Patterns of lymph node metastasis in locally advanced cervical cancer

Treatment Strategies Guided by [18F]FDG-PET/CT in Patients with Locally Advanced Cervical Cancer and [18F]FDG-Positive Lymph Nodes

BACKGROUND

Modern treatment guidelines for women with advanced cervical cancer recommend staging using 2-deoxy-2-[18F]fluoro-D-glucose positron emission computed tomography ([18F]FDG-PET/CT). However, the risk of false-positive nodes and therapy-related adverse events requires caution in treatment planning. Using data from the Netherlands Cancer Registry (NCR), we estimated the impact of [18F]FDG-PET/CT on treatment management in women with locally advanced cervical cancer, i.e., on nodal boosting, field extension, and/or debulking in cases of suspected lymph nodes.

METHODS

Women diagnosed between 2009 and 2017, who received chemoradiotherapy for International Federation of Gynaecology and Obstetrics (2009) stage IB2, IIA2-IVB cervical cancer with an [18F]FDG-positive node, were retrospectively selected from the NCR database. Patients with pathological nodal examination before treatment were excluded. The frequency of nodal boosting, extended-field radiotherapy, and debulking procedures applied to patients with [18F]FDG-positive lymph nodes was evaluated.

RESULTS

Among the 434 eligible patients with [18F]FDG-positive nodes, 380 (88%) received interventions targeting these lymph nodes: 84% of these 380 patients received nodal boosting, 78% extended-field radiotherapy, and 12% debulking surgery. [18F]FDG-positive nodes in patients receiving these treatments were more likely to be classified as suspicious than inconclusive (p = 0.009), located in the para-aortic region (p < 0.001), and larger (p < 0.001) than in patients who did not receive these treatments.

CONCLUSION

While existing guidelines advocate [18F]FDG-PET/CT-guided treatment planning for the management of advanced cervical cancer, this study highlights that not all cases of [18F]FDG-positive nodes received an intervention, possibly due to the risk of false-positive results. Improvement of nodal staging may reduce suboptimal treatment planning.

The value of multiparametric MRI combined with clinical prognostic parameters in predicting the 5-year survival of stage IIIC1 cervical squamous cell carcinoma

OBJECTIVES

To explore the value of multiparametric magnetic resonance imaging（MRI）in predicting the 5-year progression-free survival (PFS) and overall survival (OS) of cervical squamous cell carcinoma (CSCC) in 2018 FIGO stage IIIC1.

METHODS

This retrospective study collected156 patients with CSCC from Dec. 2014 to Jul. 2018. Sixty-one patients underwent radical hysterectomy (RH), and 95 patients underwent concurrent chemoradiotherapy (CCRT). Clinical and MR parameters of primary tumours were analysed. A 1:1 ratio propensity score matching (PSM) was performed for the RH group and CCRT group according to T stage. The Cox proportional hazard model was used to evaluate the associations between imaging or clinical variables and PFS and OS.

RESULTS

The 5-year PFS and OS rates were 72.6% and 78.3%, respectively. The analysis results show that the treatment method, ADCmin < 0.604 × 10-3 mm2/s, and Ktrans < 0.699 min-1 correlated with worse PFS, while SCC-Ag > 6.7 ng/L, ADCmin < 0.604 × 10-3 mm2/s, and Ktrans < 0.699 min-1 correlated with worse OS. After PSM, we confirmed that the treatment methods did not affect the long-term survival of patients with stage IIIC1 disease, and a low Ktrans value was an independent poor prognostic factor.

CONCLUSION

Functional MRI parameters and SCC-Ag have potential predictive value for the 5-year survival of 2018 FIGOIIIC1 CSCC. There were no significant differences in survival between CCRT and RH + adjuvant therapy for IIIC1 stage CSCC if the T stage was earlier.

