Treatment of bulky lymph nodes in locally advanced cervical cancer: boosting versus debulking

Ester Paulien Olthof*, Hans Wenzel, Jacobus Van Der Velden, Anje M. Spijkerboer, Ruud Bekkers, Jogchum J. Beltman, Hans W. Nijman, Brigitte Slangen, Ramon Smolders, Nienke Van Trommel, Petra L.M. Zusterzeel, Ronald Zweemer, Lukas J.A. Stalpers, Maaike Van Der Aa, Constantijne Mom

*Corresponding author for this work

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Objective Treatment strategies for bulky lymph nodes in patients with locally advanced cervical cancer scheduled for definitive chemoradiation include nodal boosting with radiotherapy, surgical debulking, or both. The aim of this retrospective cohort study was to compare survival and toxicity in patients receiving these treatments and to compare them with a group that received neither form of treatment. Methods Women diagnosed between January 2009 and January 2017 with International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB2, IIA2-IVA cervical cancer with lymph nodes ≥1.5 cm without upper limit on pretreatment imaging and treated with definitive chemoradiation were selected from the Netherlands Cancer Registry. Patients were categorized by intention-to-treat strategy: boosting, debulking, or neither treatment, with subgroup analysis for patients receiving both treatments, that is, debulking with boosting. Overall and relapse-free survival outcomes were compared by Kaplan-Meier and Cox regression analyses and toxicity by logistic regression analysis. Results Of 190 patients, 101 (53%) received only nodal boosting, 31 (16%) debulking alone, 29 (15%) debulking combined with boosting, and 29 (15%) received neither treatment. The 5 year overall and relapse-free survival for the treatment groups were 58%, 45% and 45% (p=0.19), and 47%, 44% and 46% (p=0.87), respectively. Multivariable Cox regression analyses demonstrated no differences in overall and relapse-free survival. Combination of debulking with boosting was associated with decreased overall and relapse-free survival compared with debulking alone (HR 2.47, 95% CI 1.22 to 5.00; and HR 2.37, 95% CI 1.14 to 4.93). Nodal boosting was independently associated with a decreased toxicity risk compared with debulking strategy (OR 0.37, 95% CI 0.16 to 0.83). Conclusions This study showed no survival benefit from either nodal boosting or debulking strategy in patients with suspicious bulky nodes. Nodal boosting might, however, be associated with less toxicity. Dual treatment with debulking and boosting showed a worse survival outcome because this group probably represents patients with poor prognostic factors.

Original languageEnglish
Pages (from-to)861-868
Number of pages8
JournalInternational Journal of Gynecological Cancer
Issue number7
Publication statusPublished - 4 Jul 2022

Bibliographical note

Funding Information:
1Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands 2Department of Gynecological Oncology, Amsterdam University Medical Centres, Centre for Gynecological Oncology Amsterdam (CGOA), Amsterdam, The Netherlands 3Department of Obstetrics and Gynaecology, University Medical Centre Groningen, Groningen, The Netherlands 4Department of Radiology, Amsterdam University Medical Centres, Amsterdam, The Netherlands 5Department of Obstetrics and Gynaecology, Catharina Hospital, Eindhoven, The Netherlands 6Department of Gynecology, Leiden University Medical Centre, Leiden, The Netherlands 7Department of Gynecologic Oncology, Maastricht University Medical Centre, Maastricht, The Netherlands 8Department of Gynecological Oncology, Erasmus Medical Centre, Rotterdam, The Netherlands 9Department of Gynecological Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Centre for Gynecologic Oncology Amsterdam (CGOA), Amsterdam, The Netherlands 10Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands 11Department of Gynecological Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands 12Department of Radiation Oncology, Amsterdam University Medical Centres, Amsterdam, The Netherlands Acknowledgements The authors thank the registration team of the Netherlands Comprehensive Cancer Organization (IKNL) for the collection of data for the Netherlands Cancer Registry. Contributors EO: guarantor, conceptualization, methodology, data analysis, interpretation and writing. HW, JV, LS, MA, CM: conceptualization, methodology, writing, reviewing and editing. AS: methodology, conceptualization, review and editing. RB, JB, HN, BS, RS, NT, PZ, RZ: conceptualization, review and editing. Funding This work was supported by the Dutch Cancer Society [IKNL2019-12398]. Competing interests None declared.

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