Section of Radiology with Section of Obstetrics & Gyneecology 675 One can never be complacent about the results of treatment of carcinoma of the cervix and clinical trials are a means of assessing whether a technique is valuable or not. The supplementary X-ray therapy was designed to increase the dose at the pelvic side-walls, i.e. to lymph nodes and not to increase the radiation to the cervix, as Stage I and Stage. It (early) disease can be adequately treated by the radium. This procedure did not increase survival rate. It remains to be shown by a further clinical trial whether increasing the volume irradiated by X-rays can improve survival rate. This trial has been established, but in the first instance in Stage III patients.
figures in the Report they can be used to make certain generalizations. Excluding centres reporting on less than 100 cases, the best ten results in Stage II are shown in Table 2; Japan and Germany head the list with five-year recovery rates of 74.6 % and 74.4 %; surgery was the mode of treatment in 6 of the best 10. Table 2 The ten best figures for treatment of Stage II carcinoma of the cervix (FIGO 1973)
Relative apparent
Cotuntry Japan
REFERENCE Fed6ration Internationale de Gyn6cologie et d'Obst6trique (FIGO) (1973) Annual Report of the Results of Treatment in Carcinoma of the Uterus, Vagina and Ovary. Geneva; vol. 15
Mr R M Feroze (King's College Hospital, London SE5 9RS)
Surgical Treatment of Stage II Carcinoma of the Cervix The majority of opinion in the UK and in the world at large would claim that radiotherapy is the proper definitive treatment of Stage II carcinoma of the cervix. For example in the fifteenth volume of the Report on the Results of Treatment in Carcinoma of the Uterus, Vagina and Ovary (FIGO 1973) only 28 out of 113 centres reported the use of surgery. Moreover, few surgeons with access to radiotherapy would not employ it prior to operation. In the Report only 3 of the 28 centres infer surgical treatment without preceding radiotherapy. Is there, then, any justification for using a combination of radiotherapy and surgery in the treatment of Stage II cases? Most centres in the UK have very limited series from which to draw conclusions and this is true of the cases at King's College Hospital (Table 1). We are indebted, therefore, to the Annual FIGO Report and to certain individual reports giving results from fairly large series for figures to demonstrate what can be achieved by surgery. Whilst it would be unwise to draw too firm a conclusion from the
Germany Germany Japan Denmark Czechoslovakia
recovery rates (Y.) 74.6 74.4 73.3 71 70.3 69.6 68.9 67.3 67 66
Treatment Surgery Surgery Radiotherapy Surgery Surgery Radiotherapy Surgery
Surgery Radiotherapy Radiotherapy
The ten worst results are shown in Table 3; here radiotherapy and surgery are equally represented, although surgery does not appear so unfavourably as radiotherapy. Unfortunately the variation in results from different countries is still as unfavourable to the United Kingdom as Table 3 The ten worst figures for treatment of Stage II carcinoma of the cervix (FIGO 1973)
Country Brazil United Kingdom Brazil United Kingdom United Kingdom Australia Czechoslovakia Austria Australia Finland
Relative apparent five-year recovery rates ( %) 33.7 41 41.1
41.5 42.3 42.6 43 43.1 43.9 44.1
Treatment Radiotherapy Radiotherapy Surgery Radiotherapy Radiotherapy Surgery Surgery Surgery Surgery Radiotherapy
Table 4 Comparison of results of surgery and of radiotherapy for Stage 11 carcinoma of the cervix (FIGO 1973) Relative apparentfive-year recovery rates (%)
Table I
Country
King's College Hospital: results of
treatment of Stage 11 carcinoma of the cervix
Total Five-year survival No. % cases Stage Treatment Surgery IIA 20'3l31 2 S55 hIA Radiotherapy 11, 9 33 27 tIB Surgery 7 23 Radiotherapy 30 IIB
Total
Germany Japan Japan Austria
five-year
88
29
33
Australia Austria Belgium Brazil
Germany India
Japan
Surgery Radiotherapy 40-50 50-64
43 43-70
43-69 41 53-68 42 64-74 47-60 55
Holland Romania United Kingdom 46 46 Yugoslavia
45-80
50-70 50-60 40-50 60
676 Proc. roy. Soc. Med. Volume 69 September 1976 was the case in the thirteenth volume (1964)., The reasons for these variations are not at all clear; to complicate matters further, there is considerable variation between centres in the same country. Table 4 shows the span of results of surgical treatment in certain countries compared with those of radiotherapy.
