ernscotecie oncotooy 55, 29-38 (994) Radical Hysterectomy for Recurrent Carcinoma of the Uterine Cervix after Radiotherapy Rosrat L. Coreman, M.D.,*! Evpen D. Kreney, M.D.,*? Rac S. Frespwan, M.D., Px.D.,* ‘Tuowas W. Buxke, M.D.,* Parnicta J. E1fet, M.D.,t aND FRLIX N. RuTLEbGE, M.D.* ‘Deparment of Gynecologle Oncology and tDivision of Clic Therapeutic Radiovterapy, The Unversity of Tevas M. D. Anderson Cancer ‘Center, Houston, Texas 77030 Received August 9, 1983, Patients with small recurrent cervical carcinomas following radiation therapy may be salvaged with radical hysterectomy father than exenteration. Betwezn 1953 and 1983, $0 patleas underwent radial hysterectomy for persistent (n = 18) or re- current ( = 32) cevial cancer after primary radiotherapy. ‘The mean age of the cohort was 44 years (range, 23-70). Hsto- logic types were squamous in 4, adenocarcinoma in 3, and ad- enosquamous in 1. OF 37 patients with staged disease, 24 had stoge IB/IA, 7 had stage IIB, 2 had stage IIA, and 2 had stage IIB. Combination radiotherapy, consisting of 40-45 Gy exteral-beam radiation plus brachytherapy (mean 6980 mg/h), ‘was performed in 32 patients (64%). In the 32 patints with re- current lesion, the median interval from definitive radiotherapy to radical hysterectomy was 16 months (4301), with 19 ofthese patients (60%) presenting within the fst 24 months. Patients with persistent carcinomas underwent radical hysterectomy after ‘8 median observation interval of 2 months (18). A class Tl or TH radical hysterectomy was performed in 39 78%) cases. Pel vic and para-aortic Iymph node samplings were performed in 39 patents (78%), including 33 (65%) who underwent complete pelvic lymphadenectomy. Among those sampled, $ (13%) had Ietasttic nodal disease. AIS patents died of disease at a mes dian 13 months after surgery. Severe postoperative complica- tions occurred in 21 patents (42%). The most common site of injury was the urinary tract, with 14 patients 28%) developing ‘esicovaginal or recovaginal fistulae, 11 @22%) developing ur (eral injuries, and 10 20%) developing severe long-term bladder dysfunction. There was one postoperative death from sepsis among the entire population. Patients with abnormal preopera- tive intravenous pyelograms (P < 0.08), patients with recurrent presugical lesions (P ~< 0.0), and patents with postoperative Presented at the 25th Annual Mecting ofthe Society of Gynceologic ‘Oncologists, Orlando, FL, February 6-9, 1994. " Carrent address: Division of Gynecologic Oncology. Department of Obsttses and Gyaecology, Creighton University, Omaha, NE GB131 * Current adéress: Division of Gynecologic Oncology, Deparment of Obstetrics and Gynecology, Loma Linda University, CA 92384 » pelvic cellulitis (P < 0.01) were more likely to develop fistulae ‘The 5+ and 10-year actuarial survival rates for all cases was 72 and 60%, respectively. Tumor size at radical hysterectomy was, significantly associated with survival. Five-year actuarial sur- vival in 12 of 44 patients (276) with identiiable lesion diame- fers less than 2 em 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 sta- tus at followup, whereas recurrence after radical hysterectomy was seen in 24 patients (48%). Four of 17 (24%) patients who had lesions outside the cervix were without disease, compared with 22 of 33 patients (67%) who had lesions contained within the cervie (P < 0.01). A subgroup of 10 patients who had nor- ‘mal preoperative intravenous pyelograms, lesions limited to the cervix and less than 2 cm in greatest dimension, had a S-year actuarial survival of 90%, and only 1 patient (10%) developed fistula. These data suggest that patients with small central re- current tumors may be salvaged with les than exenteratve sur= ‘ery. However, excessive morbidity limits application t0 only, highly selected patients.» 