Evaluation of late morbidity in patients with carcinoma of the uterine cervix following a dose rate change.

BACKGROUND: A retrospective analysis of late complications for patients with cervical cancer treated with two different brachytherapy schedules in one institute, using the French-Italian glossary. MATERIALS AND METHODS: From 1979 until 1986, a total of 77 patients were treated with external radiation followed by two intracavitary applications with the Gynatron Cs-137 afterloading (dose rate 0.54 Gy/h). After 1986, 66 patients received intracavitary applications with Selectron-LDR (dose rate 1.07 Gy/h). Because of the expected increase in complications with increasing dose rate, the dose per application was reduced from 25 Gy to 20 Gy. RESULTS: 49/77 late gastrointestinal and urinary complications were scored in the Gynatron group and 46/68 in the Selectron group. Actuarial estimates at 5 years showed 42% and 54.1% late gastrointestinal complications and 16.9% and 24.1% for late urinary complications in the patients treated with, respectively, the Gynatron and Selectron. CONCLUSIONS: Despite the dose reduction, there remains a clear dose rate influence on the late morbidity. Correction for this influence is essential.

Late radiotherapeutic morbidity in patients with carcinoma of the uterine cervix: the application of the French-Italian glossary.

BACKGROUND AND PURPOSE: The aim of this study was to perform a retrospective analysis of the complications observed and the importance of delayed symptoms for radiotherapeutic morbidity in patients treated by radiotherapy alone for cervical cancer. MATERIALS AND METHODS: From 1979 to 1991, 145 patients with primary uterine cervical cancer were treated with external radiotherapy and intracavitary applications. During the follow-up, all signs, symptoms and therapy of late treatment complications were recorded. Complications were graded according to the French-Italian glossary. This glossary is used for recording morbidity after treatment of gynaecological cancer. RESULTS: Overall, 119 late complications were recorded. They were most frequently located in the gastro-intestinal system (53%) with a median time to development of 9 months. Urinary complications were recorded in 20%. Very few complications were recorded in vagina/uterus (12%) and pelvic soft tissue (5%). The probability of surviving without tumour recurrence and/or late combined moderate to severe organ morbidity decreased with increasing FIGO stage. CONCLUSIONS: For reporting gynaecological morbidity, the French-Italian glossary is useful. Treatment optimization must take into account actuarial estimates of survival and morbidity.

Invasive bladder cancer. Should patients who respond to radiotherapy be treated by cystectomy?

A retrospective study was carried out on the long-term survival (5-12 years) of 160 patients with invasive transitional cell cancer of the bladder treated with irradiation between 1972 and 1980. Following 40 Gy irradiation of the lower abdomen, treatment consisted of cystectomy or continued irradiation of the bladder region only. A full urological examination of the bladder established whether a patient was a responder or non-responder. The patients were divided into four groups: 27 responders treated with cystectomy and diversion; 48 responders treated with continued radiotherapy up to 65 Gy; 24 non-responders treated with cystectomy and diversion; 42 non-responders treated with continued radiotherapy up to 65 Gy. Survival and complications of treatment were compared with regard to category and grade of the tumours and sex and age of the patients. It was concluded that the responders who underwent cystectomy after 40 Gy irradiation survived longer than those who received a full course of radiotherapy. The responders had a better survival rate than non-responders, regardless of further treatment. Salvage cystectomy was rarely carried out and proved to be an unsatisfactory alternative, with a high operative risk and short survival.

The evaluation of postoperative irradiation in patients with early-stage ovarian cancer.

This is a retrospective study of 127 patients with ovarian carcinoma stage I, II, and III with no or minimal residual disease postoperatively. Patients were treated with radiotherapy by the moving strip technique from 1970 through 1984. The 5-year actuarial survival rate was 73%. Analysis was made on subgroups such as a complete versus incomplete staging procedure, stage, histopathology, grade, and amount of residual tumor. In this study, grade is a significant prognostic indicator (survival in grade 1 versus grade 2 and 3 tumors was statistically different (P less than 0.005). Stage 1 and 2 patients do better than stage 3 patients. Residual tumor does not influence survival rate. The disease-free survival of patients with serous cystadenocarcinoma is better than that of patients with mucinous cystadenocarcinoma (P less than 0.004). The incidence of severe complications was 4%.

A review of prognostic factors in early-stage carcinoma of the cervix (FIGO I B and II A) and implications for treatment strategy.

Several prognostic factors in stages I B and II A cervical carcinoma have been widely studied to define groups of patients with a poor prognosis. Most of these factors are interrelated. The characteristics which should be regarded as main factors have not yet been defined, because the studies reported were based on mainly retrospective and non-randomized analysis. Reviewing the literature, lymph node metastasis, differentiation grade, tumor size, parametrial extension, lymph-blood vessel invasion and cervical invasion seem to be prognostically important factors, which suggests that the subdivision of patients according to the FIGO classification alone is inaccurate. It seems useful to define subgroups of patients according to tumor characteristics, determined after surgical treatment and accurate histologic examination of the surgical specimen. Patients with one or more of these tumor features need additional treatment to improve survival. The current treatment modalities, such as postoperative radiotherapy, have not been thoroughly evaluated, but doubt exists as to their efficacy. Data in the literature suggest that particularly patients with para-aortic or multiple pelvic lymph node metastasis (greater than 3) have already developed distant metastases at the time of primary treatment and therefore need adjuvant systemic therapy. Patients with tumors larger than 4 cm in diameter, differentiation grade III, lymph-blood vessel invasion or cervical invasion (of more than 70%) seem to have high recurrence rates at both pelvic and distant sites, indicating that there is also a need for better pelvic control.

cis-Diaminechloroplatinum in the treatment of advanced primary squamous cell carcinoma of the vaginal wall: a case report.

A 34-year-old patient with advanced primary squamocellular vaginal carcinoma was treated with external radiation (4000 cGy to the pelvis) and a line source Cesium application delivering 4000 cGy to the vaginal wall. During this treatment the patient developed a lesion on her back that proved to be a metastasis of a squamocellular cancer. The patient was started on six courses of cisplatin as a single agent. After the fourth course a complete remission was reached lasting for 4 months. By that time the metastasis recurred and was surgically excised. Sixteen months after diagnosis and 9 months after chemotherapeutic treatment there is no evidence of disease.