Table 7 Results of radiotherapy plus surgery In Staus U carcinoma of the cervix (Schlink 1960) No. of No. qf cases Survival ('%) years 57.6 288 5 1 173 446
0(1930-58)
20J
An interesting variation was noted by Isaacs (1971) between series of patients treated by the same protocol but who were either private patients or clinic patients: the results shown in Table 5 are strikingly dissimilar; the disease and the treatment are apparently the same, the host different. Perhaps it is more instructive to consider the results from all the reporting centres in the Annual. Report (Table 6), of which the majority fall within the 45-60% range, which is the least that should be aimed for in results. Incidentally 19 of the 28 surgical centres fall within this range. If any conclusion can be drawn from this study of the Annual Report it must be that surgery combined with radiotherapy offers as good if not better results than radiotherapy alone.
62
27.4
61
72.1
Table 8 Results of treatment In carcinoma df the cervix: sursery preceded by radiotherapy Stallworthy (1964)
Currie (1971)
Kelso & Funnell (1973)
Five-year Five-year Five-year Stage No. survival ( %) No. survival (Y.) No. survival( %) 189 86.3 I 132 84.8 II 92 78.2 241 67 III 16 25 9 77.7
All
244 71
552 71.3
233 81.9
Table 9
Table 5 Comparison of clinic and private patients treated for carcinoma of the cervix by the same methods (Isaacs 1971) Stage I II All
5 (1949-53)
Five-year survival rate ('%) Clinic Private 61.2 93.5
38.8
75.0
33
60.4
Table 6 Five-year recovery rates reported by various contre (FIGO 1973) Five-year
No. of
30-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80
2 6 17 21 22 20 13 11 4 2
recovery rates ( %)
centres
It is worth remembering that as long ago as 1960 Schlink was advocating combined therapy and reported the results shown in Table 7. More recent reports from individual surgeons (Table 8) show equally good results. Currie (1971) divides his cases into IIA and IIB (Table 9) showing that the latter is the less favourable condition probably because lymph node spread is more likely, a point confirmed in the King's College Hospital results (Table 1).
Results of surgery plus radiotherapy in Stage II carcinoma of the cervix (Curric 1971) No. of Stage cases IIA 153 1 88
Five-year survival (Y.) All cases With positive nodes 71.8 61.7 55.6 40
If the quantitative results for combined treatment are acceptable, are the qualitative ones equally so? The major fear of the surgeon is the complication of ureteric fistula and in this respect the incidence has steadily and dramatically improved: Currie (1957) 2.3%, Schlink (1960) 1.4% and Stallworthy (1964) 0.7%. All are agreed that the ureter must receive its due respect and the avoidance of traumatic handling and the minimal amount of devascularization by stripping is obligatory. Hydronephrosis in some degree is common initially and soon settles but it may be permanent, something that may also follow radiotherapy. Stress incontinence of urine or loss of bladder sensation occurs with radical excision of the uterosacral ligaments and can be very distressing; although these symptoms do not occur with radiotherapy other bladder symptoms do. Pelvic abscess is not now common and the risk is diminished by routine drainage of the pelvis. Shortening of the vagina is inevitable but can be obviated where indicated by a Williams procedure which can with advantage be performed at the same time as fashioning a vaginal cuff. Vaginal stenosis also occurs commonly after radiotherapy. Lymphocyst is not a common complica-
Section of Radiology with Section of Obstetrics & Gynecology 677 Dr Joan W Baker (Royal Marsden Hospital, Downs Road, Sutton, Surrey, SM2 SPT)
tion and when it occurs usually follows preliminary external irradiation rather than intracavitary radium. Bowel complications do not commonly follow surgery. On balance it is fair to say that the quality of life after successful surgery is as good as after successful radiotherapy.
