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Rowinski E, Magné N, Fayette J, Daguenet E, Racadot S, Pommier P, Méry B, Vallard A, Tinquaut F, Neidhardt-Berard EM, Cassier P, Attignon V, Pissaloux D, Wang Q, Sohier E, Pérol D, Blay JY, Trédan O. Radioresistance and genomic alterations in head and neck squamous cell cancer: Sub-analysis of the ProfiLER protocol. Head Neck 2021; 43:3899-3910. [PMID: 34643313 DOI: 10.1002/hed.26891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 08/25/2021] [Accepted: 09/21/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Genome analysis could provide tools to assess predictive molecular biomarkers of radioresistance. METHODS Head and neck squamous cell carcinoma patients included in ProfiLER study and who underwent a curative radiotherapy were screened. Univariate and Cox multivariate analyses were performed to explore the relationships between molecular abnormalities, infield relapse and complete tumor response after radiation. RESULTS One hundred and forty-three patients were analyzed. PIK3CA mutation and genomic instability of MAP kinases pathway were found to be prognostic factors of loco-regional relapse in multivariate analysis with respectively HR 0.33, 95% CI 0.13-0.83, p = 0.005 and HR 0.61, 95% CI 0.38-0.96, p = 0.025. Instability of apoptosis pathway was found to be a prognostic factor of complete response after radiotherapy with HR 0.24, 95% CI 0.07-0.88, p = 0.04. CONCLUSION This sub analysis suggests that PIK3CA mutation, variation of copy number of MAP kinases and apoptosis pathways play a significant role in the radioresistance phenomenon.
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Affiliation(s)
- Elise Rowinski
- Department of Medical Oncology, Lucien Neuwirth Cancer Institute, Saint-Priest-en-Jarez, France
| | - Nicolas Magné
- Department of Radiation Oncology, Lucien Neuwirth Cancer Institute, Saint-Priest-en-Jarez, France.,Laboratory of Molecular and Cellular Radiobiology, CNRS UMR 5822, Institut de Physique Nucléaire de Lyon (IPNL), Lyon, France
| | - Jérôme Fayette
- Department of Medical Oncology, Léon Bérard Cancer Centre, Lyon, France
| | - Elisabeth Daguenet
- University Department of Research and Teaching, Lucien Neuwirth Cancer Institute, Saint-Priest-en-Jarez, France
| | - Séverine Racadot
- Department of Radiation Oncology, Léon Bérard Cancer Centre, Lyon, France
| | - Pascal Pommier
- Department of Radiation Oncology, Léon Bérard Cancer Centre, Lyon, France
| | - Benoîte Méry
- Department of Medical Oncology, Lucien Neuwirth Cancer Institute, Saint-Priest-en-Jarez, France
| | - Alexis Vallard
- Department of Radiation Oncology, Lucien Neuwirth Cancer Institute, Saint-Priest-en-Jarez, France
| | - Fabien Tinquaut
- University Department of Research and Teaching, Lucien Neuwirth Cancer Institute, Saint-Priest-en-Jarez, France
| | | | - Philippe Cassier
- Department of Medical Oncology, Léon Bérard Cancer Centre, Lyon, France.,Department of Translational Research and Innovation, Léon Bérard Cancer Centre, Lyon, France
| | - Valéry Attignon
- Department of Translational Research and Innovation, Léon Bérard Cancer Centre, Lyon, France
| | - Daniel Pissaloux
- Department of Translational Research and Innovation, Léon Bérard Cancer Centre, Lyon, France
| | - Qing Wang
- Department of Translational Research and Innovation, Léon Bérard Cancer Centre, Lyon, France
| | - Emilie Sohier
- Department of Translational Research and Innovation, Léon Bérard Cancer Centre, Lyon, France
| | - David Pérol
- Department of Clinical Research and Innovation, Léon Bérard Cancer Centre, Lyon, France
| | - Jean-Yves Blay
- Department of Medical Oncology, Léon Bérard Cancer Centre, Lyon, France.,Department of Translational Research and Innovation, Léon Bérard Cancer Centre, Lyon, France
| | - Olivier Trédan
- Department of Medical Oncology, Léon Bérard Cancer Centre, Lyon, France.,Department of Translational Research and Innovation, Léon Bérard Cancer Centre, Lyon, France
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Patients treated with neoadjuvant chemotherapy + radical surgery + adjuvant chemotherapy in locally advanced cervical cancer: long-term outcomes, survival and prognostic factors in a single-center 10-year follow-up. Med Oncol 2016; 33:110. [PMID: 27577931 DOI: 10.1007/s12032-016-0830-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 08/25/2016] [Indexed: 10/21/2022]
Abstract
We report the long-term follow-up in patients with locally advanced cervical cancer treated with neoadjuvant chemotherapy (NACT) + radical surgery (RS) + adjuvant chemotherapy (ACT) analyzing prognostic factors which may more influence, in a long time, the survival outcome using univariate and multivariate analysis. In this study, we included all patients with diagnosis of locally advanced cervical cancer (IB2-IIB) treated with NACT + RS + ACT from June 2000 and February 2007 as previously described by Angioli et al. (Gynecol Oncol 127(2):290-6, 2012). The primary end-point of the study was overall survival (OS) in patients with node metastases and in those without positive lymph nodes at the end of 10-year follow-up in order to confirm the prognostic role of nodes involvement for a long period. Moreover, we analyzed the impact of other prognostic factors, such as histotype, tumor size, grading and parametrial invasion. Secondary end-point was evaluated in the subgroup of patients with positive nodes the following prognostic factors: number of positive lymph nodes and site of positive lymph nodes. In the subgroup of patients with positive nodes, the OS was 63 %, and in that with negative nodes, the OS was 75 %. On multivariate analysis, the number of nodal metastases, parametrial involvement, grading and the lesion diameter were noted to be significant factors in determining OS. Neither the histotype nor the lymph nodal site is related to survival. Results suggest that CT alone may be an alternative postoperative therapy for patients with cervical cancer.
