Paraaortic lymph node irradiation in cervical carcinoma without prior lymphadenectomy

Treatment outcomes and prognostic factors in uterine cervical cancer patients treated with postoperative extended field radiation therapy

OBJECTIVE

To evaluate treatment outcomes and prognostic factors in uterine cervical cancer patients treated with postoperative extended field radiation therapy (POEFRT) with or without chemotherapy.

METHODS

Between 1983 and 2006, 35 patients with a pathologically confirmed positive para-aortic node (PAN) or common iliac node (CIN) who underwent a radical hysterectomy with bilateral pelvic lymph node dissection and PAN dissection received POEFRT with (N=23) or without (N=12) chemotherapy. Prognostic factors such as age, stage, size, parametrium invasion, lymphovascular space invasion, nodal station, depth of stromal invasion and use of chemotherapy were analyzed.

RESULTS

With a median follow-up of 44 months, the 5-year overall survival (OS), disease-free survival (DFS), distant failure-free survival (DFFS) and loco-regional failure-free survival rates were 51%, 51%, 59% and 93%, respectively. The use of chemotherapy significantly improved the 5-year OS rate (61% vs. 48%, p=0.004), the 5-year DFS rate (54% vs. 38%, p=0.004) and the 5-year DFFS rate (57% vs. 48%, p=0.009). PAN involvement resulted in a compromised 5-year DFS rate (42% vs. 73%, p=0.002) and 5-year DFFS rate (47% vs. 82%, p=0.004) as compared to CIN involvement. Grade 3 or higher hematological toxicity was observed more frequently in patients who received POEFRT combined with chemotherapy as compared to patients who received POEFRT alone (52% vs. 17%, p=0.04).

CONCLUSION

The use of POEFRT resulted in an excellent loco-regional control rate. The addition of chemotherapy may improve outcome in patients who have received POEFRT, but with higher manageable toxicity.

Radiation therapy with or without chemotherapy for cervical cancer with periaortic lymph node metastasis

The purpose of this article is to evaluate the efficacy of chemoradiation therapy (CRT) and radiation therapy (RT) alone for cervical cancer with periaortic nodal metastasis (PANM). Twenty-one patients with cervical cancer with PANM were identified. Eleven patients received concomitant CRT with cisplatin-based chemotherapy and 10 received RT alone. The median age was 44 years. Ten, 5, and 6 patients had International Federation of Gynecology and Obstetrics stages IB, IIB, and IIIB disease. The RT doses to point A and the periaortic region were 80 to 85 Gy (low dose rate equivalent) and 45 Gy. The median follow-up was 26 months (range 3 to 141 months). The 1- and 3-year disease-specific survival were 81.8% and 81.8%, and 70% and 30%, respectively, for the CRT and RT groups, (P = 0.11). The 1- and 3-year pelvic and periaortic control rates (PPC) were 100% and 100% (CRT), and 56.3% and 42.2% (RT) (P = 0.03). The 1- and 3-year free-from-distant metastasis (DM) rates were 81.8% and 81.8% (CRT), and 78.7% and 49.2% (RT) (P = 0.54). All patients who developed DM died of their disease. CRT is a feasible treatment option to improve the PPC for these patients. Because of the high rate of distant metastasis despite PPC, more effective systemic therapy should be explored.

Clinical evaluation of dynamic arc conformal radiotherapy for paraaortic lymph node metastasis

PURPOSE

This study was performed to evaluate the efficacy and safety of dynamic arc conformal radiotherapy, a simple intensity modulated radiation therapy (IMRT), for the treatment of paraaortic lymph node metastases.

MATERIALS AND METHODS

Twenty-nine patients with paraaortic lymph node metastases were enrolled in this study. The total planned dose was 55-60 Gy. A computed tomography (CT) simulator was used in the treatment planning.

RESULTS

The total radiation dose delivered was 50-63.4 Gy (median 60 Gy). Sixteen of 29 patients showed local tumor shrinkage on CT, and the 2 year in-field recurrence free survival rate was 58%. Acute Grade 1 and Grade 2 gastrointestinal disorders occurred in 31% and 17%, respectively, and acute Grade 2 liver dysfunction occurred in 7%. As a late complication, Grade 1 and Grade 2 liver dysfunction occurred in six patients (21%) and five patients (17%), respectively. There was no renal dysfunction or myelopathy detected.

CONCLUSION

Dynamic arc conformal radiotherapy, a simple IMRT, is a safe and effective treatment method for paraaortic lymph node metastasis.

Analysis of recurrence of squamous cell carcinoma of the uterine cervix after definitive radiation therapy alone: patterns of recurrence, latent periods, and prognosis

PURPOSE

A retrospective analysis was performed with emphasis on the patterns of recurrence, latent period, and prognosis in patients with cervical squamous cell carcinoma of the uterus treated with definitive radiation therapy alone. Late recurrence, which was observed more than 5 years after the initial radiation therapy, was finally focused on and discussed.

