Globally cervical cancer is the fourth common cancer and second most common cancer in women [1]. In India it is the second commonest cancer after breast cancer in women [2]. Though there are awareness programmes and screening programmes majority of these patients still present with locally advanced disease in our part of the world [3, 4]. Incidence of metastasis to pelvic and paraaortic lymph node increases as stage advances [5, 6]. One of the important prognostic factor in cervical carcinoma is lymph nodal metastasis [7]. The presence of pelvic lymph node metastases has been associated with increased pelvic recurrence and distant metastases, and a decrease in overall survival [8-12]. As of now the standard of care for stage IB2 – IVA carcinoma cervix is concurrent chemoradiation [13]. In patients with paraaortic lymph node metastasis, extended field radiotherapy (EFRT) has shown improvement in survival at the expense of increased toxicities [14]. However EFRT delivered with conformal techniques like 3 DCRT and IMRT results in decreased toxicity compared to conventional radiation therapy. With IMRT or VMAT toxicities are lesser than 3DCRT and dose escalation is also possible with these techniques without increasing the incidence of grade III and IV bowel toxicities [15].

In this study we aim to analyse the outcome of node positive cervical cancer patients treated at our centre with protocol treatment using VMAT and to assess the associated grade III/IV toxicities.

The primary objective is to determine the patterns of failure in node positive cervical cancer patients treated with radiotherapy or chemo-radiation. Other objectives are to determine the factors associated with treatment failure, to analyse the disease free survival and overall survival and associated grade III and IV toxicities.

This was a retrospective study done at the Department of Radiation Oncology, Malabar Cancer Centre, Kerala. The patients included in the study were cervical cancer patients with positive pelvic and /or paraaortic lymph node who were treated with concurrent chemoradiation or radiotherapy alone from Jan 2015 to Dec 2016.

Patients whose case records do not have documentation on details of treatment or toxicities and those who were not treated with conformal therapy were excluded from the study.

A total of 62 patients with node positive cervical cancer were included in the study. 26 (42%) patients had comorbidities, of which 8 (31%) had multiple comorbidities. Majority 54 (87.1%) patients were having squamous cell carcinoma, 6 (9.7%) had adenocarcinoma and 2 (3.2%) had adenosquamous carcinoma.

The clinical details are given in Table 1.

Cervical cancers are the second commonest cancer in India among women. External beam radiotherapy with concurrent chemotherapy followed by brachytherapy is the standard of care in cervical caners as of now.

In a study by Zhikai Liu analysis of stage IIB cervical cancers showed that 25.8% of patients had positive lymph nodes and majority of the nodes were in externl iliac, internal iliac and obturator nodes and the least number of nodes were in the presacral and common iliac group which is in concordance with our study [16].

In our study at a median follow up of 33 months 11 patients had recurrence. Majority of patients had distant metastasis, lung being the most common site. In a study byAnisBandyopadhyay et al stage at presentation, histology, treatment duration and treatment gap were associated with treatment failure [17]. But in our study stage of the disease and residue at end of therapy were significantly associated with failure. Size or site of the node, lymph nodes at multiple sites or multiple lymph nodes or total dose of RT did not show any association with recurrence as expected. The mean duration of treatment in our cohort of patients was 54 days and 68 % of patients completed treatment within 56 days. Except for two patients who refused brachytherapy none of our patients had break during radiotherapy.

A study on patterns of recurrence in node positive cervical cancer patients was done by Rajni Sethi et al showed that the 3-year overall survival (OS) and disease- free survival (DFS) were 65% and 50% respectively. In our study at median follow up of 33 months, the three year OS and DFS was 91.4% and 77.2% respectively. Regarding the pattern of failure, in their study majority of patients had distant failure similar to the findings in our study [18].

E.M. Osborne et al studied on definitive Extended- Field Radiation Therapy for Cervical Cancer patients with para-aortic lymph node metastases and the rate of grade 3 or higher late toxicities was 17% and most frequently involved the gastrointestinal and genitourinary systems [19-21]. In our study 13% of patients had acute and 19.4% had late toxicities. Majority had small bowel toxicity in the acute phase.

In conclusion, node positive cervical cancer is known to have poor prognosis. The current retrospective analysis shows that with aggressive management, the overall survival and disease free survival could be improved. The recurrence in our study is low compared to other studies. Longer follow is desired for more authentic conclusion. But being a retrospective analysis, inherent flaws of retrospective studies may be attributed to better result. The diagnosis of nodal positivity is based on radiological findings and the pathological involvement is unknown. Hence the possibility of pathologically node negative diseases might have been included in the analysis. Prospective studies with pathological evaluation of nodes and longer follow up may be required to confirm the findings.