Radical hysterectomy and pelvic lymphadenectomy versus radiation therapy for small (less than or equal to 3 cm) stage IB cervical carcinoma

Predicting the rate of adjuvant postoperative chemo/radiation in cervical cancer with tumor size ≥2 cm and <4 cm: An Israeli Gynecologic Oncology Group study

OBJECTIVE

Women with cervical cancer who undergo radical hysterectomy are often treated postoperatively with chemoradiation. Patient selection that minimizes adjuvant treatment is valuable. We compared two methods for predicting postoperative adjuvant treatment of women with tumor size ≥2 cm and <4 cm.

STUDY DESIGN

This multicenter retrospective study included 272 women with tumor size ≥2 cm and <4 cm. A receiver operating characteristic curve (ROC) analysis was used to determine the optimal tumor cutoff size to predict adjuvant treatment. A second analysis compared the rate of adjuvant treatment between women with and without lymph vascular space involvement (LVSI).

RESULTS

According to the ROC, the optimal cutoff value of tumor size for predicting adjuvant treatment was 2.95 cm (sensitivity 0.70, specificity 0.67). Tumors were ≥3.0 cm in 166 (61.0%) women. The rate of adjuvant treatment was higher in women with larger tumor diameter (73.8% vs. 47.9%, p < 0.0001). Of the 241 women with a LVSI record, LVSI was present in 81 (34%) women. Among women with LVSI, rates were higher of positive lymph nodes (41.0% vs 14.5%, p < 0.0001) and postoperative adjuvant treatment (83.3% vs. 53.7%, p < 0.001). Among women with tumor size ≥3.0 cm and LVSI, the rate of adjuvant treatment was 90.0%. In the multivariate analysis, both tumor size ≥3.0 cm and the presence of LVSI were independently associated with adjuvant treatment (OR 3.9, 95% CI 2.1-7.1; p < 0.0001 and OR 4.9, 95% CI 2.4-10.0; p < 0.0001, respectively).

CONCLUSION

In women with cervical cancer who underwent radical hysterectomy, tumors ≥3 cm were associated with a >70% rate of adjuvant treatment, and LVSI was associated with a >80% rate. These data should be weighed in multidisciplinary consultation with radiation oncologists when deciding treatment strategy.

Preoperative Prediction of Lymphovascular Space Invasion in Cervical Cancer With Radiomics -Based Nomogram

PURPOSE

To build and evaluate a radiomics-based nomogram that improves the predictive performance of the LVSI in cervical cancer non-invasively before the operation.

METHOD

This study involved 149 patients who underwent surgery with cervical cancer from February 2017 to October 2019. Radiomics features were extracted from T2 weighted imaging (T2WI). The radiomic features were selected by logistic regression with the least absolute shrinkage and selection operator (LASSO) penalty in the training cohort. Based on the selected features, support vector machine (SVM) algorithm was used to build the radiomics signature on the training cohort. Incorporating radiomics signature and clinical risk factors, the radiomics-based nomogram was developed. The sensitivity, specificity, accuracy, and area under the curve (AUC) and Receiver operating characteristic (ROC) curve were calculated to assess these models.

RESULT

The radiomics model performed much better than the clinical model in both training (AUCs 0.925 vs. 0.786, accuracies 87.5% vs. 70.5%, sensitivities 83.6% vs. 41.7% and specificities 90.9% vs. 94.7%) and testing (AUCs 0.911 vs. 0.706, accuracies 84.0% vs. 71.3%, sensitivities 81.1% vs. 43.4% and specificities 86.4% vs. 95.0%). The combined model based on the radiomics signature and tumor stage, tumor infiltration depth and tumor pathology yielded the best performance (training cohort, AUC = 0.943, accuracies 89.5%, sensitivities 85.4% and specificities 92.9%; testing cohort, AUC = 0.923, accuracies 84.6%, sensitivities 84.0% and specificities 85.1%).

CONCLUSION

Radiomics-based nomogram was a useful tool for predicting LVSI of cervical cancer. This would aid the selection of the optimal therapeutic strategy and clinical decision-making for individuals.

