Editorial on “The influence of tumor size and morphology on the outcome of patients with FIGO stage IB squamous cell carcinoma of the uterine cervix”

“Let’s treat the cancer, not an alphabet.” This motto by barrel contains tumor that FIG0 would call Stage IB. A Dr. G. Fletcher has never been more appropriate than retrospective attempt was made to separate out the FIG0 today. There is a growing consensus of the necessity for Stage II patients (“only those patients that appeared to be tailoring radiation portals in radical radiation therapy. confined to the uterine cervix by clinical exam”), but it For cancer of the cervix, tumor size and nodal status have is subject to error as, among others, the authors never saw been repeatedly shown as powerful prognostic factors ( 1, the patient. Furthermore, the authors point out that many 5, 7, 10, 13, 14, 17, 18, 19, 22). While theimportanceof of these bulky tumors were categorized as Stage IB because recording the tumor measurement is emphasized, the definite evidence of parametrial or pelvic wall involvement method of measuring the tumor size is a subject of conwas not appreciated at the initial clinical examination. troversy. Clinical measurement has been used for years, After tumor regression, during external beam irradiation, although its limitations have been acknowledged. Clinical parametrial or pelvic wall involvement was suspected, assessment of tumor size is often “given as a range” (5) however, in many of these patients (5). The difficulties in “faculty evaluation of tumor diameter differs” (5), sepaclinical FIG0 staging are well recognized. The study by ration between the true tumor diameter and adjacent cerAverett et al. shows that as compared with surgical staging, vical or uterine tissue is not possible, and bulky or primary clinical FIG0 staging is subject to errors of as high as 26% endocervical tumors are difficult to evaluate clinically. for Stage IB disease, 45% for Stage IIA disease, 60% for An elegant study by P. Eifel et al. testifies to the imporStage IIB disease, 66% for Stage IIIA disease, and 95% for tance of recording tumor size when treatment results for Stage IIIB disease (2). Cross-sectional imaging modalipatients with FIG0 Stage IB carcinoma of the uterine ties-ultrasound (US), computed tomography (CT), and cervix are reported (5). The control rates achieved with magnetic resonance imaging (MRI)-have all shown aggressive radiotherapy were excellent, but the correlation merits in the evaluation of invasive cancer of the cervix. between minimum tumor dose and size of the tumor or The usefulness of transrectal ultrasound (TRUS) ( 14) and the correlation between tumor size and complications was MRI (3, 9) in determining tumor size has been reported. not given. The study analyzes the largest number of paFor TRUS, the tumor size has shown strong correlation tients reported today, thus providing strong statistical with tumor relapse ( 14). Transrectal ultrasound, however, evaluation. The study is retrospective, and “maximum shows poor discrimination for small volume tumors, is tumor or cervical diameter were determined from clinical inaccurate in assessing the anteroposterior tumor diamdescription” (5). In an indirect fashion, the study points eter, and due to its small field of view, is unable to assess to the limitations and ambiguity of clinical assessment of pelvic lymph nodes (14). Computed tomography assesstumor size. Although tumor size was divided into 10 difment of tumor size is limited, as soft tissue contrast resferent groups, individual recording for tumor size 2 and olution of CT does not allow separation between the nor3 cm in diameter was not reported, as by clinical exammal cervical or uterine tissue and tumor (25). The main ination it is often difficult to separate a small tumor from advantage of CT is in the evaluation of lymphadenopathy the adjacent cervical or uterine tissue. The definition by and tumor extent in advanced stages (23, 24, 25). Magthe M.D. Anderson group of Stage IIB barrel tumor in a netic resonance imaging combines the advantages of way also points to the limitations of the clinical exam. TRUS and CT. Using linear regression analysis, excellent Stage IIB barrel tumors were classified as tumors over 6 correlation between tumor size measured by MRI and cm in diameter, but still confined to the cervix. Thus, IIB pathological specimen has been shown (3,9). Several sur-