Postoperative radiotherapy in stage I endometrial adenocarcinoma

OBJECTIVE: To evaluate postoperative whole pelvic radiation for high-risk patients with Stage I endometrial adenocarcinoma. METHODS: One hunderd and twenty-two patients with irregular premenopausal or postmenopausal haemorrhage were included into the study. Fractional curettage was performed in all cases. When the pathohistological report confirmed endometrial adenocarcinoma, abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Low-risk patients include women with Stage IA tumours and Stage IB grade 1 or 2 histology. High-risk group include patients with Stage IB grade 3 tumours and Stage IC carcinomas. High-risk patients received whole pelvic radiotherapy between two and four weeks after surgery. RESULTS: Eighty-two patients (67.21%) were low-risk and forty patients (32.79%) were high-risk. In the low-risk group of patients, CA-125 was negative in ten cases and positive in 72 patients with a mean value of 30.12 +/- 12.42 U/ml serum. In the high-risk group of the patients, CA-125 was negative in two cases and positive in 38 patients with a mean value of 60, 48 +/- 20, 14 U/ml serum. Locoregional recurrences were diagnosed in four patients (4.87%) in the surgery group and in two patients (5.00%) assigned to radiotherapy. The incidence of distant metastases was 2.43% in the surgery group and 2.50% in the radiotherapy group. Overall survival at five years was 90.25% in the low-risk group and 87.50% in the high-risk group of patients. CONCLUSION: Five-year overall survival, locoregional and distant metastasis were similar in the low-risk and high-risk groups of patients. That emphasizes the value of whole pelvic radiation in patients with unfavourable prognostic factors in Stage I endometrial cancer.     

Randomized study of preoperative radiation and surgery or irradiation alone in the treatment of stage IB and IIA carcinoma of the uterine cervix: final report

A prospective randomized study in selected patients with Stage IB and IIA carcinoma of the uterine cervix was carried out at Washington University between January 1966 and December 1979. Patients were randomized to be treated with irradiation alone consisting of 1000 cGy whole pelvis, additional 4000 cGy to the parametria with a step wedge midline block, and two intracavitary insertions for 7500 mgh; or irradiation and surgery, consisting of 2000 cGy whole pelvis irradiation, one intracavitary insertion for 5000-6000 mgh followed 2 to 6 weeks later by a radical hysterectomy with pelvic lymphadenectomy. A total of 40 patients with Stage IB and 16 with Stage IIA were randomized to be treated with irradiation alone. A similar group of 48 patients with Stage IB and 14 with IIA were randomized to the preoperative radiation and surgery group. The 5-year, tumor-free actuarial survival for Stage IB patients treated with radiation was 89% and with preoperative radiation and surgery 80%. In Stage IIA, the tumor-free actuarial 5-year survival was 56% for the irradiation alone group and 79% for the patients treated with preoperative radiation and radical hysterectomy. In the patients with Stage IB treated by irradiation alone only one pelvic failure combined with distant metastasis occurred, and 3 patients developed distant metastasis. In the 48 patients treated with combined therapy, there were six pelvic failures (12.5%) all combined with distant metastases and two distant metastases alone. In the 16 patients with Stage IIA treated with radiotherapy alone, there were four pelvic failures (all parametrial), three of them combined with distant metastasis. In the 14 patients treated with irradiation and surgery, two developed a pelvic recurrence, and one distant metastasis. In the preoperative radiation group, the incidence of metastatic pelvic lymph nodes was 6.3% in Stage IB and 7.1% in Stage IIA. Major complications of therapy in the patients treated with radiation alone (10%) consisted of one rectovaginal fistula, two vesicovaginal fistulas, and one rectal stricture. In the preoperative radiation group, three ureteral strictures and two severe proctitis-rectal strictures were noted (8%). The present study shows no significant difference in therapeutic results or morbidity for invasive carcinoma of the uterine cervix Stage IB or IIA treated with irradiation alone or combined with a radical hysterectomy and lymphadenectomy.     