Image-guided intensity-modulated radiotherapy in patients with FIGO IIIC1 cervical cancer: efficacy, toxicity and prognosis

Background: To investigate the efficacy, toxicity and prognosis of image-guided intensity-modulated radiotherapy (IG-IMRT) in patients with FIGO IIIC1 cervical cancer. Methods: We retrospectively reviewed clinical records of patients with FIGO IIIC1 cervical cancer treated with definitive IG-IMRT in our institute from January 2008 to December 2017. A dose of 50.4Gy in 28 fractions was prescribed to at least 95% of PCTV, the positive pelvic lymph nodes received a dose of 56-61.6Gy in 28 fractions with simultaneous integrated boost (SIB). Weekly cone beam compute tomography (CBCT) and daily megavoltage CT (MVCT) was performed before treatment. Both 2D brachytherapy and 3D brachytherapy were allowed in our study. Weekly Cisplatin (30-40mg/m2) was the first line regimen for concurrent chemotherapy. Overall survival (OS), disease free survival (DFS), local control (LC) and local regional control (LRC) was calculated with Kaplan-Meier method. Cox proportional hazard model was used to perform univariate and multivariate analyses. Results: A total of 502 patients were enrolled in this study. The median follow-up duration was 42.1 months (range: 2.3-137.3 months). The 3-year and 5-year estimated OS, DFS, LC, LRC were 81.7% and 75.5%, 71.4% and 68.6%, 89.9% and 89.9%, 86.1% and 84.3%, respectively. The incidences of chronic grade 3 or greater gastrointestinal and genitourinary toxicities were 2.7 % and 0.8%, respectively. Pelvic lymph nodes recurrence occurred in 21 patients (4.2%). Advanced T stage was identified as adverse factor for OS and LC. More positive lymph nodes (≥2) were associated with worse OS, DFS and LRC. The cycles of concurrent chemotherapy significantly affected OS, DFS and LRC. Conclusion: For patients with FIGO IIIC1 cervical cancer, IG-IMRT was well tolerated with excellent survivals. T stage and number of positive lymph nodes significantly influenced the survivals indicating the heterogeneity of stage IIIC1 cervical cancer patients. Adequate cycles of chemotherapy (≥4 cycles) was of great value for this group of patients.

Recent Advances in Cervical Cancer Management: A Review on Novel Prognostic Factors in Primary and Recurrent Tumors

BACKGROUND

Several pathological parameters, including tumor size, depth of stromal invasion, lympho-vascular space invasion and lymph node status, have been proposed as prognostic predictors in cervical cancer. However, given the high mortality and recurrence rate of cervical cancer, novel parameters that are able to provide additional prognostic information are needed in order to allow a better prognostic stratification of cervical cancer patients.

METHODS

A search was conducted on PubMed to identify relevant literature data regarding prognostic factors in cervical cancer. The key words "cervical cancer", "prognostic factors", "pathology", and "outcome" were used.

RESULTS

The novel pathological grading system based on tumor budding and cell nest size appeared the most relevant prognostic factor in primary neoplasms. Moreover, other potentially useful prognostic factors were tumor size, depth of stromal invasion, lympho-vascular space invasion, perineural invasion, tumor-free distance and tumor-infiltrating lymphocytes. Prognostic factors related to advanced-stage cervical cancer, including lymph-nodes status, endometrial and cervical involvement as well as distant metastases, were also taken into consideration.

CONCLUSIONS

According to our findings, tumor budding and cell nest size grading system, depth of stromal invasion, lympho-vascular space invasion, perineural invasion, tumor-free distance and tumor-infiltrating lymphocytes appeared the most relevant factors included in the pathology report.

Pretreatment Radiologically Enlarged Lymph Nodes as a Significant Prognostic Factor in Clinical Stage IIB Cervical Cancer: Evidence from a Taiwanese Tertiary Care Center in Reaching Consensus

The incidence of lymph node (LN) involvement and its prognostic value based on radiological imaging in stage IIB cervical cancer (CC) remains unclear, and evidence regarding oncological outcomes of patients with stage IIB CC with LN metastases is limited. In this study we retrospectively reviewed the incidence and prognostic significance of pretreatment radiologic LN status in 72 patients with clinical stage IIB CC (FIGO 2009), with or without radiologic evidence of LN enlargement. An enlarged LN was defined as a diameter > 10 mm on CT/MRI. Progression-free survival (PFS) and overall survival (OS) were assessed. Radiologic LN enlargement of >10 mm was observed in 45.8% of patients with stage IIB CC. PFS (p = 0.0088) and OS rates (p = 0.0032) were significantly poorer in the LN group (n = 33) than in the non-LN group (n = 39). Univariate Cox analysis revealed that LN > 10 mm contributed to a higher rate of recurrence and mortality. In conclusion, nearly half of the patients with clinical stage IIB CC had enlarged LNs (>10 mm) identified during pretreatment radiologic evaluation, which negatively impacted prognosis. Our findings highlight the need to incorporate CT- or MRI-based LN assessment before treatment for stage IIB CC.

