complete clinical response to CRT. The mean follow-up was 61.7?months. There were no central pelvic relapses and two pelvic sidewall failures (97% pelvic control). The mean time to progression was 31.6?months, and 5-year disease-specific survival was 81%. Three (4.3%) patients developed symptomatic vaginal stenosis. CRT plus adjuvant hysterectomy for stage IB-2 cervical cancer resulted in excellent pelvic control and 5-year survival. Vaginal stenosis was rare.     

Primary malignant melanoma of the uterine cervix: case report and review of the literature.

This is a case report and review of the literature on primary melanoma of the cervix. There have been only 26 published cases of primary cervical melanoma and most are poorly documented and doubtful. The patients' ages ranged from 26 to 78 years old with a mean age of 55 +/- 13 years. The main presenting symptom was vaginal bleeding (83.0%). The majority of the patients, 88%, presented in stage I or II. Treatment varied from a simple excision of a cervical mass to a radical hysterectomy with lymph node dissection and adjuvant radiation or chemotherapy. Our patient presented with vaginal bleeding and was diagnosed as having stage IIa cervical melanoma. She underwent a radical hysterectomy, partial vaginectomy, and pelvic and paraaortic lymph node dissection. She received adjuvant radiation therapy and her survival was 29 months. The prognosis of primary cervical melanoma is usually poor and unpredictable. We recommend a radical hysterectomy and vaginectomy, if necessary, to obtain negative surgical margins of at least 2 cm. We advocate lymphadenectomy only for grossly positive nodes.     

Modification of radiation therapy following operative evaluation of patients with cervical carcinoma

Twelve of thirty-nine patients with cervical cancer who underwent bilateral pelvic and periaortic lymphadenectomy through an extraperitoneal approach had lymph node metastases. Four patients had metastases to pelvic lymph nodes only and eight had metastases to common iliac or periaortic lymph nodes in addition to other pelvic lymph nodes. The operative findings permitted the modification of radiation therapy on the basis of known extent of tumor. All patients with common iliac or periaortic lymph node metastases had ports of external therapy extended to the level of the diaphragm and had more emphasis placed on external radiation therapy and less on intracavitary therapy. The sequence of operation through an extraperitoneal approach followed by conventional or extended radiation therapy was tolerated with minimal morbidity and no mortality.     

放疗对早期子宫颈癌患者移位卵巢功能的影响

目的探讨放疗对早期(Ⅰ~Ⅱa期)宫颈癌患者移位卵巢功能的影响。方法对早期宫颈癌患者62例行广泛性全子宫切除加盆腔淋巴结切除加双侧卵巢结肠旁沟侧方移位术,术后随访患者有无绝经期症状,并测定血清中卵泡刺激素和雌二醇水平以判定卵巢功能。62例患者中, 30例未予任何放疗(G0组); 17例患者仅术前接受了A点剂量为15Gy的腔内后装治疗(G1组); 15例术后予以45~50Gy盆腔外照射(G2组),其中14例术前已接受了放疗(方法同G1组)。结果G0、G1和G2组患者卵巢功能衰竭的发生率分别为20% (6 /30)、35% (6 /17)和64% (9 /14),分别两两比较,差异均有统计学意义(P<0 01); 3组术后发生卵巢功能衰竭的患者中,其平均衰竭时间分别为15 7、12 0和9 2个月,分别两两比较,差异均有统计学意义(P<0 05)。2例(3% )发生了移位卵巢囊肿,未发现卵巢转移。结论早期宫颈癌患者术前或术后放疗均能明显引起卵巢功能衰竭,甚至卵巢移位手术本身也会影响卵巢的功能。     

Intestinal surgery and surgery of urinary tract in treatment of recurrent cervical cancer--case report

A case of a 31-year-old patient admitted to the Institute with a diagnosis of recurrent cervical cancer after radical hysterectomy and radiation therapy 12 months before. The patient had intestinal and urinary obstruction and also the tumor compressed the iliac blood vessels superficially. She underwent clinical examination, pelvic and abdominal ultrasound and multislice CT scan. A recurring tumor with a diameter of 7 cm was diagnosed. It was localized in the left parailiac and obturator region and infiltrated the left ureter, left bladder side wall, sigmoid colon and iliac blood vessels superficially. The patient had left pelvic sidewall relapse, so she underwent a palliative surgical procedure. We evacuated the complete tumor together with the infiltrated parts of the left ureter, sigmoid colon and bladder. At the end of operation left ureterocystoneostomy was performed as well as the Hartmann procedure with anus praeter insertion. There were no significant postoperative complications. After the surgical treatment of the recurrence, we suggested that the patient continue treatment of her disease with chemotherapy.     

