Neoadjuvant chemotherapy plus radical surgery followed by chemotherapy in locally advanced cervical cancer

Efficacy and tolerability of paclitaxel, ifosfamide, and cisplatin as a neoadjuvant chemotherapy in locally advanced cervical carcinoma

OBJECTIVE

To evaluate the efficacy and tolerability of a neoadjuvant paclitaxel, ifosfamide, and cisplatin chemotherapy in patients with locally advanced cervical carcinoma.

METHODS

Patients with histologically confirmed locally advanced cervical carcinoma, aged ≥18 years, were treated with intravenous ifosfamide 5,000 mg/m² and mesna 5,000 mg/m², on day 1; intravenous paclitaxel 175 mg/m² and cisplatin 75 mg/m², on day 2; every 3 weeks for three cycles. Following chemotherapy, operable patients underwent radical hysterectomy and pelvic lymphadenectomy, and, if necessary, adjuvant radiotherapy.

RESULTS

One hundred fifty-two patients with median age 53 years (range, 24 to 79 years), FIGO stage IIB in 126 (89%), were treated with chemotherapy for median 3 cycles (range, 1 to 3). Treatment was delayed or withdrawn in 23 patients (15%). One hundred thirty-nine patients (91%) underwent surgery. Postchemotherapy pathological complete response rate was 18% (25 patients). Postoperative radiotherapy was administered in 100 patients (72%). The 5-year overall survival and progression-free survival were 87.3% (95% confidence interval [CI], 84.5 to 90.3) and 76.4% (95% CI, 73.5 to 79.5), respectively.

CONCLUSION

Neoadjuvant paclitaxel, ifosfamide, and cisplatin chemotherapy was feasible and effective in the treatment of locally advanced cervical carcinoma patients with older age and more advanced disease stage than reported in previous studies. Hematological and renal toxicity could be carefully prevented.

Simultaneous changes of magnetic resonance diffusion-weighted imaging and pathological microstructure in locally advanced cervical cancer caused by neoadjuvant chemotherapy

PURPOSE

To investigate the changes to diffusion-weighted imaging (DWI) correlated with histopathology after neoadjuvant chemotherapy (NACT) in patients with locally advanced cervical cancer (LACC).

MATERIALS AND METHODS

Thirty-three patients with LACC were examined with 3T magnetic resonance imaging (MRI) with DWI and apparent diffusion coefficient (ADC) maps. MRIs were performed for each patient at three timepoints: before the first NACT, 2 weeks after the first NACT, and 2 weeks after the second NACT. Uterine cervical specimens were collected at the same timepoints. Specimens were stained for tumor cell density, proliferating cell nuclear antigen (PCNA), and aquaporin 1 (AQP1). Treatment responses were classified as the effective group (complete and partial response) and the ineffective group (stable and progressive disease).

RESULTS

The ADC value of the effective group after the first chemotherapy was higher than that before chemotherapy (P = 0.002), and expressions of three pathological indicators (tumor cell density, PCNA, and AQP1) significantly decreased after the first NACT compared with those prechemotherapy (P < 0.001). Changes of PCNA expression were negatively correlated with changes of ADC values after the first NACT in the effective group (r = -0.56, P = 0.03). Changes of cellular density were negatively correlated with changes of ADC values from the time of prechemotherapy to after the second NACT in the effective group (r = -0.51, P = 0.04).

CONCLUSION

The ADC change after successful chemotherapy is closely related with cellular characteristics preceding size reduction. ADC may be used as an early imaging biomarker of NACT response in LACC.

Feasibility and safety of carboplatin plus paclitaxel as neoadjuvant chemotherapy for locally advanced cervical cancer: a pilot study