Adjuvant radiotherapy following radical hysterectomy for patients with stage IB and IIA cervical cancer

From 1971 through 1984, 320 women underwent radical hysterectomy as primary therapy of stage IB and IIA cervical cancer. Two hundred forty-eight patients (78%) were treated with surgery alone and 72 patients (22%) received adjuvant postoperative external-beam radiotherapy. Presence of lymph node metastasis, large lesion (greater than 4 cm in diameter), histologic grade, race (noncaucasian), and age (greater than 40 years) were significant poor prognostic factors for the entire group of patients. Patients treated with surgery alone had a better disease-free survival than those who received combination therapy (P less than 0.001). However, patients receiving adjuvant radiation therapy had a higher incidence of lymphatic metastases, tumor involvement of the surgical margin, and large cervical lesions. Adjuvant pelvic radiation therapy did not improve the survival of patients with unilateral nodal metastases or those who had a large cervical lesion with free surgical margins and the absence of nodal involvement. Radiation therapy appears to reduce the incidence of pelvic recurrences. Unfortunately, 84% of patients who developed recurrent tumor after combination therapy had a component of distant failure. The incidence of severe gastrointestinal or genitourinary tract complications was not different in the two treatment groups. However, the incidence of lymphedema was increased in patients who received adjuvant radiation therapy. Although adjuvant radiation therapy appears to be tolerated without a significant increase in serious complications, the extent to which it may improve local control rates and survival in high-risk patients appears to be limited. In view of the high incidence of distant metastases in high-risk patients, consideration should be given to adjuvant systemic chemotherapy in addition to radiation therapy.     

Recurrent cervical carcinoma after primary radical surgery.

OBJECTIVE: This study was undertaken to investigate prognostic factors in patients with recurrent cervical carcinoma who had undergone a primary radical hysterectomy and pelvic lymphadenectomy. STUDY DESIGN: A retrospective analysis of 177 patients with recurrent cervical carcinoma after radical hysterectomy and pelvic lymphadenectomy for stage IB to II disease at a single institution was performed to evaluate clinicopathologic parameters, time to recurrence, pattern of failure, use of salvage therapy, and survival after recurrence. RESULTS: The 5-year survival rate from diagnosis of recurrence in this series was 10.1%. Survival after recurrence was significantly decreased in patients with pelvic lymph node metastasis at primary surgery and adenocarcinoma-adenosquamous carcinoma histologic type. Patients with extravaginal recurrences receiving chemoradiation for recurrent cervical carcinoma had significantly better outcomes than those receiving radiation alone. Six patients who had a distant relapse at a sole site had prolonged survival after salvage therapy, which was accomplished by chemoradiation, surgery plus radiotherapy, or surgery alone. CONCLUSIONS: Our results demonstrate the benefit of adding chemotherapy to radiotherapy in the treatment of recurrent cervical carcinoma. Salvage multimodality treatment should be offered to selected patients who have isolated relapse at a single distant site.     

Identification of prognostic factors and risk groups in patients found to have nodal metastasis at the time of radical hysterectomy for early-stage squamous carcinoma of the cervix

In a retrospective study conducted at the University of Alabama at Birmingham, the University of Michigan, and the Mayo Clinic, 185 patients with previously untreated FIGO stage IB and IIA squamous cell carcinoma of the cervix were found to have nodal metastasis at the time of radical hysterectomy and pelvic lymphadenectomy. Of these patients, 103 received adjuvant pelvic irradiation. Cancer recurred in 76 patients; the median time to recurrence was 3.1 years. The prognostic significance of patient age, clinical stage, lesion diameter, number and location of nodal metastases, and use of adjuvant radiation therapy was determined by multivariate analysis. Only patient age (P = 0.0006), lesion diameter (P less than 0.0001), and number of nodal metastases (P = 0.0004) were noted to be significant factors in determining overall survival. Rates of recurrence were also related to these factors. Employment of these significant variables led to identification of four risk groups. In general, patients with small cervical lesions (diameter less than 1 cm) and no more than two nodes with metastases fell into the low-risk category; those patients with large cervical lesions (diameter greater than 4 cm) and more than two involved nodes fell into the high-risk category. All other patients were categorized into intermediate-risk groups. Ten-year survival was 92% in the low-risk group (n = 13), 70% in the low-intermediate-risk group (n = 66), 56% in the high-intermediate-risk group (n = 66), and 13% in the high-risk group (n = 20). This risk group classification identifies subgroups of early-stage cervical carcinoma patients found to have nodal metastasis at the time of radical hysterectomy that warrant appropriately selected adjuvant therapy.     

