Para-aortic lymph node involvement revisited in the light of the revised 2018 FIGO staging system for cervical cancer

Risk Factor Analysis and Prediction of Para-Aortic Lymph Node Metastases in Locally Advanced Cervical Cancer

BACKGROUND AND PURPOSE

The indications of prophylactic extended-field radiotherapy (EFRT) remain uncertain. This study aims to identify the risk factors for para-aortic lymph node (PALN) metastases in locally advanced cervical cancer (LACC) and determine which part of patients may benefit from prophylactic EFRT.

MATERIALS AND METHODS

Between January 2015 and July 2023, a single-center retrospective analysis was performed on patients with stages IB3 and IIA2-IVA cervical cancer. Lymph node involvement was assessed using positron emission tomography/computed tomography (PET/CT). Risk factors were evaluated by logistic regression. A prediction nomogram model was developed and validated.

RESULTS

Among 329 patients, 64 (19.5%) had PALN metastases. Univariate analysis indicated that tumor size > 5.3 cm, tumor maximum standardized uptake value (SUVmax) > 9.8, bilateral pelvic lymph node (PLN) metastases, the number of positive PLNs ≥ 3, and T3-T4 stages were related to PALN metastases. After multivariate logistic analysis, it was found that tumor size > 5.3 cm (odds ratio [OR] = 3.129, 95% confidence interval [CI] = 1.536-6.374, p = 0.002), and the number of positive PLNs ≥ 3 (OR = 11.260, 95% CI = 3.506-36.158, p < 0.001) were independent risk factors. The C-index of the nomogram was 0.886 (95% CI = 0.844-0.927). The calibration plot showed that the nomogram was well-fitted. Decision curve analysis (DCA) exhibited excellent clinical utility.

CONCLUSION

Tumor size > 5.3 cm and the number of positive PLNs ≥ 3 are independent risk factors of PALN metastases. The nomogram shows pretty good accuracy, which may provide a valuable reference for guiding patients who are very likely to develop PALN metastases to receive prophylactic EFRT.

Curative treatment for stage IIIC2 cervical cancer: what to expect?

Background

Since the GOG125 study, treating radically patients with positive para-aortic lymph nodes has been a valid approach. Nevertheless, literature lacks data on how to better treat these patients since they are usually excluded from trials. In this study, we aimed to report the outcomes of patients with advanced cervical cancer and positive para-aortic lymph nodes (PAN) treated in a single tertiary/academic institution and try to identify variables that may impact survival.

Materials and methods

We retrospectively reviewed patients with positive para-aortic lymph nodes treated in our institution. Demographic variables and treatment options were assessed and their impact on overall survival (OS), locorregional control, distant metastasis free survival, and para-aortic lymph node progression was analyzed.

Results

We assessed 65 patients treated from April 2010 to May 2017. Median OS was 38.7 months. Median locorregional and para-aortic progression free survivals were not reached. Median distant metastasis progression-free survival was 64.3 months. Better ECOG performance status (p > 0.001), concurrent chemotherapy (p = 0.031), and brachytherapy (p = 0.02) were independently related to better overall survival.

Conclusion

Patients with current stage IIIC2 cervix cancer may present long term survival. Treating positive PAN cervical cancer patients with concurrent chemoradiation including brachytherapy with curative intent should be standard. Poor PS and more advanced pelvic disease may represent a higher risk for worse outcomes. Distant metastases are still a challenge for disease control.

Current Update on PET/MRI in Gynecological Malignancies-A Review of the Literature

Early detection of gynecological malignancies is vital for patient management and prolonging the patient's survival. Molecular imaging, such as positron emission tomography (PET)/computed tomography, has been increasingly utilized in gynecological malignancies. PET/magnetic resonance imaging (MRI) enables the assessment of gynecological malignancies by combining the metabolic information of PET with the anatomical and functional information from MRI. This article will review the updated applications of PET/MRI in gynecological malignancies.

Prognostic value of the 2018 FIGO staging system for cervical cancer

OBJECTIVE

To compare the prognostic performance of the FIGO 2009 and FIGO 2018 staging systems for cervical cancer (CC) in regards to risk stratification, survival and treatment outcome.

METHODS

A total of 4461 CC patients diagnosed in Denmark during 2005-2018 were identified through the Danish Gynaecological Cancer Database and restaged from the 2009 FIGO to the 2018 FIGO staging system. 5-year survival estimates were made for each group. Also, association between lymphovascular space invasion (LVSI) and lymph node metastasis (LNM) was assesed for tumors with a horizontal spread >7 mm and depth of invasion ≤5 mm.

