PROGNOSTIC FACTORS IN PATIENTS WITH CARCINOMA OF THE UTERINE CERVIX TREATED WITH EXTERNAL-BEAM IRRADIATION AND IR-192 HIGH-DOSE-RATE BRACHYTHERAPY

Purpose: Prognostic factors in cancer of the cervix for patients treat ed with external beam irradiation (EER) and lo iv dose-rate (LDR) brac hytherapy have been characterized. However, despite the increasing use of high-dose-rate (HDR) intracavitary placements (ICP), few studies w ith adequate follow-up have analyzed prognostic factors. This study in vestigates pretreatment and treatment factors for their correlation wi th treatment outcome after EER and HDR-ICP. Methods and Materials: Bet ween September 1985 and December 1994, 181 patients with carcinoma of the cervix FIGO stages IB-IV received EER and HDR brachytherapy. Hemog lobin (Hb) levels were maintained above a level of 11 g/dl during the treatment by transfusion. Patient age ranged from 34 to 84 years (medi an: 66). The median follow-up time for patients at risk is 69 months ( range: 23-140). Pretreatment and treatment parameters analyzed to dete rmine their prognostic value included age, FIGO stage, tumor size, tum or type and grade, pretreatment Hb level, number of HDR-ICP, total dos e from HDR-ICP, overall dose to point A, and overall treatment time. A lso evaluated was the prognostic value of enlarged lymph nodes noted o n pretreatment CAT scan of the abdomen and pelvis. Endpoints studied i n uni- and multivariate analyses were disease-specific survival (DSS), freedom from disease (FFD), pelvic control (PC), and probability of d istant metastases (DM), Results: At 5 years the DSS, FFD, and PC rates for all patients were 60%, 58%, and 67%, respectively. The 5-year FFD by stage was: IB: 94%; II: 63%; IIIB: 43%; and TV: 0%. The PC rates w ere 94%, 66%, 59%, and 0%, respectively. In univariate analysis the pr ognostic factors identified for FFD were FIGO stage, tumor size, initi al Hb level, and enlarged pelvic and/or paraaortic nodes tall: p < 0.0 001). Age was inversely correlated with outcome (p = 0.0081). The 5-ye ar FFD rates for tumors (< 3, greater than or equal to 3 < 6, greater than or equal to 6 cm) were 97%, 65%, and 24%; patients with initial H b levels less than or equal to 11g/dl had a FFD of 26% versus 69% for patients with levels > 11g/dl; and those,vith pelvic and/or paraaortal nodes greater than or equal to 1 cm had a survival of 32% versus 68% in patients with negative readings. The same factors were also prognos tically significant for DSS, PC, and DM. Patients with persistent dise ase or pelvic failures had a significantly higher incidence of DM than patients in whom pelvic disease was controlled (p < 0.0001). Histolog ical and treatment parameters including overall treatment time were no t of prognostic significance for any of the endpoints studied. In mult ivariate analysis tumor size was the most powerful parameter for DSS, FFD, PC (p < 0.0001) and DM (p = 0.0001), followed by low initial Hb l evel (DSS: p 0.0004, FFD: p = 0.0009, PC: p = 0.0012, DM: p = 0.0265), and enlarged pelvic and/or paraaortic nodes which were predictive for DSS (p = 0.0210) and DM (p = 0.0011). Conclusion: This study confirms that prognostic factors for patients treated with HDR brachytherapy a re similar to those reported in previous series that employed LDR brac hytherapy. The significance of tumor size, pretreatment Hb level, and enlarged pelvic and/or paraaortic lymph nodes on CAT scan over FIGO st age of disease were demonstrated. Future prospective trials should be undertaken to confirm the validity of these factors and to elucidate t heir therapeutic implications. (C) 1998 Elsevier Science Inc.