Contribution of surgery in patients with bulky residual disease after chemoradiation for advanced cervical carcinoma

doi:10.1016/j.ejso.2006.10.011

European Journal of Surgical Oncology (EJSO)

Volume 33, Issue 4, May 2007, Pages 498-503

https://doi.org/10.1016/j.ejso.2006.10.011 Get rights and content

Abstract

Aim

To report the outcome of 30 patients who underwent surgery after concomitant chemoradiation for locally advanced cervical cancer with residual disease ≥2 cm.

Methods

From 1988 to 2004, 143 patients with FIGO stage IB2–IVA cervical cancer underwent surgery after concurrent chemoradiotherapy. Among them, 30 had a residual cervical tumour ≥2 cm prior to surgery. Surgery consisted in a simple or radical hysterectomy (n = 15) or in a pelvic exenteration (n = 15). Endpoints were recurrence and distant metastasis rates, overall survival (OS) and disease-free survival (DFS) at 3 and 5 years. Analysis included FIGO stage, response to chemoradiation, para-aortic lymphatic status or type of surgery: palliative (remaining disease after surgery) or curative (no evidence of remaining disease after surgery).

Results

Surgery has been only palliative in 11 cases. Pelvic recurrences occurred in 8 patients after a median interval of 8.8 months. Distant metastases occurred in 8 patients after a median interval of 13 months. So far, 16 patients have died (53.3%). The 3-year and 5-year OS rates are 64.9% and 55.6%, respectively, for the 19 patients who had a curative surgery. The DFS rate is 50.8% at 3 and 5 years in this latter group. Overall 12 patients (40%) are alive and free of disease after a median follow-up of 32.5 months.

Conclusions

Adjuvant surgery may improve the outcome of patients with bulky residual tumour after chemoradiation for locally advanced cervical cancer, allowing a 5-year OS of 55.6% after curative intervention.

Introduction

Despite the decrease in the incidence of invasive cervical carcinoma thanks to the screening for dysplasias, locally advanced cervical tumours remain not exceptional. Two therapeutic options are then to consider: either neoadjuvant chemotherapy followed by surgery or concomitant chemoradiation followed by endocavitary brachytherapy, the latter being the standard treatment.¹ The benefit of surgery after chemoradiation is debated and literature does not give much information.

In previous works, we have reported our experience of adjuvant surgery for locally advanced cancers (FIGO stage IB2–IVA).2, 3 In a recent study, Azria et al.⁴ suggest that additional surgery has probably no benefit for patients with bulky residual disease after chemoradiation. Their series included 10 patients with FIGO IB2/II cancers.

In this current work, we report the outcome of patients with bulky residual disease after chemoradiation and brachytherapy for stage IB2, IIA (>4 cm) and for stage IIB, IIIB and IVA cancers, who had an adjuvant surgery.

Section snippets

Patients and methods

From February 1988 to August 2004, 143 patients have been treated by concomitant chemoradiation therapy, brachytherapy and adjuvant surgical resection for locally advanced cervical cancer (FIGO stage IB2–IVA). A residual tumour measuring 2 cm or more (“bulky residual disease”) has been found at pathological examination of the surgical specimen in 30 patients (study group). This cut-off at 2 cm has been chosen to fit with a recent paper by Azria et al. on the same subject.⁴ Pre-treatment

Results

Table 1 shows the characteristics of the 143 patients according to the residual cervical tumour. Thirty patients had a residual disease ≥2 cm. Significant differences have been observed according to the histological type, the administration or not of brachytherapy, the type of surgery (curative or palliative), and the pelvic lymph node involvement. A residual tumour of 2 cm or more has been more frequently observed in the adenocarcinoma cases when compared with the squamous carcinoma cases, or if

Discussion

Persistent residual tumour after radiotherapy or chemoradiotherapy is a major adverse factor.6, 7 Only 63% of the patients with residual disease ≥2 cm could benefit from curative surgery whereas the proportion of patients who could undertake curative surgery was significantly higher (97.3%) among those who had no residual tumour (or <2 cm) after chemoradiation. In spite of residual bulky disease (≥2 cm), 15 patients out of 19 who had curative surgery did not develop any local recurrence, with

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145 patients with locally advanced cervical cancer were treated at our institution. Patients underwent RCT and IGABT, then hysterectomy (HT) as completion of treatment was performed, with the exception of patients with surgical contraindications, para aortic metastatic disease or patients who refused surgery. Clinical outcomes and morbidity were retrospectively reviewed in both groups. Local relapse free survival (LRFS), pelvic relapse free survival (PRFS) and overall survival (OS) were analyzed.
Completion HT was performed in 90 (62.1%) patients. Complete histological response and microscopic disease were found in 77 patients (85.6%). Local relapse was observed in 14 patients (9.6%) without differences between completion HT group and the definitive RCT and IGABT group (Odds Ratio OR = 1.73 [0.57–5.23], p = 0.33). The estimated 3-year LRFS and PRFS for the entire population were respectively 90% [84%–94%] and 93% [87%–96%], with no significant differences between them (respectively Hazard Ratio HR = 0.57 [0.20–1.64], p = 0.30 and HR = 0.37 [0.10–1.31], p = 0.12). The estimated 3-year OS rate for the whole population was 84% [75%–91%] with no significant differences between groups (HR = 0.81 [0.32–2.06], p = 0.65). Regarding morbidity, grade ≥ 2 vaginal toxicity was more frequent in the definitive RCT and IGABT group (43.6% vs 26.7%, p = 0.04). All grade 4 toxicity events were reported in the completion HT group.
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Contribution of surgery in patients with bulky residual disease after chemoradiation for advanced cervical carcinoma

Abstract

Aim

Methods

Results

Conclusions

Introduction

Section snippets

Patients and methods

Results

Discussion

Lancet

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Cancer Radiother

Gynecol Oncol