IRRADIATION ALONE OR COMBINED WITH SURGERY IN STAGE IB, IIA, AND IIB CARCINOMA OF UTERINE CERVIX - UPDATE OF A NONRANDOMIZED COMPARISON

Purpose: Definitive radiation therapy alone or combined with surgery i n carcinoma of the uterine cervix yields comparable tumor control and survival in Stages I and IIA when patients are adequately treated with either modality. Our 30-year institutional experience is described. M ethods and Materials: This is a nonrandomized comparison of treatment results of 415 patients with Stage IB, 137 with Stage IIA, and 340 wit h Stage IIB carcinoma of the uterine cervix treated with irradiation a lone and 197 with Stage IB, 44 with Stage IIA, and 65 with limited Sta ge IIB treated with pre- or postoperative irradiation and surgery. Irr adiation alone consisted of a combination of external beam therapy and intracavitary insertions to deliver doses of 70 to 85 Gy to point A f or patients with Stages IB and IIA disease and 80 to 90 Gy for patient s with bulky or Stage IIB tumors. For patients treated with irradiatio n and surgery, various combinations of external beam and intracavitary therapy were used to deliver 60 to 75 Gy to point A. Surgical procedu res consisted of radical hysterectomy with or without lymph node disse ction in 130 patients with Stage IB, 28 patients with Stage IIA, and 1 0 patients with limited Stage IIB. Fifty-seven patients had total abdo minal or conservative hysterectomy with or without lymph node dissecti on, and 3 had vaginal hysterectomy. In addition, 51 patients with Stag e IIB tumors underwent pelvic lymphadenectomy after definitive irradia tion. Results: The 5-year cause-specific survival (CSS) rates for pati ents with Stage IB nonbulky tumors treated with irradiation alone or i rradiation combined with surgery were 90 and 85%, respectively, and th e 10-year survival rate was 84% with either modality. In patients with bulky tumors (> 5 cm), the 5-year CSS rates were 61% with irradiation alone and 63% with irradiation plus surgery; at 10 years the rates we re 61 and 68%, respectively (p = 0.5). For those with Stage IIA nonbul ky tumors, the 5-year CSS rates were 75% with irradiation alone and 83 % with combined irradiation and surgery, and 10-year CSS rates were 66 and 71%, respectively. In patients with Stage IIA bulky tumors, the 5 -year CSS rates were 69% with irradiation alone and 60% with irradiati on plus surgery, and at 10 years, 69 and 44%, respectively (p, = 0.05) . In patients with Stage IIB nonbulky tumors treated with irradiation alone or combined with surgery, the 5- and 10-year CCS rates were 72 a nd 65%, respectively; the corresponding survival rates with bulky tumo rs or bilateral parametrial involvement were 56 and 50%. Incidence of pelvic failures, alone or with distant metastasis, for Stage IB was 10 % (43 out of 415) with irradiation alone and 14% (28 of 197) with irra diation plus surgery; for Stage IIA, 17% (23 out of 137) with irradiat ion alone and 20% (9 out of 44) with irradiation plus surgery; and for Stage IIB, 23% (88 out of 391) with irradiation atone and 29% (4 out of 14) with irradiation plus surgery. Grade 3 sequelae were comparable in both groups (irradiation alone, 5% to 11%; irradiation combined wi th surgery, 8% to 12%); the differences are not statistically signific ant. The most frequent major sequelae in 892 patients receiving irradi ation only were rectovaginal fistula (13 cases, 1.5%), proctitis (10, 1.1%), small bowel obstruction (16, 1.8%), ureteral stricture (16, 1.8 %), and vesicovaginal fistula (8, 0.9%). In 306 patients treated with irradiation plus surgery, the most commonly recorded major sequelae we re small bowel obstruction/perforation (13 cases, 4.2%), ureteral stri cture (8, 2.6%), vesicovaginal fistula (5, 1.6%), and rectovaginal fis tula (4, 1.3%). Conclusion: Irradiation alone or combined with surgery yields comparable pelvic tumor control, survival, and morbidity in pa tients with Stage IB, IIA, and limited IIB carcinoma of the uterine ce rvix.