Salvage surgery for patients with residual disease after chemoradiation therapy for locally advanced cervical cancer: A systematic review on indication, complications, and survival

Abstract

Introduction Standard treatment for locally advanced cervical cancer is chemoradiation therapy. Treatment with chemoradiation therapy harbors a risk of local residual disease, which can be curatively treated with salvage surgery, but the risk of complications following surgical procedures in radiated tissue is not negligible. The presence of residual disease can be radiologically and/or histologically diagnosed. The objective of this study is to describe studies that report on salvage surgery for patients with locally advanced cervical cancer after primary treatment with chemoradiation therapy. Therefore, we assessed the method of determining the presence of residual disease, the risk of complications, and the survival rate after salvage surgery. Material and methods PubMed, EMBASE, and the Cochrane database were searched from inception up to 6 March 2020. Titles and abstracts were independently assessed by two researchers. Studies were eligible for inclusion when patients had locally advanced cervical cancer with radiologically suspected or histologically confirmed residual disease after chemoradiation therapy, diagnosed with a CT, MRI, or PET‐CT scan, or biopsy. Information on complications after salvage surgery and survival outcomes had to be reported. Methodological quality of the articles was independently assessed by two researchers with the Newcastle‐Ottawa scale. Results Of the 2963 screened articles, six studies were included, representing 220 women. A total of 175 patients were treated with salvage surgery, of whom 27%‐100% had residual disease on the surgery specimen. Of the 161 patients treated with salvage surgery based on positive biopsy results, 72%‐100% showed residual disease on the surgery specimen. Of the 44 patients treated with salvage surgery based on suspected residual disease on radiology, 27%‐48% showed residual disease on the salvage surgery specimen. A total of 105 complications were registered in 175 patients treated with salvage surgery. The overall survival rate after salvage surgery was 69% (mean follow‐up period of 24.9 months). Conclusions It is necessary to confirm residual disease by biopsy before performing salvage surgery in patients with locally advanced cervical cancer primarily treated with chemoradiation therapy. Salvage surgery only based on radiologically suspected residual disease should be avoided to prevent unnecessary surgery and complications.

Post treatment imaging in patients with local advanced cervical carcinoma

“…The role of completion surgery after CCRT is currently controversial, since surgery has a high postoperative morbidity ( 12 , 13 ). The rate of residual disease after CCRT is 40%, and these patients generally have a poor prognosis because they show scarce response to cisplatin-based chemotherapy ( 14 ). In these cases, some authors propose radical hysterectomy as an adjunctive treatment, although no guidelines recommend it as a treatment for residual tumors.…”

“…and Cochrane et al. observed no significant differences in DFS and OS ( 17 , 18 ).According to Kim G. Van Kol, salvage surgery should be performed only if residual disease is histologically confirmed by biopsy in patients treated with CCRT, to avoid unnecessary surgery and complications ( 14 ). Surgery after CCRT undoubtedly leads to improved local control rates; however, distant recurrence often occurs in LACC ( 19 ).…”

Adjuvant Hysterectomy for Cervical Cancer Patients Treated with Chemoradiation Therapy: A Systematic Review on the Pathology-Proven Residual Disease Rate

“…However, the time between chemoradiation therapy and adjuvant hysterectomy has not been assessed before [ 4 , 9 ]. Performing adjuvant hysterectomy after chemoradiation therapy is associated with a high complication risk because of radiation-induced tissue damage and reduced propensity to healing [ 11 , 12 ]. This may negatively influence the quality of life of patients.…”

Efetividade e custo-efetividade da braquiterapia guiada por imagem 3D versus braquiterapia convencional (2D) em pacientes com câncer do colo uterino

“…Decidimos, então, para fins do modelo, listar dados apenas dos estudos primários incluídos em nossa revisão que utilizaram quimioterapia, EBRT e BT de HDR ou BT de PDR, para evitar outros fatores de confusão além dos já existentes devido ao desenho observacional dos estudos. [15][16][17][72][73][74]78 Como os dados das revisões sistemáticas não foram suficientes para fornecer informações para todos os parâmetros do modelo, utilizamos como fonte adicional de dados grandes estudos de coortes de pacientes tratadas com BT 3D guiada por RM 126,131 e guiada por TC, 132 resultados de um dos braços de um estudo randomizado comparando os efeitos da BT 2D de HDR versus LDR (apenas o braço HDR), 133 dados de estudos que acompanharam pacientes após cirurgia de resgate, [134][135][136][137][138][139] dados provenientes dos modelos anteriores comparando BT 3D versus BT 2D, 123,124 A incidência relatada ao longo de um determinado período (em anos) foi convertida em probabilidade anual dividindo a incidência pelo tempo.…”

“…138 Kol et al publicaram uma revisão sistemática sobre cirurgia de resgate em pacientes com doença de colo uterino residual após quimiorradioterapia. 139 A Tabela 29 apresenta as probabilidades de sucesso (ausência de doença) após cirurgia de resgate, óbito relacionado à cirurgia de resgate, recorrência local e metástase à distância após cirurgia de resgate em populações de baixo e alto risco utilizadas no modelo. Assumimos que o risco de recorrência e progressão para metástase à distância após cirurgia de resgate diminui ao longo do tempo e é mínimo após cinco anos.…”