Dose to pelvic lymph nodes during brachytherapy of locally advanced cervical cancer with 60Co HDR source

PURPOSE

This study investigated the correlation between the prescription dose and dose to the Manchester and International Commission on Radiation Units and Measurements-report 38 (ICRU-38) lymphatic trapezoid points during high-dose-rate (HDR) brachytherapy of locally advanced cervical cancer with (Cobalt-60) 60Co .

METHODS AND MATERIALS

A retrospective study was designed for; patients with locally advanced cervical cancer, treated by external beam radiotherapy and concurrent weekly Cisplatin-based chemotherapy, had no extended parametrial invasion and was treated by tandem-ovoid set, from 2017 to 2020. Groupe Européen de Curiethérapie-European Society for Radiotherapy and Oncology (GEC-ESTRO) based target's volume, ICRU-89 revised version of Manchester points A and B, and ICRU-38 lymph node surrogate points were determined, and their dose was recorded. Paired sample t-test, linear regression analysis, and Pearson correlation analyses were done considering a statistical significance level of 0.05 and using IBM SPSS statistics (Version 23, IBM Crop.).

RESULTS

Seventy-four brachytherapy cases were included. A positive and strong correlation was observed between D₉₀ of clinical target volume (CTV_HR) and points A and B dose for CTV_HR〈 15 cc and 〉 35 cc. Strong and significant (p < 0.05) correlations were achieved between pelvic wall points dose and D₉₀ and D₁₀₀ of the obturator and between D₅₀ and hot points of internal iliac lymph nodes. A strong correlation was obtained between D₅₀ and D₉₀ of external iliac lymph nodes and their ICRU points.

CONCLUSIONS

Strong correlations were obtained between dose to the pelvic lymphatic chains and their historical ICRU-38 surrogate points during HDR brachytherapy of locally advanced cervical cancer patients with 60Co tandem-ovoid applicator sets. The correlation strength between point A and prescription dose highly depends on the CTV_HR volume.

Laparoscopic retroperitoneal para-aortic lymph node biopsy in advanced cervical cancer with pelvic lymph node metastases: A single-center prospective study

AIM

Extended-field concurrent chemoradiation therapy (Ex-CCRT) has been widely used for para-aortic lymph node (PAN) metastases confirmed by radiographic assessment without surgical exploration. The objective of this prospective study was to evaluate the clinical value of laparoscopic retroperitoneal PAN biopsy in locally advanced cervical cancer (LACC) with pelvic lymph node (PLN) metastases.

METHODS

From May 2017 to March 2020, stage IIB-IIIB cervical cancer patients who were diagnosed with PLN metastasis using positron emission tomography-computed tomography (PET-CT) with maximum standardized uptake value (SUVmax) ≥2.0 underwent laparoscopic retroperitoneal PAN biopsy. The radiation fields were extended to PAN areas with pathological metastases.

RESULTS

Fourteen patients were diagnosed with cervical squamous cell carcinoma of the International Federation of Gynecology and Obstetrics (FIGO) stage IIB (n = 7) and IIIB (n = 7). The median operating time was 138 min (range, 104-184 min). The median number of harvested PANs was 19 (range, 6-36). Three patients were positive for PAN metastasis on histological analysis. In this study, the sensitivity and specificity of PET-CT were 66.7% and 90.9%, respectively.

CONCLUSION

Our study is characterized by the use of more appropriate eligibility criteria for LACC with PLN metastases. Our results revealed that laparoscopic retroperitoneal PAN biopsy may be a useful approach to determine the radiation field for PANs during standard radiotherapy planning.

Combined dynamic contrast enhanced MRI parameter with clinical factors predict the survival of concurrent chemo-radiotherapy in patients with 2018 FIGO IIICr stage cervical cancer

PURPOSE

Combined clinical prognostic factors and magnetic resonance imaging (MRI) parameters on predicting the prognosis after concurrent chemo-radiotherapy (CCRT)in patients with 2018 International Federation of Gynecology and Obstetrics (FIGO) IIICr stage patients.

