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Radiotherapy versus surgery in the treatment of cervix stage Ib cancer
??Original Contribution RADIOTHERAPY
FABIO VOLTERRANI,
VERSUS SURGERY IN THE TREATMENT STAGE Ib CANCER
OF CERVIX
M.D.? LUCIA FELTRE, M.D.,*DAVIDE SIGURTA’, M.D.,?, M.D.$ AND LUCIANO LUCIANI, M.D.$
MARIA DI GIUSEPPE,
In the years 1971-77 we have treated 250 Stage Ih patients with cancersof the cervix. One hundred twenty-three operation, and 86 had a lymphadenectomy (49.2 % ) underwent a radical surgery, 37 had a classical Wertheim-Meigs that was extended to the lumbar-aortic region. When feasible, all patients received postoperative radiumtherapy on the vaginal vault. The remaining 127 patients received a complete course of radiotherapy. This was not a randomized clinical trial. In fact surgery was preferred for patients who were younger (mean age: 49.6 years) and more physically fit, while radiotherapy was the treatment chosen for those who were older (mean age: 57.7) and generally less fit or obese. The 5 year NED survival was 89.3% in the surgical group and 90.9 % in the radiotherapy group (P L .05). Four fatal complications were observed in the surgical group (3.2 % ). Rate and causes of failures or complications are analyzed in detail. Uterine cervix, Stage Ib, Treatment. METHODS
INTRODUCTION
AND MATERIALS
Historically, the treatment of Stage Ib invasive carcinoma of the uterine cervix has been a controversy between supporters of surgery and the supporters of radiotherapy. This controversy dates back to the first quarter of this century. Until now it has not been possible to establish an adequate comparison between the two methods and the choice is left to personal belief and experience rather than to objective elements available for judgment. The purpose of this paper is to compare the results achieved by radiotherapy and by surgery in the treatment of Stage I cervical cancer, using a series of selected 2.50 patients treated consecutively at the National Cancer Institute of Milan in the years 1971-77. This was not a randomized clinical trial but a retrospective study. The study only excludes rare histotypes such as clear cell adenocarcinoma, carcinoma having an adenoid cystic pattern and verrucous carcinoma. In fact these tumors give rise to particular diagnostic and therapeutic problems. The microinvasive carcinomas (with invasion depth ~0.3 cm) are also excluded as it appears that a less aggressive treatment may be possible in comparison to clearly invasive carcinoma.3,4,‘0
We have treated 250 Stage lb patients with cervical carcinomas at the National Cancer Institute of Milan during the years 1971-77. One hundred twenty-three underwent surgery (49.2%‘). Thirty-seven of these had a classical Wertheim-Meigs operation; the other 86 patients (69.9%) underwent a lymphadenectomy extended to the lumbar-aortic region as far as the renal hilus. The patients with positive nodes were 3 (8.1%) and I I (I 2.8%), respectively, for a total of 14/ 123 (I I .4%). The hypogastric nodes were most frequently affected and proved positive in 7/ 14 N + patients. Only 2/86 patients undergoing the extended lymphadenectomy proved to have positive nodes in the lumbar-aortic area (2.3%). Both patients showed diffused nodal metastases in the pelvis. After surgery a complementary endocavitary curietherapy was carried out with “‘Ra sources on the vaginal stump with a median administration of 3.800 mgh (total activity employed: 20 mg). This treatment was not given to 17 patients (I 3.8%) mainly because of postoperative complications. For the same reason, only 7/14 patients with nodal metastases received an adjuvant “Co-telether-
*Istituto di Scienze Radiologiche, Universita degli StudiMilano. tservizio di Radiologia B. lstituto Nazionale per lo Studio e la Cura dei Tumori-Milano. SDivisione di Oncologia Clinica B. lstituto Nazionale per lo Studio e la Cura dei Tumori-Milano.
