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293
Uterine Cervical Cancer: Treatment with Megavoltage Radiation Results and Afterloading Intracavitary Techniques -....
S. Kurohara,1 Di Saia,2
Samuel
Philip Jonathan
Kurohara,1
Irwin Grossman,1 Frederick W. George III,i and Charles P. Morrow2
Results were evaluated for 651 consecutive patients with invasive intact uterine cervix. From 1 963 through I 967 31 9 patients were treated the older Los Angeles County Hospital system of orthovoltage radiation tary radium therapy. Thereafter, 1 968-1 974, 332 patients were treated
a newer
modified
M. D. Anderson
Since
1 968
gynecologic
the
Divisions
malignancies.
cancers
of the
extension
of Radiation
sion,
can
infiltration,
Presented can
Radium I
tion
, LAC/USC St., Los Angeles,
Department of
Medical 3
Medical
AJR
133:293-297,
Radia-
Patient Department Center, 1 200 N. State
Los Angeles,
and
Gynecology,
LAC/USC
CA 90033.
Department
August
1978. of
Oncology,
and Gynecology, University College of Medicine, Irvine,
revi-
of the AmenApril
Division
CA 90033. of Obstetrics
address:
after
meeting Orleans,
Gynecobogic
Center,
Present
New
of Radiology, 1 P-i , Out
Bldg. 2
accepted
at the annual Society.
Department Medicine,
Division
1 978;
of Obstetrics of California, Irvine, CA 92717. 1979
0361 -803X/79/1 332-0293 $00.00 © American Roentgen Ray Society
cervix.
interest
Cancer
progression.
and
Medicine
of megavoltage
and
has
of the
radiation
It encroaches
permeation.
and
improve
Gynecologic
The
lateral
the
end
results
been
cervix
and
Oncology Medical management
the treatment to spread
on surrounding
tissues
spread
in the
toward
and vagina intracavitary management
the
of Cenof
of invasive
tends
tissue adjacent to the cervix, uterus, radiation therapy and well developed
substantially
Materials May 25, 8, 1979.
system
of Southern California (LAC/USC) application of newer regimens for
Of primary
uterine
in a step
involve the megavoltage
Received March
Institute
afterloading intracavitary radium therapy. Age distribution and histology were similar for both groups, but clinical stage was slightly more advanced for patients treated earlier. Crude and net 5 year survival rates were 36% and 49% for the early group and 54% and 67% for the later group. Net 5 year survival rates for the earlier group by stage were: stage I, 74%; II, 62%; III, 23%; and IV, 6%. Survival rates for the later group were: I, 81 %; II 76%; III, 50%; and IV, 1 5%. We believe this improvement can be attributed to more effective intracavitary radium therapy for handling local cancer and to delivery of cancericidal doses of radiation to regional nodes with the megavoltage radiation apparatus, as well as to the greater cooperative efforts put forth in the management of County Hospital patients.
Los Angeles County/University ter have collaborated in the
sion
Tumor
cancer of the primarily with and Intracaviprimarily with
by
direct
by expan-
pelvic
wall
may
[1 ]. Higher energy radium methods of cervix
cancer.
Methods
From January 1 963 through December 1 974, 735 untreated patients with a histologic diagnosis of invasive cancer of the uterine cervix were registered for consultation for treatment in the radiation medicine department. From 1 963 through 1 967, 359 patients were registered, and from 1 968 through 1 974, 376 patients were registered. Of these, 40 patients during the first period and 44 patients during the second period refused treatment, were transferred to another county facility for treatment, or were ineligible for county medical care. The remaining 31 9 patients from the first period were initiated for treatment primarily with the orthovoltage radiation and an older locally developed radium therapy technique; the 332 patients from the second period were initiated for treatment primarily with the megavoltage radiation and the newer M. D. Anderson Tumor Institute radium therapy technique. General workup of the patients consisted of a history and physical examination, complete blood cell count, urinalysis, blood urea nitrogen, excretory urography, cystoscopy, and sigmoidoscopy. by
gynecologist
carefully
drawn
At the Gynecobogic and
radiation
on special
Tumor therapist
pelvic
cancer
Board together.
diagram
Meeting The
forms.
each extent
lesion of the
International
was
clinically
patient’s
Federation
staged
cancer
was
of Gyne-
KUROHARA
294
cology
and
Obstetrics
Evaluation groups:
cancer
group
A,
and
1 968
from
turnover
altered
was
in the
clinical
were
used
[2].
for the two patient between 1 963 and 1 967, and 1 968 through 1 974. During 1967
treated
treated
a complete
significantly
definitions
results
patients
B, patients
group
staging
of treatment
made
radiotherapy
outlook
and
physician
treatment
staff
philosophies.
AJR:133,
parallel
to each other.
number
of
August
1979
The duration of application was such that the of emitted dose was close to 3,000. The second application was done in a similar manner, usually within 101 4 days. An average patient received a combined radiation and radium dose of about 8,000-8,500 nad to the paracenvical region and about 4,000-4,500 rad to the pelvic nodal region. milligram-hours
After
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1 974 the intracavitary radium therapy techniques were gradaltered to include interstitial iridium-i 92 implantation of parametnia in cases with advanced disease or in cases with narrow vagina [3]. Since these patients were treated too recently for cal-
ET AL.
ually
culation
S year
of
experimental treated after
survival
stage
rates,
and
of development
1 974
were
not
the
procedure
was
still
in this
B Treatment
From
in an
at the time of this writing,
included
Group
used
cases
1 968
used
Before
treat
1 967
most
group
the
of
copper.
orthovoltage
patients
operated
beam
The
radiation
with cervix
A patients
quality
Technique
used
often
therapy
fields the
was
often
clinical
cut
down
situation.
10
two
fields
x
value
lead
were
to
The
separated
from
fields,
bilaterally
opposed
The
portal
roughly
pelvic
sizes
The
beam with
daily
midline
estimated 20 with
started
with
posterior
each
of
right
stages,
the
3,000 The
for
Los
similar
to
Angeles
his
treatment on less
of the on other
of
mg
with
20,
and
taming
Plaques
25, 20
25, mg.
various
the
of the
repeated of 1 .800
right
and
applicator. directed was Midline
pelvic
panametrial
regions
was
estimated
Hospital
at about
radium
of
were
and
1 5 mg
primarily the
tubes
x
3
of radium
loaded or
x
used 0.8 tubes
or
mg-hr
or two
intact
[4]. In
early
stage
I
of intracavitary
were
treated
2-3
delivered
with
and posteriorly of emitted dose
mg-hr
about
in
weeks
apart.
weeks to the pelvic portals
21/2
directed
pelvic
midline
in
Ill and
dose
was
all
for
1 -2
4,000
radiation
to
200
Often involved
6,000-7,000
pelvis
was
and
about
administered
in
schedule
nad
posteriorly
equally
the
IV lesions
fractionation
(e.g.,
and
in
intervals.