METHODS

A total of 117 patients with cervical cancer (2018 FIGO stage IIICr) who underwent CCRT were enrolled from Dec.2014 to Jul.2017. 47 patients developed outcome events, including 32 recurrences and 15 deaths. Clinical and MR parameters of primary tumors were analyzed, including apparent diffusion coefficient (ADC) values (ADC_mean, ADC_min, and ADC_max) and dynamic contrast-enhanced MRI (DCE-MRI) parameters (K^trans, K_ep, V_e) were recorded. The short diameters of visible lymph nodes in the MRI and enhanced computed tomography (CT) images were measured. Progression-free survival (PFS) was compared by Kaplan-Meier analysis and independent predictors were identified using cox regression analysis.

RESULTS

The median PFS was 35 months (6-68 month). The 1-year and 3-year PFS rates were was 90.4 %, 74.4 %, respectively. Multivariate analysis showed that 2018 FIGOIIIC2r stage (HR 2.701,95 %CI1.259to. 5.797; p = 0.011), K^trans(HR 0.353;95 %CI 0.189 to 0.659; p = 0.001) and ADC_min (HR0.423,95 %CI0.229to0.783; p = 0.006) were highly correlated with poor PFS.

CONCLUSION

In conclusion, we have identified IIIC2r stage, K^trans value and ADC_min value as the most important factors in evaluating the survival rate and prognosis of patients with stage IIICr cervical cancer. For stage IIIC1r subgroup, K^trans, ADC_min value and site of positive lymph node >2 were independent prognostic factors.

Frequency of Pelvic Lymphatic Metastases in Patients with Cervical Cancer – A Retrospective Study

Introduction and objective: The aim of this study was to determine the incidence of pelvic lymph metastases in cervical cancer, depending on the biology of the tumor and the new changes in the staging.

Material and methods: A retrospective database analysis involving 85 patients with cervical carcinoma for a 5-year period was performed. Various factors were analyzed for the purpose of the study.

Results: In 20% of our patients lymph metastases were found with more frequent locus in the right lymph chains. The average number of metastases was equal to or greater than 2. Moderately differentiated cervical carcinomas metastasized most commonly. The most frequent were metastases in squamous cell carcinoma and in Stage 2B under the TNM classification. After changes in FIGO’s classification the presence of positive lymph nodes defined the disease as III stage.

Conclusion: Our study confirms that cervical carcinoma metastasizes in the pelvic lymph nodes before it reaches the para-aortic lymph nodes.

Carbonic Anhydrase IX Promotes Human Cervical Cancer Cell Motility by Regulating PFKFB4 Expression

Simple Summary

Carbonic anhydrase IX (CAIX) is a hypoxia-induced protein that is highly expressed in numerous human cancers. However, the molecular mechanisms involved in CAIX and human cervical cancer metastasis remain poorly understood. Our study found that CAIX overexpression increases PFKFB4 expression and EMT, promoting cervical cancer cell migration. CAIX could contribute to cervical cancer cell metastasis and its inhibition could be a cervical cancer treatment strategy.

Abstract

Carbonic anhydrase IX (CAIX) is a hypoxia-induced protein that is highly expressed in numerous human cancers. However, the molecular mechanisms involved in CAIX and human cervical cancer metastasis remain poorly understood. In this study, CAIX overexpression in SiHa cells increased cell migration and epithelial-to-mesenchymal transition (EMT). Silencing CAIX in the Caski cell line decreased the motility of cells and EMT. Furthermore, the RNA-sequencing analysis identified a target gene, bifunctional 6-phosphofructo-2-kinase/fructose-2,6-bisphosphatase (PFKFB4), which is influenced by CAIX overexpression and knockdown. A positive correlation was found between CAIX expression and PFKFB4 levels in the cervical cancer of the TCGA database. Mechanistically, CAIX overexpression activated the phosphorylation of extracellular signal-regulated kinases (ERKs) to induce EMT and promote cell migration. In clinical results, human cervical cancer patients with CAIX^high/PFKFB4^high expression in the late stage had higher rates of lymph node metastasis and the shortest survival time. Our study found that CAIX overexpression increases PFKFB4 expression and EMT, promoting cervical cancer cell migration. CAIX could contribute to cervical cancer cell metastasis and its inhibition could be a cervical cancer treatment strategy.

