The treatment of stage III carcinoma of the uterine cervix with telecobalt irradiation

A radioterapia do colo do útero no Brasil

O câncer do colo do útero tem expressiva significação no Brasil; como é uma patologia cuja radioterapia constitui um dos tratamentos mais importantes, é possível fazer uma análise da radioterapia e dos métodos usados para o seu tratamento utilizando este tumor como instrumento de análise. Os objetivos deste estudo são levantar o número e a forma como os tumores de colo uterino vêm sendo tratados no Brasil e, através desta análise, estudar a possibilidade de um protocolo nacional de tratamento. Foi elaborado um formulário com dados cadastrais e detalhes sobre o número, a maneira e o equipamento usado no tratamento dos tumores ginecológicos, que foi enviado a 117 instituições para serem respondidos, espontaneamente. Foram obtidos 80% de retorno, e a análise mostrou que 89% eram tumores do colo e 1 1 % do corpo do útero. Setenta e cinco por cento das instituições são privadas e apenas 5% são em hospitais-escola. Cinqüenta e oito por cento dos serviços ainda utilizam cálculo manual na braquiterapia e 70% das pacientes receberam tratamento combina do de tele-braquiterapia. Dos 22.750 casos de tumor do colo do útero estimados pelo Instituto Nacional de Câncer (INCA), para o ano de 1995, apenas 49% receberam radioterapia a despeito de se esperar uma taxa de 80%. Os autores fazem um ensaio sobre as possíveis causas que levam a discrepância entre estes dados e sugerem um protocolo nacional multi-institucional, coordenado pelo INCA e pelo Colégio Brasileiro de Radioloia (CBR), para o tratamento dos tumores de colo do útero, levando em consideração a realidade nacional.

Literature Review of Vaginal Stenosis and Dilator Use in Radiation Oncology

PURPOSE

Guidelines for the care of women undergoing pelvic radiation therapy (RT) recommend vaginal dilator therapy (VDT) to prevent radiation-induced vaginal stenosis (VS); however, no standard protocol exists. This review seeks to update our current state of knowledge concerning VS and VDT in radiation oncology.

METHODS AND MATERIALS

A comprehensive literature review (1972-2017) was conducted using search terms "vaginal stenosis," "radiation," and "vaginal dilator." Information was organized by key concepts including VS definition, time course, pathophysiology, risk factors, and interventions.

RESULTS

VS is a well-described consequence of pelvic RT, with early manifestations and late changes evolving over several years. Strong risk factors for VS include RT dose and volume of vagina irradiated. Resultant vaginal changes can interfere with sexual function and correlational studies support the use of preventive VDT. The complexity of factors that drive noncompliance with VDT is well recognized. There are no prospective data to guide optimal duration of VDT, and the consistency with which radiation oncologists monitor VS and manage its consequences is unknown.

CONCLUSIONS

This review provides information concerning VS definition, pathophysiology, and risk factors and identifies domains of VDT practice that are understudied. Prospective efforts to monitor and measure outcomes of patients who are prescribed VDT are needed to guide practice.

Literature Review of Vaginal Stenosis and Dilator Use in Radiation Oncology

PURPOSE

Guidelines for the care of women undergoing pelvic radiation therapy (RT) recommend vaginal dilator therapy (VDT) to prevent radiation-induced vaginal stenosis (VS); however, no standard protocol exists. This review seeks to update our current state of knowledge concerning VS and VDT in radiation oncology.

METHODS AND MATERIALS

A comprehensive literature review (1972-2017) was conducted using search terms "vaginal stenosis," "radiation," and "vaginal dilator." Information was organized by key concepts including VS definition, time course, pathophysiology, risk factors, and interventions.

RESULTS

VS is a well-described consequence of pelvic RT, with early manifestations and late changes evolving over several years. Strong risk factors for VS include RT dose and volume of vagina irradiated. Resultant vaginal changes can interfere with sexual function and correlational studies support the use of preventive VDT. The complexity of factors that drive noncompliance with VDT is well recognized. There are no prospective data to guide optimal duration of VDT, and the consistency with which radiation oncologists monitor VS and manage its consequences is unknown.

CONCLUSIONS

This review provides information concerning VS definition, pathophysiology, and risk factors and identifies domains of VDT practice that are understudied. Prospective efforts to monitor and measure outcomes of patients who are prescribed VDT are needed to guide practice.

