Elsevier

Gynecologic Oncology

Volume 144, Issue 1, January 2017, Pages 34-39
Gynecologic Oncology

Disease courses in patients with residual tumor following concurrent chemoradiotherapy for locally advanced cervical cancer

https://doi.org/10.1016/j.ygyno.2016.10.032Get rights and content

Highlights

  • 60% of patients with residual tumor did not show further progression without salvage treatment.

  • The type of salvage treatment did not affect survival.

  • Initial and residual tumor sizes were significant prognostic factors for survival.

Abstract

Objective

To investigate the disease course and identify prognostic factors for survival in patients with residual disease according to post-treatment magnetic resonance imaging (MRI) following definitive concurrent chemoradiotherapy (CCRT) for locally advanced cervical cancer.

Methods

We reviewed clinical data from the medical records of 545 consecutive women with biopsy-proven, International Federation of Gynecology and Obstetrics stage IB2–IVA uterine cervical cancer treated with CCRT. Post-treatment MRI was checked in all patients 3 months after CCRT completion. Out of the 545 patients, 53 with residual cervical cancer based on MRI following definitive CCRT were included in this analysis.

Results

Thirty-two patients were disease-free at the last follow-up. Of them, 31 had a residual tumor size of ≤ 2 cm. Of these 32 women, 30 showed spontaneous regression of residual tumor during follow-up without salvage treatments, whereas the remaining two were alive with no evidence of disease after salvage surgery and chemotherapy. Disease progression was observed in 21 patients, including 7 local, 8 distant and 6 local and distant failures. Of these 21 women, 13 died of disease, 6 were alive with disease, and 2 remained disease-free after salvage treatments. Initial and residual tumor sizes were significant prognostic factors for overall survival; only residual tumor size was significant for local progression-free survival.

Conclusions

About 60% of patients with residual disease detected on post-treatment MRI remained disease-free without further disease progression. Careful observation without immediate salvage treatments might be feasible in selected patients with a residual tumor size ≤ 2 cm.

Introduction

Cisplatin-based concurrent chemoradiotherapy (CCRT) has become the standard treatment for bulky and locally advanced cervical cancer [1]. However, the disease course and appropriate salvage treatments of patients with residual cervical tumor following definitive CCRT remain undefined. By reference to preoperative CCRT results due to a lack of reports after definitive CCRT, as many as 30%–65% of patients still have residual disease after preoperative CCRT [2], [3]. Completion surgery following preoperative CCRT to eliminate potential residual disease and obtain better outcomes has been attempted, but the results did not indicate a survival benefit [4], [5]. Another possible approach is additional chemotherapy, but its role also remains inconclusive [6].

Several imaging modalities, including computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET), can be used to assess the tumor response after CCRT in cervical cancer. MRI is more effective than CT for evaluating the response and extents of disease after CCRT [7], and PET is more useful for measuring tumor metabolism than MRI. However, the appropriate timing of the use of imaging modalities to evaluate the tumor response varies from 1 to 2 months after treatment completion, and PET is often done at 3 months post completion of treatment according to investigators at Washington university [3], [8], [9], [10].

In our institution, pelvic MRI has routinely been performed as a baseline evaluation before CCRT, prior to brachytherapy, and at 3 months after the completion of CCRT. In the present study, the authors retrospectively reviewed the disease courses in women with residual disease detected by post-treatment MRI to compare the prognosis according to salvage treatment and to identify prognostic factors related to survival.

Section snippets

Methods

From 1998 to 2013, 545 consecutive women with biopsy-proven, International Federation of Gynecology and Obstetrics (FIGO) stage IB1 to IVA uterine cervical cancer were treated with curative radiotherapy (RT). Because 52 were lost to follow-up, post-treatment MRI data were available in 493 women. Of the 493 patients, 384 achieved a complete response, 13 had progressive disease outside of the RT field, and 96 had residual tumors. Of the 96 women with residual disease, 53 met the following

Results

The characteristics of the 53 women analyzed in this study are listed in Table 1. Eight patients (15.1%) had non-squamous cell carcinoma: five had adenocarcinoma, one had adenosquamous, one had glassy cell carcinoma, and one had poorly differentiated carcinoma. The size of the primary tumor ranged from 2.7 to 10.0 cm (median, 5.0 cm). The characteristics of the residual disease based on post-treatment MRI are summarized in Table 2. The size of the residual tumor ranged from 0.3 to 4.6 cm (median,

Discussion

In the present study, we analyzed the disease courses and patterns of failure in cervical cancer patients with residual disease on post-treatment MRI, finding that about 60% of patients remained progression free. In patients with disease progression after CCRT, the incidences of local and distant progression were similar. Furthermore, more than half of further disease progression occurred within 1 year from the initial CCRT. Although salvage surgery may be helpful to evaluate pathologic

Conflict of interest statement

The authors have no conflict of interest to report.

Acknowledgement

This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIP) (NRF-2016R1C1B2012823).

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1

Ja Young Kim and Sang Jun Byun contributed equally to this work and are considered co-first authors.

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