16 Cervix Carcinoma

Cervix Cancer 355

11.2 Adverse side effects The diversity and severity of early and late complications in patients with gynecological tumors have led to the development of different scoring systems. The two systems which have been the most widely used are the Franco-Italian glossary and the RTOG-EORTC Lent-Soma scale (72,84,103). The Franco-Italian glossary scored the complications in four grades of increasing severity in 14 different organs or normal tissues and took into account different treatments (14). The aim of this glossary was to standardize complication assessment and allow comparisons between different therapeutic strategies. This glossary is specific for gynaecological tumors. It has been shown to be very useful in evaluating treatment protocols. Prospective evaluation of complications appeared to be the best approach as it made it possible not only to grade them at a particular point in time, but also to record their duration and their possible re-occurrence. With this information about the evaluation of mostly late complications, their occurrence has been modified by adapting brachytherapy techniques (19). These data have been recently updated and have confirmed the reliability of the glossary with good correlation of morbidity with survival over time (4). In this series, the glossary had limited usefulness in the grade 3 complication group which appeared to comprise an inhomogeneous cohort of patients. The scoring 3 did not take into account the assessment of the complication by the patient with potential long-term detriment, and a division into three subgroups was therefore proposed. The RTOG-EORTC Lent-Soma scale was designed in 1995 with the aim of encompassing all complications regardless of tumor site. This scale combines acute and late morbidity, for objective and subjective symptoms. It is not specific for pelvic malignancies and is restricted to post radiation changes. It is still under evaluation in prospective studies and clinical trials. The main complications following treatment of cervical cancer involve the bowel and urinary tract. The overall actuarial 5-year severe complication-rate ranges between 8 and 10%. Late sequelae mainly occur during the first 3 to 5 years following treatment, with a decrease later on. Digestive complications usually occur earlier than urinary complications (30 months vs 48 months). There is a continuous risk of all types of complications as demonstrated in the Eifel series (73) of 1784 patients with an estimated rate of 0.34% per year after treatment: rectal complications increased by 1% during the first 2 years with a decrease to 0.06% per year after, while bladder complications increased by 0.7% during the first 3 years, later stabilising at 0.25% per year. Factors responsible for radiotherapy-induced toxicity are divided into two categories: some are directly linked to the radio-brachytherapeutic techniques and doses, others are independent of irradiation, and include surgery, concomitant chemotherapy, diabetes, HTA…We will focus in this chapter on the factors directly related to irradiation. 11.2.1 Total dose Perez (87) showed that the most significant factor affecting the appearance of complications was the total dose of irradiation to the pelvic organs by both whole pelvic irradiation and intracavitary insertions. The incidence of complications significantly increased when the dose exceeded 80 Gy. A more recent analysis with a larger number of patients (up to 1456) confirmed the role of the total dose (89). For the bladder, a dose below 80 Gy correlated with less than 3% of morbidity while this rate reached 5% with higher doses. In the rectosigmoid, the incidence of morbidity significantly increased when the total dose exceeded 75 Gy: 4% with doses below 75Gy and 9% with higher doses. The dose to the latero-pelvic wall was also a significant factor influencing small intestinal complications: the complication rate was less than 1% with a total dose of 50 Gy or less, 2% with 50 to 60 Gy, and 5% with higher doses. The influence of total dose was also demonstrated by other authors. As an example, Sinistrero (107) reported a mean total dose of 55.7 Gy for patients without