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Kido A, Fujimoto K, Okada T, Togashi K. Advanced MRI in malignant neoplasms of the uterus. J Magn Reson Imaging 2013; 37:249-64. [PMID: 23355429 DOI: 10.1002/jmri.23716] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Accepted: 05/02/2012] [Indexed: 12/17/2022] Open
Abstract
Conventional magnetic resonance imaging (MRI) such as T1-weighted and T2-weighted images of the female pelvis provide morphological information with excellent tissue contrast, which reflects the pathology of malignant diseases of the uterus. Owing to the recent improvement in hardware and software, in combination with extensive research in imaging techniques, not only MRI at higher magnetic field was facilitated, but also insight into tumor pathophysiology was provided. These methods include diffusion-weighted imaging (DWI), dynamic contrast-enhanced MRI (DCE-MRI) with pharmacokinetic analysis, and MR spectroscopy (MRS). The application of these techniques is expanding from the brain to the body because information on the tissue microenvironment and cytoarchitecture is helpful for lesion characterization, evaluation of treatment response after chemotherapy or radiation, differentiating posttherapeutic changes from residual active tumor, and for detecting recurrent cancer. These techniques may provide clues to optimize the treatment of patients with malignant diseases of the uterus. In the first half of this article we provide an overview of the technical aspects of MRI of the female pelvis, especially focusing on the state-of-the-art techniques such as 3 T MRI, DCE-MRI, DWI, etc. For the latter half we review the clinical aspects of these newly developed techniques, focusing on how these techniques are applicable, what has been revealed with respect to clinical impact, and the remaining problems.
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Affiliation(s)
- Aki Kido
- Department of Diagnostic Radiology and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
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Lee WM, Park SI, Kim BJ, Kim MH, Choi SC, Lee ED, Ryu SY. Clinicopathologic factors for central recurrence in patients with locally advanced bulky cervical cancer. Eur J Obstet Gynecol Reprod Biol 2012; 161:219-23. [PMID: 22326616 DOI: 10.1016/j.ejogrb.2011.12.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Revised: 11/22/2011] [Accepted: 12/20/2011] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Locally advanced bulky cervical cancer (LABCC) is characterized by poor local control. The objective of this study was to identify the clinicopathologic variables associated with one-year central-only recurrence, which will serve as criteria for adjuvant hysterectomy after radiation (AHR) in patients with LABCC. STUDY DESIGN Between January 2000 and August 2007, we retrospectively evaluated outcomes in 225 patients with LABCC who were initially treated with radiation or chemoradiation. RESULTS Among the 225 patients with LABCC, there were 41 recurrences within one year after treatment (8 central-only and 33 pelvis and/or distant site recurrences). Age, stage, and treatment type were not associated with the one-year central-only recurrences, but tumor size ≥8cm had a statistically significant association based on multivariate analysis (OR, 5.39; 95% CI, 1.15-25.31; p=0.03). The combination of non-squamous cell (non-SCC) type and tumor size ≥8cm had a significantly higher rate of recurrence within one year (OR, 43.0; 95% CI, 4.78-386.68; p<0.01). CONCLUSIONS Of patients with LABCC, those with non-SCC tumors ≥8cm in size were at high risk for early central-only recurrence after cisplatin-based chemoradiation, and represent the subset of patients for whom AHR is beneficial.
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Affiliation(s)
- Won-Moo Lee
- Department of Obstetrics & Gynecology, Korea Cancer Center Hospital, Korea Institute of Radiological and Medical Sciences, 215-4 Gongneung-dong, Nowon-gu, Seoul, Republic of Korea
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5
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Class II radical hysterectomy for stage I-IIA cervix cancer: Prognostic factors associated to recurrence and survival in a northeast Brazil experience. J Surg Oncol 2011; 104:255-9. [DOI: 10.1002/jso.21939] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 03/16/2011] [Indexed: 11/07/2022]
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6
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Lutgens L, van der Zee J, Pijls-Johannesma M, De Haas-Kock DF, Buijsen J, Mastrigt GAV, Lammering G, De Ruysscher DKM, Lambin P. Combined use of hyperthermia and radiation therapy for treating locally advanced cervix carcinoma. Cochrane Database Syst Rev 2010; 2010:CD006377. [PMID: 20238344 PMCID: PMC8601104 DOI: 10.1002/14651858.cd006377.pub3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Hyperthermia is a type of cancer treatment in which body tissue is exposed to high temperatures to damage and kill cancer cells. It was introduced into clinical oncology practice several decades ago. Positive clinical results, mostly obtained in single institutions, resulted in clinical implementation albeit in a limited number of cancer centres worldwide. Because large scale randomised clinical trials (RCTs) are lacking, firm conclusions cannot be drawn regarding its definitive role as an adjunct to radiotherapy in the treatment of locally advanced cervix carcinoma (LACC). OBJECTIVES To assess whether adding hyperthermia to standard radiotherapy for LACC has an impact on (1) local tumour control, (2) survival and (3) treatment related morbidity. SEARCH STRATEGY The electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL), (Issue 1, 2009) and Cochrane Gynaecological Cancer Groups Specialised Register, MEDLINE, EMBASE, online databases for trial registration, handsearching of journals and conference abstracts, reviews, reference lists, and contacts with experts were used to identify potentially eligible trials, published and unpublished until January 2009. SELECTION CRITERIA RCTs comparing radiotherapy alone (RT) versus combined hyperthermia and radiotherapy (RHT) in patients with LACC. DATA COLLECTION AND ANALYSIS Between 1987 and 2009 the results of six RCTs were published, these were used for the current analysis. MAIN RESULTS 74% of patients had FIGO stage IIIB LACC. Treatment outcome was significantly better for patients receiving the combined treatment (Figures 4 to 6). The pooled data analysis yielded a significantly higher complete response rate (relative risk (RR) 0.56; 95% confidence interval (CI) 0.39 to 0.79; p < 0.001), a significantly reduced local recurrence rate (hazard ratio (HR) 0.48; 95% CI 0.37 to 0.63; p < 0.001) and a significantly better overall survival (OS) following the combined treatment with RHT(HR 0.67; 95% CI 0.45 to 0.99; p = 0.05). No significant difference was observed in treatment related acute (RR 0.99; 95% CI 0.30 to 3.31; p = 0.99) or late grade 3 to 4 toxicity (RR 1.01; CI 95% 0.44 to 2.30; p = 0.96) between both treatments. AUTHORS' CONCLUSIONS The limited number of patients available for analysis, methodological flaws and a significant over-representation of patients with FIGO stage IIIB prohibit drawing definite conclusions regarding the impact of adding hyperthermia to standard radiotherapy. However, available data do suggest that the addition of hyperthermia improves local tumour control and overall survival in patients with locally advanced cervix carcinoma without affecting treatment related grade 3 to 4 acute or late toxicity.