Pelvic Lymphadenectomy in Gynecologic Oncology-Significance of Anatomical Variations

Pelvic lymphadenectomy is a common surgical procedure in gynecologic oncology. Pelvic lymph node dissection is performed for all types of gynecological malignancies to evaluate the extent of a disease and facilitate further treatment planning. Most studies examine the lymphatic spread, the prognostic, and therapeutic significance of the lymph nodes. However, there are very few studies describing the possible surgical approaches and the anatomical variations. Moreover, a correlation between anatomical variations and lymphadenectomy in the pelvic region has never been discussed in medical literature. The present article aims to expand the limited knowledge of the anatomical variations in the pelvis. Anatomical variations of the ureters, pelvic vessels, and nerves and their significance to pelvic lymphadenectomy are summarized, explained, and illustrated. Surgeons should be familiar with pelvic anatomy and its variations to safely perform a pelvic lymphadenectomy. Learning the proper lymphadenectomy technique relating to anatomical landmarks and variations may decrease morbidity and mortality. Furthermore, accurate description and analysis of the majority of pelvic anatomical variations may impact not only gynecological surgery, but also spinal surgery, urology, and orthopedics.

Distribution patterns of lymph node metastasis in early stage invasive cervical cancer

The spatial distribution of lymph node (LN) metastasis was analyzed to provide data for an evidence-based approach to radiotherapy field design, particularly for guiding intensity-modulated radiation therapy. A total of 1886 postoperative patients were retrospectively reviewed. Pelvic LNs were classified as common iliac nodes, external iliac nodes, internal iliac nodes/obturator nodes, and deep inguinal nodes. The distribution of LN metastasis in these subgroups was calculated, and the distribution patterns of LN metastasis according to the pathologic types were investigated.We identified 392 eligible patients with LN metastasis. The frequency and number of external iliac node metastasis were higher in the left side in both single subgroup (P < .01) and cosubgroup (P = .04) analyses, whereas few differences were found in other subgroups. Among patients with squamous cell carcinoma, left external iliac node metastasis was observed in 102 (15.13%) patients, whereas right metastasis was observed in 65 (9.64%) patients, and the difference was significant (P < .01).The present results indicated uneven distribution of LN metastasis in the different subgroups, which could help surgeon focus on the dissection of the left subgroups, and help oncologists define margins, refine target volumes for radiation, and improve the accuracy of postoperative radiotherapy especially in patients with squamous cell carcinoma.

Analysis of prognostic factors and clinical outcomes in uterine cervical carcinoma with isolated para-aortic lymph node recurrence

To evaluate clinical outcomes and to identify prognostic factors in isolated para-aortic lymph node (PALN) recurrence, we retrospectively reviewed 65 patients who developed PALN recurrence as the first site of tumor progression from a total of 1521 patients who were treated with curative pelvic radiation therapy (RT) for uterine cervical carcinoma between May 1993 and January 2017. Forty-five of the 65 patients received salvage therapy. The median salvage PALN radiation dose was 54 Gy (range: 18 to 62 Gy). Prognostic factors for overall survival (OS) and distant metastases (DMs) were analyzed with univariate and multivariate Cox regression. The median follow-up period for surviving patients was 61 months (4-202 months). The median OS was 27.7 months (0.3-202 months). The highest level of PALN metastases at or above the L1 spinal level (hazard ratio [HR] 9.88, 95% confidence interval [CI] 3.44-28.38, P<0.001) and the presence of leg edema and/or back pain at recurrence (HR 3.25, 95% CI 1.57-6.75, P=0.002) were significantly associated with worse OS. A significantly higher incidence of DMs (HR 5.97, 95% CI 2.05-17.35, P=0.001) was found in the patients with a high level (≥L1) of PALN metastases. Salvage RT (HR 0.35, 95% CI 0.17-0.71, P=0.004) and restaging with positron emission tomography/computed tomography (PET/CT) (HR 0.2, 95% CI 0.04-0.93, P=0.039) were independent predictors of a better OS. In conclusion, a high level (≥L1) of PALN metastases predicts poor survival and a high rate of DMs. Periodic surveillance for early detection and restaging by PET/CT imaging to identify the optimal treatment at recurrence is recommended.

