Study Illuminates Nodal Failure After Cervix Cancer Therapy

Kate Johnson

April 28, 2015

BARCELONA, Spain — In patients with advanced cervical cancer treated with chemoradiation and image-guided adaptive brachytherapy (IGABT), the pattern of nodal failure occurs mainly in the para-aortic (PAO) region.

The finding comes from an analysis of data from the EMBRACE study (the intErnational study on Mri-guided BRachytherapy in locally advanced CErvical cancer).

Current treatment "results in high local control rates and acceptable morbidity," said investigator Christel Nomden, MD, from UMC Utrecht, the Netherlands.

"However, we know that when patients develop a nodal failure, the overall survival is poor."

Understanding the pattern of nodal failure could help identify deficits in radiation dose delivery, her group suggested.

Dr Nomden presented the study at the European Society for Radiotherapy and Oncology (ESTRO) 3rd Forum, where it was one of the three highest scoring abstracts.

"Main Pattern of Failure"

Approached by Medscape Medical News to comment on the findings, Carien Creutzberg, MD, PhD, professor of radiation oncology at Leiden University Medical Center, in the Netherlands, said: "This work clearly shows that ― now local and locoregional control rates, even of advanced disease, have become very high, with primary radiation therapy using current image-guided brachytherapy according to GEC-ESTRO guidelines ― nodal recurrence, especially in the para-aortic region, has become the main pattern of failure."

"With increasingly high local/regional control, reduction of failures at distant sites and reduction of morbidity become ever so much important," she continued.

"Cervix cancer mostly spreads by lymphatic route, so treatment of the para-aortic region in high-risk cases should be considered. In order to improve nodal control and survival, risk factors for para-aortic failure and tailored indications for nodal boost and para-aortic radiotherapy need to be explored."

She added that "current image-guided intensity modulated radiotherapy will enable radiation (with concurrent chemotherapy), including the para-aortic region, while sparing normal tissues, such as bowel and bone marrow. Current trials are also exploring the role of adjuvant chemotherapy, especially in patients with lymph node metastases."

Details of the Results

The EMBRACE analysis included 857 patients who had received treatment with chemoradiation and IGABT.

About half of the patients (n = 421) had lymph node involvement at the time of diagnosis.

After a mean follow-up of 24 months, 62 patients (7%) had a nodal failure ― two patients with persistent disease, and 60 with disease recurrence. Most failures (70%) were detected within the first year after treatment.

Although nodal disease at the time of diagnosis was seen mainly in the pelvis, the majority (69%) of nodal failures occurred in the PAO region, reported Dr Nomden.

Two-year survival was 65% and 93%, respectively, for patients with and without nodal failure.

The proportion of patients who went on to develop nodal failure was double among women who had nodal involvement, a proportion comparable with those who did not (10% vs 5%).

The rate of 2-year nodal control was 92% among women who were node negative at diagnosis, compared with 83% among those who were node positive (P < .001).

On multivariate analysis, hemoglobin level, white blood cell count, number of chemotherapy cycles, and lymph node status at diagnosis were predictive of nodal failure, said Dr Nomden.

Dr Nomden and Dr Creutzberg have disclosed no relevant financial relationships.

European Society for Radiotherapy and Oncology (ESTRO) 3rd Forum: Abstract OC-0486. Presented April 27, 2015.

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