Postoperative radiotherapy for patients with invasive cervical cancer following treatment with simple hysterectomy

Background: This study aimed to investigate the survival and complications of patients who received adjuvant radiotherapy for invasive cervical cancer following inadvertent simple hysterectomy. Methods: From September 1992 through to December 1998, 54 patients who had received simple hysterectomies for benign lesions, but were incidentally found with invasive carcinoma of the cervix in the surgical specimen, were referred to our department for postoperative irradiation. They were categorized into two groups according to pathological findings. Group A consisted of 25 patients whose specimen showed microinvasion alone, with the depth of stromal invasion <5 mm. Group B consisted of 29 patients whose pathological findings included deep stromal invasion, tumor emboli in cervix, lymphovascular permeation, positive or close resection margin, endometrial or myometrial invasion and vaginal involvement. After external beam irradiation dose of 44 Gy in 22 fractions over 4-5 weeks to the whole pelvis, the radiation field was reduced to true pelvis for a further 10 Gy in five fractions. Brachytherapy was performed using an Ir-192 remote after-loading technique for 1-2 courses. The prescribed dose for each treatment was 7.5 Gy to the vaginal surface. A retrospective analysis was conducted to compare radiation-therapy outcomes for these 54 patients. Results: After 37-102 months of follow-up (median, 58 months), 47 patients were alive without evidence of disease; five patients in Group B died of the disease (three with distant metastasis, one with local relapse, one with both). Two patients died of other concurrent diseases. The 5-year actuarial survival (AS) and disease-free survival (DFS) rates for all patients were 88 and 90%, respectively. The respective 5-year AS and DFS rates for Group A/B were 95/82% (P = 0.07) and 100/83% (P = 0.03). Ten patients (18.5%) developed RTOG Grade 1-4 rectal complications. Five patients (9.3%) developed RTOG Grade 3-4 bladder complications. Eight patients (14.8%) had RTOG Grade 1-4 non-rectal gastrointestinal complications. Conclusions: For patients with invasive cervical cancer following inadvertent simple hysterectomy, external beam radiotherapy combined with one or two fractions of intravaginal brachytherapy could achieve satisfactory disease control. It is recommended to select a high-risk group for intensive adjuvant treatment. Further optimization of the irradiation strategy is also imperative to decrease the incidence of complications.