Evaluation of Late Toxicities of Patients with Carcinoma of the Cervix Treated with Radical Radiotherapy: An Audit from India

AIMS

To evaluate the incidence of, and factors affecting, late toxicities of women with carcinoma of the cervix treated with radical radiotherapy.

MATERIALS AND METHODS

Between 1996 and 2001, 1069 women with carcinoma of the cervix (stage I-IVA) were treated at our centre with external-beam radiotherapy (EBRT) and intra-cavitary radiotherapy (ICRT) (n = 871) or EBRT alone (n = 198). Median follow-up was 34 months. Median dose to point A was 81 Gy.

RESULTS

Five-year actuarial incidence of overall (all grades) and severe (grade 3/4) late toxicities in the rectum, bladder, small intestine and subcutaneous tissue were 12.3% and 1.1%, 11.2% and 1.2%, 9.2% and 0.2%, and 23.1% and 1.2%, respectively. Vaginal adhesions were seen in 29.6% of cases and stenosis in 33.9% of cases. On multivariate analysis, factors adversely affecting overall incidence of proctitis were anterior-posterior (AP) separation of patient more than 18 cm and presence of comorbid diseases. Presence of comorbid diseases was the only factor affecting the incidence of severe proctitis (grade 3/4). AP separation more than 18 cm adversely affected the incidence of cystitis, both overall and severe. Late toxicities (all grades) in small bowel were increased in subsets, like women younger than 50 years and women with comorbid diseases, but no factor emerged as significant for incidence of severe toxicities. Subcutaneous fibrosis was significantly higher in patients with AP separation over 18 cm, those treated by cobalt machines and those who received EBRT only. Severe subcutaneous fibrosis was influenced by the use of EBRT alone. Overall incidence of vaginal toxicity was higher in women whose overall treatment time (OTT) was shorter and in women who received ICRT. Vaginal stenosis was higher in elderly women and in women who received ICRT by low dose rate.

CONCLUSIONS

Even with telecobalt machines, impressive results with acceptable late toxicity can be achieved in the treatment of cancer of the cervix using an ideal combination of EBRT with ICRT.

Long-term results of high-dose rate brachytherapy in cervix cancer using a small number of fractions

OBJECTIVES

To evaluate the long-term treatment outcome of patients with carcinoma of the cervix treated with high dose rate brachytherapy (HDRB) using a small number of fractions.

METHODS

Between 1984 and 1997, 282 patients with cervix cancer (stages IB to IVA) were treated with external beam radiotherapy to the whole pelvis (median dose of 45 Gy) and HDRB (median dose of 24 Gy at point A in 3 insertions given weekly). Endpoints assessed were survival, patterns of failure and complications. Multivariate analysis was performed to identify variables predictive for overall survival and local control. Variables investigated were stage, age, overall duration of treatment, HDRB scheduling and total dose to point A.

RESULTS

At a median follow-up of 86.3 months for patients at risk, the 5-, 10- and 15-year overall survival rates are 57%, 52% and 47%, respectively. On multivariate analysis, only stage and age correlated with improved survival. Treatment duration beyond 47 days was associated with poorer overall survival, although it did not reach statistical significance (P = 0.10). Brachytherapy scheduling and BED to point A had no impact on overall survival. Stage and age significantly correlated with pelvic disease control. Duration of therapy, scheduling of the brachytherapy and BED at point A were not individual predictors for overall local control. Overall, gastrointestinal and genitourinary actuarial complication rates were 15% and 8%, respectively.

CONCLUSIONS

In our experience, HDRB using 3 insertions is well tolerated and the results are comparable to HDRB using larger number of fractions and to low dose rate brachytherapy.

Concurrent chemotherapy and hypofractionated twice-daily radiotherapy in cervical cancer patients with stage IIIB disease and bilateral parametrial involvement: A phase I-II study

PURPOSE

Stage IIIB cervical cancer patients with bilateral parametrial involvement have a poor prognosis with low survival rates. In an effort to improve outcome of these patients, we initiated a prospective, Phase I-II trial of concomitant chemotherapy with cisplatin and 5-fluorouracil and hypofractionated twice-daily radiotherapy. This program was initiated on the basis of the encouraging results obtained in the treatment of bladder cancer using a similar regimen. The purpose of this study was to evaluate the results of treatment (toxicity, survival, and patterns of failure) using this novel approach.

