| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology, National Hospital Kure Medical Center, Chugoku Cancer Center, Kure, Japan; and the Department of Obstetrics and Gynecology, Hiroshima University School of Medicine, Hiroshima, Japan.
Address reprint requests to: Kazushi Shigemasa, MD, PhD, Department of Obstetrics and Gynecology, Hiroshima University School of Medicine, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan; E-mail: kaz{at}mcai.med.hiroshima-u.ac.jp.
 |
ABSTRACT |
|---|
TOP
 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
METHODS: Patients (n = 827) with invasive cervical carcinoma were treated and received follow-up care for up to 29 years. Late recurrence was defined as recurrence more than 5 years after initial therapy. The probability of late recurrence was evaluated in terms of clinical stage, histologic type, and type of initial therapy.
RESULTS: Late recurrence was seen in 21 of 569 patients who had survived 5 years (3.7%). Recurrence rates were 1.8% (six of 331) in stage I, 5.2% (eight of 154) in stage II, 8.6% (seven of 81) in stage III, and 0% (none of three) in stage IV. The probability of late recurrence in patients with stage I disease was significantly lower than that in stage II and stage III diseases (stage I compared with stage II, P = .038, stage I compared with stage III, P = .002). Late recurrence occurred in 21 (3.8%) of 547 cases of squamous cell carcinoma, whereas no late recurrences were found in 22 cases of adenocarcinoma. The late recurrence rate in patients who received radiation (7.1%, 17 of 241) was significantly higher than that in patients who received surgery (1.2%, four of 328; P = .001).
CONCLUSION: Patients with uterine cervical squamous cell carcinoma, especially those with stage II or stage III diseases who received radiation therapy as initial treatment, warrant annual follow-up care beyond the standard 5 years after initial therapy.
Deaths resulting from cancer of the cervix occur most frequently in the first years after therapy: about half of all deaths occur in the first year, 25% occur in the second year, and 15% occur in the third year, for a total of approximately 90% by the end of the third year.1,2 Paunier et al3 indicated that 92.5% of deaths resulting from carcinoma of the cervix occur in the first 5 years after diagnosis. However, we sometimes find patients with recurrences of uterine cervical carcinoma after a long tumor-free period. After initial therapy for cervical carcinoma, adequate follow-up care is the key to early detection of cancer, which may recur over 5 years later. Because few studies regarding late recurrence of cervical carcinoma have been reported, it is worthwhile to investigate the risk factors that may contribute to it. In the present study, we estimated the probability of and risk factors for recurrence of uterine cervical carcinoma at over 5 years after initial therapy.
|
MATERIALS AND METHODS |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
2 test and Fisher exact test of significance were used to test for a relationship between the probability of late recurrence and clinicopathologic factors. Values were considered statistically significant at the level of P < .05. |
RESULTS |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
. Actuarial 5- and 10-year survival rates and confidence intervals (CI) are shown in Table 1. Five-year actuarial survival rates were 70.5% (CI 0.68, 0.73) of total population, 88.7% (CI 0.86, 0.92) for stage I disease, 65.9% (CI 0.60, 0.72) for stage II disease, 45.6% (CI 0.39, 0.52) for stage III disease, and 14.2% (CI 0.01, 0.29) for stage IV disease.
