16 Cervix Carcinoma

304 Cervix Cancer

Fig 14.2 (continued): Bilateral Stage III B cervix cancer: B. MRI (T2 weighted) shows an extensive tumour (high signal intensity; normal uterus: low signal intensity), expanding the uterus in the side to side and in anterior - posterior direction with infiltration of the major part of the uterine body; bilateral parametrial extension right more than left; infiltration along both sacro-uterine ligaments with extension into the perirectal space. Width 8.2 cm, thickness 6.8 cm, height 9.8 cm, as measured from coronal and sagittal MRI; volume of GTV (w x t x h x 0.52) 284 cm 3 . Transverse CT shows a large soft tissue mass extending bilaterally into the parametria: no discrimination between uterine and tumour tissue possible (for endocavitary combined with interstitial brachytherapy of this patient compare chapter on interstitial gynaecological brachytherapy Fig 17.8). Further diagnostic studies depend on the tumour extent: rectoscopy and cystoscopy to identify organ infiltration, intravenous pyelography to detect ureteral obstruction, chest radiography to identify lung metastases; barium enema to check large bowel disease, scintigraphy to detect bone metastases. Laboratory studies are performed including blood count (hemoglobin level), urinanalysis, general chemistry (including creatinine) (109). Based on all these findings - including general medical status - the different possibilities for treatment will be decided upon by the gynaecological surgeon and the radiation oncologist. In the context of definitive radiotherapy, limited disease is usually defined as disease primarily accessible by brachytherapy, whereas extended disease means that tumour extension and tumour volume will only allow brachytherapy after tumour shrinkage by external beam therapy.