RADICAL HYSTERECTOMY FOR RECURRENT CARCINOMA OF THE UTERINE CERVIX AFTER RADIOTHERAPY

Patients with small recurrent cervical carcinomas following radiation therapy may be salvaged with radical hysterectomy rather than exentera tion. Between 1953 and 1993, 50 patients underwent radical hysterectom y for persistent (n = 18) or recurrent (n = 32) cervical cancer after primary radiotherapy. The mean age of the cohort was 44 years (range, 23-70). Histologic types were squamous in 46, adenocarcinoma in 3, and adenosquamous in 1. Of 37 patients with staged disease, 24 had stage IB/HA, 7 had stage IIB, 2 had stage IIIA, and 2 had stage IIIB. Combin ation radiotherapy, consisting of 40-45 Gy external-beam radiation plu s brachytherapy (mean 6980 mg/hr), was performed in 32 patients (64%). In the 32 patients with recurrent lesions, the median interval from d efinitive radiotherapy to radical hysterectomy was 16 months (4-301), with 19 of these patients (60%) presenting within the first 24 months. Patients with persistent carcinomas underwent radical hysterectomy af ter a median observation interval of 2 months (1-4). A class II or III radical hysterectomy was performed in 39 (78%) cases. Pelvic and para -aortic lymph node samplings were performed in 39 patients (78%), incl uding 33 (66%) who underwent complete pelvic lymphadenectomy. Among th ose sampled, 5 (13%) had metastatic nodal disease. All 5 patients died of disease at a median 13 months after surgery. Severe postoperative complications occurred in 21 patients (42%). The most common site of i njury was the urinary tract, with 14 patients (28%) developing vesicov aginal or rectovaginal fistulae, 11 (22%) developing ureteral injuries , and 10 (20%) developing severe long-term bladder dysfunction. There was one postoperative death from sepsis among the entire population. P atients with abnormal preoperative intravenous pyelograms (P < 0.05), patients with recurrent presurgical lesions (P < 0.05), and patients w ith postoperative pelvic cellulitis (P < 0.01) were more likely to dev elop fistulae. The 5- and 10-year actuarial survival rates for all cas es was 72 and 60%, respectively. Tumor size at radical hysterectomy wa s significantly associated with survival. Five-year actuarial survival in 12 of 44 patients (27%) with identifiable lesion diameters less th an 2 cm was 90% compared with 64% in patients with larger lesions (P < 0.01). Prolonged disease-free survival occurred in 26 of 50 patients (52%) who had known disease status at follow-up, whereas recurrence af ter radical hysterectomy was seen in 24 patients (48%). Four of 17 (24 %) patients who had lesions outside the cervix were without disease, c ompared with 22 of 33 patients (67%) who had lesions contained within the cervix (P < 0.01). A subgroup of 10 patients who had normal preope rative intravenous pyelograms, lesions limited to the cervix and less than 2 cm in greatest dimension, had a 5-year acturarial survival of 9 0%, and only 1 patient (10%) developed fistula. These data suggest tha t patients with small central recurrent tumors may be salvaged with le ss than exenterative surgery. However, excessive morbidity limits appl ication to only highly selected patients. (C) 1994 Academic Press, Inc .