Postoperative pelvic radiotherapy for cervical cancer patients with positive parametrial invasion

Is there a benefit for adjuvant radio(chemo)therapy in early cervical cancer? Results from a population-based study

PURPOSE

Due to insufficient and conflicting prospective evidence, the recommendations on when to apply adjuvant radiochemotherapy in early-stage cervical cancer vary between international guidelines. In this population-based study, we evaluated the outcome of patients with early-stage cervical cancer based on risk factors and the adjuvant therapy they received.

METHODS

The effect of primary therapy (surgery and radiochemotherapy RCT, surgery and radiotherapy RT, and surgery alone) on overall survival (OS) and recurrence-free survival (RFS) was evaluated in the complete cohort of 442 patients and in subgroups according to risk profile and nodal status.

RESULTS

In low-risk patients, there was no difference in OS (p = 0.276) depending on whether patients received adjuvant therapy or not. Concerning RFS, patients with RT (including one patient with RCT) exhibited a significantly worse outcome compared to the group with surgery alone (p = 0.015). In intermediate-risk patients, the administration of adjuvant RT significantly benefited RFS when compared to surgery only in multivariate analysis (p = 0.031). Concerning OS, no significant influence for adjuvant treatment could be seen (p = 0.354). Though trends towards better OS and RFS could be observed in patients of the high-risk group-both in RCT and RT groups compared to surgery alone-the effects did not prove to be significant.

CONCLUSION

Our study reaffirms the evidence against the use of adjuvant radio(chemo)therapy in low-risk early-stage cervical cancer. In intermediate-, and less pronounced in high-risk patients, however, it seems to be beneficial. The role of adjuvant radio(chemo)therapy in early cervical cancer should be further investigated in prospective randomized trials.

Prognostic factors influencing pelvic, extra-pelvic, and intraperitoneal recurrences in lymph node-negative early-stage cervical cancer patients following radical hysterectomy

OBJECTIVE

The aim of this study was to evaluate the clinicopathologic factors influencing pelvic, extra-pelvic, and intraperitonal recurrences and survival in patients with lymph node-negative early-stage cervical cancer treated with abdominal/laparoscopic/robotic radical hysterectomy (ARH/LRH/RRH).

STUDY DESIGN

We retrospectively reviewed clinicopathologic data of 342 patients with FIGO stage IB-IIA cervical cancer (2018 FIGO staging) treated with RH and retroperitonal lymphadenectomy between February 2000 and November 2018. Several clinicopathologic factors such as surgical methods including LRH/RRH-vaginal colpotomy (VC) and LRH/RRH-intracorporeal colpotomy (IC), surgical resection margin, and parametrial/endomyometrial infiltration were selected. Univariate and multivariate Cox proportional hazard regression and logistic regression models were used to determine prognostic factors.

RESULTS

The median follow-up time was 54 months (range, 6-202 months). In multivariate analysis, positive endomyometrial infiltration (HR, 13.576; 95 % CI, 2.917-63.179; P = 0.001), positive parametrial resection margin (HR, 32.648; 95 % CI, 2.774-384.181; P = 0.006), and LRH/RRH-IC (HR, 4.752; 95 % CI, 1.154-19.578; P = 0.031) were significantly related to overall survival. Six (26.3 %) out of 21 patients with endomyometrial infiltration showed extra-pelvic recurrences associated with lung, liver, and brain. Three (50.0 %) out of 6 patients with positive parametrial margin showed both pelvic and extra-pelvic metastases, such as pelvis and supraclavicular/paratracheal lymph nodes. Five (62.5 %) out of the eight relapsed patients who received LRH/RRH-IC showed intraperitoneal recurrences including omentum, liver surface, colon serosa, and splenic hilum.

CONCLUSIONS

Three risk factors including parametrial margin, endomyometrial infiltration, and laparoscopic IC appear to be involved in pelvic, extra-pelvic, and intraperitoneal recurrences in node-negative early-stage cervical cancer patients following RH. In particular, endomyometrial infiltration may be one of the strongest independent prognostic factors for extra-pelvic recurrence. Adjuvant systemic therapy may be indicated for lymph node-negative early-stage cervical cancer patients with endomyometrial infiltration.