Treatment of Stage II Carcinoma of the Cervix with Wide-field Irradiation
Are there any specific indications for surgery in Stage II disease of the cervix? If preliminary radiotherapy is to be employed the answer must -be no. Three situations must be mentioned:
An attempt has been made to show the extent of disease in patients with Stage II carcinoma of the cervix and to treat all this disease, in the hope of improving the results.
(1) Failed or failing radiotherapy: Although an obvious indication for surgery, the results are not good. The concept of radiosensitivity as an indicator to which cases might be better treated by radiotherapy and which by surgery has not found general acceptance, and it is probable that those cases which do badly when treated with radiotherapy would do equally badly if treated by surgery.
The involvement of pelvic lymph nodes in cervical carcinoma is an established fact and as the disease progresses, so the likelihood of pelvic and para-aortic nodal involvement increases. Although surgery may be a part of treatment in the early stage, the later stages of the disease are more amenable to radiotherapy because of this increasing node involvement. Radiation has been shown by Fletcher and others to be effective in eliminating gross tumour from lymph nodes (Rutledge et al. 1965, Fletcher 1972).
(2) Associated pregnancy: Whether or not pregnancy influences the outcome in cervical carcinoma is in doubt; probably it does not. Most series are small and so conclusions are difficult to reach. Surgical treatment perhaps offers a slight advantage in that abortion in early cases or delivery in late cases does not interfere with treatment in quite the same way as with radiotherapy.
(3) Endocervical adenocarcinoma is thought by many to do better with surgery but again there is little evidence to confirm this. Lewis et al. (1970) report 28 cases in Stages I and II with a 64 % survival at five years. In conclusion, therefore, the choice of treatment remains personal and dependent on the relative surgical skill and radiotherapeutic ex-
pertise available, but the combined method has been shown to be an effective form of treatment for Stage IX carcinoma of the cervix. REFERENCES Currie D W
(1957) Journal of Obstetricsand Gynecology of the British Empire64, 871 (1971) Journal of Obstetrics and Gynecology of the British Commonwealth 78, 385 F6d6ratidn International* de Gyn6cologie et d'Obstetrique (FIGO) (1973) Annual Report of the Results of Treatment in Carcinoma of the Uterus, Vagina and Ovary. Geneva; vol. 15 lIaacs J H (1971) American Journal of Obstetrics and Gynecology 110, 390 Kelso J W & Funnell J D (1973) American Journal of Obstetrics and Gynecology 116, 205 Lewis B V, Diaz P R L, Stallworthy J & Ellis F E (1970) Journal of Obstetrics and Gynecology of the British Commonwealth 77,277 Schlink H H (1960) Journal of Obstetrics and Gynecology ofthe British Commonwealth 67, 402 Stallworthy J (1964) Annals of the Royal College ofSurgeons 34, 161
Whilst the primary and secondary nodes draining a cervical carcinoma, namely parametrial, obturator, hypogastric and external iliac, are usually included in the standard treatment field, the next proximal group of nodes, the para-aortic, lies beyond the usual treatment field applied to the pelvis. If the disease has already spread to these lymph nodes, the normal treatment technique will not be effective in eradicating it. We felt it was important to try to establish the full extent of disease in every patient with carcinoma of the cervix, but this paper is concerned only with Stage II disease.
