Cervical Stump Research Articles

Carcinoma of the cervical stump. A case report and literature review.

Subtotal hysterectomy for benign uterine disease was a common surgical procedure in the past decades. Keeping in place the uterine cervix predisposes to late complications such as cervico-vaginal prolapse, chronic cervicitis or even malignant transformations of the cervical stump. We present the case of a 56 year old patient who was submitted to subtotal hysterectomy for a large uterine fibroma 4 years before and who presented vaginal bleeding and pelvic pain. She was diagnosed with cervical stump carcinoma and a radical resection including trachelectomy with pelvic and para-aortic lymph node dissection was performed. The histopathological studies revealed a well differentiated squamous cell cervical cancer.

Surgical Methods for the Treatment of Uterine Fibroids - Risk of Uterine Sarcoma and Problems of Morcellation: Position Paper of the DGGG.

The appropriate surgical technique to treat patients with uterine fibroids is still a matter of debate as is the potential risk of incorrect treatment if histological examination detects a uterine sarcoma instead of uterine fibroids. The published epidemiology for uterine sarcoma is set against the incidence of accidental findings during surgery for uterine fibroids. International comments on this topic are discussed and are incorporated into the assessment by the German Society for Gynecology and Obstetrics (DGGG). The ICD-O-3 version of 2003 was used for the anatomical and topographical coding of uterine sarcomas, and the "Operations- und Prozedurenschlüssel" (OPS) 2014, the German standard for process codes and interventions, was used to determine surgical extirpation methods. Categorical qualifiers were defined to analyze the data provided by the Robert Koch Institute (RKI), the German Federal Bureau of Statistics (DESTATIS; Hospital and Causes of Death Statistics), the population-based Cancer Register of Bavaria. A systematic search was done of the MEDLINE database and the Cochrane collaboration, covering the period from 1966 until November 2014. The incidence of uterine sarcoma and uterine fibroids in uterine surgery was compared to the literature and with the different registries. The incidence of uterine sarcoma in 2010, standardized for age, was 1.53 for Bavaria, or 1.30 for every 100 000 women, respectively, averaged for the years 2002-2011, and 1.30 for every 100 000 women in Germany. The mean incidence collated from various surveys was 2.02 for every 100 000 women (0.35-7.02; standard deviation 2.01). The numbers of inpatient surgical procedures such as myoma enucleation, morcellation, hysterectomy or cervical stump removal to treat the indication "uterine myoma" have steadily declined in Germany across all age groups (an absolute decrease of 17 % in 2012 compared to 2007). There has been a shift in the preferred method of surgical access from an abdominal/vaginal approach to endoscopic or endoscopically assisted procedures to treat uterine fibroids, with the use of morcellation increasing by almost 11 000 coded procedures in 2012. Based on international statements (AAGL, ACOG, ESGE, FDA, SGO) on the risk of uterine sarcoma as an coincidental finding during uterine fibroid surgery and the associated risk of a deterioration of prognosis (in the case of morcellation procedures), this overview presents the opinion of the DGGG in the form of four Statements, five Recommendation and four Demands.

Arteriovenous Malformation of the Cervix: A Rare Cause of Vaginal Bleeding after Supracervical Hysterectomy

Background: Cyclic vaginal bleeding is a well-known complication after a supracervical hysterectomy; however, severe delayed vaginal bleeding occurs infrequently. Case: A 29-year-old woman underwent a supracervical hysterectomy for dysmenorrhea and pelvic pain refractory to multiple medical modalities. Eight weeks after surgery, the patient began to experience persistent heavy vaginal bleeding that continued in spite of application of silver nitrate to the cervical stump. The patient subsequently underwent vaginal trachelectomy for definitive management of the bleeding. Results: Histologic and immunohistochemical evaluation of the excised cervical stump revealed chronic cervicitis and an arteriovenous malformation of the cervix confirmed by elastic staining. Conclusions: Our case highlights that an arteriovenous malformation of the cervix can be an exceedingly rare cause of severe delayed vaginal bleeding after a supracervical hysterectomy, and should be considered in the differential diagnosis of vaginal bleeding after a supracervical hysterectomy.

