A proposed method of selecting patients with carcinoma of the cervix for radiotherapy or surgery.

Abstract

Aperusal of world literature indicates that the results of treatment of Stages I and II carcinoma of the cervix, whether surgical or radiotherapeutic, are approximately equal. The causes of failure in the two groups may not be the same, however, in that some of the surgical failures might have been cured by radiotherapy whereas some patients treated by radiotherapy might have been dealt with more successfully by surgery. The purpose of the investigation reported here was to find a simple method of indicating which cases might be better treated by one method than by the other. Either method will fail if the tumor has already spread beyond the pelvis. Apart from this, surgical failures are due to incomplete removal, particularly of lymph node metastases. On the other hand, radiotherapy fails because of radioresistance or underdosage. Sherman (1) found that recurrence of carcinoma of the cervix after radiotherapy was associated with non-ideal application of radium, and we felt that it would be fruitful to investigate underdosage at our own center to see if we could find a group which might be better treated surgically. Material and Methods Influenced by these considerations, we conducted a retrospective investigation on 348 consecutive patients with Stage I or Stage II carcinoma of the cervix, treated radically at The Queensland Radium Institute during the period 1957–1961 inclusive. These patients were divided into 2 groups referred to as standard and nonstandard. In the standard group, the Manchester system (2) was applied. This method is well known and consists of the use of an intrauterine tube and 2 ovoids in the vaginal vault. We regarded as nonstandard the use of a short intrauterine tube, the absence of an intrauterine tube, and the use of ovoids in any position or combination other than in the lateral fornices. These nonstandard applications were necessitated by stenosis of the vaginal vault, cervical canal obstruction, size of tumor, or uterine prolapse. In the standard group, the dose from radium at point A was 6,300 rads, and in the nonstandard group, it was less than 6,000 rads. In many of the nonstandard cases it was less than 5,000 rads. The dosage at point B was correspondingly less in the nonstandard group. In these patients doses at points A and B could not be made equal to those achieved in the standard group without exceeding rectal tolerance. However, modifications of the external x-ray therapy technic and dosage were used to improve the dosage distributions as far as possible, e.g., by alteration of central shielding dimensions. Local recurrence in the pelvis was the point of special interest, as distant metastases or death from intercurrent disease are unlikely to have been influenced to any extent by the form of treatment.