Robot-assisted Surgery in Gynecologic Cancers

Robotic-assisted surgery is a technological advancement that facilitates the application of minimally invasive techniques for complex operations in gynecologic oncology. The objective of this article was to review the literature regarding the role of robotic-assisted surgery to treat women with gynecologic cancers. The majority of publications on robotic surgery are still retrospective or descriptive in nature; however, the data for managing patients with a robotic-assisted approach show comparable, and at times improved, outcomes compared with both laparoscopy (2-dimensional) and laparotomy approaches. Robotic-assisted surgery has been used for patients with endometrial cancer and resulted in the increased use of minimally invasive surgery with improved outcomes compared with laparotomy and partially with laparoscopy. This has been shown in large cohorts of patients as well as in obese patients in whom the complication rates have significantly decreased. For early cervical cancer, robotic radical hysterectomy seems to be safe and feasible and to be preferable to laparotomy with seemingly comparable oncologic outcomes. Robotic-assisted surgery and conventional laparoscopy to stage women with early-stage ovarian cancer seem to have similar surgical and oncologic outcomes, with a shorter learning curve for robotic-assisted surgery. However, robotic-assisted surgery appears to be more expensive than laparotomy and traditional laparoscopy. In conclusion, robotic-assisted surgery appears to facilitate the surgical approach for complex operations to treat women with gynecologic cancers. Although randomized controlled trials are lacking to further elucidate the equivalence of robot-assisted surgery with conventional methods in terms of oncologic outcome and patients' quality of life, the technology appears to be safe and effective and could offer a minimally invasive approach to a much larger group of patients.

The surgical management of cervical cancer: an overview and literature review

IMPORTANCE

Surgery has evolved into the standard therapy for nonbulky carcinoma of the cervix. The mainstay of surgical management is radical hysterectomy; however, less radical procedures have a small but important role in the management of cervical tumors.

OBJECTIVE

Our objective was to discuss the literature behind the different procedures utilized in the management of cervical cancer, emphasizing the radical hysterectomy. In addition, we aimed to discuss ongoing trials looking at the utility of less radical surgeries as well as emerging technologies in the management of this disease.

EVIDENCE ACQUISITION

We performed a PubMed literature search for articles in the English language that pertained to the topic of surgical techniques and their outcomes in the treatment of cervical cancer.

RESULTS

The minimally invasive approaches to radical hysterectomy appear to reduce morbidity without affecting oncological outcomes, although further data are needed looking at long-term outcomes with the robotic platform. Trials are currently ongoing looking at the role of less radical surgery for patients with low-risk disease and the feasibility of sentinel lymph node mapping.

CONCLUSIONS AND RELEVANCE

Radical hysterectomy with pelvic lymphadenectomy has evolved into the standard therapy for nonbulky disease, and there is a clear advantage in the use of minimally invasive techniques to perform these procedures. However, pending ongoing trials, less radical surgery in patients with low-risk invasive disease as well as sentinel lymph node mapping may emerge as standards of care in selected patients with cervical carcinoma.

The effects of age on treatment and outcomes in women with stages IB1-IIB cervical cancer

OBJECTIVE

Age may affect the treatment choice and subsequent outcome in elderly patients with cervical cancer. Given the potential for cure with either surgery or chemoradiation in early stage disease, we aimed to determine whether a patient's age influenced treatment received and the ensuing outcome.

MATERIALS AND METHODS

We identified 303 patients with stages IB1-IIB cervical carcinoma treated at our institution between 2000 and 2010, who were divided into two groups based on age at time of diagnosis: < 65 and ≥ 65 years. Adjusted odd ratios were calculated to determine variables associated with treatment received. Single and multivariate Cox proportional hazards modeling were used to estimate hazard ratios (HRs) for variables associated with disease-specific survival.

RESULTS

Patients were more commonly <65 years at diagnosis (83% versus 17% ≥ 65 years). There was no difference between the two groups in terms of tumor histology, stage at presentation, and grade. Women ≥ 65 years of age were less likely to receive primary surgical management (p=0.03). Age did not influence disease-specific or all-cause mortality. However, women over 65 years who underwent primary surgery were at significantly increased risk of all-cause mortality compared to younger women (HR 6.53, 95% CI: 2.57-16.6).

CONCLUSIONS

Age appears to influence treatment received by patients with stages IB1-IIB cervical cancer. Although there was no difference in cancer-specific mortality stratified by type of treatment received, surgery was associated with a 6.5-fold increased risk of all-cause mortality among women 65 years or over.

Primary surgery versus primary radiotherapy with or without chemotherapy for early adenocarcinoma of the uterine cervix

BACKGROUND

For early squamous cell carcinoma of the uterine cervix, the outcome is similar after either primary surgery or primary radiotherapy. There are reports that this is not the case for early adenocarcinoma (AC) of the uterine cervix: some studies have reported that the outcome is better after primary surgery. There are no systematic reviews about surgery versus chemoradiation in the treatment of cervical cancer. This is an updated version of the original Cochrane review published in Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD006248. DOI: 10.1002/14651858.CD006248.

OBJECTIVES

The objectives of this review were to compare the effectiveness and safety of primary surgery for early stage AC of the uterine cervix with primary radiotherapy or chemoradiation.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2009, MEDLINE (1950 to July week 5, 2009), EMBASE (1980 to week 32, 2009) and we also searched the related articles feature of PubMed and the Web of Science. We also checked the reference lists of articles. For this update, the searches were re-run in June 2012: MEDLINE 2009 to June week 2, 2012, EMBASE 2009 to 2012 week 24, CENTRAL Issue 6, 2012, Cochrane Gynaecological Specialised Register June 2012.

