Impact of adjuvant hysterectomy for bulky cervical cancer after definitive chemoradiotherapy with insufficient brachytherapy dose: a retrospective analysis

Background: Concurrent chemoradiotherapy (CCRT) plus intracavitary brachytherapy (ICBT) is standard of care for locally advanced cervical cancer (LACC). However, because of differences in tissue response and anatomy, brachytherapy sometimes fails to deliver adequate doses and may result in higher recurrence rates. Thus, there have been studies discussing the role of adjuvant hysterectomy (AH). National Comprehensive Cancer Network cervical guidelines (NCCN ver. 2022.1) listed AH as an option after CCRT when patient has bulky tumor, disease extended or poor response to CCRT. The purpose of this study was to analyze the impact of AH on bulky cervical cancer patients after CCRT with insufficient brachytherapy dose. Methods: Forty-two patients had bulky (>4 cm) cervical cancer were treated with CCRT +/− ICBT with insufficient brachytherapy dose, after CCRT, 16 patients received observation and 26 patients received AH. The median follow-up of the study was 39 months. Survival analysis used the Kaplan-Meier method, log-rank test, and Cox proportional hazards model. Post-operative complication assessment is based on the need for long-term urological follow-up. Results: Forty-two patients who had bulky tumor (>4 cm), CCRT with insufficient brachytherapy dose followed by AH a tended to prolong the disease specific survival (DSS) (OR: 0.25, 95% CI: 0.09–0.71, P=0.001) compared with CCRT alone. In multivariate analysis, AH (OR: 0.27, 95% CI: 0.08–0.90, P=0.032) was reported as independent risk factors of DSS. Urinary complications occurred in 5 of 26 patients received hysterectomy and in 2 of 18 patients who received modified radical hysterectomy (Piver class II). Conclusions: In conclusion, patients with bulky cervical cancer failed to deliver adequate brachytherapy doses may achieve better outcomes combined with AH. Modified radical hysterectomy (Piver class II) was safe with complication rate of 11%. However, the advantage of AH on survival needs to be evaluated through further randomized control trials.