16 Cervix Carcinoma

Cervix Cancer 305

5 Indications Indications for brachytherapy will be divided according to stage, schematically separated between limited disease and locally extensive disease. Brachytherapy combined or not with external beam radiotherapy and/or with surgery plays a crucial role in invasive cervical cancer treatment (stage I-IVA) as it permits the delivery of a very high radiation dose to the central pelvis, while sparing bladder, rectum and small bowel. Uterovaginal brachytherapy should therefore always be considered as a major curative or palliative treatment option. 5.1 Limited Disease Limited disease in invasive cancer of the cervix is stage IA/B1 and stage IIA/B (with a tumour size of less than 4cm) /, tumour extension limited to the upper third of the vagina and/or to the internal third of the parametrium and accessible by brachytherapy. There is no standard treatment and different treatment protocols may be applied: surgery alone; radiotherapeutic and surgical combinations; radiation therapy alone: brachytherapy alone, brachytherapy with additional external beam irradiation. 5.1.1 Surgery alone Classical surgery is the transabdominal approach according to Wertheim-Meigs: en bloc tumour resection including total hysterectomy, partial colpectomy, bilateral oophorectomy, and systematic pelvic lymphadenectomy, starting usually with paraaortic lymph node assessment (10,11,20,77). More recently, a vaginal surgical approach according to the classical technique of Schauta has been reported assisted by laparoscopic pelvic lymphadenectomy (21,43,67). 5.1.2 Radiotherapeutic and surgical combinations Brachytherapy in the setting of these radiotherapeutic and surgical combinations aims at sterilisation of microscopic disease, at performance of surgery in tissues sterilised from tumour, at reduction of extensive surgery allowing an increase in local control with a decrease in surgical morbidity (compared to radical surgery alone). Surgery in this setting aims to remove eventual residual macroscopic and microscopic disease in the tumour region, to increase locoregional control, to assess lymph node status by the performance of lymphadenectomy and so aid selection of indications for external beam irradiation, and to decrease morbidity from brachytherapy (compared to the combination of external irradiation and brachytherapy). To obtain optimal results, brachytherapy and surgery must be individually adapted for each case and treatment combination (39,42). 5.1.2.1 Uterovaginal brachytherapy followed by surgery +/- postoperative external irradiation A uterovaginal brachytherapy is performed, followed six weeks later by surgery which consists of total hysterectomy with adapted resection of the parametria, partial limited colpectomy, and bilateral oophorectomy, and pelvic lymphadenectomy. After surgery external beam irradiation with concomitant chemotherapy is given if there are positive pelvic nodes.