Age-standardized incidence of cervical cancer
in selected worldwide countries
Zimbabwe, Harare
Peru, Trujilo
India, Madras
Colombia, Cali
Argentina
India, Bombay
New Zealand, Maori
Costa Rica
Thailand
Mali, Bamako
Korea,Kangwha
US, SEER, Black
Canada
Denmark
Belgium
Israel
53.5
67.2
38.9
34.2
32.2
27.7
26.7
24.2
12.0
7.8
7.6
7.5
4.8
24.0
23.2
21.8
Rate per 100,000
( IARC, 1996 )
Cumulative 5 year survival
according to
120
Annual Report Gynecological Cancer, 1994
Stage I
Stage III
100
survival(%)
clinical stage
Stage I I
Stage IV
88%
80
Kim et al ., 2003 (Yonsei Univ.)
120
Stage I
Stage III
100
86%
80
69%
60
Stage I I
Stage IV
75%
60
40
41%
20
12%
0
52%
40
20
10%
0
0
6
12 18 24 30 36 42 48 54 60
months
0
6
12 18 24 30 36 42 48 54 60
months
Definition
Recurrence after radiation
A regrowth of tumor in the pelvis or distally, noted after
complete healing of the cervix and vagina have been
achieved.
Persistent disease after radiation therapy
The continuous presence of original tumor or the
development of a new tumor in the pelvis within 3 months
of radiotherapy completion
( DiSaia et al ., 1992 )
Definition
Recurrence after surgery
Evidence of a tumor mass after operation in which all
gross tumor was removed and the margins of the
specimen were free of disease.
Persistent disease after surgery
Defined as the continuous presence of gross tumor in the
operative field.
( DiSaia et al ., 1992 )
Incidence of recurrence
Kim et al ., 2003 (Yonsei Univ.)
300
251
No. of patients
227
Total number of patients
Recurrent cases
28.7%
72
26.0%
59
0
1990-95
1996-99 Year
Incidence of recurrence
according to clinical stage
Kim et al ., 2003 (Yonsei Univ.)
250
100%
No. of patients
80.0
47.5
Total number of patients
27.9
Recurrent cases
10.7
0%
0
I
II
Stage
III
IV
Colpophotograph of vaginal recurrence
Pre-treatment
Post-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
Classification of
Vaginal Recurrence of Cervical Cancer
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
Management of vaginal recurrence
Mode of previous treatment
Extent of recurrent disease
Patients’ 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 patients
Clinicopathologic analysis
Management modalities(radiation, chemotherapy, combination)
Age, Cell type, Previous treatment modalities,
Extent of recurrence,
Patient characteristics
Characteristics
Age( years)
Median
Range
FIGO stage at initial diagnosis
I
II
III
Histology type
Squamous cell carcinoma
Adenocarcinoma
Adenosquamous carcinoma
Previous treatment
Radiation
CTx + RTx
CTx + Surgery
Surgery
Time to recurrence (months)
Median
Patients
No.
Percent
58
38 - 75
13
17
25
23
31
46
43
8
4
78
14
8
19
15
2
19
34
28
3
35
10.5
Patient characteristics
Characteristics
Patients
No.
Percent
Extent of recurrence
group I
group II
group III
12
24
19
22
44
34
Treatment of recurrent cervical cancer
Radiotherapy
Chemotherapy
Radiotherapy + Chemotherapy
Surgery
20
24
8
3
36
43
16
5
Chemotherapy regimen
DDP + Taxol
DDP + 5-FU
DDP + VCR
DDP + ADR
Ifosfamide + Carboplatin + Cisplatin
8
10
3
2
9
25
31
9
6
29
Survival month (median)
21
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
Auther
Number of
Number of
Number
patients treated
operative deaths
surviving 5 years
23
1 (4.3%)
5 (22%)
Parsons and Friedell(1964)
112
24 (21.4%)
24 (21.4%)
Brunschwig(1967)
535
86 (16%)
108 (20.1%)
Bricker(1967)
153
15 (10%)
53 (34.6%)
35
4 (11%)
Ketcham er al.(1970)
162
12 (7.4%)
62 (38.2%)
Symmonds et al.(1975)
198
16 (8%)
64 (32.3%)
Douglas and Sweeney(1957)
Krieger and Embree(1969)
13 (37%)
34
1 (2.9%)
Rutledge et al.(1977)
296
40 (13.5%)
99 (33.4%)
Averette et al.(1984)
92
23 (25%)
34 (37%)
Lawhead et al.(1989)
65
6 (9.2%)
15 (23%)
Soper et al.(1989)
69
5 (7.2%)
28 (40.5%)
143
9 (6.3%)
71 (50%)
1917
242 (12.6%)
Morley and Lindenauer(1976)
Shingleton et al.(1989)
Total
21 (62%)
647
(33.8%)
Pelvic exenteration
Initial Age
stage
Type
Status
IB
53
post*
NED
9
IIA
43
post*
NED
11
IIB
47
post*
DOD
6
post*, posterior exenteraion;
NED, no evidence of disease;
DOD, dead of disease
Months of
follow-up
Age distribution
Group(%)
II
III
Age
I
30-39
2(10)
1(6)
1(6)
4(7)
40-49
7(33)
2(11)
3(19)
12(22)
50-59
6(29)
10(56)
9(56)
25(46)
60-69
5(24)
5(28)
2(13)
12(22)
70
1(5)
-
1(6)
2(4)
21
18
16
55
Total
Total
Relationship between primary clinical
stage and recurrent group
Group
Clinical stage
I
II
III
Total
I
9
2
10
21
II
3
3
12
18
III
1
12
3
16
Total
13
17
25
55
Cumulative 5 year survival
according to
Ijaz et al., 1998
120
Kim et al ., 2003 (Yonsei Univ.)
120
Squamous carcinoma
Squamous carcinoma
100
Adenocarcinoma
100
survival(%)
histological cell type
80
Adenosqumou cell cancer
Adenocarcinoma
80
52%
60
40
60
46%
40
18%
20
20%
20
P= 0.05
0
p< 0.01
0
0
6
12 18 24 30 36 42 48 54 60
months
0
12%
6 12 18 24 30 36 42 48 54 60
months
Cumulative 5 year survival
according to
groups
Kim et al ., 2003 (Yonsei Univ.)
survival(%)
100
80
48%
60
40
p< 0.01
20
0
16%
0
6 12 18
24 30 36
42 48 54
60
months
12%
Group I
Group II
Group III
Cumulative 5 year survival
according to treatment modalities
Kim et al ., 2003 (Yonsei Univ.)
100
Chemoradiotherapy
Radiotherapy
Chemotherapy
survival(%)
80
60
40
16%
20
12%
0
0
6
12
18
24
30
36
months
42
48
54
60
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.