Radical hysterectomy and pelvic lymphadenectomy for stage IB2 cervical cancer

OBJECTIVE: We wished to evaluate survival and adverse outcomes of patients with stage IB2 cervical cancer treated primarily with radical hysterectomy and lymphadenectomy. METHODS: A review was performed of all patients undergoing primary radical hysterectomy for stage IB2 cervical cancer at two institutions from 1987 to 2002. Patients were stratified into low, intermediate (Gynecologic Oncology Group protocol 92 criteria), and high-risk (positive nodes, margins, or parametria) groups. Survival and progression-free interval were analyzed using the Kaplan-Meier method and multivariate analysis. RESULTS: Seventy-two patients underwent primary type III radical hysterectomy and lymphadenectomy (72 pelvic, 58 pelvic and paraaortic). Patients were classified as low (n = 6), intermediate (n = 49), or high (n = 17) risk for recurrence. Adjuvant therapy was administered to 94%, 12%, and 0% of the high-, intermediate-, and low-risk groups, respectively. Five-year survival was 72%, while 5-year progression-free survival was 63%. Five-year overall and progression-free survival by risk group were 47% and 40% (high-risk), 80% and 66% (intermediate-risk), 100% and 100% (low-risk). Predictors of survival in multivariate analysis were Caucasian race (P = 0.001), older age (P = 0.017), inner 2/3 cervical wall invasion (P = 0.045), and absence of lymph-vascular invasion (P < 0.001). Major complications were experienced by 10/72 (13.9%) patients. Among 34 patients who received radiation therapy, two (5.9%) experienced complications attributable to radiation. CONCLUSIONS: Radical hysterectomy and lymphadenectomy followed by tailored adjuvant therapy is a reasonable alternative to primary radiotherapy for stage IB2 cervical cancer. Patients with low- and intermediate-risk factors have satisfactory results after primary surgical management. A prospective randomized trial will clarify the optimal mode of initial therapy for patients with stage IB2 disease.     

Invasive squamous cell carcinoma of the vulva: defining low and high risk groups for recurrence

Abstract. One hundred and ten patients with invasive squamous cell carcinoma of the vulva, treated primarily with surgery at Toronto General Hospital between 1970 and 1981, were studied to determine recurrence patterns and factors predictive of relapse and survival. The overall and cause-specific actuarial 5-year survival rates were 63 and 73%, respectively. Eleven factors were studied for their prognostic value. Only Stage and, within Stage II, tumor thickness and nodal status, were independently prognostic. Six relapses occured in 8 Stage II patients who had both positive nodes and tumor thickness > 5 mm (Unfavorable Stage II), compared to 0/17 with neither or just one factor present (favorable Stage II, P = 0.0002). These results were used to define a low-risk group (Stages I and favorable II) and a high-risk group (Stages III, IV and unfavorable II). In the low-risk group, 6/69 relapsed and the 10-year actuarial relapse-free rate was 88%. This was significantly different from the high-risk group, where 24/32 relapsed ( P < 10^-6) and the 10-year relapse-free rate was only 11% ( P < 0.00005). The recognition of these two prognostic groups brings the therapeutic challenges in vulvar cancer into clearer focus. In the low-risk group there is a need to reduce surgical morbidity without compromising cure rates. In the high-risk group, locoregional control rates must be improved in order to improve cure rates. As 27 of the 30 relapses in the high-risk group were confined to the vulva or groin, adjunctive radiotherapy might improve cure rates if used in these patients.     

