Extended Field Radiotherapy With or Without Chemotherapy in Patients with Cervical Cancer and Positive Para-Aortic Lymph Nodes: a Single Institution Retrospective Review

  • Ng, Boon Huat (Clinical Oncology Unit, Faculty of Medicine, University of Malaya) ;
  • Rozita, AM (Clinical Oncology Unit, Faculty of Medicine, University of Malaya) ;
  • Adlinda, A (Clinical Oncology Unit, Faculty of Medicine, University of Malaya) ;
  • Lee, Wei Ching (Department of Clinical Oncology and Radiotherapy, Penang General Hospital) ;
  • Zamaniah, WI Wan (Clinical Oncology Unit, Faculty of Medicine, University of Malaya)
  • 발행 : 2015.05.18


Background: Positive para-aortic lymph node (PALN) at diagnosis in cervical cancer patients confers an unfavorable prognosis. This study reviewed the outcomes of extended field radiotherapy (EFRT) and concurrent chemotherapy with extended field RT (CCEFRT) in patients with positive PALN at diagnosis. Materials and Methods: Medical records of 407 cervical cancer patients between 1st January 2002 to 31st December 2012 were reviewed. Some 32 cases with positive PALN were identified to have received definitive extended field radiotherapy with or without chemotherapy. Treatment outcomes, clinicopathological factors affecting survival and radiotherapy related acute and late effects were analyzed. Results: Totals of 13 and 19 patients underwent EFRT and CCEFRT respectively during the period of review. The median follow-up was 70 months. The 5-year overall survival (OS) was 40% for patients who underwent CCEFRT as compared to 18% for patients who had EFRT alone, with median survival sof 29 months and 13 months, respectively. The 5-years progression free survival (PFS) for patients who underwent CCEFRT was 32% and 18% for those who had EFRT. Median PFS were 18 months and 12 months, respectively. Overall treatment time (OTT) less than 8 weeks reduced risk of death by 81% (HR=0.19). Acute side effects were documented in 69.7% and 89.5% of patients who underwent EFRT and CCEFRT, respectively. Four patients (12.5%) developed radiotherapy late toxicity and there was no treatment-related death observed. Conclusions: CCEFRT is associated with higher 5-years OS and median OS compared to EFRT and with tolerable level of acute and late toxicities in selected patients with cervical cancer and PALN metastasis.


