Invasive carcinoma of the cervix in young women: clinical data and prognostic features

Prognostic significance of pretherapeutic and therapeutic factors in patients with advanced cancer of the uterine cervix treated with radical radiotherapy alone

The prognostic importance of various pretherapeutic and therapeutic factors was analysed in a group of 413 cervical cancer patients with stage IIB (183 pts) and IIIB (230 pts) treated with radical radiotherapy, which consisted of external irradiation and intracavitary brachytherapy. Univariate analysis of pretherapeutic factors revealed the prognostic significance of patient age, history of abortion, stage, haemoglobin and hematocrit levels. Five-year overall survival rate in stage IIB patients was 51%, in stage IIIB 40% and the respective rates for local control at each stage were 61%, and 46%. Univariate analysis of therapeutic factors showed that survival and local control rates increased with the dose, but a significant difference was found only in the case of a paracentral (point A) dose. In a multivariate analysis only patient age, abortions, and clinical stage appeared to have a significant and independent impact on survival. Linear regression analysis results indicated that prolongation of treatment time between 33 and 108 days caused a loss of local control of 0.36% per day.

Treatment results and prognostic factors in inoperable carcinoma of the cervix treated with external plus high dose brachytherapy

Patients with inoperable carcinoma of the cervix treated with external plus high dose rate brachytherapy (HDRB), between 1988 and 1995 were evaluated retrospectively. According to stage, 5 year survival rates were 67.3% in stage IIb and 52.6% in stage III (P = 0001) and disease free survival (DFS) rates were 54.0% in stage IIb and 43.9% in stage III (P = 0.01). The following parameters were studied: age; stage; external beam dose; brachytherapy dose; total dose to point A; tumor mass; tumor response rate; bilateral or unilateral invasion of parametria in stage IIb; and bilateral or unilateral invasion of pelvic wall in stage IIIb; and the existence of hydronephrosis. The only significant parameter of 5 year survival and local control was tumor mass (P = 0.003).

Prognostic factors in patients with carcinoma of the uterine cervix treated with external beam irradiation and IR-192 high-dose-rate brachytherapy

PURPOSE

Prognostic factors in cancer of the cervix for patients treated with external beam irradiation (EBR) and low-dose-rate (LDR) brachytherapy have been characterized. However, despite the increasing use of high-dose-rate (HDR) intracavitary placements (ICP), few studies with adequate follow-up have analyzed prognostic factors. This study investigates pretreatment and treatment factors for their correlation with treatment outcome after EBR and HDR-ICP.

METHODS AND MATERIALS

Between September 1985 and December 1994, 181 patients with carcinoma of the cervix FIGO stages IB-IV received EBR and HDR brachytherapy. Hemoglobin (Hb) levels were maintained above a level of 11 g/dl during the treatment by transfusion. Patient age ranged from 34 to 84 years (median: 66). The median follow-up time for patients at risk is 69 months (range: 23-140). Pretreatment and treatment parameters analyzed to determine their prognostic value included age, FIGO stage, tumor size, tumor type and grade, pretreatment Hb level, number of HDR-ICP, total dose from HDR-ICP, overall dose to point A, and overall treatment time. Also evaluated was the prognostic value of enlarged lymph nodes noted on pretreatment CAT scan of the abdomen and pelvis. Endpoints studied in uni- and multivariate analyses were disease-specific survival (DSS), freedom from disease (FFD), pelvic control (PC), and probability of distant metastases (DM).