Prognostic factors and sites of failure in FIGO Stage I, Grade 3 endometrial carcinoma

The results of therapy and patterns of failure were analyzed for 60 patients with Stage I, Grade 3 endometrial cancer seen at Yale-New Haven Hospital between 1960 and 1980. Fifty-eight patients were treated with a combination of surgery and radiation; one was treated with surgery only; and one received radiation only. The overall absolute 5-year survival rate was 72.9% with poorer prognosis noted for patients greater than 65 years of age, older at time of their menopause, and with Stage IA disease. Of the 14 patients who recurred, distant sites were involved in 93% (13/14), with the lung the most common site of distant failure (5/14), followed by the upper abdomen (4/14). Pelvic sites were involved in 43% (6/14) of the treatment failures. The use of pelvic external beam radiation resulted in a reduction in pelvic recurrences, but did not improve overall survival. The predominance of distant failures despite pelvic radiation suggests the possibility of early vascular and transcoelomic spread in Stage I, Grade 3 endometrial adenocarcinomas. Thorough exploration of the upper abdomen, paraaortic nodes, and the obtaining of pelvic washings for cytology at the time of initial surgery, are recommended in addition to chest CT scans to help identify those patients with occult metastases. Prospective randomized trials in Stage I, Grade 3 patients employing adjuvant cytotoxic chemotherapy, hormonal therapy, and/or whole abdominal-pelvic radiation, should be considered in an attempt to improve survival in high-risk patients.     

High-risk group in node-positive patients with stage IB, IIA, and IIB cervical carcinoma after radical hysterectomy and postoperative pelvic irradiation

OBJECTIVE: The goal of this study was to identify risk factors in patients with node-positive stage IB, IIA, and IIB cervical carcinoma after radical hysterectomy with pelvic lymph node dissection and postoperative irradiation. METHODS: Two hundred forty-two patients with FIGO stage IB, IIA, and IIB cervical carcinoma underwent radical hysterectomy with pelvic lymph node dissection; pathological analysis of the surgical specimen showed positive lymph nodes in 59 patients. These 59 patients were further treated with postoperative radiotherapy. Eighteen patients were in stage IB, 4 in stage IIA, and 37 in stage IIB. Histological tumor type, tumor size, lymph-vascular space invasion, parametrium infiltration, number of positive nodes, and involvement of common iliac nodes were assessed for correlation with cancer recurrence. RESULTS: When all these variables were assessed in the Cox proportional regression analysis, parametrium infiltration (P = 0. 0199) and number of positive nodes (two or more nodes) (P = 0.0483) revealed the factor correlating significantly with disease-specific survival. Based on these two factors, node-positive patients could be divided into low-risk (n = 11), intermediate-risk (n = 29), and high-risk (n = 19) groups. The 5-year disease-specific survival for the low-risk group was 100% which was significantly better than the 39.1% for the high-risk group (P = 0.0012). CONCLUSION: For patients in the high-risk group, it may be worthwhile to consider new strategies to improve survival.     

Identification of High-Risk Groups among Node-Positive Patients with Stage IB and IIA Cervical Carcinoma

The purpose of the present study was to identify a subset of high-risk patients among surgically treated node-positive patients with stage IB and IIA cervical carcinoma. From 1982 through 1991, 334 patients underwent radical hysterectomy for FIGO stage IB and IIA cervical carcinoma. In 68 patients pathological analysis of the surgical specimen revealed positive pelvic nodes. In this group, a Cox proportional hazard analysis was performed to examine the prognostic significance of clinicopathological variables. Only for adenocarcinoma (P= 0.002) and parametrium infiltration (P= 0.003) was evidence of an association with prognosis found. Based on these two factors, patients with positive pelvic nodes were categorized into a low-risk group (squamous cell carcinoma without parametrium infiltration,N= 33) and a high-risk group (squamous cell carcinoma with parametrium infiltration or adenocarcinoma,N= 34). The 5-year disease-specific survival in the low-risk group was 94% compared with 60% in the high-risk group (P= 0.003). For patients in the high-risk group, there is an urgent need for alternative adjuvant treatment to improve outcome.     

A randomized trial of adjuvant chemotherapy after radical hysterectomy in stage Ib-IIa cervical cancer patients with pelvic lymph node metastases.

Seventy-one patients with Stage Ib-IIa cervical cancer treated by radical hysterectomy and found to have pelvic lymph node metastases were entered on a randomized trial comparing standard pelvic radiotherapy versus three cycles of combination chemotherapy with cisplatin, vinblastine, and bleomycin followed by pelvic radiotherapy. After a median follow-up of 2.5 years, 24 patients have relapsed. In 12 patients, the first evidence of relapse was in the pelvis, in 11 patients the first relapse was evident at a distant site, and in 1 patient the local recurrence and distant metastases were documented simultaneously. No difference in disease-free or overall survival has emerged between the two treatment groups. Relapse was more common in patients with non-squamous tumors (44%) and in those with metastases in several pelvic lymph nodes. We conclude that patients with pelvic lymph node metastases have a rather poor prognosis, but it remains to be determined how they should best be treated after radical surgery.     

