Nodal failure after chemo-radiation and MRI guided brachytherapy in cervical cancer: Patterns of failure in the EMBRACE study cohort

Abstract

To investigate the patterns of nodal failure in patients enrolled in the international multicentre EMBRACE study. Materials/Methods: Nodal disease at diagnosis (NÀ, N+) and nodal failure were analysed per region (NF) (pelvic (parametrial, common iliac, internal/external iliac), inguinal and para-aortic (PAO)) in 1338 patients. Treatment consisted of chemo-radiation and MRI guided brachytherapy. PAO radiotherapy and/or nodal boost was left to the treating centre. At time of diagnosis 52% of patients had pathologic nodes. Frequency analyses were performed in relation to patient, primary tumour and nodal disease characteristics, and treatment related factors. Results: Median follow up was 34 months and 83% of NF occurred within 24 months. At diagnosis 99% of the N+ patients had pathologic nodes in the pelvis and 14% in the PAO. NF pelvic and NF PAO were reported in 55% and 68% of patients with NF, respectively. Overall NF was reported in 152 patients (11%); 7 and 16% for N-and N+ patients. Of the patients with NF, 41% were located outside the elective target (39% PAO), 40% inside and 35% inside the nodal boost target. Twelve percent of N+ patients that received a nodal boost had a NF inside the nodal boost target. Conclusion: Within the EMBRACE study cohort the overall number of patients developing nodal failure is low, significantly lower for NÀ compared to N+ patients. Pathological nodes at diagnosis are mainly located in the pelvis, whereas nodal failures are more often reported in the PAO region. About 40% of all nodal failures were reported outside the treatment targets.

Prospective observational study evaluating acute and delayed treatment related toxicities of prophylactic extended field volumetric modulated arc therapy with concurrent cisplatin in cervical cancer patients with pelvic lymph node metastasis

“…We found that prophylactic para aortic RT reduced the incidence of para aortic lymph node failures as well as distant metastasis when compared to pelvic RT alone. In the Embrace cohort, Nomden et al analyzed pelvic lymph node status at diagnosis and the patterns of failures [5] . It was seen that almost half of the cohort had pelvic lymph node involvement at diagnosis and elective radiation to para aortic region in these patients reduced failure rate to 7% in patients with documented pelvic lymph nodes [5] .…”

“…In the Embrace cohort, Nomden et al analyzed pelvic lymph node status at diagnosis and the patterns of failures [5] . It was seen that almost half of the cohort had pelvic lymph node involvement at diagnosis and elective radiation to para aortic region in these patients reduced failure rate to 7% in patients with documented pelvic lymph nodes [5] . A Cochrane review of studies which tested EF-RT showed improved para aortic region and distant control when compared to pelvic RT alone.…”

“…Radical pelvic chemo-radiation followed by brachytherapy has produced 5 year overall survival rates, nodal and systemic control rates of 89, 87% and 77% respectively (all stages). After chemo radiation, most failures occur in para aortic region (69%) and involvement of pelvic lymph nodes at diagnosis was the strongest predictor of para aortic lymph node recurrences [3] , [4] , [5] . Thus prophylactic irradiation of the para aortic region in cervical cancer was hypothesized to reduce para aortic failures and overall treatment results [6] , [7] .…”

Cervical cancer apparent diffusion coefficient values during external beam radiotherapy

“…However, within the same patient, tumour biology of within separate lymph nodes may be similar. During median follow-up of 15 months, lymph node relapse rate was 15% (literature 11–13%), and overall failure was 20% (literature 20%) [5] , [32] , [33] , [34] .…”

Prophylactic Extended-Field Irradiation in Patients With Cervical Cancer: A Literature Review

“…However, LNs failure are more often in PALN region. Of patients with nodal failure, 39% were located in PALN region ( 10 ). Huang et al ( 11 ) reported that 11% of patients with cervical cancer experienced PALN recurrence after pelvic radiotherapy.…”