The avoidance of small intestine injury in gynecologic cancer

The evolution of systematized operative staging and radical surgical procedures in the management of gynecologic cancer has increased the complexities of integrating radiation therapy. High dose irradiation to large treatment volumes has been associated with an increased incidence of small intestine injury. This complication is morbid and often fatal. Although predisposing factors have been extensively studied, there has been a paucity of reports evaluating preventative measures. Between 1975 and 1980, 140 patients with gynecologic cancer were treated at the Valley Presbyterian Hospital in the Division of Radiation Therapy. Twenty-six patients with cervix cancer received definitive irradiation and seven received adjunct irradiation. Seventy-two with corpus cancer received adjunct irradiation, seven received definitive irradiation and three palliative irradiation. Eleven patients with ovarian cancer received adjunct irradiation and 15 palliative irradiation. Eight-five patients were at potential risk for small intestine injury and had treatment planning small intestine X rays. Fixation was observed in 7/39 (18%) without prior pelvic surgery and 30/46 (65%) with prior pelvic surgery. Information from the small intestine X rays were used in 41 patients to make 60 treatment modifications. Twenty-five of 140 (17%) had a reduction of total dose, 26/140 (18%) had exclusion of the small intestine by shrinking fields, or patient positioning and 13/140 (9%) had displacement of the small intestine by distention of the bladder. No patient developed small intestine injury. The disease free survival for cervix cancer was 27/33 (82%), corpus cancer 68/79 (86%) and ovarian cancer 5/11 (45%). Pelvic failure was observed in 19/123 patients who received definitive or adjunct irradiation. One patient with corpus cancer and three patients with ovarian cancer might have benefited from the use of a larger treatment volume or a higher total dose.