Adjuvant pre- and postoperative radiation therapy, influence on negative prognostic factors - A review of the recent literature
The purpose of this article is to review the known and new prognostic factors in carcinoma of the uterine cervix with reference to pre- and postoperative radiotherapy. A literature search of the most recent articles was done and reviewed. Risk factors identified include tumor volume and stage, lymph node status, number of positive lymph nodes, depth of invasion, histology, vascular invasion, anaemia, vascular stromal invasion, radiosensitisers, tumour grade, tumour markers, HPV status, positive surgical margins, interval between surgery and radiotherapy, parametrial invasion, radiotherapeutic technique, upper versus lower node involvement and overall radiotherapeutic treatment time. Several possibly useful new insights have emerged. Of these, of immediate practical use is the observation that lower pelvic node involvement, or a single positive node, did not affect survival when postoperative radiotherapy was given. Paraaortic node involvement remains a serious matter, but postoperative irradiation of these nodes does seem useful to prevent recurrence in this region. Parametrial invasion plus more than two positive lymph nodes is a cut-off point with regard to prognosis. Postoperative radiotherapy for patients with the more common risk factors did succeed in securing an excellent local control. Overall treatment time for radiotherapy, as well as the interval between surgery and radiotherapy are important factors to ensure successful postoperative radiotherapy. Tumour size, differentiation and ploidy all correlated with treatment outcome. Among patients with pelvic lymph node metastases without parametrial extension, those who received postoperative chemotherapy or chemoradiation had significantly better recurrence-free survival (p = 0.017) and overall survival (p = 0.043) than those who received no adjuvant therapy. Specific survival rates for defined nodal status could be demonstrated. Strategies to improve survival in patients with many positive nodes are urgently needed. Three-dimensional (3D) and parallel-opposed techniques are equi-effective, but the 3D technique is far less damaging to the normal structures. A very promising finding is that elevated squamous cell carcinoma antigen (SCCA) at the time of diagnosis of stage IB-IIA cervical cancer indicated a three-times increase in risk of tumour recurrence, independent of tumour diameter, grade or the presence of lymph node metastases. High pre-treatment SCCA could therefore be used to select high-risk patients for adjuvant therapy. Preoperative radiochemotherapy led to a response in 100% of patients: 64% complete and 36% partial; of 24 patients operated on, 23/24 showed negative section margins. In early-stage patients, dose at point A was a significant prognostic factor. Postoperative radiotherapy after inappropriate surgery seemed to be effective in retrospective stage IA or IB disease.