Patterns of recurrence following hysterectomy and radiation for cervical carcinoma: relationship to residual disease and brachytherapy techniques

Conventional postoperative irradiation following hysterectomy for cervical carcinoma has consisted of external pelvic with or without intra-cavitary vaginal irradiation. In the presence of macroscopically positive margins after initial hysterectomy or in the subsequent context of a central recurrence, such techniques may not be optimum as manifested by the significant rate of local recurrence following conventional irradiation in these settings. The purpose of the retrospective review was to: (a) evaluate pelvic recurrence patterns following initial hysterectomy and radiation in relationship to margin status and brachytherapy techniques in 24 group 1 patients; and (b) evaluate pelvic recurrence patterns in 10 group 2 patients with recurrent disease in relationship to the bulk of residuum after salvage external beam and the brachytherapy techniques used to address this disease. The use of interstitial implantation in select patients with macroscopically positive margins after hysterectomy or persistent central pelvic disease after salvage external beam irradiation is proposed.     

Recurrent cervical carcinoma after radical hysterectomy

The characteristics of recurrent carcinoma following radical hysterectomy and pelvic lymphadenectomy for cervical carcinoma are not well known. Disease recurrence was noted in 27 of 249 patients (11%) with stage IB cervical carcinoma who were treated with a primary surgical approach between January 1962 and December 1984. Fourteen recurrences (52%) occurred within 1 year of surgery, and 24 (89%) within 2 years. Patients with pelvic node metastases or adenocarcinoma had a significantly higher recurrence rate than did patients with negative nodes (33% vs 8%) or with squamous carcinoma (22% vs 8%). Seventeen patients (63%) had disease recurrence in the pelvis or vulva and 12 of these patients had recurrences within 1 year. Eight patients developed asymptomatic pelvic or vulvar recurrences, and all were diagnosed within 1 year. Ten patients (37%) developed recurrences outside the pelvis and 8 of these experienced recurrence after 1 year. Successful treatment after recurrence was independent of clinical or histopathologic parameters except site of recurrence. Eight of 15 patients (53%) who were treated with irradiation for a recurrence in the pelvis or vulva are free of disease 10 to 126 months (median, 48 months) after recurrence. Since irradiation can aid in salvaging patients with recurrent cervical carcinoma confined to the pelvis following radical surgery, clinical vigilance for this site of recurrence is emphasized.     

Adjuvant chemotherapy after radical hysterectomy for cervical carcinoma

Three hundred and sixty-eight cases of invasive cervical cancer (stage IB through early stage IIB) were treated with radical abdominal hysterectomy and bilateral pelvic lymphadenectomy at Chang Gung Memorial Hospital. Of these patients, 172 were classified postoperatively as a high-risk group after surgical-pathological assessment of tumor extent. Among these high-risk patients, 40 received adjuvant chemotherapy with cisplatin, vinblastine, and bleomycin (PVB), 38 received adjuvant radiotherapy, and 79 refused adjuvant treatment. The 3-year cumulative disease-free survival rate was 91.6% for the low-risk group and 59.7% for those at high risk. Among patients in the high-risk group, the 3-year survival rate was 75.0% for patients treated with adjuvant chemotherapy and 46.8% for those not treated with adjuvant therapy (P less than 0.05). The preliminary results of this pilot study showed a significant activity of adjuvant chemotherapy, which warrants further investigation of its role in the treatment of cervical cancer.     

Retrospective evaluation of recurrence after radical abdominal hysterectomy in patients with cervical carcinoma

Out of total 176 patients with cervical carcinoma treated with radical abdominal hysterectomy at GCRI, 27 developed recurrence. The results of this study (Study A) were compared with the study carried out by Figge & Tamini, 1981 (Study B) and Thomas W. Burke, 1987 (Study C) as the approaches in all the three studies were more or less similar. The recurrence rates were 15.3%, 11.8% and 11.3% respectively in three studies. In cervical stage IB carcinoma, which is usually treated with this line of treatment, the recurrence rates were 20%, 12.3% and 11.3% respectively in three studies. The highest recurrence rates were observed in adenocarcinoma/adenosquamous carcinoma i.e. 50% in Study A, 33.3% in Study B and 17.4% in Study C. The adverse effects of high risk factors such as lymph node metastases and CLS involvement were less in Study A as compared to B. The deep stromal invasion was equally responsible in both the studies. The mean and median time interval until observed recurrence with post-operative radiotherapy were better in Studies B and A. Nearly 86% developed recurrence within 24 months which is useful observation for predicting the prognosis in similar situations. The evaluation and comparison of studies stresses the importance of new approaches to treatment on the current modalities as the present approach seems to be less effective especially in the presence of high risk factors.     