weeks
irradiation
cases,
mg-hr
to the entire
of intracavitary
anteriorly
5,000
the same
stage
weeks
same
through
was
of about
stage
The
patients
year
after
followed
at
4-6
was
supplemented
the top
to midline
opposed
was level
portals
of
daily,
followed
During
3 month
at 1 -2
month
the second and during Information
intervals
month with
Fewer
they
California
were
intervals.
information
clinical
same
time.
files.
cm1
and
were
often
Crude life
4%
these
had
Tumor
from
the
intervals
during
and third year they the fourth and fifth on survival status
California
Tumor
Reg-
of the
patients
Registry
coding
[5].
to include forms
were
data
(observed) table
method.
was
The
rates net
their
clinic
that
time,
data
appoint-
through for these
the
patients
in this report. prepared
to
abstract
the
therapy records and Tumor on IBM cards for computer
punched
survival
to keep
via correspondence
After
data from the radiation The
failed
to be followed
too incomplete
Special
con-
than
Since
ments,
20,
and
were
therapy.
patients were followed less than S years or into 1 975. However, data on the exact site of initial recurrence was not available in about half the cases 2 years after files.
the
evenly
full
delivered
sessions.
the
pelvis
at
spaced
with
8,000
dose
in 7_81/2
at about
was
ovoids
the
was
bulky
year
with
the
wide.
radium
For
were
of uterine
often
4 cm
nad
the
loaded
from
less
plaques
were
depth
on
courses
lesions
doses
nad was
II lesions
delivered
Generally
and was
were
IIA
About
in two sessions
1 ,SO0
diagnosis.
longer
on the
vaginal
2
was
a
system.
or
stage
to the
therapy
two
stage
divided
intnacavitary
to
one
2,500-
ago,
years
was often
radium
radium
used
cm
depending
Bakelite
of
70
therapy
2.5-7
a 7 cm tandem 1 0 mg
of radium
over
cervix
4 days/week).
six portals, dose
layer
of Radiotherapy
via 1 5 x 1 5 cm2 similarly
block
doses
istry
system
Soiland
radium,
the
5
patient.
tandems
bulky
the first of the
value
half
weeks and the intracavitany radium dose was about 6,000 mg-hr in equally divided doses in two sessions 2-3 weeks apart. For stage Ill lesions the full pelvic dose was 5,000 nad/6 weeks
tolerance,
radiation
of
patients
with
portals.
of 2,000
regions
3,000-4,000
situation. R in air to each
were:
I and
equally
dose
a sagittal
rad
left
advanced
patient
mm
via 1 S x 1 S cm2 anteriorly
pelvic
in
parametnium.
anterior
A in air/portal
on
cancer
treated
stage
opposite applied
1 ,000
for
1 2.5
Textbook
policies were
in 21/2 weeks
nad
was
times
For
for
in Fletcher’s
Larger
2,000
divided
left booster
6
were
therapy using the Fletcher-Suit aftenloading applicator. About 4,000 to 5,000 mg-hr/session was administered, lasting about 60-72 hr each. The time between the two courses of radium application was about 2-3 weeks. The total was 8,000-1 0,000 mghr, depending on the patient’s anatomy and the configuration of the
and
patient
the
unit
who
radium
of daily
administered
2,100-2,400
depending
wall
amounts
with
usually
total
or
left
4,
A/portal.
The
Brass
the
day were
was
Stockholm
and
1 5, 25,
each
per
1 , treatment
therapy
or patients
rad/S
of the
sized
2, with
portal;
weeks.
or more
frequently with
is described
with
(FSD)
sequence
day
day
dose
Albert
For example,
end
of
clinically
axis
average
technique
1 cm
one portal
central
The
was:
up to about
County by
an
7-8
intrauterine
25-75
cavity.
loaded
pelvic
that
management
lesions
distance
the
treatments
an average-sized
begun
Metallic
6, with
clinical
was
and
rad
wide.
cm
portal;
of 1 .800
course
reportedly
with
and
administration
parametnial
for
36
posterior
in air dose
through
was
general
a pair as
beam
an
1 0 x 1 5 cm2.
focus-to-surface
SO rad
administered,
response,
For
location
portals
right
cycle
roentgens
treatment
about
and
of the six portals,
Radiation
occasionally
tumor
used,
dose
these
S and
a cumulative
was
each
and
the
days
and
cumulative
often
size
cm
anterior
with
respectively.
days/week
50
at
at 1 35-1 thick
portal;
portals,
Less
were in
pelvic
cm
the
3,
day
1 0 cm2.
The
For
was
portal;
varied
R in air through
a pelvis
irradiation
x
portals
were
necessary. A dose of 300 was administered day.
10
of the
was
Angeles
cm.
for about 1 -2 cm on each side of the sagittal plane. The usual level of the inferior margin of the portals was near the midsymphysis of the pubic bone but was lowered depending on the amount of vaginal cancer involvement. There was a parallel pair of similar right and left posterior pelvic portals directly opposite the anterior ones. The last pair of portals was usually one of booster peninealparavaginal
radiation
quality
The
left
each
accelerator
therapy at Los
of lead. The 25 MV betatron was used to treat patients with advanced lesions that required doses of 6,000 nad or more, or patients who were relatively thick. The FSD for both units was 100
uterus
depending
cancer
lesions
of
width
strips
linear
radiation
cervix
early
layer
and
6 MV
with
with
the of
of right
thin.
megavoltage
patients
patients
and
consisted
pair
1 5 cm2.
with
used
kVp
half
usually
a parallel cm
was
unit used to treat
of 300
2 mm
technique
to 8-9
The
voltage
was
arrangement of six portals, with anterior pelvic open-cone portals,
unit
The x-ray
at a peak
most
radiation
therapy
cancer.
1 974, all
The
to treat
relatively
A Treatment
nearly
Hospital.
was
Group
through
to treat
County
study.
