Definitive Chemoradiation for Cervical Cancer Patients with PETPositive Paraaortic Lymphadenopathy

1
Definitive 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.