Is lymphadenectomy useful in the treatment of endometrial carcinoma?

In our institution endometrial carcinoma stages I and II is treated with uterovaginal brachytherapy and radical hysterectomy with pelvic lymphadenectomy. We have made a retrospective analysis of the results of lymphadenectomy to determine its place in the treatment strategy. Between 1976 and 1986, 155 patients were treated with these modalities (107 were stage I, 48 were stage II). The mean age was 60.2 years. Brachytherapy delivered 60 Gy, and then radical hysterectomy with pelvic lymphadenectomy was performed. Twenty-six patients received pelvic external-beam irradiation because of lymph node involvement and or deep tumor invasion into the myometrium. Fourteen patients (9%) had lymph node involvement. External iliac lymph nodes were involved in 78.5% of these cases. The lymph node involvement rate was higher for patients with stage II disease, patients with grade 3 tumors, and patients in whom there was deep tumor invasion into the myometrium. Pelvic failure rate was 12% for node-negative patients and 36% for node-positive patients. The 5-year actuarial survival rates were 83% for node-negative and 41% for node-positive patients. We administer pelvic external-beam radiotherapy to all stage II patients, grade 2 or 3 patients, and patients in whom there is deep tumor invasion into the myometrium. We do not perform lymphadenectomy on these patients. We perform only external iliac sampling for patients with stage I, grade 1 tumor without deep tumor invasion.     

术中放疗配合根治术治疗Ⅱb期宫颈癌

目的 :探讨术中放疗的实施及对Ⅱb期宫颈癌术中放疗的临床价值。方法 :Ⅱb期宫颈癌患者先体外全盆照射加根治术 ,再术中放疗。盆腔平面照射总剂量为 4 5Gy ,术中一次照射剂量为 17 5～ 2 0Gy。结果 :术中放疗手术时间仅比常规手术延长约 2 0min ,近期无严重并发症发生 ,切口愈合良好 ,不增加住院天数 ,也不影响其他治疗 ,近期疗效满意。结论 :术中放疗可提高肿瘤的局部照射剂量 ,作为一种放疗加量的手段 ,在综合治疗妇科恶性肿瘤中具有一定的临床应用价值     

子宫颈癌术前辅助治疗的规范化

新辅助化疗（neoadjuvant  chemotherapy, NACT）是子宫颈癌术前或放疗前辅助治疗的主要方式,原则上适用于局部晚期（ⅠB3 ～ⅣA期）和部分特殊类型的子宫颈癌患者。顺铂为首选药物,推荐化疗2～3个疗程。肿瘤直径大于4 cm的ⅠB3～ⅡA2期的子宫颈鳞癌和腺癌的部分患者可以采用新辅助化疗+根治性手术+盆腔淋巴结切除术的治疗模式。子宫颈小细胞神经内分泌肿瘤采用新辅助化疗后行全子宫切除术,术后辅助性放疗或同期放化疗,后续再联合其他全身治疗。规范应用NACT术前辅助治疗子宫颈癌,严格把握适应证,充分发挥其疗效优势至关重要。     

Multivariate analysis of histopathologic prognostic factors for invasive cervical cancer treated with radical hysterectomy and systematic retroperitoneal lymphadenectomy

