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Radiation Therapy With or Without Chemotherapy for Cervical Cancer With Periaortic Lymph Node Metastases
Reviewer: Ryan Smith, MD
Last Modified: October 7, 2002
Presenter: Saad, Ayman
Presenter's Affiliation: Wayne State University
Type of Session: Scientific
Several large randomized studies have demonstrated increased local control and overall survival in patients with cervical cancer. However, patients with documented spread to the paraaortic lymph nodes have not been actively investigated. This study reports on patients with cervical cancer with metastatic spread to the periaortic lymph nodes, and whether chemoradiation is tolerable and efficacious in these patients.
Materials and Methods
- Retrospective study of 294 patients with cervical cancer, 21 of which had periaortic lymph node metastases
- 11 of those patients were treated with chemoradiation (CRT), 10 were treated with radiation alone (RT).
- Though no mention was given in the presentation, the choice of therapy appeared to be non-randomized
- All patients received external beam radiation therapy to a pelvic + periaortic (PA) field to 45 Gy. This was followed by a brachytherapy boost (HDR over 8-11 fractions or LDR implant) to 85 Gy prescribed to point A.
- Chemotherapy consisted of cisplatin 15 mg/m2 q 3 weeks x 3 + MMC 10 mg/m2 q 6 weeks x 2 (4 patients), cisplatin 75 mg/m2 q 3 weeks x 3 + 5FU 1000 mg/m2 over a 96 hour infusion q 3 weeks x 3 (1 patient), or cisplatin alone 40 mg/m2 weekly (6 patients)
- Median age of patients was 44 years
- Median FU was 26 months
- 3 year overall survival was 72% (CRT) vs. 30% (RT)
- Median overall survival was 64 months (CRT) vs. 15 months (RT)
- 3 yr DSS was 82% (CRT) vs. 30% (RT)
- 3 yr pelvic control was 100% (CRT) vs. 51% (RT)
- 3 yr PA node + pelvic control was 100% (CRT) vs. 42% (RT), p=.03
- Freedom from distant metastatic disease was 82% (CRT) vs. 49% (RT)
- Except for PA + pelvic control, all results were not significant
- Patients with cervical cancer with PA nodal metastases are potentially curable
- The addition of cisplatin based chemotherapy to XRT improved local control and overall survival without increasing Grade 3/4 toxicity
- Because of the continued fairly high rate of DM, the use of maintenance chemotherapy is recommended
Several randomized studies have proven the efficacy of chemoradiation over radiation alone in the treatment of cervical cancer. However, only one such study (RTOG 90-01) compared PA node + pelvic radiation to chemoradiation (pelvic XRT only). Though this study also showed the benefit of chemoradiation, there has not been an arm that investigated PA node + pelvic radiation with chemotherapy. Also, there has not been a study investigating this question in patients with documented PA nodal metastases. General consensus is that patients with PA nodal metastases do poorly, and that PA node + pelvic radiation with full dose chemotherapy would be difficult to tolerate. This study demonstrates that chemotherapy can be given with extended field radiation without increased toxicity (though it should be pointed out that no data was presented on toxicity). Also, this study shows that many patients have a favorable outcome if treated aggressively. Chemoradiation patients had better outcomes that patients treated with radiation alone. The fact that none of the differences reached statistical significance is simply a reflection of inadequate patient numbers, rather than an absence of efficacy. Weaknesses in this report is the obvious retrospective nature of the study, which exposes patients to many selection biases. Also, though they claim that chemotherapy was given without delay, dose reduction, or increased toxicity, no data was presented on this subject. Also, the claim that maintenance chemotherapy should be given to these patients should be interpreted with caution, as no study has documented the efficacy of adjuvant chemotherapy, and the fact that maintenance chemotherapy can expose the patient to a multitude of toxicity.
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