Laparoscopic subtotal hysterectomy in the era of minimally invasive surgery

Abstract According to a nation-wide population-based study in Taiwan, along with the expanding concepts and surgical techniques of minimally invasive surgery, laparoscopic supracervical/subtotal hysterectomy (LSH) has been blooming. Despite this, the role of LSH in the era of minimally invasive surgery remains uncertain. In this review, we tried to evaluate the perioperative and postoperative outcomes of LSH compared to other types of hysterectomy, including total abdominal hysterectomy (TAH), vaginal hysterectomy, laparoscopic-assisted vaginal hysterectomy, and total laparoscopic hysterectomy (TLH). From the literature, LSH has a better perioperative outcome than TAH, and comparable perioperative complications compared with laparoscopic-assisted vaginal hysterectomy. LSH had less bladder injury, vaginal cuff bleeding, hematoma, infection, and dehiscence requiring re-operation compared with TLH. Despite this, LSH has more postoperative cyclic menstrual bleeding and re-operations with extirpations of the cervical stump. LSH does, however, have a shorter recovery time than TAH due to the minimally invasive approach; and there is quicker resumption of coitus than TLH, due to cervical preservation and the avoidance of vaginal cuff dehiscence. LSH is therefore an alternative option when the removal of the cervix is not strictly necessary or desired. Nevertheless, the risk of further cervical malignancy, postoperative cyclic menstrual bleeding, and re-operations with extirpations of the cervical stump is a concern when discussing the advantages and disadvantages of LSH with patients.

Survival and Prognostic Factors in Patients with Carcinoma of Cervical Stump

Purpose: To evaluate patients with carcinoma of cervical stump (CCS) and analyse different clinico-pathologic factors affect prognosis. Patients and Methods: This study was carried out through review of clinical records of patients. Recorded data included information on age, tumor stage, presenting symptoms, size of tumor, histopathology, grade, type, cause of subtotal hysterectomy (STH), treatment and follow-up results. Staging according to International Federation of Gynecology and Obstetrics (FIGO) staging system was done through: PHYSICAL examination, pelvic examination under anaesthesia, chest X-ray, magnetic resonance imaging (MRI) of the abdomen and pelvis, cystoscopy, rectosigmoidoscopy and intravenous pyelography. Prognostic factors as age, size of tumor, stage, lymph node (LN) involvement, pathological type, grade and type of CCS either true or coincidental were analysed through multivariate analysis. Results: 62% of patients are above 50 years with stage II in 48.7%. Squamous cell carcinoma was more common but 54% are of GIII. 89% were true CCS. Positive lymph nodes were reported in 27%. The predominant reason for STH was abnormal bleeding (73%). In about 95% of cases, women seeked medical attention because of symptoms and the most common presenting symptom was bleeding (54%). According to the stage and performance status of patients, treatment consisted of radiotherapy either external or interstitial, chemotherapy and chemoradiotherapy. Through multivariate analysis, the following was found to have adverse impact on survival: Coincidental type (P = 0.04), high grade (P = 0.03), advanced stage (P = 0.01), larger tumor size (P = 0.02), lymph node involvement (P = 0.029) and older age (P = 0.035). While pathological type was not (P = 0.52). After median follow-up of 52 months; 5-year overall survival was 65%. Conclusion: CCS has a low morbidity. Adverse survival outcomes can be anticipated in those patients with: high grade lesions, advanced stages, large tumor size, coincidental type, older age and positive lymph node involvement.

Does the Uterine Cervix Become Abnormally Reinnervated After Subtotal Hysterectomy and What Is the Association With Future Trachelectomy?

