Long-term follow-up of the first randomized trial using neoadjuvant chemotherapy in stage Ib squamous carcinoma of the cervix: the final results

Randomized trial of neoadjuvant cisplatin, vincristine, bleomycin, and radical hysterectomy versus radiation therapy for bulky stage IB and IIA cervical cancer

PURPOSE

To compare the efficacy of neoadjuvant chemotherapy (NAC) followed by radical hysterectomy with that of radiotherapy (R/T) for bulky early-stage cervical cancer.

PATIENTS AND METHODS

Women with previously untreated bulky (primary tumor >/= 4 cm) stage IB or IIA non-small-cell carcinoma of the uterine cervix were randomly assigned to receive either cisplatin 50 mg/m(2) and vincristine 1 mg/m(2) for 1 day and bleomycin 25 mg/m(2) for 3 days for three cycles followed by radical hysterectomy (NAC arm) or receive primary pelvic radiotherapy only (R/T arm). The ratio of patient allocation was 6:4 for the NAC and R/T arms. Women with enlarged para-aortic lymph nodes on image study were ineligible unless results of cytologic or histologic studies were negative.

RESULTS

Of the 124 eligible patients, 68 in the NAC arm and 52 in the R/T arm could be evaluated. The median duration of follow-up was 39 months. Thirty-one percent of patients in the NAC arm and 27% in the R/T arm had relapse or persistent diseases after treatment, and 21% in each group died of disease. Estimated cumulative survival rates at 2 years were 81% for the NAC arm and 84% for the R/T arm; the 5-year rates were 70% and 61%, respectively. There were no significant differences in disease-free survival and overall survival.

CONCLUSION

NAC followed by radical hysterectomy and primary R/T showed similar efficacy for bulky stage IB or IIA cervical cancer. Further study to identify patient subgroups better suited for either treatment modality and to evaluate the concurrent use of cisplatin and radiation without routine hysterectomy is necessary.

Predicting response to neoadjuvant chemotherapy in patients with cervical carcinoma: can we do without any longer?

The aim of the study was to identify variables that may predict the response to neoadjuvant chemotherapy (NACT) in patients with cervical cancer as maturing data from the literature indicate that this therapeutic strategy might be beneficial to some but harmful to others. Clinico-pathologic variables including age, histology, tumor differentiation, as well as immunohistochemical overexpression of p53, mdm2, c-erbB-2, and cathepsin D in 37 of these patients were evaluated as possible predictors of response to the NACT. Fifty-five patients with stage IIB cervical cancer submitted to two courses of cisplatin/ifosfamide/mesna prior to definitive treatment with radical surgery or radiation therapy were the subjects of this study. The clinical response rate was 80% but none of the variables was able to predict response to NACT. Unless methods are found enabling us to predict response and therefore to identify those patients that could benefit from including NACT in the treatment of locally advanced cervical cancer, only women with primarily resectable tumors should be selected for this multimodality approach as a result of the possibility of cross-resistance with radiation therapy in nonresponders.

Laparoscopic staging in locally advanced cervical carcinoma: A new possible philosophy?

OBJECTIVES

The aim of this study was to evaluate the feasibility and efficacy of designing the therapeutic management of each patient, morbidity, and mortality using laparoscopic staging in locally advanced cervical carcinoma and to establish the standard procedure for a "complete" staging.

METHODS

From July 10, 1995, to June 30, 1998, 98 pts were included. Clinical staging was performed according to FIGO's criteria (22 Ib2; 38 IIb; 25 IIIb; and 6 IV). The Quetelet index was calculated for each patient. Forty-nine pts were submitted to a previous CT scan. Surgical steps for a complete staging were: (1) peritoneal washings for cytology; (2) whole abdominal cavity exploration, with a biopsy of all suspicious lesions; (3) exploration of the vesicocervical and rectovaginal septums with a biopsy of suspicious areas; (4) bilateral pelvic lymphadenectomy and, when macroscopically positive, paraaortic lymphadenectomy.

RESULTS

Eighty-four of 91 pts were evaluable. The average duration for the procedure was 108 min, and blood loss was less than 200 cc. Hospitalization time ranged from 24 to 48 h. The average number of resected pelvic nodes was 18.5 (9-31). Positive nodes were found in 38 cases; 19 pts had unresectable positive nodes. Paraaortic dissection was performed in 26 cases and 11 cases were positive. When tumor was <5 cm, 8/32 (25%) lymphadenectomies were positive; when it was >5 cm, 30/52 (58%) were positive. Thirty-eight of 49 pelvic CT scans were reported to be normal (18/38 had positive nodes) and 11/49 suspicious (6/11 had positive nodes). Tumor invasion of the vesicocervical space or of the anterior parametrium was found in 23/84 patients. The rectovaginal septum was positive in 10 cases. Four of 84 patients (4.7%) presented with intraperitoneal spread. Only one trauma to the vena cava occurred at the time of the Verres needle insertion and two postoperative lymphoceles were observed. All patients began curative treatment within 3 to 7 days.