SELECTION CRITERIA

Studies of treatment of patients with early AC of the uterine cervix were included. Treatment included surgery, surgery followed by radiotherapy, radiotherapy and chemoradiation.

DATA COLLECTION AND ANALYSIS

Forty-three studies were selected by the search strategy and 30 studies were excluded. Twelve studies were considered for inclusion. Except for one randomised controlled trial (RCT), all other studies were retrospective cohort studies with variable methodological quality and had limitations of a retrospective study. Comparing the results from these retrospective studies was not possible due to diverging treatment strategies.

MAIN RESULTS

Analysis of a subgroup of one RCT showed that surgery for early cervical AC was better than radiotherapy. However, the majority of operated patients required adjuvant radiotherapy, which is associated with greater morbidity. Furthermore, the radiotherapy in this study was not optimal, and surgery was not compared to chemoradiation, which is currently recommended in most centres. Finally, modern imaging techniques (i.e. magnetic resonance imaging (MRI) and positive emission tomography - computed tomography (PET-CT) scanning) allow better selection of patients and node-negative patients can now be more easily identified for surgery, thereby reducing the risk of 'double trouble' caused by surgery and adjuvant radiotherapy.  

AUTHORS' CONCLUSIONS

We recommend surgery for early-stage AC of the uterine cervix in carefully staged patients. Primary chemoradiation remains a second best alternative for patients unfit for surgery; chemoradiation is probably first choice in patients with (MRI or PET-CT-suspected) positive lymph nodes. Since the last version of this review no new studies were found.

The twenty-first century role of Piver-Rutledge type III radical hysterectomy and FIGO stage IA, IB1, and IB2 cervical cancer in the era of robotic surgery: a personal perspective

Type III radical hysterectomy reported in 1974 by Piver, Rutledge, and Smith is considered worldwide by many as the standard surgical therapy for invasive cervical carcinoma stage IB and IIA. With the increasing number of robotic surgeries being performed for early stage cervical cancer worldwide, the purpose of the paper is to present our personal perspective of the 21st century role of Piver-Rutledge type III radical hysterectomy for stage IB cervical cancer in the era of robotic surgery using the da Vinci robot.

Primary surgery versus primary radiation therapy with or without chemotherapy for early adenocarcinoma of the uterine cervix

BACKGROUND

For early squamous cell carcinoma of the uterine cervix, the outcome is similar after either primary surgery or primary radiotherapy. There are reports that this is not the case for early adenocarcinoma (AC) of the uterine cervix: some studies have reported that the outcome is better after primary surgery. There are no systematic reviews about surgery versus chemoradiation in the treatment of cervical cancer.

OBJECTIVES

The objectives of this review were to compare the effectiveness and safety of primary surgery for early stage AC of the uterine cervix with primary radiotherapy or chemoradiation.

SEARCH STRATEGY

We searched Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2009, MEDLINE (1950 to July week 5, 2009), EMBASE (1980 to week 32, 2009) and we also searched the related articles feature of PubMed and the Web of Science. We also checked the reference lists of articles.

SELECTION CRITERIA

Studies of treatment of patients with early AC of the uterine cervix were included. Treatment included surgery, surgery followed by radiotherapy, radiotherapy and chemoradiation.

DATA COLLECTION AND ANALYSIS

Forty-three studies were selected by the search strategy and thirty studies were excluded. Twelve studies were considered for inclusion. Except for one randomised controlled trial (RCT), all other studies were retrospective cohort studies with variable methodological quality and had limitations of a retrospective study. Comparing the results from these retrospective studies was not possible due to diverging treatment strategies.

MAIN RESULTS

Analysis of a subgroup of one RCT showed that surgery for early cervical AC was better than RT. However, the majority of operated patients required adjuvant radiotherapy, which is associated with greater morbidity. Furthermore, the radiotherapy in this study was not optimal, and surgery was not compared to chemoradiation, which is currently recommended in most centres. Finally, modern imaging techniques, i.e. MR-imaging and PET-CT-scanning, allow better selection of patients and node negative patients can now be more easily identified for surgery, there by reducing the risk of 'double trouble' caused by surgery and adjuvant radiotherapy.

AUTHORS' CONCLUSIONS

We recommend surgery for early stage AC of the uterine cervix in carefully staged patients. Primary chemoradiation remains a second best alternative for patients unfit for surgery; chemoradiation is probably first choice in patients with (MRI or PET-CT-suspected) positive lymph nodes.

