Practical radiation oncology 2017
Impact of treatment year on survival and adverse effects in patients with cervical cancer and paraortic lymph node metastases treated with definitive extended-field radiation therapy.
Abstract
Purpose
Treatment for locoregionally advanced cervical cancer has changed dramatically since 2000. In that year, delivery of radiation therapy with concurrent chemotherapy became standard, and in the early 2000s, use of intensity modulated RT (IMRT) and positron emission tomography (PET) became more prevalent. We sought to determine the impact of these changes on disease-specific survival (DSS) and treatment-related adverse effects in patients with cervical cancer with para-aortic lymph node (PAN) metastases treated with definitive extended-field radiation therapy.
Methods and materials
We reviewed the medical records of 103 patients with cervical cancer with PAN metastases treated with curative intent at our institution during 2000 to 2013. DSS, disease control in PANs, and treatment-associated adverse effects were compared between patient groups defined by treatment year.
Results
The 5-year DSS rate was 23% (95% confidence interval, 9%-38%) for the 34 patients treated from 2000 to 2004, and 47% (95% confidence interval, 36%-59%) for the 69 patients treated from 2005 to 2013 (P = .005). Factors associated with improved DSS included concurrent chemoradiation (P = .001), baseline PET imaging (P = .01), and treatment of PANs with IMRT (P = .02). Only 3 patients (4%) treated from 2005 to 2013 versus 6 patients (18%) treated from 2000 to 2004 had recurrence in PANs (P = .03). Most recurrences in patients treated from 2005 to 2013 were at distant sites. The crude rate of grade 3 or higher late treatment-related adverse effects was 17%; of the 18 patients who developed serious adverse effects, 8 were being treated for recurrent disease at the time. Adverse effects most frequently involved the gastrointestinal and genitourinary systems.
Conclusions
Outcomes for patients with cervical cancer with PAN metastases have improved concurrently with advances in treatment, including PET and IMRT. Future studies should focus on ways to improve systemic treatments and reduce late adverse effects without compromising local control.
Related Questions
Do you consider high para-aortic nodes above the renal vessels to be locally advanced or metastatic in cervical cancer?
It sounds like you are asking how aggressively to treat patients with para-aortic nodal spread. My limit for "para-aortic" or "regional LAD" is usually anything below the diaphragm. I generally think of and treat these patients as advanced stage III.I would also advocate for definitively treating ce...
For gyn cancers receiving chemoradiation, how high can you boost grossly positive nodes with SIB if not near bowel?
I typically will give a simultaneous integrated boost (SIB) of 60 Gy in 30 fractions to the pelvic and para-aortic nodal CTV, which is the PET positive GTV plus a 3 mm margin. If possible I will boost the GTV of larger gross nodes (>1 cm) to 66 Gy (2.2 Gy/fx) with no margin, if constraints can be me...
How would you manage locally advanced anal cancer patients with PET positive para-aortic lymph nodes?
I would recommend a curative attempt in such patients, based on the following 5 considerations:1. Para-aortic spread, although lumped together as stage IV in the AJCC 7th edition, is not the same as distant hematogenous spread. There is no magical line of demarcation at L4-L5 at which the lymph node...