Study ObjectiveTo compare nerve fiber density in the cervices removed by trachelectomy from women with pelvic pain with those cervices removed for nonpain indications. DesignRetrospective cohort study (Canadian Task Force classification II-2). SettingTwo university hospitals. PatientsSubjects who underwent trachelectomy during a 10-year time frame were identified. InterventionsTwo tissue sections were obtained from each preserved cervix specimen and stained for S100 antibody. The numbers of S100-immunoreactive peripheral nerve fibers were assessed in 6 high-powered fields (HPFs) per tissue section (12 total HPFs per patient). Information collected included patient characteristics and surgical findings. We excluded any patients with dysplasia/cancer and those without an available adequate specimen. Measurements and Main ResultsWe evaluated the cervix specimens from 35 patients who underwent trachelectomy for pain (n = 25, group 1) and nonpain (n = 10, group 2) indications in addition to control cervices (n = 15, group 3) from benign hysterectomies performed for nonpain indications. There were increased numbers of nerve fibers in trachelectomy patients with pain versus those without pain (group 1 vs group 2, p = .02). There were also increased numbers of nerve fibers in both trachelectomy groups compared with the control group (group 1 vs group 3, p < .01; group 2 vs group 3, p = .04). Adjusted average cervical nerve counts/HPF were 17.8 (95% confidence interval [CI], 13.2–22.3) for pain-indicated trachelectomies, 11.5 (95% CI, 4.8–18.2) for nonpain, and 6.3 (95% CI, 0.8–11.8) for controls. Regardless of trachelectomy indication, adjusted average nerve counts/HPF were 17.7 (95% CI, 13.4–22.0) for patients with endometriosis and 14.6 (95% CI, 12.2–17.1) for patients without endometriosis. ConclusionNerve fibers in the cervical stump after supracervical hysterectomy are significantly increased in women undergoing trachelectomy for pain indications compared with those who underwent trachelectomy for nonpain indications and controls. Although not statistically significant, endometriosis may be an independent risk factor for increased nerve fibers. These histopathologic observations may support the idea that the cervix should be removed in women undergoing hysterectomy for chronic pelvic pain or endometriosis.

Laparoscopic Radical Trachelectomy in a Pregnant Patient with Invasive Cervical Cancer at the Second Trimester

This video is to show the first case of laparoscopic radical trachelectomy in a young pregnant patient with cervical cancer FIGO stage IB1 at the second trimester. During the procedure, pelvic lymph nodes were removed completely and sent for frozen section. The result was reported as negative. Then the excised cervix was removed and sent for frozen section. After a negative endocervical margin was confirmed on frozen section, the cervical stump were closed and the upper vagina sutured. It took us about 6 hours to finish the procedure, no intraoperative complications occurred and blood loss was 400ml.

ALEEP (Abdominal Loop Electrical Excision Procedure) – A Newly Developed Instrument to Reduce Post-Operative Cervical Bleeding in LASH Procedure Patients

Laparoscopically assisted supracervical hysterectomy (LASH) has gained in incidence with benign diseases of the uterus undergoing hysterectomy. Besides the multiple clinical benefits of this procedure to the patient, the remaining cervical stump my cause problems, which may reduce patient satisfaction and in some even necessitates further surgical intervention.

Laparoscopic Supracervical Hysterectomy With Transcervical Morcellation: Our Experience

Study ObjectiveTo present our experience with laparoscopic supracervical hysterectomy with transcervical morcellation (LSH-TM). DesignA retrospective observational study (Canadian Task Force Classification III). SettingGynecologic Department at Brunico Hospital, Brunico, Italy. PatientsThree hundred sixty-five patients affected by gynecologic benign diseases who underwent LSH-TM. InterventionsA minimally invasive surgical technique for supracervical hysterectomy that involves extraction of the morcellated uterus through the cervical canal. Measurements and Main ResultsWe performed LSH-TM successfully in 365 patients; the mean (standard deviation) operating time was 72.24 (23.21) minutes. We registered no intraoperative complications. The main postoperative complications resulted in 2 cases of second-look laparoscopy because of internal bleeding, 5 cases of asymptomatic hematoma around the cervical stump, and 7 cases of pelvic pain. ConclusionOur experience shows that LSH-TM is a safe and easy to perform technique and that it ensures minimal blood loss.

