The value of preoperative imaging for identification of metastatic disease and prediction of adjuvant therapy in clinical early-stage cervical cancer

Abstract

Objectives: The FIGO 2018 revised cervical cancer (CC) staging includes radiologic and pathologic data. No standardized guidelines exist guiding routine pre-operative (pre-op) imaging in patients (pts) with presumed early stage disease. Adjuvant chemoradiotherapy (CRT) increases morbidity, highlighting the need for improved preoperative risk assessment. Identification of clinical scenarios where imaging may be omitted is needed for cost effectiveness. We evaluated the ability of preoperative imaging to predict need for adjuvant CRT in pts with clinical early stage CC. Methods: This is a retrospective review of all pts with CC treated surgically at our institution between 2010 and 2017. All pts had negative imaging or no imaging prior to surgery. Demographic and clinicopathologic data was abstracted from medical records. Included pts had squamous, adenocarcinoma, or adenosquamous histology treated primarily with abdominal, laparoscopic, or robotic radical hysterectomy. Pts were assigned to 1 of 2 groups: those who had pre-op imaging with MRI, CT, or PET, and those who had none. Primary outcome was percentage of pts requiring adjuvant CRT by imaging group. Secondary outcomes were rate of nodal metastasis, five year overall survival (OS), progression free survival (PFS), and treatment-related morbidity. Statistical tests used were chi-square, logistic regression, and Kaplan-Meier survival analysis. Results: Of 147 pts, 104 underwent pre-op imaging and 43 did not. Demographics did not differ between groups, except for more self-pay pts (16% vs 39.5%, p=0.002) and pts with adenocarcinoma (31% vs 44%, p=0.047) receiving no pre-op imaging. Pre-op imaging was not associated with a significant difference in the rate of adjuvant CRT (40% vs 35%, p=0.49), or nodal disease (15% vs 11.6%, p=0.55). There was no difference in rate of recurrence (15% vs 11.6%, p=0.55), OS (91% vs 89%, p=0.92), or PFS (76% vs 83%, p=0.66). Groups had similar rates of morbidity (35% vs 30%, p=0.53). Small tumor size predicted negative lymph nodes; 4.1% of pts with tumors less than 2cm had positive nodes on final pathology (OR=0.11, p=0.028). Many pts with clinical early stage disease do not receive surgery; thus, additional data was abstracted for pts with clinical stages I-IIA2 CC who underwent primary CRT. Of 92 pts who might otherwise have been eligible for surgical treatment, 39 (43%) had imaging findings suspicious for lymph node metastasis. Download : Download high-res image (144KB) Download : Download full-size image Conclusions: Though limited by sample size, approximately 20% of all clinically early stage pts in our cohort were upstaged by imaging and were not offered primary surgery. Imaging appears to be useful for initial disposition to primary surgery vs. CRT, but does not predict the need for adjuvant CRT, recurrence risk, or survival in pts treated with primary surgery. In pts with small tumors, (