Low-Dose, Prophylactic, Extended-Field, Intensity-Modulated Radiotherapy Plus Concurrent Weekly Cisplatin for Patients With Stage IB2-IIIB Cervical Cancer, Positive Pelvic Lymph Nodes, and Negative Para-aortic Lymph Nodes

Comparative Analysis of Oncologic Outcomes in Patients with Squamous Cell Carcinoma of the Uterine Cervix with High-Risk Features for Para-Aortic Recurrence: Prophylactic Extended-Field versus Pelvic Chemoradiotherapy

Purpose

To compare the oncologic outcomes of prophylactic extended-field radiation therapy (EFRT) and whole pelvic radiation therapy (WPRT) in cervical patients at high risk of para-aortic lymph node (PALN) recurrence.

Patients and Methods

From July 1999 to May 2022, a total of 115 patients with cervical cancer and high-risk features of PALN recurrence based on tumor markers, positive LNs and extensive parametrial invasion were retrospectively analyzed. All patients had received EFRT or WPRT at a dose of 39.6-45 Gy and concurrent chemotherapy. In EFRT, coverage was extended to include the para-aortic region below the level of the left renal vein or T12.

Results

Twenty-eight and 87 patients underwent EFRT and WPRT, respectively. For patients who survived, the median follow-up time was 60.8 months (range 9.2-131.6 months) in the EFRT group and 115.9 months (range 16.9-212.1 months) in the WPRT group. The 5-year overall survival (OS) and pelvic, extrapelvic and PALN recurrence rates were 87.7% vs 60.8% (p=0.019), 10.9% vs 25.3% (p=0.119), 18.1% vs 45.8% (p=0.011), and 0% vs 30.4% (p=0.005), respectively, between the EFRT and WPRT groups. Multivariate analysis revealed that EFRT and 2018 FIGO stage IV disease status were significant predictors of OS and extrapelvic recurrence.

Conclusion

Compared to WPRT, EFRT significantly improved OS and reduced extrapelvic and PALN recurrence in patients with cervical cancer with high-risk recurrence features.

Prophylactic Extended-Field Irradiation Versus Pelvic Irradiation in Patients With Cervical Cancer With 2018 FIGO Stage IIIC1 Disease

PURPOSE

The aim of this study was to compare the survival rates and toxicities of prophylactic extended-field radiation therapy (EFRT) and pelvic radiation therapy (PRT) among patients with cervical cancer with 2018 International Federation of Gynecology and Obstetrics (FIGO) stage IIIC1 disease.

METHODS AND MATERIALS

We retrospectively analyzed patients with 2018 FIGO stage IIIC1 disease who were treated with definitive concurrent chemoradiotherapy at our institute between 2011 and 2015. A dose of 50.4 Gy in 28 fractions was delivered to the pelvic region (by PRT) or the pelvic plus para-aortic lymph node region (by EFRT) with intensity modulated radiation therapy. The first-line regimen of concurrent chemotherapy was weekly cisplatin.

RESULTS

A total of 280 patients were included, with 161 patients treated with PRT and 119 patients treated with EFRT. After propensity score matching (1:1), 71 pairs of patients were selected. The respective 5-year rates of the patients treated with PRT and EFRT were 61.9% and 85.0% for overall survival (P = .025) and 53.0% and 77.9% for disease-free survival (DFS) (P = .004), respectively, after matching. In the subgroup analysis, patients were grouped into a high-risk group (122 patients) and a low-risk group (158 patients) based on 3 factors: positive common iliac lymph nodes, ≥3 pelvic lymph nodes, and 2014 FIGO stage IIIB disease. In both the high-risk and low-risk groups, EFRT significantly improved DFS compared with PRT. The rates of grade ≥3 chronic toxicities were 1.2% and 5.9% in the PRT and EFRT groups, respectively (P = .067).

CONCLUSIONS

In comparison to PRT, prophylactic EFRT was associated with improved overall survival, DFS, and para-aortic lymph node control in patients with cervical cancer with FIGO stage IIIC1 disease. The incidence of grade ≥3 toxicities was higher in the EFRT group than in the PRT group, although the difference was not significant.

Prophylactic extended-field irradiation for locally advanced cervical cancer

Concomitant chemoradiotherapy is the standard treatment for locally advanced cervical cancer. Pelvic irradiation is commonly recommended for patients with negative para-aortic lymph nodes(PALNs). However, owing to the development of imaging-guided brachytherapy, distant failure has become the main failure pattern. The PALNs are a vital site of distant metastasis, and the para-aortic region may contain occult microscopic metastases that are barely detected owing to imaging technology restriction. The prognostic of patients who experienced PALN failure is dismal. Typically, there are four ways to decrease PALN failure. First, surgical staging can be performed to assess the occurrence of metastasis in the para-aortic region; however, the application of surgical staging is decreasing owing to controversial survival benefits and accompanying complications of surgery. Second, regular imaging surveillance and timely salvage of early recurrences could reduce PALN failure. Third, better systemic adjuvant therapy could be recommended since it has enormous potential to reduce distant metastases and improve overall survival. Fourth, performing prophylactic extended-field irradiation (EFI), including pelvic and para-aortic region irradiation, can sterilize occult microscopic metastases in the para-aortic region and improve survival. Prior investigations have revealed that prophylactic EFI could reduce PALN failure as well as distant metastasis and present the benefit of survival. Yet, owing to the serious morbidity induced by enlarged irradiation field in the era of conventional irradiation techniques, further research on EFI is stagnated. Nowadays, with the development of new technologies, intensity modulated radiation therapy can deliver a higher dose to tumors with acceptable toxicity. Prophylactic EFI regained attention. However, the inclusion criteria of prophylactic EFI in existing studies reveal great discrepancies. Thus, it is urgent to precisely identify indications for better survival and lower complications in patients with cervical cancer. In this review, we identify indications and summary guidelines for prophylactic EFI, which may provide a foundation for further trials and clinical applications.

The impact of para-aortic lymph node irradiation on disease-free survival in patients with cervical cancer: a systematic review and meta-analysis

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Standard of care of locally advanced cervical cancer is based on concurrent chemoradiotherapy.

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Para-aortic radiotherapy (PAO-RT) has become controversial in the chemotherapy era.

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Systematic review on impact of PAO-RT on disease-free survival yielded 11 studies.

