Age-standardized incidence of cervical cancer in selected worldwide countries

Zimbabwe, HararePeru, TrujiloIndia, MadrasColombia, CaliArgentinaIndia, BombayNew Zealand, MaoriCosta RicaThailandMali, BamakoKorea,Kangwha US, SEER, BlackCanadaDenmarkBelgiumIsrael

Rate per 100,000 ( IARC, 1996 )

67.253.5

38.934.2

32.227.7

24.224.0

23.221.8

12.07.87.6

4.87.5

26.7

Cumulative 5 year survival according to clinical stage

surv

ival

(%)

0

20

40

60

80

100

120

0 6 12 18 24 30 36 42 48 54 60

12%

41%

months

Stage IStage I

Annual Report Gynecological Cancer, 1994 Kim et al ., 2003 (Yonsei Univ.)

69%

88%Stage IIIStage III Stage IVStage IV

Stage I IStage I I

10%

52%

Stage IStage I

75%

86%Stage IIIStage III Stage IVStage IV

Stage I IStage I I

months

0

20

40

60

80

100

120

0 6 12 18 24 30 36 42 48 54 60

Definition

Recurrence after radiationA regrowth of tumor in the pelvis or distally, noted after complete healing of the cervix and vagina have been achieved.

The continuous presence of original tumor or the development of a new tumor in the pelvis within 3 months of radiotherapy completion

Persistent disease after radiation therapy

( DiSaia et al ., 1992 )

Definition

Recurrence after surgeryEvidence of a tumor mass after operation in which all gross tumor was removed and the margins of the specimen were free of disease.

Defined as the continuous presence of gross tumor in the operative field.

Persistent disease after surgery

( DiSaia et al ., 1992 )

Incidence of recurrence

227

251

5972

0

300

1990-95 1996-99 Year

No.

of

pati

en

ts

28.7% 26.0%

Total number of patientsTotal number of patients

Recurrent casesRecurrent cases

Kim et al ., 2003 (Yonsei Univ.)

Incidence of recurrence according to clinical stage

0

250

I II III IV

100%

Stage

No.

of

pati

en

ts

0%

Total number of patientsTotal number of patients

Recurrent casesRecurrent cases10.710.7

27.927.9

47.547.5

80.080.0

Kim et al ., 2003 (Yonsei Univ.)

Colpophotograph of vaginal recurrence

Pre-treatmentPre-treatment Post-treatmentPost-treatment

Classification of Vaginal Recurrence of Cervical Cancer

Ito et al, 1997

Vaginal recurrence determined by bimanual rectovaginal examination

Small : involving only vaginal surface

Medium : recurrent mass less than 3 cm

Large : tumor mass exceeds 3 cm or larger extends to the pelvic cavity

Ijaz et al, 1998

In a manner of paralleling the FIGO classification of vaginal cancer

Group 1 : mucosal involvement only

Group 2 : paravaginal extension

Group 3 : central recurrence with pelvic side wall extension

Group 4 : recurrence limited to the pelvic sidewall

Classification of Vaginal Recurrence of Cervical Cancer

Management of vaginal recurrence

Mode of previous treatmentExtent of recurrent diseasePatients’ performance status

Initial treatment Surgery : radiation therapy chemoradiotherapy Radiation : surgical treatment Chemotherapy investigational or palliative

Various Radiotherapeutic Approaches

Interstitial implant

Altered fractionation of radiation

Hyperbaric oxygen therapy

Hyperthermia / Radiotherapy

Intraoperative radiotherapy (IORT)

Combined operative and radiotherapeutic treatment (CORT)

Patients and Methods

1990-2000, Dept of OB/GYN, Yonsei University College of Medicine

478 Patients with cervical cancer (retrospective review)

131 recurrent cervical cancer (27.4%)

Previous treatment modality

Surgery : 16 patients

Radiation therapy ; 125 patients

Vaginal recurrence including pelvic site ; 55 patientsClinicopathologic analysis

Management modalities(radiation, chemotherapy, combination) Age, Cell type, Previous treatment modalities,

Extent of recurrence,

Characteristics

Age( years) Median RangeFIGO stage at initial diagnosis I II IIIHistology type Squamous cell carcinoma Adenocarcinoma Adenosquamous carcinomaPrevious treatment Radiation CTx + RTx CTx + Surgery SurgeryTime to recurrence (months) Median

