This study aimed to assess the specific outcomes of patients locally advanced node-positive cervical cancer according to the International Federation of Gynaecology and Obstetrics receiving concurrent chemoradiotherapy and image-guided adaptive brachytherapy before adjuvant immunotherapy.

A cohort of 388 women with non-metastatic advanced cervical cancer and lymph node involvement treated at a single tertiary centre (2016–2021) was analysed. All patients underwent chemoradiotherapy followed by brachytherapy. Disease-free survival and overall survival were compared between patients with only pelvic node involvement ( n = 175) and those with at least para-aortic node involvement ( n = 213), as well as across node staging methods. Notably, some patients also had bladder or rectal involvement.

With a median follow-up of 54.8 months, 152 progressions or recurrences were reported, including metastatic event in 99 cases (65.1 % of first events). Additionally, 22 deaths occurred without previous progression/relapse. This resulted in a 5-year disease-free survival rate of 50.8 % (95 % confidence interval [CI]: 45.2–56.2 %) for the entire cohort, significantly differing between the pelvic (58.5 %; 95 % CI: 50.1–65.9 %) and para-aortic (44.2 %; 95 % CI: 36.7–51.4 %) groups ( p = 0.007). The 5-year overall survival rate was 61.0 % (95 % CI: 55.7–65.8 %) in the entire cohort and was poorer in patients with para-aortic involvement (52.5 %; 95 % CI: 45.1–59.3 %; p = 0.002). A larger high-risk clinical target volume at least 43.5 cm ³ ( p = 0.0001), para-aortic node involvement ( p = 0.01), and a total treatment duration of more than 55 days ( p = 0.01) were associated with a higher recurrence risk.

Chemoradiotherapy followed by brachytherapy is effective and feasible for patients with node-positive cervical cancer. However, two-thirds of progressions or recurrences involved a distant event, suggesting the need to evaluate incremental systemic treatment strategies.