The aim of this study is to evaluate the efficacy and safety of the combination of carboplatin and paclitaxel as neoadjuvant chemotherapy (NACT) in patients affected by locally advanced cervical cancer. Between June 2007 and May 2012, all patients with a diagnosis of locally advanced cervical cancer (IB2–IIB) were eligible for this protocol. All patients have received 3 cycles of carboplatin (AUC6) and paclitaxel 175 mg/mq in neoadjuvant setting. The NACT-induced toxicity and the response to treatment were evaluated according to the World Health Organization (WHO) criteria. After NACT, all patients with complete or partial response were submitted to classical radical hysterectomy type III or C2, according to different classifications, and were submitted to four adjuvant cycles of platinum-based chemotherapy. The primary endpoints of the study were to evaluate the efficacy and feasibility of carboplatin regimen. Thirty-five patients with locally advanced cervical cancer were considered. A total of 23 patients completed 3 cycles of NACT. The overall clinical response rate after NACT was 78.3% including 43.5% (n = 10) with complete response, 34.8% (n = 8) with partial response, 17.4% (n = 4) with stable disease and 4.3% (n = 1) of those who suffered disease progression. The most common toxicity was haematologic, nausea/vomiting and neuropathy with grades 1 and 2 and occurred in 56.5, 56.5 and 17.4%, respectively. No renal toxicity was registered. Our results suggest that carboplatin is a well-tolerated drug with a response rate similar to standard cisplatin. Then, it represents, in neoadjuvant setting, a valid alternative in patients affected by locally advanced cervical cancer.

Different strategies of treatment for uterine cervical carcinoma stage IB2-IIB

Uterine cervical cancer is the second most common gynecological malignancy. It is estimated that over 35% of tumors are diagnosed at locally advanced disease, stage IB2-IIB with an estimated 5-year overall survival of 60%. During the last decades, the initial treatment for these women has been debated and largely varies through different countries. Thus, radical concurrent chemoradiation is the standard of care in United Sated and Canada, and neoadjuvant chemotherapy followed by radical surgery is the first line of treatment in some institutions of Europe, Asia and Latin America. Until today, there is no evidence of which strategy is better over the other. This article describe the evidence as well as the advantages and disadvantages of the main strategies of treatment for women affected by uterine cervical cancer stage IB2-IIB.

Assessment of the early predictive power of quantitative magnetic resonance imaging parameters during neoadjuvant chemotherapy for uterine cervical cancer

OBJECTIVES

The purpose of this study was to quantitatively evaluate 3 types of magnetic resonance imaging (MRI) parameters in parallel for the early prediction of neoadjuvant chemotherapy (NACT) effectiveness in cervical cancer-tumor volume parameters, diffusion parameters, and perfusion parameters.

MATERIALS AND METHODS

We prospectively evaluated 13 patients with International Federation of Gynecology and Obstetrics stage IB to IIB cervical squamous cell carcinoma who underwent 3 serial MRI studies, that is, pretreatment, post-first course NACT, and post-second course NACT followed by radical hysterectomy. We obtained tumor volume parameters, diffusion parameters, and dynamic contrast material-enhanced perfusion parameters quantitatively from pretreatment MRI and post-first course MRI. The correlation of these parameters and the eventual tumor volume regression rate (TVRR) obtained from pretreatment MRI and post-second course MRI before surgery were investigated, statistically based on the Pearson correlation coefficient.

RESULTS

Thirteen patients had a total of 39 scans. Early TVRR (r = 0.844; P < 0.001), the fractional volume of the tissue extracellular extravascular space (Ve, r = 0.648; P < 0.05), and the change of Ve during the first course of NACT (r = -0.638; P < 0.05) correlated with eventual TVRR.

CONCLUSIONS

Early TVRR, Ve, and the change of Ve could be useful predictors for the treatment effectiveness of NACT. These parameters could help to modify strategy in the early stage of NACT and to choose individualized treatment to avoid the delay of radical treatment, even when NACT is ineffective.

Detection of cell apoptosis in pelvic lymph nodes of patients with cervical cancer after neoadjuvant chemotherapy

OBJECTIVE

To investigate if the administration of neoadjuvant chemotherapy (NACT) reduces pelvic lymph node metastasis by inducing tumour cell apoptosis in patients with cervical cancer.

METHODS

This study enrolled patients with stage Ib2-IIb cervical cancer who underwent surgery with (NACT group) or without (control group) prior cisplatin-based chemotherapy. Immunohistochemical staining of caspase-3 and an in situ terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labelling assay were used to measure the levels of apoptosis in primary tumours and pelvic lymph nodes.

RESULTS

A total of 185 patients participated in the study: 102 in the NACT group and 83 in the control group. Treatment was considered to be clinically effective in 69.6% (71/102) of the NACT group. The rate of metastasis in the NACT group (20.6%; 21/102) was significantly lower than the control group (42.2%; 35/83). The level of caspase-3 immunostaining and the rate of apoptosis in primary tumours and pelvic lymph nodes in the NACT group were significantly higher than in the control group.

CONCLUSIONS

NACT appeared to limit pelvic node metastasis by inducing tumour cell apoptosis in patients with cervical cancer.