Stump recurrence after radical hysterectomy for patients with uterine cervical cancer

Of a total of 1,025 cases of radical hysterectomy for histological squamous cell carcinoma (543 stage I cases and 482 stage II cases), we examined 50 cases of recurrence of the carcinoma (4.9 percent; 24 stage I cases and 26 stage II cases) at the site of the vaginal stump. The percentage of recurrence at the site of the vaginal stump was significantly higher in stage I and stage II cases, in which metastases to the lymph nodes or vascular invasion was observed (p less than 0.01). The length of vagina excised during the radical hysterectomy was measured and its relationship to recurrence at the site of the vaginal stump was investigated. In stage I cases that did not exhibit metastases to the lymph nodes, the shortest vaginal length excised in cases with a positive recurrence at the site of the vaginal stump was 2.5 +/- 0.9 cm; the shortest vaginal length in cases with a negative recurrence at the site of the vaginal stump was 1.8 +/- 0.8 cm. A significant difference (p less than 0.05) was observed between them. Furthermore, in stage I cases with no metastases to the lymph nodes, one recurrence at the site of the vaginal stump was observed when the vaginal length excised was 3 cm. In stage I cases with metastases to the lymph nodes and in stage II cases, no significant difference was discovered between the length of vagina excised in cases with positive and those with negative recurrences of the carcinoma at the site of the vaginal stump.     

Optimal therapy for pelvic recurrence after radical hysterectomy for early-stage cervical cancer

Forty-eight patients with pelvic recurrence after radical hysterectomy were evaluated. The influence of location of pelvic recurrence (sidewall versus central), histological grade, histological type, and interval from hysterectomy to recurrence had no influence upon curability by radiotherapy. Ten of twenty-eight patients treated by primary radiation therapy for recurrent disease remain without evidence of disease a minimum of 12 months post-therapy, with a projected 5-year disease-free survival in excess of 30%. No patient treated with adjuvant radiation after initial surgery was rendered disease free by subsequent treatment with radiotherapy. Eleven patients were explored for exenterative surgery. Three of six in whom exenteration was technically feasible remain alive without evidence of disease. None of 15 patients treated with chemotherapy remain free of disease. Radiation therapy remains the treatment of choice in post-radical hysterectomy recurrences confined to the pelvis. As exenterative therapy will result in the cure of a small number of patients with disease confined to the pelvis, exenteration should be considered in patients treated previously by radiotherapy. If these efforts fail, chemotherapy is unlikely to result in cure.     

Diagnosis of recurrent cervical carcinoma after radical hysterectomy

A standard surveillance program for cervical carcinoma patients treated with radical hysterectomy is reviewed. Between 1962-1984, 249 patients with stage IB cervical carcinoma treated with radical hysterectomy and pelvic lymphadenectomy were entered in the surveillance program. Of the 27 patients (11%) diagnosed with recurrent carcinoma, 17 (63%) were identified by clinical history, 22 (81%) by physical examination, five (18%) by vaginal cytology, six (22%) by chest radiography, and eight (30%) by renal contrast imaging. Combined clinical history and physical examination identified 24 patients (89%) with recurrent carcinoma. Disease recurrence was detected by vaginal cytology in one asymptomatic patient with a normal examination. The recommended surveillance procedures for patients with cervical carcinoma after radical hysterectomy include clinical history, physical examination, and vaginal cytology. Chest radiography and renal contrast imaging should be reserved for symptomatic patients.     