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Meta-analysis of 3 studies showed pooled adjusted HR of 0.87 (95% CI: 0.79–0.97).

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Findings support further investigation in prospective controlled trials.

Background

Patients with locally advanced cervical cancer without para-aortic lymph node metastases (PAO-LNM) at diagnosis who undergo concurrent chemoradiotherapy are at 4–11% risk of developing PAO-LNM during follow-up. Some studies suggest a beneficial influence of elective para-aortic radiotherapy (PAO-RT) on disease-free survival (DFS) in these patients. The aim of this study was to systematically review and meta-analyse literature on the impact of PAO-RT on DFS in cervical cancer patients.

Methods

A systematic search of PubMed/MEDLINE and EMBASE databases was performed. The analysis included intervention studies that reported on DFS in patients with cervical cancer who received chemotherapy and pelvic radiotherapy with or without PAO-RT. From each included study, relevant study characteristics and outcome data including the hazard ratio (HR) adjusted for potential confounders were extracted. An overall pooled adjusted hazard ratio (aHR) for DFS after PAO-RT versus no PAO-RT was calculated using a random-effects model.

Results

A total of 2,016 articles were evaluated. Eleven articles were included in the systematic review, of which 3 were appropriate for quantitative meta-analysis. Pooling of these 3 cohorts (including 1,113 patients) demonstrated a statistically significant association between PAO-RT and DFS (pooled aHR 0.87, 95% confidence interval: 0.79–0.97). No significant heterogeneity among reported aHRs was observed (I² = 0.0%).

Conclusions

This meta-analysis suggests a modest but significant beneficial impact of elective para-aortic radiotherapy on DFS in patients with locally advanced cervical cancer who undergo concurrent chemoradiotherapy. This finding based on non-randomized studies provides an imperative for further investigation in prospective controlled trials.

Neoadjuvant Chemotherapy in Locally Advanced Cervical Carcinoma - a Role in Patients with Para-aortic Lymph Node Involvement? A 10-year Institutional Experience

AIMS

Overall survival and progression-free survival with concomitant chemoradiotherapy for locally advanced cervical carcinoma have been described as 66% and 58%, respectively, at 5 years. Para-aortic lymph node involvement significantly increases the risk of relapse and death. The role of additional chemotherapy in these patients is as yet undefined. This aim of the present study was to determine the outcome of a cohort of para-aortic lymph node-positive patients treated with neoadjuvant chemotherapy followed by extended-field chemoradiation compared with patients treated with extended-field chemoradiation without neoadjuvant chemotherapy.

MATERIALS AND METHODS

We reviewed patients with International Federation of Gynaecology and Obstetrics (FIGO) 2014 stage IB1-IVA cervical carcinoma who received extended-field radiotherapy in addition to standard pelvic chemoradiotherapy with or without neoadjuvant chemotherapy, at University College London Hospital (January 2007 to January 2018). Patients in open clinical trials were excluded.

RESULTS

Overall, 47 patients (15.8% of 298 eligible patients) with pelvic and/or para-aortic lymph node-positive cervical carcinoma received extended-field radiotherapy. Nineteen patients (40.4%) had both neoadjuvant chemotherapy (all received six cycles) and extended-field radiotherapy (median 44 days); 28 (59.6%) patients received extended-field radiotherapy alone (median 43 days). All patients completed radical radiotherapy within 49 days. We observed evidence that patients receiving neoadjuvant chemotherapy and extended-field radiotherapy had a lower risk of death (median follow-up 4.8 years, three deaths) compared with extended-field radiotherapy alone (median follow-up 3.0 years, 11 deaths; hazard ratio = 0.27, 95% confidence interval 0.08-1.00; P = 0.05). Three-year overall survival rates were 83.3% (95% confidence interval 66.1-100) and 64.6% (95% confidence interval 44.6-84.6), respectively. A PFS benefit was seen (hazard ratio 0.25, 95% confidence interval 0.08-0.77; P = 0.02), with 3-year PFS rates of 77.8% (95% confidence interval 58.6-97.0) and 35.0% (95% confidence interval 14.0-56.0), respectively.

CONCLUSIONS

Our institutional experience suggests that the use of additional systemic therapy before chemoradiotherapy benefits patients with locoregionally advanced (FIGO 2018 IIIC2) cervical cancer. Neoadjuvant chemotherapy was associated with longer overall survival and PFS, without compromising definitive extended-field chemoradiation.

A modified delineation method of para-aortic nodal clinical target volume in patients with locally advanced cervical cancer

PURPOSE

To validate the nodal center coverage (NCC) of the three mainstream delineation methods of para-aortic nodal clinical target volume (CTV) and propose a modified delineation method of para-aortic nodal CTV in prophylactic extended-field irradiation (EFI) of cervical cancer.

METHODS

A total of 106 patients with para-aortic lymph nodes (PALNs) identified on PET/CT were included at Peking Union Medical College Hospital between 2011 and 2020. PALNs were classified as left lateral para-aortic (LLPA), aorto-caval (AC), and right para-caval (RPC). Distances from the nodal center to the aorta and inferior vena cava (IVC) were measured. The NCC of the three mainstream delineation methods of para-aortic nodal CTV (CTV-K, CTV-S, and CTV-D) and a modified CTV (CTV-M) was calculated. Radiotherapy plans were created based on 4 CTVs for 10 selected patients who received prophylactic EFI. The chi-squared test and the Student's t-test were performed.

RESULTS

We identified 344 PALNs (216 LLPA, 101 AC, and 27 RPC) in 106 patients. Mean distance from the nodal center to the aorta was 9.6 mm in the LLPA and 7 mm in the AC and from the nodal center to the IVC was 5.6 mm in the AC and 5.6 mm in the RPC. CTV-D improved the NCC of 98% compared with 92% for CTV-K (p = 0.002) and 95% for CTV-S (p = 0.046). CTV-M provided the same satisfactory NCC as CTV-D (97% vs. 98%, p = 0.485). The V_50Gy to the duodenum, the D_mean to the bilateral kidneys, and the V_45Gy to the small bowel were significantly lower on the CTV-M-based plan than on the CTV-D-based plan (p = 0.001, 0.011, and 0.001, respectively).

CONCLUSION

CTV-D provided more satisfactory NCC than CTV-K and CTV-S. CTV-M provided the same satisfactory NCC as CTV-D and reduced the dose to the critical structures.