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Affiliation(s)
- Ludy Lutgens
- Radiation Oncology, Maastro Clinic, Dr. Tanslaan 12, 6229 ET Maastricht, Postbus 5800, Maastricht, Netherlands, 6202 AZ
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7
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Overgaard J. The influence of haemoglobin concentration on the response to radiotherapy. Scandinavian Journal of Clinical and Laboratory Investigation 2010. [DOI: 10.1080/00365518809168189] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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8
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Lutgens L, van der Zee J, Pijls-Johannesma M, De Haas-Kock DF, Buijsen J, Mastrigt GAV, Lammering G, De Ruysscher DKM, Lambin P. Combined use of hyperthermia and radiation therapy for treating locally advanced cervical carcinoma. Cochrane Database Syst Rev 2010:CD006377. [PMID: 20091593 DOI: 10.1002/14651858.cd006377.pub2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Hyperthermia is a type of cancer treatment in which body tissue is exposed to high temperatures to damage and kill cancer cells. It was introduced into clinical oncology practice several decades ago. Positive clinical results, mostly obtained in single institutions, resulted in clinical implementation albeit in a limited number of cancer centres worldwide. Because large scale randomised clinical trials (RCTs) are lacking, firm conclusions cannot be drawn regarding its definitive role as an adjunct to radiotherapy in the treatment of locally advanced cervical carcinoma (LACC). OBJECTIVES To assess whether adding hyperthermia to standard radiotherapy for LACC has an impact on (1) local tumour control, (2) survival and (3) treatment related morbidity. SEARCH STRATEGY The electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL), (Issue 1, 2009) and Cochrane Gynaecological Cancer Groups Specialised Register, MEDLINE, EMBASE, online databases for trial registration, handsearching of journals and conference abstracts, reviews, reference lists, and contacts with experts were used to identify potentially eligible trials, published and unpublished until January 2009. SELECTION CRITERIA RCTs comparing radiotherapy alone (RT) versus combined hyperthermia and radiotherapy (RHT) in patients with LACC. DATA COLLECTION AND ANALYSIS Between 1987 and 2009 the results of six RCTs were published, these were used for the current analysis. MAIN RESULTS 74% of patients had FIGO stage IIIB LACC. Treatment outcome was significantly better for patients receiving the combined treatment (Figures 1 to 3). The pooled data analysis yielded a significantly higher complete response rate (relative risk (RR) 0.56; 95% confidence interval (CI) 0.39 to 0.79; p < 0.001), a significantly reduced local recurrence rate at 3 years (hazard ratio (HR) 0.48; 95% CI 0.37 to 0.63; p < 0.001) and a significanly better overall survival (OS) at three years following the combined treatment with RHT(HR 0.67; 95% CI 0.45 to 0.99; p = 0.05). No significant difference was observed in treatment related acute (RR 0.99; 95% CI 0.30 to 3.31; p = 0.99) or late grade 3 to 4 toxicity (RR 1.01; CI 95% 0.44 to 2.30; p = 0.96) between both treatments. AUTHORS' CONCLUSIONS The limited number of patients available for analysis, methodological flaws and a significant over-representation of patients with FIGO stage IIIB prohibit drawing definite conclusions regarding the impact of adding hyperthermia to standard radiotherapy. However, available data do suggest that the addition of hyperthermia improves local tumour control and overall survival in patients with locally advanced cervical carcinoma without affecting treatment related grade 3 to 4 acute or late toxicity.
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Affiliation(s)
- Ludy Lutgens
- Radiation Oncology, Maastro Clinic, Dr. Tanslaan 12, 6229 ET Maastricht, Postbus 5800, Maastricht, Netherlands, 6202 AZ
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9
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Huang Z, Mayr NA, Yuh WTC, Lo SS, Montebello JF, Grecula JC, Lu L, Li K, Zhang H, Gupta N, Wang JZ. Predicting outcomes in cervical cancer: a kinetic model of tumor regression during radiation therapy. Cancer Res 2010; 70:463-70. [PMID: 20068180 DOI: 10.1158/0008-5472.can-09-2501] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Applications of mathematical modeling can improve outcome predictions of cancer therapy. Here we present a kinetic model incorporating effects of radiosensitivity, tumor repopulation, and dead-cell resolving on the analysis of tumor volume regression data of 80 cervical cancer patients (stages 1B2-IVA) who underwent radiation therapy. Regression rates and derived model parameters correlated significantly with clinical outcome (P < 0.001; median follow-up: 6.2 years). The 6-year local tumor control rate was 87% versus 54% using radiosensitivity (2-Gy surviving fraction S(2) < 0.70 vs. S(2) > or = 0.70) as a predictor (P = 0.001) and 89% vs. 57% using dead-cell resolving time (T(1/2) < 22 days versus T(1/2) > or = 22 days, P < 0.001). The 6-year disease-specific survival was 73% versus 41% with S(2) < 0.70 versus S(2) > or = 0.70 (P = 0.025), and 87% vs. 52% with T(1/2) < 22 days versus T(1/2) > or = 22 days (P = 0.002). Our approach illustrates the promise of volume-based tumor response modeling to improve early outcome predictions that can be used to enable personalized adaptive therapy.