Characterization of an intraperitoneal ovarian cancer xenograft model in nude rats using noninvasive microPET imaging

MicroPET is a noninvasive imaging modality that can potentially track tumor development in nude rats using the radiotracer fluorine 18-fluorodeoxyglucose (18F-FDG). Our goal was to determine whether microPET, as opposed to more invasive techniques, could be used to noninvasively monitor the development of ovarian cancer in the peritoneal cavity of nude rats for monitoring treatment response in future studies. Female nude rats were inoculated intraperitoneally with 36 million NIH:OVCAR-3 cells. Imaging was carried out at 2, 4, 6, or 8 weeks postinoculation. Each rat was fasted overnight and intravenously injected with 11.1 MBq (300 μCi) of18F-FDG in 0.2 mL of saline. Thirty minutes following injection, the rats were placed in the microPET and scanned for 30 min. After imaging, rats were euthanized for ascites and tissue collection for biodistribution and histopathologic correlation. Standard uptake values (SUVs) of18F-FDG within the peritoneal cavity were also calculated from regions of interest analysis of the microPET images. MicroPET images showed diffuse increased uptake of18F-FDG throughout the peritoneal cavity of tumor rats (mean SUV = 4.64) compared with control rats (mean SUV = 1.03). Ascites gathered from tumor-bearing rats had increased18F-FDG uptake as opposed to the peritoneal fluid collected from control rats. Biodistribution data revealed that the percent injected dose per gram (% ID/g) was significantly higher in tumor-bearing rats (6.29%) than in control rats (0.59%) in the peritoneal lymph nodes. Pathology verified that these lymph nodes were more reactive in tumor-bearing rats. By 6 weeks, some rats developed solid masses within the peritoneum, which could be detected on microPET images and confirmed as tumor by histopathology.18F-FDG uptake in these tumors at necropsy was 2.83% ID/g. These results correlate with previous invasive laparoscopic studies of the same tumor model and demonstrate that microPET using18F-FDG is a promising noninvasive tool to localize and follow tumor growth in an intraperitoneal ovarian cancer model.

Intraarterial cisplatin/nedaplatin and intravenous 5-fluorouracil with concurrent radiation therapy for patients with high-risk uterine cervical cancer

OBJECTIVE

The purpose of this study was to determine the effectiveness of the combination of intraarterial and intravenous concurrent chemoradiation therapy (CIAIV-CCRT) for the treatment of high-risk uterine cervical cancer.

METHODS

Between January 2000 and November 2004, we reviewed 45 cervical cancer patients treated by CIAIV-CCRT. The numbers of patients with stage IB2, IIA, IIB, IIIA, IIIB, and IVA were 3, 6, 14, 1, 17, and 4, respectively. Patients with stage III and IVA or patients with tumors >3 cm in diameter were enrolled in this study. Two sessions of CCRT were administered every 3 weeks using a combination of 70 mg/m2 x h(-1) cisplatin or 50 mg/m2 x h(-1) nedaplatin via the bilateral uterine artery and 2800 mg/m2 x 96 h(-1) 5-fluorouracil intravenously. Patients concurrently received external beam radiation therapy and brachytherapy. A nonrandomized control group of 47 patients who underwent radiation therapy alone between 1993 and 2000 was used for comparison.

RESULTS

Of the 45 patients, 28 (62%) exhibited complete response and 16 (36%) exhibited partial response. One IIIB patient (2%) did not show any response. The 5-year overall survival (OAS) rates in the CCRT group and control group were 80.6% and 54.9%, respectively. With regard to late toxicities, no statistically significant differences were observed between the two groups. In uni- and multivariate analyses, positive pelvic lymph node showed a statistically significant influence on the OAS in the CIAIV-CCRT group (P = 0.049).

CONCLUSION

These preliminary results suggest that CIAIV-CCRT can improve the prognosis of patients with high-risk cervical cancer.

Quality of life and sexual functioning in cervical cancer survivors

PURPOSE

To compare quality of life and sexual functioning in cervical cancer survivors treated with either radical hysterectomy and lymph node dissection or radiotherapy.

METHODS

Women were interviewed at least 5 years after initial treatment for cervical cancer. Eligible women had squamous cell tumors smaller than 6 cm at diagnosis, were currently disease-free, and had either undergone surgery or radiotherapy, but not both. The two treatment groups were then compared using univariate analysis and multivariate linear regression with a control group of age- and race-matched women with no history of cancer.

RESULTS

One hundred fourteen patients (37 surgery, 37 radiotherapy, 40 controls) were included for analysis. When compared with surgery patients and controls using univariate analysis, radiation patients had significantly poorer scores on standardized questionnaires measuring health-related quality of life (physical and mental health), psychosocial distress and sexual functioning. The disparity in sexual function remained significant in a multivariate analysis. Univariate and multivariate analyses did not show significant differences between radical hysterectomy patients and controls on any of the outcome measures.

