Adjuvant radiotherapy following radical hysterectomy for patients with early-stage cervical carcinoma (1984-1996)
Introduction
Although radiation therapy for early cervical cancer is as effective as radical hysterectomy, the standard treatment in many oncology centers is radical hysterectomy with pelvic lymph node dissection, achieving 5-year survival rates of 80–90% [1], [6], [8], [9], [11], [18], [20]. A number of risk factors that predict poor prognosis have been described [1], [5], [6], [8], [9], [11], [18], [20]. They include: age, FIGO- stage, tumor size, depth of tumor invasion into the cervical stroma (DI), histological type of tumor, capillary lymphatic space involvement (CLS), involvement of the lower uterine segment, parametria and surgical margins. Various studies found, with the help of multivariate analysis, different sets of combined factors that identify high risk patients [1], [5], [6], [8], [9], [11], [18], [20]. However, there was no generally accepted rule indicating which factors had to be present in which size or magnitude to turn the scale towards the need of adjuvant radiation treatment. Delgado et al. [6] found clinical tumor size, CLS, and DI to be the combination best predicting prognosis and proposed a scoring system that identifies three separate risk groups for recurrence. Others found adenocarcinoma histology in combination with CLS were the factors associated with recurrence [2] and found no correlation with depth of invasion.
Before 1986 the indications for adjuvant radiotherapy in our center were: lymphnode metastases, parametrial involvement and positive or close surgical margins. In 1986 we decided to extend the indication for the use of postoperative radiotherapy in early cervical cancers: in case of the combination of three factors namely positive CLS, poor differentiation grade and bulky tumor (≥40 mm) or the combination of tumor size ≥40 mm and depth of invasion ≥15 mm. The choice for these factors was partly based on a retrospective analysis of our own unpublished patient material indicating that depth of invasion was an independent prognostic factor for recurrence free survival and partly based on reports from the literature supporting this finding [6], [9], [20]. At the same time, we learned from this retrospective analysis that the adjuvance of pelvic radiotherapy did not significantly increase the morbidity [16] compared to hysterectomy alone – a subject on which the reports in literature are controversial [8], [16], [18], [19]. In the period from 1986 to 1996 inclusive, 233 evaluable patients had a radical hysterectomy in our center of which 77 (33%) were given postoperative adjuvant radiotherapy. The aim of this study was to assess the results of treatment in terms of survival, site and time of recurrence in comparison with surgery alone, and to determine the morbidity associated with adjuvant pelvic radiotherapy. Furthermore we wanted to evaluate if the decision to irradiate a subset of patients with adverse tumor factors only was the right decision and if the selection of these two subgroups for the indication of adjuvant radiotherapy was the right choice.
Section snippets
Patients and methods
From 1984 to 1996, 247 patients were treated for cervical carcinoma stage I and IIA. Of this entire group of patients relevant clinical and pathological parameters were prospectively collected in a database. Fourteen patients were excluded from this analysis for the following reasons: three had non-epithelial tumors, three had bulky paraaortic lymphnode metastases, one pulmonary metastasis, three had extension of tumor to bladder or rectum and four refused postoperative irradiation. Of the
Results
The 5-year survival and disease free survival of the entire group of 233 patients was 84 and 78%, standard error (SE) ±3.2 and ±3.5%, respectively. Of the patients in the surgery alone group (n=156) the 5-year survival and disease free survival was 93% (±2.8%) and 88% (±3.4%), respectively and in the group with adjuvant radiotherapy this was 68% (±6.6%) and 58% (±7.2%), respectively (Fig. 1A,B). Thirty-eight patients died, 31 due to their cervical carcinoma and seven from intercurrent disease.
Discussion
The overall 5-year survival of the entire group of 233 patients treated for stage I and IIA cervical carcinoma was 84% which is in accordance with the literature [1], [6], [8], [9], [11], [15], [17], [18], [20]. The overall survival of the patients treated with surgery alone was 93% which is also comparable with results reported in the literature [3], [13]. Among the patients who underwent postoperative irradiation was a subset of 10 patients with tumor related adverse prognostic factors and
Conclusions
In our series of 77 patients postoperatively irradiated for early-stage cervical carcinoma the percentage of radiation related side effects was low probably due to careful planning and the routine use of cerrosafe blocks or multileaf collimation.
The recurrence rate of 7.7% in the group of 156 patients who underwent surgery alone for early stage cervical cancer was lower than the average reported in literature [13]. The recurrence rate was 0% in the 10 node negative patients postoperatively
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