74 Andes, ne INTRODUCTION Following primary radiotherapy for carcinoma of the uterine cervix, certain patients may develop persistent or recurrent tumors that are treatable by radical surgical resection. In these patients, surgery may offer the only opportunity for long-term disease-free survival. The most commonly performed procedure today for treatment of central failure is total pelvic exenteration [1,2]. However, in approximately one-fifth of cases, the tumor is small and limited to the cervix (2). Certain patients, therefore, ‘whose disease has failed primary treatment and who pres- ent with small centrally located tumors may undergo re- section without sacrificing the bladder or rectum. Radical hysterectomy as a treatment for stall centrally recurrent cervical carcinomas after primary radiation ther~ Coit © 1994 wy Academe reste, ‘A igh of repro sy fom Tees30 COLEMAN ET AL. apy has received little attention (3-7. Few published re ports have excluded patients whose surgical treatment was principally an adjuvant to radiation therapy or for whom the procedure offered palliation [3,6]. Additionally, there are no generally accepted guidelines for patient selection [3.6.7]. Rubin er ai., in an attempt to define a cohort of, patients at low risk for failure after surgery. studied 21 Patients treated with radical hysterectomy after primary radiotherapy and found that size of the recurrent lesion is important [3]. They demonstrated that treatment in none of 11 patients with recurrent lesions smaller than 2 cm failed, whereas disease recurred in 7 of 10 patients who had larger lesions [3]. A high rate of bladder and rectal fistulae, however, precluded any specific recom- mendation regarding the utilization of radical hysterec- tomy in this situation. We report our experience with this surgical technique in 50 patients with local persistence or recurrence after prior treatment with radiotherapy and identify certain factors that may predict for @ more sue- cessful outcome. MATERIALS AND METHODS Between May 1953 and June 1993, 65 patients at The University of Texas M. D. Anderson Cancer Center underwent radical hysterectomy after primary radiother- apy for carcinoma of the uterine cervix. These patients were subclassified into three main groups: those with re- current disease, defined as biopsy-confirmed lesions ap- pearing aftcra disease-free interval of more than 4 months from the completion of radiotherapy (n = 32); those ‘with persistent disease, defined as biopsy-confirmed tu- mors either grossly visible or growing up to 4 months after completion of primary radiation therapy (n = 18). and those who underwent radical hysterectomy as an ad- juvant to planned primary radiotherapy. This third group (n= 15) was not included in this analysis, All but six patients (88%) were referred to the insti tution because of poor response to completed irradiation or because recurrent disease after radiation was the pri- mary foundation for this population of patients. In most cases, records of external beam treatment fields, interval fractions, and total dose were available. Exact dosimetry from brachytherapy systems was available in fewer cases and varied between referral sites. Patients with centrally located carcinomas were selected for radical hysterectomy if their tumors were clinically considered resectable using a surgical margin that would rot entail resection of bladder or rectum. Aside from these features, no other specific eligibility factors were identified from the medical records, operative reports, radiotherapy summaries, and, if available, clinie records from referring physicians Surgical pathology from all patients was reviewed. In formation obtained for each of these two subgroups (re- current and persistent disease) included demographic formation, size and location of primary and recurrent lesions, operative time, complications and blood toss, ad- equacy of pathological resection, immediate and lony term complications, and survival parameters. Clinical stage was assigned by guidelines established by Inter- national Federation of Gynecology and Obstetrics (FIGO) and categorized according to outlined parameters, [8]. Classification of radical hysterectomy conformed to the description of Piver and Rutledge [9]. Complications were classified based on the amount of time to occurrence, on whether resolution followed con- servative management, and on whether surgery was needed. Postoperative complications not responding to conservative treatment were classified 8s permanent. If surgery was required, the complication was classified as permanent-severe. Complications treated and resolved by conservative measures were considered temporary severe. Statistical methods included x? and Fisher's exact test for nominal comparisons. Continuous variables were re lated to nominal variables by analysis of variance and ‘unpaired continuous variables by Student 1 test. Cate~ gorical variables were related to continuous variables by Mann-Whitney U test. Survival data were analyzed using Cox regression analysis, actuarial survival models, and the method of Kaplan-Meier [10], RESULTS. Fifty patients meeting the criteria