Colposcopy and Treatment of Cervical Intraepithelial Neoplasia - RHO

An introduction to invasive cancer of the uterine cervix
choice once the disease has spread beyond the confines
of the cervix and vaginal fornices, when surgery is not
effective. The management of cervical cancer with
radiotherapy may often involve a combination of
external radiotherapy (for the entire pelvis) and
intracavitary irradiation (to the central part of the
disease). The addition of intracavitory irradiation to
external beam radiotherapy is associated with improved
disease control and survival, as compared to external
radiotherapy alone for locally advanced disease such as
stage IIB and III.
Women with microinvasive cancer (stage IA) may be
treated with conization or total hysterectomy or
extended hysterectomy. Those with stage IB and IIA
cancer may be treated with radical (Wertheim’s)
hysterectomy, and pelvic lymphadenectomy or with
intracavitary radiotherapy, or with a combination of
external radiotherapy and intracavitary radiotherapy.
In selected cases of small (< 2 cm) stage IB carcinoma,
radical trachelectomy combined with laparoscopic
lymphadenectomy, to salvage the reproductive
function of the patient, can be performed.
Radiotherapy and surgery produce similar results for
early invasive cancer (stages IB and IIA). Stage IIB and
III cancers are treated with a combination of external
and intracavitary radiotherapy. Women with stage IV
disease are treated palliatively with external
radiotherapy and/or with chemotherapy.
Concomitant chemotherapy with cisplatin has
improved the results of radiotherapy in advanced
cervical cancer. Randomized clinical trials have shown
a significant gain in overall and disease free survival
for cisplatin-based therapy given concurrently with
radiotherapy (Thomas, 2000; Green et al., 2001). A
significant benefit of chemo-radiation on both local and
distant recurrence has been observed. The absolute
benefit with combined therapy in overall survival was
16%. Based on this evidence, concurrent chemotherapy
with radiotherapy is emerging as the new standard of
care for advanced cervical cancer.
Clinical stage of disease at presentation is the single
most important predictor of long-term survival; survival
rates also decline with advancing age. Other factors
influencing survival include general health and
nutritional status. Anaemic patients respond poorly to
treatment; as do those with HIV-seropositive disease.
Several clinical and population-based studies have
demonstrated consistently high five-year survival
associated with stage I disease (> 75%), with rapidly
decreasing survival with advanced stages of disease
(< 10% in stage IV) (Delgado et al., 1990; Fagundes et
al., 1992; Kosary et al., 1994; Gatta et al., 1998;
Sankaranarayanan et al., 1998; Denton et al., 2000). In
a large series of cervical cancer patients treated by
radiation therapy, the frequency of distant metastases
(most frequently to para-aortic lymph nodes, lung,
abdominal cavity, liver and gastrointestinal tract) was
shown to increase with increasing stage of disease from
3% in stage IA to 75% in stage IVA (Fagundes et al.,
1992). In a study of 1028 patients treated with radical
surgery, survival rates correlated consistently with
tumour volume (Burghardt et al., 1992). Five-year
survival rates ranged between 91% for patients with
tumours of < 2.5 cm 3 and 70% for those with tumours of
10-50 cm 3 . The three-year disease-free survival ranged
from 94.6% for stage I tumours 5 mm to 59.5% for
stage I tumours 21 mm (Delgado et al., 1990).
Advanced clinical stages are associated with increasing
frequency of vascular invasion and spread to pelvic and
para-aortic lymph nodes and distant metastases.
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