Technique
were
survival
calculated rates
(death
patients’
Registry analysis.
by the
actuarial
is
to
due
on cervix
AJR:133,
August
RADIOTHERAPY
1979
OF CERVICAL
cancer if cancer of cervix in part I of the death certificate endpoint of interest) were calculated using the competing method,
which
risks
is the
eliminated
probability
of survival
with
is the
CANCER
1 : Clinical
TABLE
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Table 1 shows the general of the cervix cancer patients Center,
Radiation
Group
years
and
52.7
years.
all noncervix
cancer
ci
Department,
332
with
patients
distribution
during a mean
with
of clinical
the
age
age
was
1 00
A all but one case
radiotherapy istered
(table
In group surgery.
hysterectomy,
two
dissection,
cases
carcinoma
and tion
consisted therapy
of
total
three
abdominal had
of 4,000 and one
radiation
therapy,
with
2).
to
was
Patients
who
radium
years.
weeks
megavoltage (table
was
their
2). The
installed
gained easily
therapy
6 mV linear
in 1 963
and,
therapy
none
or
to
three
2). Most On several
combined Table each
of the
1 967. profound
trend
for
stage
of
for patients 7%,
and
experience
the
varied
clinical
techniques. crude and
net
of
in groups
stage
in net 5 year whereas
Ill 27%,
for and
alone and surgery
lesions degree rates
stage
for stage
survival
in end II or III lesions. survival II the IV, 9%.
rate
Si
improvement
B, it was
52
7
=
Patients
1 963319)
Group 1974
B. I 968(n - 332)
306 26
(92) (8)
ii
(3)
This
was
For
The
group
III, 49%, rates
also
(16)
41
265 (84) 51 (1 6)
(13)
(16)
41
net
B, the 42%
survival 55%
rates
II, 63%;
rates
Overall
and
and
survival
I, 75%;
who
for
for
stage
these
A,
B, 280 patients
I, 90%;
A, and
not
and IV, 9%. II, 77%;
and net 5 year
group
did
‘curative” In group
in group
III, 30%;
were:
crude
of
59%
survival and
72%
B. 1 plots
treatment
the for
B. The
Treatment case; fistula
patients
their course were excluded.
radiotherapy
5 year
(12)
46(14) 202 (61) 43(13)
when
complete therapy
and IV, 26%.
group
for
4 (1) 31 7 (99)
percentages
maintained
A): stage
were
A and
B.
are
completed
(group
after
for
was
patients
were
rates
in parentheses
trend
patients.
situation
280 (84)
7(2) 252(79) 9(3)
for whatever reasons radiation and radium
net survival each
definite
B, two); (A, one;
rates
clinical
against
stage
improvement
complications
addition, group and death.
were:
length
of cancer trend
rectal
is clearly fistula
of time
for groups evident.
(group
A, one
rectal stricture (A, three; B, four); bladder B, one); and hip fracture (A, one; B, one). In B had
one
case
of large
bowel
perforation
in since
is more
Discussion
For example,
for stage
A, (n
Si
unit
A and
results
Cancer
265 (83)
therapy (A, n = 31 6; B, n = 321): Orthovoltage Megavoltage Radium application (no.):
265
from
of improvement for all stages
in group
31 8 (1 00) 1 (0)
and radium
Note-Numbers
radiation therapy. therapy was used
on
improvement with
Group 1967
2 3
A patients
procedures
depending
stages
of Cervical
Radiation
were
therapy
53 4 years;
External
alone,
radium application methods were intracavioccasions, interstitial radium therapy was
clinical
the improvement is only
more
A was
percentages.
1
that could not be therapy. In group
megavoltage radiation
there is a measurable and net 5 year survival
This
clinical
for cases radiation
application
with intracavitary 3 shows the 5 year
Generally, the crude
of group
.3)
3 (0.9) 7 (2.1)
3(1)
Figure of radium
in group
are
Modes
Radiotherapy Radiotherapy
therapy alone
radiation
while
in its use, it was used handled with orthovoltage
palliatively. The number (table tary.
in 1 6%
accelerator
B nearly all cases received In four patients, orthovoltage
of patients
Treatment
Therapy
Radiation
after
initial course of radiation treatment. radiation therapy was used in 84%
radiation
age
in parentheses
2: Radiation
-
usually elderly and in poor general health from other causes, but with very early lesions; those who received radiation alone had very advanced cancer (e.g. , stage IVB) or failed to complete Orthovoltage
(91
19 (5.7)
2 (0.6)
Radium
In all 26
radium
303
6 (1 .9)
mean
Numbers
TABLE
with
or radiation
received
(25.0)
29(8.7)
(95.6)
carcinoma
0
radium
83
Radiotherapy:
preoperatively
4-6
305
Miscellaneous
re-
of megavoltage radiaradium application of done
(31 .3)
Treatment:
admin-
spread
given
rad/5 weeks intracavitary was
(table
was
exenteration.
was
about 3,000 mg-hr. Surgery completion of radiotherapy. The mode of radiotherapy alone
with
hysterectomy
pelvic
B, radiotherapy
therapy
primarily
cancer
1968332)
slightly
distributed
radiotherapy
=
100 (30.2) 120 (36.1)
6 (1 .9)
Adenosquamous
B, 26 patients had radiotherapy Of these, 21 had total abdominal
had
and
in group
similarly
managed
case
because
gional nodes. combined with node
were
2). In this
postoperatively
were
GroupB. 1974 (n
42(13.2)
Note-The
cancer
1963319)
=
106(33.2) 71 (22.3)
Adenocarcinoma
of
more advanced in group A. There were 3% more stage I, 6% more stage Ill, and 5% more stage IV lesions in group A, while there were 14% more stage II lesions in group B. Histologic types of cervical in both groups (table 1).
Patients
stage:
Epidermoid
two
of 53.4
a mean
stages
Cancer
GroupA. 1967 (n
iruca IF eatures
I II III IV Pathology:
and pathologic features at the LAC/USC Med-
31 9 patients
B had
The
clinical treated
Medicine
A had
group
In group
of Cervical
[6].
Results
ical
Features
risk
Clinical
periods.
295
I cases is 14%,
the
Before crediting the newer improved results in patients
other aspects the ultimate
of the outcome
present must
radiotherapeutic treated from series that may be considered.
regimen for 1 968 to 1974, have Age
affected did not
KUROHARA
296
CANCER LAC
OF /U5C
UTERINE
AJR:i33,
cytology localized
CERVIX
MEDICAL
ET AL.
CENTER
these 76%
in screening cervical cancer
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Histologically,
the
tumors
such
as
nomas.
This
distribution
previous
>
majority
carcinomas. (about 4%)
(about
reports
of
[7].
93%)
The
proportion to one-third
of in
from 46% 1 956 [5].
to
of the cases
Adenocarcinomas and the rest were
mesonephric
i979
the close
county patients. In contrast, it increased for private patients from 1 952 through
epidermoid percentage
4 >
uterine cancer, has remained
August
formed composed
and
adenosquamous
histologic
types
distribution
carciis
similar
to
variety
of
in histologic
lesions was similar for both groups and, therefore, have explained the difference in end results.
z
This explain
0.
study covered a period of only the little variation between the
factors
such
selection
as
age,
played
The
technique
veloped
clinical
of
invasive
Fig. 1 -Net plotted
histology.
Case
survival
rates.
radiation
radium
therapy
cervical
cancer
and
was
used
patients
stage.
1 963-1
967;
Broken
solid
lines
lines
represent
represent
patients
patients
treated
treated
1968-
localized lesions
1974.
the TABLE
Five Year Survival
3:
Cervical
Treatment
of
Cancer Group
C linical
Rates in Radiation
A, 1963-1967
Stage
Survival No.
Group
Rate
(%) No.