for this analysis had undergone radical hysterectomy for postradiotherapy le- ns. Thirty-two patients had recurrent tumors, and 18 had persistent lesions. The median age of the cohort was 44 years (range, 23-70). Forty-six patients (92%) had squamous lesions; 3 patients (6%) had adenocarcinomas, and 1 (2%) had an adenosquamous carcinoma. Initial staging of the untreated cervical carcinoma could be as- certained in 37 patients (74%) and was distributed as follows: IA, 2 patients (4%); IB, 14 patients (28%); ILA, 10 patients (20%); IIB, 7 patients (14%); IILA, 2 patients (4%); and IIB, 2 patients (4%). An appropriate FIGO clinical stage could not be identified or assigned in 13 patients. There were no statistically significant differences in age, weight, stage at presentation, or histology among the recurrent or persistent disease subgroups. The max- imum diameter of the primary tumor at the onset of radiotherapy ranged from 1 to 8 em with a median of 4.0.om, Recurrent lesions were generally smaller, ranging from occult to 8 cm with a median maximum diameter of 2.5 cm (Table 1). Patients with persistent tumors at radical hysterectomy had had significantly larger un- treated primary tumors (mean, 5.4 vs 3.8 cm) than pa-RADICAL HYSTERECTOMY FOR RECURRENT CERVIX CANCER 31 TABLE 1 Clinical Parameters of 50 Patients Undergoing Radical Hysterectomy after Radiation Therapy Number of| Parameter Median Range patients (%) Age (years) «a OC) ‘Weight (kg) BI ——-$0-100), ‘Tumor size, cm ‘A ital diagnosis oe 30 (0) At recurrence/persistence 250-8 4) tients with recurrent tumors at radical hysterectomy (P° < 0.05). However, lesion size at the time of radical hys- terectomy was no different between the two groups. Radiotherapy was administered as exteral-beam plus intracavitary radiation for 40 of the 50 (80%) patients. ‘Six patients (12%) were treated with only external-beam radiation and 4 (8%) with only brachytherapy. Of the 40 patients receiving combination radiotherapy, 32 (80%) received 40-45 Gy external-beam radiotherapy combined with 1 to 3 intracavitary systems. The exact dosimetry of the brachytherapy systems was not known for certain patients but had a mean of 6980 mg/hr (range, 5960- 7980 mg,/hr) in 20 of 44 patients who received brachyther- apy. Four patients (9% ) received less than 30 Gy of whole pelvis radiotherapy, and 2 (5%) received greater than 50 Gy. Patients receiving either single modality treatment were proportionately more likely to have persistent le- sions at the time of radical hysterectomy but this dif- ference was not statistically significant. Although 24 of 32 patients (75%) in the recurrent subgroup had com- tion radiotherapy for their primary lesions, only 11 of them (34%) had treatment doses adequate for expected local control. Likewise, 8 of 18 (44%) patients with per- sistent lesions undergoing surgery had appropriate do- simetry to their primary lesions. ‘The disease-free interval for patients in the recurrent subgroup ranged from 4 to 301 months, with a median of 16 months, The mean interval from the disgnosis of persistence to radical hysterectomy was 2 months (range, 1-4 months). The following symptoms preceded histo- pathologic diagnosis of recurrent disease in 22 patients (44%): bleeding. 13 patients; pelvic pain, 4; vaginal dis- ‘charge, 4; and bleeding and pain, 1. Twenty-eight patients, (56%) were asymptomatic, Fourty-two of 50 patients (64%) undergoing surgery had clinically identifiable tu- mor involvement of the cervix, the adjacent tissues, or both. The remaining 8 patients had clinically occult dis- ‘ease diagnosed by biopsy alone, Location of recurrence is listed in Table 2 and did not differ significantly between the two study groups. Most of the recurrent and persistent lesions were limited to the cervix, vagina, or both. A preoperative intravenous pyelogram (IVP) had been ob- tained in 43 patients (86%) and no difference was seen in the frequency of abnormal studies between the subgroups. Ureteral obstruction was identified in 9 pa- tients (18%), and ureteral deviation was noted in one additional patient A class IL or class III radical hysterectomy was the most common procedure, performed in 39 of S0 cases (78%). The relationship of the complexity of the pro cedure and the operative time was significant (Table 3). Histopathologic examination of the radical hysterectomy specimen showed an absence of tumor at the surgical margins in 42 of 50 patients (84%). Thirty-nine of 50 patients (78%) had cither