The diagnosis and staging of carcinoma of the cervix is made at the time of the examination under anesthesia and dilatation and curettage. This clinical staging establishes the extent of disease in the pelvis, whether the parametria are involved, how far the disease has extended towards the pelvic wall and whether it has spread upwards into the body -of the uterus, or downwards into the upper half of the vagina. This evaluation of the disease does not, however, give any information regarding lymphatic spread, which may have occurred already when the patient is first seen. We therefore perform lymphography on all patients with carcinoma ofthe cervix unless they have severe chronic chest disease such as asthma, bronchitis or emphysema, severe cedema of the ankles, a bad history of deep vein thrombosis or immobility due to severe arthritis, or extreme age.
figures in the Report they can be used to make certain generalizations. Excluding centres reporting on less than 100 cases, the best ten results in Stage II are shown in Table 2; Japan and Germany head the list with five-year recovery rates of 74.6 % and 74.4 %; surgery was the mode of treatment in 6 of the best 10. Table 2 The ten best figures for treatment of Stage II carcinoma of the cervix (FIGO 1973)
Relative apparent
Cotuntry Japan
REFERENCE Fed6ration Internationale de Gyn6cologie et d'Obst6trique (FIGO) (1973) Annual Report of the Results of Treatment in Carcinoma of the Uterus, Vagina and Ovary. Geneva; vol. 15
Mr R M Feroze (King's College Hospital, London SE5 9RS)
Surgical Treatment of Stage II Carcinoma of the Cervix The majority of opinion in the UK and in the world at large would claim that radiotherapy is the proper definitive treatment of Stage II carcinoma of the cervix. For example in the fifteenth volume of the Report on the Results of Treatment in Carcinoma of the Uterus, Vagina and Ovary (FIGO 1973) only 28 out of 113 centres reported the use of surgery. Moreover, few surgeons with access to radiotherapy would not employ it prior to operation. In the Report only 3 of the 28 centres infer surgical treatment without preceding radiotherapy. Is there, then, any justification for using a combination of radiotherapy and surgery in the treatment of Stage II cases? Most centres in the UK have very limited series from which to draw conclusions and this is true of the cases at King's College Hospital (Table 1). We are indebted, therefore, to the Annual FIGO Report and to certain individual reports giving results from fairly large series for figures to demonstrate what can be achieved by surgery. Whilst it would be unwise to draw too firm a conclusion from the
Germany Germany Japan Denmark Czechoslovakia
recovery rates (Y.) 74.6 74.4 73.3 71 70.3 69.6 68.9 67.3 67 66
Treatment Surgery Surgery Radiotherapy Surgery Surgery Radiotherapy Surgery
Surgery Radiotherapy Radiotherapy
The ten worst results are shown in Table 3; here radiotherapy and surgery are equally represented, although surgery does not appear so unfavourably as radiotherapy. Unfortunately the variation in results from different countries is still as unfavourable to the United Kingdom as Table 3 The ten worst figures for treatment of Stage II carcinoma of the cervix (FIGO 1973)
Country Brazil United Kingdom Brazil United Kingdom United Kingdom Australia Czechoslovakia Austria Australia Finland
Relative apparent five-year recovery rates ( %) 33.7 41 41.1
41.5 42.3 42.6 43 43.1 43.9 44.1
Treatment Radiotherapy Radiotherapy Surgery Radiotherapy Radiotherapy Surgery Surgery Surgery Surgery Radiotherapy
Table 4 Comparison of results of surgery and of radiotherapy for Stage 11 carcinoma of the cervix (FIGO 1973) Relative apparentfive-year recovery rates (%)
Table I
Country
King's College Hospital: results of
treatment of Stage 11 carcinoma of the cervix
Total Five-year survival No. % cases Stage Treatment Surgery IIA 20'3l31 2 S55 hIA Radiotherapy 11, 9 33 27 tIB Surgery 7 23 Radiotherapy 30 IIB
Total
Germany Japan Japan Austria
five-year
88
29
33
Australia Austria Belgium Brazil
Germany India
Japan
Surgery Radiotherapy 40-50 50-64
43 43-70
43-69 41 53-68 42 64-74 47-60 55
Holland Romania United Kingdom 46 46 Yugoslavia
45-80
50-70 50-60 40-50 60
676 Proc. roy. Soc. Med. Volume 69 September 1976 was the case in the thirteenth volume (1964)., The reasons for these variations are not at all clear; to complicate matters further, there is considerable variation between centres in the same country. Table 4 shows the span of results of surgical treatment in certain countries compared with those of radiotherapy.