Adjuvant chemotherapy after primary treatments for cervical cancer: a critical point of view and review of the literature

Cervical cancer is the second most frequent female malignancy worldwide. Concurrent chemoradiotherapy represents the standard of care for patients with advanced stage cervical cancer, while radical surgery (RS) and radiotherapy is widely used for treating early stage cervical cancer. However, the poor control of micrometastasis, declining operability, the lack of radiotherapy departments and the high incidence of long-term complications due to radiotherapy have brought about the development of different therapeutic approaches such as neoadjuvant chemotherapy followed by RS. Unfortunately, treatment results are still unsatisfactory due to a high recurrence rate and several authors have studied the possibility to add an adjuvant treatment to primary therapy. We reviewed the literature concerning the role of adjuvant chemotherapy in advanced cervical cancer after neoadjuvant chemotherapy followed by RS and after chemoradiotherapy.

Platinum-based neoadjuvant chemotherapy followed by radical surgery for cervical carcinoma international federation of gynecology and obstetrics stage IB2-IIB

OBJECTIVE

The objective of this study was to determine the response rate to chemotherapy, as well as the progression-free survival (PFS), the overall survival (OS), and the main prognostic factors in patients treated at the European Institute of Oncology in Milan, Italy.

METHODS

Retrospective data were collected on patients with uterine cervical carcinoma, International Federation of Gynecology and Obstetrics (FIGO) stage IB2 to IIB, who underwent platinum-based neoadjuvant chemotherapy (NACT) followed by radical hysterectomy.

RESULTS

A total of 121 patients were studied. The median (range) age was 45 years old (23-69 years). The distribution of patients by International Federation of Gynecology and Obstetrics stage was as follows: n = 88 (73%) with stage IB2, n = 7 (6%) with stage IIA, and n = 26 (21%) with stage IIB. The median (range) tumor size was 50 mm (20-90 mm). Neoadjuvant chemotherapy involved a combination of cisplatin, paclitaxel, and ifosfamide in 80 patients (65%). Using this treatment, 112 patients (93%) received 3 cycles of NACT, whereas 6 (5%) received 4 cycles. Complete and partial pathology response was observed in 9 patients (7%) and 79 patients (66%), respectively. Adjuvant radiotherapy was not necessary in 65% of patients. A 5-year PFS and OS of 58% and 71%, respectively, were observed. Independent prognostic factors for PFS and OS were identified, including response to NACT, persistent lymph node metastases, and parametrial involvement.

CONCLUSIONS

Neoadjuvant chemotherapy in this group of tumors is a promising treatment strategy and should be discussed with patients. Although these results are comparable to those obtained by standard chemoradiation treatment, one strategy should not be recommended over the other until the results of the ongoing phase 3 trial for NACT are released.

Interobserver variability of the International Federation of Gynecology and Obstetrics staging in cervical cancer

OBJECTIVE

The objective of this study was to assess the interobserver variability of pelvic examination under anesthesia (EUA) in cervical cancer.

METHODS

Subsequent patients undergoing a staging procedure under anesthesia for primary cervical cancer were enrolled in the study. All clinicians assessed "blinded" tumor size, and the involvement of vagina, parametria, sacrouterine ligaments, pelvic sidewalls, bladder, and/or rectum. Items were scored varying from 1 ("certainly no involvement"), 2 ("not sure about involvement"), to 3 ("involvement"). Each individual decided on the International Federation of Gynecology and Obstetrics (FIGO) stage; also, the urge for imaging and treatment proposal were accounted for. Final FIGO staging was obtained by consensus of the team. Investigators were classified as experienced after more than 50 EUAs. All others were classified less experienced. The free-marginal κ values between experienced and less experienced investigators were calculated for all previously mentioned items.

RESULTS

Between February 2009 and December 2010, a total of 86 patients were enrolled. Among experienced investigators, a moderate interobserver agreement was found with regard to FIGO stage (free-marginal κ value of 0.49) and an excellent interobserver agreement on their proposed therapy (free-marginal κ value of 0.84). A lower level of agreement was found when comparing experienced with less experienced investigators: only a slight level of agreement on FIGO stage and a substantial agreement on their therapy proposal (free-marginal κ values of 0.03 and 0.66).

CONCLUSIONS

We describe only a moderate interobserver agreement on clinical staging of patients with cervical cancer. The interobserver agreement increases in the group of experienced doctors, indicating that EUA can be learned.