Prognostic Impact of a Negative Central Pelvic Biopsy after Definitive Chemoradiotherapy (CRT) for Locally Advanced Cervical Cancer (LACC)

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Central pelvic biopsies are occasionally performed during post-treatment surveillance of locally advanced cervical cancer (LACC) after a change in symptoms, abnormal pelvic exam, pap smear or imaging. Although it is established that a positive result is considered disease recurrence, it is unclear the prognostic impact of a negative biopsy. Here, we investigated the characteristics and the clinical course of patients with negative biopsy, focusing on central pelvic recurrence. Our institutional database of female patients with diagnosis of cervical cancer treated with definitive CRT was retrospectively reviewed (2013-2022). The central pelvic region was subdivided in: I) cervix, II) endocervix/endometrium, III) vagina, IV) vulva, V) bladder and VI) rectum. Each subsite sampled was considered a distinct biopsy event, but multiple samples from one subsite at the same procedure were considered one biopsy event. We calculated the rate of initial negative and positive biopsies. The central pelvic control (local recurrence rate [LCRR]) for patients with negative biopsy was estimated with Kaplan Meier method. Two hundred and twenty-five consecutive patients were included (initial FIGO 2018 staging: 30% I/II and 70% III-IVA). Of these, 66 (29.3%) underwent 112 central pelvic biopsies (average 1.7 per patient) during a median follow up time of 27.1 months [range: 0.2-94.0], with median time from treatment to first biopsy of 7.0 months [range: 1.0-41.7]. Biopsies were triggered by: symptoms/physical exam in 83 (73.4%), imaging abnormalities in 21 (18.6%), and abnormal pap smear in 9 (8%). The most common structures biopsied were: cervix (53.6%, n = 60), vagina (17.9%, n = 20), endocervix/endometrium (11.6%, n = 13), rectum/sigmoid (11.6%, n = 13), bladder (4.5%, n = 5) and vulva (0.9%, n = 1). Overall, 13.6% cases (9/66) had an initial positive biopsy, while 86.4% (57/66) had an initial negative biopsy. Of these patients with negative biopsies, 84.2% (48/57) remained without evidence of local recurrence and 15.8% (9/57) were subsequently diagnosed with local disease recurrence (1y post-biopsy LCRR 15.0% [95% CI 4.8-24.0]). Although most (>85%) post-treatment central pelvic biopsies are negative, these patients are still at considerable risk of early local recurrence thereafter (post-biopsy 1y-LCRR 15%). Strategies to intensify surveillance may be beneficial in the first year after a negative biopsy.