Clinical Observation of Prophylactic Extended-Field Intensity-Modulated Radiation Therapy with Synchronous Chemotherapy in Locally Advanced Cervical Cancer

BACKGROUND We aimed to evaluate the value of prophylactic extended-field intensity-modulated radiation therapy (IMRT) in the treatment of locally advanced cervical cancer with multiple pelvic lymph node metastases (≥2) and negative common iliac and paraaortic lymph nodes. MATERIAL AND METHODS Thirty-four patient with newly diagnosed cervical cancer (IB1-IVA) and multiple pelvic lymph node metastases (≥2) confirmed by computed tomography and magnetic resonance imaging were randomly divided into an extended-field group (17 patients) and a pelvic-field group (17 patients). In the extended-field group, we added the drainage area of paraaortic lymph nodes on the pelvic field. The pelvic field was administered Dt 45.0 to 50.4 Gy, while the drainage area of paraaortic lymph nodes was administered Dt 40.0 to 45.0 Gy. Both groups were given Irl92 intracavitary radiotherapy after 3 weeks of external irradiation. The total dose of point A was 25.0 to 30.0 Gy, fractional 6.0 to 7.0 Gy. All patients had concurrent platinum-based chemotherapy once weekly until the end of radiotherapy. RESULTS No paraaortic lymph node metastasis was found in the extended-field group (P=0.0184), and disease-free survival (DFS) was prolonged (P=0.0286). Adverse effects in patients with III-IV degree myelosuppression were increased in the extended-field group (P=0.0324). However, all patients recovered after symptomatic treatment. CONCLUSIONS Prophylactic extended-field IMRT with chemotherapy reduced the metastasis rate of paraaortic lymph nodes and prolonged the DFS in patients with locally advanced cervical cancer and multiple pelvic lymph node metastases (≥2), while the toxic adverse effects were tolerated.

Effect of Prophylactic Radiotherapy on Patients with Stage II-III Esophageal Cancer after Esophageal Cancer Radical Operation and Influencing Factors in Its Recurrence

Objective

To explore the effect of prophylactic radiotherapy on patients with stage II-III esophageal cancer (EC) after esophageal cancer radical operation (ECRO) and influencing factors on EC recurrence.

Methods

Totally, 65 patients with EC in our hospital were enrolled. Among them, 30 patients were treated by routine ECRO as a control group (Con group) and 35 patients by prophylactic radiotherapy as a research group (Res group). Then, the following measures were taken: record the efficacy on both groups, quantify their C-reactive protein (CRP) and white blood cell count (WBC) before and after therapy, evaluate their mental state through the revised piper fatigue scale (PFS-R) before and after therapy, determine their changes in Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS) before and after therapy, compare them in terms of lymph-node metastatic rate (LNMR), hematogenous metastasis rate (HMR), anastomotic recurrence rate (ARR), and 3-year survival rate, compare them in terms of life quality after therapy via the Quality of Life-Core Questionnaire (QLQ-C30), and analyze influencing factors on their recurrence.

Results

The Res group showed a notably higher total effective rate (TER) than the Con group (P=0.037). After therapy, CRP and WBC in both groups increased, but their levels were not considerably different in both (P > 0.05). Additionally, after therapy, in contrast to the Con group, the Res group got notably lower PFS-R, SDS, and SAS scores, showed notably lower LNMR and ARR and notably higher 3-year survival rate, and experienced notably higher life quality (all P < 0.05), and the HMR results were not considerably different in both groups (P > 0.05). Moreover, carcinoembryonic antigen (CEA), carbohydrate antigen 125 (CA125), esophageal inflammation history, family medical history, postoperative complications, and lymphatic and vascular infiltration were risk factors for the disease recurrence, and treatment method was the protective factor for it.

Conclusion

For patients with stage II-III EC after ECRO, prophylactic radiotherapy is highly effective and safe and can lower the recurrence rate, so it is worth popularizing in clinical practice.

Mapping patterns of para-aortic lymph node recurrence in cervical cancer: a retrospective cohort analysis

BACKGROUND

To map anatomic patterns of para-aortic lymph node (PALN) recurrence in cervical cancer patients and validate currently available guidelines on PA clinical target volumes (CTV).

METHODS

Cervical cancer patients who developed PALN recurrence were included. The PALNs were classified as left-lateral para-aortic (LPA), aorto-caval (AC), and right para-caval (RPC). Four PA CTVs were contoured for each patient to validate PALN coverage. CTV_RTOG was contoured based on the Radiation Therapy Oncology Group guideline. CTV_K was contoured as proposed by Keenan et al. CTV_M was contoured by expanding symmetrical margins around the aorta and inferior vena cava of 7 mm up to the T12-L1 interspace. CTV_new was created by modifying CTV_RTOG to obtain better coverage.

RESULTS

We identified 92 PALNs in 35 cervical cancer patients. 46.8% of the PALNs were at LPA, 38.0% were at AC, and 15.2% were at RPC areas. CTV_RTOG, CTV_K, and CTV_M covered 87.0%, 88.0%, and 62.0% of all PALNs, respectively. PALN recurrence above the left renal vein was associated with PALN involvement at diagnosis (p = 0.043). Extending upper border to the superior mesenteric artery allowed the CTV_new to cover 96.7% of all PALNs and all nodes in 91.4% of patients.

CONCLUSION

CTV_RTOG and CTV_K encompassed most PALN recurrences. For high-risk patients, such as those having PALN involvement at diagnosis, extending the superior border of CTV from the left renal vein to superior mesenteric artery could be considered.

Comparison of Definitive Cervical Cancer Management With Chemotherapy and Radiation Between Two Centers With Variable Resources and Opportunities for Improved Treatment

PURPOSE

Cervical cancer remains a major health challenge in low- to middle-income countries. We present the experiences of two centers practicing in variable resource environments to determine predictors of improved radiochemotherapy treatment.

METHODS AND MATERIALS

This comparative review describes cervical cancer presentation and treatment with concurrent chemoradiotherapy with high-dose-rate brachytherapy between 2014 and 2017 at the National Radiotherapy Oncology and Nuclear Medicine Center (NRONMC) in Korle-Bu Teaching Hospital, Accra, Ghana, and Moffitt Cancer Center (MCC), Tampa, FL.