Reprint requests to: Dr. lstituto Nazionale per lo Venezia, I, 20133-Milano, Accepted for publication
1781
F. Volterrani. Servizio di Radiologia, Studio e la Cura dei Tumori, Via Italy. 21 July 1983.
1782
Radiation Oncology 0 Biology 0 Physics
December 1983, Volume 9, Number I2
Table I. Histologic type distribution Radical surgery
No. Keratinizing and large 92 cell carcinomas Small cell and undifferentiated 12 carcinomas Endocervical adenoca. 19 and mixed carcinomas Total (%) 123
used for the older patients who were inoperable because of obesity or whose general health conditions were poor. As compared with patients who received irradiation alone, the group undergoing radical surgery only had a higher incidence of adenocarcinomas or mixed carcinomas, for which the risk of nodal metastases is considered higher and therefore radical surgery with lymphadenectomy is believed more suitable.
Radiotherapy
(%)
No.
(%)
(74.8)
101
(79.5)
(9.7)
18
(14.2)
(15.5) (100.0)
8 127
(6.3) (100.0)
RESULTS We have evaluated the disease-free survival, calculated by the actuarial method.’ Patients with lethal complications because of treatment are excluded. The causes of failure and the complications in relation with the type of treatment have been considered separately. The immediate results and the medium-term ones are very similar (Fig. 2). The disease-free survival at 5 years is a few points higher for the group treated with radiotherapy alone, but the difference is not statistically significant. It is interesting to note that the extension of lymphadenectomy to the lumbar-aortic nodes did not determine any improvement in the results. The survival of patients who underwent a classical Wertheim-Meigs operation was 96.3% at 5 years, as compared to 86.7% of the patients undergoing an extended lymphadenectomy (the difference is not statistically significant.) Table 2 gives the analysis of the causes of failure. The most frequent failure cause is pelvic relapse, which in the group undergoing radical surgery mainly occurred in histologically N + (5/ 14 patients). Pelvic relapses are usually accompanied by a central relapse of the disease, which in the surgical group nearly always occurred in N + cases. As far as the patients treated with radiotherapy alone are concerned, no certain elements emerged regard-
apy (45 Gy in 5-6 weeks, through opposed A-P pelvic fields). None of these patients received prophylactic irradiation of the lumbar aortic nodes. The treatment of 127 patients was radiotherapy alone. As a rule, the patients first received endocavitary curietherapy (with radium-226 sources, except for 10 patients for whom I37 cesium sources were used). The classical “Paris” technique was selected for endocavitary treatment (1 fraction in 7 days with median administration of 5,100 to 8,500 mgh); a total activity of 40 to 55 mg was employed. All the patients were subsequently irradiated with 60Co-teletherapy to the pelvis by means of opposed A-P fields, with total doses around 43 to 48 Gy in 5-6 weeks with interposition of Pb screens to protect the endocavitary treatment area. Table 1 and Figure 1 show the histological type and age distribution for the two groups. This was not a properly randomized study but the choice of the treatment was not conditioned by oncologic considerations. In fact, surgery was preferred for the younger patients whose general health conditions were better. while radiotherapy was TYPE 0 m
5
46
OF
TREATMENT-HEAR
RADICAL
46
RAPIOTHERAPY
5 65
66
(,
-
66 YEARS
Fig. I
Age distribution
by type of treatment
OF AGE
SURGERY-49.6 57.7
1 66 OF AGE
in 250 Stage lb cancers of the cervix.
1783
Uterine cervix Stage Ib cancer 0 F. VOLTERRANIef al.
On the other hand, the arising in the radiotherapy cially rectal.
most frequent complications group were intestinal, espe-
DISCUSSION
s
I
M
A
RADICAL
SUROERY
4
a\’ b
0
I
I
1
I 2
4
I
I
I
4
YEARS Fig. 2
NED survival from radical surgery vs. radiotherapy
ing a higher risk of relapse. However, it should be noted that in a subgroup of 15 patients undergoing lymphography prior to treatment, both the patients with nodal metastases at the radiologic examination developed a pelvic relapse, one of whom had a central recurrence. On the other hand, all the patients considered to be free of nodal metastases had a favorable outcome. Lastly, the histologic type did not appear to influence the results in either of the two groups-radical surgery and radiotheraPY. Table 3 gives the incidence and nature of the complications with respect to the treatment methods. The non lethal complications that did not require surgical treatment have been classified as moderate and those that required a surgical reparation were recorded as severe. A patient who had multiple complications was recorded only once and was counted as a more severe complication. On the whole, the risk is equal for radical surgery and radiotherapy. However, a slightly higher incidence of severe or even lethal complications is associated with surgery. As may well be expected, the most frequent complications in the radical surgery group were ureteral.
