Bulky stage Ib and II squamous cell carcinoma of the uterine cervix treated by combined preoperative radiation therapy and surgery

Fifty-two women with stage Ib2 and II bulky squamous cell carcinoma of the uterine cervix (mean size : 5,65 +/- 0, 12 cm, range : 5-8 cm) were treated between July 1982 and December 1993. The median follow-up was 73 months. Their patient's age ranged from 25 to 77 years (median : 45 years). There were 18 stage Ib2, 8 stage IIa and 26 stage IIb operable patients. External radiotherapy was delivered using photons of 6 MV to 25 MV and a four-field <<box>> technique (upper limit situated between L4-L5). Mean total dose at mid-plane to the whole pelvis was 38.6 Gy (range : 37.4-40.6 Gy) in 18 fractions over 30 days. A boost dose of 20 Gy was given by intracavitary brachytherapy (utero-vaginal). After a mean rest of 48 days, total abdominal hysterectomy and bilateral salpingo-oophorectomy combined with bilateral pelvic lymphadenectomy was performed. Following surgery no remaining tumor on pathological examination of uterine cervix was observed in 39 cases (75 %) and positive external iliac nodes were found in 4 cases. Five- and 10-year specific survival rates were 80 % and 75 %, respectively. The 5-year local tumour recurrence and nodal recurrence rates were 18 % and 15 %, respectively There were 7 para-aortic nodal recurrences (3 were isolated para-aortic nodal relapses). There were five late severe complications necessiting surgical intervention. A combination of preoperative radiation therapy and concomitant chemotherapy and the extended dissection of common iliac and para-aortic lymph nodes or a post operative prophylactic extended field irradiation including para-aortic lymph nodes is now being attempted in order to improve the locoregional tumour and para-aortic lymph node control rates.