pelvic Iymphadenectomies (33, Patients) or pelvic node biopsies (6 patients). The median number of nodes examined was 16 (range, 1-36). Thirty- four patients had pathologically negative nodes, and 5 patients had postive nodes. “The median absolute survival for the $0 patients in this review was 93 months (y, 141 months; range, 1-467 ‘months) with 5- and 10-year survival rates of 72 and 60%, respectively. Overall survival was influenced by disease study subgroup, tumor size of the recurrent disease at radical hysterectomy, and the presence of an abnormal IVP. Patients with persistent disease were significantly more likely to survive 5 years (P < 0,001) and 10 years (P < 0.01) after surgery than patients with recurrent disease. The respective 5- and 10-year survival rates were 82 and 68% for the persistent disease subgroup compared to 65 and 54% for patients in the recurrent disease subgroup. The median survival for these subgroups were 148.5 and 87.5 months, respectively. Actuarial survival curves for these subgroups and the total population are depicted in Fig. 1. Size of the recurrent or persistent tumor at the time of radical hysterectomy was also im- portant to survival. Patients with lesions less than 2 cm hhad a 90% S-year survival and 80% 10-year survival eom- pared with 64 and 48% 5- and 10-year survival in patients with larger lesions, respectively (Fig. 2, P< 0.001). Ad- ditionally, patients with an obstructed or deviated ureter on preoperative IVP had a lower survival rate than those ‘with normal studies (62 months vs 179 months, P < 0.02). ‘Twenty-six patients (52%) were disease-free atthe time TABLE 2 ‘Tumor Location in $0 Patients Who Underwent Radical Hys- terectomy for Recurrent or Persistent Disease after Radiotherapy Location of recurrence "(%) NED DOD* Cervix only 33 (66) 2 1" Vagina only (2) 1 5 Vagina end cervix 500) 3 2 Cervis, vagina, parametria 612) ° 6 «NED, no evidence of disease at death oF Inst follow-up, * DOD, dead of disease,2 COLEMAN ET AL, TABLE 3 ‘Type of Radical Hysterectomy, Number of Patients for Each Procedure, Intraoperative Blood Replacement, Operative Time, nd ‘Adequacy of Resection as Measured by Negative Surgical Margins in SO Patients Undergoing Radical Hysterectomy for Recurrent ‘or Persistent Disease after Radiotherapy ‘Type of radical Number ‘Blood replacement OR? time ‘Adequacy of hrysteretomy of patients (omits * SEM) (hr = SEM) resection (8) Cas " 29210 37203 on Cass 2% 36 = 08 ass 02 2 Gas V ® 47 209 Wes 50 Vaginal 5 36214 37207 100 * OR, operating room. death or last notification, Factors predicting disease-tree status were location of recurrence at radical hysterectomy, development of a secondary recurrence, and histopath- ology of the lymph nodes. Patients dying of their disease ‘were significantly more likely to have had pre-radical hys- terectomy recurrence sites outside the cervix. Survivor- ship among the various pre-radical hysterectomy recurr- ence sites is listed in Table 2. Only 4 of 17 patients (24%) with lesions outside the cervix or involving the cervix, with other sites were salvaged compared with 22 of 33 (67%) patients with disease limited to the cervix (P< 0.01). Patients with histologically positive Iymph node ‘metastases faired poorly. All 5 patients with positive nodes died from cancer, whereas 14 of 34 patients (41%) with negative nodes were dead of cancer (P < 0.02). Mean survival for this latter group was 179 months and Percent Survival FIG. 1. Survival curves fr the total population (sli ine) and the ‘wo trcatment sobpopuations. The overall S- and 10.year actual sur vival sates were 72 and 60%, respectively. Patients with persistent cx cease (hatched line) atthe time of radical hysterectomy had S- and I0- year survival ates of 82 and 68%, respectively. Patents presenting with Tecurtence after a disease-free interval (rte fine) had a 5+ and 10- year survival rates of 65 and 51%, respectively significantly greater than those patients with histologically positive nodes (mean, 62 months; P < 0.02). Progression-free interval (PFI) to secondary recurrence (or recurrence after radical hysterectomy) was calculated from the time of radical hysterectomy to histologic doc- umentation of secondary recurrence, ‘This PFI was sig- nificantly longer among patients undergoing radical hys- terectomy for persistent disease than for patients who developed new recurrent lesions. Of the 18 patients in whom the PFI was determined, 5 were in the persistent ‘tumor subgroup and had a PFI