The Characteristics and Survival of Patients with Mesorectum Metastatic Lymph Nodes from Cervical Cancer

Purpose

To analyze the characteristics and survival of patients with mesorectum metastatic lymph nodes (MLNs) from cervical cancer.

Patients and methods

We retrospectively reviewed 1194 consecutive patients with FIGO stage IA–IVA cervical cancer who were treated with definitive radiotherapy between January 2011 and December 2015 in our institute. Patients were treated with intensity-modulated radiation therapy (IMRT) and brachytherapy, combined with concurrent chemotherapy. Mesorectum, pelvic and para-aortic MLNs were boosted 59–61Gy with IMRT. We calculated the clinical characteristics and survival of the patients with and without mesorectum MLNs and made comparisons between them.

Results

The incidence rate of mesorectum MLNs was 0.8% (10/1194). The incidence rates for patients with FIGO stages I, II, III, and IVA disease were 0%, 0.4%, 2.0%, and 33.3%, respectively. Mesorectum MLNs were associated with more advanced stage (p <0.001); larger tumor size (p = 0.002), para-aortic MLNs (p <0.001), common iliac MLNs (p <0.001), and bilateral pelvic MLNs (p <0.001). All patients with mesorectum MLNs experienced treatment failure and died during follow-up. The median overall survival was 10.43 months. The 2-year overall survival (OS), disease-free survival (DFS), and local control (LC) rates were 10%, 0%, and 30%, respectively. Multivariate analysis showed that that mesorectum MLNs (hazard ratio, HR 4.0, 95% CI 1.8–9.1, p=0.001), para-aortic MLNs (HR 1.8, 95% CI 1.1–2.8, p=0.017) and pelvic MLNs (HR 2.5, 95% CI 1.7–3.7, p<0.001) were independent prognostic factors of OS.

Conclusion

Mesorectum MLNs from cervical cancer are rare. And, the survival of patients with mesorectum MLNs was poor after dose-escalated concurrent chemoradiotherapy.

Prophylactic Extended-Field Irradiation for Patients With Cervical Cancer Treated With Concurrent Chemoradiotherapy: A Propensity-Score Matching Analysis

Supplemental digital content is available in the text.

Objective

The aim of the study was to evaluate the efficacy and toxicity of prophylactic extended-field radiation therapy (RT) for cervical cancer patients treated with concurrent chemoradiotherapy (CCRT).

Methods

Records of patients with cervical cancer without para-aortic metastatic lymph nodes who were treated with definitive RT or CCRT between January 2011 and December 2014 were reviewed. Patients were classified into the pelvic RT and extended-field RT groups. An additional dose of 50.4 Gy in 28 fractions was delivered to para-aortic lymph node regions for patients in the extended-field RT group. Cox regression and propensity-score matching (1:1) were used to compare the overall survival (OS), disease-free survival (DFS), distant failure, and para-aortic lymph node failure (PALNF) between the pelvic RT and extended-field RT groups.

Results

A total of 778 patients were analyzed. Of them, 624 patients were treated with pelvic RT and 154 patients received extended-field RT. The median follow-up period was 37.5 months. In multivariate analysis, extended-field RT was an independent prognostic factor of distant failure (hazard ratio [HR] = 0.49, 95% confidence interval [CI] = 0.26–0.90, P = 0.023) and PALNF (HR = 0.012, 95% CI = 0.00–0.49, P = 0.019). However, it was not significant in predicting OS (P = 0.546) and DFS (P = 0.187). With propensity-score matching, 108 pairs of patients were selected. The 3-year OS, DFS, local control, distant failure, and PALNF rates in the pelvic RT and extended-field RT groups were 87.1% and 85.7% (P = 0.681), 71.0% and 80.6% (P = 0.199), 86.6% and 85.0% (P = 0.695), 21.7% and 7.0% (P = 0.016), and 6.6% and 0% (P = 0.014), respectively. The incidences of grade 3 or greater chronic toxicities were 3.5% and 6.5% in the pelvic RT and extended-field RT groups, respectively (P = 0.097).

Conclusions

Prophylactic extended-field RT was associated with decreased distant failure and PALNF and showed a trend in improving DFS in patients with cervical cancer treated with CCRT.