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Affiliation(s)
- Zhibin Huang
- Department of Radiation Medicine, The Ohio State University, Columbus, Ohio 43210, USA
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10
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Mayr NA, Wang JZ, Zhang D, Montebello JF, Grecula JC, Lo SS, Fowler JM, Yuh WTC. Synergistic effects of hemoglobin and tumor perfusion on tumor control and survival in cervical cancer. Int J Radiat Oncol Biol Phys 2009; 74:1513-21. [PMID: 19286329 DOI: 10.1016/j.ijrobp.2008.09.050] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2008] [Revised: 09/27/2008] [Accepted: 09/30/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE The tumor oxygenation status is likely influenced by two major factors: local tumor blood supply (tumor perfusion) and its systemic oxygen carrier, hemoglobin (Hgb). Each has been independently shown to affect the radiotherapy (RT) outcome in cervical cancer. This study assessed the effect of local tumor perfusion, systemic Hgb levels, and their combination on the treatment outcome in cervical cancer. METHODS AND MATERIALS A total of 88 patients with cervical cancer, Stage IB2-IVA, who were treated with RT/chemotherapy, underwent serial dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) before RT, at 20-22 Gy, and at 45-50 Gy. The DCE-MRI perfusion parameters, mean and lowest 10th percentile of the signal intensity distribution in the tumor pixels, and the Hgb levels, including pre-RT, nadir, and mean Hgb (average of weekly Hgb during RT), were correlated with local control and disease-specific survival. The median follow-up was 4.6 years. RESULTS Local recurrence predominated in the group with both a low mean Hgb (<11.2 g/dL) and low perfusion (lowest 10th percentile of signal intensity <2.0 at 20-22 Gy), with a 5-year local control rate of 60% vs. 90% for all other groups (p = .001) and a disease-specific survival rate of 41% vs. 72% (p = .008), respectively. In the group with both high mean Hgb and high perfusion, the 5-year local control rate and disease-specific survival rate was 100% and 78%, respectively. CONCLUSION These results suggest that the compounded effects of Hgb level and tumor perfusion during RT influence the radioresponsiveness and survival in cervical cancer patients. The outcome was worst when both were impaired. The management of Hgb may be particularly important in patients with low tumor perfusion.
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Affiliation(s)
- Nina A Mayr
- Department of Radiation Medicine, Ohio State University, Columbus, OH 43210, USA.
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11
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Petsuksiri J, Chansilpa Y, Therasakvichya S, Suntornpong N, Thephamongkhol K, Dankulchai P, Mahasitthiwat P, Ieumwananonthachai N, Veerasarn V, Sangruchi S, Pattaranutaporn P. Treatment options in bulky stage IB cervical carcinoma. Int J Gynecol Cancer 2008; 18:1153-62. [DOI: 10.1111/j.1525-1438.2008.01195.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Cervical cancer is the most common female cancer in the developing countries. Treatments of bulky stage IB cervical cancer have been challenged as the local control is relatively poor compared to smaller stage I disease, whether treated by radical surgery or irradiation. The treatment options are definitive concurrent chemoradiation therapy or radical surgery with or without neoadjuvant or adjuvant therapy. The treatment decision is based on the patients' status and preferences, tumor characteristics, and experiences of clinician. This study will review and compare the treatment modalities and rationales of a combination of treatment including surgery, radiation therapy, and chemotherapy for bulky stage IB cervical carcinoma.
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12
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Schultheiss TE. The radiation dose-response of the human spinal cord. Int J Radiat Oncol Biol Phys 2008; 71:1455-9. [PMID: 18243570 DOI: 10.1016/j.ijrobp.2007.11.075] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2007] [Revised: 11/20/2007] [Accepted: 11/27/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE To characterize the radiation dose-response of the human spinal cord. METHODS AND MATERIALS Because no single institution has sufficient data to establish a dose-response function for the human spinal cord, published reports were combined. Requisite data were dose and fractionation, number of patients at risk, number of myelopathy cases, and survival experience of the population. Eight data points for cervical myelopathy were obtained from five reports. Using maximum likelihood estimation correcting for the survival experience of the population, estimates were obtained for the median tolerance dose, slope parameter, and alpha/beta ratio in a logistic dose-response function. An adequate fit to thoracic data was not possible. Hyperbaric oxygen treatments involving the cervical cord were also analyzed. RESULTS The estimate of the median tolerance dose (cervical cord) was 69.4 Gy (95% confidence interval, 66.4-72.6). The alpha/beta = 0.87 Gy. At 45 Gy, the (extrapolated) probability of myelopathy is 0.03%; and at 50 Gy, 0.2%. The dose for a 5% myelopathy rate is 59.3 Gy. Graphical analysis indicates that the sensitivity of the thoracic cord is less than that of the cervical cord. There appears to be a sensitizing effect from hyperbaric oxygen treatment. CONCLUSIONS The estimate of alpha/beta is smaller than usually quoted, but values this small were found in some studies. Using alpha/beta = 0.87 Gy, one would expect a considerable advantage by decreasing the dose/fraction to less than 2 Gy. These results were obtained from only single fractions/day and should not be applied uncritically to hyperfractionation.
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Affiliation(s)
- Timothy E Schultheiss
- Department of Radiation Oncology, City of Hope Cancer Center, 1500 Duarte Road, Duarte, CA 91010, USA.
