The prognostic value of radiological and pathological lymph node status in patients with cervical cancer who underwent neoadjuvant chemotherapy and followed hysterectomy

Abstract

To investigate the prognostic value of lymph node status in patients with cervical cancer (CC) patients who underwent neoadjuvant chemotherapy (NACT) and followed hysterectomy. Patients in two referral centers were retrospectively analyzed. The baseline tumor size and radiological lymph node status (LNr) were evaluated on pre-NACT MRI. Tumor histology, differentiation and pathological lymph node status (LNp) were obtained from post-operative specimen. The log-rank test was used to compare survival between patient groups. Cox proportional hazards regression models were employed to estimate the hazard ratio (HR) of various factors with progression-free survival (PFS) and overall survival (OS). A total of 266 patients were included. Patients with 2018 FIGO IIIC showed worse PFS compared to those with FIGO IB-IIB (p < 0.001). The response rate in patients with LNp(-) was 64.1% (134/209), significantly higher than that of 45.6% (26/57) in patients with LNp( +) (p = 0.011). Multivariate Cox analysis identified the main independent predictors of PFS as LNp( +) (HR = 3.777; 95% CI 1.715-8.319), non-SCC (HR = 2.956; 95% CI 1.297-6.736), poor differentiation (HR = 2.370; 95% CI 1.130-4.970) and adjuvant radiation (HR = 3.266; 95% CI 1.183-9.019). The interaction between LNr and LNp regarding PFS were significant both for univariate and multivariate (P = 0.000171 and 1.5357e^-7 respectively). In patients with LNr( +), a significant difference in PFS was observed between patients with LNp(-) and LNp( +) (p = 0.0027). CC patients with FIGO 2018 stage IIIC who underwent NACT and followed hysterectomy had worse PFS compared to those with IB-IIB. LNp( +), non-SCC, poor differentiation and adjuvant radiation were independent risk factors for PFS. The adverse prognostic value of LNp( +) was more significant in patients with LNr( +).

Figure 1

Patient recruitment flowchart.

Figure 2

Baseline lymph node measurement and signal intensity evaluation after contrast administration. (a) sagittal contrast-enhanced T1WI shows clusters of lymph nodes in the obstrutor area (arrows), the cranial-caudal and antero-posterior diameter of the largest lymph node was measured as 25.8 and 13.3mm (upper arrow). Central necrosis was identified in it. (b) Axial contrast-enhanced T1WI shows the transverse diameter of the largest obstrutor lymph node is 9.36mm (arrow). This patient was identified as with positive radiological lymph node.

Figure 3

ROC curve of baseline radiological lymph node status for the prediction of pathological lymph node status after NACT. The AUC was 0.704 (95% CI 0.6635–0.774), with sensitivity of 79.4% and specificity of 61.4% respectively.

Figure 4

Kaplan–Meier survival analysis of progression-free survival (PFS) and overall survival (OS) according to baseline radiological and post-operative pathological lymph node status and 2018 FIGO stage. Patients with LNr ( +), LNp ( +) and 2018 FIGO IIIC showed worse PFS (a,c,e), whereas for OS the difference was only found in patients with different pathological lymph node status (b,d,f).

Figure 5

The 1,2 and 3-year time-dependent ROC curves of the multivariate model for PFS and OS. The AUCs were 0.900, 0.852, and 0.851 for PFS, and 0.706, 0.792, and 0.756 for OS, respectively.

Figure 6

Kaplan–Meier survival analysis of progression-free survival (PFS) and overall survival (OS) stratified by combined radiological and pathological lymph node status. Patients with concurrent LNr ( +) and LNp ( +) demonstrated the worst PFS, and patients with both LNr (−) and LNp (−) showed the best PFS (a). In patients with LNr ( +), the pairwise comparison indicated a significant difference in PFS between patients with LNp (−) and LNp ( +) (p = 0.0027). There were no statistical differences observed in the pairwise comparison between subgroups concerning OS (b).