|
|
). Ages at late recurrence ranged from 42 to 69 years, with a mean of 55.6 years. The period from initial therapy to recurrence ranged from 61 to 140 months, with a mean of 99.4 months. Most (17 of 21, 80.9%) patients had recurrences 5–10 years after initial therapy, whereas four of 21 patients had recurrences after 10 years of follow-up. Late recurrence rate at 10 years after initial therapy was 3.0% (17 of 569 patients surviving 5 years). The probability of recurrence more than 5 years after initial therapy, evaluated in terms of clinical stage, histologic type, and type of initial therapy, is shown in Table 2. Late recurrence occurred in six patients (1.8%) with stage I disease, eight patients (5.2%) with stage II disease, seven patients (8.6%) with stage III disease, and none with stage IV disease. The probability of late recurrence in stage I disease was significantly lower than that in stage II and stage III diseases (stage I compared with stage II, P = .038, stage I compared with stage III, P = .002). Histologically, late recurrence occurred in 21 (3.8%) of 547 squamous cell carcinoma patients, whereas there were no instances of late recurrence found in 22 cases of adenocarcinoma. There was no significant difference in the probability of late recurrence between squamous cell carcinoma patients and adenocarcinoma patients. Late recurrence occurred in 17 (7.1%) of 241 patients who had received radiation therapy and in four (1.2%) of 328 patients who had undergone surgery. The probability of late recurrence in patients who had received radiation therapy was significantly higher than that for patients who had undergone surgery as initial treatment (P = .001).
|
shows the sites of late recurrence. Ten of 21 patients had locoregional recurrence, which was proven cytologically and/or histologically, four in the vaginal stump, four in the cervix, and two in the pelvic wall. Lymph node recurrences were found in nine patients, six in the para-aortic nodes, two in the supraclavicular nodes, and one in the inguinal nodes. Distant recurrences were verified in six patients, four in bone, one in the liver, and one in the lung. Two patients were proven to have recurrences in para-aortic nodes and bone, one in para-aortic nodes and the liver, and one in supraclavicular nodes and bone. Out of four late recurrences in patients who had undergone surgery as initial treatment, all showed recurrences at vaginal stump. Out of 17 late recurrences in patients who had received radiation therapy, six patients revealed local recurrences, nine patients revealed lymph node recurrences, and six patients revealed distant recurrences. It was found that surgery as initial treatment was significantly associated with vaginal stump recurrence, whereas radiation as initial treatment was significantly associated with lymph node and/or distant recurrence (P = .017).
|
. Smear abnormalities, atypical genital bleeding, and abdominal pain were common symptoms of late recurrence. For 21 late recurrent cases, radiation therapy was administered to 12 patients; in two of these patients, radiation therapy was supplemented with the use of 5-fluorouracil. Chemotherapy was administered to nine patients. Of 21 patients with late recurrence, 17 died.
|
|
DISCUSSION |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
The present study demonstrated that the probability of late recurrence in patients with stage II or stage III diseases was significantly higher than in those with stage I disease. Only three of 24 patients with stage IV disease survived at 5 years after initial therapy in the present study. Although the sample size is too small to be conclusive, patients with stage IV disease would likely have recurrence in the early years after initial therapy. We also demonstrated that the probability of late recurrence in patients who had received radiation therapy was significantly higher than that in patients who had received surgery as initial treatment. Other studies have also reported that few recurrences arise later than 5 years after the primary surgical procedure.9–11 These results suggest that advanced stage (stage II or III) and radiation therapy as initial treatment could be risk factors for late recurrence in 5-year survivors of invasive cervical cancer. All late recurrent cases were found to be squamous cell carcinoma in the present study. Van Herik et al9 demonstrated that the primary pathologic diagnosis of 16 patients who had recurrence more than 10 years after primary diagnosis was squamous cell carcinoma, with one exception. Although our study failed to demonstrate a significant difference between squamous cell carcinoma and adenocarcinoma in the probability of late recurrence, patients who had adenocarcinoma of the cervix may have had recurrence in the early years after initial therapy. Squamous cell carcinoma may have more potential to recur after a long period of dormancy than does adenocarcinoma.
Although the sites of recurrence varied in the present study, locoregional recurrence was most often found in late recurrent cases. Para-aortic lymph node and bone were also often involved. Van Herik et al9 reported that the organs and tissues within the pelvis were most frequently involved in patients who had recurrence more than 10 years after primary therapy, and that bony metastases or extensions of the recurrence into bone were found in 25% of these patients. It has been shown that bony metastases of cervical cancer are particularly rare, especially at initial staging and diagnosis.12 However, bone should be considered to be one of the more common sites of late recurrence of invasive cervical carcinoma. The interesting finding in the present study was that surgery as initial treatment was associated with vaginal stump recurrence, whereas radiation as initial treatment was associated with lymph node and/or distant recurrence.
