Outcomes of FIGO Stage Ib-IVa Cervical Cancer With or Without Nodal Metastases After Radical Radiotherapy or Chemoirradiation

Abstract

Objectives: Radical radiotherapy or chemoirradiation is the standard of care for International Federation of Gynecology and Obstetrics (FIGO) stage Ib-IVa cervical cancer. However, patients with pelvic or para-aortic nodal metastases have increased chance of recurrence and poor survival compared with those patients with no lymph node involvement. Their optimal management remains unclear. This study aimed at retrospectively evaluating the treatment outcomes of these patients in our unit to identify potential ways of improvement. Methods: From May 2007 to December 2012, 137 consecutive patients with FIGO stage Ib-IVa cervical cancers were treated with radical radiotherapy or chemoirradiation. Radical radiotherapy consisted of whole-pelvic external radiotherapy (ERT) with a median dose of 50 Gy in 2 Gy per fraction (median shield after 40 Gy), highdose-rate intracavitary brachytherapy (6.5 Gy/application for four or 7.7 Gy/application for three at Manchester point A, 2 applications/week) followed by additional external beam parametrial boost of 6 to 8 Gy, if indicated. Involved pelvic lymph nodes were boosted with a total dose of 60 to 64 Gy. Para-aortic nodal metastases were treated upfront by extended anteroposterior-posteroanterior field ERT covering both the para-aortic regions and the whole pelvis with a dose of 30 Gy in 2 Gy per fraction, followed by split-field 3-dimensional conformal boost of 20 Gy. Routine intracavitary brachytherapy, parametrial boost, and pelvic nodal boost were then given, when appropriate. Concurrent chemotherapy, when given, consisted of weekly cisplatin (40 mg/m 2). Treatment outcome parameters including overall survival (OS), cancer-specific survival (CSS), relapse-free survival (RFS), and patterns of failure were evaluated in all patients. Survival data were compared with the log-rank test and prognostic factors were analysed with the Cox proportional hazards regression model. Results: Of the 137 patients, 99 (72%) received chemoirradiation; 37 (27%) had either pelvic and / or paraaortic nodal metastases on radiological or pathological examination. After a median follow-up of 31 (range, 2-72) months, a significantly higher proportion of patients in group A (those with lymph node metastasis, 35%) had disease recurrence than in group B (those without lymph node metastasis, 19%; p = 0.047). Patients in group A had poorer 3-year OS (60%) and CSS (64%) compared with those in group B (OS, 75%, p = 0.08; CSS, 81%, p = 0.051) but the difference did not reach statistical significance. Patients in group A had significantly poorer 3-year RFS (50%) compared with those in group B (RFS, 73%; p = 0.009). FIGO stage III-IVa, presence of nodal metastases, and overall treatment time of more than 56 days were significant poor prognostic factors for both OS and RFS in multivariate analysis. Among patients with relapse, the majority (77% in group A and 84% in group B) developed first recurrence at distant sites with or without local relapse at a median time of 9.6 (range, 1.3-39.6) months. Only four (11...