Rate
Crude
Net
Crude
Net
106
67
74
100
69
81
II Ill IV
71 100 42
40 13 S
62 23 6
120 83 29
65 36
76 50
11
15
319
36
49
332
54
67
Note-Zero from
time is the day
all causes.
Net
survival
radiotherapy rates include
began. Crude survival deaths from cervix cancer
account for the differences in end results ment periods since the mean ages (53.4 and
age
distributions
youngest patient Since the patients population older than tially of
1 952-1 years
in age
956,
about
of stage
tions
deaths
occurred 1 942-1
one-half
of
with
946,
the
similar.
time.
(The
For each
1 947-1
patients
showed treatment
II lesions
951 , and
were
have
due
B staff
proportions (A). This to
second
the
Despite
in staging the
wide
(B) was
by
with since
offset
group use
therapy.
The
3).
to
wall.
of
by
A and vaginal
With
deliver
fields
In these
pelvic
the
basically
lesions
nodes
the
same
of
tumor
tissues
therapy
radiation
large
extends
paracervical
soft
radiation
with
the
adjacent and
amounts
pelvis,
Hos-
by the modifica-
[4].
the
megavoltage
sufficient
throughout directed tionated regresses
the
County
methods, substantial improvement in patients with stages II, III, and
to involve
often
Angeles
were
Tucancer,
Services. for ortho-
were replaced With minor
textbook
(table
pelvic
Los
methods
cervix
the
old
treatment in Fletcher’s
outside and
and the Gynecological with gynecologic
applicators apparatus.
IVA lesions sues
of South-
Center facilitated recruitment of new closer collaboration between the
therapy afterloading
new
tis-
along
the
it is possible
homogeneously
anteriorly
and
posteriorly
radiation beams. The external irradiation is fracand protracted over several weeks. As the tumor and the peripheral extensions diminish, the radiaare
reduced
Finally,
intracavitary
of stage I, III, and IV lesions relatively small difference may
differences
members.
group
decades
For regional rates during
from County Health Paramedical radiation therapy was substituted
as described
tion
35-54
only a slight difference in distnibugroups. The much higher proporin the
Cancer members,
With the new treatment in survival rates occurred
for the two treatand 52.7 years) were
for
were 37%, 38%, and 38%. the late 1 960s of the University
radiation
of tumor.
higher group
been
include
voltage
[5].
the slightly in the first group
distribution periods
Clinical stage tion for the two tion
groups
periods during
pital radium Fletcher-Suit
was 22 years and the oldest was 94.) in this series represent the indigent
chronologic old
two
rates only.
above Planning
and support Megavoltage
of central Los Angeles County, they tend to be private noncounty patients by 5-7 years. Essen-
no shift the
for the
deman-
for patients constant
(clinical stage I) were all 74%. II and III combined) the survival
Radiation Medicine Department mor Service to manage patients
(%)
Cases
I
Total
lesions (stages
em California medical staff
B, 1968-1974 Survival
Cases
locally in the
about 1 950 and are the same as those reported in this series for group A (personal communication, California Tumor Registry, 1 975). For the periods 1 950-1 959, 19601 971 , and for our group A, the S year net survival rates for
TREATMENT
survival rates of cervical cancer patients years after onset of therapy, according to
against
clinical
AFTER
which may in natural
and
before 1 968. The 5 year net survival rates localized or regional cancer have remained YEARS
not
in affecting
of orthovoltage
intracavitary
agement
role
could
1 1 years, two groups
stage,
a minimal
were a small of rare
to cover
the
administration
curietherapy
by the
technique primary
eradicates site. If there
the central is residual
additional
radiation
is administered
booster radiation For localized
portals. cancers
as
as
substantial
the
expected,
residual
of two
Fletcher-Suit core lateral
improved since
central
or more
regions
courses
of
afterloading
of the tumor at the extension of tumor,
to the survival sufficient
parametnia rate
with was
cancericidal
not
AJR:133,
August
doses
of radiation
cervix
by both
applicators. method and
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spots
may
a small radiation
have
group and
may
stage
can
the
be delivered
County
Radium the use
barrel-shaped
they
RADIOTHERAPY
1979
of
to the
Hospital
and
placement computer
contributed
with the dosimetry
to the
small
of patients were radium therapy.
managed These
cervix
with
have
or
fared
a few
better
confines
the
than
OF CERVICAL
of the
gain.
selective end
were
to
factors
results
with preoperative were patients with
adenocarcinoma,
and
the rest of the unselected
facilities,
probably
because
the same
of partially 14%).
other the
had
only
patients
nearly
on the
same
(1 5%
preliminary 4.
5.
We thank the staff of the California Tumor Registry, Los Angeles County General Hospital Branch for providing the follow-up inforthe
clerical
and
nursing
staff
of
the
Radiation
Medicine
LS, Paloucek
Saunders,
1 962,
FK: Carcinoma
of the
Cervix.
pp 62-66
report
on
the
revival
of Waterman’s
approach.
J Radiat Onco! Biol Phys 4 : 735-742, 1978 Fletcher GH: Textbook of Radiotherapy. Philadelphia, Febiger, 1 973, pp 620-665 Cancer Registration and Survival in California. Berkeley, fonnia
Tumor
Registry,
State
of California
Department
Int Lea
&
Cali-
of Public
Health, 1963, pp 210-214 Peto A, Pike MC, Anmitage P, Breslow NE, Cox DA, Howard SV, Mantel N, McPherson K, Peto J, Smith PG: Design and analysis of randomized observation of each patient. II. Analysis and examples. Br J Cancer 35 : 1 -39, 1977 7. del Aegato JA, Spjut HJ: Cancer, Diagnosis, Treatment and Prognosis, 5th ed, St. Louis, Mosby, 1 977, pp 761-799
6.
mation,
of these
2. Manual for Staging of Cancer 1977. Chicago, American Joint Committee for Cancer Staging and End-Results Reporting, p 90 3. Feder BH, Syed ANM, Neblitt DL: Treatment of extensive carcinoma of the cervix with the ‘ ‘transpenineal butterfly, a
and
ACKNOWLEDGMENTS
JB, Sotto
Philadelphia,
patients
and the proportions the
1 . Graham
These
effect
of untreated
groups
were
deterioration.
a minor
proportions
(1 1 %) for both
treated
or
in retrieval of the medical records Hill for computing the statistical data.
REFERENCES
Furthermore,
I cases.
transfer
for helping and Annlia
297
Fletcher-Suit to avoid cold
As mentioned, some patients were not treated or failed to complete their treatment course because of refusal, ineligibility,
Division
patients,
Fletcher-Suit
CANCER
293
Uterine Cervical Cancer: Treatment with Megavoltage Radiation Results and Afterloading Intracavitary Techniques -....