Smear abnormalities, atypical genital bleeding, and abdominal pain were the most common symptoms and signs of late recurrence in the present series. The latest recurrence found in the present study occurred 140 months after initial treatment. These data suggest that patients with invasive cervical squamous cell carcinoma, especially those with stage II or stage III diseases who had received radiation therapy as initial treatment, warrant annual follow-up care for over 5 years after initial therapy. Because our data in the present study showed most of patients had late recurrences 5–10 years after initial therapy, at least 10 years of follow-up might be expected. Regular gynecologic follow-up assessments should include a careful pelvic examination and vaginal or cervical Papanicolaou smear. Computed tomography and bone survey may be necessary for patients with symptoms and signs of late recurrence, especially in patients who received radiation as initial treatment. The prognosis of late recurrent invasive cervical cancer is poor; therefore, the gynecologist should always consider that recurrences of cervical cancer might occur even after long periods of dormancy. Adequate follow-up care is the key to early detection of cancer that recurs over 5 years after initial therapy.
|
Footnotes |
|---|
Received February 16, 2001. Received in revised form May 30, 2001. Accepted June 7, 2001.
|
REFERENCES |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
2. Fuller AF, Elliott N, Kosloff C, Hoskins WJ, Lewis JL Jr. Determinants of increased risk for recurrence in patients undergoing radical hysterectomy for stage Ib and IIa carcinoma of the cervix. Gynecol Oncol 1989;33:34–9.[Medline]
3. Paunier JP, Delclos L, Fletcher GH. Causes, time of death, and sites of failure in squamous-cell carcinoma of the uterine cervix on intact uterus. Radiology 1967;88: 555–62.[Medline]
4. International Federation of Gynecology and Obstetrics (FIGO) Committee on Gynecologic Oncology, Benedet JL, Bender H, Jones H III, Ngan HYS, Pecorelli S. FIGO staging classifications and clinical practice guidelines in the management of gynecological cancers. Int J Gynecol Obstet 2000;70:209–62.[Medline]
5. Wright TC, Ferenczy A, Kurman RJ. Carcinoma and other tumors of the cervix. In: Kurman RJ, ed. Blaustein’s pathology of the female genital tract. New York: Springer-Verlag, 1995:279–326.
6. Cutler SJ, Ederer F. Maximum utilization of the life table method in analyzing survival. J Chronic Dis 1958;8: 699–712.[Medline]
7. Decker DG, Van Herik M. Survival in invasive carcinoma of the cervix five to ten years after radiation therapy. Am J Roentgenol 1961;85:488–96.
8. Van Herik M, Friche RE. The results of radiation therapy for recurrent cancer of the cervix uteri. Am J Roentgenol 1955;73:437–41.
9. Van Herik M, Decker DG, Lee RA, Symmonds RE. Late recurrence in carcinoma of the cervix. Am J Obstet Gynecol 1970;108:1183–6.[Medline]
10. Munnell EW, Bonney WA. Critical points of failure in the therapy of cancer of the cervix. Am J Obstet Gynecol 1961;81:521–34.[Medline]
11. Brunschwig A. Surgical treatment of carcinoma of the cervix, recurrent after irradiation or combination of irradiation and surgery. Am J Roentgenol 1967;99:365–71.[Abstract]
12. Disaia PJ, Creasman WT. Clinical gynecologic oncology. St Louis: Mosby Year Book, 1993.
This article has been cited by other articles:
|
|
 |
|
  P. Morice, C. Deyrolle, A. Rey, D. Atallah, P. Pautier, S. Camatte, A. Thoury, C. Lhomme, C. Haie-Meder, and D. Castaigne Value of routine follow-up procedures for patients with stage I/II cervical cancer treated with combined surgery-radiation therapy Ann. Onc., February 1, 2004; 15(2): 218 - 223. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