  1. Alvarez RD, Soong SJ, Kinney WK, et al (1989). Identification of prognostic factors and risk groups in patients found to have nodal metastasis at the time of radical hysterectomy for early-stage squamous carcinoma of the cervix. Gynecol Oncol, 35, 130-5.
  2. Beriwal S, Gan GN, Heron DE, et al (2007). Early clinical outcome with concurrent chemotherapy and extended-field, intensity-modulated radiotherapy for cervical cancer. Int J Radiat Oncol Biol Phys, 68, 166-71.
  3. Berman ML, Keys H, Creasman W, et al (1984). Survival and patterns of recurrence in cervical cancer metastatic to periaortic lymph nodes (a gynecologic oncology group study). Gynecol Oncol, 19, 8-16.
  4. Boughanim M, Leboulleux S, Rey A, et al (2008). Histologic results of para-aortic lymphadenectomy in patients treated for stage IB2/II cervical cancer with negative [18F] fluorodeoxyglucose positron emission tomography scans in the para-aortic area. J Clin Oncol, 26, 2558-61.
  5. Chou HH, Wang CC, Lai CH, et al (2001). Isolated paraaortic lymph node recurrence after definitive irradiation for cervical carcinoma. Int J Radial Oncol Biol Phys, 51, 442-8.
  6. Esthappan J, Chaudhari S, Santanam L, et al (2008). Prospective clinical trial of positron emission tomography/computed tomography image-guided intensity-modulated radiation therapy for cervical carcinoma with positive para-aortic lymph nodes. Int J Radiat Oncol Biol Phys, 72, 1134-9.
  7. Ferlay J, Soerjomataram I, Ervik M, et al (2013). GLOBOCAN 2012 v1.0, cancer incidence and mortality worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: international agency for research on cancer; 2013.
  8. GCC Lim, Y Halimah, S Rampal (2007). Cancer incidence in Peninsular Malaysia, 2003-2005. the third report of the national cancer registry, Malaysia.
  9. Gouy S, Morice P, Narducci F, et al (2013). Prospective multicenter study evaluating the survival of patients with locally advanced cervical cancer undergoing laparoscopic para-aortic lymphadenectomy before chemoradiotherapy in the era of positron emission tomography imaging. J Clin Oncol, 31, 3026-33.
  10. Grigsby PW, Heydon K, Mutch DG, et al (2001a). Long-term follow-up of RTOG 92-10: Cervical cancer with positive para-aortic lymph nodes. Int J Radiat Oncol Biol Phys, 51, 982-7.
  11. Grigsby PW, Perez CA, Chao KS, et al (2001b). Radiation therapy for carcinoma of the cervix with biopsy-proven positive para-aortic lymph nodes. Int J Radiat Oncol Biol Phys, 49, 733-8.
  12. Haie C, Pejovic MH, Gerbaulet A, et al (1988). Is prophylactic para-aortic irradiation worthwhile in the treatment of advanced cervical carcinoma? Results of a controlled clinical trial of the EORTC radiotherapy group. Radiother Oncol, 11, 101-12.
  13. Hong JH, Tsai CS, Lai CH, et al (2004). Recurrent squamous cell carcinoma of cervix following definitive radiotherapy. Int J Radiat Oncol Biol Phys, 60, 249-57.
  14. Hu Y, Cai ZQ, Su XY (2012). Concurrent weekly cisplatin versus triweekly cisplatin with radiotherapy in the treatment of cervical cancer: a meta-analysis result. Asian Pac J Cancer Prev, 13, 4301-4.
  15. Jang H, Chun M, Cho O, et al (2013). Prognostic factors and treatment outcome after radiotherapy in cervical cancer patients with isolated para-aortic lymph node metastases. J Gynecol Oncol, 24, 229-35.
  16. Jensen LG, Hasselle MD, Rose BS, et al (2013). Outcomes for patients with cervical cancer treated with extended-field intensity-modulated radiation therapy and concurrent cisplatin. Int J Gynecol Cancer, 23, 119-25.
  17. Kazumoto T, Kato S, Yokota H, et al (2011). Is a low dose of concomitant chemotherapy with extended-field radiotherapy acceptable as an efficient treatment for cervical cancer patients with metastases to the para-aortic lymph nodes? Int J Gynecol Cancer, 21, 1465-71
  18. Keys HM, Bundy BN, Stehman FB, et al (1999). Cisplatin, radiation, and adjuvant hysterectomy compared with radiation and adjuvant hysterectomy for bulky stage IB cervical carcinoma. N Engl J Med, 340, 1154-61.
  19. Kim YS, Kim JH, Ahn SD, et al (2009). High-dose extended-field irradiation and high-dose-rate brachytherapy with concurrent chemotherapy for cervical cancer with positive para-aortic lymph nodes. Int J Radiat Oncol Biol Phys, 74, 1522-8.
  20. Krusun S, Pesee M, Supakalin N, et al (2014). Treatment interruption during concurrent chemoradiotherapy of uterine cervical cancer; analysis of factors and outcomes. Asian Pac J Cancer Prev, 15, 5653-7.
  21. Lovecchio JL, Averette HE, Doinato D, et al (1989). 5-Year survival of patients with periaortic nodal metastases in clinical stage IB and II cervical carcinoma. Gynecol Oncol, 34, 43-5.