S. Kurohara,1 Di Saia,2
Samuel
Philip Jonathan
Kurohara,1
Irwin Grossman,1 Frederick W. George III,i and Charles P. Morrow2
Results were evaluated for 651 consecutive patients with invasive intact uterine cervix. From 1 963 through I 967 31 9 patients were treated the older Los Angeles County Hospital system of orthovoltage radiation tary radium therapy. Thereafter, 1 968-1 974, 332 patients were treated
a newer
modified
M. D. Anderson
Since
1 968
gynecologic
the
Divisions
malignancies.
cancers
of the
extension
of Radiation
sion,
can
infiltration,
Presented can
Radium I
tion
, LAC/USC St., Los Angeles,
Department of
Medical 3
Medical
AJR
133:293-297,
Radia-
Patient Department Center, 1 200 N. State
Los Angeles,
and
Gynecology,
LAC/USC
CA 90033.
Department
August
1978. of
Oncology,
and Gynecology, University College of Medicine, Irvine,
revi-
of the AmenApril
Division
CA 90033. of Obstetrics
address:
after
meeting Orleans,
Gynecobogic
Center,
Present
New
of Radiology, 1 P-i , Out
Bldg. 2
accepted
at the annual Society.
Department Medicine,
Division
1 978;
of Obstetrics of California, Irvine, CA 92717. 1979
0361 -803X/79/1 332-0293 $00.00 © American Roentgen Ray Society
cervix.
interest
Cancer
progression.
and
Medicine
of megavoltage
and
has
of the
radiation
It encroaches
permeation.
and
improve
Gynecologic
The
lateral
the
end
results
been
cervix
and
Oncology Medical management
the treatment to spread
on surrounding
tissues
spread
in the
toward
and vagina intracavitary management
the
of Cenof
of invasive
tends
tissue adjacent to the cervix, uterus, radiation therapy and well developed
substantially
Materials May 25, 8, 1979.
system
of Southern California (LAC/USC) application of newer regimens for
Of primary
uterine
in a step
involve the megavoltage
Received March
Institute
afterloading intracavitary radium therapy. Age distribution and histology were similar for both groups, but clinical stage was slightly more advanced for patients treated earlier. Crude and net 5 year survival rates were 36% and 49% for the early group and 54% and 67% for the later group. Net 5 year survival rates for the earlier group by stage were: stage I, 74%; II, 62%; III, 23%; and IV, 6%. Survival rates for the later group were: I, 81 %; II 76%; III, 50%; and IV, 1 5%. We believe this improvement can be attributed to more effective intracavitary radium therapy for handling local cancer and to delivery of cancericidal doses of radiation to regional nodes with the megavoltage radiation apparatus, as well as to the greater cooperative efforts put forth in the management of County Hospital patients.
Los Angeles County/University ter have collaborated in the
sion
Tumor
cancer of the primarily with and Intracaviprimarily with
by
direct
by expan-
pelvic
wall
may
[1 ]. Higher energy radium methods of cervix
cancer.
Methods
From January 1 963 through December 1 974, 735 untreated patients with a histologic diagnosis of invasive cancer of the uterine cervix were registered for consultation for treatment in the radiation medicine department. From 1 963 through 1 967, 359 patients were registered, and from 1 968 through 1 974, 376 patients were registered. Of these, 40 patients during the first period and 44 patients during the second period refused treatment, were transferred to another county facility for treatment, or were ineligible for county medical care. The remaining 31 9 patients from the first period were initiated for treatment primarily with the orthovoltage radiation and an older locally developed radium therapy technique; the 332 patients from the second period were initiated for treatment primarily with the megavoltage radiation and the newer M. D. Anderson Tumor Institute radium therapy technique. General workup of the patients consisted of a history and physical examination, complete blood cell count, urinalysis, blood urea nitrogen, excretory urography, cystoscopy, and sigmoidoscopy. by
gynecologist
carefully
drawn
At the Gynecobogic and
radiation
on special
Tumor therapist
pelvic
cancer
Board together.
diagram
Meeting The
forms.
each extent
lesion of the
International
was
clinically
patient’s
Federation
staged
cancer
was
of Gyne-
KUROHARA
294
cology
and
Obstetrics
Evaluation groups:
cancer
group
A,
and
1 968
from
turnover
altered
was
in the
clinical
were
used
[2].
for the two patient between 1 963 and 1 967, and 1 968 through 1 974. During 1967
treated
treated
a complete
significantly
definitions
results
patients
B, patients
group
staging
of treatment
made
radiotherapy
outlook
and
physician
treatment
staff
philosophies.
AJR:133,
parallel
to each other.
number
of
August
1979
The duration of application was such that the of emitted dose was close to 3,000. The second application was done in a similar manner, usually within 101 4 days. An average patient received a combined radiation and radium dose of about 8,000-8,500 nad to the paracenvical region and about 4,000-4,500 rad to the pelvic nodal region. milligram-hours
After
Downloaded from www.ajronline.org by 161.0.62.19 on 10/06/15 from IP address 161.0.62.19. Copyright ARRS. For personal use only; all rights reserved
1 974 the intracavitary radium therapy techniques were gradaltered to include interstitial iridium-i 92 implantation of parametnia in cases with advanced disease or in cases with narrow vagina [3]. Since these patients were treated too recently for cal-
ET AL.
ually
culation
S year
of
experimental treated after
survival
stage
rates,
and
of development
1 974
were
not
the
procedure
was
still
in this
B Treatment
From
in an
at the time of this writing,
included
Group
used
cases
1 968
used
Before
treat
1 967
most
group
the
of
copper.
orthovoltage
patients
operated
beam
The
radiation
with cervix
A patients
quality
Technique
used
often
therapy
fields the
was
often
clinical
cut
down
situation.
10
two
fields
x
value
lead
were
to
The
separated
from
fields,
bilaterally
opposed
The
portal
roughly
pelvic
sizes
The
beam with
daily
midline
estimated 20 with
started
with
posterior
each
of
right
stages,
the
3,000 The
for
Los
similar
to
Angeles
his
treatment on less
of the on other
of
mg
with
20,
and
taming
Plaques
25, 20
25, mg.
various
the
of the
repeated of 1 .800
right
and
applicator. directed was Midline
pelvic
panametrial
regions
was
estimated
Hospital
at about
radium
of
were
and
1 5 mg
primarily the
tubes
x
3
of radium
loaded or
x
used 0.8 tubes
or
mg-hr
or two
intact
[4]. In
early
stage
I
of intracavitary
were
treated
2-3
delivered
with
and posteriorly of emitted dose
mg-hr
about
in
weeks
apart.
weeks to the pelvic portals
21/2
directed
pelvic
midline
in
Ill and
dose
was
all
for
1 -2
4,000
radiation
to
200
Often involved
6,000-7,000
pelvis
was
and
about
administered
in
schedule
nad
posteriorly
equally
the
IV lesions
fractionation
(e.g.,
and
in
intervals.