RESULTS

Overall, stage migration was observed in 41.4% of our cases due to the introduction of stage IIIC (20.1%), refined tumor size criteria within stage I (76.2%), and use of radiological findings to define stage IV (3.7%). 5-year overall survival increased for all stages except IA2, IIA2, IIIA and IIIB. Restaging of 2009 IB1 to 2018 FIGO resulted in significant stage allocations. Furthermore, an association between LVSI and LNM was observed in squamous cell carcinomas with a depth of invasion of 3-5 mm and a horizontal spread >7 mm (p = 0.03).

CONCLUSION

The 2018 FIGO staging system provided improved discriminatory ability for stage I and IV. Grouping all patients with positive pelvic or paraortal lymph nodes to stage IIIC led to pronounced heterogenous survival rates within these stages. Lymph node assessment was proven imperative in FIGO 2018 IA2 squamous cell carcinomas with a depth of invasion of 3-5 mm, a horizontal spread >7 mm and LVSI.

Magnetic resonance imaging-based validation of the 2018 FIGO staging system in patients treated with definitive radiotherapy for locally advanced cervix cancer

OBJECTIVE

To validate the revised 2018 International Federation of Gynecologic and Obstetrics (FIGO) staging system in patients who underwent diagnostic magnetic resonance imaging (MRI) and radiotherapy (RT) for locally advanced cervix cancer.

METHODS

We analyzed 677 patients who were diagnosed with pelvic MRI and treated with definitive (chemo-)RT for locally advanced cervix cancer (stage IB2/IIA2-IVA or N+) between 1992 and 2018. Patients were classified according to 2009 and 2018 FIGO staging, and survival outcomes were compared. We developed a nomogram to improve prediction of progression-free survival (PFS).

RESULTS

Pelvic and paraaortic lymph nodes were positive in 331 (48.9%) and 78 (11.5%) patients, respectively. At a median follow-up of 77.9 months, the 5-year PFS was 83.5%, 65.2%, 71.0%, 60.6%, 37.6% and 38.9% for IB, IIA, IIB, IIIA, IIIB and IVA according to FIGO 2009 and 88.9%, 60.0%, 73.8%, 66.7%, 36.3%, 68.9%, 43.6%, and 38.9% for IB, IIA, IIB, IIIA, IIIB, IIIC1, IIIC2, and IVA according to FIGO 2018, respectively. Survival of stage IIIC cervix cancer depended on the local extent of the tumor: the 5-year PFS of T1, T2, and T3 stages were 80.3%, 73.9%, and 45.5% for IIIC1 and 100%, 44.9%, and 23.4% for IIIC2. Histology, tumor size, node metastasis, FIGO 2009, and treatment modality were independent prognostic factors in the Cox regression analysis, and the nomogram incorporating these factors outperformed FIGO 2009 and FIGO 2018 (AUC 0.718 vs. 0.616 vs. 0.594).

CONCLUSIONS

FIGO 2018 revision was associated with heterogenous outcomes among stage III cervix cancer patients. Our nomogram can assist the FIGO system in predicting PFS after definitive RT.

2018 FIGO Staging Classification for Cervical Cancer: Added Benefits of Imaging

Cervical cancer is the fourth most common cancer in women of all ages worldwide. The disease is staged using the International Federation of Gynecology and Obstetrics (FIGO) system, which was updated in 2018. The authors explain the key changes from the 2009 version and the rationale behind them. The changes have been made to reflect common clinical practice, differentiate prognostic outcomes, and guide treatment stratification. Treatment options are dependent on the stage of disease and include fertility-sparing and non-fertility-sparing surgical options as well as chemoradiotherapy for locally advanced disease. The updated FIGO staging gives added importance to MRI as a method of accurately measuring tumor size and depicting the presence of parametrial involvement. With the inclusion of lymph node involvement in the updated 2018 FIGO staging, cross-sectional imaging-and in particular, fluorodeoxyglucose PET/CT-has an increasing role in the depiction of nodal disease. Understanding the radiologic techniques used, the literature supporting them, and common imaging pitfalls ensures accurate staging of disease and optimization of treatment. ^©RSNA, 2020 See discussion on this article by Javitt (pp 1823-1824).