Of 107 patients with stage IIb cervical cancer who underwent laparotomy, 82 (77%) could be treated with radical hysterectomy (RAH) and pelvic-node dissection (PND). The remaining 25 patients were unsuitable for radical surgery because of para-aortic lymph node metastases, direct cancer invasion into the bladder muscle, and/or fixed enlarged pelvic lymph nodes (PLN): Such patients were treated with radiation therapy after laparotomy. Fifty-nine of RAH patients were given postoperative pelvic radiation because they had PLN metastases, parametrial invasion, and/or full thickness cervical stromal invasion. The overall 5-year survival of the patients undergoing RAH was significantly better than that of those who could not be treated with RAH (P< 0.001). In the RAH patients, parametrial invasion, which clinically defines stage IIb, was found only in 45%. Univariate analysis of histopathologic prognostic factors revealed that PLN metastasis, parametrial invasion, adenocarcinoma, and lymph-vascular space invasion significantly affected survival of the RAH patients (P< 0.05). Multivariate analysis using Cox's proportional hazards regression model, however, selected only PLN metastasis as a strong prognostic factor (P< 0.001). Concerning PLN metastasis patients with two or more positive nodal groups vs. 49%,P< 0.0001). The logistic regression analysis revealed that tumor diameter, parametrial invasion and lymph-vascular space invasion were independently correlated with PLN metastases in two or more nodal groups. The present data suggest that (i) the patients with massive pelvic extension of cancer cannot be cured by radiation therapy alone, (ii) the strong determinant of the prognosis of the patients undergoing RAH and PND is PLN metastasis. Therefore, for these patients with poor prognosic factors, other treatment modalities should be considered. From the present study it seems that planning RAH and PND for patients with stage IIb disease might make it possible to select poor prognostic subgroups, who have extra cervical extension or PLN metastases in two or more groups, and be useful in individualizing treatment.
Impact of time interval between radical hysterectomy with pelvic node dissection and initial adjuvant therapy on oncological outcomes of early stage cervical cancer
