Brachytherapy and vaginal hysterectomy for low-stage uterine cervix carcinoma

Laparoscopic Pelvic and Paraaortic Lymphadenectomy in Gynecologic Oncology

In the early 1990s, different authors independently developed techniques for pelvic and paraaortic lymph node sampling. Since then, laparoscopic lymphadenectomy has been demonstrated to yield the same number of nodes when compared with the laparotomic approach. Only one microscopically involved lymph node was lost at laparoscopic lymphadenectomy when a laparotomic control followed immediately after. It seems bleeding, which is the most serious perioperative complication, is more common during laparoscopic lymphadenectomy than during laparotomy; however, the incidence will decrease with experience of the surgeon. The laparoscopic procedure does not seem to influence negatively the survival of patients with early stage endometrial and cervical cancer. There does not seem to be a significant reduction in overall hospital charges for laparoscopic surgery in oncology, but patients who undergo laparoscopic surgery recover significantly sooner than those who undergo laparotomy.

The role of the French–Italian glossary of complications in the outcome evaluation of cervical cancer treatment: an Italian multicentric study

The optimal treatment for cervical cancer is still a controversial matter: in the last two decades a lot of different modalities combining surgery, radiotherapy (RT) and chemotherapy (CHT) have been suggested and analysed in clinical trials. Nevertheless, analysis of treatment in cancer patients should be directed not only to survival, but also to the cost of complications and quality of life. In June 1988, a French-Italian co-operative group set up a glossary in which the complications of the treatment of cervical cancer are described and ranked. Nowadays, this is the only international system based upon an accurate description of symptoms and signs of complications following multidisciplinary treatment. The glossary was based on our previous experience in treating patients by surgery alone, RT or their combinations. Recently multimodality treatment includes also CHT. The aim of the present study was to verify whether the glossary is still a useful clinical instrument in outcome evaluation of cervical cancer treatment.

MATERIALS AND METHODS

The analysis has been done on a retrospective consecutive series of 579 patients affected by cervical cancer, treated in five Italian institutions. A minimum of 12 months follow up was required. All medical records of the patients enrolled, were examined by two independent reviewers in order to classify the complications according to the glossary.

RESULTS

Out of 579 patients 319 (55.1%) were free of complications and 260 (44.9%) experienced at least one complication. We found 436 complications. The distribution by Grade was: G1 58.9%, G2 27.5%, G3 13.5%. We had no fatal complication (G4). The glossary included all observed complications, except for pulmonary fibrosis.

CONCLUSION

The glossary is still a useful instrument in evaluating the outcome of cervical cancer treatment, whatever the therapy, and should be considered in quality of life assessment.

Shortcomings and deficits in surgical treatment of gynecological cancers: a German problem only?

OBJECTIVES

The objective of this study was to assess the quality of preoperative diagnostic, primary surgical, and postoperative treatment of ovarian, endometrial, and cervical cancers in women in Hesse, Germany, in relation to current international recommendations.

METHODS

Data on all diagnostic, surgical, and postoperative gynecological procedures undertaken in Hesse in 1997-2001 were collected in a standardized form and validated for clinical quality. Databases were generated for cases of endometrial, ovarian, and cervical cancer, and details of treatment were analyzed.

RESULTS

There were 1119 cases of endometrial, 824 cases of ovarian, and 472 cases of cervical cancer. The malignancy remained undiagnosed until after surgery in 17.8% (199/1119) of endometrial cancers, 28.5% (245/824) of ovarian cancers, and 15.5% (73/472) of cervical cancers. There was evidence of suboptimal surgical treatment. Lymphadenectomy rates were low in endometrial and ovarian cancers (about 32%), and omentectomy rates in were low in ovarian cancer (about 50%). Furthermore, 10.7% (31/289) of patients with cervical cancer diagnosed before hospital admission did not undergo radical surgery.

CONCLUSION

Discrepancies between guidelines and treatment of gynecological cancers in Hesse were striking, particularly for endometrial and ovarian cancer, and this situation may be mirrored internationally. The fact that many guidelines are not supported by results from clinical studies may be a factor in this apparently suboptimal treatment. Clinical collaborative trials are needed to provide the necessary evidence to support current recommendations and benchmarks of survey are required to facilitate future quality assessment.

Combined brachytherapy and surgery for early carcinoma of the uterine cervix: analysis of extent of surgery on outcome

PURPOSE

The aim of this retrospective study was to evaluate the survival data and rates and patterns of complications and recurrences for patients who had early uterine cervix carcinoma and underwent brachytherapy and subsequent surgery.

METHODS AND MATERIALS

Between January 1990 and December 1997, 192 women with cervical carcinoma (Stages IA2 with vascular invasion [n = 28], IB1 [n = 144], and IIA [n = 20]) underwent brachytherapy, delivering 60 Gy and then hysterectomy with external iliac lymphadenectomy. Piver class I, II, and III hysterectomies were performed on 136, 38, and 18 patients, respectively. Adjuvant chemoradiotherapy was delivered to patients with positive lymph nodes.

RESULTS

The median follow-up time was 61 months. After brachytherapy, a pathologically complete response (CR) was observed in 137 (71.3%) of 192 women. The distribution of CRs according to tumor stage was as follows: Stage IA2, 24 (85.7%) of 28; Stage IB1, 105 (72.9%) of 144; and Stage IIA, 8 (40%) of 20. Patients with Stage IB1 cancer had 13 lymph node metastases (9%), as did 6 with Stage IIA disease (30%). Pelvic recurrences occurred in 9 (4.6%) of the 192 patients; in 3, local relapses were associated with relapses at distant sites. Ten patients had systemic relapses (5.2%). Recurrences at distant sites were more frequent (p < 0.02) in partial responders, and other recurrences were more frequent in patients with lymph node metastases (p < 0.04). The overall 5-year disease-free survival rate was 91.2% (96.2% for Stage IA2, 91% for Stage IB1, and 84.4% for Stage IIA cancers). The class of hysterectomy did not influence the outcome. Late complications occurred in 28 patients (Grade 1, 24 [12.5%]; Grade 2, 4 [2%]; and Grade 3, 1 [0.5%] of 192 patients).

CONCLUSIONS

Combined treatments resulted in high local control and low morbidity rates in patients with early-stage cervical carcinoma. Limited surgery seemed to be adequate after intracavitary therapy.