Prognostic value of Node-RADS scoring in stage IIICr cervical cancer: development and validation of novel nomograms

OBJECTIVES: This study aimed to establish and validate nomograms integrating the Node-Reporting and Data System (Node-RADS) score and clinical variables to predict overall survival (OS) and progression-free survival (PFS) in patients with International Federation of Obstetrics and Gynecology (FIGO) 2018 stage IIICr cervical cancer receiving definitive chemoradiotherapy. MATERIALS AND METHODS: A retrospective two-center cohort study was conducted, enrolling eligible patients treated between March 2011 and December 2022. Nomograms were established based on least absolute shrinkage and selection operator (LASSO) regression, and Cox regression was used to identify prognostic features. The performance of the nomograms was assessed using receiver operating characteristic curves (ROC), calibration curves, and decision curve analysis (DCA). RESULTS: A total of 307 eligible patients were analyzed. For OS, independent prognostic factors included para-aortic lymph node (PALN) metastasis, non-squamous histology, Node-RADS score, and lymph node (LN) boost irradiation ≥ 60 Gy EQD2 (Equivalent dose in 2Gy fractions); for PFS, these were T stage, non-squamous histology, and LN boost irradiation ≥ 60 Gy EQD2. Nomograms outperformed FIGO 2009/2018 staging in discrimination and clinical utility, with calibration curves showing good agreement between predicted and observed outcomes. Kaplan-Meier analysis linked higher Node-RADS scores, PALN metastasis, > 3 positive LNs, and LN boost irradiation < 60 Gy EQD2 to poorer OS and PFS. CONCLUSION: A nomogram incorporating the Node-RADS score, which is significantly associated with survival, can serve as a potential prognostic marker to assist clinicians in making informed decisions and developing individualized treatment strategies. Notably, the inherent treatment-selection bias in the retrospective design limits its direct therapeutic implications. CRITICAL RELEVANCE STATEMENT: Node-RADS-based nomograms offer superior risk stratification and prognosis prediction for stage IIICr cervical cancer patients. KEY POINTS: The nomogram incorporating the Node-Reporting and Data System (Node-RADS) score can serve as a potential prognostic marker to assist clinicians. The nomogram incorporating the Node-RADS score, which integrated clinicopathological data and therapies, outperformed Federation of Obstetrics and Gynecology (FIGO) staging in discriminative ability and clinical utility. Higher Node-RADS scores correlated with worse survival outcomes of patients, and lymph node (LN) boost irradiation ≥ 60 Gy EQD2 might provide survival benefits.