METHODS AND MATERIALS

A total of 34 patients with Stage IIIB squamous cell cervical cancer and bilateral parametrial involvement entered the study. After inclusion of the first 14 patients, the study was put on hold for 6 months, and the patients were carefully observed. Once the toxicity level was found acceptable, the remaining 20 patients entered the study. External beam radiotherapy was delivered twice daily on Days 1 and 3, 15 and 17, 45 and 47, and 59 and 61. The whole pelvis was treated each treatment day at a dose of 2.5 Gy b.i.d. Low-dose-rate brachytherapy (35 Gy to Point A) was delivered on Day 29. Chemotherapy was administered on Days 1-3, 15-17, 45-47, and 59-61 and consisted of cisplatin 15 mg/m(2) and 5-fluorouracil 400 mg/m(2).

RESULTS

The treatments were well tolerated. None of the patients developed Grade 3-4 acute toxicity. Late Grade 3-4 GI or GU toxicity was seen in 4 (11.7%) and 1 (3%) patient, respectively. At a median follow-up of 60 months, 18 patients were alive. The 3-year and 5-year overall survival rate was 76% and 59%, respectively.

CONCLUSION

This protocol, comprising concomitant chemotherapy and twice-daily hypofractionated split-course radiotherapy was associated with moderate toxicity and a survival that exceeds that previously reported for this high-risk population.

Preventing vaginal stenosis after brachytherapy for gynaecological cancer: an overview of Australian practices

Despite advances in brachytherapy techniques in recent years, patients still experience a variety of treatment-related complications. Vaginal stenosis is a recognised toxicity of brachytherapy for the treatment of gynaecological cancer. It can result in long-term sexual dysfunction and painful vaginal examinations; however, it is generally accepted that it may be prevented by regular sexual intercourse or the use of vaginal dilators. The incidence of vaginal stenosis is variably reported in the literature, while preventative strategies and compliance are infrequently described and rarely evaluated. A telephone survey of radiation oncology centres in Australia was undertaken as a quality improvement activity to determine best practice for the use of vaginal dilators for the prevention of vaginal stenosis, by way of identifying similarities of practice. The results revealed a lack of consistency for all variables, including which patients are advised to use vaginal dilators, the time to initiate use, frequency of use, insertion time and duration of use. These findings suggest that current methods for preventing radiation-induced vaginal stenosis warrant formal evaluation in order to establish an evidence base for practice.

Radiotherapy alone in the treatment of uterine cervix cancer with telecobalt and low-dose-rate brachytherapy: retrospective analysis of results and variables

PURPOSE

This retrospective analysis aims to report results and variables from patients with cervix cancer treated by radiation therapy alone with telecobalt and low-dose-rate brachytherapy (LDRB).

METHODS AND MATERIALS

Between September 1989 and September 1995, 190 patients with histologic diagnosis of cervix carcinoma were treated with telecobalt for external beam radiotherapy (EBR), followed by one or two insertions of LDRB. Stage distribution according to patients was the following: IB, 12; IIA, 4; IIB, 105; and IIIB, 69. Median dose of EBR at whole pelvis was 40 Gy, and median parametrial doses for Stages II and III patients were 50 Gy and 60 Gy, respectively. Median doses of LDRB at point A for patients treated with one and two insertions were 38 Gy and 50 Gy, respectively.

RESULTS

Median follow-up time was 70 months (range: 8-127 months). Overall survival, disease-free survival, and 5-year local control of patients at Stages I, II, and III were 83%, 78%, and 46%; 83%, 82%, and 49%; and 92%, 87%, and 58%, respectively. Overall incidence of late complications in the rectum, small bowel, and urinary tract was 15.3% (19/190), 4.2% (8/190), and 6.8% (13/190), respectively. The actuarial 5-year rectal, small bowel, and urinary incidence of late complications was 16.1%, 4.6%, and 7.6%, respectively. Clinical stage was the only significant variable for overall 5-year survival (p = 0.001), for disease-free survival (p = 0.001), and for local control (p = 0.001). Stage II patients more than 50 years old had better disease-free survival and local control at 5 years (p = 0.004). None of the analyzed variables influenced the actuarial 5-year incidence of late complications.

CONCLUSIONS

Results of this series suggest that the use of telecobalt equipment for EBR with doses up to 50 Gy at whole pelvis, prior to brachytherapy, is an acceptable technique for radiation therapy alone in the treatment of cervix cancer, especially in developing countries, including Brazil, where telecobalt machines still prevail.