Table 2. Failures analysis Radical surgery
Radiotherapy
[IO41
Pelvic relapse* Distant metastases Pelvic relapse & metastases 2nd tumor *Central recurrence
[LO51
No.
(%)
No.
(%)
8 2
(7.7) (1.8)
8
(7.6) (0.9)
1
(0.9) (5.7)
L 5
6
The choice of the optimal treatment for Stage lb cervical cancer, excluding microinvasive lesions, is still very controversial. There are no randomized clinical studies for comparison between radical surgery and radiotherapy and non-randomized studies, either retrospective or prospective, and carried out in the same institution are rare. The efficacy of radiotherapy is recognized as being equal to that of surgery but attention is drawn to the difficulty of using salvage surgery on radiological relapses, as compared with the prospects of saving surgical relapses through radiotherapy.‘.’ Our study is not a randomized clinical trial by the choice between surgery and radiotherapy was not conditioned by oncological discriminations. The results in terms of disease-free survival were practically the same and the very small differences found are not statistically significant. Furthermore, the incidence of pelvic relapses and those patients having a central recurrence was the same for patients receiving radiotherapy and those treated surgically. The salvage possibilities after relapse always appeared slight independently from the type of primary treatment. With equal results surgery is considered advantageous with respect to radiotherapy because it allows a more exact definition of the real loco-regional extension, it is more rapid (when free of complications), it permits a more prompt and complete solution of the emotional stress caused by the diagnosis of the disease and allows a partial conservation of the ovary function in young women without compromising the recovery.‘,’ Furthermore, our study gives medium-term results; an additional disadvantage represented by a possible higher incidence of radio-induced second tumors arising later may not have emerged. In any case, it must be kept in mind that radiotherapy still remains the only radical treatment practical in more than half of the patients observed, who, because of obesity or contraindications of a various nature, could not receive surgery. In fact, without prejudice in favor of the advantages of the surgical approach, a comparison between surgery and radiotherapy can only be made on the basis of an impartial and correct analysis of the respective rates and gravity
1
(0.9)
[ ] number of patients with follow-up a-2 years
(4.8)
Table 3. Complications Radical surgery
Lethal Moderate Severe Total (%)
No.
(%)
4 13 20 37
(3.2) (10.6) (16.2) (30.1)
analysis Radiotherapy No.
3: 4:
(%) (0.8) (25.2) (6.3) (32.3)
1784
Radiation
Oncology 0 Biology 0 Physics
of both immediate and late complications. This is prevented by the lack of a glossary and a unanimous criterion to be adopted for this analysis. Moreover, the evaluation of the gravity of the complications may easily be subjective and not take into account the emotional involvement. The surgical treatment of cervical carcinomas in the early stages may involve different classes of extended hysterectomy.‘.’ In our institute we have, until now, treated Stage Ib invasive cervical cancer with a class IV extended hysterectomy in association with a lymphadenectomy, sometimes extended as far as the lumbar-aortic region. It is a matter of discussion whether it is necessary to adopt this kind of extended surgery that is accompanied by too high a risk factor of severe complications. In fact, the incidence of nodal metastases was, on the whole, found to
December
1983, Volume 9, Number 12
be low and the lumbar-aortic metastases incidence minimal. Cervical carcinoma seems to be evolving towards less aggressive forms, and the more differentiated histotypes are more frequent.” The observation of bulky lesions is more rare and the incidence of clinically “occult” lesions is increasing. The pelvic node positivity is low, while lumbar-aortic positivity is exceptional and usually accompanied by a diffused involvement of the pelvis. On the other hand, historical evidence proves that under favorable conditions, endocavitary curietherapy alone is capable of curing invasive cervical carcinomas of a limited size.‘,” Therefore, in our opinion there is room for more personalized and less aggressive therapeutic protocols in the treatment of Stage lb cervical carcinomas.