weeks
irradiation
cases,
mg-hr
to the entire
of intracavitary
anteriorly
5,000
the same
stage
weeks
same
through
was
of about
stage
The
patients
year
after
followed
at
4-6
was
supplemented
the top
to midline
opposed
was level
portals
of
daily,
followed
During
3 month
at 1 -2
month
the second and during Information
intervals
month with
Fewer
they
California
were
intervals.
information
clinical
same
time.
files.
cm1
and
were
often
Crude life
4%
these
had
Tumor
from
the
intervals
during
and third year they the fourth and fifth on survival status
California
Tumor
Reg-
of the
patients
Registry
coding
[5].
to include forms
were
data
(observed) table
method.
was
The
rates net
their
clinic
that
time,
data
appoint-
through for these
the
patients
in this report. prepared
to
abstract
the
therapy records and Tumor on IBM cards for computer
punched
survival
to keep
via correspondence
After
data from the radiation The
failed
to be followed
too incomplete
Special
con-
than
Since
ments,
20,
and
were
therapy.
patients were followed less than S years or into 1 975. However, data on the exact site of initial recurrence was not available in about half the cases 2 years after files.
the
evenly
full
delivered
sessions.
the
pelvis
at
spaced
with
8,000
dose
in 7_81/2
at about
was
ovoids
the
was
bulky
year
with
the
wide.
radium
For
were
of uterine
often
4 cm
nad
the
loaded
from
less
plaques
were
depth
on
courses
lesions
doses
nad was
II lesions
delivered
Generally
and was
were
IIA
About
in two sessions
1 ,SO0
diagnosis.
longer
on the
vaginal
2
was
a
system.
or
stage
to the
therapy
two
stage
divided
intnacavitary
to
one
2,500-
ago,
years
was often
radium
radium
used
cm
depending
Bakelite
of
70
therapy
2.5-7
a 7 cm tandem 1 0 mg
of radium
over
cervix
4 days/week).
six portals, dose
layer
of Radiotherapy
via 1 5 x 1 5 cm2 similarly
block
doses
istry
system
Soiland
radium,
the
5
patient.
tandems
bulky
the first of the
value
half
weeks and the intracavitany radium dose was about 6,000 mg-hr in equally divided doses in two sessions 2-3 weeks apart. For stage Ill lesions the full pelvic dose was 5,000 nad/6 weeks
tolerance,
radiation
of
patients
with
portals.
of 2,000
regions
3,000-4,000
situation. R in air to each
were:
I and
equally
dose
a sagittal
rad
left
advanced
patient
mm
via 1 S x 1 S cm2 anteriorly
pelvic
in
parametnium.
anterior
A in air/portal
on
cancer
treated
stage
opposite applied
1 ,000
for
1 2.5
Textbook
policies were
in 21/2 weeks
nad
was
times
For
for
in Fletcher’s
Larger
2,000
divided
left booster
6
were
therapy using the Fletcher-Suit aftenloading applicator. About 4,000 to 5,000 mg-hr/session was administered, lasting about 60-72 hr each. The time between the two courses of radium application was about 2-3 weeks. The total was 8,000-1 0,000 mghr, depending on the patient’s anatomy and the configuration of the
and
patient
the
unit
who
radium
of daily
administered
2,100-2,400
depending
wall
amounts
with
usually
total
or
left
4,
A/portal.
The
Brass
the
day were
was
Stockholm
and
1 5, 25,
each
per
1 , treatment
therapy
or patients
rad/S
of the
sized
2, with
portal;
weeks.
or more
frequently with
is described
with
(FSD)
sequence
day
day
dose
Albert
For example,
end
of
clinically
axis
average
technique
1 cm
one portal
central
The
was:
up to about
County by
an
7-8
intrauterine
25-75
cavity.
loaded
pelvic
that
management
lesions
distance
the
treatments
an average-sized
begun
Metallic
6, with
clinical
was
and
rad
wide.
cm
portal;
of 1 .800
course
reportedly
with
and
administration
parametnial
for
36
posterior
in air dose
through
was
general
a pair as
beam
an
1 0 x 1 5 cm2.
focus-to-surface
SO rad
administered,
response,
For
location
portals
right
cycle
roentgens
treatment
about
and
of the six portals,
Radiation
occasionally
tumor
used,
dose
these
S and
a cumulative
was
each
and
the
days
and
cumulative
often
size
cm
anterior
with
respectively.
days/week
50
at
at 1 35-1 thick
portal;
portals,
Less
were in
pelvic
cm
the
3,
day
1 0 cm2.
The
For
was
portal;
varied
R in air through
a pelvis
irradiation
x
portals
were
necessary. A dose of 300 was administered day.
10
of the
was
Angeles
cm.
for about 1 -2 cm on each side of the sagittal plane. The usual level of the inferior margin of the portals was near the midsymphysis of the pubic bone but was lowered depending on the amount of vaginal cancer involvement. There was a parallel pair of similar right and left posterior pelvic portals directly opposite the anterior ones. The last pair of portals was usually one of booster peninealparavaginal
radiation
quality
The
left
each
accelerator
therapy at Los
of lead. The 25 MV betatron was used to treat patients with advanced lesions that required doses of 6,000 nad or more, or patients who were relatively thick. The FSD for both units was 100
uterus
depending
cancer
lesions
of
width
strips
linear
radiation
cervix
early
layer
and
6 MV
with
with
the of
of right
thin.
megavoltage
patients
patients
and
consisted
pair
1 5 cm2.
with
used
kVp
half
usually
a parallel cm
was
unit used to treat
of 300
2 mm
technique
to 8-9
The
voltage
was
arrangement of six portals, with anterior pelvic open-cone portals,
unit
The x-ray
at a peak
most
radiation
therapy
cancer.
1 974, all
The
to treat
relatively
A Treatment
nearly
Hospital.
was
Group
through
to treat
County
study.