Table 7 Results of radiotherapy plus surgery In Staus U carcinoma of the cervix (Schlink 1960) No. of No. qf cases Survival ('%) years 57.6 288 5 1 173 446
0(1930-58)
20J
An interesting variation was noted by Isaacs (1971) between series of patients treated by the same protocol but who were either private patients or clinic patients: the results shown in Table 5 are strikingly dissimilar; the disease and the treatment are apparently the same, the host different. Perhaps it is more instructive to consider the results from all the reporting centres in the Annual. Report (Table 6), of which the majority fall within the 45-60% range, which is the least that should be aimed for in results. Incidentally 19 of the 28 surgical centres fall within this range. If any conclusion can be drawn from this study of the Annual Report it must be that surgery combined with radiotherapy offers as good if not better results than radiotherapy alone.
62
27.4
61
72.1
Table 8 Results of treatment In carcinoma df the cervix: sursery preceded by radiotherapy Stallworthy (1964)
Currie (1971)
Kelso & Funnell (1973)
Five-year Five-year Five-year Stage No. survival ( %) No. survival (Y.) No. survival( %) 189 86.3 I 132 84.8 II 92 78.2 241 67 III 16 25 9 77.7
All
244 71
552 71.3
233 81.9
Table 9
Table 5 Comparison of clinic and private patients treated for carcinoma of the cervix by the same methods (Isaacs 1971) Stage I II All
5 (1949-53)
Five-year survival rate ('%) Clinic Private 61.2 93.5
38.8
75.0
33
60.4
Table 6 Five-year recovery rates reported by various contre (FIGO 1973) Five-year
No. of
30-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80
2 6 17 21 22 20 13 11 4 2
recovery rates ( %)
centres
It is worth remembering that as long ago as 1960 Schlink was advocating combined therapy and reported the results shown in Table 7. More recent reports from individual surgeons (Table 8) show equally good results. Currie (1971) divides his cases into IIA and IIB (Table 9) showing that the latter is the less favourable condition probably because lymph node spread is more likely, a point confirmed in the King's College Hospital results (Table 1).
Results of surgery plus radiotherapy in Stage II carcinoma of the cervix (Curric 1971) No. of Stage cases IIA 153 1 88
Five-year survival (Y.) All cases With positive nodes 71.8 61.7 55.6 40
If the quantitative results for combined treatment are acceptable, are the qualitative ones equally so? The major fear of the surgeon is the complication of ureteric fistula and in this respect the incidence has steadily and dramatically improved: Currie (1957) 2.3%, Schlink (1960) 1.4% and Stallworthy (1964) 0.7%. All are agreed that the ureter must receive its due respect and the avoidance of traumatic handling and the minimal amount of devascularization by stripping is obligatory. Hydronephrosis in some degree is common initially and soon settles but it may be permanent, something that may also follow radiotherapy. Stress incontinence of urine or loss of bladder sensation occurs with radical excision of the uterosacral ligaments and can be very distressing; although these symptoms do not occur with radiotherapy other bladder symptoms do. Pelvic abscess is not now common and the risk is diminished by routine drainage of the pelvis. Shortening of the vagina is inevitable but can be obviated where indicated by a Williams procedure which can with advantage be performed at the same time as fashioning a vaginal cuff. Vaginal stenosis also occurs commonly after radiotherapy. Lymphocyst is not a common complica-
Section of Radiology with Section of Obstetrics & Gynecology 677 Dr Joan W Baker (Royal Marsden Hospital, Downs Road, Sutton, Surrey, SM2 SPT)
tion and when it occurs usually follows preliminary external irradiation rather than intracavitary radium. Bowel complications do not commonly follow surgery. On balance it is fair to say that the quality of life after successful surgery is as good as after successful radiotherapy.