Long-term results of low-dose-rate interstitial-intracavitary brachytherapy in the treatment of carcinoma of the cervix

PURPOSE

Brachytherapy plays a major role in the treatment of patients with carcinoma of the cervix. However, routine intracavitary brachytherapy may not be feasible or adequate to treat locally advanced disease. The purpose of this retrospective study (spanning a 20-year period) was to determine the outcome of interstitial low-dose-rate brachytherapy in the treatment of bulky or locally advanced cervical cancer. The long-term survival and safety of this technique were evaluated, along with its impact on local and locoregional control, disease-free survival, and complications.

METHODS AND MATERIALS

A total of 185 previously untreated patients with cervical cancer were treated between 1977 and 1997. According to the International Federation of Gynecology and Obstetrics classification, 21 patients had Stage IB (barrel), 77 Stage II, 77 Stage III, and 10 Stage IV disease. All patients were treated by a combination of external megavoltage irradiation to the pelvis to a dose of 5040 cGy followed by interstitial-intracavitary implants to a dose of 40-50 Gy to the implanted volume in two applications.

RESULTS

Clinical local control was achieved in 152 (82%) of the 185 patients. A 5-year disease-free survival rate of 65%, 67%, 49%, and 17% was achieved for patients with Stage IB, II, III, and IV disease, respectively. Eighteen (10%) of the 185 patients developed Radiation Therapy Oncology Group Grade 3 or 4 late complications.

CONCLUSION

Patients with locally advanced cervical cancer, or with distorted anatomy, may be treated adequately with interstitial brachytherapy to achieve excellent locoregional control and a reasonable chance of cure with acceptable morbidity.

Treatment failure in vaginal cancer

OBJECTIVE

The aim of this study was to analyze the pattern of treatment failure in patients with vaginal cancer.

METHODS

Fifty-one patients with primary vaginal cancer (registered between 1957 and 1995) were reviewed. Primary treatment consisted of surgery in 12 patients and radiation in 39 patients. In these patients, the prognosis and treatment failure were analyzed in relation to clinicopathological factors.

RESULTS

The 5-year survival rate was 100% in stage 0 (N = 5), 82% in stage I (N = 11), 70% in stage II (N = 23), 0% in stage III (N = 5), 14% in stage IV (N = 7), and 61% overall (N = 51). Although early disease had a relatively favorable prognosis, two of five patients with stage 0 disease developed local recurrence. There was no site-related difference in survival, but survival was better when the tumor occupied less than one-third of the vaginal wall compared with more than one-third. All relapses in stage 0-II patients were local recurrences, whereas treatment failure in stage III-IV patients was due to either persistent local disease or new distant metastasis.

CONCLUSION

The present findings suggest that more intensive local therapy may achieve a better prognosis for patients with early disease. Conversely, suppression of distant metastasis along with aggressive local control is needed for advanced disease. Conventional radiotherapy alone is of little value for advanced disease.

Long-term survival following neoadjuvant chemotherapy and radical surgery in locally advanced cervical cancer

The aim of this study was to analyse the long-term survival and the relationships between prognostic factors at presentation, chemoresponsiveness and disease outcome in patients with locally advanced cervical cancer treated by neoadjuvant chemotherapy and radical surgery (RS). Two consecutive studies of neoadjuvant chemotherapy containing cisplatin, bleomycin plus/minus methotrexate followed by radical hysterectomy and systematic aortic and pelvic lymphadenectomy were carried out between January 1986 and September 1990 on 130 patients with > or = 4 cm stage IB2-III cervical cancer. Survival analysis was performed using the Kaplan and Meier test and Cox's multivariate regression analysis. 128 (98%) of the patients enrolled were evaluable for clinical response and survival, 83% (106) of the patients responded to chemotherapy, with a 15% complete response rate. Logistic regression analysis demonstrated that International Federation of Gynecology and Obstetrics (FIGO) stage, cervical tumour size, parametrial involvement and histotype are highly predictive of response. Responding patients underwent laparotomy, but 8% were not amenable for radical surgery. The 10-year survival estimates were 91%, 80% and 34.5% for stage IB2-IIA bulky, IIB and III, respectively (P < 0.001). After Cox's regression analysis, the parameters significantly associated with survival were the same factors predicting response to neoadjuvant chemotherapy. No stage IB2-IIA bulky patient has so far relapsed, while 12% stage IIB and 56% stage III patients recurred. The 10-year disease-free survival estimates are 91% and 44% for stage IB2-IIB and III, respectively (P < 0.001). Metastatic nodes and persistent tumour in the parametria were the only two independent factors for disease-free survival after multiple regression analysis. After a long-term follow-up (median follow-up 98 months (20-129+)), our results give new evidence of the prognostic value of response to neoadjuvant chemotherapy and of a possible therapeutic benefit of the sequential treatment adopted which, however, must be verified in a randomised setting.

