16 Cervix Carcinoma

Cervix Cancer 357

treated with radium without any sophisticated dosimetry and more recent patients treated with high dose-rate using more advanced technology. Haie et al. (50) conducted a randomised trial comparing two pre-operative brachytherapy low dose rates in cervical carcinoma. The statistical analysis carried out by the prevalence method, showed that the higher dose rate (0.73 Gy/h) was associated with 45% of complications at 2 years versus 30% for the lowest dose rate (0.38 Gy/h). The severe complications were also increased (13% versus 7%). Two other authors: Newman (80) and Rodrigus (100) reported increased morbidity following the introduction of remote afterloading, with increased dose rate, for cancer of the cervix. Rodrigus et al decided to reduce the brachytherapy dose per application from 25 Gy to 20 Gy in order to prevent the risk of complications with increasing dose rate (0.54 Gy/h versus 1.07 Gy/h). These authors observed an increase in late gastro-intestinal sequelae of 12% and in late rectal complications of 7% with an increase of dose rate above 0,5 Gy/h for rectal and bladder complications. A significant increase in complications was also seen in the Manchester trials when comparing the classical dose rate of Radium (0.53 Gy/h) with dose rates of Cesium (1.4 - 1.8 Gy/hour). The rate of complications at 5 years was the same with a total dose of 60 Gy of Cesium as with 75 Gy of Radium, (dose ratio of 1.25), whereas for the same total dose applied with Cesium (75 Gy), there was an increase in complications at 5 years from 15% to 56% compared to the same dose given with Radium (62). Leborgne et al (71) also showed a marked dose-rate effect at 1.6 Gy/h to point A. The highest complication rates were observed with a schedule of two fractions of 24 Gy or three fractions of 15.3 Gy. With these schedules the grade 2 and 3 rectal or bladder complications were 83% and 30% respectively. 11.2.5 Other factors * Previous pelvic or abdominal surgery has been shown to have an impact on colonic or small intestinal late injuries. The risk appeared to be proportional to the number of previous laparotomies irrespective of time or purpose. * Extended fields to the para-aortic area have been shown from 3 randomised studies comparing pelvic to pelvic plus para-aortic radiotherapy to have an impact on the incidence of gastro-intestinal complications (17,49,101). For Chatani et al (17), the overall complication rate was 30% in the para- aortic arm, with 7% of enteritis ileus and less than 10% in the pelvic arm. Rotman (101) reported a 6% lethal complication rate in the para-aortic arm compared with 1% in the pelvic arm. * Concomitant radiochemotherapy is also a factor increasing the complication rate. Averette HE, Nguyen HN, Donato DM, et al. Radical hysterectomy for invasive cervical cancer. A 25-year prospective experience with the Miami technique. Cancer 1993; 71(suppl. 4) : 1422- 37. 2. Bachaud JM, Fu RC, Delannes M, et al. Non-randomized comparative study of irradiation alone or in combination with surgery in stage Ib, IIa and “proximal” IIb carcinoma of the cervix. Radiother Oncol 1991; 22(2) : 104-10. 3. Barillot I, Horiot JC, Pigneux J, et al. Carcinoma of the intact uterine cervix treated with radiotherapy alone: a French cooperative study: update and multivariate analysis of prognostic factors. Int J Radiat Oncol Biol Phys 1997; 38 : 969-78. 4. Barillot I, Horiot J, Maingon P, et al. Impact on Treatment Outcome and Late Effects of Customized Treatment Planning in Cervix Carcinomas: Baseline Results to Compare New Strategies. Int J Radiat Oncol Biol Phys 2000; 48 : 189-200. 5. Benda JA. Pathology of cervical carcinoma and its prognostic implications. Semin Oncol 1994; 21(1) : 3-11. 12 References 1.