Prognostic significance of cervical lesion size and pelvic node metastases in cervical carcinoma.

There were 289 radical hysterectomies performed at Roswell Park Memorial Institute for Stage IB, IIA, and recurrent cervical cancer from 1957 to 1967. The prognostic significance of cervical lesion size, pelvic node metastases, and type of radical hysterectomy have been evaluated. Excellent 5-year survival rates for women with Stage IB cervical carcinoma were associated with cervical lesions measuring less than 3 cm and resected pelvic lymph nodes which did not contain metastatic cancer. In addition, 31% of women with recurrent cervical cancer treated by radical hysterectomy survived 5 years without recurrence.     

Surgery without radiotherapy for primary treatment of endometrial cancer

Objective: To analyze the role of surgery alone, including pelvic and para-aortic lymphadenectomy, in patients with endometrial cancer who did not receive radiotherapy.Methods: Between August 1987 and January 1997, 225 women with disease clinically confined to the uterus were staged surgically by a standard protocol that included pelvic and para-aortic lymphadenectomy in women with high risk factors. No radiation was administered before or after surgery.Results: The combination of preoperative endometrial biopsy grade and gross depth of myometrial invasion identified 123 (55%) high-risk patients who had lymphadenectomy and 102 (45%) low-risk patients who did not. Eighteen (15%) high-risk patients had lymph node metastases and received postoperative systemic therapy. Three low-risk, eight high-risk-node-negative, and no high-risk-node-positive patients were diagnosed with recurrent cancer, corresponding to 5-year recurrence-free proportions of 0.95, 0.89, and 1.00, respectively. Although sample sizes and limited follow-up limit conclusions, the experience to date suggests a high rate of survival in all three groups.Conclusion: Our preliminary experience indicates that even high-risk patients have an excellent prognosis when treated with surgery, including pelvic and para-aortic lymphadenectomy, without radiotherapy.     

Results of radical surgical procedures after radiation for treatment of invasive carcinoma of the uterine cervix in a private practice

An analysis is made of the results of treatment of 96 women with carcinoma of the cervix, Stages IB and II, in a private practive. All 96 women were treated preoperatively with uterine intracavitary radium, followed 6 weeks later by Wertheim hysterectomy with pelvic lymphadenectomy. If malignant tumor was present in the lateral pelvic lymph nodes, external radiation was given postoperatively. The over-all survival rates were: Stage IB, 88% and 84% at 5 and 10 years; Stage II, 72% and 62% at 5 and 10 years. Regardles of the clinical stage, the highest survival rates were found in those patients who had no malignancy in the lateral pelvic lymph nodes and no residual cervical carcinoma. The lowest survical rates were found in those patients who had both residual cervical carcinoma and lymph node metastases.     

Early cervical adenocarcinoma: selection criteria for radical surgery.

OBJECTIVE: To identify selection criteria for radical surgery in early cervical adenocarcinoma based on pretreatment clinical stage and correlation with high-risk surgical-pathologic factors. METHODS: One hundred seventy-five women with International Federation of Gynecology and Obstetrics (FIGO) clinical stage IB1 (n = 132) and IB2-IIA (n = 43) cervical adenocarcinoma were treated primarily at our institutions from 1982 to 1996. Histopathologic sections were reviewed by a gynecologic pathologist. Medical records were reviewed retrospectively and clinical follow-up was done. RESULTS: The overall 5-year survival rate was 87% (95% confidence interval [CI] 81%, 93%) for stage IB1 and 61% (95% CI 46%, 77%) for stage IB2-IIA (P<.001). Adenosquamous cell type, deep cervical invasion, and lymph-vascular space invasion were significant independent high-risk surgical-pathologic factors that affected disease-free survival (each P<.002). One hundred fourteen (86%) of 132 stage IB1 patients and 19 (44%) of 43 stage IB2-IIA subjects were treated primarily with radical surgery. Lymph node metastases, lymph-vascular space invasion, adenosquamous cell type, deep cervical invasion, and positive surgical margins were more than twice as frequent in stage IB2-IIA patients who had radical surgery than in stage IB1 patients (each P <.05). Based on high-risk surgical-pathologic factors in 133 subjects who had radical surgery, postoperative radiotherapy was recommended for 18 (16%) of 114 stage IB1 patients and 18 (95%) of 19 stage IB2-IIA subjects (P<.001). CONCLUSION: Radical surgery for FIGO clinical stage IB1 cervical adenocarcinoma and primary radiotherapy for stage IB2-IIA disease would largely avoid combined-modality therapy, thereby reducing treatment-related toxicity and cost.     

