Abstract
ObjectivesTo investigate the safety and outcomes of elective para-aortic (PA) nodal irradiation utilizing modern treatment techniques for patients with node positive cervical cancer.MethodsPatients with pelvic lymph node positive cervical cancer who received radiation were included. All patients received radiation therapy (RT) to either a traditional pelvic field or an extended field to electively cover the PA nodes. Factors associated with survival were identified using a Cox proportional hazards model, and toxicities between groups were compared with a chi-square test.Results96 patients were identified with a mean follow up of 40 months. The incidence of acute grade ≥ 2 toxicity was 31% in the elective PA nodal RT group and 15% in the pelvic field group (Chi-square p = 0.067. There was no significant difference in rates of grade ≥ 3 acute or late toxicities between the two groups (p>0.05). The KM estimated 5-year OS was not statistically different for those receiving elective PA nodal irradiation compared to a pelvic only field, 54% vs. 73% respectively (log-rank p = 0.11).ConclusionsElective PA nodal RT can safely be delivered utilizing modern planning techniques without a significant increase in severe (grade ≥ 3) acute or late toxicities, at the cost of a possible small increase in non-severe (grade 2) acute toxicities. In this series there was no survival benefit observed with the receipt of elective PA nodal RT, however, this benefit may have been obscured by the higher risk features of this population. While prospective randomized trials utilizing a risk adapted approach to elective PA nodal coverage are the only way to fully evaluate the benefit of elective PA nodal coverage, these trials are unlikely to be performed and instead we must rely on interpretation of results of risk adapted approaches like those used in ongoing clinical trials and retrospective data.
Highlights
The use of definitive chemoradiation in the management of locally advanced cervical cancer has been well validated [1,2,3,4,5] and remains the standard of care for these patients [6]
The decision to use an extended field technique is commonplace for those with involved PA lymph nodes; the use of elective PA fields is less clear in patients with clinically negative PA lymph nodes
Initial support for the use of an extended field technique came from the randomized Radiation Therapy Oncology Group (RTOG) 79-20, which showed an overall survival (OS) and distant metastasis advantage with elective PA coverage compared to traditional whole pelvis fields in the absence of chemotherapy [10, 11]
Summary
The use of definitive chemoradiation in the management of locally advanced cervical cancer has been well validated [1,2,3,4,5] and remains the standard of care for these patients [6]. Initial support for the use of an extended field technique came from the randomized Radiation Therapy Oncology Group (RTOG) 79-20, which showed an overall survival (OS) and distant metastasis advantage with elective PA coverage compared to traditional whole pelvis fields in the absence of chemotherapy [10, 11]. Results from the European Organization for Research and Treatment of Cancer (EORTC) showed only a potential decrease in isolated PA nodal failures with an extended field technique, but no differences in local control, distant metastases, or overall survival [12]. In the era of chemotherapy for cervical cancer, results from RTOG 92-10 raised concerns over significant toxicity in patients with involved PA nodes treated using extended fields with twice daily radiation with concurrent chemotherapy in the 2D era [13]. RTOG 90-01 compared concurrent chemoradiation with a whole pelvic field to an extended field without chemotherapy and found that the survival benefit seen in 79-20 disappeared and favored the whole pelvic field chemoradiation arm [14, 15]
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