Prognostic factors for and pattern of lymph-node involvement in patients with operable cervical cancer

PURPOSE

Lymph node metastases significantly worsen the prognosis in cervical carcinoma. Risk factors-pathological and patient related-could select patients at high risk for lymph node involvement.

METHODS

This retrospective analysis was performed by analyzing data from patients with cervical carcinoma treated between 2000 and 2017 at the Department of Obstetrics and Gynecology of the University Hospital Ulm.

RESULTS

In total, 261 patients with cervical carcinoma (International Federation of Gynecology and Obstetrics (FIGO) stage IA-IIB) and lymphadenectomy with at least 10 removed lymph nodes were available for analysis. Overall, 86 (33.0%) patients had lymph node metastases; 73 patients had pelvic lymph node metastases only and 13 patients had both pelvic and paraaortic lymph node metastases. Lymph node metastases were found most often in the region of the external iliac artery and obturator fossa, with 57.0% and 54.7% of all 86 node-positive patients, respectively. Univariable analyses showed that presence of lymph node metastases was significantly associated with both preoperative FIGO stage (p = 0.001) and final pathological tumor stage (p < 0.001), status of resection margin (p = 0.002), lymphovascular space invasion (LVSI), (p < 0.001) and vascular space invasion, (p < 0.001). In a multivariable logistic regression model with presence of lymph node metastases (yes/no) as binary response variable, only LVSI (p < 0.001) and body mass index (BMI), (p = 0.035) remained as significant independent predictors of lymph node involvement. Subgroup analyses showed that LVSI was a significant predictive factor for lymph node involvement in patients with a preoperatively assessed FIGO stage < IIB (p < 0.001), but not for patients with a preoperatively assessed FIGO stage ≥ IIB (p = 0.122).

CONCLUSIONS

The risk factor LVSI should play an important role in deciding whether an individualized therapy concept is based on escalating or deescalating treatment. In future, the sentinel concept could reduce morbidity and at the same time provide an important prognostic assessment for a subset of cervical cancer patients.

The issues regarding postoperative adjuvant therapy and prognostic risk factors for patients with stage I-II cervical cancer: A review

The treatment for most patients with early-stage cervical cancer involves radical hysterectomy and pelvic lymph node dissection, and indications for postoperative adjuvant therapy have been determined by evaluating the prognostic risk factors for recurrence in each case. The aim of this review is to raise and discuss the various issues that have not yet been resolved regarding the prognostic risk factors and postoperative adjuvant therapy. Several clinicopathological factors, such as tumor size, lymphovascular space involvement, deep stromal invasion, parametrial involvement and lymph node metastasis, have been identified to have prognostic significance in early-stage cervical cancer. However, this remains controversial because there is suggested to be substantial heterogeneity among patients after radical hysterectomy and lymphadenectomy and it would be difficult to define the risk groups clearly. This indicates the need to develop more convenient and accurate criteria to define risk groups. According to the currently available evidence, patients in the high-risk group should receive adjuvant concurrent chemoradiotherapy (CCRT) with cisplatin (CDDP) and fluolouracil. However, CCRT with CDDP administered weekly (CCRT-P) has instead been applied in a clinical context worldwide. Whether CCRT-P has a survival benefit compared with radiotherapy (RT) alone is unknown because no randomized phase III trials have been performed for patients in the high-risk group after radical surgery. Patients with high-risk factors have a high incidence of distant metastasis, for whom systemic chemotherapy might be a key to improving overall survival. The pivotal study that investigated the role of RT alone for patients with intermediate-risk factors after hysterectomy is the GOG092 trial. This trial showed a 47% reduction in the risk of recurrence after RT compared with no further treatment (NFT). However, the improvement in overall survival with RT did not reach statistical significance, while patients allocated to the RT group did experience an increase in severe toxicities compared with the NFT group. This could be why many physicians are reluctant to treat patients with this approach, although guidelines recommend RT for patients with intermediate-risk factors. With regard to toxicities, postoperative RT would be problematic because the organs in the pelvis targeted by RT have already been damaged by radical surgery. To reduce the toxicities, intensity-modulated radiotherapy would best be used worldwide. Further improvement in adjuvant therapy will come from enhanced definition of prognostic risk factors, better patient selection, and refinements in both local and systematic therapies.