Radiation therapy duration influences overall survival in patients with cervical carcinoma

OBJECTIVE

This article analyses the influence of treatment duration on survival in patients with invasive carcinoma of the cervix treated by radical radiation therapy.

METHOD

Three hundred and sixty patients with FIGO stage IB-IIIB carcinoma of the cervix were treated in Lausanne (Switzerland) with external radiation and brachytherapy as first line therapy. Median therapy duration was 45 days. Patients were classified according to the duration of the therapies, taking 60 days (the 75th percentile) as an arbitrary cut-off.

RESULTS

The 5-year survival was 61% (S.E. = 3%) for the therapy duration group of less than 60 days and 53% (S.E. = 7%) for the group of more than 60 days. In terms of univariate hazard ratio (HR), the relative difference between the two groups corresponds to a 50% increase of deaths (HR = 1.53, 95% CI = 1.03-2.28) for the longer therapy duration group (P = 0.044). In a multivariate analysis, the magnitude of estimated relative hazards for the longer therapies are confirmed though significance was reduced (HR = 1.52, 95% CI = 0.94-2.45, P = 0.084).

CONCLUSION

These findings suggest that short treatment duration is a factor associated with longer survival in carcinoma of the cervix.

Hyperfractionated external radiation therapy in stage IIIB carcinoma of uterine cervix: a prospective pilot study

PURPOSE

Brazil has one of the highest incidence of carcinoma of the cervix in the world. Half of the patients have advanced stages at the diagnosis. Due to this large number of patients we decided to conduct a prospective pilot study to investigate the tolerance to and survival rate with hyperfractionated external radiotherapy only in patients with Stage IIIB carcinoma of the uterine cervix.

METHODS AND MATERIALS

Between January 1991 and December 1993, 23 patients underwent hyperfractionated external beam radiotherapy without brachytherapy. All cases were biopsy proven squamous cell carcinoma of cervix clinically Staged as IIIB (FIGO). Hyperfractionation (HFX) was given with 1.2 Gy doses, twice daily at 6-h interval, 5 days/week, to the whole pelvis up to 72 Gy within 30 working days. Complications were evaluated by an adaptation ot the RTOG Radiation Morbidity Scoring Table graded as 1 = none/mild; 2 = moderate, and 3 = severe.

RESULTS

Follow-up ranged from 27 to 50 months (median 40 months) on the 9 to 23 living patients at the time of the analysis in December 1995. There was no severe acute toxicity, but moderate acute reaction was high: 74%. The commonest site of complication was the intestine where severe late toxicity occurred in 2 of 23 (9%). Overall survival rate at 27 months was 48% and at 40 months was 43%.

DISCUSSION

There is little information in literature about HFX in carcinoma of the cervix. This is the third published study about it and the one that gave the highest total dose with external HFX of 60 x 1.2 Gy = 72 Gy. Theoretically, through the linear quadratic formula this schedule of HFX would be equivalent to 30 x 2 Gy = 60 Gy of standard fractionation, both treatments given in 30 working days. HFX schedules must be tested to establish their safety. Present results suggest being possible to further increase the total dose in the pelvis with hyperfractionated irradiation.

Heuristically derived tumor burden score as a prognostic factor for stage IIIB carcinoma of the cervix

PURPOSE

A retrospective analysis of radiotherapeutic management of locally advanced carcinoma of the uterine cervix was performed to evaluate the effect of various treatment parameters and disease extent upon treat outcome.

METHODS AND MATERIALS

Between 1976 and 1989, 89 patients with Stage IIIB disease were treated with external beam radiotherapy and brachytherapy. Treatment outcomes were evaluated by dose to Point A, the proportion of Point A dose delivered by brachytherapy, clinical response at 3 months, and a newly developed tumor burden scoring system that quantifies the anatomical extent of disease. Kaplan-Meier estimates of tumor control and survival parameters were determined.