CONCLUSIONS

This method is feasible, complications are infrequent, and subsequent treatment is not delayed.

Laparoscopically assisted Schauta operation: learning experience at the Gynecologic Oncology Unit, Buenos Aires University Hospital

OBJECTIVES

The aim of this study was to show the learning experience of the employment of laparoscopic lymphadenectomy followed by a Schauta operation to treat patients with cervical carcinoma at a university hospital and to evaluate the feasibility, complications, hospital stay, delay in return to work, and overall survival of this procedure.

METHODS

Between June 1, 1993, and December 30, 1997, 56 patients were selected. Surgical treatment began with a pelvic laparoscopic lymphadenectomy followed by a Schauta operation. Patients were staged according to FIGO criteria (Ia2, 10 cases; Ib1, 33 patients; Ib2, 8 cases; IIa, 3 cases; and IIb, 2 patients). Patients had a follow-up of 47 months. Overall survival was calculated with Kaplan-Meier tables.

RESULTS

The procedure was not completed in 9 pts, in 5 cases among the first 20 pts that were entered on the trial due to technical problems and in 4 due to extracervical spread of disease (2 with gross laparoscopically unresectable lymph node metastases, 1 with parametrial infiltration, and 1 with rectovaginal septum involvement). In the 47 pts in which the procedure could be completed, the laparoscopic approach was done in 102 min and the vaginal part in 165 min. There were 4 complications: 1 ureteral injury, 1 abscess of the ischiorectal fossa, 1 hematoma of the Schuchardt incision, and 1 case of leg edema. The mean number of resected nodes was 17. Among the 47 cases in which the surgical procedure was completed, overall survival was 100% for Stage Ia, 88% for Ib1, and 85% for Ib2 after a mean follow-up of 4 years. Four pts have relapsed and died; 3 were stage Ib1 and the other was stage Ib2. They had pelvic recurrences.

CONCLUSIONS

This surgery is secure and has an excellent outcome, so it can be considered a valid approach for the treatment of patients with cervical carcinoma, but in our hands, 20 cases were needed to obtain the minimum skill needed to perform it.

Paclitaxel, ifosfamide and cisplatin (TIP) chemotherapy for recurrent or persistent squamous-cell cervical cancer

PURPOSE

The results of salvage chemotherapy for recurrent or persistent squamous-cell cervical cancer are unsatisfactory. Cisplatin and Ifosfamide are effective compounds in cervical cancer. Paclitaxel has recently been tested with promising results. The aim of this study was to assess the efficacy of a combination of paclitaxel, ifosfamide and cisplatin (TIP) for persistent/recurrent squamous-cell cervical carcinoma in a phase II trial.

PATIENTS AND METHODS

Forty-five women were treated with the TIP regimen. Thirty-one had received prior irradiation. Paclitaxel was given at a dose of 175 mg/m2, ifosfamide at a dose of 5 g/m2, and cisplatin at a dose of 75 mg/m2 (50 mg/m2 in irradiated patients) at three-week intervals.

RESULTS

We observed 15 clinical complete responses, 15 partial responses, 9 stable diseases and 6 progressions. The objective response rate was 67% (95% confidence interval: 51%-81%). Ten complete responders underwent subsequent surgery and seven had pathology-defined complete responses (two in irradiated areas). The response rate was 52% in irradiated and 75% in non-irradiated areas. The median survival for non-responders is 6 months, 9+ month for partial responders and 13+ for complete responders. The most relevant side effect was myelotoxicity, with 91% of patients experiencing grade 3-4. One woman had life-threatening toxic effects.

CONCLUSIONS

This combination is highly effective for salvage treatment in non-irradiated patients. For irradiated women the response rate is higher than that observed with other regimens but further investigation is warranted. The toxicity is relevant but adequate hydration and prolonged infusion of ifosfamide make it acceptable.