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13
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Atahan IL, Onal C, Ozyar E, Yiliz F, Selek U, Kose F. Long-term outcome and prognostic factors in patients with cervical carcinoma: a retrospective study. Int J Gynecol Cancer 2007; 17:833-42. [PMID: 17367320 DOI: 10.1111/j.1525-1438.2007.00895.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
This study evaluates treatment outcomes and possible prognostic factors of inoperable cervical cancer patients treated with external beam radiotherapy (EBRT) and high-dose rate brachytherapy (HDR BRT). Between 1993 and 2000, 183 patients with cervical cancer were treated at our institute. Radiotherapy was the sole treatment modality until January 1997; after the announcement of National Cancer Institute in 1999, 40 mg/m(2) of cisplatin (49%) was routinely applied every week. Median age was 54 years (32-92 years). Most patients (88%) had advanced-stage disease (IIB-IIIB). With a median follow-up time of 45 months (6-121 months), the 5-year overall survival (OS), local recurrence-free survival, disease-free survival (DFS), and distant metastasis-free survival (DMFS) rates were 55%, 71%, 51%, and 77%, respectively. Univariate analysis revealed that age, tumor size, lymph node status, and concomitant cisplatin were prognostic factors for OS. The DFS rates were lower in young age group. Patients with tumor greater than 4 cm and age greater than 40 were at greater risk for local recurrence. Distant metastases were more frequent in patients with adenocarcinoma. Concurrent cisplatin use increases DMFS rates (91% vs 78%; P= 0.05). In multivariate analysis, extensive stage, parametrial infiltration, young age, adenocarcinoma histopathology, and lymph node metastasis were negative prognostic factors for OS while concomitant cisplatin increases OS. Likewise, patients with extensive stage, adenocarcinoma, and without concurrent cisplatin administration had more risk for distant metastasis. There was no treatment-related mortality. Grade 3-4 morbidity rates were seen only in eight patients (4%). The combination of EBRT and HDR BRT together with concomitant chemotherapy in the treatment of locally advanced carcinoma of cervix is safe and well tolerated with acceptable morbidity.
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Affiliation(s)
- I L Atahan
- Department of Radiation Oncology, Hacettepe University School of Medicine, Sihhiye, Ankara, Turkey
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14
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Lavey RS, Liu PY, Greer BE, Robinson WR, Chang PC, Wynn RB, Conrad ME, Jiang C, Markman M, Alberts DS. Recombinant human erythropoietin as an adjunct to radiation therapy and cisplatin for stage IIB–IVA carcinoma of the cervix: a Southwest Oncology Group study. Gynecol Oncol 2004; 95:145-51. [PMID: 15385124 DOI: 10.1016/j.ygyno.2004.07.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2004] [Indexed: 01/02/2023]
Abstract
OBJECTIVE The survival of cervix cancer patients is associated with their hemoglobin (Hgb) level during radiotherapy. The Southwest Oncology Group (SWOG) conducted a phase II trial to determine whether recombinant human erythropoietin (rHuEPO) safely corrects anemia during chemoradiotherapy for cervix cancer. METHODS Patients had stage IIB-IVA cervix cancer and a Hgb between 8.0 and 12.5 g/dl. All patients received rHuEPO thrice weekly and oral iron starting 10-15 days before their 5-week course of whole pelvic irradiation and weekly cisplatin followed by intracavitary brachytherapy. RESULTS Fifty-three patients from 26 institutions received the protocol treatment. The mean Hgb was 10.4 +/- 1.3 g/dl on the first day of rHuEPO administration (baseline), 11.0 +/- 1.6 g/dl on the first day of chemoradiotherapy, 11.6 +/- 1.9 g/dl at the midpoint of chemoradiotherapy, and 11.8 +/- 2.2 g/dl at the end of chemoradiotherapy. The target Hgb level of 12.5 g/dl was achieved in 40% of patients (95% CI 26-56%) by the midpoint of Chemoradiotheraphy. Change in Hgb was associated with baseline serum iron (P = 0.008) and transferrin saturation (P = 0.05) levels, but not with baseline Hgb or serum ferritin, or patient age. Seven patients developed deep vein thrombosis. Two-year progression-free survival (PFS) was 43% and overall survival (OS) was 51%. Survival was significantly associated with Hgb level at the end of chemoradiotherapy, but not with the baseline Hgb level. CONCLUSIONS rHuEPO and iron gradually increased Hgb levels in anemic women with local advanced cervix cancer during chemoradiotherapy. There was a higher than expected incidence of deep vein thrombosis. The progression-free and overall survival rates were lower than reported for women with normal Hgb levels.
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Affiliation(s)
- Robert S Lavey
- University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA.
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Keys HM, Bundy BN, Stehman FB, Okagaki T, Gallup DG, Burnett AF, Rotman MZ, Fowler WC. Radiation therapy with and without extrafascial hysterectomy for bulky stage IB cervical carcinoma: a randomized trial of the Gynecologic Oncology Group. Gynecol Oncol 2003; 89:343-53. [PMID: 12798694 DOI: 10.1016/s0090-8258(03)00173-2] [Citation(s) in RCA: 182] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate, in a randomized clinical trial, the role of adjuvant hysterectomy after standardized radiation in improving progression-free survival and survival for patients with "bulky" stage IB cervical cancer. METHODS A total of 256 eligible patients with exophytic or "barrel" shaped tumors measuring > or = 4 cm were randomized to either external and intracavitary irradiation (RT, N = 124) or attenuated irradiation followed by extrafascial hysterectomy (RT + HYST, N = 132). Twenty-five percent of patients had tumors with a maximum diameter of > or =7 cm. RESULT Tumor size was the most pronounced prognostic factor followed by performance status 2 and age at diagnosis. Hysterectomy did not increase the frequency of reported grade 3 and 4 adverse effects (both groups, 10%). The majority of these adverse effects were from the gastrointestinal or genitourinary tracts exclusively. There was a lower cumulative incidence of local relapse in the RT + HYST group (at 5 years, 27% vs. 14%). There were no statistical differences in outcomes between regimens except for the adjusted comparison of progression-free survival, although all indicated a lower risk in the adjuvant hysterectomy regimen (unadjusted relative risk [URR] of progression, 0.77, P = 0.07; URR of death, P = 0.26, both one tail). CONCLUSION Overall, there was no clinically important benefit with the use of extrafascial hysterectomy. However, there is good evidence to suggest that patients with 4-, 5-, and 6-cm tumors may have benefitted from extrafascial hysterectomy (URR of progression; 0.58; URR of death, 0.60).
