Prognostic factors of local control and progression-free survival in AJCC stages T1 and T2 cervical cancer patients treated with adjuvant brachytherapy after chemoradiotherapy

Purpose:
We assessed prognostic factors of local control and progression-free survival (PFS) of patients treated for AJCC stages T1 and T2 cervical cancer using utero-vaginal brachytherapy after chemoradiotherapy.

Material and methods:
This retrospective single-institution analysis included patients who underwent brachytherapy after radiochemotherapy between 2005 and 2015 at the Institut de Cancérologie de Lorraine. Adjuvant hysterectomy was optional. A multivariate analysis of prognostic factors was carried out.

Results:
Of 218 patients, 81 (37.2%) were AJCC stage T1, and 137 (62.8%) were AJCC stage T2. 167 (76.6%) patients had squamous cell carcinoma, 97 (44.5%) patients had pelvic nodal disease, and 30 (13.8%) patients had para-aortic nodal disease. One hundred eighty-four patients (84.4%) underwent concomitant chemotherapy, while adjuvant surgery was performed in 91 patients (41.9%) and 42 (46.2%) patients had pathological complete response. Median follow-up was 4.2 years, and local control was reported in 87.8% (95% CI: 83.0-91.8) and 87.2% (95% CI: 82.3-91.3) of patients at 2 and 5 years, respectively. In multivariate analysis, T stage (hazard ratio [HR] = 3.65, 95% CI: 1.27-10.46, p = 0.016) was associated with local control. PFS was reported in 67.6% (95% CI: 60.9-73.4) and 57.4% (95% CI: 49.3-64.2) of patients at 2 and 5 years, respectively. In multivariate analysis, para-aortic nodal disease (HR = 2.03, 95% CI: 1.16-3.54, p = 0.012), pathological complete response (HR = 0.33, 95% CI: 0.15-0.73, p = 0.006), and intermediate-risk clinical tumor volume of > 60 cc (HR = 1.90, 95% CI: 1.22-2.98, p = 0.005) were associated with PFS.

Conclusions:
Lower dose brachytherapy may benefit AJCC stages T1 and T2 tumors, whereas higher doses are required for larger tumors and para-aortic nodal disease involvement, respectively. Pathological complete response should be associated with better local control and not surgery.