Title: Definitive Chemoradiation for Cervical Cancer Patients with PETPositive Paraaortic Lymphadenopathy
1Definitive Chemoradiation for Cervical Cancer
Patients with PET-Positive Para-aortic
Lymphadenopathy Ryan M. Tierney, Matthew A.
Powell, David G. Mutch, Janet S. Rader, and Perry
W. Grigsby Washington University School of
Medicine, Departments of Radiation Oncology and
Obstetrics and Gynecology, St. Louis, MO
- Results
- All patients were able to complete their full
treatment course without treatment interruption.
Grade 4 late complications occurred in 6 of 45
patients (13). - Mean follow-up for surviving patients was 30.1
months (range 3 to 84 months). - The Kaplan-Meier 5-year cause-specific survival
estimate was 54 and 5-year progression-free
survival esimate was 42. - The 5-year cause-specific survival estimates were
58 for those with FDG-PET positive only lymph
nodes and 45 for those with FDG-PET/CT positive
lymph nodes (p 0.71). - At last follow-up, 21 patients were alive and
free of disease and 24 had developed recurrent
disease. - Recurrent disease was in the pelvis only in 3/24
(12) and 21/24 (88) had evidence of systemic
metastases. - Four patients failed in the para-aortic region, 2
in each group, and all four had an additional
component of metastatic disease.
- IMRT Planning
- The plans were optimized with the goal of
delivering 95 of the prescription dose to 100
of the volume of the PTV while minimizing the
volume of the PTV receiving greater than 110 of
the prescription dose. - Dose-volume constraints for normal tissues
- lt 40 of the small bowel, rectum to receive 40 Gy
- lt 40 of the large bowel to receive 30 Gy
- lt 40 of the pelvic bones to receive 30 Gy
- lt 40 of the femoral heads to receive 30 Gy
- - All normal structures were restricted to a
maximum dose of 54 Gy.
Purpose The purpose of this study was to compare
the outcome of patients with pre-treatment CT
positive para-aortic lymph nodes to the outcome
of patients with pre-treatment positive
para-aortic lymph nodes detected by FDG-PET only
(CT negative).
- Methods
- Patients
- Pre-treatment positive para-aortic
lymphadenopathy detected by CT and/or FDG-PET
occurred in 45 patients entered onto a
prospective tumor registry of cervical cancer
patients. - Patients were treated at Barnes-Jewish Hospital
and Siteman Cancer Center in St. Louis, MO. - All patients received a CT scan and FDG-PET
imaging for staging purposes upon pathologic
diagnosis of cervical cancer (see Fig. 1, Fig.
2). - Patients with para-aortic lymphadenopathy gt 1 cm
on CT scan were considered to be positive. - 26 patients had positive para-aortic
lymphadenopathy detected on FDG-PET alone, and 19
patients had positive para-aortic lymphadenopathy
detected on both FDG-PET and CT imaging. - 18 pts were FIGO stage IIb, 17 patients stage
IIIb, 6 patients stage Ib2, 2 patients stage IIa,
and 2 patients stage IVa.
Figure 1. Pre-treatment CT scan demonstrating
positive left para-aortic lymphadenopathy by CT
criteria (gt 1 cm)
Figure 3. 4000 cGy isodose shown. Prescription
dose to involved left para-aortic LN 60 Gy.
Maximum dose, this axial level 5885 cGy.
Conclusions
Figure 2. Pre-treatment FDG-PET scan performed
along with the CT scan in Figure 1 also
demonstrating left para-aortic lymphadenopathy
- The survival outcome of patients with cervical
cancer with para-aortic metastases at diagnosis
is poor regardless of whether the para-aortic
disease is detected by CT (gt 1 cm) or by FDG-PET
(lt 1 cm). - Tumor control in the para-aortic region is gt 90.
- The majority of patients who fail develop
distant metastases.
- External Beam Radiation Therapy
- The pelvic and para-aortic lymph nodes that were
not metabolically active on FDG-PET imaging were
treated to 50 Gy in 30 fractions with 167 cGy
daily fractions. - Metabolically active pelvic and para-aortic lymph
nodes were treated to 60 Gy in 200 cGy daily
fractions. - The metabolically-active primary tumor was
treated to 20 Gy in 67 cGy daily fractions.
- Chemotherapy and Brachytherapy
- Treatment consisted of weekly cisplatin
chemotherapy, external beam radiation therapy to
the pelvis and para-aortic regions, and
brachytherapy. - Tandem and ovoid high-dose rate (HDR)
brachytherapy was performed weekly for six
consecutive weeks. The patients received a total
of 3900 cGy to Point A at 650 cGy per fraction.
Figures 4. 4000 cGy isodose shown. Prescription
dose to involved left para-aortic LN 60 Gy.
Maximum dose, this axial level 6370 cGy.