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  Cervical Cancer Outcomes Database
  
 

Interactions Between Tumor Diameter, Volume, and FIGO Stage in Locally-Advanced Cervical Cancer Patients, with MRI & PET  Staging and Treatment for Curative Intent using Concurrent Chemo-Radiotherapy

    During the NCI-sponsored Cervical Cancer State-of-the-Science (SOTS) meeting in Washington, and subsequent ESGO meeting in Berlin, there was considerable discussion with regard to the interactions between tumor size and FIGO stage in locally-advanced cervical cancer.

    It was felt that sharing of staging and outcomes data from a consecutive group of cervical cancer patients treated with curative intent would be useful.  Dr. Kailash Narayan (Division of Radiation Oncology, Peter MacCallum Cancer Center, Melbourne, Australia) has offered to share his institutional data with IGCS Members, including stage, diameter, nodes (PET), volume (MRI), and patterns of failure.  It is hoped that interested Members can view and re-analyze the actual data to clarify many confusing aspects of clinical staging and prognosis in cervical cancer. For example, these data could be particularly useful to those who may wish to design patient selection criteria for clinical trials.

    Download the Full Cervical Cancer Database: 

     (1) Excel Spreadsheet (XLS) Format

     (2) Tab Delimited Text Format

     (save as TXT file and import with database software)

  
     
 


Detailed Materials, Methods, and Data

   Following the use of cisplatin based concurrent chemo-radiotherapy, the survival for patients with locally advanced cervical cancer has improved (1). The identification of pre-treatment prognostic factors has helped in appropriate treatment selection for various groups of cancer patients which in turn has resulted in improved loco-regional control and reduction in treatment related morbidity. The study of patterns of relapse in radically treated cancer patients greatly helps in understanding the clinical biology of cancer that provides clues for identifying further prognostic factors and assists in improving cancer treatment.

    In an earlier paper, we showed, using multifactor analysis in 179 patients with locally advanced cervical cancer, investigated by MRI and treated with concurrent cis-platin and radiotherapy, that tumor volume and corpus invasion provided important prognostic information, for overall and failure-free survival, over and above that provided by FIGO stage, clinical diameter, histology and age (2). Previously we had shown that corpus invasive tumours were associated with increased incidence of nodal metastases as investigated by pre-treatment positron emission tomographic scan (PET) (3).

Patient Selection Criteria

  • Previously untreated cervical cancer patients, presenting to Peter MacCallum Cancer Centre (PMCC), between December 1999 and December 2005 for definitive treatment using chemo-radiotherapy.
  • Squamous cell carcinoma and adenocarcinoma (including clear cell, endometrioid, mucinous, and serous) histology.
  • Stage Ib to IVa, inclusive.
  • Pre-treatment clinical (FIGO) staging, PET and MRI performed.
Staging
 
    Two hundred and thirty seven patients were examined under anaesthesia (EUA) as per FIGO staging protocol. All patients had pre-treatment MRI and PET scan prior to commencement of their curative treatment. One hundred and seven patients were node positive on PET scan. The information on lymph node status obtained from PET was used in planning of treatment fields and radiation boost dose to the nodal sites. Measurement of tumor volume and corpus invasion has been described previously.

Treatment Policy

   Radical radiotherapy: Patients with FIGO stage Ib1, node positive and all Ib2 and above were treated by radical chemo-radiation. Concurrent chemotherapy consisted of 4 weekly cis-platinum 40 mg/m2 during the course of their external beam radiotherapy (EBRT) component of their treatment. All patients received both EBRT and intracavitary brachytherapy (ICRT). ICRT was given within 7-10 days of completion of EBRT. EBRT consisted of either 40 Gy in 20 fractions to the whole pelvis or 45 Gy in 1.8 Gy fractions, when extended field radiotherapy was used. ICRT consisted of 30 Gy in 5 fractions using high dose rate (HDR) brachytherapy, given twice weekly or 40-45 Gy in 2 fractions using low dose rate (LDR) brachytherapy. Parametrial or nodal boost, if required, consisted of 6-10 Gy in 2 Gy fractions given in between ICRT fractions using EBRT. Patients receiving EFRT were treated supine whereas those receiving pelvic radiotherapy were treated prone on a belly board.

   Radiation portals consisted of typical pelvic field, upper boarder being L5 – S1 or extended field radiotherapy (EFRT) based on the levels of nodal involvement.
Patients receiving EFRT were treated supine whereas those receiving pelvic radiotherapy were treated prone on a belly board.

   Follow-up and salvage: All patients were recommended the use of vaginal cylinder and oestrogen cream twice daily for the first 2-3 months following completion of radiotherapy and twice a week thereafter, indefinitely, to avoid vaginal strictures and narrowing. All patients were examined once, at 4 weeks and thereafter every 3 months for 1 year, every 4 months in their 2nd and 3rd year, 6 monthly in the 4th and 5th year following completion of radiotherapy. After 5 years patients were reviewed every year, indefinitely. Those suspected of harbouring residual disease at the primary site due to persistent bulky cervix were investigated with cytology, CT, MRI and or PET as appropriate, to exclude multiple sites of residual or recurrent disease. Cut off observation date was Dec. 2006.

Data Tables

    The enclosed table provides the cervical cancer staging information and patterns of failure. Neither the salvage data nor time to failure data is included. Part of this information is published and interested readers may wish to down load the enclosed publication. (Patterns of failure and prognostic factor analyses in locally advanced cervical cancer patients staged by magnetic resonance imaging and treated with curative intent. K Narayan, RJ Fisher & D Bernshaw. Int J Gynecol Cancer 2007.)

References
  1. Thomas GM. Improved treatment for cervical cancer--concurrent chemotherapy and radiotherapy. N Engl J Med 1999; 340(15):1198-1200.
  2. Narayan K, Fisher R, Bernshaw D. Significance of tumor volume and corpus uteri invasion in cervical cancer patients treated by radiotherapy. International Journal of Gynecological Cancer 2006; 16(2):623-630.
  3. Narayan K, McKenzie AF, Hicks RJ, Fisher R, Bernshaw D, Bau S. Relation between FIGO stage, primary tumor volume, and presence of lymph node metastases in cervical cancer patients referred for radiotherapy. Int J Gynecol Cancer 2003; 13(5):657-663.

 

 

  
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