Patients
This study includes 49 patients with biopsy proven cervical cancer between June 2006 and October 2012 was treated in department of Radiotherapy Center and Gynecology of the Affiliated Hospital of Qingdao University. The Institutional Review Board approved this study and informed consent was obtained. Inclusion criteria: a) Eastern Cooperative Oncology Group (ECOG) status was less than or equal to 1; b) International Federation of Gynecology and Obstetrics (FIGO) stages ⅡB–Ⅲ cervical cancer through gynecological examination by two veteran gynecologic oncologists; c) All patients underwent a medical history, gynecological examination; punch biopsy, chest X-ray, pelvic magnetic resonance imaging (MRI) and transvaginal ultrasound (TVS). Exclusion criteria: a) Patients with serious heart, lung, liver or hematologic system disease; b) Patients with other cancer; c) Treatment was interrupted or radiotherapy did not reach the radical dose; d) Lost to follow-up or death from other causes.
CCRT
All patients completed the radical radiotherapy in department of Radiotherapy Center. Patients were immobilized with a body net in the supine position and underwent a computed tomography (CT) simulation scan (General Electric, Milwaukee WI, USA) with intravenous contrast, using 5 mm slice thickness. Simulation images extended from L1 to 5 cm below the ischial tuberosities. The gross tumor volume (GTV), clinical target volume (CTV) and planning target volume (PTV) were defined according to Radiation Therapy Oncology Group (RTOG) guidelines. The CTV-high risk included the GTV, parametrium, the upper part of the vagina to 3 cm below the tumor invasion, and metastasis lymph node. The CTV-low risk included the CTV-high risk and regional lymph nodes (common, external, internal iliac lymph nodes, obturator and presacral lymph nodes). The treatment planning was designed and computed using the Plato system version 2.7.5 (Varian, USA). The external radiation dose was 40-50 Gy in 20-25 fractions with 2 Gy per fraction using a linear accelerator (Trilogy, Varian, USA). And followed by high-dose-rate brachytherapy to 90% of the high-risk CTV was delivered with 30-40 Gy using an intracavity applicator (microSelectron-HDR Ir-192 set; Nucletron, Veenendaal, Netherlands). All patients received concomitant chemotherapy of cis-platinum (40mg/m2) alone every week starting with external radiotherapy (4-5 circles).
Adjacent surgery
After reevaluated the relationship between cervix, bladder, rectum and parauterine tissue through gynecological examination and pelvic MRI, all patients underwent extrafascial hysterectomy with adnexectomy followed by CCRT. According to postoperative pathology, nine patients with invading ½ of the cervical stroma recived 4 circles chemotherapy consisted of the association of cis-platinum (100mg/ m2) in combination with paclitaxel (135mg/ m2).
Follow-up
Patient follow-up was designed to be conducted every 3 months during the first two years and every 6 months over the next three years after surgery. The follow-up included gynecological examination, TVS, vaginal apical cytology, abdominal plevic and chest CT.
Statistical analysis
All data were performed using SPSS 20.0 (Chicago IL, USA). Quantitative data are expressed as the mean ± standard deviation (S.D.). 2 test or Fisher exact test was used to evaluate categorical variable. Groups were compared using Student’s t-test. . Multivariate analysis of prognostic factors was performed with Cox proportional hazards regression. A p < 0.05 was regarded as statistically significant.