REFERENCES Cancer 48: 548-559, I98 I. Hamberger, A.D., Fletcher, G.H.. Wharton, J.T.: Results of treatment of early Stage I carcinoma of the uterine cervix with intracavitary radium alone. Cancer 41: 980-985, 1978. Leman, M.N., Jr., Benson, W.L., Kurman, R.J.. Park, R.C.: Microinvasive carcinoma of the cervix. Obstet. Gynecol. 48: 57 l-578, 1976. Luciani. L.. Bulfoni, G.: Possibilita di attuazione du una terapia pii conservativa nel carcinoma del cello uterino allo 1972. stadio preclinico. Minerva Ginecol. 24: 655-659. Morley, G.W.. Seski, J.C.: Radical pelvic surgery versus radiation therapy for Stage I carcinoma of the cervix (exclusive of microinvasion). Am. .I. Obstet. Gynecol. 126: 7855798, 1976. Newton, M.: Radical hysterectomy or radiotherapy for with 5 Stage I cervical cancer. A prospective comparison
1. Di Saia, P.J.: Surgical 2.
3.
4.
5.
6.
aspects of cervical
carcinoma.
7.
8.
9.
IO.
I I.
and IO year follow-up. .4m. J. Obsfet. Gynecol. 123: 5355 542, 1975. Piver, M.S., Rutledge, F., Smith, J.P.: Five classes of extended hysterectomy for women with cervical cancer. Obsret. G,vnecol. 44: 2655272, 1974. Reagan, J.W., Fu, Y.S.: Histologic types and prognosis of cancers of the uterine cervix. Inf. J. Radial. Oncol. Biol. Phys. 5: 1015~1020.1979. Schwartz. D., Flamant, R.. Lellouch, J.: L’essai ThCrapeufique Che: /‘Hornme. Paris, Ed. Medicales Flammarion. 1970. Seski. J.C., Abell, M.R.. Morley, G.W.: Microinvasive squamous carcinoma of the cervix. Definition, histologic analysis, late results of treatment. Obstet. Gynecol. 50: 410~414.1977. Volterrani. F., Lombardi, F.: Long term results of radium therapy in cervical cancer. Inf. J. Radiat. Oncol. Biol. Phys. 6: 5655570. 1980.
FABIO VOLTERRANI,
VERSUS SURGERY IN THE TREATMENT STAGE Ib CANCER
OF CERVIX
M.D.? LUCIA FELTRE, M.D.,*DAVIDE SIGURTA’, M.D.,?, M.D.$ AND LUCIANO LUCIANI, M.D.$
MARIA DI GIUSEPPE,
In the years 1971-77 we have treated 250 Stage Ih patients with cancersof the cervix. One hundred twenty-three operation, and 86 had a lymphadenectomy (49.2 % ) underwent a radical surgery, 37 had a classical Wertheim-Meigs that was extended to the lumbar-aortic region. When feasible, all patients received postoperative radiumtherapy on the vaginal vault. The remaining 127 patients received a complete course of radiotherapy. This was not a randomized clinical trial. In fact surgery was preferred for patients who were younger (mean age: 49.6 years) and more physically fit, while radiotherapy was the treatment chosen for those who were older (mean age: 57.7) and generally less fit or obese. The 5 year NED survival was 89.3% in the surgical group and 90.9 % in the radiotherapy group (P L .05). Four fatal complications were observed in the surgical group (3.2 % ). Rate and causes of failures or complications are analyzed in detail. Uterine cervix, Stage Ib, Treatment. METHODS
INTRODUCTION
AND MATERIALS
Historically, the treatment of Stage Ib invasive carcinoma of the uterine cervix has been a controversy between supporters of surgery and the supporters of radiotherapy. This controversy dates back to the first quarter of this century. Until now it has not been possible to establish an adequate comparison between the two methods and the choice is left to personal belief and experience rather than to objective elements available for judgment. The purpose of this paper is to compare the results achieved by radiotherapy and by surgery in the treatment of Stage I cervical cancer, using a series of selected 2.50 patients treated consecutively at the National Cancer Institute of Milan in the years 1971-77. This was not a randomized clinical trial but a retrospective study. The study only excludes rare histotypes such as clear cell adenocarcinoma, carcinoma having an adenoid cystic pattern and verrucous carcinoma. In fact these tumors give rise to particular diagnostic and therapeutic problems. The microinvasive carcinomas (with invasion depth ~0.3 cm) are also excluded as it appears that a less aggressive treatment may be possible in comparison to clearly invasive carcinoma.3,4,‘0