RESULTS

Median follow-up for this study was 16.9 months. NRONMC patients presented with predominantly stage III disease (42% v 16%; P = .002). MCC patients received para-aortic node irradiation (16%) and interstitial brachytherapy implants (19%). Median treatment duration was longer for NRONMC patients compared with MCC patients (59 v 52 days; P < .0001), and treatment duration ≥ 55 days predicted worse survival on multivariable analysis (MVA; P = .02). Stage ≥ III disease predicted poorer local control on MVA. There was a difference in local control among patients with stage III disease (58% v 91%; P = .03) but not in survival between MCC and NRONMC. No significant difference in local control was observed for stage IB, IIA, and IIB disease.

CONCLUSION

Although there were significant differences in disease presentation between the two centers, treatment outcomes were similar for patients with early-stage disease. Longer treatment duration and stage ≥ III disease predicted poor outcomes.

Muscle Loss after Chemoradiotherapy as a Biomarker of Distant Failures in Locally Advanced Cervical Cancer

This study aimed to evaluate whether computed tomography (CT)-based muscle measurement predicts distant failure in patients with locally advanced cervical cancer (LACC). Data from 278 patients with LACC who underwent chemoradiation therapy (CCRT) between 2004 and 2017 were analysed. Changes in the skeletal muscle index (SMI), skeletal muscle density, and total adipose tissue index during CCRT were calculated from CT images taken at the baseline and after CCRT. The predictive capability of CT-based muscle measurement for distant failure was evaluated using Cox proportional hazards regression, Harrell’s concordance index (C-index), and time-dependent receiver operating characteristic curves. SMI loss ≥ 5% was independently associated with worse distant recurrence-free survival (DRFS) (HR: 6.31, 95% CI: 3.18–12.53; p < 0.001). The addition of muscle change to clinical models, including International Federation of Gynaecology and Obstetrics (FIGO) stage, lymph nodes, pathology, and squamous cell carcinoma-antigen, achieved higher C-indices (0.824 vs. 0.756; p < 0.001). Models including muscle change had superior C-indices than those including weight change (0.824 vs. 0.758; p < 0.001). The area under the curve for predicting 3-year DRFS was the highest for the muscle-loss model (0.802, muscle-loss model; 0.635, clinical model; and 0.646, weight-loss model). Our study demonstrated that muscle loss after CCRT was independently associated with worse DRFS and that integrating muscle loss into models including classical prognostic factors improved the prediction of distant failure.

Early clinical experience with varian halcyon V2 linear accelerator: Dual-isocenter IMRT planning and delivery with portal dosimetry for gynecological cancer treatments

Purpose

Varian Halcyon linear accelerator version 2 (The Halcyon 2.0) was recently released with new upgraded features. The aim of this study was to report our clinical experience with Halcyon 2.0 for a dual‐isocenter intensity‐modulated radiation therapy (IMRT) planning and delivery for gynecological cancer patients and examine the feasibility of in vivo portal dosimetry.

Methods

Twelve gynecological cancer patients were treated with extended‐field IMRT technique using two isocenters on Halcyon 2.0 to treat pelvis and pelvic/or para‐aortic nodes region. The prescription dose was 45 Gy in 25 fractions (fxs) with simultaneous integrated boost (SIB) dose of 55 or 57.5 Gy in 25 fxs to involved nodes. All treatment plans, pretreatment patient‐specific QA and treatment delivery records including daily in vivo portal dosimetry were retrospectively reviewed. For in vivo daily portal dosimetry analysis, each fraction was compared to the reference baseline (1st fraction) using gamma analysis criteria of 4 %/4 mm with 90% of total pixels in the portal image planar dose.

Results

All 12 extended‐field IMRT plans met the planning criteria and delivered as planned (a total of 300 fractions). Conformity Index (CI) for the primary target was achieved with the range of 0.99–1.14. For organs at risks, most were well within the dose volume criteria. Treatment delivery time was from 5.0 to 6.5 min. Interfractional in vivo dose variation exceeded gamma analysis threshold for 8 fractions out of total 300 (2.7%). These eight fractions were found to have a relatively large difference in small bowel filling and SSD change at the isocenter compared to the baseline.

Conclusion

Halcyon 2.0 is effective to create complex extended‐field IMRT plans using two isocenters with efficient delivery. Also Halcyon in vivo dosimetry is feasible for daily treatment monitoring for organ motion, internal or external anatomy, and body weight which could further lead to adaptive radiation therapy.

Benefits of Elective Para-Aortic Radiotherapy for pN1 Prostate Cancer Using Arc Therapy (Intensity-Modulated or Volumetric Modulated Arc Therapy): Protocol for a Nonrandomized Phase II Trial

BACKGROUND

In patients with prostate cancer (PCa) with histopathologically proven pelvic lymph node (LN) metastasis (pN1) after extended pelvic lymph node dissection (ePLND), multimodality treatment consisting of treatment of the primary tumor and whole pelvic radiotherapy (WPRT) combined with androgen deprivation therapy (ADT) offers promising results, leading to better cause-specific survival rates compared with ADT alone. However, in case more than one pelvic LN is invaded by the tumor, approximately 40% of the patients relapse biochemically and clinically. Clinical relapse is present in the para-aortic LNs (M1a disease) in up to 77% of the relapsing cases.

OBJECTIVE

We hypothesize that, based on the evidence that positive LNs represent the door to hematogenous dissemination, elective para-aortic irradiation will reduce the development of both retroperitoneal nodal (M1a) and distant metastasis (M1b or M1c disease), postpone the need for palliative ADT, and prolong the time to castration-refractory disease.

METHODS

To test this hypothesis, we will conduct a prospective, nonrandomized phase II trial to study the efficacy of additional elective para-aortic radiotherapy (PART) in pN1 patients compared with those who were historically treated with adjuvant WPRT alone. We aim to include 137 patients with PCa and presence of pN1 disease after ePLND. With this number of patients, an improvement of 15% in the 5-year clinical relapse-free survival can be detected with a power of 80%.

RESULTS

Recruitment of patients for this trial started in 2017 and will be completed approximately by March 2020.