RESULTS

Loco-regional control (LRC), disease-free survival (DFS), and overall survival (OVS) at 5 years were 52.9%, 45.5%, and 50.3%, respectively. Clinical response at 3 months was highly predictive of local and distant tumor control. There was no correlation between proportion of brachytherapy dose and treatment outcome. The tumor burden scoring system demonstrates that FIGO Stage IIIB disease can be clinically divided into two prognostic groups of low and high tumor burden. Five year LRC was 62.9% and 40.2% for the low and high tumor burden groups, respectively (p = 0.024). Within the high tumor burden group the LRC was 53.0% and 22.5% when the point A dose given was > 78 Gy and < or = 78 Gy, respectively (p = 0.047). This correlated with improved DFS and OVS.

CONCLUSION

The tumor burden scoring system subdivides FIGO Stage IIIB cervical carcinoma into two prognostic groups, predicting for overall survival and demonstrating a dose response in the high tumor burden group. This system may serve to improve future comparison of treatment outcome and to guide selection of patients who may benefit from a more aggressive treatment approach.

Weekly cisplatin plus external beam radiotherapy and high dose rate brachytherapy in patients with locally advanced carcinoma of the cervix

PURPOSE

Prospective, single arm, Phase I/II trial performed to assess the efficacy and toxicity of the concomitant use of weekly cisplatin and pelvic radiotherapy in patients with locally advanced carcinoma of the cervix.

METHODS AND MATERIALS

Between December 1988 and April 1991, 50 previously untreated patients with bulky, locally advanced, squamous cell carcinoma entered the study. All patients were evaluated by a gynecologist and a radiation oncologist and were submitted to standard pre-treatment staging procedures. The International Federation of Gynecology and Obstetrics stage distribution was as follows: IIA three patients, IIB seventeen, IIIA two, IIIB 25, and IVA three. Radiotherapy consisted of 46 Gy external beam irradiation plus three high dose rate intracavitary treatments given on a weekly basis to a total dose of 30 Gy to point A. Cisplatin 30 mg/m2 was also given weekly starting on day 1 of radiotherapy.

RESULTS

With a median follow-up time of 27 months, complete response was seen in 88% (44/50) of the patients. The actuarial survival rate at 44 months was 65%. Total pelvic failure rate was 26% (13/50). Of the 44 patients who achieved a complete remission, only seven have failed in the pelvis. Distant disease was observed in 24% of the cases. Treatments were well tolerated with no patient requiring an interruption in the radiotherapy. However, the incidence of late gastrointestinal toxicity was high, with 10 patients developing a rectal ulcer (four colostomies for severe bleeding), two patients a small bowel obstruction, and two patients a recto-vaginal fistula. Moreover, gastrointestinal complications appeared sooner than expected, at a median follow-up time of 11 months after completion of treatment.

CONCLUSION

The combination of weekly cisplatin and radiotherapy appears to be a very effective regimen for patients with locally advanced carcinoma of the cervix, but resulted in a relatively high frequency of late gastrointestinal complications.

Prognostic factors in advanced stage squamous cell cancer of the cervix

BACKGROUND

This study was undertaken to review prognostic factors for advanced squamous cell cancer of the cervix.

METHODS

A clinicopathologic review of patients diagnosed with advanced stage squamous cell cancer of the cervix was performed at the University of Michigan Medical Center, Ann Arbor, Michigan, from 1970-1985.

RESULTS

All patients had squamous cell disease and were divided according to the following stages: Stage IIIa (4), Stage IIIb (113), Stage IVa (32), and Stage IVb (26). The cumulative 5-year survival was as follows: Stage IIIa (50%), Stage IIIb (37%), Stage IVa (14%), and Stage IVb (4%). Prognostic features for Stage IIIb disease showed that the intravenous pyelogram status significantly predicted cumulative 5-year survival (P = 0.00001). When the intravenous pyelogram was normal, 47% survived. When ureteral obstruction was present without renal failure, 29% survived, and when renal failure occurred, all patients were dead of disease by 16 months. The lymph node status significantly influenced cumulative 5-year survival (P = 0.004). When lymph nodes were negative, 47% survived. When three or fewer were positive, 44% survived. When more than three were positive, 11% survived. When pelvic lymph nodes were positive and paraaortic node status was determined, 25% survived when paraaortic lymph nodes were negative, while 8% survived when these were positive (P = 0.06). Factors that did not influence 5-year survival included one or both sidewall involvement (P = 0.77), tumor grade (P = 0.23), diabetes (P = 0.92), hypertension (P = 0.85), and obesity (P = 0.47). The diagnosis of Stage IVa disease was made by the presence of fistula at initial presentation (n = 8), cystoscopy (n = 21), and sigmoidoscopy (n = 1). One patient developed a treatment-related vesicovaginal fistula when bladder involvement was diagnosed by cystoscopy. All 18 patients who presented with renal failure (Stage IIIb, 9; Stage IVa, 9) were analyzed as a group, and only 1 patient survived. The median survival in 15 patients who underwent nephrostomy was 8 months, range 1-36 months. Ten of 15 patients (66%) were dead of disease within 1 year. Three patients refused renal bypass, and these three patients died at 1, 2, and 3 months, respectively.