58 38 - 75

13 2317 3125 46 43 78 8 14 4 8

19 3415 28 2 319 35 10.5

Patients

No. Percent

Patient characteristics

Patients No. Percent

Extent of recurrence group I group II group III

Treatment of recurrent cervical cancer Radiotherapy Chemotherapy Radiotherapy + Chemotherapy Surgery

Chemotherapy regimen DDP + Taxol DDP + 5-FU DDP + VCR DDP + ADR Ifosfamide + Carboplatin + Cisplatin Survival month (median)

12 2224 4419 34

20 3624 43 8 16 3 5

8 2510 31 3 9 2 6 9 29

21

Characteristics

Patient characteristics

Surgical approaches

Pelvic exenteration - surgical treatment of choice for some patients having centrally recurrent cervical cancer after radiation therapy

- exenterative procedures may be partial (conservation of bladder or rectum) or total.

Pelvic exenteration

Douglas and Sweeney(1957)

Parsons and Friedell(1964)

Brunschwig(1967)

Bricker(1967)

Krieger and Embree(1969)

Ketcham er al.(1970)

Symmonds et al.(1975)

Morley and Lindenauer(1976)

Rutledge et al.(1977)

Averette et al.(1984)

Lawhead et al.(1989)

Soper et al.(1989)

Shingleton et al.(1989)

Total

23

112

535

153

35

162

198

34

296

92

65

69

143

1917

(4.3%)

(21.4%)

(16%)

(10%)

(11%)

(7.4%)

(8%)

(2.9%)

(13.5%)

(25%)

(9.2%)

(7.2%)

(6.3%)

(12.6%)

5

24

108

53

13

62

64

21

99

34

15

28

71

647

Number of

patients treated

Number of

operative deaths

1

24

86

15

4

12

16

1

40

23

6

5

9

242

Number

surviving 5 years

(22%)

(21.4%)

(20.1%)

(34.6%)

(37%)

(38.2%)

(32.3%)

(62%)

(33.4%)

(37%)

(23%)

(40.5%)

(50%)

(33.8%)

Auther

Pelvic exenteration

Initial stage

IB

IIA

IIB

Age

53

43

47

Type

post*

post*

post*

Status

NED

NED

DOD

Months offollow-up

9

11

6

post*, posterior exenteraion;post*, posterior exenteraion;NED, no evidence of disease;NED, no evidence of disease;DOD, dead of diseaseDOD, dead of disease

2(10)

7(33)

6(29)

5(24)

1(5)

21

1(6)

3(19)

9(56)

2(13)

1(6)

16

4(7)

12(22)

25(46)

12(22)

2(4)

55

AgeGroup(%)

I III Total

Age distribution

II

1(6)

2(11)

10(56)

5(28)

-

18

30-39

40-49

50-59

60-69

70

Total

I

II

III

Total

GroupClinical stage

I II III Total

Relationship between primary clinical stage and recurrent group

9

3

1

13

2

3

12

17

10

12

3

25

21

18

16

55

Cumulative 5 year survival according to histological cell type

0

20

40

60

80

100

120

0 6 12 18 24 30 36 42 48 54 60months

surv

ival

(%)

p< 0.01

AdenocarcinomaAdenocarcinoma

Adenosqumou cell cancerAdenosqumou cell cancer

Squamous carcinomaSquamous carcinoma

46%

20%

12%0

20

40

60

80

100

120

0 6 12 18 24 30 36 42 48 54 60

18%

52%

months

AdenocarcinomaAdenocarcinoma

Squamous carcinomaSquamous carcinoma

P= 0.05

Ijaz et al., 1998 Kim et al ., 2003 (Yonsei Univ.)

Cumulative 5 year survival according to groups

0 6 12 18 24 30 36 42 48 54 60

0

20

40

60

80

100

months

surv

ival

(%)

p< 0.01

Group IIIGroup IIIGroup IIGroup IIGroup IGroup I

48%

16%

12%

Kim et al ., 2003 (Yonsei Univ.)

Cumulative 5 year survival according to treatment modalities

0 6 12 18 24 30 36 42 48 54 60

0

20

40

60

80

100

months

surv

ival

(%)

ChemotherapyChemotherapyRadiotherapyRadiotherapyChemoradiotherapyChemoradiotherapy

16%

12%

Kim et al ., 2003 (Yonsei Univ.)

Conclusions

Control of vaginal recurrence of cervical cancer remains beyond the reach of current treatment modalities. Because the benefits of the various therapies are not great, every effort should be made to enroll patients on new trials such as paclitaxel chemotherapy, amiphostine chemoprotection, combined use of retinoic acids, and gene therapy.