CONCLUSION

Cervical cancer survivors treated with radiotherapy had worse sexual functioning than did those treated with radical hysterectomy and lymph node dissection. In contrast, these data suggest that cervical cancer survivors treated with surgery alone can expect overall quality of life and sexual function not unlike that of peers without a history of cancer.

Identification of micrometastases in histologically negative lymph nodes of early-stage cervical cancer patients

OBJECTIVE

Despite histologically negative lymph nodes, approximately 15% of patients with early-stage cervical cancer will develop recurrence. Micrometastases have been shown to be important in staging and treatment of breast cancers and melanoma and have been identified by polymerase chain reaction analysis in cervical cancers. This study sought to estimate the frequency of micrometastases identified by immunohistochemistry in histologically negative lymph nodes and compare this to other known risk factors for recurrence of cervical cancer.

METHODS

Early-stage (stages IA2, IB1, and IB2) cervical cancer patients of all histologic subtypes were identified from the surgical logs of the Los Angeles County-University of Southern California Medical Center for the period 1994-2000. One hundred thirty-two patients had histologically negative lymph nodes. Immunohistochemical assay was performed on 3,106 lymph nodes by using antibodies against cytokeratins AE-1 and CAM 5.2 in combination according to standard protocols. The stained nodes were then evaluated for the presence of micrometastases and compared against the respective clinicopathologic information in each case.

RESULTS

Micrometastases were detected in 19 of 132 (15%, 95% confidence interval [CI] 9%, 22%) patients, found in 29 of the 3,106 (0.9%) lymph nodes evaluated. Vascular space invasion was seen in 50 of 132 cases (38%, 95% CI 30%, 47%) and in 8 of 19 (42%, 95% CI 21%, 66%) cases with micrometastases. Surgical margins of the resected specimen were negative in 120 of 132 cases (91%, 95% CI 84%, 95%) and in 16 of 19 (84%, 95%CI 60%, 96%) of those cases with micrometastases. Micrometastases were seen most frequently in pelvic lymph nodes (25 of 29, 86%). Patients with more than 20 lymph nodes removed were more likely to demonstrate metastasis (P <.001). There was no statistically significant association between micrometastasis and vascular space invasion or tumor volume.

CONCLUSION

Micrometastases are identifiable in histologically negative lymph nodes in 15% (95% CI 9%, 22%) of early-stage cancer patients, a frequency which approximates the recurrence rate for patients with negative nodes. In this series, patients with greater numbers of lymph nodes analyzed were more likely to have lymph node micrometastasis identified. There appears to be no relationship between tumor volume and the identification of micrometastases. Although micrometastases can be identified in histologically negative lymph nodes, their presence is not strongly associated with other known factors of cervical cancer recurrence. Further research is needed to determine whether the presence of lymph node micrometastases is associated with an unfavorable prognosis.

LEVEL OF EVIDENCE

II-3

Stage Ia-IIa Cancer of the Cervix

Early-stage cervical cancer is unique among malignancies in that two radically different yet equally efficacious treatments can be offered to most patients with the disease. The choice between surgery and radiation therapy depends on the patient's age and comorbidities, tumor factors, physician bias, and discussion of the risks and benefits of each modality. A thorough discussion between the physician and patient is necessary to determine the optimal management for each individual. This review discusses the major factors that influence physician and patient management choices.

[First surgery followed by vaginal curietherapy in small-volume uterine cervix cancer: an alternative to the association of uterovaginal curietherapy and surgery]

PURPOSE

Evaluate the results of the treatment of small uterine cervix cancer with the association of surgery and postoperative vaginal brachytherapy, without unfavourable prognostic factors.

PATIENTS AND METHODS

After radical hysterectomy with lymphadenectomy, 29 women (mean age: 44 years) with carcinoma < 25 mm (26 stage IB1, 3 IIA, mean size: 15 mm) were treated by post-operative prophylactic vaginal brachytherapy using low dose rate. Ovarian transposition was performed at the surgical time in 14 young women (mean age 35 years).

RESULTS

The actuarial specific survival rates at 5 and 10 years were 100% and 90% respectively, with a mean follow-up 75 months. Only one local recurrence was observed. The rate of grade 1 post-operative complication was 7%. The conservation rate of the ovarian function was 85% for young women.

CONCLUSION

Treatment of small volume uterine cervix cancer using first surgery and post-operative vaginal brachytherapy is a reliable therapeutic option. The results in terms of specific survival and complications are the same with those after standard association of preoperative uterovaginal brachytherapy and surgery.