of 89 months compared {0 15 months among 13 patients in the recurrent tumor subgroup (P < 0.05). In 3 patients, the PFI could not be accurately ascertained. Recurrence after radical hysterectomy was observed in 23 of 45 patients (49%) in whom the recurrence site could be monitored. ‘The median time to recurrence was 13.5 Percent Survive SRF 5F 3 z FIG. 2. Patents with small tumors (<2 em; slid line) had superior Sand 10-year survival rates compared to patients with larger ‘amons (arched line). The 5- and 10-year survival for the former group were 0 and 80S compared with 64 and 48% for the later. This survival advantage was significant (P «< 0.1).RADICAL HYSTERECTOMY FOR RECURRENT CERVIX CANCER 3 TABLE 4 Significant Complications, Time from Surgery, and Outcome Observed in 0 Patients Undergoing Radical Hysterectomy for “Treatment of Persistent or Recurrent Carcinoma of the Cervix Following Radiation Therapy Complication <2 months oe Calitics Lymphooyst Plrnonary embolus Bowel obstruction Pelvic necrosis Bladder dysfunction ‘Ureteralinury Vesicovaginal fistula Rectovagial fstula 26 months Tora (%) Outeome: 2 1 @) 4 persistent ° 5.00) Al resolved 1 50) All resolved 0 2a) Al resolved 1 1@ Resolved 1 2) All resolved 6 10.20) 6 1@2) repaired 2 Rew 7 surgically repeired a 5 (9) 4 surgically sepaived UTE, urinary tract infeton months. In 5 patients, the site of this “secondary” re- currence could not be monitored. Location of the failure was central in 9, regional in 10, and distant in 2. Eight patients were candidates for further curative surgery and underwent pelvic exenteration: 4 remained disease free, and 4 died of cancer. The development of a recurrence after radical hysterectomy was a strong predictor of shorter survival time (P < 0.001). These patients were also significantly more likely to die of their disease than those not developing a recurrence (P< 0.0001). The median survival after a recurrence was 13 months Factors predicting a recurrence after radical hyster- ‘ectomy were tumor size of the initial recurrent lesion and presence of nodal metastases at radical hysterectomy Patients from either subgroup who recurred after radical hysterectomy had significantly larger primary tumors than those who did not recur (mean, 3.6 cm vs 2.3 em; P< 0.05). Of note, recurrence size was larger in patients who died of their disease (3.5 cm vs 2.3 om, P = 0.05). All 5 patients with positive nodes at radical hysterectomy relapsed compared with 14 of 30 patients (47%) with negative nodes who subsequently relapsed (P < 0.05) ‘Table 4 lists the significant complications that occurred after radical hysterectomy following radiotherapy. Over- all, 32 of 50 (64%) patients suffered some postoperative complication. Temporary-severe conditions were the only postoperative complication for 11 of these 32 patients and included conservatively managed thromboembolic events, bowel and bladder obstruction, and lymphedema, Permanent-scvere conditions were identified in the re- ‘maining 21 patients and are shown in Table 4. One patient (2%) died from sepsis. Injuries to the bladder, bowel, and pelvic soft tissues were the most frequent observed. Seventeen occurrences of fistula developed from bladder, rectum, or both to the vagina in 14 patients (28%). Most of these appeared within 6 months of surgery (Table 4). “The occurrence of vesicovaginal and rectovaginal fistulae was significantly related to treatment subgroup atthe time of surgery, presence of an abnormal preoperative IVP, ‘and development of postoperative infection. Of the 18 nts with persistent disease, only 2 developed fistulae compared with 12 of 32 patients with recurrent disease at the time of surgery (P < 0.05). Likewise, 5 of 10 patients (50%) with abnormal preoperative IVPs devel- ‘oped vesicovaginal fistulae compared with 5 of 32 patients (16%) with normal IVPs (P < 0.05). The only other factor predicting fistulae formation was the development of post- ‘operative pelvic cellulitis. Four of the 5 patients with diagnosed pelvie cellulitis developed fistulae compared with 10 of 45 patients developing fistulae without the occurrence of cellulitis (P < 0.01). Additional factors examined that were not associated were age, stage, grade, histologic diagnosis, original tumor size, tumor size at recurrence, radiation treatment dose, location of initial recurrence, surgical procedure, histology of the surgical margin, adequacy of radiation, weight, or performance of pelvic node dissection. Other complications