16 Cervix Carcinoma

306 Cervix Cancer

5.1.2.2 S urgery followed by vaginal brachytherapy In women under 40 years with a small tumour (equal or less than 2 cm), surgery can be performed first to preserve ovarian function: after transposition of the ovaries, total hysterectomy and pelvic lymphadenectomy are performed with frozen sections. If pelvic nodes are positive, para-aortic lymphadenectomy is performed. Vaginal brachytherapy may be indicated if there is a high risk of vaginal recurrence because of close surgical margins. In case of positive margins or tumour emboli, or positive pelvic nodes, concomitant chemoradiation followed by vaginal brachytherapy is given (40,51,77). 5.1.2.3 External irradiation plus brachytherapy followed by surgery If there is a barrel-shaped cervix, which is initially inaccessible to brachytherapy, pelvic external beam irradiation combined with concomitant chemotherapy (if tumor size exceeds 4 cm) precedes brachytherapy allowing a shrinking of the tumour volume which then can be appropriately irradiated Dependent on tumour volume, tumour extension, and the risk of lymph node involvement, brachytherapy may be used alone or in combination with external beam radiotherapy. In stage IA tumours, brachytherapy alone is indicated, if surgery is not a treatment option, since the risk of lymph node involvement is very low (<1%). In IB1 tumours with little risk of microscopic parametrial and lymph node invasion, the dose of external beam radiotherapy is kept low (true pelvis, 30 - 40 Gy). 5.2 Locally extended disease Locally extended disease includes stage IB2, IIA/B when the tumoral size exceeds 4cm or when the extension is beyond the upper third of the vagina and/or beyond the inner third of the parametria, stage IIIA, stage IIIB, stage IVA, and stage IVB (with paraaortic lymph node involvement). A combination of external beam radiotherapy with concomitant chemotherapy and brachytherapy (intracavitary +/- interstitial brachytherapy) is the treatment of choice. In certain specific situations surgery is performed. 5.2.1 Definitive radiotherapy with concomitant chemotherapy The individual strategy is dependent on tumour volume, tumour extension, and the risk of lymph node involvement. Several randomized trials with more than 3000 patients included have shown a benefit of a concomitant radiochemotherapy regimen in terms of overall survival, disease-free survival and local control as well as metastases (46,112). The absolute benefit in progression-free and overall survival was 16% and 12% respectively. The standard treatment in locally advanced tumors i.e. tumors exceeding 4cm, is external beam radiotherapy combined with concomitant Platinum based chemotherapy and according to tumour shrinkage during external beam radiotherapy, endocavitary brachytherapy +/- interstitial brachytherapy. The role of concomitant chemotherapy during brachytherapy has not been clearly demonstrated. For patients with Stage III and IVA, the real benefit of this concomitant radio-chemotherapy approach has not been clearly defined. 5.2.2 Combination of surgery with postoperative radiotherapy In extended disease, surgery first is rarely indicated. If it has been done, the following recommendations are given: by pre-operative brachytherapy. 5.1.3 Definitive Radiotherapy