Patterns of spread in node-positive cervical cancer: the relationship between local control and distant metastases

The presence of metastatic pelvic nodes in stage I and II cervical cancer predicts for pelvic and distant recurrence. Whether this malignancy is a systemic disease at onset or locoregionally advanced disease is unclear. To examine this issue, we reviewed cases of node-positive stage I and II cervical cancer to analyze the patterns of spread and the relationship between local control and distant metastasis.

Between 1964 and 1993, 163 patients with FIGO stage I-II cervical cancer underwent exploratory laparotomy and bilateral pelvic lymph node dissection and were found to have metastatic pelvic nodes. Patients with positive para-aortic nodes were excluded. Of these patients, 108 underwent radical hysterectomy and postoperative pelvic irradiation, 35 underwent radical hysterectomy without postoperative pelvic irradiation, and 20 did not undergo radical hysterectomy and were treated with definitive radiation therapy.

The overall 5- and 10-year actuarial disease-free survival rates for the entire group were 55% and 49%, respectively. The 5- and 10-year actuarial pelvic failure rates were 30.5% and 37%, respectively. The actuarial distant metastatic rates at 5 and 10 years were 30% and 34%, respectively. Patients who were controlled in the pelvis (114) had significantly lower rates of developing distant metastases at 5 and 10 years (21% and 22%, respectively) compared with patients who failed in the pelvis (49) with rates of 59% and 84%, respectively. Multivariate analysis found that pelvic failure had the strongest association with the development of distant metastases. Using the formula of Suit et al to assess potential improvement in cure from perfect local and distant control, survival advantages from increased local and distant control were 24% and 21%, respectively. Of those patients who failed both locally and distantly (22), 27% failed distantly 6 months or more after failing locally.

Early-stage node-positive cervical cancer is associated with both increased distant and local failure. There appear to be two patterns of disease spread: patients whose disease is locoregional, in whom improvements in local control can result in improved cure, and patients with biologically aggressive cancer, who probably have disseminated disease at presentation, in whom improved locoregional control will not be enough to increase survival but who require improved distant control.