Intracavitary Preoperative Brachytherapy Followed By Whertheim-Type Hysterectomy in Localized Cervical Cancer: Clinical Data and Toxicity Results from a Single Institution Experience

Abstract

Optimal management of localized cervical cancer is still controversial. The purpose of this study is to report our experience regarding early stage cervical cancer treated with preoperative intracavitary brachytherapy (IBT) and Wertheim-type hysterectomy (HT). From 01/2000 to 12/2013, all consecutive patients treated for a localized cervical cancer by preoperative IBT and HT were recorded. They underwent pelvic lymph node assessment by lymphadenectomy prior to IBT. Pulse dose rate IBT was performed with 2D technique between 2000 and 2006 and with 3D technique after 2006. IBT aimed to deliver 60 Gray to the clinical target volume (CTV) defined as the Gross Tumor Volume (GTV) and the cervical tissue, according to GYN-GEC-ESTRO guidelines with limited dose to the surrounding organs. HT was performed 8 weeks after IBT. Data were retrospectively collected from patients’ medical files. 80 patients were enrolled. 64 (80%) of them had squamous cell carcinoma. 72 patients (90%) had FIGO stage IB1, 8 patients (10%) had stage II. Median clinical tumor size was 25 mm (0-40). Pelvic lymphadenectomy was performed in 79 patients (99%). 71 patients (90%) had no lymph node involvement, whereas 8 patients (10%) presented micro-metastasis. Median dose of preoperative IBT was 60 Gray (45-70) delivered in 120 pulses. Median delay between brachytherapy and surgery was 57 days (34-154). All patients underwent Wertheim HT. 61 patients (76%) had a histological complete response. For those with incomplete response, residual tumor was located at cervix and only one patient had lymphovascular invasion. With a median follow-up of 6.7 years, 16 patients (20%) presented a tumor relapse, with only 2 local relapse (3%), 11 regional recurrence, and 9 metastatic relapse. 5-year DFS rate and 5-year OS rate were 82% (71-89) and 88% (78-94) respectively. 26 patients (33%) had grade 2 late toxicity and 10 (13%) had grade 3 late toxicity; there was no grade ≥ 4 complications. In univariate analysis, only overweight (body mass index ≥ 25) was associated with poorer PFS, with a hazard ratio of 3.05 (1.20 – 7.76, p=0.019). Preoperative IBT followed by HT is safe and effective for women with localized stage cervical cancer. It remains a therapeutic option for those patients.