Technique
were
survival
calculated rates
(death
patients’
Registry analysis.
by the
actuarial
is
to
due
on cervix
AJR:133,
August
RADIOTHERAPY
1979
OF CERVICAL
cancer if cancer of cervix in part I of the death certificate endpoint of interest) were calculated using the competing method,
which
risks
is the
eliminated
probability
of survival
with
is the
CANCER
1 : Clinical
TABLE
Downloaded from www.ajronline.org by 161.0.62.19 on 10/06/15 from IP address 161.0.62.19. Copyright ARRS. For personal use only; all rights reserved
Table 1 shows the general of the cervix cancer patients Center,
Radiation
Group
years
and
52.7
years.
all noncervix
cancer
ci
Department,
332
with
patients
distribution
during a mean
with
of clinical
the
age
age
was
1 00
A all but one case
radiotherapy istered
(table
In group surgery.
hysterectomy,
two
dissection,
cases
carcinoma
and tion
consisted therapy
of
total
three
abdominal had
of 4,000 and one
radiation
therapy,
with
2).
to
was
Patients
who
radium
years.
weeks
megavoltage (table
was
their
2). The
installed
gained easily
therapy
6 mV linear
in 1 963
and,
therapy
none
or
to
three
2). Most On several
combined Table each
of the
1 967. profound
trend
for
stage
of
for patients 7%,
and
experience
the
varied
clinical
techniques. crude and
net
of
in groups
stage
in net 5 year whereas
Ill 27%,
for and
alone and surgery
lesions degree rates
stage
for stage
survival
in end II or III lesions. survival II the IV, 9%.
rate
Si
improvement
B, it was
52
7
=
Patients
1 963319)
Group 1974
B. I 968(n - 332)
306 26
(92) (8)
ii
(3)
This
was
For
The
group
III, 49%, rates
also
(16)
41
265 (84) 51 (1 6)
(13)
(16)
41
net
B, the 42%
survival 55%
rates
II, 63%;
rates
Overall
and
and
survival
I, 75%;
who
for
for
stage
these
A,
B, 280 patients
I, 90%;
A, and
not
and IV, 9%. II, 77%;
and net 5 year
group
did
‘curative” In group
in group
III, 30%;
were:
crude
of
59%
survival and
72%
B. 1 plots
treatment
the for
B. The
Treatment case; fistula
patients
their course were excluded.
radiotherapy
5 year
(12)
46(14) 202 (61) 43(13)
when
complete therapy
and IV, 26%.
group
for
4 (1) 31 7 (99)
percentages
maintained
A): stage
were
A and
B.
are
completed
(group
after
for
was
patients
were
rates
in parentheses
trend
patients.
situation
280 (84)
7(2) 252(79) 9(3)
for whatever reasons radiation and radium
net survival each
definite
B, two); (A, one;
rates
clinical
against
stage
improvement
complications
addition, group and death.
were:
length
of cancer trend
rectal
is clearly fistula
of time
for groups evident.
(group
A, one
rectal stricture (A, three; B, four); bladder B, one); and hip fracture (A, one; B, one). In B had
one
case
of large
bowel
perforation
in since
is more
Discussion
For example,
for stage
A, (n
Si
unit
A and
results
Cancer
265 (83)
therapy (A, n = 31 6; B, n = 321): Orthovoltage Megavoltage Radium application (no.):
265
from
of improvement for all stages
in group
31 8 (1 00) 1 (0)
and radium
Note-Numbers
radiation therapy. therapy was used
on
improvement with
Group 1967
2 3
A patients
procedures
depending
stages
of Cervical
Radiation
were
therapy
53 4 years;
External
alone,
radium application methods were intracavioccasions, interstitial radium therapy was
clinical
the improvement is only
more
A was
percentages.
1
that could not be therapy. In group
megavoltage radiation
there is a measurable and net 5 year survival
This
clinical
for cases radiation
application
with intracavitary 3 shows the 5 year
Generally, the crude
of group
.3)
3 (0.9) 7 (2.1)
3(1)
Figure of radium
in group
are
Modes
Radiotherapy Radiotherapy
therapy alone
radiation
while
in its use, it was used handled with orthovoltage
palliatively. The number (table tary.
in 1 6%
accelerator
B nearly all cases received In four patients, orthovoltage
of patients
Treatment
Therapy
Radiation
after
initial course of radiation treatment. radiation therapy was used in 84%
radiation
age
in parentheses
2: Radiation
-
usually elderly and in poor general health from other causes, but with very early lesions; those who received radiation alone had very advanced cancer (e.g. , stage IVB) or failed to complete Orthovoltage
(91
19 (5.7)
2 (0.6)
Radium
In all 26
radium
303
6 (1 .9)
mean
Numbers
TABLE
with
or radiation
received
(25.0)
29(8.7)
(95.6)
carcinoma
0
radium
83
Radiotherapy:
preoperatively
4-6
305
Miscellaneous
re-
of megavoltage radiaradium application of done
(31 .3)
Treatment:
admin-
spread
given
rad/5 weeks intracavitary was
(table
was
exenteration.
was
about 3,000 mg-hr. Surgery completion of radiotherapy. The mode of radiotherapy alone
with
hysterectomy
pelvic
B, radiotherapy
therapy
primarily
cancer
1968332)
slightly
distributed
radiotherapy
=
100 (30.2) 120 (36.1)
6 (1 .9)
Adenosquamous
B, 26 patients had radiotherapy Of these, 21 had total abdominal
had
and
in group
similarly
managed
case
because
gional nodes. combined with node
were
2). In this
postoperatively
were
GroupB. 1974 (n
42(13.2)
Note-The
cancer
1963319)
=
106(33.2) 71 (22.3)
Adenocarcinoma
of
more advanced in group A. There were 3% more stage I, 6% more stage Ill, and 5% more stage IV lesions in group A, while there were 14% more stage II lesions in group B. Histologic types of cervical in both groups (table 1).
Patients
stage:
Epidermoid
two
of 53.4
a mean
stages
Cancer
GroupA. 1967 (n
iruca IF eatures
I II III IV Pathology:
and pathologic features at the LAC/USC Med-
31 9 patients
B had
The
clinical treated
Medicine
A had
group
In group
of Cervical
[6].
Results
ical
Features
risk
Clinical
periods.
295
I cases is 14%,
the
Before crediting the newer improved results in patients
other aspects the ultimate
of the outcome
present must
radiotherapeutic treated from series that may be considered.
regimen for 1 968 to 1974, have Age
affected did not
KUROHARA
296
CANCER LAC
OF /U5C
UTERINE
AJR:i33,
cytology localized
CERVIX
MEDICAL
ET AL.
CENTER
these 76%
in screening cervical cancer
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Histologically,
the
tumors
such
as
nomas.
This
distribution
previous
>
majority
carcinomas. (about 4%)
(about
reports
of
[7].
93%)
The
proportion to one-third
of in
from 46% 1 956 [5].
to
of the cases
Adenocarcinomas and the rest were
mesonephric
i979
the close
county patients. In contrast, it increased for private patients from 1 952 through
epidermoid percentage
4 >
uterine cancer, has remained
August
formed composed
and
adenosquamous
histologic
types
distribution
carciis
similar
to
variety
of
in histologic
lesions was similar for both groups and, therefore, have explained the difference in end results.
z
This explain
0.
study covered a period of only the little variation between the
factors
such
selection
as
age,
played
The
technique
veloped
clinical
of
invasive
Fig. 1 -Net plotted
histology.
Case
survival
rates.
radiation
radium
therapy
cervical
cancer
and
was
used
patients
stage.
1 963-1
967;
Broken
solid
lines
lines
represent
represent
patients
patients
treated
treated
1968-
localized lesions
1974.
the TABLE
Five Year Survival
3:
Cervical
Treatment
of
Cancer Group
C linical
Rates in Radiation
A, 1963-1967
Stage
Survival No.
