Clinical Investigation
Image-Guided Stereotactic Body Radiation Therapy in Patients With Isolated Para-Aortic Lymph Node Metastases From Uterine Cervical and Corpus Cancer

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Purpose

The aims of this study were to evaluate the role of stereotactic body radiation therapy (SBRT) as a local treatment for isolated para-aortic lymph node (PALN) metastases originating from uterine cervical and corpus cancer.

Methods and Materials

We retrospectively enrolled 30 patients with isolated PALN metastases originating from uterine cervical and corpus cancer who had received SBRT using the CyberKnife (CK). All patients were shown to have isolated PALN metastases by computed tomography (CT) and/or positron emission tomography (PET)–CT. The overall survival (OS), local control (LC) rate, and disease progression–free survival (DPFS) rate were calculated according to the Kaplan-Meier method. Comparison between prognosis groups was performed using log-rank analysis. Toxicities were also evaluated.

Results

The 4-year OS rate was 50.1%, and the median survival time was not reached. The OS rate among symptomatic patients was significantly lower than that among asymptomatic patients (p = 0.002). The 4-year actuarial LC rate was 67.4%. Patients with a planning target volume of ≤17 ml had significantly higher LC rates (p = 0.009). The 4-year DPFS rate was 45.0%, and the median time to disease progression was 32 months. Small planning target volume was a favorable prognostic factor (p = 0.043). Grade 3 or 4 complications requiring hospitalization were reported in 1 patient at 20 months after SBRT.

Conclusion

The OS and LS rates were promising, and the incidence of toxicities was low. Use of SBRT with the CyberKnife is an effective modality for treating isolated PALN metastases in patients with uterine cervical and corpus cancer.

Introduction

Carcinomas of uterus, such as cervix uteri and corpus uteri, are the most common gynecologic cancers. These carcinomas are known to have a relatively good prognosis compared with other malignancies. However, prognosis after recurrence is poor 1, 2, 3, and it is estimated that 30% of patients develop recurrent disease at local and/or distant sites 4, 5, 6, 7.

Isolated para-aortic lymph node (PALN) metastasis is defined as metastasis only to the PALNs, and this type of metastasis is rare. The survival outcome in patients with isolated PALN metastases is dismal. Grigsby et al.(8) reported that all patients with PALN metastasis died within 2 years after recurrence, despite the use of salvage radiation therapy (RT). This is due to the limited effectiveness of salvage therapies (9). Salvage surgery and RT have limited roles in patients with isolated PALN metastasis because their associated morbidity and mortality rates are high. Delivery of a therapeutic dose of radiation to the PALNs is limited by the sensitivity of the surrounding normal tissues, such as those in the gastrointestinal tract, liver, spinal cord, and kidneys. However recent technologies such as intensity-modulated RT (IMRT), image-guided RT (IGRT), and stereotactic body RT (SBRT) have allowed higher doses to be delivered to tumors.

We hypothesized that SBRT using the CyberKnife (CK; Accuray Inc., Sunnyvale, CA) system would lead to better local control through delivery of a higher radiation dose to the tumor and that this would ultimately translate into survival gain. Furthermore, SBRT would provide convenience for patients through a short treatment period. In this study, we investigated the clinical application of this new approach for isolated PALN metastases from uterine cervical and corpus cancer, with special attention focused on feasibility and efficacy.

Section snippets

Patient characteristics

Between September 2002 and October 2007, we retrospectively enrolled 30 patients with isolated PALN metastases from uterine cervical and corpus cancer who received SBRT using CK at the Korea Institute of Radiological and Medical Sciences (KIRAMS). All patients were shown to have isolated PALN metastases by computed tomography (CT) and/or positron emission tomography (PET)–CT. Patients were excluded from this analysis if they had any evidence of metastatic disease in addition to PALN metastases.

Tumor response

Clinical tumor responses were evaluated at 4 months after SBRT using CT and/or PET-CT scans. All patients except 1 were available for follow-up. Among 29 patients, 19 patients showed CR (65.5%), 9 showed PR (31.0%), and 1 (3.5%) showed PD at that time.

Survival and prognostic factors

Although 1 patient was lost during the follow-up period, the final status of all patients was confirmed using the National Database at the Ministry of Internal Affairs. The 4-year overall survival (OS) rate for the 30 patients was 50.1%, and the

Discussion

The incidence of radiologically detected isolated PALN metastasis is 1.7% to 12% after definitive treatment of carcinoma of the uterus. Carl et al.(10) found para-aortic metastases in 20 of 173 patients (12%). The incidence in the study of Singh et al.(11) was 1.7%. The studies of Grigsby et al.(8) and Chou et al.(12), with a combined total of 2087 patients, found the incidence of isolated PALN metastasis to be approximately 2%.

Few reports address the results of radiotherapy with or without

Conclusion

In conclusion, although this is small and retrospective study, the OS and LC rates were promising in our study, with low toxicities. Use of SBRT with the CK is an effective modality for treating isolated PALN metastases originating from uterine cervical and corpus cancer.

References (13)

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Conflict of interest: none.

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