CONCLUSIONS

Advanced stage disease represents a significant challenge, and when ureteral obstruction or renal failure is present, the prognosis is markedly decreased.

Preliminary results of concurrent radiotherapy and chemotherapy with cis-platinum, vincristine, and bleomycin in bulky, advanced cervical carcinoma: A pilot study

Twenty-four patients with bulky (greater than 4 cm), advanced (stages IIB-IVA) carcinoma of the uterine cervix were prospectively treated with a concurrent combination of radiotherapy (RT) and chemotherapy (CT). RT consisted of 4400 cGy (22 fractions) to the whole pelvis and a 1400-cGy boost to the parametrium. This was followed by two to three intracavitary brachytherapy courses. CT consisted of one to four course (median, three) of cisplatin (50 mg/m2) on Day 1, vincristine (1 mg/m2) on Day 2, and bleomycin (25 mg/m2) on Days 2-4. CT was started on the first day of external radiation and the scheduled course interval was 21 days. Among the 20 evaluable patients who completed at least one course of chemotherapy and a full course of radiation, 13 (65%) achieved complete response and 5 (25%) had partial response. Fatal complication occurred in 1 patient with stationary disease who died of septic shock due to ruptured pyometra. The other patient with primary stage IVA disease had progressive disease with ascites appearance after two courses of CT and later expired. Transient drug fever occurred in 19 (40.4%) of the 47 bleomycin-containing CT cycles. Grade 2 or 3 hematological toxicities occurred in 16 (30.2%) of a total of 53 CT cycles. Treatment delays of 1 to 7 days occurred in 15 (28.3%) CT cycles. Except for the case of septic shock, all of the other toxicities were generally tolerable and reversible. From this preliminary result we concluded that this particular combination of RT and CT in bulky, advanced cervical carcinoma is effective in enhancing local pelvic tumor control and well tolerated if strict selection of accrued patients is applied. Further investigation to assess its impact on long-term survival is in progress.

A reappraisal of the International Federation of Gynecology and Obstetrics staging system for cervical cancer. A study of patterns of care

The Patterns of Care Study (PCS) database for squamous cell cancer of the uterine cervix has been used to evaluate the International Federation of Gynecology and Obstetrics (FIGO) staging system, with particular focus on the association of tumor bulk with outcome. The 1558 patients treated in the United States in 1973 and 1978 constitute the data set, and survival and in-field pelvic control were the end point of assessment. In summary, this reappraisal of the FIGO staging system for cancer of the uterine cervix showed that the current FIGO system is not discriminating within stage. This study suggests specific indicators of progressive bulk of cancer that should be considered, because they were associated with significant differences in survival rate and in-field pelvic control within Stage II and III disease.

Surgical management of radiation enteropathy

Acute radiation enteropathy is usually self-limited and rarely requires surgical intervention. Chronic radiation enteropathy may occur months, years, or decades after treatment. Patients may present with crampy abdominal pain, diarrhea, or cachexia or may present acutely with bowel obstruction or fistula. The bowel and its mesentery are shortened, and mucosal ulceration and submucosal fibrosis are present. The vasculature of the bowel is markedly compromised by progressive endarteritis. Ideally, nutritional support should be given and surgery performed electively. Regardless of presentation, both large and small bowel must be evaluated for concurrent problems. At surgery, resection and restoration of continuity of the gastrointestinal tract is optimal management. Recurrent obstruction and fistulae are real risks, and optimal management is resection of bowel damaged by radiation and anastomosis using bowel spared from irradiation. However, if the patient is unstable or necessary dissection and mobilization of the bowel judged too morbid, bypass of the affected loop is acceptable. Occasionally, only diversion of the bowel by enterostomy is possible.