RESULTS

At 5 years the DSS, FFD, and PC rates for all patients were 60%, 58%, and 67%, respectively. The 5-year FFD by stage was: IB: 94%; II: 63%; IIIB: 43%; and IV: 0%. The PC rates were 94%, 66%, 59%, and 0%, respectively. In univariate analysis the prognostic factors identified for FFD were FIGO stage, tumor size, initial Hb level, and enlarged pelvic and/or paraaortic nodes (all: p < 0.0001). Age was inversely correlated with outcome (p = 0.0081). The 5-year FFD rates for tumors (< 3, > or = 3 < 6, > or = 6 cm) were 97%, 65%, and 24%; patients with initial Hb levels < or = 11g/dl had a FFD of 26% versus 69% for patients with levels > 11g/dl; and those with pelvic and/or paraaortal nodes > or = 1 cm had a survival of 32% versus 68% in patients with negative readings. The same factors were also prognostically significant for DSS, PC, and DM. Patients with persistent disease or pelvic failures had a significantly higher incidence of DM than patients in whom pelvic disease was controlled (p < 0.0001).Histological and treatment parameters including overall treatment time were not of prognostic significance for any of the endpoints studied. In multivariate analysis tumor size was the most powerful parameter for DSS, FFD, PC (p < 0.0001) and DM (p = 0.0001), followed by low initial Hb level (DSS: p = 0.0004, FFD: p = 0.0009, PC: p = 0.0012, DM: p = 0.0265), and enlarged pelvic and/or paraaortic nodes which were predictive for DSS (p = 0.0210) and DM (p = 0.0011).

CONCLUSION

This study confirms that prognostic factors for patients treated with HDR brachytherapy are similar to those reported in previous series that employed LDR brachytherapy. The significance of tumor size, pretreatment Hb level, and enlarged pelvic and/or paraaortic lymph nodes on CAT scan over FIGO stage of disease were demonstrated. Future prospective trials should be undertaken to confirm the validity of these factors and to elucidate their therapeutic implications.

Analysis of prognostic factors in stage IIB-IVA cervical carcinoma treated with radiation therapy: value of computed tomography

PURPOSE

To define the influence of the tumor size measured by computed tomography (CT) and lymph node involvement detected by CT in patients treated with radiation therapy for Stage IIB-IVA carcinoma of intact uterine cervix.

METHODS AND MATERIALS

This was a retrospective analysis of 233 patients with uterine cervical cancer managed with both external irradiation and high-dose-rate intracavitary brachytherapy (HDR-ICR) at Kanagawa Cancer Center. The results were analyzed for the end points of absolute survival (AS), disease-free survival (DFS), pelvic control (PC), and central control (CC). The parameters of stage, CT-measured anterior-posterior (AP) cervix size, and CT-detected lymph node metastases were evaluated using univariate and multivariate analysis.

RESULTS

The stage, AP cervix size, and lymph node involvement were significant pretreatment factors in univariate analysis with respect to AS, DFS, PC, and CC. Multivariate analysis confirmed that significant risk was associated with certain prognostic parameters. Those in terms of AS, in order of decreasing significance, were lymph node involvement, AP cervix size, age, and total HDR-ICR dose. When DFS was studied, lymph node involvement and AP cervix size were demonstrated to have a significant effect. Stage and lymph node involvement significantly affected PC.

CONCLUSION

Because the International Federation of Gynecological Obstetrics staging system fails to incorporate important prognostic information about tumor volume and lymph node involvement, CT-detected lymph node metastases as well as CT-measured cervix size should be determined as complementary additional prognostic measures.

Flow cytometric DNA content analysis of paraffin-embedded tissue derived from cervical carcinoma

PURPOSE

Flow cytometric deoxyribonucleic acid (DNA) content analysis has been shown to be of prognostic importance in some cancers. There have been recent reports of a prognostic importance for DNA content analysis in cervical carcinoma.

METHODS AND MATERIALS

We retrospectively reviewed the hospital and radiation oncology records of cervical carcinoma patients who presented between 1984-1990.

RESULTS

A total of 101 archival paraffin-embedded blocks were processed, of which 77 were of technical quality for analysis. Thirty-five percent were found to be DNA content aneuploid (DNA-A) and 65% DNA content diploid (DNA-D). No statistical difference was found between the two groups in age at diagnosis, % S-phase, coefficient of variation (CV), or proliferative index (PI). A statistical difference was noted in the G2M phase between the two groups (p = 0.004). The median % S-phase was 8.4% in the DNA-D group. A statistical difference (p = 0.017) in survival was noted between the low and high % S-phase DNA-D groups. In patients who received radiation alone, high-PI patients had improved survival compared to low-PI patients. No statistical difference in survival was noted in the high % S-phase DNA-D group and DNA-A group (p = 0.28). Proportional Hazard (Cox) Regression found clinical stage the only independent prognostic indicator for survival.