Carcinoma of the cervical stump--multicenter study

Cervix-sparing hysterectomy due to benign conditions remains controversial, especially when the presumed risk of cervical cancer in the retained cervical stump is concerned. On the other hand, supracervical hysterectomy is associated with shorter operative time, decreased blood loss and decreased intraoperative complications. Moreover, beneficial effects of retaining the cervix on the pelvic statics and female psychosexual functioning have been suggested, although not yet proven. The aim of the study was to determine the frequency and types of cervical cancers in the retained cervical stump after supracervical hysterectomy performed due to benign diseases of the uterine corpus in four academic settings. Retrospective review of medical records of 903 women who underwent treatment due to cervical carcinoma in four departments participating in the study: Centre 1- 2nd Department of Gynecology, Medical University Lublin (years: 2001- 2011); Centre 2- Department of Gynecology and Gynecologic Oncology, Military Institute of Medicine, Warsaw (years: 2002-2012); Centre 3- Katedra i Kliniki Poloźnictwa, Chorób Kobiecych i Ginekologii Onkologicznej II Wydziału Lekarskiego WUM, Warsaw (years: 2008-2013) and Centre 4- Department of Gynecologic Oncology, Poznań University of Medical Sciences, (years: 2000-2012). The occurrence rate of cervical stump carcinoma was reported in relation to patient age, time elapsed between supracervical hysterectomy and diagnosis stump cancer and histological type of cancer. Only 3 cases of cervical stump carcinoma (0.33%) were identified among the 903 investigated women. In all these cases, cervical stump cancers were diagnosed several years after supracervical hysterectomy. In one case the only treatment was radiotherapy in one case only trachelectomy was performed, whereas in one case surgery followed by radiotherapy was used. It should be remembered that subtotal hysterectomy carries a risk, albeit relatively low, of developing stump cancer. Therefore, patients should be informed that after such operation further cervical cancer screening is mandatory. Moreover subtotal hysterectomy should not be offered in populations at risk of developing cancer of the uterine cervix.

Persistent bleeding after laparoscopic supracervical hysterectomy.

Background and Objectives:In our clinical experience, there seemed to be a correlation between cervical stump bleeding and adenomyosis. Therefore, we wanted to conduct a study to determine whether there was an actual correlation and to identify other risk factors for persistent bleeding after a laparoscopic supracervical hysterectomy.Methods:The study included women who underwent laparoscopic supracervical hysterectomy from January 1, 2003, through December 31, 2012. Data were collected on age, postmenopausal status, body mass index (BMI), uterine weight, indication for hysterectomy, concomitant bilateral salpingo-oophorectomy (BSO), presence of endometriosis, surgical ablation of the endocervix, adenomyosis, presence of endocervix in the specimen, and postoperative bleeding.Results:The study included 256 patients, of whom 187 had no postoperative bleeding after the operation, 40 had bleeding within 12 weeks, and 29 had bleeding after 12 weeks. The 3 groups were comparable in BMI, postmenopausal status, uterine weight, indication for hysterectomy, BSO, surgical ablation of the endocervix, adenomyosis, and the presence of endocervix. However, patients who had postoperative bleeding at more than 12 weeks were significantly younger (P = .002) and had a higher rate of endometriosis (P < .001).Conclusions:Risks factors for postoperative bleeding from the cervical stump include a younger age at the time of hysterectomy and the presence of endometriosis. Therefore, younger patients and those with endometriosis who desire to have no further vaginal bleeding may benefit from total hysterectomy over supracervical hysterectomy. All patients who are undergoing supracervical hysterectomy should be counseled about the possible alternatives, benefits, and risks, including continued vaginal bleeding from the cervical stump and the possibility of requiring future treatment and procedures.

Laparoscopy-assisted supracervical hysterectomy for ovarian cancer: cervical recurrence.

Background and Objectives:The purpose of our study is to evaluate the incidence of cervical recurrence after laparoscopic supracervical hysterectomy for ovarian cancer debulking or staging.Methods:From a prospective surgical database, we identified 51 cases of laparoscopic supracervical hysterectomy for ovarian cancer debulking or staging. No cases were excluded.Results:From 2009 to 2012, 51 patients were identified. The median age was 62 years (range, 32–83 years), and the median body mass index was 29 kg/m2 (range, 16–41 kg/m2). Medical comorbidities were present in 40 patients (78%), and 53% had prior abdominal surgery. The median operative time was 2 hours (range, 1–3.5 hours), and the median blood loss was 200 mL (range, 50–900 mL). The median length of stay was 1 day (range, 0–12 days). The stage was I in 12 patients, II in 6, and III/IV in 33. At a median follow-up time of 1.7 years (range, 0.3–2.6 years), 20 patients (39%) had recurrence of cancer, with a median time of recurrence of 1.1 years (range, 0.3–2.3 years). All recurrences were in the abdomen or pelvis except for 1 axillary node recurrence and 1 recurrence in the distal vagina. There were no recurrences in the remaining cervical stump. No patient had a postoperative vaginal cuff infection. Among the 104 cycles of intraperitoneal chemotherapy, there was no vaginal leakage of intraperitoneal chemotherapy.Conclusion:Laparoscopic supracervical hysterectomy for ovarian cancer debulking or staging does not result in cervical recurrence.