CONCLUSIONS

This is the first phase II trial to investigate the benefits of an elective PART in patients with PCa. The results of this trial will potentially serve as a sound base for a later randomized phase III trial. All participants are given a PART information sheet and required to give written informed consent. Results are expected to be published in a peer-reviewed journal.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03079323; https://clinicaltrials.gov/ct2/show/NCT03079323 (Archived by WebCite at http://www.webcitation.org/73ELimv1d).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/11256.

The role of para-aortic nodal irradiation in cervical cancer

The current standard of care for locally advanced cervical cancer is whole pelvis and para-aortic radiation when indicated, delivered concomitantly with chemotherapy and brachytherapy. Para-aortic node involvement is a predictor of survival in locally advanced disease but presence of metastases is difficult to determine because the currently available imaging methods lack enough sensitivity to be able to detect accurately para-aortic metastases when surgical staging is not feasible. The objective of this review is to describe the current status of para-aortic lymph node irradiation in locally advanced cervical cancer. It includes analysis of the diagnostic imaging and surgical approaches for assessment of para-aortic lymph node dissemination, together with indications for radiotherapy and radiotherapeutic techniques.

Extended-field radiotherapy for locally advanced cervical cancer

BACKGROUND

The para-aortic lymph nodes (located along the major vessels in the mid and upper abdomen) are a common place for disease recurrence after treatment for locally advanced cervical cancer. The para-aortic area is not covered by standard pelvic radiotherapy fields and so treatment to the pelvis alone is inadequate for women at a high risk of occult cancer within para-aortic lymph nodes. Extended-field radiotherapy (RT) widens the pelvic RT field to include the para-aortic lymph node area. Extended-field RT may improve outcomes in women with locally advanced cervical cancer by treating occult disease in para-aortic nodes not identified at pretreatment imaging. However, RT treatment of the para-aortic area can cause severe adverse effects, so may increase harms.Studies of pelvic chemoradiotherapy (CRT) demonstrated improved survival rates compared to pelvic RT alone. CRT is now the standard of care in the treatment of locally advanced cervical cancer. Studies comparing pelvic RT alone (without concurrent chemotherapy) with extended-field RT should therefore be viewed with caution, since they compare treatments against what is now substandard treatment (pelvic RT alone). This review should therefore be read with this in mind and comparisons with pelvic RT cannot be extrapolated to pelvic CRT.

OBJECTIVES

To evaluate the effectiveness and toxicity of extended-field radiotherapy in women undergoing first-line treatment for locally advanced cervical cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 7), MEDLINE via Ovid (1946 to August week 4, 2018), and Embase via Ovid (1980 to 2018, week 35). We checked registers of clinical trials, grey literature, conference reports, and citation lists of included studies to August 2018.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) evaluating the effectiveness and toxicity of extended-field RT for locally advanced cervical cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected potentially relevant RCTs, extracted data, assessed risk of bias, compared results, and made judgements on the quality and certainty of the evidence for each outcome. Any disagreements were resolved by discussion or consultation with a third review author.

MAIN RESULTS

Five studies met the inclusion criteria. Three included studies compared extended-field RT versus pelvic RT, one included study compared extended-field RT with pelvic CRT, and one study compared extended-field CRT versus pelvic CRT.Extended-field radiotherapy versus pelvic radiotherapy aloneCompared to pelvic RT, extended-field RT probably reduces the risk of death (hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.48 to 0.94; 1 study; 337 participants; moderate-certainty evidence) and para-aortic lymph node recurrence (risk ratio (RR) 0.36, 95% CI 0.18 to 0.70; 2 studies; 477 participants; moderate-certainty evidence), although there may or may not have been improvement in the risk of disease progression (HR 0.92, 95% CI 0.69 to 1.22; 1 study; 337 participants; moderate-certainty evidence) and severe adverse events (RR 1.05, 95% CI 0.79 to 1.41; 2 studies; 776 participants; moderate-certainty evidence).Extended-field radiotherapy versus pelvic chemoradiotherapyIn a comparison of extended-field RT versus pelvic CRT, women given pelvic CRT probably had a lower risk of death (HR 0.50, 95% CI 0.39 to 0.64; 1 study; 389 participants; moderate-certainty evidence) and disease progression (HR 0.52, 95% CI 0.37 to 0.72; 1 study; 389 participants; moderate-certainty evidence). Participants given extended-field RT may or may not have had a lower risk of para-aortic lymph node recurrence (HR 0.44, 95% CI 0.20 to 0.99; 1 study; 389 participants; low-certainty evidence) and acute severe adverse events (RR 0.05, 95% CI 0.02 to 0.11; 1 study; 388 participants; moderate-certainty evidence). There were no clear differences in terms of late severe adverse events among the comparison groups (RR 1.06, 95% CI 0.69 to 1.62; 1 study; 386 participants; moderate-certainty evidence).Extended-field chemoradiotherapy versus pelvic chemoradiotherapyVery low-certainty evidence obtained from one small study (74 participants) showed that, compared to pelvic CRT, extended-field CRT may or may not have reduced risk of death (HR 0.37, 95% CI 0.14 to 0.96) and disease progression (HR 0.25, 95% CI 0.07 to 0.87). There were no clear differences between the groups in the risks of para-aortic lymph node recurrence (RR 0.19, 95% CI 0.02 to 1.54; very low-certainty evidence) and severe adverse events (acute: RR 0.95, 95% CI 0.20 to 4.39; late: RR 0.95, 95% CI 0.06 to 14.59; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that, compared with pelvic RT alone, extended-field RT probably improves overall survival and reduces risk of para-aortic lymph node recurrence. However, pelvic RT alone would now be considered substandard treatment, so this result cannot be extrapolated to modern standards of care. Low- to moderate-certainty evidence suggests that pelvic CRT may increase overall and progression-free survival compared to extended-field RT, although there may or may not be a higher rate of para-aortic recurrence and acute adverse events. Extended-field CRT versus pelvic CRT may improve overall or progression-free survival, but these findings should be interpreted with caution due to very low-certainty evidence.High-quality RCTs, comparing modern treatment techniques in CRT, are needed to more fully inform treatment for locally advanced cervical cancer without obvious para-aortic node involvement.

Impact of para-aortic recurrence risk-guided intensity-modulated radiotherapy in locally advanced cervical cancer with positive pelvic lymph nodes

OBJECTIVES

A previous study has suggested the benefit of sub-renal vein radiotherapy (SRVRT) for pelvic lymph node (PLN)-positive cervical cancer. In order to better select patients for SRVRT, this study aimed to evaluate the value of a risk-based radiation field based on PLN location and number in PLN-positive cervical cancer.