We have treated 250 Stage lb patients with cervical carcinomas at the National Cancer Institute of Milan during the years 1971-77. One hundred twenty-three underwent surgery (49.2%‘). Thirty-seven of these had a classical Wertheim-Meigs operation; the other 86 patients (69.9%) underwent a lymphadenectomy extended to the lumbar-aortic region as far as the renal hilus. The patients with positive nodes were 3 (8.1%) and I I (I 2.8%), respectively, for a total of 14/ 123 (I I .4%). The hypogastric nodes were most frequently affected and proved positive in 7/ 14 N + patients. Only 2/86 patients undergoing the extended lymphadenectomy proved to have positive nodes in the lumbar-aortic area (2.3%). Both patients showed diffused nodal metastases in the pelvis. After surgery a complementary endocavitary curietherapy was carried out with “‘Ra sources on the vaginal stump with a median administration of 3.800 mgh (total activity employed: 20 mg). This treatment was not given to 17 patients (I 3.8%) mainly because of postoperative complications. For the same reason, only 7/14 patients with nodal metastases received an adjuvant “Co-telether-
*Istituto di Scienze Radiologiche, Universita degli StudiMilano. tservizio di Radiologia B. lstituto Nazionale per lo Studio e la Cura dei Tumori-Milano. SDivisione di Oncologia Clinica B. lstituto Nazionale per lo Studio e la Cura dei Tumori-Milano.
Reprint requests to: Dr. lstituto Nazionale per lo Venezia, I, 20133-Milano, Accepted for publication
1781
F. Volterrani. Servizio di Radiologia, Studio e la Cura dei Tumori, Via Italy. 21 July 1983.
1782
Radiation Oncology 0 Biology 0 Physics
December 1983, Volume 9, Number I2
Table I. Histologic type distribution Radical surgery
No. Keratinizing and large 92 cell carcinomas Small cell and undifferentiated 12 carcinomas Endocervical adenoca. 19 and mixed carcinomas Total (%) 123
used for the older patients who were inoperable because of obesity or whose general health conditions were poor. As compared with patients who received irradiation alone, the group undergoing radical surgery only had a higher incidence of adenocarcinomas or mixed carcinomas, for which the risk of nodal metastases is considered higher and therefore radical surgery with lymphadenectomy is believed more suitable.
Radiotherapy
(%)
No.
(%)
(74.8)
101
(79.5)
(9.7)
18
(14.2)
(15.5) (100.0)
8 127
(6.3) (100.0)
RESULTS We have evaluated the disease-free survival, calculated by the actuarial method.’ Patients with lethal complications because of treatment are excluded. The causes of failure and the complications in relation with the type of treatment have been considered separately. The immediate results and the medium-term ones are very similar (Fig. 2). The disease-free survival at 5 years is a few points higher for the group treated with radiotherapy alone, but the difference is not statistically significant. It is interesting to note that the extension of lymphadenectomy to the lumbar-aortic nodes did not determine any improvement in the results. The survival of patients who underwent a classical Wertheim-Meigs operation was 96.3% at 5 years, as compared to 86.7% of the patients undergoing an extended lymphadenectomy (the difference is not statistically significant.) Table 2 gives the analysis of the causes of failure. The most frequent failure cause is pelvic relapse, which in the group undergoing radical surgery mainly occurred in histologically N + (5/ 14 patients). Pelvic relapses are usually accompanied by a central relapse of the disease, which in the surgical group nearly always occurred in N + cases. As far as the patients treated with radiotherapy alone are concerned, no certain elements emerged regard-
apy (45 Gy in 5-6 weeks, through opposed A-P pelvic fields). None of these patients received prophylactic irradiation of the lumbar aortic nodes. The treatment of 127 patients was radiotherapy alone. As a rule, the patients first received endocavitary curietherapy (with radium-226 sources, except for 10 patients for whom I37 cesium sources were used). The classical “Paris” technique was selected for endocavitary treatment (1 fraction in 7 days with median administration of 5,100 to 8,500 mgh); a total activity of 40 to 55 mg was employed. All the patients were subsequently irradiated with 60Co-teletherapy to the pelvis by means of opposed A-P fields, with total doses around 43 to 48 Gy in 5-6 weeks with interposition of Pb screens to protect the endocavitary treatment area. Table 1 and Figure 1 show the histological type and age distribution for the two groups. This was not a properly randomized study but the choice of the treatment was not conditioned by oncologic considerations. In fact, surgery was preferred for the younger patients whose general health conditions were better. while radiotherapy was TYPE 0 m
5
46
OF
TREATMENT-HEAR
RADICAL
46
RAPIOTHERAPY
5 65
66
(,
-
66 YEARS
Fig. I
Age distribution
by type of treatment
OF AGE
SURGERY-49.6 57.7
1 66 OF AGE
in 250 Stage lb cancers of the cervix.
