Prognostic factors in cervical carcinoma: implications in staging and management

Individualization of treatment using judicious combinations of external and intracavitary irradiation remains the cornerstone of the radiation management of carcinoma of the cervix. The inherent propensity of this cancer to either confine itself to the pelvis or else spread in a systematic and predictable manner through lymphatic channels has facilitated its therapeutic control. The treatment of most early invasive cervical carcinomas is equally advantageous using either intracavitary radium or surgery. However, certain Stage I patients have morphologic and histologic characteristics that militate against tumor control. Factors such as tumor size, depth of invasion, vascular infiltration, uterine extension, and barrel-shaped presentation affect the course of the disease and survival. A clinical-pathologic staging for cervical carcinoma incorporating the above mentioned factors into the current clinical FIGO staging system has been suggested. It aims to facilitate the recognition of those early tumors that require additional external radiotherapy. A description of the role of surgery, intracavitary and external radiation, and their combinations is included. In advanced carcinoma of the cervix, failure can be attributed to either large tumors containing cores of hypoxic cells resistant to conventional radiation therapy or to uncontrolled subclinical disease in the lymphatics at or near the border of the irradiated area. Radiotherapy combined with surgery, oxygen enhancers, infusion chemotherapy, and large particle high LET radiation has been implemented to increase local control; for distal failures, extended field irradiation of paraaortic nodes has been found to be technically feasible and well tolerated and is being studied for its effects on increased survival. The rationale for newer treatment procedures, including preliminary results and their complications, is discussed.