Recurrent squamous cell carcinoma of cervix after definitive radiotherapy

Purpose To study retrospectively the characteristics and survival of patients with recurrent squamous cell carcinoma (SCC) of the cervix after definitive radiotherapy (RT) and to identify subsets of patients who might benefit from aggressive salvage treatment. Methods and materials Between 1990 and 1999, 1292 patients with Stage I-IVA SCC of the cervix underwent full-course RT. Of the 1292 patients, 375 (29%) had either local or distant failure and were included in this analysis. The 35 patients (2.7%) with both pelvic and distant relapse were excluded. In the 162 patients with local failure, 71 (44%) had persistent disease and 91 (56%) had a relapse after complete tumor regression. Of these 162 patients, 47 (29%) received salvage surgery. In the 213 patients with distant failure, 46 (22%) had isolated para-aortic lymph node (PALN) metastasis, and 35 (76%) of them were treated with concurrent chemoradiotherapy/RT. Patients with supraclavicular lymph node (SCLN) relapse usually underwent concurrent chemoradiotherapy. Palliative chemotherapy and/or RT were given by decision of the responsible attending physician. Results The independent prognostic factors for local failure were advanced stage and young age (<45 years) and, for distant failure, were advanced stage, positive pelvic lymph nodes, and high serum SCC-antigen levels. The 5-year overall survival rate was 10% and 11%, respectively, for patients with local or distant failure. For local relapse, the 5-year overall survival rate was 29% vs. 3% (p = 0.0001) for patients with vs. without salvage surgery and 22% vs. 9% vs. 4% for patients with tumors confined to the cervix, tumors extending but not beyond the cervix and adjacent tissues, and tumor extending beyond adjacent tissues but contained within the pelvis (p = 0.005). The survival rates, either with or without salvage surgery, were nearly identical between patients with persistent disease and those with relapse after complete regression. The 3-year overall survival rate was 34%, 28%, and 5% (p = 0.001), respectively, for patients with PALN relapse alone, SCLN relapse with or without PALN relapse, and relapse other than PALN and SCLN. Of the patients with PALN relapse alone, 27% survived >5 years. Conclusion For recurrent SCC of the cervix after RT, patients with isolated PALN relapse salvaged by RT or combined chemoradiotherapy or those with cervical relapse salvaged by surgery can achieve long-term survival. Early detection of relapse with aggressive salvage treatment is important for achieving better outcome. Patients with persistent disease or relapse after complete remission had similar outcomes. Patients with SCLN relapse had a longer survival time than those with other metastases (except PALN), and palliative RT might be beneficial.