| Background and the aims:Large tumor size (LTS), depth of invasion (DI) and lymph-vascular space invasion (LVSI) are regarded as intermediate-risk factors for recurrence in patients with FIGO stage IB-ⅡA cervical cancer who underwent radical surgery. There is no consensus on the postoperative indication and treatment choice for these patients. In this study, we aimed to sum up the clinical and pathological features, treatment mode, recurrence and survival outcome in patients without high-risk factors (lymphnode metastasis, parametrial invasion, and/or positive surgical margin) postoperatively in order to analyze prognostic factors and treatment outcome. The second purpose is to verify whether the Gynecologic Oncology Group (GOG) criteria are valid in a different cohort of patients and to investigate simplified model tailoring adjuvant therapy for patients with intermediate-risk factors after radical hysterectomy.Methods:Patients who underwent radical surgery without high-risk factors for FIGO stage IB-IIA cervical cancer at Fudan University Shanghai Cancer Center from July2006to December2010were retrospectively analyzed. The clinical data were reviewed including age at diagnosis, pathological features, postoperative therapy, recurrence and survival outcome. Patients were divided into low-risk group (0-1intermediate-risk factor) and high-risk group (2-3intermediate-risk factors) according to the two-factor model (two or three following factors:TS≥4cm,DI≥1/2,LVSI), and stratified by adjuvant therapy (radiotherapy, chemoradiotherapy, chemotherapy). T-test, chi-square test or Fisher’s exact test was used to compare variables among groups. Survival analysis was performed by Kaplan-Meier methods, and comparison between curves was determined by Log-Rank method. Multivariate analysis was carried out using Cox stepwise regression model to determine independent prognostic factors. We used the receiver operating characteristic (ROC) curve for RFS and OS in order to compare the performance of two-factor model with the GOG criteria. Results:A total of1541patients were incorporated into the study. Mean age was45.6years. Median follow-up time was36.0months. Most patients had stage IB1disease (58.5%) and squamous cell carcinoma histology (90.1%). Survival analysis for the whole patients showed3-year RFS and3-OS of90.8%and96.3%, respectively. In no further therapy group (NFT group), recurrence rate of patients in low-risk group was5.6%(34/608), significantly less than17.1%(7/41) in patients in high-risk group (P=0.003). The difference of recurrence rate between patients in low-risk group and high-risk group disappeared in the treatment group (Tx group)(8.1%vs11.7%, P=0.079). In high-risk group, recurrence rate was slightly lower in Tx group (11.7%) than NFT group (17.1%)(P=0.319), although adjuvant treatment significantly reduced pelvic recurrence rate (17.1%vs6.6%, P=0.013) but not distant recurrence rate (7.3%vs5.9%, P=0.076). In NFT group, patients in high-risk group displayed significantly lower RFS and OS than patients in low-risk group (P=0.002for RFS, P=0.022for OS). And difference in RFS and OS between patients in low-risk (RFS:91.5%, OS:96.5%) and high-risk group (RFS:87.5%,OS:94.5%) disappeared in the Tx group (P=0.169for RFS; P=0.065for OS). Radiotherapy (RT) and chemoradiotherapy (CRT) significantly reduced pelvic recurrence rate for patients in high-risk group than that in NFT group (P=0.036for RT, P=0.014for CRT), while chemotherapy (CT) didn’t. With regard to distance recurrence rate, none of the three types of adjuvant therapy differed from NFT group. Multivariate analysis demonstrated that FIGO stage, deep stromal invasion (DI≥1/2), and large tumor size (TS≥4cm) were independently associated with RFS, while only FIGO stage (Odds Ratio,2.166,95%CI,1.269-3.697) and large tumor size (Odds Ratio,3.100,95%CI,1.780-5.397) were significantly related to OS. Data of1518patients were available for using GOG criteria. There was no statistical difference between the ROC curves of both criteria on RFS (P=0.43) and OS (P=0.43).Conclusions:FIGO stage, DI≥1/2and TS≥4cm were independent prognostic factors for FIGO stage IB-ⅡA cervical cancer patients without high-risk factors. Patients with2or more intermediate-risk factors displayed significantly worse prognosis than those with only0-1intermediate-risk factors and demanded adjuvant treatment. Postoperative radiotherapy and chemoradiotherapy significantly reduced pelvic recurrence in patients with2or more intermediate-risk factors, and brought similar prognosis for high-risk patients compared with low-risk group patients. The GOG criteria were still valid in the study population, and the more simplified two-factor model showed similar performance compared with GOG criteria. |
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