1783
Uterine cervix Stage Ib cancer 0 F. VOLTERRANIef al.
On the other hand, the arising in the radiotherapy cially rectal.
most frequent complications group were intestinal, espe-
DISCUSSION
s
I
M
A
RADICAL
SUROERY
4
a\’ b
0
I
I
1
I 2
4
I
I
I
4
YEARS Fig. 2
NED survival from radical surgery vs. radiotherapy
ing a higher risk of relapse. However, it should be noted that in a subgroup of 15 patients undergoing lymphography prior to treatment, both the patients with nodal metastases at the radiologic examination developed a pelvic relapse, one of whom had a central recurrence. On the other hand, all the patients considered to be free of nodal metastases had a favorable outcome. Lastly, the histologic type did not appear to influence the results in either of the two groups-radical surgery and radiotheraPY. Table 3 gives the incidence and nature of the complications with respect to the treatment methods. The non lethal complications that did not require surgical treatment have been classified as moderate and those that required a surgical reparation were recorded as severe. A patient who had multiple complications was recorded only once and was counted as a more severe complication. On the whole, the risk is equal for radical surgery and radiotherapy. However, a slightly higher incidence of severe or even lethal complications is associated with surgery. As may well be expected, the most frequent complications in the radical surgery group were ureteral.
Table 2. Failures analysis Radical surgery
Radiotherapy
[IO41
Pelvic relapse* Distant metastases Pelvic relapse & metastases 2nd tumor *Central recurrence
[LO51
No.
(%)
No.
(%)
8 2
(7.7) (1.8)
8
(7.6) (0.9)
1
(0.9) (5.7)
L 5
6
The choice of the optimal treatment for Stage lb cervical cancer, excluding microinvasive lesions, is still very controversial. There are no randomized clinical studies for comparison between radical surgery and radiotherapy and non-randomized studies, either retrospective or prospective, and carried out in the same institution are rare. The efficacy of radiotherapy is recognized as being equal to that of surgery but attention is drawn to the difficulty of using salvage surgery on radiological relapses, as compared with the prospects of saving surgical relapses through radiotherapy.‘.’ Our study is not a randomized clinical trial by the choice between surgery and radiotherapy was not conditioned by oncological discriminations. The results in terms of disease-free survival were practically the same and the very small differences found are not statistically significant. Furthermore, the incidence of pelvic relapses and those patients having a central recurrence was the same for patients receiving radiotherapy and those treated surgically. The salvage possibilities after relapse always appeared slight independently from the type of primary treatment. With equal results surgery is considered advantageous with respect to radiotherapy because it allows a more exact definition of the real loco-regional extension, it is more rapid (when free of complications), it permits a more prompt and complete solution of the emotional stress caused by the diagnosis of the disease and allows a partial conservation of the ovary function in young women without compromising the recovery.‘,’ Furthermore, our study gives medium-term results; an additional disadvantage represented by a possible higher incidence of radio-induced second tumors arising later may not have emerged. In any case, it must be kept in mind that radiotherapy still remains the only radical treatment practical in more than half of the patients observed, who, because of obesity or contraindications of a various nature, could not receive surgery. In fact, without prejudice in favor of the advantages of the surgical approach, a comparison between surgery and radiotherapy can only be made on the basis of an impartial and correct analysis of the respective rates and gravity
1
(0.9)
[ ] number of patients with follow-up a-2 years
(4.8)
Table 3. Complications Radical surgery
Lethal Moderate Severe Total (%)
No.
