The use of para-aortic radiation therapy based on lymphangiogram interpretation in uterine cervical carcinoma

A review of prognostic factors in early-stage carcinoma of the cervix (FIGO I B and II A) and implications for treatment strategy

Several prognostic factors in stages I B and II A cervical carcinoma have been widely studied to define groups of patients with a poor prognosis. Most of these factors are interrelated. The characteristics which should be regarded as main factors have not yet been defined, because the studies reported were based on mainly retrospective and non-randomized analysis. Reviewing the literature, lymph node metastasis, differentiation grade, tumor size, parametrial extension, lymph-blood vessel invasion and cervical invasion seem to be prognostically important factors, which suggests that the subdivision of patients according to the FIGO classification alone is inaccurate. It seems useful to define subgroups of patients according to tumor characteristics, determined after surgical treatment and accurate histologic examination of the surgical specimen. Patients with one or more of these tumor features need additional treatment to improve survival. The current treatment modalities, such as postoperative radiotherapy, have not been thoroughly evaluated, but doubt exists as to their efficacy. Data in the literature suggest that particularly patients with para-aortic or multiple pelvic lymph node metastasis (greater than 3) have already developed distant metastases at the time of primary treatment and therefore need adjuvant systemic therapy. Patients with tumors larger than 4 cm in diameter, differentiation grade III, lymph-blood vessel invasion or cervical invasion (of more than 70%) seem to have high recurrence rates at both pelvic and distant sites, indicating that there is also a need for better pelvic control.

Combined radiotherapy and chemotherapy for advanced carcinoma of the cervix

Until recently the use of cytotoxic drugs in the treatment of squamous carcinoma of the cervix has been limited to patients with local recurrence after primary therapy or with distant metastases. The effectiveness of some cytotoxic drugs, especially cisplatin, in producing tumour regression in this group of patients with a poor prognosis, has encouraged the use of chemotherapy at an earlier stage of the disease process. Since 1979 patients with FIGO IIb squamous carcinoma of the cervix extending more than half-way to the pelvic side-wall and Stages III and IV disease have been treated with a combination of cisplatin or methotrexate and radiotherapy. The complete remission rate of Stage III tumours was 89% with a local recurrence rate of only 8%. In patients with advanced Stage IIb disease only 44% achieved complete remission and three patients with Stage IV disease failed to respond. The projected 5-year survival rate is 66% for patients with Stage III disease and 49% for all patients. The results of this combined treatment are presented and discussed and the suggestion made that chemotherapy combined with radiotherapy can be safely used to advantage in patients at high risk of local relapse.

Strategies in late stage cervix carcinoma

Stage IIB-IV squamous cell carcinoma of the cervix when treated by irradiation has a significant failure rate. Causes of pelvic and distant failure are discussed. New techniques employed to improve local control and decrease distant metastasis are presented. Data on morbidity, mortality, and survival will be reviewed with respect to these new strategies employed.

The value of lymphography in the management of carcinoma of the cervix

Lymphography has been used to evaluate the pelvic and para-aortic nodes in 205 patients with carcinoma of the cervix treated between 1970 and 1979. The incidence of positive nodes was found to be 17% for Stage I, 24% for Stage II, 52% for Stage III and 100% for Stage IV. Of 73 patients who had lymphograms before Wertheim's hysterectomy, four out of 59 patients (7%) with negative lymphograms had histologically positive nodes; four out of 14 (28%) with positive lymphograms had negative nodes. Within each FIGO stage a positive lymphogram indicated a poor prognosis. The actuarial 5-year survival rates for patients with negative and positive lymphograms were 94% and 55% respectively for Stage I, 72% and 64% for Stage II, and 34% and 17% for Stage III. Of 39 patients with positive lymphograms who died of tumour, 31 out of 39 (80%) had distant metastases, compared with nine out of 29 patients (31%) with negative lymphograms. It is concluded that lymphography is a valuable method of evaluating lymph node status in carcinoma of the cervix.