Disease-free interval and recurrence pattern after the Okabayashi variant of Wertheim's radical hysterectomy for stage IB and IIA cervical carcinoma

From January 1982 to December 1991 271 patients underwent radical hysterectomy according to the Okabayashi modification for cervical carcinoma stage IB and IIA. Intraoperative complications occurred in 3.3%. The urinary fistula rate was only 2.2%. The 5-year Disease-free Interval (DFI) was 90%. In a univariate analysis tumor size 3 cm ( n = 99), positive pelvic nodes ( n = 53), adenocarcinoma ( n = 58) and parametrial involvement ( n = 36) were all associated with a significantly decreased DFI. Recurrence occurred in 27 patients (10%) of whom 22 died of disease. In adenocarcinoma, DFI was poor when positive pelvic nodes were present. In squamous cell carcinoma however, DFI was not influenced by pelvic node status. In patients with squamous cell carcinoma the locoregional recurrence rate was 3.4% when pelvic nodes were negative, whereas in those with positive nodes it was 5.8%. These data show that the Okabayashi modification of Wertheim's radical hysterectomy is a safe procedure resulting in very good locoregional tumor control, especially in patients with squamous cell cancer of the cervix.     

Vaginal repair in the radical operation for cervical carcinoma.

An attempt was made to preserve postoperative sexual function and the recovery of bladder function by a simple modification of technique in 22 cases of radical operations for invasive carcinoma of the cervix. The procedures consisted of two parts. After removal of the specimen, the bladder peritoneal flap is sutured to the anterior vaginal wall leaving a 2 to 3 cm margin between the line of suture and the edge of the peritoneum. Similarly, the posterior peritoneal flap is sutured to posterior vaginal wall leaving a margin. Both edges of the peritoneum are then closed forming a pouch as an extension of vaginal canal. The length of the vagina was successfully elongated by this procedure, thus adding to better postoperative sexual function.     

Drain-site metastasis after radical hysterectomy for squamous cervical cancer

Drain-site metastasis occurred after radical hysterectomy for squamous cervical cancer.     

Malignant mesenchymoma developing 6 years after radical hysterectomy and postoperative radiotherapy for cervical carcinoma

A 25-year-old woman with Stage IB cervical cancer had adjuvant postoperative radiotherapy for a positive pelvic node found in her radical hysterectomy and pelvic lymphadenectomy specimen. Six years later she developed a malignant mesenchymoma in the sacral area while there was no evidence of cervical carcinoma. This is the first reported association of these disorders. It is possible that the malignant mesenchymoma may have been induced by postoperative irradiation.     

Urinary tract dysfunction after radical hysterectomy for cervical cancer

OBJECTIVES: To evaluate the urinary tract dysfunction following a radical hysterectomy and to compare the baseline urodynamical parameters of women who had uterine cervical carcinoma with women who had CIN 3. METHODS: A prospective case-control study was conducted to evaluate preoperative and postoperative urinary tract function of thirty-two cervical carcinoma patients using twenty-seven CIN 3 patients' preoperative urodynamical parameters as a baseline control. RESULTS: The rate of detrusor instability in women with preoperative cervical carcinoma was higher than that of women with CIN 3 (37.5 % vs. 14.8 %, P < 0.05). In the cervical carcinoma patients, there were 53.1 % who had normal urinary tract function, but after a radical hysterectomy they began voiding by abdominal straining. The impairment of bladder sensation, alteration of bladder capacity and bladder compliance, compromise of detrusor function, reduction of maximal urethral pressure and maximal urethral closure pressure, and the decrease of the pressure transmission ratio were significantly noted after a radical hysterectomy. The rate of genuine stress incontinence did not increase significantly (9.4 % vs. 18.8%, P > 0.05), but the rate of detrusor instability decreased significantly (37.5% vs. 15.6%, P < 0.05) after a radical hysterectomy. CONCLUSIONS: Changes of urinary tract function after a radical hysterectomy might be related to the partial sympathetic and parasympathetic denervation during a radical dissection. More than half of the women who preoperatively had normal urinary tract function needed to void by abdominal straining after radical surgery.     

