The Combination of T Stage and the Number of Pathologic Lymph Nodes Provides Better Prognostic Discrimination in Early-Stage Cervical Cancer With Lymph Node Involvement

Abstract

ObjectiveStage I and II cervical cancer with pelvic and/or para-aortic lymph node (LN) metastases are upstaged to stage IIIC under the new FIGO 2018 staging system, and radical chemoradiotherapy was recommended. But heterogeneity in outcome existed in this group of patients. We conducted this retrospective analysis to evaluate the heterogeneity of these patients and tried to provide a more detailed classification to reflect the prognosis and guide the treatment. We also evaluated the efficacy and toxicity of surgery followed by sequential chemoradiotherapy in this cohort.MethodsEarly-stage cervical cancer with LN involvement that had radical hysterectomy followed by sequential chemoradiotherapy were retrospectively analyzed. Survival analyses were conducted to identify the prognostic factors.ResultsA total of 242 patients were included in the study; 64 (26.4%) patients had treatment failure, and 51 (21.1%) died. Pathology, T stage, the number of pathologic LN (pLN), and neoadjuvant chemotherapy or not were independent prognostic factors for disease-free survival and overall survival (OS). Patients with T1N < 3 pLN had significantly better survival than T2N < 3 pLN/T1-2 N≥ 3 pLN, with failure rates of 11.6% and 35.8% in each group; and 5 year OS was 92% and 62%, respectively (P = 0.000). About 1.5% of the patients discontinued radiotherapy, and 14.1% had G3-4 hematological toxic effects during radiotherapy; 1.7% developed G2-3 lower limb edema, and 2.9% developed severe urinary toxicity.ConclusionNodal involvement alone is inadequate as the sole pathologic factor to predict survival in early-stage cervical cancer. The combination of tumor and node subcategory provides better prognostic discrimination.

Rationality of FIGO 2018 IIIC restaging of cervical cancer according to local tumor size: A cohort study

“…Information about para‐aortic LN metastasis was not available in the study; hence, there was only a single IIIC1 cohort. Bai et al 21 performed a survival analysis of 242 patients with early cervical cancer and LN‐positive disease to determine its prognostic factors. That study reported that T stage was an independent prognostic factor for DFS and OS and that patients with Stage T2 disease had a poorer prognosis than those with Stage T1 disease (T1 vs. T2, 5‐year OS: 86% vs. 58%, p = 0.001; 5‐year DFS: 80% vs. 20%, p = 0.007).…”

“…We particularly excluded cases with preoperative treatment or underdosage of radiotherapy according to the NCCN guidelines. Laparoscopy cases were also excluded to rule out deviation, because Bai et al 21 reported that in women with early cervical cancer, the DFS and OS rates after minimally invasive radical hysterectomy were lower than those after open radical hysterectomy.…”

“…However, one idea worth considering is that LN status alone is insufficient for determining the clinical characteristics of Stage IIIC patients and may not be appropriate in the clinical setting. Some recent studies explored the rationality of Stage IIIC from the perspective of oncology prognosis and demonstrated that the survival rate of women with positive LN (Stage IIIC) disease was superior to that of those with Stage IIIA and IIIB tumors 5,8,18–21 …”

“…Some recent studies explored the rationality of Stage IIIC from the perspective of oncology prognosis and demonstrated that the survival rate of women with positive LN (Stage IIIC) disease was superior to that of those with Stage IIIA and IIIB tumors. 5,8,[18][19][20][21] In several studies, the effect of local tumor size and extent on Stage IIIC outcomes was further explored according to the T classification of the TNM staging system. Consistent with our results, these studies indicated that primary cervical mass was an independent survival risk factor for patients with Stage IIIC disease.…”

Survival outcomes of 2018 FIGO stage IIIC versus stages IIIA and IIIB in cervical cancer: A systematic review with meta‐analysis

“…5,6 Since the introduction of 2018 FIGO staging system, there have been increasing concerns regarding the reliability of 2018 FIGO stage IIIC due to considerable heterogeneity in classifying lymph node metastases, regardless of tumor size or number of nodal metastases. [14][15][16][17][18][19] For example, a study from National Cancer Database (NCDB) reported that the 5-year survival rates of FIGO 2018 stages IA, IB, II, and III were 94%, 86.3%, 66.9%, and 47.7%, respectively. The 5-year survival rate of stage IIIC1 was 61.9%, while the 5-year survival rates of IIIC1 with T1a, T1b, T2 and T3 stages were 95.8%, 80.3%, 57.2%, and 39.7%, respectively.…”