Long-term survival following definitive radiation therapy for recurrence or oligometastases in gynecological malignancies: A landmark analysis

Abstract

Objective: Radiation therapy (RT) may improve outcomes for patients with oligometastatic cancer. We sought to determine if there are long-term survivors treated with definitive RT for recurrent or oligometastatic gynecological cancer (ROMGC), and to evaluate the clinical and disease characteristics of these patients.

Methods: We performed a landmark analysis in 48 patients with ROMGC who survived for ≥5 years following definitive RT of their metastasis. Patient characteristics were extracted from the medical record. DFS was modeled using the Kaplan-Meier method.

Results: This cohort included 20 patients (42%) with ovarian cancer, 16 (33%) with endometrial cancer, 11 (23%) with cervical cancer, and one (2%) with vaginal cancer. The sites of ROMGC were the pelvic (46%), para-aortic (44%), supraclavicular (7%), mediastinal (4%), axillary (4%) lymph nodes and the lung (5.5%). Median total RT dose and fractionation were 62.1 Gy and 2.1 Gy/fraction; one patient was treated with SBRT. 32 patients (67%) received chemoradiation; these patients had higher rates of median DFS than those treated with RT alone (93 vs. 34 months, P = 0.05). At median follow-up of 11.7 years, 11 (23%) patients had progression of disease. 20 (42%) patients had died, 9 (19%) died from non-gynecologic cancer and 8 (17%) from gynecologic cancer (three were unknown). 25 (52%) patients were alive and disease-free (10 initially had endometrial cancer [63% of these patients], eight had cervical cancer [73%], six had ovarian cancer [30%], one had vaginal cancer [100%]).

Conclusions: Long-term survival is possible for patients treated with definitive RT for ROMG, however randomized data are needed to identify which patients derive the most benefit.

Keywords: Gynecologic neoplasms; Neoplasm metastasis; Radiotherapy.

Figure 1:

Two case reports of patients with long-term survival following definitive radiation therapy (RT) for recurrent or oligometastatic gynecological cancer (ROMGC). (a) Patient A is a 59 year-old female diagnosed with stage IA endometrioid adenocarcinoma of the uterus in 2003. She was treated with hysterectomy. In 2005, surveillance imaging showed two enlarged common iliac lymph nodes measuring 3.1 cm and 1.8 cm. Biopsy confirmed metastatic adenocarcinoma. She was treated with definitive IMRT (66Gy in 30 fractions) to the pelvic lymph nodes with weekly cisplatin and 4 cycles of adjuvant carboplatin/taxol. Six months later, surveillance imaging showed complete resolution of the metastatic lymph nodes. Surveillance imaging in 2011 continued to show no evidence of disease. She was without evidence of disease at her last follow-up in 2021. (b) Patient B is a 51 year-old female diagnosed with stage IB adenocarcinoma of the cervix in 2004. She was treated with chemoradiation. In 2010, surveillance imaging showed two enlarged para-tracheal lymph nodes measuring 2.5cm and 1.7cm. Biopsy confirmed metastatic adenocarcinoma of cervical origin. She was treated with definitive IMRT (66Gy in 30 fractions) to the mediastinal lymph nodes with weekly cisplatin. Six months later, surveillance imaging showed stable treated para-tracheal lymph nodes. Surveillance PET scan in 2011 showed resolution of the metastatic lesion with no other sites of disease. She was without evidence of disease at her last follow-up in 2020.

Figure 1:

Two case reports of patients with long-term survival following definitive radiation therapy (RT) for recurrent or oligometastatic gynecological cancer (ROMGC). (a) Patient A is a 59 year-old female diagnosed with stage IA endometrioid adenocarcinoma of the uterus in 2003. She was treated with hysterectomy. In 2005, surveillance imaging showed two enlarged common iliac lymph nodes measuring 3.1 cm and 1.8 cm. Biopsy confirmed metastatic adenocarcinoma. She was treated with definitive IMRT (66Gy in 30 fractions) to the pelvic lymph nodes with weekly cisplatin and 4 cycles of adjuvant carboplatin/taxol. Six months later, surveillance imaging showed complete resolution of the metastatic lymph nodes. Surveillance imaging in 2011 continued to show no evidence of disease. She was without evidence of disease at her last follow-up in 2021. (b) Patient B is a 51 year-old female diagnosed with stage IB adenocarcinoma of the cervix in 2004. She was treated with chemoradiation. In 2010, surveillance imaging showed two enlarged para-tracheal lymph nodes measuring 2.5cm and 1.7cm. Biopsy confirmed metastatic adenocarcinoma of cervical origin. She was treated with definitive IMRT (66Gy in 30 fractions) to the mediastinal lymph nodes with weekly cisplatin. Six months later, surveillance imaging showed stable treated para-tracheal lymph nodes. Surveillance PET scan in 2011 showed resolution of the metastatic lesion with no other sites of disease. She was without evidence of disease at her last follow-up in 2020.

Figure 2:

(a) Disease-free survival (DFS) and (b) overall survival (OS) following definitive radiation treatment (RT) of recurrent or oligometastatic gynecological cancer (ROMGC). Time is measured in months from completion of ROMGC treatment.

Figure 3:

Disease-free survival (DFS) following radiation alone versus chemoradiation for recurrent or oligometastatic gynecological cancer (ROMGC). Time is measured in months from completion of ROMGC treatment.