Preoperative intracavitary brachytherapy in early-stage cervical carcinoma

Local failure within the central pelvis is a common site of recurrence in patients with early stage cervical carcinoma who experience recurrence after radical hysterectomy and pelvic lymphadenectomy. To reduce the risk of local failure, the authors treated selected patients with early stage cervical carcinoma with a moderate dose (45 Gy) of preoperative intracavitary brachytherapy before radical hysterectomy and pelvic lymphadenectomy. Given the low risk of recurrence in patients with small (<2 cm) tumors, the authors included only patients with tumors 2 cm or more in size. Forty-three patients (37 with stage IB disease, six with stage IIA disease) were treated from 1986 through 1995. Forty-two completed intracavitary brachytherapy; intracavitary brachytherapy was stopped early in one patient secondary to a low-grade fever. Exploratory laparotomy and planned radical hysterectomy were performed 2 weeks later. Radical hysterectomy was aborted in patients found to have extrauterine disease. At a median follow-up of 45 months, only one local failure has been noted, which occurred in the patient unable to complete intracavitary brachytherapy as planned. The most significant factor correlated with poor outcome was nodal involvement (p < 0.0004). A trend to a better disease-free survival was seen in patients with no residual or only microscopically residual disease. No patients developed significant chronic bowel or bladder toxicity, including fistulae. The results suggest that preoperative intracavitary brachytherapy in selected patients with early stage cervical carcinoma is a promising approach and is associated with a high rate of local control without significant adverse sequelae. Further data is needed to determine whether this approach improves the long-term outcome of these patients.

Stage I adenocarcinoma of the cervix: does lesion size affect treatment options and prognosis?

A retrospective analysis of 93 patients with International Federation of Gynecology and Obstetrics stage I adenocarcinoma of the cervix was performed to determine the significance of tumor size, patient age, tumor grade, lymph node status, and primary treatment modality as prognostic variables of 5-year survival and 5-year progression-free survival (PFS). Multivariate analysis demonstrated that patient age and tumor grade were significant variables prognostic of survival (p < 0.01 and p = 0.01, respectively). Tumor size was a significant (p < 0.01) prognostic variable of PFS in a multivariate model that included tumor size and patient age. An important advantage in survival and PFS for patients with lesions smaller than 3 cm compared with those patients with lesions 3 cm or more was observed (92% vs. 76% and 89% vs. 67%, respectively). Among surgically treated patients, survival and PFS among patients with lesions smaller than 3 cm were significantly improved compared with patients with tumors 3 cm or more (97% vs. 77% [p = 0.03] and 90% vs. 69% [p = 0.03], respectively). Significant improvement in survival and PFS was observed among patients with lesions smaller than 3 cm who were treated with surgery compared with those who received radiation therapy (97% vs. 77% [p = 0.03] and 90% vs. 77% [p = 0.048], respectively).

Randomised study of radical surgery versus radiotherapy for stage Ib-IIa cervical cancer

BACKGROUND

Stage Ib and IIa cervical carcinoma can be cured by radical surgery or radiotherapy. These two procedures are equally effective, but differ in associated morbidity and type of complications. In this prospective randomised trial of radiotherapy versus surgery, our aim was to assess the 5-year survival and the rate and pattern of complications and recurrences associated with each treatment.

METHODS

Between September, 1986, and December, 1991, 469 women with newly diagnosed stage Ib and IIa cervical carcinoma were referred to our institute. 343 eligible patients were randomised: 172 to surgery and 171 to radical radiotherapy. Adjuvant radiotherapy was delivered after surgery for women with surgical stage pT2b or greater, less than 3 mm of safe cervical stroma, cut-through, or positive nodes. The primary outcome measures were 5-year survival and the rate of complications. The analysis of survival and recurrence was by intention to treat and analysis of complications was by treatment delivered.

FINDINGS

170 patients in the surgery group and 167 in the radiotherapy group were included in the intention-to-treat analysis; scheduled treatment was delivered to 169 and 158 women, respectively, 62 of 114 women with cervical diameters of 4 cm or smaller and 46 of 55 with diameters larger than 4 cm received adjuvant therapy. After a median follow-up of 87 (range 57-120) months, 5-year overall and disease-free survival were identical in the surgery and radiotherapy groups (83% and 74%, respectively, for both groups), 86 women developed recurrent disease: 42 (25%) in the surgery group and 44 (26%) in the radiotherapy group. Significant factors for survival in univariate and multivariate analyses were: cervical diameter, positive lymphangiography, and adeno-carcinomatous histotype. 48 (28%) surgery-group patients had severe morbidity compared with 19 (12%) radiotherapy-group patients (p = 0.0004).

INTERPRETATION

There is no treatment of choice for early-stage cervical carcinoma in terms of overall or disease-free survival. The combination of surgery and radiotherapy has the worst morbidity, especially urological complications. The optimum therapy for each patient should take account of clinical factors such as menopausal status, age, medical illness, histological type, and cervical diameter to yield the best cure with minimum complications.

