A third GOG trial evaluated patients with stage IB to IVA cervical cancer. Of the patients enrolled in this study, 70% had stage IB or IIA disease (131). A total of 403 patients were enrolled and evaluated. The 5-year survival rates were 73% in patients treated with chemoradiation and 58% in patients treated with radiation therapy alone. The cumulative rates of disease-free survival at 5 years were 67% in patients treated with concurrent chemoradiation and 40% in patients treated with radiation therapy alone. Survival and progression-free intervals for patients receiving concurrent chemoradiation were significantly improved (131). The results of this study suggested that chemoradiation is the treatment of choice for stage IIB to IVA disease and that those patients with stage IB2 and IIA disease may benefit from chemoradiation.
A GOG study of chemoradiation comparing concurrent cisplatin and radiation with radiation alone in patients with bulky IB cervical cancer included adjuvant hysterectomy after completion of the radiation (132). There were 183 patients assigned to the concurrent chemotherapy and radiation arm and 186 patients treated with radiation alone. The median duration of follow-up was 36 months, with disease recurrence detected in 37% of the patients treated with radiation alone, compared with 21% who were treated with concurrent chemoradiation (132). The 3-year survival rates were 83% in the group who received concurrent chemoradiation and 74% in the group who received radiation alone (132). The study also included adjuvant hysterectomy after completion of radiation treatment. Because the results did not show an improvement in survival by using adjuvant hysterectomy, the authors concluded that adjuvant hysterectomy would not be part of their recommendations. This study supports the results of previous studies and shows that patients with bulky stage IB and IIA cervical cancer treated with concurrent chemoradiation have survival rates superior to those treated with radiation alone. These two studies indicate that patients with bulky stage IB and IIA disease should have primary treatment consisting of chemoradiation, with the chemotherapy agent being weekly cisplatin.
Surgical staging procedures designed to discover positive lymph nodes may be forgone with use of PET/CT imaging studies. The use of transperitoneal exploration was associated with a 16% to 33% mortality rate from radiotherapy-induced bowel complications and a 5-year survival rate of only 9% to 12% (133,134). To avoid these complications, extraperitoneal dissection of the para-aortic nodes is recommended, and the radiation dose should be reduced to 5,000 cGy or less (135,136). When this approach is used, postradiotherapy bowel complications occur in fewer than 5% of patients, and the 5-year survival rate is 15% to 26% in patients with positive para-aortic nodes (19,137,138). Survival appears to be related to the amount of disease in the para-aortic nodes and to the size of the primary tumor. In patients whose metastases to the para-aortic lymph nodes are microscopic and whose central tumor has not extended to the pelvic sidewall, the 5-year survival rate improves to 20% to 50% (139,140). Surgical staging techniques have improved to include laparoscopic assessment of the para-aortic and pelvic lymph nodes. Studies demonstrated benefit from surgical staging with improved survival and changes in treatment plans in 40% of patients (136,137). When PET/CT is compared with surgicopathological staging of para-aortic lymph nodes, some patients with histologically positive para-aortic lymph nodes are missed with surgicopathological staging (141).
Management of Grossly Positive Para-aortic Lymph Nodes