Prognostic factors in FIGO stage IB cervical cancer without lymph node metastasis and the role of adjuvant radiotherapy after radical hysterectomy

OBJECTIVES: The aim of this study was to evaluate the clinical and pathologic prognostic variables for disease free survival, overall survival and the role of adjuvant radiotherapy in FIGO stage IB cervical carcinoma without lymph node metastasis. METHODS: A retrospective review was performed of 393 patients with lymph node negative stage IB cervical cancer treated by type 3 hysterectomy and pelvic lymphadenectomy at the Hacettepe University Hospitals between 1980 and 1997. RESULTS: The disease free survival and overall survival were 87.6 and 91.0%, respectively. In univariate analysis, tumor size, depth of invasion, vaginal involvement, lympho-vascular space involvement (LVSI) and adjuvant radiotherapy were found significant in disease free survival. Overall survival was affected by tumor size, LVSI, vaginal involvement and adjuvant radiotherapy. Tumor size, LVSI and vaginal involvement were found as independent prognostic factors for overall and disease free survival in multivariate analysis. Disease free survival, recurrence rate and site did not differ between patients underwent radical surgery and radical surgery plus radiotherapy. CONCLUSION: Tumor size, LVSI and vaginal involvement were independent prognostic factors in lymph node negative FIGO stage IB cervical cancer. Adjuvant radiotherapy in stage IB cervical cancer patients with negative nodes provides no survival advantage or better local tumoral control.     

Pretreatment tumor diameter/volume and pelvic lymph node status assessed by magnetic resonance imaging for uterine cervical carcinoma treated with concurrent chemotherapy and radiotherapy

Aim:  The aim is to evaluate the prognostic value of tumor diameter, volume and pelvic lymph node status assessed by magnetic resonance imaging (MRI) in patients with uterine cervical carcinoma patients treated with concurrent chemotherapy and radiotherapy.
Methods:  Ninety-eight patients diagnosed with stage IB to IIIB cervical carcinoma were entered into the study. Tumor diameter was evaluated in T2-weighted image. The tumor volume was calculated by the equation (volume = width × length × height × π/6) as an ellipsoid approximation. Univariate and multivariate analyses were performed to identify the prognostic factors for overall survival (OS), disease-free survival (DFS), pelvic control (PC) and distant metastasis-free survival (DMFS).
Results:  The 5-year OS, DFS, PC and DMFS rate were 59.8%, 57.3%, 67.9% and 78.8%, respectively. Using univariate analyses, large MRI tumor diameter (≥4 cm), large tumor volume (≥30 mL), pelvic enlarged pelvic lymph nodes, large clinical diameter (≥4 cm) and International Federation of Gynecology and Obstetrics (FigO) stage showed a statistically significantly unfavorable influence on OS and DFS. In multivariate analyses, large tumor volume affected OS, DFS, PC and DMFS, and enlarged pelvic lymph nodes also affected OS.
Conclusion:  Tumor volume and enlarged pelvic lymph nodes determined by pretreatment MRI examinations were significant prognostic factors for patients with invasive cervical carcinoma treated with concurrent chemotherapy and radiotherapy.     