METHODS

We reviewed 198 patients with FIGO stage IB2-IVA cervical cancer, positive PLNs, and negative para-aortic lymph nodes (PALNs) from 2004 to 2015 at two tertiary centers. All patients underwent pelvic radiotherapy (PRT) or SRVRT with IMRT. The SRVRT extended the PRT field cranially to the level of the left renal vein. The prescribed doses were 45-50.4Gy in 1.8Gy per fraction.

RESULTS

Overall, 118 and 80 patients underwent PRT and SRVRT, respectively. The SRVRT group had more advanced disease based on FIGO stage, common iliac PLNs, and number of PLNs. The median follow-up was 63months (range: 7-151months). PALN failure was experienced by 28 patients (23.7%) in the PRT group and 1 patient (1.3%) in the SRVRT group (p<0.001). Compared with PRT, SRVRT significantly improved 5-year PALN recurrence-free survival (56.8% vs. 100%, p<0.001) and cancer-specific survival (56.5% vs. 93.9%, p<0.001) among patients with common iliac PLNs or ≥3 PLNs. No significant differences were observed in these outcomes among patients with PLNs below the common iliac bifurcation and 1-2 PLNs. The SRVRT did not increase severe toxicities.

CONCLUSIONS

Risk-based radiation field based on PLN location and number could optimize outcomes for PLN-positive cervical cancer.

Lymph flow guided irradiation of regional lymph nodes in patients with cervical cancer: Preliminary analysis of scintigraphic data

Purpose

To evaluate patterns of lymph flow from primary lesions in patients with cervical cancer and to determine how useful for radiotherapy planning this information can be.

Materials and methods

SPECT-CT visualization of sentinel (SLN) lymph nodes (LNs) was performed in 36 primary patients with IB-IIB cervical cancer. The acquisition started 120-240 min after 4 peritumoral injections of 99mTc-radiocolloids (150-300 MBq in 0.4-1 ml). We determined localization of LN with uptake of radiocolloids, type of lymph flow (mono-, bi-lateral) and lymph flow patterns (supraureteral paracervical, infraureteral paracervical and directly to para-aortic LNs).

Results

SLNs were visualized in 31 of 36 women. Bilateral lymph-flow was detected in 22 (71%), monolateral - in the other 9 (29%) cases. The distribution of SLNs was as follows: external iliac - 64.5%, internal iliac - 54.8%, obturator - 32.2%, common iliac - 35.5% and pre-sacral 3.2%. Para-aortic LNs were visualized in 5 (16.1%) patients. The supraureteral paracervical pattern of lymph flow was identified in 22, infraureteral paracervical - in 4 and their combination - in the other 5 women.

Conclusion

Visualization of an individual pattern of lymph flow from primary cervical cancer can be considered as a promising tool for optimization of the volume of irradiated regional LNs.

An atlas to aid delineation of para-aortic lymph node region in cervical cancer: Design and validation of contouring guidelines

INTRODUCTION

Previous studies have investigated the anatomical distribution of para-aortic lymph nodes (PAN) in patients with cervical cancer. However, an atlas for accurate clinical target volume (CTV) delineation has yet to be defined. The purpose of this study was to design and verify a computerized tomography (CT) atlas to provide guidance for contouring the PAN CTV in patients with cervical cancer.

MATERIALS AND METHODS

This prospective study included 21 cervical cancer patients (design cohort) with 39 pathological PAN identified on (18)F-FDG PET-CT. PAN [left lateral para-aortic (LLPA), aorto-caval (AC), right para-caval (RPC) nodes] were delineated on CT simulation scans. Measurements were taken from the volumetric centre of the nodes to the edge of aorta and inferior vena-cava (IVC). Initially the aorta and IVC were expanded by the mean distance to the lymph node centre to create a CTV. Expansion margins were then increased asymmetrically until the CTV resulted in a clinically acceptable number of PAN included. The CTV was validated on a further 10 patients (validation cohort) with 29 PAN. A detailed contouring guide and accompanying visual atlas for elective PAN CTV delineation was created based on the validated margins.

RESULTS

For the design cohort (n = 21 patients, 39 PAN), the mean distance from the centre of the node to the aorta was 8 mm (range 4-17) for both LLPA (range 4-17) and AC (range 4-15) regions. Mean distance from the IVC to the centre of the nodes was 5 mm (range 4-6) in the RPC region and 6 mm (range 3-15) in the AC region. No PAN was superior to the T12-L1 interspace or the left renal vein or inferior to the L5-S1 interspace. For validation cohort (n = 10 patients, 29 PAN), mean distance from centre of the node to the aorta was 9 mm (range 5-15) in the LLPA region, 7 mm (range 6.5-14) in the AC region. Mean distance from the ICV to the centre of the nodes was 3 mm (range 2.5-4) in the RPC region and 5 mm (range 3-10) in the AC region. A CTV expansion from the aorta of 10 mm circumferentially and 15 mm laterally, and from the IVC of 8 mm anteromedially and 6 mm posterolaterally resulted in coverage of 97% (38/39) of PAN in the design cohort. On prospective validation, the described CTV included 97% (28/29) of PAN in the validation cohort.

CONCLUSION

We propose the following PAN CTV; expansion from aorta of 10 mm circumferentially except 15 mm laterally, expansion from the IVC of 8 mm anteromedial and 6 mm posterolaterally. The suggested CTV includes 97% (28/29) PAN in a validated patient cohort. A detailed guide and accompanying visual atlas is provided to aid delineation of the PAN CTV in patients with cervical cancer.

Chemoradiotherapy in combination with radical surgery is associated with better outcome in cervical cancer patients

Objectives

To retrospectively assess the influence of radical surgery following concurrent chemoradiotherapy (CCRT) on outcomes in cervical cancer (CC) patients.

Methods

Patients diagnosed with cervical squamous cell carcinoma or adenocarcinoma (FIGO stages IB2 to IIB) at the Yinbin Second People's Hospital between September 2008 and September 2013, were included in this study. Patients were classified into 2 groups based on the treatment received: surgery group (CCRT plus radical surgery) and non-surgery groups (CCRT only). In addition to clinical information, inter-group differences with respect to local control rate (LCR), local recurrence rate (LRR), metastasis rate, overall survival (OS), progress free survival(PFS) and complications were assessed.