Group
Rate
(%) No.
Rate
Crude
Net
Crude
Net
106
67
74
100
69
81
II Ill IV
71 100 42
40 13 S
62 23 6
120 83 29
65 36
76 50
11
15
319
36
49
332
54
67
Note-Zero from
time is the day
all causes.
Net
survival
radiotherapy rates include
began. Crude survival deaths from cervix cancer
account for the differences in end results ment periods since the mean ages (53.4 and
age
distributions
youngest patient Since the patients population older than tially of
1 952-1 years
in age
956,
about
of stage
tions
deaths
occurred 1 942-1
one-half
of
with
946,
the
similar.
time.
(The
For each
1 947-1
patients
showed treatment
II lesions
951 , and
were
have
due
B staff
proportions (A). This to
second
the
Despite
in staging the
wide
(B) was
by
with since
offset
group use
therapy.
The
3).
to
wall.
of
by
A and vaginal
With
deliver
fields
In these
pelvic
the
basically
lesions
nodes
the
same
of
tumor
tissues
therapy
radiation
large
extends
paracervical
soft
radiation
with
the
adjacent and
amounts
pelvis,
Hos-
by the modifica-
[4].
the
megavoltage
sufficient
throughout directed tionated regresses
the
County
methods, substantial improvement in patients with stages II, III, and
to involve
often
Angeles
were
Tucancer,
Services. for ortho-
were replaced With minor
textbook
(table
pelvic
Los
methods
cervix
the
old
treatment in Fletcher’s
outside and
and the Gynecological with gynecologic
applicators apparatus.
IVA lesions sues
of South-
Center facilitated recruitment of new closer collaboration between the
therapy afterloading
new
tis-
along
the
it is possible
homogeneously
anteriorly
and
posteriorly
radiation beams. The external irradiation is fracand protracted over several weeks. As the tumor and the peripheral extensions diminish, the radiaare
reduced
Finally,
intracavitary
of stage I, III, and IV lesions relatively small difference may
differences
members.
group
decades
For regional rates during
from County Health Paramedical radiation therapy was substituted
as described
tion
35-54
only a slight difference in distnibugroups. The much higher proporin the
Cancer members,
With the new treatment in survival rates occurred
for the two treatand 52.7 years) were
for
were 37%, 38%, and 38%. the late 1 960s of the University
radiation
of tumor.
higher group
been
include
voltage
[5].
the slightly in the first group
distribution periods
Clinical stage tion for the two tion
groups
periods during
pital radium Fletcher-Suit
was 22 years and the oldest was 94.) in this series represent the indigent
chronologic old
two
rates only.
above Planning
and support Megavoltage
of central Los Angeles County, they tend to be private noncounty patients by 5-7 years. Essen-
no shift the
for the
deman-
for patients constant
(clinical stage I) were all 74%. II and III combined) the survival
Radiation Medicine Department mor Service to manage patients
(%)
Cases
I
Total
lesions (stages
em California medical staff
B, 1968-1974 Survival
Cases
locally in the
about 1 950 and are the same as those reported in this series for group A (personal communication, California Tumor Registry, 1 975). For the periods 1 950-1 959, 19601 971 , and for our group A, the S year net survival rates for
TREATMENT
survival rates of cervical cancer patients years after onset of therapy, according to
against
clinical
AFTER
which may in natural
and
before 1 968. The 5 year net survival rates localized or regional cancer have remained YEARS
not
in affecting
of orthovoltage
intracavitary
agement
role
could
1 1 years, two groups
stage,
a minimal
were a small of rare
to cover
the
administration
curietherapy
by the
technique primary
eradicates site. If there
the central is residual
additional
radiation
is administered
booster radiation For localized
portals. cancers
as
as
substantial
the
expected,
residual
of two
Fletcher-Suit core lateral
improved since
central
or more
regions
courses
of
afterloading
of the tumor at the extension of tumor,
to the survival sufficient
parametnia rate
with was
cancericidal
not
AJR:133,
August
doses
of radiation
cervix
by both
applicators. method and
Downloaded from www.ajronline.org by 161.0.62.19 on 10/06/15 from IP address 161.0.62.19. Copyright ARRS. For personal use only; all rights reserved
spots
may
a small radiation
have
group and
may
stage
can
the
be delivered
County
Radium the use
barrel-shaped
they
RADIOTHERAPY
1979
of
to the
Hospital
and
placement computer
contributed
with the dosimetry
to the
small
of patients were radium therapy.
managed These
cervix
with
have
or
fared
a few
better
confines
the
than
OF CERVICAL
of the
gain.
selective end
were
to
factors
results
with preoperative were patients with
adenocarcinoma,
and
the rest of the unselected
facilities,
probably
because
the same
of partially 14%).
other the
had
only
patients
nearly
on the
same
(1 5%
preliminary 4.
5.
We thank the staff of the California Tumor Registry, Los Angeles County General Hospital Branch for providing the follow-up inforthe
clerical
and
nursing
staff
of
the
Radiation
Medicine
LS, Paloucek
Saunders,
1 962,
FK: Carcinoma
of the
Cervix.
pp 62-66
report
on
the
revival
of Waterman’s
approach.
J Radiat Onco! Biol Phys 4 : 735-742, 1978 Fletcher GH: Textbook of Radiotherapy. Philadelphia, Febiger, 1 973, pp 620-665 Cancer Registration and Survival in California. Berkeley, fonnia
Tumor
Registry,
State
of California
Department
Int Lea
&
Cali-
of Public
Health, 1963, pp 210-214 Peto A, Pike MC, Anmitage P, Breslow NE, Cox DA, Howard SV, Mantel N, McPherson K, Peto J, Smith PG: Design and analysis of randomized observation of each patient. II. Analysis and examples. Br J Cancer 35 : 1 -39, 1977 7. del Aegato JA, Spjut HJ: Cancer, Diagnosis, Treatment and Prognosis, 5th ed, St. Louis, Mosby, 1 977, pp 761-799
6.
mation,
of these
2. Manual for Staging of Cancer 1977. Chicago, American Joint Committee for Cancer Staging and End-Results Reporting, p 90 3. Feder BH, Syed ANM, Neblitt DL: Treatment of extensive carcinoma of the cervix with the ‘ ‘transpenineal butterfly, a
and
ACKNOWLEDGMENTS
JB, Sotto
Philadelphia,
patients
and the proportions the
1 . Graham
These
effect
of untreated
groups
were
deterioration.
a minor
proportions
(1 1 %) for both
treated
or
in retrieval of the medical records Hill for computing the statistical data.
REFERENCES
Furthermore,
I cases.
transfer
for helping and Annlia
297
Fletcher-Suit to avoid cold
As mentioned, some patients were not treated or failed to complete their treatment course because of refusal, ineligibility,
Division
patients,
Fletcher-Suit
CANCER