The effect of volume of disease in patients with carcinoma of the uterine cervix

This is a retrospective study of 635 consecutively treated patients with FIGO Stage IIB or IIIB carcinoma of the uterine cervix. All patients were treated definitively with radiation therapy. The effect of volume of disease on outcome was studied. The 5-, 10-, and 15-year disease-free survivals (DFS) for the 346 Stage IIB patients were 64%, 61%, and 58%, respectively. Corresponding DFS for the 289 Stage IIIB patients were 40%, 38%, and 34%, respectively. The presence of bilateral parametrial invasion did not alter the 10-year DFS in Stage IIB patients (61% vs 64%, p = 0.60) but did decrease it in Stage IIIB patients (34% vs 50%, p = 0.006). Patients with both Stage IIB and IIIB cancers and central bulky disease (greater than or equal to 5 cm in diameter) had decreased DFS when compared to those without central bulky disease. Stage IIB patients with the lateral half of the parametrium involved had a decreased 10-year DFS in comparison with medial half involvement (52% vs 68%, p = 0.004). The total pelvic failure rate was 23% for Stage IIB and 41% for Stage IIIB patients. Central bulkiness increased the pelvic failure rate by about 11% for all patients. Bilateral parametrial disease increased the pelvic failure rate in Stage IIIB patients but not in patients with Stage IIB disease. The total pelvic failure rate for Stage IIB patients was greater in those whose disease extended into the lateral parametrium. Multivariate analysis was done using stage, lateral pelvic wall dose, parametrial disease, central bulkiness, age, and total dose to point A as variables. With local control as the endpoint, only stage (IIB vs IIIB) was significant (p = 0.008). Using DFS as the endpoint, stage (p = 0.0001) and central bulkiness of tumor (p = 0.026) were significant. Complications were not increased in patients with bulky or bilateral disease. We conclude that there is justification for subdividing FIGO Stage IIIB patients into those with unilateral or bilateral disease; however, these data do not support such a division for FIGO Stage IIB patients. These latter patients would be better analyzed with reference to medial versus lateral parametrial extension because of the difference in pelvic control and survival.

Pretreatment and treatment factors associated with improved outcome in squamous cell carcinoma of the uterine cervix: a final report of the 1973 and 1978 patterns of care studies

The Patterns of Care Study (PCS) conducted two national surveys of patients treated in 1973 and 1978 for squamous cell cancer of the uterine cervix. In addition, a survey of patients treated in 1973 from selected large facilities was conducted to establish outcome with "optimal" radiotherapy. The large facility survey consistently reported improved outcome compared to both national average surveys when analyzed by stage and other significant pretreatment factors. That improved outcome was associated with the paracentral (PCS point A) dose and the use of intracavitary irradiation. In this study, we report the pretreatment and treatment factors associated with improved outcome in squamous cell carcinoma of the uterine cervix by analysis of the 1973 and 1978 PCS data. Pretreatment factors associated with improved pelvic control in multivariate analysis include higher Karnofsky Performance Status (KPS) (Stage I and II), older age (Stage I and II), unilateral parametrial involvement (Stage IIB), and unilateral sidewall involvement (Stage III). The only treatment factor associated with improved pelvic control in multivariate analysis is the use of intracavitary irradiation. However, a dose response for infield pelvic control was demonstrated only in Stage III cervix cancer with the highest rate of pelvic control with paracentral (PCS point A) dose greater than 8500 cGy. Multivariate analysis revealed that unilateral parametrial involvement for Stage IIB and unilateral sidewall involvement for Stage III are significant positive prognostic factors with respect to survival after treatment with radiotherapy. No FIGO substage significantly affected survival after radiotherapy. Although FIGO staging is the single most important pretreatment prognostic factor with respect to survival and infield pelvic failure, FIGO substaging deserves reappraisal and further refinement. Major complications were seen in only 9.5% of patients treated with radiotherapy and were stage but not survey related. There is a significant relationship between PCS point A dose and complications with the highest rate of complications for PCS point A dose greater than 8500 cGy. A significant relationship between lateral (external iliac lymph nodes or PCS point P) dose and major complications is also found, and doses greater than 5000 cGy are associated with a significant increase in complications. The PCS has established two sequential national benchmarks of treatment outcome for squamous cell carcinoma of the uterine cervix treated with radiotherapy with respect to survival, infield pelvic control, and complications.(ABSTRACT TRUNCATED AT 400 WORDS)