  22. Morris M, Eifel PJ, Lu J, et al (1999). Pelvic radiation with concurrent chemotherapy compared with pelvic and paraaortic radiation for high risk cervical cancer. N Eng J Med, 340, 1137-43.
  23. Mutic S, Malyapa RS, Grigsby PW, et al (2003). PET-guided IMRT for cervical carcinoma with positive para-aortic lymph nodes-a dose-escalation treatment planning study. Int J Radiat Oncol Biol Phys, 55, 28-35.
  24. Nori D, Valentine E, Hilaris B (1985). The role of paraaortic node irradiation in the treatment of cancer of the cervix. Int J Radiat Oncol Biol Phys, 211, 1469-73.
  25. Obel J, Souares Y, Hoy D, et al (2014). A systematic review of cervical cancer incidence and mortality in the pacific region. Asian Pac J Cancer Prev, 15, 9433-7.
  26. Perez-Medina T, Pereira A, Mucientes J, et al (2013). Prospective evaluation of 18-fluoro-2-deoxy-D-glucose positron emission tomography for the discrimination of paraaortic nodal spread in patients with locally advanced cervical carcinoma. Int J Gynecol Cancer, 23, 170-5.
  27. Petereit DG, Sarkaria JN, Chappell R, et al (1995). The adverse effect of treatment prolongation in cervical carcinoma. Int J Radiat Oncol Biol Phys, 32, 1301-7.
  28. Peters WA, Liu PY, Barrett RJ, et al (2000). Concurrent chemotherapy and pelvic radiation therapy compared with pelvic radiation therapy alone as adjuvant therapy after radical surgery in high-risk early-stage cancer of the cervix. J ClinOncol, 18, 1606-13.
  29. Podczaski E, Stryker JA, Kaminski P, et al (1990). Extendedfield radiation therapy for carcinoma of the cervix. Cancer, 66, 251-8.<251::AID-CNCR2820660210>3.0.CO;2-E
  30. Portelance L, Chao KS, Grigsby PW, Bennet H, Low D (2001). Intensity-modulated radiation therapy (IMRT) reduces small bowel, rectum, and bladder doses in patients with cervical cancer receiving pelvic and para-aortic irradiation. Int J Radiat Oncol Biol Phys, 51, 261-6.
  31. Rajasooriyar C, Van Dyk S, Bernshaw D, et al (2011). Patterns of failure and treatment-related toxicity in advanced cervical cancer patients treated using extended field radiotherapy with curative intent. Int J Radiat Oncol Biol Phys, 80, 422-8.
  32. Rash DL, Lee YC, Kashefi A, et al (2013). Clinical response of pelvic and para-aortic lymphadenopathy to a radiation boost in the definitive management of locally advanced cervical cancer. Int J Radiat Oncol Biol Phys, 87, 317-22.
  33. Rose PG, Bundy BN, Watkins EB, et al (1999). Concurrent cisplatin-based radiotherapy and chemotherapy for locally advanced cervical cancer. N Eng J Med, 340, 1144-53.
  34. Small W, Winter K, Levenback C, et al (2007). Extended-field irradiation and intracavitary brachytherapy combined with cisplatin chemotherapy for cervical cancer with positive para-aortic or high common iliac lymph nodes: Results of arm 1 of RTOG 0116. Int J Radiat Oncol Biol Phys, 68, 1081-7.
  35. Sood BM, Timmins PF, Gorla GR, et al (2002). Concomitant cisplatin and extended field radiation therapy in patients with cervical and endometrial cancer. Int J Gynecol Cancer, 12, 459-64.
  36. Stryker JA, Mortel R (2000). Survival following extended field irradiation in carcinoma of cervix metastasis to para-aortic lymph nodes. Gynecol Oncol, 79, 399-405.
  37. Szu-Yuan WU, Eng-Yen HUANG, et al (2014). Prognostic factors associated with radiotherapy for cervical cancer with computed tomography-detected para-aortic lymph node metastasis. J Radiat Res, 55, 129-38.
  38. Varia MA, Bundy BN, Deppe G, et al (1998). Cervical carcinoma metastatic to para-aortic nodes: extended field radiation therapy with concomitant 5-fluorouracil and cisplatin chemotherapy: a Gynecologic Oncology Group study. Int J Radiat Oncol Biol Phys, 42, 1015-23.
  39. Whitney CW, Sause W, Bundy BN, et al (1999). Randomized comparison of fluorouracil plus cisplatin vs hydroxyurea as an adjunct to radiation therapy in stages IIB-IVA carcinoma of the cervix with negative para-aortic lymph nodes: Gynecologic Oncology Group and Southwest Oncology Group Study. J Clin Oncol, 17, 1339-48.
  40. Zamaniah WI, Mastura MY, Phua CE, et al (2014). Definitive concurrent chemoradiotherapy in cervical cancer-a University of Malaya Medical Centre experience. Asian Pac J Cancer Prev, 15, 8987-92.
  41. Zand B, Euscher ED, Soliman PT, et al (2010). Rate of para-aortic lymph node micrometastasis in patients with locally advanced cervical cancer. Gynecol Oncol, 119, 422-5.
  42. Zhang G, Fu C, Zhang Y, et al (2012). Extended-field intensity-modulated radiotherapy and concurrent cisplatin-based chemotherapy for postoperative cervical cancer with common iliac or para-aortic lymph node metastases: a retrospective review in a single institution. Int J Gynecol Cancer, 22, 1220-5.

피인용 문헌

  1. Advances in diagnosis and treatment of metastatic cervical cancer vol.27, pp.4, 2016,