Transvaginal color Doppler for predicting pathological response to preoperative chemoradiation in locally advanced cervical carcinoma: a preliminary study

To evaluate the role of transvaginal color Doppler ultrasonography (TCD) in predicting pathological response to preoperative chemoradiation in patients with locally advanced cervical cancer, 10 patients (mean age: 45.2 y, range: 31 to 75 y) with histologically proven locally advanced cervical cancer who were scheduled for preoperative chemoradiation were evaluated by TCD prior to beginning the treatment protocol. Tumor volume, number of vessels within the tumor, lowest resistance index (RI), maximum peak systolic velocity (PSV), and the ratio between the number of vessels and tumor volume (tumor vascular density, TVD) were calculated. All patients underwent preoperative chemoradiation and radical surgery. Complete pathological response (pathCR) was considered when no residual tumor was found on surgical specimens. Partial pathological response (pathPR) was considered when residual tumor was found. PathCR was achieved in three patients (30%), whereas 7 (70%) had pathPR. Mean tumoral volume was not statistically different between those with pathCR (33.2 cm3) and those with pathPR (20.3 cm3) (p = 0.305). Those tumors with pathCR had lower mean number of vessels (3.3 vs. 5.3, p = 0.01), lower TVD (0.1 vs. 1.1, p = 0.05) and higher RI (0.41 vs. 0.29, p = 0.03). No differences were found in PSV. Although these data are preliminary, our results suggest that TCD may be used to predict pathological response to preoperative chemoradiation in patients with locally advanced cervical cancer.

Long-term follow-up of neoadjuvant cisplatin and 5-fluorouracil chemotherapy in bulky squamous cell carcinoma of the cervix

Fifteen patients with bulky (designated as > 3 cm largest diameter) FIGO stage Ib or IIa squamous cervical cancer were treated with cisplatin (100 mg/m2 on day 1) and 5-fluorouracil (1000 mg/m2 continuously on days 1-5) administered intravenously at 21-day intervals for a total of two or three courses before planned radical hysterectomy. A complete clinical response was noted in four patients and a partial response in ten patients, which represents a 93% overall response rate. One patient had stable disease (two courses of chemotherapy), and none had progressive disease. Median tumor volume was 78.5 cm3 and 2.5 cm3 at diagnosis and after neoadjuvant chemotherapy, respectively (p < 0.001). This indicates that chemotherapy resulted in a 97% median reduction of tumor volume. Median overall and disease-free survival was not reached, and the actuarial five-year survival rate was 73% and 67%, respectively. There was no grade 4 toxicity. Myelosuppression was acceptable; however, two patients experienced significant ototoxicity, and in two patients serum creatinine increased. All patients with major toxicity received two cycles of chemotherapy only. The improved local control and survival in our series are in accordance with other results reported, but need to be confirmed in a randomized prospective trial.

Modification of the Radiation Response of Patients With Carcinoma of the Uterine Cervix

BACKGROUND: The purpose of this review is to summarize clinical trials for patients with cervical cancer treated with irradiation and modifiers of the irradiation response. METHODS: The MEDLINE database was used to identify clinical studies that evaluated modifiers of the irradiation response for patients with carcinoma of the uterine cervix from 1970 through 1998. The studies included were prospective, randomized phase III clinical trials comparing irradiation alone to irradiation plus a chemical modifier for carcinoma of the uterine cervix. RESULTS: Various chemical agents have been combined with irradiation in the treatment of patients with carcinoma of the uterine cervix. These agents include hyperbaric oxygen, hydroxyurea, nitroimidazoles, neoadjuvant chemotherapy, and concurrent chemotherapy. CONCLUSIONS: Many prospective, randomized studies evaluating the use of chemical agents to modify the irradiation response in patients with carcinoma of the uterine cervix indicate no improvement over radiation therapy alone. However, the February 1999 NCI clinical announcement describes a survival advantage for cisplatin-based therapy and concurrent irradiation.

Adjuvant high-dose chemotherapy supported by peripheral blood stem cell transplantation for high-risk cervical carcinoma

Cervical carcinoma is a common disease for which the prognosis has not been substantially improved with standard locoregional treatments. Three stage IB patients with untreated cervical carcinoma were treated with high-dose chemotherapy and refrigerated peripheral blood stem cell support using the ICE program (Ifosfamide 10 g/m2 plus mesna at 100% of the ifosfamide dose; Carboplatin at 1.5 g/m2 and Etoposide 2.1 g/m2). Patients received the treatment in an adjuvant setting after radical hysterectomy with pelvic lymph-node dissection and postoperative cisplatin-based standard-dose chemotherapy. All patients underwent postoperative radiotherapy. The treatment was well-tolerated, all patients had rapid hematologic recovery, and the most frequent complications were grade 3 mucositis and neutropenic fever. The three patients are disease-free at 58, 60, and 63 months of follow-up. Our results show that adjuvant high-dose chemotherapy could be effective to reduce the likelihood of relapse in high-risk patients. High-dose chemotherapy deserves a formal evaluation in high-risk cervical cancer.