调强放射治疗在宫颈癌术后治疗中的临床研究

目的 探讨调强放射治疗（IMRT）用于宫颈癌术后提高靶区受照射剂量,减少并发症的价值。方法 对2002年6月至2006年6月山东省肿瘤医院20例宫颈癌术后患者放疗前均给予2-3个周期化疗,并行全程IMRT,每日1次,每次1.8-2.2Gy,每周5次,给予处方剂量50-60Gy,中位剂量54.5Gy;同时拟设计该20例患者的普通2野放疗计划,拟给予相同的处方剂量,比较危险器官（OAR）受照射剂量;选取同期23例接受普通放疗的完整病例,比较调强放疗和普通放疗急、慢性毒副反应及近期存活率。结果 20例患者均完成全程IMRT,放射治疗计划靶区（planning target volume,PTV）内的平均剂量为56.2Gy,90%的等剂量曲线（中位剂量54.5Gy）可以覆盖99%以上的肉眼靶区（gross target volume,GTV）体积。IMRT与拟行普通2野放疗计划比较,小肠、直肠、膀胱的受照射剂量均明显减小,P均〈0.01;IMRT与普通放疗比较,急慢性毒副反应明显降低,但1、2、3年存活率比较差异无显著性意义,P〉0.05。结论 IMRT技术使宫颈癌术后患者的靶区获得理想的剂量分布,邻近危险器官得到很好的保护,毒副反应可以耐受,但未能提高患者近期存活率。     

Sexual function after radical hysterectomy for early-stage cervical cancer

IntroductionFor early-stage cervical cancer, treatment with radical surgery appears effective with excellent survival. However, the treatment is associated with significant morbidities. Sexual dysfunction is the leading cause of symptom-induced distress after the treatments for early-stage cervical cancer. There has been no study that evaluates the effect of surgical treatments for cervical cancer on sexual function in the Eastern/Asian patients.AimTo examine the effect of radical hysterectomy on postoperative sexual function in women with early-stage cervical cancer.Main Outcome MeasuresThe visual analog score on seven aspects of sexual function: overall satisfaction with sexual intercourse, sexual desire, vaginal lubrication, vaginal elasticity, orgasmic satisfaction, patient-perceived partner satisfaction, and associated anxiety.MethodsThirty patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB cervical cancer undergoing radical hysterectomy and pelvic lymphadenectomy at the Chiang Mai University Hospital were recruited. All of the patients were interviewed by questionnaire on sexual function at preoperative hospital admission and then at 3 and 6 months after surgery. Relevant clinical and pathologic data were also prospectively collected.ResultsThe mean age of the patients was 45.3 ± 6 years (range 28–59). Seven (23%) of the patients were postmenopausal. Almost all (97%) had FIGO stage IB1 disease. Fourteen (46.7%) patients had bilateral salpingo-oophorectomy, and one (3.3%) patient had unilateral salpingo-oophorectomy. Squamous-cell carcinoma and adenocarcinoma were diagnosed in 83% and 17%, respectively. At 3 and 6 months after operation, 63% and 93% of the patients had sexual intercourse, respectively. Considering the overall sexual satisfaction, the patient-rated visual analog score appeared comparable at preoperative and 6-month postoperative assessment (4.2 ± 2.5 vs. 3.6 ± 2.2, P > 0.05).ConclusionRadical hysterectomy using the current technique has a minimal short-term impact on sexual function. A comparative study with long-term follow-up would provide clearer information on permanent effect of radical hysterectomy on sexual function. Jongpipan J, and Charoenkwan K. Sexual function after radical hysterectomy for early-stage cervical cancer.     

Recurrent carcinoma of the vagina following Okabayashi's radical hysterectomy for cervical carcinoma

Between 1962 and 1976, 1847 cases of cervical cancer were treated by Okabayashi's radical hysterectomy. Of these, 42 cases developed vaginal invasive carcinoma and 5 developed vaginal intraepithelial carcinoma thereafter, giving a recurrence rate of 2.5%. The vaginal recurrence rate declined annually during the period 1962-1976, and was thought to be due to the efficacy of routinization of postoperative vaginal cuff irradiation. Of the 47 recurrent cases 33 were discovered within 2 years following the operation. Seventy-two percent of the recurrent cases were asymptomatic. The importance of close follow-up of the patients during the first 2 postoperative years was denoted. The incidence of developing a secondary vaginal cancer in the cases of cervical adenocarcinoma was 10.0%, higher than the 2.2% for squamous cell carcinoma. All the recurrent cases were treated with vaginal cuff irradiation, either alone or with external irradiation and/or chemotherapy. The 3-year survival rate of the patients who had vaginal recurrence alone was 40.0%, better than that of the cases accompanied with recurrence at the other sites.