Adenosquamous histology predicts poor outcome in low-risk stage IB1 cervical adenocarcinoma

OBJECTIVE: The purpose of this study was to identify poor prognostic factors of low-risk stage IB1 cervical adenocarcinoma METHODS: .All women diagnosed with stage IB1 cervical adenocarcinoma between 1982 and 2002 were identified at our three institutions. Data were extracted from medical records. Patients were retrospectively assigned to a low- or intermediate/high-risk cohort based on the surgical-pathologic eligibility criteria of two randomized controlled trials of adjuvant therapy in early stage cervical cancer, Gynecologic Oncology Group protocols 92 and 109. Multivariate analysis was performed. RESULTS: Two hundred thirty women diagnosed with stage IB1 cervical adenocarcinoma had an overall 5-year survival of 89%. Adenosquamous cell type (P < 0.01) was the only independent risk factor of disease recurrence in the low-risk group (n = 178). The 5-year disease-free survival for low-risk adenosquamous patients was 79%, compared to 96% for other histologic subtypes (P < 0.01). Low-risk case subjects developed fewer disease recurrences than those in the intermediate/high-risk (n = 52) category (7% vs 46%; P < 0.01). The 5-year disease-free survival for intermediate/high-risk patients was 51% and no additional risk factors were identified. CONCLUSION: Adenosquamous histology is predictive of disease recurrence and decreased survival in low-risk stage IB1 cervical adenocarcinoma. This risk factor should be considered in future clinical trials of adjuvant therapy.     

Survival and patterns of recurrence in cervical cancer metastatic to periaortic lymph nodes (a Gynecologic Oncology Group study)

Ninety-eight of 621 evaluable patients (16%) with cervical cancer enrolled into Gynecologic Oncology Group protocols were found to have periaortic lymph node metastases at staging laparotomy or at exploration for definitive operative management. As expected there was a progressive increase in the prevalence of periaortic metastases including 5% of 150 patients with Stage IB, 16% of 222 patients with Stage II, and 25% of 135 patients with Stage III. Periaortic lymph node metastases in the absence of pelvic lymph node metastases was an infrequent occurrence in patients so evaluated. The median survival of patients with periaortic metastases was 15.2 months with a survival probability of 25% at 3 years. The median duration of survival following recurrence was only 5 months. Recurrences were divided approximately equally between the pelvis and distant sites.     

Radiochemotherapy for patients with locally advanced cervical cancer: early results

PURPOSE: Radiotherapy is the standard treatment for locally advanced cervical cancer. Recent results of the prospective randomized trials have shown an overall survival and local control advantage for cisplatin-based therapy given concurrently with radiation therapy. Thirty-nine patients who received concurrent chemoradiation between October 1999 and December 2000 were evaluated for treatment response, local control and toxicity. MATERIALS AND METHODS: Thirty-nine patients with Stage IB through IVA cervical carcinoma received weekly cisplatin (40 mg/m2) concurrent with radiotherapy. Thirty-two patients received both external and intracavitary radiotherapy and seven patients received only external radiotherapy because of insufficient tumor response for intracavitary application. Total external radiotherapy dose was 64.8 Gy with 1.8 Gy daily fractions in patients who received only external radiotherapy. Midline shielding was performed at 50.4 Gy in patients who were going to receive brachytherapy and the total external radiotherapy dose was 54-59.4 Gy. Brachytherapy was performed with a Rotterdam applicator via the microSelectron HDR machine. A total dose of 8.5-18 Gy was applied to point A. RESULTS: Median age was 55. Distribution by stages were as follows: Stage IB 5.1%, IIA 28.2%, IIB 43.6%, IIIA 7.7%, IIIB 12.8% and IVA 2.6%. Histologically 33 (84.6%) were epidermoid carcinoma, one was adenocarcinoma, two were undifferentiated carcinoma, one was malignant epithelial tumor. In two patients histological type could not be specified. The median duration of follow-up was 20 months. Four patients had local recurrence and three developed distant metastases. Thirty patients (76.9%) had complete response, eight had (20.5%) partial response and one had (2.6%) stable disease. During or after radiochemotherapy 46.2% of the patients developed toxicity due to chemotherapy. Early and late radiation morbidity rates were 66.7% and 71.8%, respectively. No grade III-IV toxicity was observed. CONCLUSION: Concurrent chemoradiation for locally advanced cervical cancer is the treatment of choice in suitable patients providing high response rates with acceptable toxicity.