FDG-PET lymph node staging and survival of patients with FIGO stage IIIb cervical carcinoma

doi:10.1016/S0360-3016(02)04521-2

International Journal of Radiation OncologyBiologyPhysics

Volume 56, Issue 2, 1 June 2003, Pages 489-493

https://doi.org/10.1016/S0360-3016(02)04521-2 Get rights and content

Abstract

Purpose

To evaluate the outcome of patients with International Federation of Gynecology and Obstetrics (FIGO) clinical Stage IIIb cervical carcinoma as a function of site of initial regional lymph node metastasis as detected by 2[¹⁸F]fluoro-2-deoxy-d-glucose (FDG)-positron emission tomography (PET).

Methods and materials

Forty-seven patients with FIGO Stage IIIb cervical cancer were evaluated before therapy with whole-body FDG-PET. Most patients were treated with external beam irradiation, intracavitary brachytherapy, and weekly cisplatin for six cycles. Overall and cause-specific survival rates were calculated by the Kaplan-Meier method.

Results

The pretreatment whole-body FDG-PET demonstrated that all patients had FDG uptake in the cervix. Of 47 patients, 13 (28%) had no evidence of lymph node metastasis, 20 (43%) had metastasis to pelvic lymph nodes only, 7 (15%) had pelvic and para-aortic lymph node metastases, and 7 (15%) had metastases to pelvic, para-aortic, and supraclavicular lymph nodes. The 3-year estimate of cause-specific survival was 73% for those with no lymph node metastasis, 58% for those with only pelvic lymph node metastasis, 29% for those with pelvic and para-aortic lymph node metastases, and 0% for those with pelvic, para-aortic, and supraclavicular lymph node metastasis (p = 0.0005).

Conclusion

The cause-specific survival for patients with FIGO Stage IIIb carcinoma is highly dependent on the extent of lymph node metastasis as demonstrated by whole-body FDG-PET.

Introduction

The International Federation of Gynecology and Obstetrics (FIGO) has promulgated two criteria for the diagnosis of clinical Stage IIIb carcinoma of the uterine cervix: tumor extending to the pelvic sidewall, or tumor causing hydronephrosis or a nonfunctioning kidney (1). These two features have been incorporated into the clinical staging system because of their importance in predicting a poor survival outcome. Survival rates at 5 years for patients with Stage IIIb cervical cancer range from 30% to 50% 2, 3, 4, 5, 6. Bilateral pelvic sidewall disease and more superior levels of anatomic ureteral obstruction are additional variables predicting a worse prognosis 7, 8.

Several additional prognostic factors have been identified for patients with advanced cervical cancer. A review of 626 patients undergoing surgical staging by the Gynecologic Oncology Group identified para-aortic lymph node metastasis and tumor size as the two most significant prognostic factors for survival outcome. By multivariate analysis, these two factors were more important than clinical tumor stage, patient age, or performance status (9).

Patients with clinical Stage IIIb cervical cancer may develop pelvic recurrences or distant metastases, or both. We have recently reported the prognostic significance of lymph node metastases detected by positron emission tomography (PET) with 2[¹⁸F]fluoro-2-deoxy-D-glucose (FDG) in patients with cervical cancer (10). We performed this review to evaluate the frequency and patterns of pretreatment regional lymph node metastases as determined by FDG-PET and to correlate these patterns of metastasis with survival outcome and sites of recurrent or metastatic disease.

Section snippets

Methods and materials

Between March 1998 and January 2002, 47 consecutive patients with a new diagnosis of FIGO clinical Stage IIIb cervical cancer were evaluated before therapy with total-body FDG-PET. The PET studies were performed as part of the routine staging workup at our institution for patients with newly diagnosed cervical cancer who are being evaluated for radiotherapy (RT). The Washington University Human Studies Committee approved this retrospective record review. Data from 28 of these 47 patients were

Results

The 47 patients ranged in age from 27 to 78 years (mean 48). All patients had FIGO clinical Stage IIIb cervical cancer. Hydronephrosis was present in 20 patients. The histologic subtype of the tumor was squamous cell carcinoma in 43, adenosquamous carcinoma in 3, and adenocarcinoma in 1 patient.

Pretreatment FDG uptake was present in the cervix in all patients. FDG uptake was present in the cervix only in 13 patients. Metastases were limited to the pelvic lymph nodes in 20 patients, involved

Discussion

Previously described prognostic factors for patients with clinical Stage IIIb cervical cancer include the presence of hydronephrosis, unilateral vs. bilateral pelvic sidewall disease, and the anatomic level of ureteral obstruction. Treatment-related factors affecting outcome in these patients include the use of intracavitary brachytherapy, total radiation dose, and, possibly, the use of concurrent RT and chemotherapy 14, 15, 16.

The frequency of regional lymph node metastasis in patients with

Conclusion

Patients with clinical Stage IIIb cervical cancer have bulky pelvic disease that can be controlled in most patients with the aggressive use of combined pelvic EBRT and intracavitary brachytherapy and possibly concurrent chemotherapy. Involvement of para-aortic nodes, managed by para-aortic RT, with or without concurrent chemotherapy, eventuates in a poor survival outcome. Those with supraclavicular lymph node metastasis uniformly die of their disease.

On the basis of our results, we recommend

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Clinical investigation: cervixFDG-PET lymph node staging and survival of patients with FIGO stage IIIb cervical carcinoma

Abstract

Purpose

Methods and materials

Results

Conclusion

Introduction

Section snippets

Methods and materials

Results

Discussion

Conclusion

Int J Radiat Oncol Biol Phys

Radiother Oncol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Gynecol Oncol

Int J Radiat Oncol Biol Phys

Classification and staging of malignant tumors in the female pelvisAnnual report on the results of treatment in gynecological cancer

Int J Gynaecol Obstet

FIGO IIIb squamous cell carcinoma of the cervixAn analysis of prognostic factors emphasizing the balance between external beam and intracavitary radiation therapy

Int J Radiat Oncol Biol Phys

Clinical investigation: cervix
FDG-PET lymph node staging and survival of patients with FIGO stage IIIb cervical carcinoma