Management of Bulky Tumors in Cervical Cancer: Limits of the Surgical Approach

Abstract

The standard treatment for cervical tumors larger than 4 cm, known as bulky tumors, currently involves concurrent chemoradiotherapy followed by vaginal brachytherapy. However, radical surgery is an alternative option in some cases, particularly for those in which a combination of risk factors is not anticipated. Recent studies show that neoadjuvant chemotherapy may help reduce tumor size in these bulky tumors, enabling subsequent surgical intervention reducing the adverse effects derived from radiotherapy. Evidence about fertility sparing surgery in patients with bulky tumors is limited, although some retrospective studies reported good oncological outcomes when adequate tumor reduction is achieved through neoadjuvant chemotherapy. Moreover, the administration of adjuvant radiotherapy after radical surgery in patients with tumor sizes ≥ 4 cm in the final pathological report, combined with other intermediate risk factors for recurrence, remains a topic of debate. Current evidence indicates no significant differences in overall survival or disease-free survival between follow-up alone and the use of adjuvant radiotherapy in these cases, although further research is needed to refine treatment strategies for these patients. This narrative review aims to summarize the available evidence on the comprehensive management of bulky cervical tumors, addressing relevant issues and controversies in the field.

Keywords: adjuvant radiotherapy; bulky tumors; cervical cancer; neoadjuvant chemotherapy.

Figure 1

Pelvic magnetic resonance imaging of a bulky cervical tumor (marked with the dotted circle). The image corresponds to a 43-year-old patient diagnosed with cervical squamous cell carcinoma, with tumor dimensions of 43 × 41 × 39 mm on imaging and no parametrial involvement. She underwent primary surgical treatment with bilateral pelvic lymphadenectomy and radical hysterectomy (in 2015), with a postoperative stage of IIA2 (FIGO 2018). Adjuvant treatment with external beam radiotherapy (EBRT), chemotherapy (CT), and brachytherapy (BT) was administered. She was disease-free at the time of writing this article.

Figure 2

Surgical specimen of a cervical bulky tumor after cut-through surgery. The image corresponds to a 39-year-old patient diagnosed with a 44 × 40 cm cervical squamous cell carcinoma. The preoperative assessment showed no evidence of parametrial invasion. However, during the radical hysterectomy procedure, the left parametrium appeared to be involved, which was later confirmed by the histopathological analysis of the surgical specimen. Despite receiving adjuvant CTRT, the patient experienced a recurrence at 14 months and ultimately passed away due to disease progression.