The current role of laparoscopic surgery in gynecological oncology

Transabdominal laparotomy is currently the standard approach to the surgical diagnosis and treatment of gynecological malignancies. Despite the fact that laparoscopy has been widely embraced by our gynecological/infertility colleagues for many years, it has only sporadically been utilized by gynecological oncologists. With the advent of video laparoscopy, novel instrumentation, and new techniques, a reevaluation of the applicability of this procedure is certainly in order. To date, laparoscopy has been employed for the performance of a multitude of intra-abdominal procedures. However, universal applicability may not be feasible or in the best interest of all patients with gynecological malignancies. As instrumentation and techniques evolve, it is possible that procedures currently nonamenable to the laparoscopic approach may become so. However, it is wise to approach these new procedures with healthy skepticism, and within the context of proper scientific study. This article summarizes the status of laparoscopic surgery in gynecological oncology.

Single-use percutaneous catheters for intraperitoneal P32 therapy

BACKGROUND

Intraperitoneal (IP) radioactive chromic phosphate (P32) remains investigational in the treatment of patients with ovarian and/or endometrial cancer. Single-use percutaneously placed catheters offer the advantage of therapy without additional surgery.

METHODS

Between August, 1986 and October, 1992, 25 patients underwent bedside percutaneous catheter placement under local anesthesia without ultrasonographic or radiologic guidance, using a specialized central venous catheter.

RESULTS

Catheter insertion was successful in 22 of 25 patients (88%) with good IP distribution. Of these, 18 of 22 patients (82%) underwent successful catheter placement with one attempt and 4 of 22 (18%) after one to three additional attempts. The technical failure rate was 12%. Multiple catheter placement attempts were associated with an increased incidence of complications (r = 0.63). Bowel entry occurred in 4 of 25 patients (16%) during 5 of 43 attempts at catheter placement (12%) but was without clinical sequelae. The likelihood of bowel entry significantly increased with more than two attempts (P = 0.02). A median of 39 days (range, 7-156 days) elapsed between the preceding laparotomy and catheter insertion.

CONCLUSIONS

Percutaneous catheter placement is successful and well tolerated in the majority of patients and should be considered for patients receiving IP P32.

Irrigation does not dislodge or destroy tumor cells adherent to the tumor bed

Local recurrences in the surgical bed after tumor resection may be due to residual tumor cells "dropping" into the wound. Irrigation with water is often used to remove these cells. We designed experiments to determine whether irrigation would prevent tumor recurrence. Surgical wounds of uniform size in C57BL/6 mice were seeded with 5 x 10(2), 5 x 10(3), 5 x 10(4), 5 x 10(5), or 5 x 10(6) viable syngeneic B16-F10 melanoma cells to test the hypothesis that irrigation with water would decrease local tumor recurrence. The tumor-contaminated wounds were irrigated with distilled water or with saline (0.9% NaCl) immediately or 5, 30, 60, 120, or 240 min after seeding. Control wounds were seeded but not irrigated. The technique of irrigation was altered in a second group of experiments such that the amount of time the tumor cells were exposed to the water or saline was 5, 10, or 15 min. To determine the rapidity and durability of tumor cell attachment to host tissue, 1 x 10(4) viable B16-F10 tumor cells were seeded in vitro onto freshly cut disks of syngeneic mouse dermis. The tissue was irrigated with saline or distilled water 0, 2, 5, 10, 15, 30, 60, 120, or 240 min later. Tumor growth was observed in all the mice and neither the mechanical action of irrigation nor the hypotonic effect of distilled water changed the rate of growth. Scanning electron microscopy (SEM) demonstrated stable and firm attachment to mouse tissue within seconds of seeding with no noticeable dislodgement or cytotoxicity by either saline or water irrigation. The data suggest that the commonly used technique of irrigating the bed of the resected tumor may not be of value in preventing local recurrences.

Non-randomized comparative study of irradiation alone or in combination with surgery in stage Ib, IIa and "proximal" IIb carcinoma of the cervix

252 evaluable patients were treated in the Centre Claudius Regaud from January 1974 to December 1983 for stage Ib, IIa or proximal IIb carcinoma of the uterine cervix. This retrospective analysis compares results obtained either by radio-surgical combination therapy (113 patients = RS group) or by exclusive irradiation (139 patients = RT group). The comparison of the two groups in terms of patient age, obesity, associated vascular pathology and previous abdomino-pelvic surgery favored the RS group significantly. The distribution according to clinical stage also significantly favored the RS group. The proportion of patients with stage IIb disease was 12% in the RS group as opposed to 25% for the RT group. Despite unfavorable patient and tumor characteristics, therapeutic results in the RT group were similar to those of the RS group. Pelvic recurrences developed in 18/110 (16%) and 18/139 (13%) of the patients in the RS and RT groups, respectively. Distant metastases occurred in 5/92 (5%) patients in the RS group and 13/121 (11%) patients in the RT group, but the difference was not significant (p less than 0.1). Five year corrected actuarial disease-free survival was 82% in both groups. There were no major early complications in the RT group while four were found in the RS group, of which three were fatal. 2% of patients had major late complications in the RS group versus 6% in the RT group and none were lethal. 25% of the RT group patients had a moderate or mild complication versus 10% in the RS group but 2/3 of these complications recovered without sequellae.