Interstitial brachytherapy in the treatment of advanced and recurrent vulvar cancer

OBJECTIVE

Our purpose was to evaluate the role of interstitial brachytherapy in vulvar cancer management.

STUDY DESIGN

From 1985-1992 we performed a retrospective study of patients treated at the University of California, Irvine Medical Center, and Long Beach Memorial Medical Center.

RESULTS

Eleven patients received interstitial brachytherapy, with (n = 5) or without (n = 6) external beam radiotherapy, for locally advanced (n = 5) or recurrent (n = 6) vulvar cancer. Local control was achieved in all patients. Ten patients have died of disease at a mean interval of 33 months from the time of treatment, with 9 patients having maintenance of local control at death. One patient is alive without disease after 77 months of follow-up. There were 2 cases of local necrosis (18%) and 1 case of rectovaginal fistula (9%).

CONCLUSION

Local control of advanced vulvar cancer can be achieved with interstitial brachytherapy, with or without external beam radiotherapy. With improved systemic therapy this treatment modality may be used to salvage women with bulky, symptomatic tumors.

Cisplatin, radiation, and amifostine in carcinoma of the uterine cervix

A pilot, open, comparative study was performed on patients with locally advanced cervical cancer to investigate the efficacy and safety of amifostine. Twenty patients with a histologic diagnosis of squamous cervical cancer were treated with radiotherapy and randomized in two groups. Group A received cisplatin at 20 mg/m2 for five days in two cycles during intracavitary radiotherapy and 100 mg/m2 x 2 cycles during external radiotherapy, and amifostine 825 mg/m2 15 min before the cisplatin infusion. Patients in group B received cisplatin in the same doses without amifostine. All patients had complete responses during a median follow-up of 20 months. Grade three neutropenia was present in two patients in group A and in four of the control group, P = 0.31; grade 2 neurologic toxicity was seen in four patients in group B and in one of the patients in group A, P = 0.15. One patient needed temporary interruption of amifostine due to hypotension. Eight of 10 patients in group A developed hypocalcemia during the treatment with amifostine. Our findings indicate that amifostine was well tolerated. In this series a mild neurologic and hematologic protection was found in patients that received amifostine, although this was not statistically significant. No differences in disease-free survival response and overall survival was seen between the two groups.

Preoperative prognostic variables and the impact of postoperative adjuvant therapy on the outcomes of Stage IB or II cervical carcinoma patients with or without pelvic lymph node metastases: an analysis of 891 cases

BACKGROUND

The purpose of this study was to investigate pretreatment variables that could predict prognosis and to evaluate the impact of postoperative adjuvant therapy on the outcomes of patients with Stage IB or II cervical carcinoma with or without pelvic lymph node metastases.

METHODS

Eight hundred ninety-one patients with Stage IB or II cervical carcinoma who underwent radical hysterectomy and bilateral pelvic lymphadenectomy as primary treatment at a single institution were analyzed. Potential prognostic variables were studied.

RESULTS

Among the variables that could be assessed before treatment, depth of cervical stromal invasion (determined by magnetic resonance imaging), clinical stage, tumor size, grade of differentiation, and DNA index (determined by flow cytometry) were independent predictors of outcome in multivariate analysis using a Cox regression model. Three distinct prognostic groups (low, intermediate, and high risk) were defined using these variables. Five-year recurrence free survival (RFS) rates for the low, intermediate, and high risk groups were 94.6%, 82.7%, and 62.3%, respectively (P = 0.0001), and overall survival (OS) rates were 98.4%, 84.5%, and 68.7%, respectively (P = 0.0001). Among patients with pelvic lymph node metastases who were free of parametrial extension, those who received postoperative chemotherapy or chemoradiotherapy had significantly better RFS (P = 0.017) and OS (P = 0.043) than those who received no adjuvant therapy. Among patients without pelvic lymph node metastases but at high risk of recurrence, those who received adjuvant radiotherapy had significantly better RFS (P = 0.015) and marginally improved OS (P = 0.087) compared with those who received no adjuvant therapy.

CONCLUSIONS

A model containing assessable pretreatment variables for predicting the prognoses of patients with early stage cervical carcinoma was formulated. Subsets of patients for whom postoperative chemotherapy or radiotherapy might be beneficial were identified. The data from this retrospective review may be useful when future prospective trials of the treatment of early stage cervical carcinoma are designed.