Results

A total of 314 patients were included in the analysis. Parametrial invasion, pelvic lymph node metastasis, tumor diameter > 4 cm and presence of residual disease were risk factors for recurrence in the non-surgery group. In patients with risk factors, radical surgery significantly improved their clinical outcome. The 3-year/5-year LCR in the surgery and non-surgery groups was 88.3%/87.4% and 82.3%/77.5%, respectively (P = 0.04). The 3-year/5-year OS rate in the two groups was 87.1%/81.7% and 72.8%/67.3%, respectively (P = 0.001). The 3-year/5-year LRR in the two groups were 11.7%/12.6% and 17.7%/22.5%, respectively (P = 0.04). The metastasis rates in the two groups were 19.9% and 24.8%, respectively (P = 0.09).

Conclusions

Surgery following CCRT could improve overall survival and progressfree survival. Radical surgery following CCRT appears to confer significant benefits including an increase in LCRs and decrease in LRR in CC patients with risk factors.

Prophylactic lower para-aortic irradiation using intensity-modulated radiotherapy mitigates the risk of para-aortic recurrence in locally advanced cervical cancer: A 10-year institutional experience

OBJECTIVE

To evaluate the effects of prophylactic sub-renal vein radiotherapy (SRVRT) using intensity-modulated radiotherapy (IMRT) for cervical cancer.

METHODS

A total of 206 patients with FIGO stage IB2-IVA cervical cancer and negative para-aortic lymph nodes (PALNs) who underwent pelvic IMRT (PRT) or SRVRT between 2004 and 2013 at our institution were reviewed. SRVRT cranially extended the PRT field for PALNs up to the left renal vein level. The prescribed dose was consistent 50.4Gy in 28 fractions.

RESULTS

Overall, 110 and 96 patients underwent PRT and SRVRT, respectively. The SRVRT group had more advanced disease based on FIGO stage and positive pelvic lymph nodes (PLNs). The median follow-up time was 60months (range, 7-143). For the total study population, the 5-year PALN recurrence-free survival (PARFS) and overall survival (OS) for PRT vs. SRVRT were 87.6% vs. 97.9% (p=0.03) and 74.5% vs. 87.8% (p=0.04), respectively. In patients with FIGO III-IVA or positive PLNs, the 5-year PARFS and OS for PRT vs. SRVRT were 80.1% vs. 96.4% (p=0.02) and 58.1% vs. 83.5% (p=0.012), respectively. However, there were no significant differences in these outcomes for patients with FIGO IB-IIB and negative PLNs. In a multivariate analysis, only SRVRT was associated with better PARFS (HR, 0.21; 95% CI, 0.06-0.78; p=0.02). The SRVRT did not significantly increase severe late toxicities.

CONCLUSION

Prophylactic SRVRT using IMRT reduced PALN recurrence with tolerable toxicities, supporting the application of risk-based radiation fields for cervical cancer.

Practice guidelines for management of cervical cancer in Korea: a Korean Society of Gynecologic Oncology Consensus Statement

Clinical practice guidelines for gynecologic cancers have been developed by academic society from several countries. Each guideline reflected their own insurance system and unique medical environment, based on the published evidence. The Korean Society of Gynecologic Oncology (KSGO) published the first edition of practice guidelines for gynecologic cancer treatment in late 2006; the second edition was released in July 2010 as an evidence-based recommendation. The Guidelines Revision Committee was established in 2015 and decided to develop the third edition of the guidelines in an advanced format based on evidence-based medicine, embracing up-to-date clinical trials and qualified Korean data. These guidelines cover strategies for diagnosis and treatment of primary and recurrent cervical cancer. The committee members and many gynecologic oncologists derived key questions through discussions, and a number of relevant scientific literature were reviewed in advance. Recommendations for each specific question were developed by the consensus conference, and they are summarized here, along with the details. The objective of these practice guidelines is to establish standard policies on issues in clinical practice related to the management in cervical cancer based on the results in published papers to date and the consensus of experts as a KSGO Consensus Statement.

Safety and efficacy of semiextended field intensity-modulated radiation therapy and concurrent cisplatin in locally advanced cervical cancer patients: An observational study of 10-year experience

Patients with locally advanced cervical cancer (LACC) are at risk of para-aortic lymph node (PALN) metastasis. Pelvic concurrent chemoradiotherapy, the current standard treatment for LACC, has a PALN failure rate of 9% according to the Radiation Therapy Oncology Group Trial 90-01, suggesting that it may not completely eliminate all microscopic tumors in the PALNs. To minimize the toxicities associated with conventional prophylactic extended-field radiotherapy, our institute use prophylactic semiextended field radiotherapy that includes only the PALNs below the level of the renal vessels. Use of intensity-modulated radiotherapy (IMRT) is another means of reducing the incidence of toxicity. This study evaluated the safety and efficacy of prophylactic semiextended field IMRT (SEF-IMRT) and concurrent cisplatin chemotherapy in patients with LACC.We retrospectively assessed survival and toxicity in 76 patients with stage IB2-IVA cervical cancer and negative PALNs who received prophylactic SEF-IMRT and concurrent weekly cisplatin (40 mg/m) between 2004 and 2013. The region targeted by SEF-IMRT included the PALNs below the level of the renal vessels, and the prescribed dose was 50.4 Gy in 28 fractions. Brachytherapy was administered at a dose of 30 Gy in 6 fractions. Survival outcomes were calculated by using the Kaplan-Meier method, and acute and late toxicities were scored according to the Common Terminology Criteria for Adverse Events, version 3.0.All patients completed the planned SEF-IMRT, as well as brachytherapy. Acute grade ≥3 gastrointestinal, genitourinary, and hematologic toxicities were observed in 2, 0, and 41 patients, respectively. The median follow-up time after SEF-IMRT was 55 (range, 11-124) months. Eight patients developed out-field distant recurrences without PALN failure, and 1 patient experienced out-field PALN failure with simultaneous distant metastasis. No patients had late genitourinary toxicities, and 3 patients had late grade 3 gastrointestinal toxicities. The 5-year overall survival, disease-free survival, local failure-free survival, regional failure-free survival, PALN failure-free survival, and distant metastasis-free survival rates were 85.0%, 84.4%, 96.0%, 97.3%, 98.6%, and 88.4%, respectively.For patients with LACC, prophylactic PALN irradiation up to the level of the renal vessels reduced PALN recurrence and resulted in favorable outcomes with few severe toxicities.