Postoperative external beam irradiation with and without brachytherapy in pelvic node-positive IB1-IIA2 cervical cancer patients: a retrospective clinical study

Background

This study assessed the survival outcomes and recurrent patterns in pelvic node-positive IB1-IIA2 cervical cancer patients treated with postoperative external beam irradiation with or without vaginal brachytherapy.

Methods

The records of 1149 cervical cancer patients received radical surgery between February 2008 and March 2010 were retrospectively reviewed. 126 stages IB1-IIA2 patients with positive pelvic lymph node (LN) were included and a total of 113 patients who received different postoperative radiation therapy were identified and analyzed. Of the enrolled patients, 55 patients received pelvic external beam radiotherapy (EBRT) without vaginal brachytherapy and 58 patients received pelvic EBRT with vaginal brachytherapy. Treatment-related toxicities were evaluated. Progression-free survival (PFS) and overall survival (OS) were analyzed using Kaplan-Meier estimates and statistical significance was determined using the log-rank test.

Results

With a median follow-up of 47 months (range: 10–61 months), the group which had pelvic EBRT with brachytherapy had a significantly improved 5-year PFS rate (P = 0.044), but no significant difference in 5-year overall survival was found between the two groups (P = 0.437). In patients treated without brachytherapy, the most common site of relapse was the pelvis. No significant differences were found regards to acute and chronic radiation toxicities, including myelosuppression, dermatitis, enterocolitis, proctitis and cystitis (P = 0.485, 0.875, 0.671, 0.459 and 0.969 respectively) between the groups of pelvic EBRT with and without vaginal brachytherapy.

Conclusions

Treated with pelvic EBRT in combination with vaginal brachytherapy, cervical cancer patients with positive pelvic lymph node had a reduced risk of locoregional recurrence without increased side effects compared with patients treated with pelvic EBRT without vaginal brachytherapy.

Management of pelvic lymph nodes by sentinel node navigation surgery in the treatment of invasive cervical cancer

OBJECTIVE

Diagnosis of lymph node metastasis is a critical issue in the treatment of cervical cancer. Many studies describing sentinel node navigation surgery (SNNS) for examination of node status have been reported in the past decade. In this study, the feasibility of node status diagnosis by SNNS, including intraoperative frozen section diagnosis, in patients with early and advanced cervical cancer was evaluated.

PATIENTS AND METHODS

Fifty-eight cervical cancer patients with early and advanced stage disease were enrolled. All patients were treated with backup pelvic lymphadenectomy after SNNS. To detect sentinel lymph nodes (SLNs), radioactive material and/or blue dye were used as tracers. Lymph nodes confirmed as SLNs were immediately sent to pathologists and diagnosed by frozen section intraoperatively.

RESULTS

A total of 118 and 16 SLNs were pathologically investigated in early and advanced stage cervical cancer, respectively. The detection rate of SLNs in the early and advanced stages was 94.7% and 66.7%, respectively, whereas the detection rate using 1 or 2 tracers was 62.5% and 90%, respectively. The false-negative rate and negative predictive value was 0% and 100% for all stages. Pathological diagnosis by frozen section was completed within 30 minutes in all cases.

CONCLUSIONS

Our data demonstrate that SNNS in cervical cancer is a promising procedure for patients with early stage (up to Ib1) disease, especially patients with small tumor diameter (<2.0 cm). However, SNNS raises several points for discussion before it can be established as a practical clinical procedure or as part of a subsequent radical hysterectomy.

The vascular portion of the cardinal ligament: surgical significance during radical hysterectomy for cervical cancer

OBJECTIVE

The objective of the study was to analyze the histopathologic content of the vascular portion of the cardinal ligament in patients undergoing radical hysterectomy for cervical cancer.

STUDY DESIGN

The vascular portion of the cardinal ligament was completely removed during radical hysterectomy. The maximum cervical diameter and length of the vascular ligament were measured on the fresh specimen. After inking, the pathologist separated and embedded the entire vascular segment from each side. Microscopic examination followed.