CONCLUSION

Flow cytometric DNA content analysis is being used more frequently in the management of different malignant tumors. Our study shows that DNA content analysis is useful in determining the prognosis and survival outcomes in cervical carcinomas and may aid in predicting outcome to certain types of treatment regimens.

Cervical carcinoma in young patients: clinical and pathological variables

Twenty-five (10.2%) out of 243 untreated patients with invasive cervical carcinoma were 35 years old or younger. When matching the clinical and pathological variables between the younger and the older women, the former were characterized by a higher rate of Stage IB disease (P = 0.10), G3 and G4 tumors (P = 0.25), bulky lesions (P = 0.05) and node metastases (P = 0.50). In spite of this poorer pathological profile, both the 5-year disease-free survival rate (75%) and survival according to stage of the younger women were similar to those reported in larger series, regardless of the patients' age. No modification of the standard therapy is therefore required in younger patients.

Stage IB or IIA-B carcinoma of the intact uterine cervix treated with irradiation: a multivariate analysis

Although treatment results for Stage IB-IIA-B carcinoma of the cervix are generally stratified only by stage, several authors have found that other parameters such as tumor size, patient age, histology, and pretreatment hematocrit may influence pelvic control and/or survival. This is an analysis of 306 patients with carcinoma of the cervix treated with irradiation alone at the University of Florida between October 1964 and June 1984. Results were analyzed for the end points of pelvic control, distant metastasis, relapse-free survival, and overall survival. Stage for stage, there was a decrease of at least 20 percentage points in pelvic control rates of tumors greater than or equal to 6 cm versus those of tumors 0 to 3 cm in diameter, by univariate analysis; a similar pattern was also observed for the end point of relapse-free survival. When patients were stratified by Stages IB-IIA (greater than or equal to 6 cm and less than 6 cm) and IIB (greater than or equal to 6 and less than 6 cm), there was a clear pattern of improved pelvic control and relapse-free survival for patients over 50 years old and for patients with pretreatment hematocrits greater than 40%. The parameters of stage, tumor size, patient age, histology, and pretreatment hematocrit were evaluated in a multivariate analysis. For the end points of pelvic control, distant metastasis, and relapse-free survival, only tumor size was of independent prognostic significance for all three end points with p-values of 0.022, 0.003, and 0.0006, respectively. Stage did not show independent prognostic significance for any of these end points with p-values of 0.257, 0.878, and 0.284, respectively. The data suggest that tumor size is an important prognostic factor and should be incorporated into the reporting of cervical cancer treatment results.

Survival of younger cervical carcinoma patients treated by radical radiotherapy in the west of Scotland 1964-1984

Between 1964 and 1984, 2011 patients in the West of Scotland were treated by radical radiotherapy for carcinoma of cervix. In keeping with the rise in incidence amongst younger patients nationally, the number of women aged less than 35 years seen during the 20-year period has doubled. Younger women (aged less than 35 or less than 45) have a better prognosis mainly because more present with earlier disease. Stage for stage there has been no change in survival of women of all ages treated by identical radiotherapy during this period. The rise in mortality of younger patients from carcinoma of cervix may be due to the increased incidence of the condition rather than a more virulent form of the disease.

Box diagram to express tumour extent: basis of a new staging system in carcinoma of the cervix?

The FIGO classification for the clinical staging of carcinoma of the cervix does not adequately express primary tumour extent or volume, and contains anomalies which probably lead to a wide variation in therapeutic results between centres (particularly in Stages II and III). A box diagram method of recording primary tumour extent is proposed and was applied to a retrospective study of 191 women aged 35 years and under with invasive carcinoma of the cervix. Patients who scored one or two boxes (Stages IB, IIA and IIB with unilateral parametrial infiltration) have a similar actuarial 5 years survival rate: 70% and 69% respectively. Those with 3 boxes (Stage IIA and B, bilateral Stage IIB and unilateral IIIB) and 4 boxes or more (Stages IIA and B, bilateral IIIB) involved had a substantially worse survival: 44% and 22% respectively. No patient, with more than five boxes involved was cured. The further study of this system, its potential in clinical research, and as part of a possible revised staging system are discussed.