Фотодинамическая терапия в профилактике ВПЧ-ассоциированных рецидивов рака шейки матки

Objective. To develop methodological approaches to relapse prevention of HPV-associated cervical cancer. Materials and methods. 40 patients with PDT performed in age from 22 to 46 years (median 33 years) with primary cervical cancer after surgical treatment of organ volume - high conical cervicectomy: carcinoma in situ (n=18) and cervical cancer 1A1st. (n=22). Identification and differentiation of HPV DNA polymerase made chain reaction. Alasens dose (20% ointment) was 0,1 mg/cm2, Exposure time 6 hours light source - diode laser LFT-630-01-BIOSPEC. Results. Complete eradication of HPV DNA after PDT cervical stump was achieved in 38 (95%) of the women in the other two - after the 2nd PDT. Resistant antiviral effect during the whole observation period is preserved in 39 (97,5%) women. Findings. Photodynamic therapy can be recommended with the aim of antiviral treatment in the second stage after amputation knife, laser, electro-and radio-wave cone excision of the cervix, as well as alternative and radiokoagulyatsii diathermy, cryosurgery, laser vaporization method of treatment of cervical PVI. Conclusion. These data antiviral efficacy of PDT are of great interest in the light of proven etiologic role of HPV in cervical cancer development.

Study of the radiotherapy modality for patients with stage IIb-IIIb cervical stump cancer

To investigate the radiotherapy modality progress of stageIIb-IIIb cervical stump cancer. The clinical data of 13 patients with stageIIb-IIIb cervical stump cancer undergoing radiotherapy from January 2000 to April 2012 was reviewed. Before 2006, 8 patients received conventional external beam radiotherapy and brachytherapy.Since 2006, 5 patients received intensity-modulated radiotherapy (IMRT) and brachytherapy. The median survival was 12-139 months. The median overall survivals and disease free survivals in the conventional radiotherapy (CRT) group were 57 months and 50 months, 3 cases of them recurred during 8-19 months and died of tumor progression.While, the median overall survivals and disease free survival in the IMRT group both were 21 months and nobody recurred. In the CRT group, 7 patients suffered toxicities, including 5 patients grade I-II acute rectum reaction, 2 patients grade I bladder reaction; and 3 had grade I-III, late rectum reaction, 2 patients for grade II bladder late reaction.In the IMRT group, toxicities including 1 case grade I acute or late rectum reaction, and no bladder reaction. In our experience, the recommended IMRT and interstitial brachytherapy for the selected patients with advanced cervical stump carcinoma may be obtain better tumor dose distribution and more sparing of the organ at risk.

Novel use of a stent in a patient with cervical agenesis, partial vaginal agenesis and uterine didelphys. case report

Novel use of a stent to maintain patency after cervical reconstruction in cervical and vaginal agenesis and uterine didelphys. Case report. 19 year-old woman with primary amenorrhea due to a dydelphys uterus with total cervical and upper third vaginal agenesis. Pelvic ultrasound showed the right and left hemi-uteri completely separated and almost in contact with pelvic wall. Cervix and upper third of the vagina could not be identified. MNR revealed similar images than the sonogram. Laparoscopy demonstrated an accurate assessment of the Mullerian defect, only a cervical stump could be seen. Strassman operation was performed to correct dydelphys uterus; a new cervix was reconstructed using both cervical stumps, followed by a uterine-vaginal anastomosis. A Foley catheter was placed to keep the new cervical channel open. Patient referred a normal menstruation ten days later, first time in her life. Foley catheter was removed six weeks after surgery, follow by weekly cervical dilatations, but 8 weeks later cervical canal was definitely closed. A special stent was developed to be placed in a new cervical channel. A small incision was performed in the uterine fundus by a laparotomy to place the stent in the cervical area. A cervical lumen was drilled and then the stent was placed immediately. 15 days later patient resume her menstrual cycle. Three and a half years later the patient is still menstruating. At speculum examination it could be seen distal portion of the stent and fluid mucus filling the new cervical canal. Cervical agenesis treatment is disappointing and therefore discouraged. Cervical agenesis usually finishes with hysterectomy or serious infection as a result of treatment failure. Cervical stent is a good option to offer to these patients to recover their women status, they keep their uterus and menstruation, carry on an positive psychological impact, and the hope of future fertility, that otherwise to date was completely lost.

