Assessment of Salvage Surgery in Persistent Cervical Cancer after Definitive Radiochemotherapy: A Systematic Review

Abstract

Background and Objectives: The standard treatment approach in locally advanced cervical cancer (LACC) is exclusive concurrent chemoradiation therapy (RTCT). The risk of local residual disease after six months from RTCT is about 20–30%. It is directly related to relapse risk and poor survival, such as in patients with recurrent cervical cancer. This systematic review aims to describe studies investigating salvage surgery’s role in persistent/recurrent disease in LACC patients who underwent definitive RTCT. Materials and Methods: Studies were eligible for inclusion when patients had LACC with radiologically suspected or histologically confirmed residual disease after definitive RTCT, diagnosed with post-treatment radiological workup or biopsy. Information on complications after salvage surgery and survival outcomes had to be reported. The methodological quality of the articles was independently assessed by two researchers with the Newcastle–Ottawa scale. Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, we systematically searched the PubMed, Scopus, Cochrane, Medline, and Medscape databases in May 2022. We applied no language or geographical restrictions but considered only English studies. We included studies containing data about postoperative complications and survival outcomes. Results: Eleven studies fulfilled the inclusion criteria and all were retrospective observational studies. A total of 601 patients were analyzed concerning the salvage surgery in LACC patients for persistent/recurrent disease after RTCT treatment. Overall, 369 (61.4%) and 232 (38.6%) patients underwent a salvage hysterectomy (extrafascial or radical) and pelvic exenteration (anterior, posterior, or total), respectively. Four hundred and thirty-nine (73%) patients had histologically confirmed the residual disease in the salvage surgical specimen, and 109 patients had positive margins (overall range 0–43% of the patients). The risk of severe (grade ≥ 3) postoperative complications after salvage surgery is 29.8% (range 5–57.5%). After a median follow-up of 38 months, the overall RR was about 32% with an overall death rate of 40% after hysterectomy or pelvic exenteration with or without lymphadenectomy. Conclusions: There is heterogeneity between the studies both in their design and results, therefore the effect of salvage surgery on survival and recurrence cannot be adequately estimated. Future homogeneous studies with an appropriately selected population are needed to analyze the safety and efficacy of salvage hysterectomy or pelvic exenteration in patients with residual tumors after definitive RTCT.

Comparing Methods to Determine Complete Response to Chemoradiation in Patients with Locally Advanced Cervical Cancer

“…The recurrence rate after salvage surgery in our study is based on small numbers and is comparable with the reported literature. Two previously published systematic reviews reported overall relapse rates of 32% and 31% after salvage surgery [ 10 , 28 ]. In addition to the recurrence rate, Sardain et al reported that salvage exenteration for recurrent disease increased the five-year OS from 20% to 64% [ 29 ].…”

“…These patients have an unfavorable prognosis, with a reported 5-year survival rate of less than 5% [ 9 ]. Patients treated with CRT are clinically and/or radiologically examined during the follow-up period to evaluate the response rate of CRT [ 10 ]. Detection of locoregional residual disease can be challenging due to the effects of radiotherapy [ 11 ].…”

“…When central pelvic residual disease is radiologically suspected and/or histologically proven, without signs of metastatic disease, salvage surgery can be performed [ 7 ]. Salvage surgery, such as salvage hysterectomy or exenteration, are procedures associated with a high risk of complications and a negative impact on the quality of life of patients [ 5 , 10 ]. Therefore, a diagnostic procedure that is highly reliable in the detection of locoregional residual disease is important to select patients who would benefit from salvage surgery.…”

Abdominal type B vs. type C radical hysterectomy in early-stage cervical cancer: A matched single center cohort report

“…The recommendations for stage IA2 patients, and stage IB1, IB2 and selected IIB3-IIA1 patients who do not desire fertility preservation, are type B radical hysterectomy (RH) and type C RH, respectively ( 1 , 2 ). For patients with advanced disease, it is still inconclusive whether salvage hysterectomy either extrafascial or radical is effective in persistent or recurrent disease after definitive chemoradiation therapy ( 3 ).…”

Clinical value of conventional magnetic resonance imaging combined with diffusion-weighted imaging in predicting pelvic lymph node metastasis of cervical cancer

“…The persistent global disease burden of CC underscores the crucial need for early detection and tertiary prevention, especially in resource-limited settings. A recent report showed that pelvic lymph node (PLN) involvement reduced the 5-year survival rate for CC from 91.2% to 59.8% (5), significantly affecting the prognosis and shifting treatment from surgery to chemoradiation or brachytherapy (6)(7)(8). Guidelines recommend radiological imaging (computed tomography [CT], magnetic resonance imaging [MRI], and positron emission tomography [PET]/CT) for CC at stage IB2 or greater, particularly for nodal or extrapelvic tumor evaluation (7).…”