attributed to the surgical proce- dure were bladder dysfunction and ureteral injury. Blad- der dysfunction, primarily an inability t void, was a per- sistent problem for 6 of 10 patients found with this problem (12% of the total population), Ureteral injury requiring surgical intervention occurred in 7 of 11 patients with @ ureteral injury (14% of the total population), 3 ‘of whom required urinary conduits. Mild to moderate complications resolved spontaneously or with conserva- tive treatment Cox regression analysis of overall survival was used to ‘identify significant independent prognosticators of this parameter. Tumor size less than 2 em, lesions confined to the cervix, and normal preoperative IVP study were independently predictive of survival. In this subgroup (n = 10), median survival was 164 months (12315 months) with Slyear survival of 90%. Disease in one patient re-34 COLEMAN EP AL, cured; this patient died of disease, and one died of un- known causes after 10 years of follow-up. Complications in this cohort were minimal with 1 patient developing fistula 6 months after surgery. DISCUSSION Our investigation and those of others suggest that cer- tain patients with recurrent or persistent uterine cervical cancer may benefit from a radical hysterectomy in lieu of the usually indicated total or partial exenteration (3-7]. Fortunately, improvements in radiotherapeutic, techniques and earlier presentation at primary treatment ‘continte to diminish the mumber of patients with local, central failure. A recent review of 1522 cases of stage 1B uterine cervix cancer at the M. D. Anderson Cancer Center has demonstrated that the central failure rate with current radiotherapeutic protocols is <3% (Dr. P. Eifel, Personal communication), It is among this population of central failures that long-term disease-free survival can be attained with further intervention Persistent or recurrent cervical cancer has been treated with chemotherapy, reirradiation, and surgery, Chemo- therapeutic trials, overall, have yielded disappoi sults, although palliation and occasional long-term re- sponses may occur. Reirradiation bas largely been avoided because of toxicity [11-13]. Recently, however, interstitial radiation therapy has produced complete res- olution of small central and sidewall recurrences [13] Long-term follow-up information analyzing these tech- niques is unavailable. In the absence of fixed sidewall involvement, superior survival rates have reliably been reported with surgery in those patients whose disease is resectable. Our report is a retrospective analysis of 50 patients treated over 40 years at M. D, Anderson for recurrent or persistent car- cinoma of the uterine cervix following radiotherapy and suggests that radical hysterectomy could be an option for selected patients. In this series, the actuarial survival at 5 years was 72% (median survival, 93 months) and compares favorably with other radical hysterectomy series [3-6]. However, comparison of survival in this series with data from ex- enterative procedures is not appropriate as the treatment populations are not comparable. The subgroup of patients ‘with recurrent discase reported in this series represents, the best surgical candidates from a volume-of-disease per- spective. Stanhope ef al. reporting on the Mayo Clinic's, experience with exenteration for recurrent disease dem- onstrated an 89% S-year survival in patients with small- volume tumors, defined as less than S cm'[2]. This was significantly better than patients with larger volumes. In ‘our series the choice for surgical procedure was based oon the surgeon's individual judgment as to resectability. Since 82% of the surgical resections had adequate mat- gins, the visible or suspected recurrent tumor volume is a fair criterion for surgical choice. Whether radical hys- terectomy offers comparable disease-specific survival 10 exenteration in this event is not known The majority of cases in this retrospective analysis re ceived treatment prior to 1983 (n = 47). Since that time, nine patients have undergone radical hysterectomy after radiotherapy, with three of these meeting entry criteria for this study. The fact that very few of these procedures currently are being performed today may reflect the high complication rate associated with the procedure. In this review, 28% of the patients developed fistulae and/or trauma to the pelvic viscera. In addition, patients not salvaged by the initial procedure faired poorly, cight patients being