(%)
4 13 20 37
(3.2) (10.6) (16.2) (30.1)
analysis Radiotherapy No.
3: 4:
(%) (0.8) (25.2) (6.3) (32.3)
1784
Radiation
Oncology 0 Biology 0 Physics
of both immediate and late complications. This is prevented by the lack of a glossary and a unanimous criterion to be adopted for this analysis. Moreover, the evaluation of the gravity of the complications may easily be subjective and not take into account the emotional involvement. The surgical treatment of cervical carcinomas in the early stages may involve different classes of extended hysterectomy.‘.’ In our institute we have, until now, treated Stage Ib invasive cervical cancer with a class IV extended hysterectomy in association with a lymphadenectomy, sometimes extended as far as the lumbar-aortic region. It is a matter of discussion whether it is necessary to adopt this kind of extended surgery that is accompanied by too high a risk factor of severe complications. In fact, the incidence of nodal metastases was, on the whole, found to
December
1983, Volume 9, Number 12
be low and the lumbar-aortic metastases incidence minimal. Cervical carcinoma seems to be evolving towards less aggressive forms, and the more differentiated histotypes are more frequent.” The observation of bulky lesions is more rare and the incidence of clinically “occult” lesions is increasing. The pelvic node positivity is low, while lumbar-aortic positivity is exceptional and usually accompanied by a diffused involvement of the pelvis. On the other hand, historical evidence proves that under favorable conditions, endocavitary curietherapy alone is capable of curing invasive cervical carcinomas of a limited size.‘,” Therefore, in our opinion there is room for more personalized and less aggressive therapeutic protocols in the treatment of Stage lb cervical carcinomas.
REFERENCES Cancer 48: 548-559, I98 I. Hamberger, A.D., Fletcher, G.H.. Wharton, J.T.: Results of treatment of early Stage I carcinoma of the uterine cervix with intracavitary radium alone. Cancer 41: 980-985, 1978. Leman, M.N., Jr., Benson, W.L., Kurman, R.J.. Park, R.C.: Microinvasive carcinoma of the cervix. Obstet. Gynecol. 48: 57 l-578, 1976. Luciani. L.. Bulfoni, G.: Possibilita di attuazione du una terapia pii conservativa nel carcinoma del cello uterino allo 1972. stadio preclinico. Minerva Ginecol. 24: 655-659. Morley, G.W.. Seski, J.C.: Radical pelvic surgery versus radiation therapy for Stage I carcinoma of the cervix (exclusive of microinvasion). Am. .I. Obstet. Gynecol. 126: 7855798, 1976. Newton, M.: Radical hysterectomy or radiotherapy for with 5 Stage I cervical cancer. A prospective comparison
1. Di Saia, P.J.: Surgical 2.
3.
4.
5.
6.
aspects of cervical
carcinoma.
7.
8.
9.
IO.
I I.
and IO year follow-up. .4m. J. Obsfet. Gynecol. 123: 5355 542, 1975. Piver, M.S., Rutledge, F., Smith, J.P.: Five classes of extended hysterectomy for women with cervical cancer. Obsret. G,vnecol. 44: 2655272, 1974. Reagan, J.W., Fu, Y.S.: Histologic types and prognosis of cancers of the uterine cervix. Inf. J. Radial. Oncol. Biol. Phys. 5: 1015~1020.1979. Schwartz. D., Flamant, R.. Lellouch, J.: L’essai ThCrapeufique Che: /‘Hornme. Paris, Ed. Medicales Flammarion. 1970. Seski. J.C., Abell, M.R.. Morley, G.W.: Microinvasive squamous carcinoma of the cervix. Definition, histologic analysis, late results of treatment. Obstet. Gynecol. 50: 410~414.1977. Volterrani. F., Lombardi, F.: Long term results of radium therapy in cervical cancer. Inf. J. Radiat. Oncol. Biol. Phys. 6: 5655570. 1980.