Early stage I adenocarcinoma of the uterine cervix: treatment results in patients with tumors less than or equal to 4 cm in diameter

Between 1965 and 1985, 160 patients had initial treatment at the M. D. Anderson Cancer Center for Stage I adenocarcinoma of the uterine cervix less than or equal to 4 cm in diameter. Of these patients, 84 were treated with radiation therapy (RT) alone, 20 were treated with external and intracavitary radiation followed by total hysterectomy (R + S), and 56 were treated with radical hysterectomy (RH). Survival rate was strongly correlated with tumor volume (P = 0.0008), lymphangiogram findings (P = 0.01), and tumor grade (P = 0.0018). Patients with a normal-appearing cervix or a small visible or palpable tumor that did not expand the cervix more than 3 cm had survival and pelvic-control rates of more than 90% after treatment with RH or RT. However, after 5 years, 45% of patients treated with RH for tumors 3-4 cm in diameter had disease recurrence in the pelvis, compared with 11% of patients treated with either RT or R + S (P = 0.025). For patients treated with RH, recurrence was also strongly correlated with findings of lymph/vascular space invasion (P = 0.0004) and poorly differentiated tumor (P = 0.018). Major complication rates were comparable for the three treatment groups. The high rate of pelvic recurrence following treatment with radical hysterectomy alone for patients with tumors greater than 3 cm in diameter, particularly in the presence of lymph/vascular space invasion, poorly differentiated features, and/or positive nodes, should be considered in planning the primary management of patients with Stage I adenocarcinoma of the cervix.

Adjuvant therapy in stage I and stage II epithelial ovarian cancer. Results of two prospective randomized trials

About a third of patients with ovarian cancer present with localized disease; despite surgical resection, up to half the tumors recur. Since it has not been established whether adjuvant treatment can benefit such patients, we conducted two prospective, randomized national cooperative trials of adjuvant therapy in patients with localized ovarian carcinoma (International Federation of Gynecology and Obstetrics Stages Ia to IIc). All patients underwent surgical resection plus comprehensive staging and, 18 months later, surgical re-exploration. In the first trial, 81 patients with well-differentiated or moderately well differentiated cancers confined to the ovaries (Stages Iai and Ibi) were assigned to receive either no chemotherapy or melphalan (0.2 mg per kilogram of body weight per day for five days, repeated every four to six weeks for up to 12 cycles). After a median follow-up of more than six years, there were no significant differences between the patients given no chemotherapy and those treated with melphalan with respect to either five-year disease-free survival (91 vs. 98 percent; P = 0.41) or overall survival (94 vs. 98 percent; P = 0.43). In the second trial, 141 patients with poorly differentiated Stage I tumors or with cancer outside the ovaries but limited to the pelvis (Stage II) were randomly assigned to treatment with either melphalan (in the same regimen as above) or a single intraperitoneal dose of 32P (15 mCi) at the time of surgery. In this trial (median follow-up, greater than 6 years) the outcomes for the two treatment groups were similar with respect to five-year disease-free survival (80 percent in both groups) and overall survival (81 percent with melphalan vs. 78 percent with 32P; P = 0.48). We conclude that in patients with localized ovarian cancer, comprehensive staging at the time of surgical resection can serve to identify those patients (as defined by the first trial) who can be followed without adjuvant chemotherapy. The remaining patients with localized ovarian cancer should receive adjuvant therapy, and with adjuvant melphalan or intraperitoneal 32P should have a five-year disease-free survival of about 80 percent.

Carcinoma of the uterine cervix treated by irradiation alone. Results of treatment at the National Cancer Center, Tokyo

Six hundred and twelve patients with previously untreated invasive carcinoma of the uterine cervix were treated by irradiation alone at the National Cancer Hospital from 1972 to 1983. The number of patients was 7, 39, 43, 127, 15, 319, 28 and 34 in stages IA, IB, IIA, IIB, IIIA, IIIB, IVA and IVB respectively. Low-dose-rate intracavitary irradiation with or without external irradiation was used in 383 patients, high-dose-rate intracavitary irradiation with or without external irradiation in 130, external irradiation alone in 98, and external irradiation combined with radon-222 seed implantation in one patient. Five-year-survival rates were 85, 65, 57, 41, 14 11% for stages IB, IIA, IIB, IIIB, IVA, and IVB respectively. The rate of complications was rather high in the present series, and so we have been investigating whether it is possible to reduce the dose. Low-dose-rate intracavitary irradiation has been replaced by high-dose-rate irradiation by using a remotely controlled afterloading system.