The prognostic significance of radiation dose and residual tumor in the treatment of barrel-shaped endophytic cervical carcinoma

Objective. The aim of this study was to evaluate the impact of total radiat ion dose on residual tumor and the prognostic significance of persistent di sease in women with bulky, barrel-shaped cervical carcinoma who received de finitive radiation followed by adjuvant hysterectomy. Methods. The medical records of 57 patients with bulky endophytic cervical carcinoma treated at the University of Washington between 1976 and 1997 wer e reviewed. All patients received external beam pelvic radiotherapy supplem ented by intracavitary brachytherapy, followed by extrafascial hysterectomy 6 to 8 weeks later. Results. The mean pretreatment tumor diameter was 5.9 cm, with a range of 4 -9 cm. Total radiation dose to point A ranged from 5040 to 9700 cGy, and th e mean for the group was 7966 cGy. Residual disease was present in 35 (61%) of the hysterectomy specimens. The frequency of cervical tumor sterilizati on correlated significantly with the mean radiation dose to point A (P = 0. 016). Patients without histologic residual disease had a significantly impr oved outcome, with 95% of patients remaining clinically free of disease at last follow-up, versus 31% of those with residual disease (P < 0.001). As e xpected, the pelvic control rate was excellent (100%) in patients with comp lete tumor eradication compared to the group with residual tumor (44%). Tho se with no residual disease enjoyed a significantly improved survival compa red to those with residual tumor (P < 0.001). Furthermore, a statistically significant higher survival was realized in patients harboring only microsc opic residual compared to those with either macroscopically evident tumor r esiduum and/or positive surgical margins (P = 0.036). Conclusions. Higher radiation doses are associated with an improved likelih ood of tumor eradication in the treatment of bulky, endophytic cervical can cer and complete tumor sterilization at adjuvant hysterectomy is predictive of significantly enhanced survival and pelvic control. The high rate of hi stologic tumor persistence in our series emphasizes the need for more effic acious therapies in patients with bulky endophytic cervical cancer and argu es for escalation of radiation dose even when adjuvant hysterectomy is plan ned. (C) 2000 Academic Press.