Can the published data tell us about the effectiveness of neoadjuvant chemotherapy for locally advanced cancer of the uterine cervix?

The effect of neoadjuvant chemotherapy on survival of patients with locally advanced cervical cancer was investigated by conducting a systematic review and meta-analysis of the published data. Of the 21 randomised trials that we identified, only 15 were published. Furthermore, 2-year survival data could be extracted from only seven trial reports and 3-year survival from only nine trial reports. Meta-analyses of the published data at 2 and 3 years are neither clearly in favour of neoadjuvant chemotherapy nor control (2 years: odds ratio (OR) = 1.09, 95% confidence interval (CI) = 0.83-1.45, P = 0.37; 3 years: OR = 0.96, 95% confidence interval (CI) = 0.73-1.25, P = 0.45). Being restricted to only some of the data from a relatively small fraction of the randomised trials, these analyses potentially suffer from a number of biases and are therefore inconclusive. The only reliable way to judge the value of neoadjuvant chemotherapy in this disease is to perform a meta-analysis of centrally collected, updated, individual data on all patients from all known randomised trials. Such an analysis is currently being carried out by an international collaborative group.

Current developments in the treatment of newly diagnosed cervical cancer

The International Federation of Gynecology and Obstetrics (FIGO) staging of cervical cancer relies on physical examination. However, surgical staging, which helps determine the extent of invasion of lymph nodes by cancer, is currently used more widely to define the need for additional therapies. Examples of these additional treatments include high-dose-rate brachytherapy techniques, extension of radiotherapy fields, surgery, concurrent chemotherapy and radiotherapy, and neoadjuvant chemotherapy prior to surgery. Currently there are many ongoing randomized studies that strive to define the risk-to-benefit ratio of these additional therapies.

Neoadjuvant chemotherapy with cisplatin, ifosfamide and paclitaxel for locally advanced squamous-cell cervical cancer

BACKGROUND

Neoadjuvant chemotherapy is increasingly being used for the treatment of bulky and locally-advanced cervical cancer. Cisplatin and ifosfamide are known to be effective in cervical cancer, while paclitaxel is one of the promising new drugs for the treatment of this neoplasm.

OBJECTIVE

To assess the toxic effects and antitumor activity of a multidrug neoadjuvant regimen consisting of cisplatin, ifosfamide, and paclitaxel in bulky and locally advanced cervical cancer.

PATIENTS AND METHODS

Thirty-eight patients with pathology-confirmed squamous-cell cervical cancer (27 IB2-IIA, two IIB, eight IIIB, one IVA) were prospectively enrolled in the study. Their treatment consisted of paclitaxel 175 mg/m2 given over three hours on day 1, cisplatin 50 mg/m2 (75 mg/m2 in 10 patients), ifosfamide 5 g/m2 in a 24-hour continuous infusion and mesna 5 g/m2 in a 24-hour continuous infusion on day 2, and mesna 3 g/m2 in a 24-hour continuous infusion on day 3. The course was repeated every three weeks for three courses and all of the patients, except those with disease progression or who were inoperable, were scheduled for radical hysterectomy and pelvic lymphadenectomy.

RESULTS

All patients are evaluable for response. Eleven achieved clinical complete responses, 21 had partial responses, five had stable disease and one had progression of disease. Of 34 patients who underwent surgery, six (16%) had pathology-documented complete responses, seven (18%) had partial responses with only microscopic residual disease in the cervix, 19 had sub-optimal partial responses, and two had stable disease, for an overall response rate of 84% (95% confidence intervals (CI): 68.7%-94%). Grade 3-4 neutropenia was recorded for 27 (71%) patients, grade 3-4 thrombocytopenia for four (10.5%), and grade 2 peripheral neuropathy for two (2.5%). At a median follow-up of 16 months (range 7-22), 29 (76%) women are alive without recurrence, seven are alive with persistent/recurrent disease and two have died of their disease.

CONCLUSIONS

According to pathology examination, this regimen yields a 34% complete and optimal partial response rate with acceptable toxicity, and it should be prospectively compared to other regimens.

Cancer of the uterine cervix

The overall five-year survival of cervical cancer is only 40% worldwide despite the development of effective screening modalities. Paramount to this issue is access to appropriate medical care which remains limited to high-risk populations throughout the world. While surgery and radiation remain the mainstays of current treatment, new therapies based on the association of cervical cancer with the human papillomavirus are currently under investigation.