BACKGROUND: The aim of this study was to identify the independent histopathologic prognostic factors for patients with cervical carcinoma treated with radical hysterectomy including paraaortic lymphadenectomy. METHODS: A total of 187 patients with stage IB to IIB cervical carcinomas treated with radical hysterectomy and systematic retroperitoneal lymphadenectomy were retrospectively analyzed. The median follow-up period was 83 months. Cox regression analysis was used to select independent prognostic factors. RESULTS: Using multivariate Cox regression analysis, lymph node (LN) status (negative vs. metastasis to pelvic nodes except for common iliac nodes vs. common iliac/paraaortic node metastasis), histopathologic parametrial invasion, lymph-vascular space invasion (LVSI), and histology of pure adenocarcinoma were found to be independently related to patients' poor survival. For patients who had a tumor histologically confined to the uterus and have neither parametrial invasion nor lymph node metastasis, LVSI was the most important prognostic factor, and histologic type, depth of cervical stromal invasion, and tumor size were not related to survival. The survival of patients with a tumor extending to parametrium or pelvic lymph node(s) was adversely affected by histology of pure adenocarcinoma. When the tumor extended to common iliac or paraaortic nodes, patients' survival became quite poor irrespective of LVSI or histologic type of pure adenocarcinoma. Patients' prognosis could be stratified into low risk (patients with a tumor confined to the uterus not associated with LVSI: n = 80), intermediate risk (patients with a tumor confined to the uterus associated with positive LVSI, and patients with squamous/adenosquamous carcinoma associated with pelvic lymph node metastasis or parametrial invasion: n = 86), and high risk (patients with pure adenocarcinoma associated with pelvic lymph node metastasis or parametrial invasion, and patients with common iliac/paraaortic node metastasis: n = 21) with an estimated 5-year survival rate of 100 +/- 0 (mean +/- SE)%, 85.5 +/- 3.9%, and 25.1 +/- 9.7%, respectively. CONCLUSIONS: LN status, parametrial invasion, LVSI, and histology of pure adenocarcinoma are important histopathologic prognostic factors of cervical carcinoma treated with radical hysterectomy and systematic retroperitoneal lymphadenectomy. Prognosis for patients with cervical carcinoma may be stratified by combined analysis of these histopathologic prognostic factors. Postoperative therapy needs to be individualized according to these prognostic factors and validated for its efficacy using randomized clinical trials.     

子宫颈鳞癌Ⅰb～Ⅱa期患者预后预测系统的建立及其临床意义

目的分析子宫颈鳞癌Ⅰb~Ⅱa期患者的预后影响因素并建立预后预测系统,以探讨其在指导术后辅助治疗中的作用。方法回顾性分析接受手术治疗的306例Ⅰb~Ⅱa期宫颈鳞癌患者的临床病理资料,对影响其预后的因素进行单因素和多因素分析。结果306例患者的5年生存率为78 1%。单因素分析结果显示,与其预后有关的因素为淋巴结转移、病理分化程度、肿瘤直径、宫旁组织浸润、深肌层浸润和脉管内瘤栓(P<0 05);多因素分析结果显示,淋巴结转移、深肌层浸润、宫旁组织浸润是影响其预后的独立危险因素(P<0 05)。根据危险因素的不同建立预后预测系统,即将患者分为低危组、中危组和高危组3组,其5年生存率分别为90 3%、83 9%和43 1%。低危组(无危险因素或仅宫旁组织浸润)局部复发的发生率仅为2 2%;中危组(深肌层浸润或合并有宫旁组织浸润)局部复发的发生率为13 5%,远处转移的发生率为1 3%, 局部复发合并远处转移的发生率为0 6%;高危组(淋巴结转移或合并其他危险因素)局部复发和远处转移的发生率分别为25 9%和48 3%,局部复发合并远处转移的发生率为10 3%。结论淋巴结转移、深肌层浸润、宫旁组织浸润是影响Ⅰb~Ⅱa期宫颈鳞癌患者预后的独立因素;根据预后影响因素建立的预后预测系统有助于指导术后辅助治疗。     

Overall 5-year survival rate and prognostic factors in patients with stage IB and IIA cervical cancer treated by radical hysterectomy and pelvic lymph node dissection