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Affiliation(s)
- Henry M Keys
- Department of Radiation Oncology, Albany Medical College, Albany, NY 12208, USA.
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Harrison LB, Chadha M, Hill RJ, Hu K, Shasha D. Impact of tumor hypoxia and anemia on radiation therapy outcomes. Oncologist 2003; 7:492-508. [PMID: 12490737 DOI: 10.1634/theoncologist.7-6-492] [Citation(s) in RCA: 264] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Local recurrence remains a major obstacle to achieving cure of many locally advanced solid tumors treated with definitive radiation therapy. The microenvironment of solid tumors is hypoxic compared with normal tissue, and this hypoxia is associated with decreased radiosensitivity. Recent preclinical data also suggest that intratumoral hypoxia, particularly in conjunction with an acid microenvironment, may be directly or indirectly mutagenic. Investigations of the prognostic significance of the pretreatment oxygenation status of tumors in patients with head and neck or cervical cancer have demonstrated that increased hypoxia, typically designated in these studies as pO(2) levels below 2.5-10 mm Hg, is associated with decreased local tumor control and lower rates of disease-free and overall survival. Hypoxia-directed therapies in the radiation oncology setting include treatment using hyperbaric oxygen, fluosol infusion, carbogen breathing, and electron-affinic and hypoxic-cell sensitizers. These interventions have shown the potential to increase the effectiveness of curative-intent radiation therapy, demonstrating that the strategy of overcoming hypoxia may be a viable and important approach. Anemia is common in the cancer population and is suspected to contribute to intratumoral hypoxia. A review of the literature reveals that a low hemoglobin level before or during radiation therapy is an important risk factor for poor locoregional disease control and survival, implying that a strong correlation could exist between anemia and hypoxia (ultimately predicting for a poor outcome). While having a low hemoglobin level has been shown to be detrimental, it is unclear as to exactly what the threshold for "low" should be (studies in this area have used thresholds ranging from 9-14.5 g/dl). Optimal hemoglobin and pO(2) thresholds for improving outcomes may vary across and within tumor types, and this is an area that clearly requires further evaluation. Nonetheless, the correction of anemia may be a worthwhile strategy for radiation oncologists to improve local control and survival.
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Affiliation(s)
- Louis B Harrison
- Department of Radiation Oncology, Continuum Cancer Centers of New York, Beth Israel Medical Center, 10 Union Square East, New York, NY 10003, USA.
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Nori D, Dasari N, Allbright RM. Gynecologic brachytherapy I: Proper incorporation of brachytherapy into the current multimodality management of carcinoma of the cervix. Semin Radiat Oncol 2002; 12:40-52. [PMID: 11813150 DOI: 10.1053/srao.2002.28664] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The incidence of carcinoma of the cervix has continuously declined over the past decades because of effective screening. The International Federation of Gynecology and Obstetrics (FIGO) clinical staging, though universally used, is considered inadequate either to determine the type of treatment or to predict treatment outcome. Over the last 10 years, treatment of cervical cancer has become increasingly sophisticated with advances in external beam and brachytherapy in the radiotherapeutic management of this carcinoma. In particular, brachytherapy plays a major role in enhancing both local control and survival. Experience to date suggests that either high-dose-rate (HDR) or low-dose-rate (LDR) brachytherapy, when properly applied, can be effective and give similar rates of local control with minimal complications. This article analyzes the current literature regarding treatment techniques of radiotherapy with special emphasis on brachytherapy integration to optimize radiotherapy treatment outcome.
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Affiliation(s)
- Dattatreyudu Nori
- Department of Radiation Oncology, New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, NY 10021, USA
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Mayr NA, Taoka T, Yuh WTC, Denning LM, Zhen WK, Paulino AC, Gaston RC, Sorosky JI, Meeks SL, Walker JL, Mannel RS, Buatti JM. Method and timing of tumor volume measurement for outcome prediction in cervical cancer using magnetic resonance imaging. Int J Radiat Oncol Biol Phys 2002; 52:14-22. [PMID: 11777618 DOI: 10.1016/s0360-3016(01)01808-9] [Citation(s) in RCA: 141] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE Recently, imaging-based tumor volume before, during, and after radiation therapy (RT) has been shown to predict tumor response in cervical cancer. However, the effectiveness of different methods and timing of imaging-based tumor size assessment have not been investigated. The purpose of this study was to compare the predictive value for treatment outcome derived from simple diameter-based ellipsoid tumor volume measurement using orthogonal diameters (with ellipsoid computation) with that derived from more complex contour tracing/region-of-interest (ROI) analysis 3D tumor volumetry. METHODS AND MATERIALS Serial magnetic resonance imaging (MRI) examinations were prospectively performed in 60 patients with advanced cervical cancer (Stages IB2-IVB/recurrent) at the start of RT, during early RT (20-25 Gy), mid-RT (45-50 Gy), and at follow-up (1-2 months after RT completion). ROI-based volumetry was derived by tracing the entire tumor region in each MR slice on the computer work station. For the diameter-based surrogate "ellipsoid volume," the three orthogonal diameters (d1, d2, d3) were measured on film hard copies to calculate volume as an ellipsoid (d1 x d2 x d3 x pi/6). Serial tumor volumes and regression rates determined by each method were correlated with local control, disease-free and overall survival, and the results were compared between the two measuring methods. Median post-therapy follow-up was 4.9 years (range, 2.0-8.2 years). RESULTS The best method and time point of tumor size measurement for the prediction of outcome was the tumor regression rate in the mid-therapy MRI examination (at 45-50 Gy) using 3D ROI volumetry. For the pre-RT measurement both the diameter-based method and ROI volumetry provided similar predictive accuracy, particularly for patients with small (<40 cm3) and large (> or =100 cm3) pre-RT tumor size. However, the pre-RT tumor size measured by either method had much less predictive value for the intermediate-size (40-99 cm3) tumors, which accounted for the majority of patients (55%). Tumor regression rate (fast vs. slow) obtained during mid-RT (45-50 Gy), which could only be appreciated by 3D ROI volumetry, had the best outcome prediction rate for local control (84% vs. 22%, p < 0.0001) and disease-free survival (63% vs. 20%, p = 0.0005). Within the difficult to classify intermediate pre-RT size group, slow ROI-based regression rate predicted all treatment failures (local control rate: 0% vs. 91%, p < 0.0001; disease-free survival: 0% vs. 73%, p < 0.0001). Mid-RT regression rate based on simple diameter measurement did not predict outcome. The early-RT and post-RT measurements were least useful with either measuring method. CONCLUSION Our preliminary data suggest that for the prediction of treatment outcome in cervical cancer, initial tumor volume can be estimated by simple diameter-based measurement obtained from film hard copies. When initial tumor volume is in the intermediate size range, ROI volumetry and an additional MRI during RT are needed to quantitatively analyze tumor regression rate for the prediction of treatment outcome.