eligible for further cura dures. In this group only four additional patients were salvaged The relative rarity of this procedure additionally reflects the improvement in local control with modern radiothera- peutic techniques. Improvements to survival reflect the benefit of surgical reconstruction and postoperative care following pelvic evisceration, In this series only two-thirds of the patients were treated with what would be con- sidered standard radiotherapy for their primary lesions. ‘A large proportion of these patients came from referral institutions in the 1950s and 1960s where a wide range of radiotherapeutic strategies was practiced. Contem- porary treatment strategies are more standardized and consistent among institutions treating cervical cancer pa- tients, In the current study, we identified a population of pa- tients with recurrent disease that may benefit from radical hysterectomy after radiation therapy. These were patients whose tumor recurrences were less than 2.em in maximum diameter, had a normal preoperative IVP, and whose lesions were limited to the cervix. Although only 10 pa- tients in the series met these criteria, their 5-year survival was 90% at a median of 164 months (12-315), with only 1 patient developing a fistula and 1 patient dying of dis- ease in 10 years of follow-up. Conversely, patients who had tumors larger than 2 cm, who had abnormal IVPs, who had tumors outside the cervix, or who had a com- bination of these had poorer survival and higher mor- bidity. Identification of evaluable factors preoperatively is central in guiding patient selection, Other investigators, have found size of the recurrent lesion important to sut= vival [3]. Results from this analysis suggest that tumor location and IVP are additionally important to overall, survival and morbidity While the radiotherapy was delivered with curative in- tent, a propottion of these patients received only single- modality therapy. Six of 50 patients (12%) were treated with external-beam radiation only, and 4 patients (8%)RADICAL HYSTERECTOMY FOR RECURRENT CERVIX CANCER 35 were treated with brachytherapy alone. In these cases treatment alteration may have accounted for the central failure. The goal of treatment should be long-term remission or cure, if possible, with a minimal level of morbicity. However, in this series and as reported by others, there ‘was a high frequency of injury to the urinary system and, rectum [3,4,6,7]. In this series, 14 of 50 patients (28%) developed fistulae of the bladder, rectum, of both. These occurrences required a conduit or colostomy in 11 patients in addition to the primary procedure. In addition, there was a relatively high frequency of permanent bladder dysfunction and ureteral injury. In this series, 6 of 10 (60%) patients with postoperative bladder dysfunction had persistent dysfunction, and 7 of 11 (64%) patients with ureteral injury required urinary diversion for this. The frequency of these complications is unacceptable and suggests that the operation had not achieved its goals in these cases. It has been suggested that the etiology of these complications is directly related to the difficulty of dissection in these areas within the irradiated field [14] Mortality, however, was low in this series. Only 1 post- operative death (2%), due to sepsis, occurred. Factors that identify patients who may benefit in terms of improved disease-free survival and decreased morbidity hhave been identified in this review. With refinements in the technique of exenteration and reconstruction, in- ‘luding pelvic floor and vaginal reconstruction and con- tinent urinary conduit, the role of radical hysterectomy remains debatable. A’ careful clinical assessment needs to be donc on candidate patients to determine whether ‘exenteration or a more limited surgical procedure is in- dicated. Radical hysterectomy should be utilized in the ‘occasional patient who has a small tumor (less than 2 ‘em) that is confined to the cervix, and a normal pre- ‘operative IVP. Judgment to feasibility must additionally take into consideration the tissue reaction to previous radiotherapy, It may be prudent, even among this highly selected subgroup, to choose an exenterative procedure in patients with severe pelvic fibrosis following radio- therapy. Surgery should be performed in an optimal sur- gical setting. Patients must be counseled to the operative and postoperative tisk. REFERENCES Rutledge, F. N. 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