Long-term analysis of clinical outcome and complications in locally advanced cervical cancer patients administered concomitant chemoradiation followed by radical surgery
Introduction
Since the 1999 NCI Clinical Announcement, exclusive concomitant chemoradiotherapy (CT/RT) has been representing the standard treatment for locally advanced cervical cancer (LACC) patients based on results from 5 randomized phase III studies that demonstrated an advantage in terms of disease-free (DFS) and overall survival (OS) for CT/RT compared to exclusive radiotherapy [1], [2], [3], [4], [5], [6]. However, investigational strategies employing completion surgery after chemotherapy or CT/RT have been also explored with the aim to remove potentially chemo- and radioresistant tumor foci and improve local control and possibly overall survival [2], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16]. Indeed, preoperative CT/RT has been reported to achieve very encouraging results in terms of extent of local control and overall survival [11], [12], [13], [14], although concerns remain about the potential increase of rate and severity of treatment-related complications [2], [9], [11], [14].
Previously reported long-term analyses of clinical outcome and toxicity profile of CT/RT plus completion surgery refer to relatively small sample series [9], [15], [16] which are hardly comparable because of the differences in the distribution of patients according to stage of disease [15] or use of additional treatments such as preoperative aortic irradiation, or intraoperative radiotherapy [9]. On the other hand, the reliability of more recent series, which otherwise have presented a quite acceptable sample size is heavily impaired by the heterogeneity of surgical approaches including extrafascial versus radical hysterectomy as well as pelvic lymphadenectomy versus only aortic lymph node dissection [13], [14].
The aim of this study was to analyze the long-term clinical outcome and complication profile of a strategy employing radical surgery after CT/RT in a large, prospectively collected, single-institution series of LACC patients.
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Patients and methods
The study prospectively included 184 consecutive LACC patients accrued between March 1996 and June 2007 at the Gynecologic Oncology Units of the Catholic University of Campobasso and Rome. Inclusion criteria were the following: biopsy-proven carcinoma of the cervix (stage IB2–IVA), no evidence of disease outside the pelvis, age < 80 years, Eastern Cooperative Oncology Group performance status < 2, adequate bone marrow function (WBC > 3000, platelets > 120,000/mm3), adequate renal function (blood urea
Results
The clinicopathological characteristics and surgery details of patients in the overall series are summarized in Table 1. Overall, median age was 52.5 years (range = 25–79 years); 136 patients (73.9%) were FIGO stage IIB, while 38 cases (20.6%) had stage III–IVA disease. Seventy patients (38.0%) had positive pelvic lymph nodes at staging work up.
Fig. 1 shows the flowchart of our patients' population: 2 patients died during/after chemoradiation as a result of causes unrelated to treatment, leaving
Discussion
Even with the advent of exclusive chemoradiation, which has been recognized since 1999 as the standard treatment for LACC, the 5-year OS in this subset of patients still remains around 70%, so that the encouraging results from strategies which have revisited the role of completion surgery after CT/RT seem worthwhile [9], [16]. In this scenario, results of our study could represent a contribution to the literature since they are based on a large, prospectively collected sample population endowed
Conflict of interest statement
The authors have no conflict of interest to report.
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