Laterally Extended Endopelvic Resection Versus Chemo or Targeted Therapy Alone for Pelvic Sidewall Recurrence of Cervical Cancer

Abstract

BackgroundLaterally extended endopelvic resection (LEER) has been introduced for treatment of pelvic sidewall recurrence of cervical cancer (PSRCC), which occurs in only 8% of patients with relapsed cervical cancer. LEER can only be performed by a proficient surgeon due to the high risk of surgical morbidity and mortality, but there is no evidence as to whether LEER is may be more effective than chemo or targeted therapy alone for PSRCC. Thus, we aimed to compare the efficacy and safety between LEER and chemo or targeted therapy alone for treatment of PSRCC.MethodsWe prospectively recruited patients with PSRCC who underwent LEER between December 2016 and December 2019. Moreover, we retrospectively collected data on patients with PSRCC who received chemo or targeted therapy alone between January 2000 and December 2019. We compared treatment-free interval (TFI), progression-free survival (PFS), treatment-free survival (TFS), overall survival (OS), tumor response, neurologic disturbance of the low extremities, and pelvic pain severity in the different patient groups.ResultsAmong 1295 patients with cervical cancer, we included 28 (2.2%) and 31 (2.4%) in the prospective and retrospective cohorts, respectively. When we subdivided all patients into two groups based on the median value of prior TFI (PTFI, 9.2 months), LEER improved TFI, PFS, TRS and OS compared to chemo or targeted therapy alone (median, 2.8 vs. 0.9; 7.4 vs. 4.1; 30.1 vs. 16.9 months; P ≤ 0.05) in patients with PTFI < 9.2 months despite no difference in survival in those with PTFI ≥ 9.2 months, suggesting that LEER may lead to better TFI, PFS, TRS and OS in patients with PTFI < 9.2 months (adjusted hazard ratios, 0.28, 0.27, 0.44 and 0.37; 95% confidence intervals, 0.12-0.68, 0.11-0.66, 0.18-0.83 and 0.15-0.88). Furthermore, LEER markedly reduced the number of morphine milligram equivalents necessary to reduce pelvic pain when compared with chemo or targeted therapy alone.ConclusionCompared to chemo or targeted therapy alone, LEER improved survival in patients with PSRCC and PTFI < 9.2 months, and it was effective at controlling the pelvic pain associated with PSRCC.Trial RegistrationClinicalTrials.gov, identifier NCT02986568.

Safety and feasibility of laterally extended endopelvic resection for sarcoma in the female genital tract: a prospective cohort study

“…Therefore, the decision for surgical excision in recurrent sarcoma should be appropriately made according to the surgeon's judgment in consideration of the histologic type and the extent of surgery. Third, tumors in the pelvic sidewall cause neuropathic pain due to sciatic nerve compression or irritation [27,38]. In this study, we found no statistically significant reduction in pain due to the small sample size.…”

“…In this study, we found no statistically significant reduction in pain due to the small sample size. However, in our previous study, we reported that LEER significantly reduced pelvic sciatic pain and morphine requirements in patients with recurrent cervical cancer compared to chemotherapy [27]. However, before surgery, 55.9% of patients complained of moderate to severe pain 10 with an NRS score of 4 or higher; after surgery, the pain intensity decreased to an NRS score of 3 or lower.…”

“…A high R0 rate of 88.9% was achieved without severe complications. While the involvement of major vessels and the pelvic sidewall often impedes the decision of surgical resection, the LEER procedure enables gynecologic surgeons to resect pelvic sidewall tumors to achieve a higher rate of R0 resection [17,27]. Surgical resection of localized recurrent disease has significantly improved the local control of soft tissue sarcoma [28,29].…”

“…Based on our clinical experience with a prospective cohort of patients with sarcoma and recurrent cervical cancer [ 24 ], R0 resection can be achieved after careful review of physical and radiologic findings. As described by Höckel [ 17 ], LEER is contraindicated in pelvic sidewall tumors involving the external iliac vessels.…”

“…LEER was performed as previously described [21][22][23]. The main procedures are as follows: 1) midline incision; 2) bowel mobilization; 3) dissection of both ureters; 4) skeletonization of the mesosigmoid colon and mesorectum; 5) en bloc resection of pelvic sidewall tumors with ligation of the internal iliac artery and vein below the bifurcation level of the common iliac artery; 6) pelvic muscle (obturator internus muscle, coccygeus muscle, pubococcygeus muscle, and iliococcygeus muscle) resection depending on tumor involvement and topography; 7) resection of urethra, lower vagina, and anus through vulva incision; and 8) permanent colostomy or ileal conduit.…”