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Affiliation(s)
- Nina A Mayr
- Radiation Oncology Center, Department of Radiology, Oklahoma University Health Sciences Center, Oklahoma City, OK 73190, USA.
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Tsuda H, Tanaka M, Manabe T, Nakata S, Ishiko O, Yamamoto K. Phase I-II study of neoadjuvant chemoradiotherapy followed by radical surgery in locally advanced cervical cancer. Anticancer Drugs 2001; 12:853-8. [PMID: 11707654 DOI: 10.1097/00001813-200111000-00010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The usefulness of neoadjuvant chemotherapy (NAC) regimens has been reported; however, the effect of NAC for advanced stages (especially stage III-IVA) is thought to be insufficient. We conducted a phase I-II study of neoadjuvant chemoradiotherapy consisting of intra-arterial (i.a.) infusion of carboplatin and intracavitary brachytherapy in patients with locally advanced cervical cancer to achieve the new NAC method. Sixteen eligible patients included those with previously untreated stage IIB, III or IVA cancer with bulky tumor. Brachytherapy using iridium-192 was performed with concurrent i.a. chemotherapy with carboplatin (200, 300 and 400 mg/m2). Treatment was repeated every 4 weeks for a total of two cycles. Both hematologic and non-hematologic toxicities were generally mild. Grade 4 hematologic toxicity was observed in 12.5% and there were no grade III or IV non-hematologic toxicities. The optimal dose of carboplatin was determined to be 400 mg/m2. Among 16 patients, six showed complete response (37.5%) and nine showed partial response (56.3%), for an overall response rate of 93.8%. All 15 responding patients underwent radical surgery with a pelvic lymphadenectomy and postoperative radiotherapy. The combination of brachytherapy and i.a. chemotherapy with carboplatin is a promising regimen for NAC in locally advanced cervical cancer.
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Affiliation(s)
- H Tsuda
- Department of Obstetrics and Gynecology, Osaka City General Hospital, Miyakojima, Osaka 534-0021, Japan.
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Mayr NA, Yuh WT, Arnholt JC, Ehrhardt JC, Sorosky JI, Magnotta VA, Berbaum KS, Zhen W, Paulino AC, Oberley LW, Sood AK, Buatti JM. Pixel analysis of MR perfusion imaging in predicting radiation therapy outcome in cervical cancer. J Magn Reson Imaging 2000; 12:1027-33. [PMID: 11105046 DOI: 10.1002/1522-2586(200012)12:6<1027::aid-jmri31>3.0.co;2-5] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The purpose of this study was to assess heterogeneity of tumor microcirculation determined by dynamic contrast-enhanced magnetic resonance (MR) imaging and its prognostic value for tumor radiosensitivity and long-term tumor control using pixel-by-pixel analysis of the dynamic contrast enhancement. Sixteen patients with advanced cervical cancer were examined with dynamic contrast-enhanced MR imaging at the time of radiation therapy. Pixel-by-pixel statistical analysis of the ratio of post- to precontrast relative signal intensity (RSI) values in the tumor region was performed to generate pixel RSI distributions of dynamic enhancement patterns. Histogram parameters were correlated with subsequent tumor control based on long-term cancer follow-up (median follow-up 4.6 years; range 3.8-5.2 years). The RSI distribution histograms showed a wide spectrum of heterogeneity in the dynamic enhancement pattern within the tumor. The quantity of low-enhancement regions (10th percentile RSI < 2.5) significantly predicted subsequent tumor recurrence (88% vs. 0%, P = 0.0004). Discriminant analysis based on both 10th percentile RSI and pixel number (reflective of tumor size) further improved the prediction rate (100% correct prediction of subsequent tumor control vs. recurrence). These preliminary results suggest that quantification of the extent of poor vascularity regions within the tumor may be useful in predicting long-term tumor control and treatment outcome in cervical cancer. J. Magn. Reson. Imaging 2000;12:1027-1033.
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Affiliation(s)
- N A Mayr
- Division of Radiation Oncology, Department of Radiology, The University of Iowa College of Medicine, Iowa City, Iowa 52242, USA.
