Role of surgery in the management of cervical carcinoma.

Abstract

Cancer of the cervix uteri has been the subject of intensive investigation from time immemorial. Gradually over a period of years, the increasing knowledge of the physics of radiation and the improvement in irradiation technic have established roentgen therapy as the most effective procedure for this type of malignant growth. The status of the matter is not, however, settled or stationary, since improvement in surgical technic has influenced sound clinicians to re-adopt the operative treatment of cervical carcinoma. In spite of the present-day controversy, irradiation remains the basic method of treatment, but surgery is unquestionably a necessary adjunct in some selected cases. Consideration of the surgical indications and procedures is the purpose of this discussion, with a view to suggesting to the radiotherapist a possible source of help in salvaging some cases that might otherwise be lost and in improving results in such conditions as pre-invasive carcinoma, resistant carcinoma, and carcinoma in pregnancy. Palliative surgery will also be considered. Pre-invasive Carcinoma The term “pre-invasive carcinoma” denotes a carcinoma which is confined to the natural surface and does not penetrate the underlying stroma. An accurate diagnosis of true intra-epithelial cancer may, however, be difficult to make. Evidence as to non-invasive biologic characteristics obtained by performance of a single biopsy may be erroneous. To minimize the error, a careful study of several sections must be undertaken. Not infrequently cases interpreted as pre-invasive on single biopsy examination have been found to show true invasive properties when further areas were studied. Biopsy at four points, at least, on the cervix and a scraping of the endocervix must be done to produce reliable evidence of non-invasion. Only serial sections of removed specimens enable the clinician to make the diagnosis with finality. Some investigators maintain that a definite hazard exists in the promotion of distant metastases by diagnostic tissue excision and advise a clinical attempt at diagnosis for all cancer groups without biopsy examination. Paterson and Nuttall, in an attempt to throw light upon this question, compared the incidence of metastases in two groups of patients with comparable cervical cancer, one with biopsy and one without. In a series of 166 cases (99 with biopsy; 67 without) they found the incidence of metastasis to be slightly higher in the group in which biopsy was not done. The necessity of differentiating between the pre-invasive and the invasive carcinoma lies in the significant difference in their treatment. It is generally agreed that the cure rate of early cancers of the cervix which are treated with radiation approaches 80 to 90 per cent. Irradiation in the pre-invasive group, however, is not ideal, since the average age of these patients is between thirty-six and thirty-seven years.