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  • br Distant failure after isolated pelvic failure


    3.2. Distant failure after isolated pelvic failure
    The median time to distant failure after isolated pelvic recurrence was 20 months (95% CI 3–37) (Fig. 1A). Of the 23 patients found to have distant failure, 22 (96%) failed within 2 years of the initial isolated pelvic failure. Median time to distant failure did not significantly differ by treatment (Fig. 2A), but death was a significant competing risk in
    patients not receiving surgery nor chemotherapy. The sites of distant failure are shown in Table 2. The most common sites of distant failure for non-surgical patients were the lung (36.5%) and para-aortic nodes (27.5%); for surgical patients, they were the peritoneum (33.3%), lung (16.5%) and bone (16.5%). Patients who presented initially with both pelvic and para-aortic SYBR Safe DNA Gel Stain nodes were more likely to eventually de-velop distant failure (Table 3). Compared to pelvic exenteration, pa-tients receiving radical hysterectomy did not have a significantly different risk of distant failure (Hazard Ratio HR = 1.6, 95% CI 0.4–5.6). For the 28 patients that underwent surgery after initial isolated pelvic recurrence, the rate of distant failure was 6/18 (33%) for initial central failures, 4/6 (67%) for initial central and lymph node failures, and 2/4 (50%) for initial lymph nodes alone failures.
    3.3. Overall survival after isolated pelvic failure
    Median OS for the whole cohort was 12 months (95% CI 6–18) (Fig. 1B). Median OS for patients treated with surgery was 29 months (95% CI 16–41); median OS for patients treated with chemotherapy alone was 12 months (95% CI 3–21); median OS for patients treated with neither surgery nor chemotherapy was 3 months (95% CI 1–5) (Fig. 2B). Patients who were initially treated with definitive radiation alone without chemotherapy and patients that did not get surgery nor chemotherapy for their pelvic recurrence had worse OS (Table 4). For patients salvaged with surgery, radical hysterectomy did not have a sig-nificantly higher risk of death compared to pelvic exenteration (HR = 1.3, 95% CI 0.5–3.8).
    Fig. 2. Kaplan-Meier curves of distant failure (A) and OS (B) in cervical cancer patients with an isolated pelvic failure stratified by treatment.
    Table 2
    Sites of subsequent distant failure after isolated pelvic failure.
    Total No surgery Surgery
    4. Discussion
    Distant control following isolated pelvic failure in previously irradi-ated cervical cancer patients is not well characterized in the literature. To our knowledge, region of division study is the first to detail patterns of subsequent distant failure and clinical characteristics influencing its likelihood. Overall, 23 of 67 patients (34%) experienced distant failure following pelvic relapse. Over 95% of distant failures occurred within 2 years of local failure. There was no difference in time to distant failure after iso-lated pelvic failure between patients receiving surgical vs. non-surgical management. Among patients receiving salvage surgery, we observed a distant control rate of 53% at 5 years post recurrence. This compares fa-vorably to a recent study of 61 recurrent cervical cancer patients treated with pelvic exenteration that reported a 5-year disease free survival of 49% [14].
    Our data suggests that micrometastases may have already seeded at the time of isolated local failure. Pelvic and para-aortic nodal involvement 
    Table 4
    Cox regression for factors associated with death after isolated pelvic failure.
    Univariable p Multivariable p
    hazard ratio value hazard ratio value
    Initial histology
    Squamous Ref
    Initial FIGO stage
    Included but