Cost-effectiveness of para-aortic lymphadenectomy before chemoradiotherapy in locally advanced cervical cancer

ObjectiveRevised staging of patients with locally advanced cervical cancer is based on clinical examination, imaging, and potential surgical findings. A known limitation of imaging techniques is an appreciable rate of understaging. In contrast, surgical staging may provide more accurate information on lymph node involvement. The aim of this prospective study was to evaluate the impact of pre-treatment surgical staging, including removal of bulky lymph nodes, on disease-free survival in patients with locally advanced cervical cancer.MethodsUterus-11 was a prospective international multicenter study including patients with locally advanced cervical cancer who were randomized 1:1 to surgical staging (experimental arm) or clinical staging (control arm) followed by primary platinum-based chemoradiation. Patients with histologically proven squamous cell carcinoma, adenocarcinoma, or adenosquamous cancer International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IIB–IVA underwent gynecologic examination and pre-treatment imaging including abdominal computed tomography (CT) and/or abdominal magnetic resonance imaging (MRI). Patients had chest imaging (any of the following: X-ray, CT, or PET-CT). The primary endpoint was disease-free survival and the secondary endpoint was overall survival. An ad hoc analysis was performed after trial completion for cancer-specific survival. Randomization was conducted from February 2009 to August 2013.ResultsA total of 255 patients (surgical arm, n=130; clinical arm, n=125) with locally advanced cervical cancer were randomized. Of these, 240 patients were eligible for analysis. The two groups were comparable with respect to patient characteristics. The surgical approach was transperitoneal laparoscopy in most patients (96.6%). Laparoscopic staging led to upstaging in 39 of 120 (33%) patients. After a median follow-up of 90 months (range 1–123) in both arms, there was no difference in disease-free survival between the groups (p=0.084). For patients with FIGO stage IIB, surgical staging is superior to clinical staging with respect to disease-free survival (HR 0.51, 95% CI 0.30 to 0.86, p=0.011). In the post-hoc analysis, surgical staging was associated with better cancer-specific survival (HR 0.61, 95% CI 0.40 to 0.93, p=0.020).ConclusionOur study did not show a difference in disease-free survival between surgical and clinical staging in patients with locally advanced cervical cancer. There was a significant benefit in disease-free survival for patients with FIGO stage IIB and, in a post-hoc analysis, a cancer-specific survival benefit in favor of laparoscopic staging. The high risk of distant metastases in both arms emphasizes the need for further evaluation.

Objective : To determine whether there are differences in clinical response after radiotherapy and 1 year survival in patients with advanced cervical cancer with and without enlargement of PALN.Method : An observational analytic study using a retrospective cohort method was done using consecutive sampling. The subjects of this study were all women with a primary diagnosis of stages IIB to IVB cervical cancer who came to the gynecological oncology clinic of Dr. Cipto Mangunkusumo National General Hospital and underwent MRI examination before undergoing treatment in January 2016 to May 2017Results: Among 76 subjects studied, there were 4 (5.1%) subjects who had enlarged PALN. There were no significant differences between the enlargement status of PALN and age (p = 0.829), age of first sexual intercourse (p = 0.33), parity (p = 0.642), mass diameter (p = 0.777). Patients with PALN enlargement have 2.13 times risk of having negative radiotherapy outcome (p = 0.02, OR 2.13, CI95% 1.12 – 4.07). There was no difference in 1-year survival between patients with and without enlargement of PALN (median 201 vs. 293, p = 0.072).Conclusion: Patients with PALN enlargement have increased risk of having negative radiotherapy outcome (p < 0.05). There were no differences in 1 year survival between patients with advanced cervical cancer with enlargement PALN.Keywords : cervical cancer,  lymph node enlargement, paraaortic, radiotherapy.   Abstrak Tujuan: Mengetahui adakah perbedaan respon klinis pascaradioterapi dan kesintasan 1 tahun pada pasien kanker serviks stadium lanjut dengan pembesaran KGB paraaorta dibandingkan tanpa pembesaran KGB paraaorta.Metode: Penelitian ini merupakan penelitian analitik observasional dengan menggunakan metode kohort retrospektif. Pengambilan sampel dilakukan dengan cara pengambilan sampel berturut-turut. Subyek penelitian ini adalah semua perempuan dengan diagnosis primer kanker serviks stadium IIB hingga IVB yang datang ke poliklinik Onkologi Ginekologi RSUPN Dr. Cipto Mangunkusumo dan menjalani pemeriksaan MRI sebelum dilakukan terapi pada bulan Januari 2016 hingga Mei 2017.Hasil: Dari 76 subjek yang diteliti, didapatkan sebanyak 4 (5,1%) subyek yang mengalami pembesaran KGB paraaorta. Tidak didapatkan perbedaan yang bermakna antara status pembesaran KGB paraaorta dan usia (p = 0,829), usia hubungan seksual pertama (p = 0,333), paritas (p = 0,642), dan diameter massa (p = 0,777). Pasien dengan pembesaran KGB paraaorta memiliki risiko 2,13 kali lipat (p = 0,02, OR 2,13, IK95% 1,12-4,07) memiliki risiko respon terapi negatif. Tidak terdapat perbedaan kesintasan 1 tahun antara pembesaran KGB paraaorta dan tidak (median 201 vs. 293, p = 0,072).Kesimpulan Pasien dengan pembesaran KGB paraaorta memiliki risiko lebih tinggi mengalami respon radioterapi negatif. (p < 0,05). Tidak terdapat kesintasan 1 tahun antara pasien kanker serviks stadium lanjut dengan dan tanpa pembesaran KGB.Kata kunci: kanker serviks,  paraaorta,  pembesaran KGB, radioterapi.

PurposeLocally advanced cervical cancer (LACC) should be treated with a combination of external irradiation and brachytherapy with concurrent chemotherapy. However, as cervical carcinoma cells can disperse by way of the lymphatic system to either pelvic or para-aortic nodes, planning the extent of radiation requires precise information about the spread of the disease to the lymph nodes, especially to the para-aortic area.Material and methodsAll of the 75 women included in our study underwent chemoradiotherapy, which started with brachytherapy. Out of them, 54 have undergone radical hysterectomy with lymphadenectomy followed by chemoradiation. We have retrospectively analyzed the 5-year overall survival (OS) rates relative to the lymph node involvement, the type of lymphadenectomy performed (pelvic, para-aortic, or both), the size of the tumor (> or < 4 cm), the histological type, grading, and the age of patients.ResultsWe observed significant differences in the OS rates relative to the age of the patients with LACC. We noted significant differences in the OS rates related to para-aortic lymphadenectomy and presence of lymph node metastases.ConclusionsPara-aortic lymphadenectomy seems to have a positive influence on long-term outcomes in the LACC patients, and elderly patients may benefit more from applied therapy.