Treatment of Stage II Carcinoma of the Cervix with Wide-field Irradiation
Are there any specific indications for surgery in Stage II disease of the cervix? If preliminary radiotherapy is to be employed the answer must -be no. Three situations must be mentioned:
An attempt has been made to show the extent of disease in patients with Stage II carcinoma of the cervix and to treat all this disease, in the hope of improving the results.
(1) Failed or failing radiotherapy: Although an obvious indication for surgery, the results are not good. The concept of radiosensitivity as an indicator to which cases might be better treated by radiotherapy and which by surgery has not found general acceptance, and it is probable that those cases which do badly when treated with radiotherapy would do equally badly if treated by surgery.
The involvement of pelvic lymph nodes in cervical carcinoma is an established fact and as the disease progresses, so the likelihood of pelvic and para-aortic nodal involvement increases. Although surgery may be a part of treatment in the early stage, the later stages of the disease are more amenable to radiotherapy because of this increasing node involvement. Radiation has been shown by Fletcher and others to be effective in eliminating gross tumour from lymph nodes (Rutledge et al. 1965, Fletcher 1972).
(2) Associated pregnancy: Whether or not pregnancy influences the outcome in cervical carcinoma is in doubt; probably it does not. Most series are small and so conclusions are difficult to reach. Surgical treatment perhaps offers a slight advantage in that abortion in early cases or delivery in late cases does not interfere with treatment in quite the same way as with radiotherapy.
(3) Endocervical adenocarcinoma is thought by many to do better with surgery but again there is little evidence to confirm this. Lewis et al. (1970) report 28 cases in Stages I and II with a 64 % survival at five years. In conclusion, therefore, the choice of treatment remains personal and dependent on the relative surgical skill and radiotherapeutic ex-
pertise available, but the combined method has been shown to be an effective form of treatment for Stage IX carcinoma of the cervix. REFERENCES Currie D W
(1957) Journal of Obstetricsand Gynecology of the British Empire64, 871 (1971) Journal of Obstetrics and Gynecology of the British Commonwealth 78, 385 F6d6ratidn International* de Gyn6cologie et d'Obstetrique (FIGO) (1973) Annual Report of the Results of Treatment in Carcinoma of the Uterus, Vagina and Ovary. Geneva; vol. 15 lIaacs J H (1971) American Journal of Obstetrics and Gynecology 110, 390 Kelso J W & Funnell J D (1973) American Journal of Obstetrics and Gynecology 116, 205 Lewis B V, Diaz P R L, Stallworthy J & Ellis F E (1970) Journal of Obstetrics and Gynecology of the British Commonwealth 77,277 Schlink H H (1960) Journal of Obstetrics and Gynecology ofthe British Commonwealth 67, 402 Stallworthy J (1964) Annals of the Royal College ofSurgeons 34, 161
Whilst the primary and secondary nodes draining a cervical carcinoma, namely parametrial, obturator, hypogastric and external iliac, are usually included in the standard treatment field, the next proximal group of nodes, the para-aortic, lies beyond the usual treatment field applied to the pelvis. If the disease has already spread to these lymph nodes, the normal treatment technique will not be effective in eradicating it. We felt it was important to try to establish the full extent of disease in every patient with carcinoma of the cervix, but this paper is concerned only with Stage II disease.
The diagnosis and staging of carcinoma of the cervix is made at the time of the examination under anesthesia and dilatation and curettage. This clinical staging establishes the extent of disease in the pelvis, whether the parametria are involved, how far the disease has extended towards the pelvic wall and whether it has spread upwards into the body -of the uterus, or downwards into the upper half of the vagina. This evaluation of the disease does not, however, give any information regarding lymphatic spread, which may have occurred already when the patient is first seen. We therefore perform lymphography on all patients with carcinoma ofthe cervix unless they have severe chronic chest disease such as asthma, bronchitis or emphysema, severe cedema of the ankles, a bad history of deep vein thrombosis or immobility due to severe arthritis, or extreme age.
