Radiation Therapy Survival after radiotherapy depends on the volume of disease, the status of the surgical margins, and the length of delay from surgery to radiotherapy. Patients with microscopic disease have a 95% to 100% 5-year survival rate; the 5-year survival rate is 82% to 84% in those with macroscopic disease and free margins, 38% to 87% in those with microscopically positive margins, and 20% to 47% in those with obvious residual cancer (175–177). A delay in treatment of more than 6 months is associated with a 20% survival rate (177).
Acute Hemorrhage Occasionally, a large lesion can produce life-threatening hemorrhage. A biopsy of the lesion should be performed to verify neoplasia, and a vaginal pack soaked in Monsel’s solution (ferric subsulfate) should be packed tightly against the cervix. After proper evaluation, external radiation therapy can be started with the expectation that control of bleeding may require 8 to 10 daily treatments at 180 to 200 cGy per day. Broad-spectrum antibiotics should be used to reduce the incidence of infection. If the patient becomes febrile, the pack should be removed. Rapid replacement of the pack may be necessary, and a fresh pack should be immediately available. This approach to management of hemorrhage in patients previously untreated is preferable to exploration and vascular ligation. Vascular embolization under ﬂuoroscopic control may be required in severe cases, and this procedure may obviate a laparotomy. However, vascular occlusion ultimately may lead to decreased blood ﬂow and oxygenation of the tumor, compromising the effectiveness of subsequent radiotherapy.
Ureteral Obstruction Treatment of bilateral ureteral obstruction and uremia in previously untreated patients should be determined on an individual basis. Transvesical or percutaneous ureteral catheters should be placed in patients with no evidence of distant disease, and radiotherapy with curative intent should be instituted. Patients with metastatic disease beyond curative treatment fields should be presented with the options of ureteral stenting, palliative radiotherapy, and chemotherapy. With aggressive management, a median survival rate of 17 months may be achieved for these patients (178).
Barrel-Shaped Cervix The expansion of the upper endocervix and lower uterine segment by tumor is referred to as a barrel-shaped cervix. Patients with tumors larger than 6 cm in diameter have a 17.5% central failure rate when treated with radiotherapy alone because the tumor at the periphery of the lower uterine segment is too far from the standard intracavitary source to receive an adequate tumoricidal dose (179). Attempts were made to overcome this problem radiotherapeutically by means of interstitial implants into the tumor with a perineal template, but high central failure rates were reported with this technique (180).
One approach is to use a combination of radiotherapy and surgery for treatment of patients with a barrel-shaped cervix. An extrafascial hysterectomy is performed 2 to 3 months after the completion of radiation therapy in an effort to resect a small, centrally persistent tumor. The dose of external radiotherapy is reduced to 4,000 cGy, and a single intracavitary treatment is given, which is followed by an extrafascial hysterectomy (181,182). This method appears to result in a lower rate of central failure (2%), although it is not clear that the overall survival rate is improved. There is disagreement concerning the need for extrafascial hysterectomy, and the GOG is undertaking a randomized study to compare adjuvant hysterectomy with radiotherapy alone in patients who have no evidence of occult metastases in the para-aortic nodes (see stages IB and IIA discussion).