Abstract. Kim SM, Choi HS, Byun JS. Overall 5-year survival rate and prognostic factors in patients with stage IB and IIA cervical cancer treated by radical hysterectomy and pelvic lymph node dissection.
The objective of this paper was to analyze the 5-year survival rate and prognostic factors for stage Ib and IIa cervical cancer treated by radical hysterectomy. A total of 366 patients with invasive cervical cancer treated by radical hysterectomy from June 1985 to June 1994 at Chonnam National University Hospital, Kwangju, Korea were retrospectively analyzed. Survival analysis was performed using the Kaplan-Meier estimator. Multivariate analysis was performed using the Cox proportional hazards regression model. The overall 5-year survival rate was 92% in stage Ib and 87% in stage IIa. Factors assessed for prognostic value included age, FIGO stage, cell type, tumor size, depth of invasion, lymphovascular space invasion (LVSI), and pelvic lymph node metastases (LNM). In the multivariate analysis, age, cell type, and lymph node metastases were independent predictors of survival. Lower survival was associated with age greater than 50 years, adenocarcinoma, and presence of lymph node metastases. The higher survival rates in patients with single lymph node involvement or lymph node metastases below the level of the common iliac nodes (85 and 84.6%, respectively) versus multiple or extrapelvic lymph node metastases (50 and 20%, respectively) were statistically significant ( P < 0.01). In conclusion, patients who had lymph node metastases, adenocarcinoma, and were older than 50 years had a poorer survival rate. Such patients require more intense postoperative treatment and closer surveillance. Low-risk patients with a single lymph node metastasis below the level of the common iliac nodes may benefit from thorough lymphadenectomy without adjuvant therapy to prevent unpleasant complications.     

Chemotherapy versus radiotherapy versus observation for high-risk cervical carcinoma after radical hysterectomy: A randomized, prospective, multicenter trial.

BACKGROUND: Adjuvant treatment modalities after radical hysterectomy have long been used in an attempt to eradicate microscopic tumor residuals in patients at high risk for recurrence. However, it has not been clearly demonstrated that adjuvant radiation, adjuvant chemotherapy, or both improve the outcome. To evaluate the effect of adjuvant treatment in patients with high-risk cervical cancer after radical hysterectomy, the Austrian Gynecologic Oncology Group conducted a prospective, randomized, multicenter clinical trial between 1989 and 1995. MATERIAL AND METHODS: Seventy-six patients with stage IB-IIB cervical cancer treated with radical hysterectomy with pelvic lymph node metastases and/or vascular invasion randomly received adjuvant chemotherapy (400 mg/m2 carboplatin, and 30 mg bleomycin), standardized external pelvic radiation therapy, or no further treatment. RESULTS: After a median follow-up of 4.1 years (range, 2-7) there were no statistically significant differences (P = 0.9530) in disease-free survival among the three treatment arms. CONCLUSION: The data suggest that adjuvant chemotherapy or radiation do not improve survival or recurrence rates in high-risk cervical cancer patients after radical hysterectomy. The most important treatment for these patients seems to be radical abdominal hysterectomy with systematic pelvic lymphadenectomy.     

Radical vaginal trachelectomy and pelvic lymphadenectomy for preservation of fertility in early cervical carcinoma

OBJECTIVE: The aim of this study was to examine our experience with radical vaginal trachelectomy in women with early cervical cancers who desire to maintain fertility. METHODS: Women who underwent radical vaginal trachelectomy with pelvic lymphadenectomy over a 6-year period are the basis of this report. Subjects were selected for this treatment on the basis of favorable cervical tumors and a desire to maintain fertility. All subjects were informed that this therapy did not represent standard treatment for early stage cervical cancer. Obstetrical and oncologic outcomes were evaluated. RESULTS: Twenty-one women underwent this procedure. The median age was 30 years (range 23-41); 14 were nulligravid and 16 were nulliparous. Mean tumor diameter was 1.1 cm (range 0.3-3.0). Mean operative time was 318 min, with a mean blood loss of 293 cc, and average hospital stay was 3 days. Three patients had transient neuropathy postoperatively. No patient required laparotomy. Two patients had completion of radical vaginal hysterectomy for an inability to clear the cancer with trachelectomy and 1 had postoperative radiation for high-risk features on final pathology. With an average follow-up of 31.5 months, there have been no recurrences. Three women have become pregnant: 1 woman delivered twins at 24 weeks, 1 woman delivered a singleton at term, and 1 patient had rupture of membranes and chorioamnionitis at 20 weeks gestation. CONCLUSIONS: Radical vaginal trachelectomy with pelvic lymphadenectomy permits preservation of fertility in selected patients. To date, with more than 150 cases reported in the literature, recurrence rates are comparable to those seen with radical hysterectomy.     