Patterns of failure after use of (18)F-FDG PET/CT in integration of extended-field chemo-IMRT and 3D-brachytherapy plannings for advanced cervical cancers with extensive lymph node metastases

Background

The study is to evaluate the patterns of failure, toxicities and long-term outcomes of aggressive treatment using ¹⁸F-FDG PET/CT-guided chemoradiation plannings for advanced cervical cancer with extensive nodal extent that has been regarded as a systemic disease.

Methods

We retrospectively reviewed 72 consecutive patients with ¹⁸F-FDG PET/CT-detected widespread pelvic, para-aortic and/or supraclavicular lymph nodes treated with curative-intent PET-guided cisplatin-based extended-field dose-escalating intensity-modulated radiotherapy (IMRT) and adaptive high-dose-rate intracavitary 3D-brachytherapy between 2002 and 2010. The failure sites were specifically localized by comparing recurrences on fusion of post-therapy recurrent ¹⁸F-FDG PET/CT scans to the initial PET-guided radiation plannings for IMRT and brachytherapy.

Results

The median follow-up time for the 72 patients was 66 months (range, 3–142 months). The 5-year disease-free survival rate calculated by the Kaplan-Meier method for the patients with extensive N1 disease with the uppermost PET-positive pelvic-only nodes (26 patients), and the patients with M1 disease with the uppermost PET-positive para-aortic (31 patients) or supraclavicular (15 patients) nodes was 78.5 %, and 41.8–50 %, respectively (N1 vs. M1, p = 0.0465). Eight (11.1 %), 18 (25.0 %), and 3 (4.2 %) of the patients developed in-field recurrence, out-of-field and/or distant metastasis, and combined failure, respectively. The 6 (8.3 %) local failures around the uterine cervix were all at the junction between IMRT and brachytherapy in the parametrium. The rate of late grade 3/4 bladder and bowel toxicities was 4.2 and 9.7 %, respectively. When compared to conventional pelvic chemoradiation/2D-brachytherapy during 1990–2001, the adoption of ¹⁸F-FDG PET-guided extended-field dose-escalating chemoradiation plannings in IMRT and 3D-brachytherapy after 2002 appeared to provide higher disease-free and overall survival rates with acceptable toxicities in advanced cervical cancer patients.

Conclusions

For AJCC stage M1 cervical cancer with supraclavicular lymph node metastases, curability can be achieved in the era of PET and chemo-IMRT. However, the main pattern of failure is still out-of-field and/or distant metastasis. In addition to improving systemic treatment, how to optimize and integrate the junctional doses between IMRT and 3D-brachytherapy in PET-guided plannings to further decrease local recurrence warrants investigation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2226-0) contains supplementary material, which is available to authorized users.

Optimal Extent of Prophylactic Irradiation of Paraaortic Lymph Nodes in Patients with Uterine Cervical Cancer

Purpose

The purpose of this study was to determine optimal extent of prophylactic irradiation of paraaortic lymph nodes (PALN) in patients with uterine cervical cancer who had metastatic pelvic LNs.

Methods and Materials

We retrospectively evaluated 103 patients with cervical cancer and pelvic lymph node metastasis who were treated with prophylactic semi-extended field radiotherapy (SEFRT) between 1990 and 2012. The semi-extended field included PALN below the second lumbar spine with prescribed doses of 45 to 50 Gy. Survival outcomes were calculated using the Kaplan-Meier method, and acute and late toxicities were scored using the Radiation Therapy Oncology Group and European Organisation for Research and Treatment of Cancer toxicity criteria.

Results

The median follow-up after SEFRT was 61 (range 5–296) months. Overall, 28 patients (27.2%) experienced treatment failures, which were classified as local in 8 patients (7.8%), regional in 8 patients (7.8%), and distant in 13 patients (12.6%). Of the regional failures, only two involved PALN failure around the renal artery or the renal hilum area at the upper margin of the semi-extended field. At 5 years, the overall survival was 82%. Grade 3 or higher acute gastrointestinal and genitourinary toxicities occurred in one and two patients, respectively. As a late toxicity, one patient developed grade 3 small bowel obstruction.

Conclusion

Prophylactic SEFRT provided favorable outcomes with little acute or late gastrointestinal toxicity. For prophylaxis of PALN recurrences, upper part of PALN might not need to be included in patients with uterine cervical cancer and metastatic pelvic LNs.

The role of elective para-aortic lymph node irradiation in patients with locally advanced cervical cancer

AIMS

Pelvic lymph node positivity in cervical cancer is known to be an adverse prognostic factor and is associated with an elevated risk of clinically occult para-aortic lymph node metastases. The purpose of this study was to examine the benefit of elective para-aortic lymph node radiotherapy (PART) in patients with no clinical or radiographic evidence of para-aortic lymph node metastases receiving concurrent cisplatin chemotherapy.

MATERIALS AND METHODS

Patients treated with radiotherapy and concurrent cisplatin for cervical cancer from 1999 to 2009 were identified in two prospective databases. All patients received external beam pelvic radiotherapy (PRT) to a median dose of 50 Gy concurrently with weekly cisplatin 40 mg/m(2). This was followed by pulse dose rate intracavitary brachytherapy to a median dose of 40 Gy. Patients at high risk of occult para-aortic metastases also received PART to a median dose of 40 Gy.

RESULTS

There were 228 patients suitable for analysis; the median follow-up was 4.6 years. The addition of PART to PRT was not associated with a significant difference in disease-free survival (hazard ratio 1.1, confidence interval 0.7-1.8, P = 0.75) or overall survival (hazard ratio 1.6, confidence interval 0.9-2.7, P = 0.11) on multivariate analysis. There was no significant difference in the rate of para-aortic relapse with PART versus PRT (hazard ratio 2.01, confidence interval 0.79-5.12, P = 0.14). The 3 year grade 3-4 late toxicities were 11% for the PART group versus 8% for PRT (hazard ratio 1.39, confidence interval 0.58-3.37, P = 0.47).

CONCLUSIONS

These results suggest that cervical cancer patients treated with radiotherapy and concurrent cisplatin do not benefit from elective PART.