Curative treatment for stage IIIC2 cervical cancer: what to expect?

Introduction: Radical treatment of patients with uterine cervix cancer and positive para-aortic lymph nodes is a valid approach. In this regard, the Federatión Internationale de Gynecologie et Obstetrice (FIGO) staging has changed in 2018. Objective: To evaluate overall survival (OS), pelvic disease-free survival (PDFS), paraortic lymph node progression (PANP) and distant metastases-free survival (DMFS) of patients submitted to radical treatment for uterine cervix cancer FIGO stage IIIC2. Methods: Retrospective analysis of a single institution cohort. Inclusion criteria were biopsy proven cervical cancer and positive paraortic lymph nodes (IIIC2) in staging computed tomography, characterized as nodes larger than 1cm in any diameter. Three-year minimum follow-up was required. Radiotherapy (RT) and chemotherapy followed the institutional protocol: 45-50.4Gy to pelvic and para-aortic fields, with a boost up to 60Gy to macroscopic nodal disease. If brachytherapy was indicated, 4 fractions of 7-7.5Gy to point A were delivered. If not, a boost to primary site would be done up to 59.4Gy. Concurrent chemotherapy, when delivered, was with weekly cisplatin (40mg/m2). Demographic and treatment data were collected. OS, PDFS, PANP and DMFS were assessed from the first day of RT. Uni and multivariate analysis were performed. Results: From April 2010 to May 2017, 65 patients were included. Mean age was 53 years, 83.1% presented ECOG performance status (PS) 0 or 1, 90.8% had squamous cell carcinoma. Mean RT dose was 55.4Gy. Concomitant chemotherapy was delivered in 67.7% of the patients and 67.7% were submitted to brachytherapy. With a median follow-up of 31.6 months, mean overall survival was 53.9 months (1.8-102.9), with 35 deaths, most (77.1%) in the first 20 months of follow-up. Three and five-year OS, PDFS, PANP, and DMFS were respectively, 50.6% and 41.3%, 70.8% and 65.3%, 17.3% and 20.4%, 59.6% and 54.7%. In the univariate analysis, the variables that significantly (p<0.05) influenced the outcomes were: ECOG-PS (OS, DMFS), advanced T stage (T4) (OS, PDFS, DMFS), hydronephrosis (OS, PDFS, DMFS), brachytherapy (OS, DMFS) and concomitant chemotherapy (OS, PANP). No independent variable was selected in the multivariate analysis. Conclusion: Stage IIIC2 cervix cancer patients should be treated with curative intent, since long-term disease control and survival may be expected. Poor PS and more advanced pelvic disease may represent negative prognostic factors. Distant metastases are still a challenge for disease control.