Adjuvant combined paclitaxel and carboplatin chemotherapy for glassy cell carcinoma of the uterine cervix: report of three cases with clinicopathological analysis

Glassy cell carcinoma of the uterine cervix (GCC) is a rare form of cervical carcinoma that is characterized by aggressiveness and poor prognosis. We reviewed a variety of clinicopathological features, treatment strategies, and outcomes in three women with GCC. The three patients were successfully treated by radical hysterectomy with pelvic/para-aortic lymphadenectomy. The patients had stage Ib1, stage IIa, and stage Ib2 tumors without lymph node metastases. A 44-year-old woman with stage Ib1 tumor did not undergo adjuvant chemotherapy or radiation therapy. She had recurrent pelvic tumors 12 months after surgery, and died 6 months after the recurrent disease. The histological findings of her cervix, which were different from the other two patients, did not show the marked infiltration of eosinophils. The other two patients with stage Ib2 and IIa tumors underwent adjuvant chemotherapy with paclitaxel and carboplatin, and had disease-free survival for 4.5 and 9 years. We think that all patients with GCC of stage Ib1 or more should undergo adjuvant chemotherapy of paclitaxel and carboplatin or other adjuvant therapies.     

Resection of bulky positive lymph nodes in patients with cervical carcinoma

From January 1987 to April 1992, 34 patients had resection of bulky positive lymph nodes, detected either at the time of radical hysterectomy ( n = 23) or by computed tomographic (CT) scan of the pelvis and abdomen prior to radiation therapy for more advanced cervical cancer ( n = 11). Following nodal resection, 33 patients received pelvic external beam radiation, 28 received pelvic and para-aortic radiation, and 23 received four cycles of cisplatin chemotherapy. The median number of resected positive nodes was 4, with a range of 1–44. All macroscopic nodal metastases could be resected in each patient and morbidity was acceptably low. Positive nodes were confined to the pelvis in 17 patients, involved the common iliac group in nine patients, and involved the para-aortic area in eight patients. With a mean follow-up of 36 months, 23 patients (67.6%) were alive, of whom 20 were free of disease. For patients having a radical hysterectomy, actuarial 5-year survival was 80% for patients with disease involving pelvic and common iliac lymph nodes, and 48% for those with positive para-aortic nodes. Survival for patients with completely resected bulky pelvic and common iliac nodes was comparable to that for patients with micrometastases. This study suggests that every effort should be made to identify patients with cervical cancer who have bulky positive lymph node metastases, and to remove these nodes surgically prior to radiation therapy.     

Pelvic and aortic lymph node metastasis in epithelial ovarian cancer

OBJECTIVE: The appropriate management of advanced ovarian cancer has been controversial in recent years. There are no adequate data about the importance of lymphadenectomy and the appropriate sites for lymph node assessment. We sought to evaluate the distribution, size, and number of pelvic and aortic lymph node metastases in patients with epithelial ovarian carcinoma. METHODS: Retrospective chart review of 116 patients with stage IIIC or IV epithelial ovarian carcinoma treated at Mayo Clinic who underwent systematic bilateral pelvic and aortic lymphadenectomy between 1996 and 2000. RESULTS: Eighty-six (78%) of 110 patients who underwent pelvic lymphadenectomy were found to have nodal metastases in 422 (16%) of 2705 pelvic nodes that were removed. Eighty-four (84%) of 100 patients had documented aortic lymph node metastases in 456 (35%) of 1313 aortic nodes that were removed. Fifty-five (59%) of 94 patients had bilateral metastatic pelvic and aortic lymph nodes and bilateral aortic lymphadenectomy was conducted in 53 (72%) of 74 patients. The most representative group for detection of nodal metastases was the aortic group (83%) followed by the external iliac group (59%) and the obturator nodes (53%). There was no significant difference between the mean size of positive (1.8 cm) and negative nodes (1.6 cm). Thirty-seven patients had unilateral tumor, and 1 patient (7%) had contralateral node metastasis. CONCLUSION: The incidence of positive nodes bilaterally and positive high aortic nodes indicates the need for bilateral pelvic and aortic node dissection (extending above the inferior mesenteric artery) in all patients regardless of laterality of the primary tumor.     

