The narrow upper vagina of older patients may preclude the use of an intracavitary source of radiation. These patients must receive their entire course of therapy from external sources, leading to a higher central failure rate and more significant bowel and bladder morbidity. If stage I disease is present in such a patient, a radical hysterectomy with pelvic lymphadenectomy is preferable, if the patient’s medical condition allows this approach. There may be a role for IMRT in the management of such tumors.
Treatment of recurrent cervical cancer depends on the mode of primary therapy and the site of recurrence. Patients who were treated initially with surgery should be considered for radiation therapy, and those who had radiation therapy should be considered for surgical treatment. Chemotherapy is palliative only and is reserved for patients who are not considered curable by either surgery or radiation therapy.
Radiotherapy for recurrence after surgery consists primarily of external treatment. Vaginal ovoids may be placed in patients with isolated vaginal cuff recurrences. Patients with a regional recurrence may require interstitial implantation with a Syed type of template in addition to external therapy. A 25% survival rate can be expected in patients treated with radiation for a postsurgical recurrence (162).
Radiation Retreatment Retreatment of recurrent pelvic disease by means of radiotherapy with curative intent is confined to patients who had suboptimal or incomplete primary therapy. This may allow the radiotherapist to deliver curative doses of radiation to the tumor. The proximity of the bladder and rectum to the cancer and the relative sensitivity of these organs to radiation injury are the major deterrents to retreatment with radiation. The insertion of multiple interstitial radiation sources into locally recurrent cancer through a perineal template may help overcome these dosimetric considerations (173,183). The fistula rates are high, and those consequences must be considered before interstitial therapy is initiated. For patients considered curable with interstitial implant therapy, pelvic exenteration is a better treatment choice. Palliative radiotherapy can be given to patients with localized metastatic lesions that are deemed incurable. Painful bony metastases, central nervous system lesions, and severe urologic or vena caval obstructions are specific indications.
Surgical Therapy Surgical therapy for postirradiation recurrence is limited to patients with central pelvic disease. A few carefully selected patients with small-volume disease limited to the cervix may be treated with an extrafascial or radical hysterectomy. However, the difficulty of assessing tumor volume and the 30% to 50% rate of serious urinary complications in these previously irradiated patients have led most gynecologic oncologists to recommend pelvic exenteration as a last chance for cure (184,185).
Exenteration There are three types of exenterative procedures: (i) an anterior exenteration (removal of the bladder, vagina, cervix, and uterus), (ii) a posterior exenteration (removal of the rectum, vagina, cervix, and uterus), and (iii) a total exenteration (removal of both bladder and rectum with the vagina, cervix, and uterus (Fig. 36.9). A total exenteration that includes a large perineal phase includes the entire rectum and leaves the patient with a permanent colostomy and a urinary conduit (infralevator). In selected patients, a total exenteration may take place above the levator muscle (supralevator), leaving a rectal stump that may be anastomosed to the sigmoid, thus avoiding a permanent colostomy.