Nomograms predicting survival and patterns of failure in patients with cervical cancer treated with concurrent chemoradiotherapy: A special focus on lymph nodes metastases

Objective

To construct nomograms predicting survival and patterns of failure in patients with cervical cancer treated with concurrent chemoradiotherapy (CCRT).

Methods

A total of 833 patients with cervical cancer treated with definitive radiotherapy or CCRT in our institute from January 2011 to December 2014 were included. Cox proportional hazard regression models were used in univariate and multivariate analysis. The following variables were included in the univariate analysis: histology, FIGO stage, lymph node metastases (para-aortic, pelvic, common iliac, binary pelvic, and binary common iliac LNMs), the number of pelvic metastatic lymph nodes (MLNs), and the diameter of pelvic MLNs. Nomograms predicting the 3- and 5-year overall survival (OS), disease-free survival (DFS), local control (LC) and distant metastasis-free (DMF) were constructed. The nomograms were internally validated with respect to discrimination and calibration.

Results

The median follow-up period was 36.4 months (range,1.0 to 76.2 months). After univariate and multivariate analysis, histology, FIGO stage, para-aortic LNM, pelvic LNM, number of MLNs and diameter of pelvic MLNs significantly predicted OS, DFS, LC or DMF. Nomograms predicting the 3- and 5-year OS, DFS, LC and DMF were constructed incorporating these significant variables. These nomograms showed good discrimination and calibration, with a concordance index of 0.73 for predicting OS, 0.71 for DFS, 0.73 for LC and 0.67 for DMF.

Conclusion

We constructed nomograms predicting survival and patterns of failure with a special focus on regional LNM in patients with cervical cancer treated with concurrent chemoradiotherapy.

Incidence of mesorectal node metastasis in locally advanced cervical cancer: its therapeutic implications

OBJECTIVE

To evaluate the incidence and risk factors for mesorectal node metastasis (MRNM) in locally advanced cervical cancer.

METHODS/MATERIALS

We performed an observational retrospective cohort study of 122 patients with cervical cancer who received definitive chemo-radiation treatment between December 2013 and June 2017 to evaluate the incidence of MRNM. Three diagnostic radiologists assessed all available pre-treatment images. In this study, the pelvic node metastasis was defined as ≥ 1.0 cm and MRNM as ≥ 0.5 cm for CT and MRI scans and as a maximum standardized uptake value of > 2.5 for PET/CT. The relationship of MRNM with FIGO stage, pelvic node metastasis, and mesorectal fascia involvement was evaluated.

RESULTS

The incidence of MRNM in all 122 patients was 8 (6.6%). However, in advanced stage (III- IV) patients, MRNM occurred in 4 of 39 (10.3%) compared with 4 of 83 (4.8%) in early stage (IB1-IIB) patients (p = 0.27). In patients with a positive pelvic node, MRNM occurred in 7 of 55 (12.7%) and 1 of 67 (1.5%) in those with negative pelvic node (p = 0.02). In addition, the incidence of MRNM was 3 of 9 (33.3%) in the presence of mesorectal fascia involvement and 5 of 113 (4.4%) among those without mesorectal fascia involvement (p = 0.013).

CONCLUSION

This study indicates that pelvic node metastasis and mesorectal fascia involvement are high-risk factors for MRNM. Therefore, vigilance of reviewing images in the mesorectum for MRNM is necessary for high-risk patients.

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.

How Histopathologic Tumor Extent and Patterns of Recurrence Data Inform the Development of Radiation Therapy Treatment Volumes in Solid Malignancies

The ability to deliver highly conformal radiation therapy using intensity-modulated radiation therapy and particle therapy provides for new opportunities to improve patient outcomes by reducing treatment-related morbidities following radiation therapy. By reducing the volume of normal tissue exposed to radiation therapy (RT), while also allowing for the opportunity to escalate the dose of RT delivered to the tumor, use of conformal RT delivery should also provide the possibility of expanding the therapeutic index of radiotherapy. However, the ability to safely and confidently deliver conformal RT is largely dependent on our ability to clearly define the clinical target volume for radiation therapy, which requires an in-depth knowledge of histopathologic extent of different tumor types, as well as patterns of recurrence data. In this article, we provide a comprehensive review of the histopathologic and radiographic data that provide the basis for evidence-based guidelines for clinical tumor volume delineation.

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.

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.