Early stage cervical cancer with negative pelvic lymph nodes: pattern of failure and complication following radical hysterectomy and adjuvant radiotherapy

PURPOSE OF INVESTIGATION: The objective was to optimize the adjuvant treatment for patients with lymph node negative cervical cancer by analyzing patterns of failure and complications following radical hysterectomy and adjuvant radiotherapy. METHODS: From September 1992 to December 1998, 67 patients with lymph node negative uterine cervical cancer (FIGO stage distribution: 50 Ib. 17 IIa), who had undergone radical hysterectomy and postoperative adjuvant radiotherapy with a minimum of three years of follow-up were evaluated. All patients received 50-58 Gy of external radiation to the lower pelvis followed by two sessions of intravaginal brachytherapy with a prescribed dose of 7.5 Gy to the vaginal mucosa. For 21 patients with lymphovascular invasion, the initial irradiation field included the whole pelvis for 44 Gy. The data were analyzed for actuarial survival (AS), pelvic relapse-free survival (PRFS), distant metastasis-free survival (DMFS), and treatment-related complications. Multivariate analysis was performed to assess the prognostic factors. RESULTS: The respective five-year AS, PRFS, and DMFS for the 67 patients were 79%, 93% and 87%. Multivariate analysis identified two prognostic factors for AS: bulky tumor vs non-bulky tumor (p = 0.003), positive resection margin (p = 0.03). The independent prognostic factors for DMFS was bulky tumor (p = 0.003), while lymphatic permeation showed marginal impact to DMFS (p = 0.08). The incidence of RTOG grade 1-4 rectal and non-rectal gastrointestinal complication rates were 20.9% and 19.4%, respectively. The independent prognostic factor for gastrointestinal complication was age over 60 years (p = 0.047, relative risk 4.1, 95% CI 1.2 approximately 11.7). The incidence of non-rectal gastrointestinal injury for the patients receiving whole pelvic radiation and lower pelvic radiation was 28.5% and 15.2%, respectively (p = 0.25). CONCLUSION: For patients with lymph node negative cervical cancer following radical hysterectomy, adjuvant lower pelvic radiation appears to be effective for pelvic control. It is also imperative to intensify the strategies of adjuvant therapy for some subgroups of patients.     

Early stage I adenocarcinoma of the uterine cervix: treatment results in patients with tumors less than or equal to 4 cm in diameter

Between 1965 and 1985, 160 patients had initial treatment at the M. D. Anderson Cancer Center for Stage I adenocarcinoma of the uterine cervix less than or equal to 4 cm in diameter. Of these patients, 84 were treated with radiation therapy (RT) alone, 20 were treated with external and intracavitary radiation followed by total hysterectomy (R + S), and 56 were treated with radical hysterectomy (RH). Survival rate was strongly correlated with tumor volume (P = 0.0008), lymphangiogram findings (P = 0.01), and tumor grade (P = 0.0018). Patients with a normal-appearing cervix or a small visible or palpable tumor that did not expand the cervix more than 3 cm had survival and pelvic-control rates of more than 90% after treatment with RH or RT. However, after 5 years, 45% of patients treated with RH for tumors 3-4 cm in diameter had disease recurrence in the pelvis, compared with 11% of patients treated with either RT or R + S (P = 0.025). For patients treated with RH, recurrence was also strongly correlated with findings of lymph/vascular space invasion (P = 0.0004) and poorly differentiated tumor (P = 0.018). Major complication rates were comparable for the three treatment groups. The high rate of pelvic recurrence following treatment with radical hysterectomy alone for patients with tumors greater than 3 cm in diameter, particularly in the presence of lymph/vascular space invasion, poorly differentiated features, and/or positive nodes, should be considered in planning the primary management of patients with Stage I adenocarcinoma of the cervix.