Post-operative irradiation in stage IB carcinoma of cervix.

The continued search by oncologists for improvement in loco-regional control and survival in the treatment of early stage cervical cancer has recently shifted in emphasis from use of surgery or radiation alone to the need for multi-modality management. Irrespective of therapeutics there now appears to be a group of patients with Stage IB cervical carcinoma with poor prognostic features that show a proclivity for loco-regional failure and decreased survival. Thus, the long standing selection of either radical hysterectomy or radiation delivered by brachytherapy techniques is no longer acceptable. In Stage IB cancer, certain morpho-histological factors such as cervical stromal invasion greater than 10 mm; tumors with more than 2 quadrants of the cervix involved; uterine extension; tumor size of 2 cm; or more and a combination of the above have loco-regional recurrences of 30-40% and survival of 47-73%.1v4,‘4 The degree of aneuploidy has also been advanced as a significant prognostic factor. In spite of this data confusion remains as to what significance the clinician should delegate to any particular prognostic factor. This may be due in part to clinical retrospective reviews that make use of regression analysis and other advanced statistical methods hoping to identify prognostic factors only to have conclusions that are conflicting and contradictory. Ultimately, many investigators are convinced that the major underlying cause of death due to disease is the increased incidence of lymph node metastases in the presence of morpho-histologic poor prognostic factors. The significance of metastases to lymph nodes has been investigated extensively and is known to reduce the 5-year survival rate to 38-6 1%.3-5Y10,18 Tumor size as determined by clinical examination, extension to the corpusI and as determined by histo-pathological examination have been associated with higher rates of both nodal metastases and local recurrence. Tumors more than 4 cm in size can have up to an 80% incidence of positive nodes and a 40% local recurrence rate.4 Similarly, when the cervical stroma shows a tumor invasion of more than 70% in depth there is a nodal metastases rate of 33-40% and a local recurrence rate of 27-3 1%.2*4 Vascular invasion alone or in combination with stromal infiltration has reported lymph node involvement in Stage IB, and IIA in the range of 34-63%.2q4*18 It is doubtful that in the absence of lymph node metastases, the presence of a single prognostic factor will adversely affect survival,” although Kim et cd’s9 paper now suggests that residual disease at the surgical margin may do so. It is evident that Stage IB carcinoma of cervix as defined by FlGG represents a wide spectrum ofdisease with considerable variation in prognosis. It is surprising that a disease as small as microinvasive, and as large as 6 cm and beyond are all included in one staging group. The complete disregard of histopathological findings of positive margin, and factors such as stromal and vascular invasion that increases recurrence and the number of positive lymph nodes weakens further the present staging system. These subgroups of patients therefore need to be identified so that appropriate alterations are made in their therapeutic management. Rotman et al.” have proposed a clinical-pathological subclassification of Stage IB carcinoma. In this classification, Stage IB patients are divided into two groups IBl and IB2. Stage IBl includes patients with stromal invasion of up to 10 mm and under IB2 those patients are included who have more than 10 mm stromal invasion, corpus involvement, tumor size of more than 2 cm endocervical tumor, vascular invasion and more than two quadrant involvement of cervix with tumor. Essentially, it is thought that such patients require external radiation to irradicate disease in regional lymphatics. Guttmant? was first to report the beneficial effect of post-operative irradiation in patients who had either positive lymph nodes, positive margins of resection or both. With post-operative irradiation in Stage I and II 6 1% of her patients were alive at 5 years. Similarly other authors’ have reported better local control and improved survival rates up to 77%. Chung et al4 however reported an improved survival at 2 years (40% vs 90%) only, and improved local control (40% vs 10%). While these au-