Residual pelvic lymph node involvement after concomitant chemoradiation for locally advanced cervical cancer
Introduction
The lymph node status is one of the three principal prognostic factors of cervical cancer, the two others being the FIGO stage and the tumor size [1]. However, this factor does not appear in the FIGO classification. Moreover, it often remains unknown in locally advanced cancers treated by radiation therapy alone. From 1999, concurrent chemoradiation therapy has become the standard treatment for locally advanced cancers [2], [3], [4], [5], [6], [7]. Very few data are available on the lymph node metastasis rate in these cervical tumors, since adjuvant hysterectomy with lymphadenectomy is not routinely performed after radiotherapy [8] or chemoradiotherapy [9].
Our purpose was to evaluate the rate of pelvic lymph node involvement after chemoradiation and to determine predictive factors of this involvement.
Section snippets
Methods and materials
From February 1988 to August 2004, 113 patients have been treated by chemoradiation and brachytherapy followed by surgery for locally advanced cervical cancer (stage IB2 to IVA) including a pelvic lymphadenectomy.
Pretreatment explorations systematically included a clinical examination under general anesthesia combined with an intracavitary pelvic ultrasonography and a cystoscopy (plus a rectoscopy if suspicion of rectal involvement) [10]. A computed tomography (chest–abdomen–pelvis) and/or a
Results
The characteristics of the 113 patients are displayed in Table 1.
FIGO stage has been determined after examination under general anesthesia: 20 stage IB2 (17.7%), 50 bulky stage II (>4 cm) or IIB (44.2%), 24 stage IIIB (21.2%) and 22 stage IVA (16.8%). The mean tumor size was 50.2 mm (median 50 mm).
Radiation therapy (45 Gy over 33 days, whole pelvis) has been administered at 1.8 Gy in one fraction per day in 37.2% of the cases (42/113), or 0.9 Gy per fraction twice a day in 62.8% of the cases
Discussion
As the standard treatment of locally advanced cervical carcinomas does not include surgery [2], [3], [4], [5], [6], [7], literature does not give much information about the pelvic lymph node involvement in such cancers.
The rate of residual cervical tumor after chemoradiation has been estimated at 40/50% when completion hysterectomy has been performed: 43 to 52% in stage IB2 [3], [9], [11], 41 to 56% in stage II, 51.6 to 68% in stage III and 72.7 to 73.7% in stage IVA [9], [11]. However, the
Conclusion
Given the residual pelvic lymph node disease after chemoradiation (15.9%), performing a pelvic lymphadenectomy seems relevant, at least if the option of additional surgery has been chosen so as to remove the potential residual cervical tumor. This could decrease the risk of latero-pelvic recurrence. In 2005, criteria like residual pelvic disease, distant metastases or para-aortic lymph node involvement can be checked by the combination of FDG-PET, pelvic MRI and a cervical biopsy after
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