MATERIALS AND METHODS

Between 1976 and 1994, 256 patients with squamous cell carcinoma of the uterine cervix without hematogenous metastasis were treated with definitive radiation therapy alone. The patients were staged as follows according to the FIGO classification: 26 in Stage I, 56 in Stage II, 124 in Stage III, 28 in Stage IVa, and 22 in Stage IVb. All the patients were treated with external beam irradiation and low-dose-rate intracavitary brachytherapy.

RESULTS

A total of 74 patients had recurrence. The recurrence appeared in 67 cases (90.5%) within 5 years. Metastasis to para-aortic and/or supraclavicular nodes developed later than other types of recurrence. Among patients with lymphogenous metastasis, there were more 5-year survivors after recurrence than with other types of recurrence. Patients with early recurrence, within 2 years of the initial therapy, had a worse prognosis than those with recurrence more than 2 years after treatment. Seven patients (2.7%) in all developed late recurrence more than 5 years after the treatment. The first site of recurrence was an abdominal para-aortic or supraclavicular node in all patients, excluding one patient who developed intrapelvic lymph node metastasis. Six patients had pelvic node metastasis detected with lymphangiography at the initial treatment. Median survival after late recurrence was 16.0 months. Two of 7 patients survived more than 3 years after secondary radiation therapy, and the remainder died of recurrent disease.

CONCLUSION

Patients with para-aortic and/or supraclavicular node metastasis that developed late after the initial treatment are more likely to survive due to secondary radiation therapy. Careful follow-up is emphasized for long-term survivors.

Radiation therapy for carcinoma of the cervix with biopsy-proven positive para-aortic lymph nodes

PURPOSE

To evaluate local tumor control, cause-specific survival, patterns of relapse, and toxicity in patients with cervical cancer and positive para-aortic lymph nodes treated with radiation therapy alone.

METHODS

This is a retrospective chart review of 43 patients with cervical cancer and biopsy-proven positive para-aortic lymph nodes treated with radiation therapy treated from 1965 to 1993. There were 15 patients with clinical Stage I disease, 12 with Stage II, and 16 with Stage III. Patients were treated with external irradiation to the pelvis and para-aortic regions combined with brachytherapy. None received chemotherapy.

RESULTS

The 5-year overall survival rate was 32% and the median overall survival was 2.2 years. The 5-year cause-specific survival rate was 49% and the median cause-specific survival was 2.7 years. The cause-specific survivals at 5 years were 47% for Stage I, 64% for Stage II, and 46% for Stage III. Tumor recurrence occurred in 20 patients. The sites of recurrence were in the pelvis only in 3, the pelvis and distant metastasis in 9, and distant metastasis only in 8 patients. Severe, grade 3 complications occurred in 2 patients. One patient developed an enterovaginal fistulas and 1 developed radiation myelitis.

CONCLUSION

Pelvic and para-aortic irradiation and brachytherapy resulted in a 49%, 5-year, cause-specific survival. Clinical tumor stage did not effect outcome. The majority of relapses occurred at distant sites. Toxicity was acceptable. Systemic chemotherapy should be considered as adjunctive therapy for these patients.

Cervical cancer with paraaortic metastases: significance of residual paraaortic disease after surgical staging

Cervical carcinoma frequently metastasizes to the paraaortic region, necessitating extended field radiotherapy to effect a cure. As imaging modalities are unreliable in identifying all cases of paraaortic nodal metastases (PAN), surgical staging is often utilized prior to radiotherapy. This study was aimed at identifying factors predictive of survival in women with cervical carcinoma and paraaortic metastases. In particular, survival based on extent of paraaortic disease was examined. The study group consisted of 43 women (stages IB-IVB) identified between 1982 and 1993 who were treated with extended field radiation for cervical carcinoma with histologically confirmed paraaortic metastases. The estimated 5-year survival for the study population was 24% with a median survival of 18 months. Pelvic tumor size had a significant impact on survival with the median survival being 34 months if the primary lesion was < 6 cm compared to 14 months if > or = 6 cm (P = 0.01). Eight of the 26 (31%) women without residual PAN disease after surgical staging remain alive and disease free (mean follow-up, 74 months). In contrast, only 1 of the 17 (6%) women with gross residual PAN is alive 71 months after treatment (P = 0.05). However, a comparison of Kaplan-Meier survival curves did not show a statistically significant advantage to the surgical excision of grossly involved PAN (P = 0.98). Although long-term survival among women with grossly involved, unresected paraaortic metastases is uncommon, further study is necessary to elucidate the role of surgical excision of bulky aortic disease in women with cervical cancer.