Operable stages IB and II cervical carcinomas: A retrospective study comparing preoperative uterovaginal brachytherapy and postoperative radiotherapy

Purpose: To evaluate our data concerning prognostic factors and treatment toxicity in a series of operable cervical carcinomas. Methods and Materials: Between May 1972 and January 1994, 414 patients with cervical carcinoma, staged according-to the 1995-FIGO staging system (286 Stage 1131, 38 Stage IB2, 56 Stage IIA, and 34 Stage IIB with 1/3 proximal parametrial involvement), underwent radical hysterectomy with (n = 380) or without (n = 34) bilateral pelvic lymph node dissection (N+: n = 68). Group I included 168 patients who received postoperative radiation therapy (RT): 64 patients had low-dose-rate vaginal brachytherapy with a median total dose (MTD) of 50 Gy; 93 patients had external beam pelvic RT (EBPRT) with an MTD of 45 Gy over 5 weeks, followed by low-dose-rate vaginal brachytherapy (MTD: 20 Gy); and 11 patients had EBPRT alone (MTD: 50 Gy over 6 weeks). Group 11 included 246 patients treated with preoperative low-dose-rate uterovaginal brachytherapy (MTD: 65 Gy); 32 of these 246 patients also received postoperative EBPRT (MTD: 45 Gy over 5 weeks) delivered to the parametria and pelvic nodes. Mean follow-up from the beginning of treatment was 106 months. Results: First events included isolated locoregional recurrences (35 patients), isolated distant metastases (27 patients), and locoregional recurrences with synchronous metastases (13 patients). The 10-year disease-free survival (DFS) rate was 88% for Stage IB1, 44% for Stage 1112, 65% for Stage IIA, and 48% for Stage IIB. Multivariate analysis showed that independent factors influencing the probability of DFS were as follows: cervical site (exocervical or endocervical vs. both endo- and exocervical, relative risk [RR]:.1.77, p = 0.047), vascular space invasion (no vs. yes, RR: 1.95, p = 0.041), age (> 51 years vs. less than or equal to 51 years, RR: 1.90, p = 0.013), 1995 FIGO staging system (IB1 vs. IIA, RR: 2.95, p = 0.004; 1111 vs. 1112, RR: 3.49, p = 0.0009; and IB1 vs. 1111, RR: 4.54, p = 0.00002), and histologic pelvic lymph node involvement (N- vs. N+, RR: 2.94, p = 0.00009). The sequence of adjuvant RT did not influence the probability of DFS (Group I vs. Group 11, p = 0.10). In Group 11, after univariate analysis, DFS was significantly influenced by histologic residual cervical tumor in the hysterectomy specimen (yes vs. no: 71% vs. 93%, respectively, p < 10(-6)) and by the size of the residual tumor (:51 cm vs. > 1 cm: 83% vs. 41%, respectively, p = 0.001). The overall postoperative complication rate was 10% in Group I and 9% in Group 11 (p = 0.7). The rate of postoperative ureteral complications requiring surgical intervention was lower in Group I than in Group 11 (0.6% vs. 2.3%, respectively, p = 0.03). The overall 10-year rate for Grade 3 and 4 late radiation complications was 10.4%. Postoperative EBPRT significantly increased the 10-year rate for. Grade 3 and 4 late radiation complications (yes vs. no: 22% vs. 7%, respectively, p = 0.0002). Conclusion: The prognosis for patients with cervical carcinoma was not influenced by the sequence of adjuvant RT (preoperative uterovaginal brachytherapy vs. postoperative RT) for Stages IB, IIA, and IIB with 1/3 proximal parametrial involvement. However, postoperative EBPRT increased the risk of late radiation complications. (C) 2002 Elsevier Science Inc.