Cancer of cervical stump diagnosed in a woman with chronic myelogenous leukaemia

Cancer of cervical stump diagnosed in a woman with chronic myelogenous leukaemia

Abordaje histeroscópico del endometrio residual en muñón cervical

The main difference between subtotal and total hysterectomy lies in the persistence of the cervical stump and the possible associated problems. One of these problems is cyclical bleeding after a subtotal hysterectomy, which, depending on the series, occurs in 0% to 25% of cases. We describe resolution of cyclical bleeding after a subtotal hysterectomy by means of hysteroscopic treatment. To our knowledge, this is the first published case in which ablation of the remnant tissue was performed with a monopolar loop in order to treat cyclical bleeding. We believe this surgical treatment could be a valid alternative to resolve cyclical bleeding associated with persistence of endometrial tissue in the cervical stump.

Robotic-assisted laparoscopic trachelectomy: a case series and review of surgical technique.

We present a retrospective case series of patients who underwent robotic-assisted laparoscopic trachelectomies from August 1, 2011 to August 30, 2012, with a description of the surgical technique for successful cervical removal. The patients, at the Department of Obstetrics and Gynecology, Division of Urogynecology and Minimally Invasive Surgery at Penn State Milton S. Hershey Medical Center, were identified using ICD-9 coding for robotic-assisted trachelectomy. Of the 180 patients who had robotic-assisted gynecologic surgery during the study period, eight underwent robotic-assisted laparoscopic trachelectomy. The patients' average age was 40.4years, average parity was 1.5, and mean body mass index was 28. The time interval from initial surgery of supracervical hysterectomy to robotic-assisted trachelectomy was 4years. Pre-operative cervical cytology was negative in all patients. The average length of stay was one overnight admission. The primary indication for prior supracervical hysterectomy was dense pelvic adhesions, and the main indications for robotic-assisted trachelectomy were pelvic pain due to endometriosis and cyclic vaginal bleeding. Surgical outcomes included minimal blood loss (<50ml) and mean operative time of 1.15h (74.88min), without any immediate intra-operative or post-operative complications reported. Histopathology reports on all cervical specimens were normal. Adnexectomy is the most common concomitant procedure performed with trachelectomy. Robotic-assisted laparoscopic trachelectomy is a viable option for patients requesting a minimally invasive approach to cervical stump removal.

Approach to Cervical Myomectomy and Trachelectomy

We present an unusual case of a 40-year-old woman with pelvic pain and pressure. Patient had a history of a supracervical hysterectomy five years ago for fibroids. Imaging confirmed recurrence of a fibroid in the cervical stump. This video illustrates a laparoscopic approach to cervical myomectomy and trachelectomy, with special attention to the adhesiolysis and anterior dissection required to effectively perform the procedure.

Helical tomotherapy provides efficacy similar to that of intensity-modulated radiation therapy with dosimetric benefits for endometrial carcinoma

BackgroundThe purpose of this study was to compare the efficacy of intensity-modulated radiotherapy (IMRT) and helical tomotherapy for endometrial cancer.MethodsBetween November 1, 2006 and November 31, 2010, 31 patients with histologically confirmed endometrial cancer were enrolled. All enrolled patients received total abdominal hysterectomy and bilateral salpingo-oophorectomy with adjuvant whole pelvic IMRT or helical tomotherapy.ResultsThe actuarial 3-year overall survival, disease-free survival, locoregional control, and distant metastasis-free rates for the IMRT and helical tomotherapy groups were 87.5% versus 100%, 91.7% versus 51.7%, 91.7% versus 83.3%, and 91.7% versus 51.7%, respectively. The conformal index and uniformity index for IMRT versus helical tomotherapy was 1.25 versus 1.17 (P = 0.04) and 1.08 versus 1.05 (P < 0.01), respectively. Two of 31 patients with cervical stump failure were noted, one in the IMRT group and the other in the helical tomotherapy group. No acute or late grade 3 or 4 toxicities were noted, including proctitis, or genitourinary or gastrointestinal disturbances.ConclusionHelical tomotherapy is as effective as IMRT and has better uniformity and conformal indices, and critical organ-sparing properties. Prospective clinical trials are needed to evaluate the comparative efficacy of IMRT versus helical tomotherapy.