RESULTS

Eighty-four patients were available for analysis. The mean cervical diameter was 3.9 cm (2-8), whereas the mean vascular segment length on the right and left sides were 4 cm (1-10) and 3.8 cm (1-7), respectively. Mean number of vascular segment lymph nodes were as follows: medial right = 0.7 (0-4), medial left = 0.6 (0-5), lateral right = 0.4 (0-3), and lateral left = 0.6 (0-6). Mean diameter of medial and lateral lymph nodes were 2 mm (0.25-8) and 3.3 mm (0.25-16), respectively. The length of the vascular segment correlated inversely with maximum cervical diameter. Thirty-one percent (26 of 84) had positive pelvic side wall lymph nodes. Fourteen patients had positive vascular segment lymph nodes (1 positive = 7, more than 1 positive = 7). Three of 7 patients had bilateral positive vascular segment lymph nodes; all 7 had microscopic disease in the paravaginal soft tissue, and all 7 had positive pelvic side wall lymph nodes (6 of 7 bilateral). Including the 14 patients, a total of 19 had nodal or nonnodal microscopic disease in the vascular segment. Of these, 7 had disease in the lateral half of the vascular ligament. Histologic sectioning revealed nerve twigs and/or scattered ganglia in the vascular segment but no large nerve trunks.

CONCLUSION

Among a population of women with high-risk, early-stage cervical cancer, the lateral vascular segment of the cardinal ligament contained metastatic disease in a substantial number of patients. This segment contains no major nerve trunks. When radical hysterectomy is chosen as primary treatment for such patients, the vascular segment of the cardinal ligament should be completely excised.

Early stage cervical cancer: Adjuvant treatment in negative lymph node cases

OBJECTIVES

In early stage cervical carcinoma, most studies of the literature show that adjuvant radiotherapy significantly reduced local relapse; its impact on survival improvement is controversial. In this retrospective study, we analyze the role of adjuvant radiotherapy in negative node patients and the possibility of this treatment to improve survival in selected groups.

METHODS

Four hundred fifty-four patients with stage IB-IIA carcinoma of the uterine cervix were treated with primary radical hysterectomy and pelvic lymphadenectomy. The patients with negative nodes but with pathologic prognostic factors predictive of a poor outcome, underwent adjuvant radiation therapy, according to personalized indications.

RESULTS

Disease-free actuarial 5-year survival (DFS) was 80%: 88% and 57% in patients with negative and positive nodes, respectively. The population of negative node patients was stratified in three risk categories according to the number of worsening prognostic factors: parametrial invasion, depth of stromal invasion (SI) >1/3 and presence of lymph vascular space involvement (LVSI). In the medium risk category (1 or 2 unfavorable prognostic factors), DFS showed significant advantage for patients submitted to post-operative external beam radiation. In the subset of cases without parametrial extension (pT1B) with one or two risk factors on the surgical specimen (LVSI and/or SI >1/3), there was no difference in DFS between the two groups treated or not with adjuvant radiotherapy.

CONCLUSION

Post-operative radiotherapy is controversial in node-negative pathologic stage IB cervical cancer; radical surgery alone has low morbidity, enable more accurate prediction of prognosis and may be sufficient therapy in the majority of patients with lymph node-negative early stage cervical cancer.

Postoperative radiation therapy for carcinoma of the uterine cervix

Postoperative radiation therapy (PORT) for cervical cancer has been empirically performed for patients with pathologic risk factors for recurrence after surgery. The efficacy of PORT is mainly supported by retrospective studies. Despite convincing evidence demonstrating a reduction in pelvic recurrence rates when PORT is employed, there is no evidence that it eventually improves patient survival. Local recurrence, such as vaginal stump recurrence, is not always fatal if diagnosed earlier. Some patients, unfortunately, may develop distant metastases even after PORT. The positive effects of PORT also may be counterbalanced by increased toxicities that result from combining local therapies. These factors obscure the efficacy of PORT for cervical cancer patients. There has been no consensus on the predictive value of risk factors for recurrence, which renders indication of PORT for early-stage cervical cancer quite variable among institutions. Today, efforts have been made to divide patients into three risk groups based on the combination of risk factors present after radical hysterectomy. In Europe/USA and Japan, however, a fundamental difference exists in the indications for radical surgery, highlighting differences in the concept of PORT; "adjuvant pelvic irradiation for stage IB-IIA patients after complete resection" in Europe/USA and "pelvic irradiation after surgery irrespective of initial clinical stage and surgical margin status" in Japan. Thus, it is questionable whether scientific evidence established in Europe/USA is applicable to Japanese clinical practice. The purpose of this article is to review the role of PORT by interpreting the results of clinical studies.