Diagnosis and surgical treatment of cervical cancer

Reviewing the role of parametrial boost in patients with cervical cancer with clinically involved parametria and staged with positron emission tomography

OBJECTIVE

Primary objective was to validate the practice of not treating clinically involved parametria by parametrial boost. Secondary objective was to validate the adequacy of nodal boost in node-positive patients regardless of parametrial status.

MATERIAL AND METHODS

A retrospective analysis of 193 patients with locoregionally advanced cervical cancer treated with curative intent using external beam radiotherapy and brachytherapy. All patients were staged clinically (International Federation of Gynecology and Obstetrics) and radiologically using magnetic resonance imaging and positron emission tomography. The positron emission tomography positive nodes were boosted to an additional dose of 6 to 10 Gy after 40 Gy to the whole pelvis. Parametrial boost was not used. Patients with stages IB to IIa and stages IIB to IIIB disease were allocated to groups A and B, respectively.

RESULTS

The pelvic failure (P = 0.430) and extrapelvic failure (P = 0.437) did not differ significantly between groups A and B. In multifactor analysis, tumor volume was significantly associated with pelvic failure (P = 0.009) and node positivity was significantly associated with extrapelvic failure (P = 0.002). Clinical parametrial involvement in the absence of parametrial boost was not related to either pelvic or extrapelvic failure. None of the node-positive patients had isolated pelvic nodal failure.

CONCLUSION

Cervical cancer with clinically involved parametria can be adequately treated without parametrial boost. A dose of 46 to 50 Gy was adequate to avoid isolated pelvic nodal failure.

Site specific lymph node metastasis in carcinoma of the cervix: Is there a sentinel node?

Follow-up for at least 5 years was available for 350 cases of stage IB and IIA carcinoma of the cervix managed by radical hysterectomy and pelvic lymphadenectomy. Lymphadenectomy technique mapped the patterns of pelvic lymph node metastasis (LNM). The effects on survival of specific factors relating to the lymphadenectomy (node count, number of positive nodes, site of positive nodes, number of sites positive, location of highest positive node) were determined for 80 women with LNM. The location of metastatic disease did not significantly predict survival. The incidence of LNM was 23% and 47.5% of these women survived 5 years. Only 45% of cases with a solitary LNM survived 5 years and in 45% of these recurrence was outside the pelvis. With the exception of the presacral group, the finding of isolated LNM in any other group with metastasis to the left side of the pelvis conferred the worst prognosis. The pattern of LNM from early stage carcinoma of the cervix is therefore random and the concept of a sentinel node or group is not tenable.

Conservative surgery for microinvasive carcinoma of the cervix

OBJECTIVE

To evaluate the prognosis of patients with stage IA1 and IA2 microcarcinoma of the cervix according to the 1994 FIGO classification.

METHODS

The histologic specimens of 494 patients who underwent conization for microcarcinoma of the cervix between 1958 and 1992 were reviewed and classified according to the 1994 FIGO system.

RESULTS

After a mean follow-up of 14 years (range, 1-35) 2 patients with stage IA1 tumors and 2 patients with stage IA2 tumors died of disease. Patients with early stromal invasion only accounted for 70% of patients with stage IA1 lesions. If these patients are excluded from stage IAI, the mortality rates for stage IA1 and IA2 did not differ significantly. Surgical radicality declined markedly during the study period.

CONCLUSION

Neither the 1985 nor the 1994 FIGO classification of microcarcinoma can be used as a guide to therapy. Conization only suffices for patients with early stromal invasion or a depth of invasion of 1-3 mm without lymph vascular space involvement. Additional pelvic lymphadenectomy can be considered for patients with stage IA1 lesions with lymph vascular space involvement. Removal of the tumor and pelvic lymphadenectomy is indicated for all patients with stage IA2 lesions, regardless of lymph vascular space involvement. Radical vaginal or radical abdominal hysterectomy represent overtreatment for patients with microcarcinomas because parametrial involvement in these patients has not been demonstrated.