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Yamashita Y, Baba T, Baba Y, Nishimura R, Ikeda S, Takahashi M, Ohtake H, Okamura H. Dynamic contrast-enhanced MR imaging of uterine cervical cancer: pharmacokinetic analysis with histopathologic correlation and its importance in predicting the outcome of radiation therapy. Radiology 2000; 216:803-9. [PMID: 10966715 DOI: 10.1148/radiology.216.3.r00se07803] [Citation(s) in RCA: 135] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To investigate the histopathologic bases of different enhancement patterns on dynamic contrast material-enhanced magnetic resonance (MR) images of cervical cancer and to assess their importance in predicting the outcome of patients after radiation therapy. MATERIALS AND METHODS Dynamic enhanced MR imaging and pharmacokinetic analyses were performed in 26 patients with cervical cancer who subsequently underwent hysterectomy and in 36 patients with cervical cancer who received radiation therapy. Histopathologic findings and clinical outcomes were correlated with results of dynamic MR imaging and pharmacokinetic analysis. RESULTS On dynamic MR images of the surgical patients, areas with intense homogeneous enhancement showed increased permeability (k = 27.4 x 10(-3)) compared with areas with poor enhancement (k = 19.0 x 10(-3)). Well-enhanced areas were predominantly composed of cancer cell fascicles, whereas poorly enhanced areas were composed of fibrous tissue with scattered cancer cells. Radiation therapy was more effective in tumors with higher tissue permeability (k = 31.3 x 10(-3)) on dynamic MR images than in those with lower tissue permeability (k = 18.3 x 10(-3)). CONCLUSION Areas of increased contrast enhancement are mainly composed of abundant cancer cell fascicles, whereas poorly perfused areas are composed of fibrous tissue with scattered cancer cells. Radiation therapy is more effective in well-enhanced tumors, resulting in improved local control.
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Affiliation(s)
- Y Yamashita
- Departments of Radiology, Kumamoto University School of Medicine, Honjo, Japan.
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Dumanli H, Fielding JR, Gering DT, Kikinis R. Volume assessment of the normal female cervix with MR imaging: comparison of the segmentation technique and two geometric formula. Acad Radiol 2000; 7:502-5. [PMID: 10902958 DOI: 10.1016/s1076-6332(00)80322-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
RATIONALE AND OBJECTIVES The purpose of this study was to determine the volume of the normal female cervix and to determine the geometric formula that yields the best estimate. MATERIALS AND METHODS Magnetic resonance images of the pelvis in 30 young women were reviewed retrospectively. The volume of the cervix was estimated by using the formulas for an ellipse and a cylinder. Manual labeling and segmentation of the cervix were also performed, and the volume was calculated on the basis of the number and size of the voxels. Comparison of these methods was then performed by using a two-tailed Student t test. RESULTS No statistically significant difference was found (P = .7) between the volume calculated with the segmentation technique (25.3 mL) and that estimated with the formula for a cylinder (24.8 mL). A statistically significant difference (P < .05) was found between the volume calculated with the segmentation technique and that estimated with the formula for an ellipse (16.4 mL). CONCLUSION The normal volume of the cervix in this population of young women was approximately 25 mL. The volume of the cervix should be estimated with the formula for a cylinder.
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Affiliation(s)
- H Dumanli
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Mayr NA, Hawighorst H, Yuh WT, Essig M, Magnotta VA, Knopp MV. MR microcirculation assessment in cervical cancer: correlations with histomorphological tumor markers and clinical outcome. J Magn Reson Imaging 1999; 10:267-76. [PMID: 10508286 DOI: 10.1002/(sici)1522-2586(199909)10:3<267::aid-jmri7>3.0.co;2-y] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
This article reviews the experience available to date on microcirculation assessment in cancer of the cervix including correlation studies of magnetic resonance (MR) microcirculatory parameters with histo-morphometric predictors and direct correlation with patient outcome. The data suggest that MR microcirculation parameters do not always correlate with histo-morphometric parameters, while there is evidence that MR parameters predict patients' treatment outcome. These observations raise the issue that perhaps the histo-morphometric parameters, accepted gold standards for tumor angiogenesis and prognostic factors, reflect anatomical information at a "static" single time point and may not always provide sufficient information on the "dynamic" microcirculation function of the tumor. MR microcirculation assessment reflects both anatomical and functional information and may provide this additional information on the "dynamic" angiogenic and metabolic status of a tumor. Therefore, assessment of tumor microcirculation may augment the individual risk profile in cervical cancer patients and has the potential to impact on therapy selection and treatment outcome.
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Affiliation(s)
- N A Mayr
- Division of Radiation Oncology, Department of Radiology, The University of Iowa College of Medicine, Iowa City, Iowa 52242, USA
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Karolewski K, Korzeniowski S, Sokołowski A, Urbański K, Kojs Z. Prognostic significance of pretherapeutic and therapeutic factors in patients with advanced cancer of the uterine cervix treated with radical radiotherapy alone. Acta Oncol 1999; 38:461-8. [PMID: 10418713 DOI: 10.1080/028418699431997] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
The prognostic importance of various pretherapeutic and therapeutic factors was analysed in a group of 413 cervical cancer patients with stage IIB (183 pts) and IIIB (230 pts) treated with radical radiotherapy, which consisted of external irradiation and intracavitary brachytherapy. Univariate analysis of pretherapeutic factors revealed the prognostic significance of patient age, history of abortion, stage, haemoglobin and hematocrit levels. Five-year overall survival rate in stage IIB patients was 51%, in stage IIIB 40% and the respective rates for local control at each stage were 61%, and 46%. Univariate analysis of therapeutic factors showed that survival and local control rates increased with the dose, but a significant difference was found only in the case of a paracentral (point A) dose. In a multivariate analysis only patient age, abortions, and clinical stage appeared to have a significant and independent impact on survival. Linear regression analysis results indicated that prolongation of treatment time between 33 and 108 days caused a loss of local control of 0.36% per day.
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Affiliation(s)
- K Karolewski
- Centre of Oncology, Maria Sklodowska-Curie Memorial Institute, Department of Gynecol.-Oncology, Kracow, Poland
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Jurado M, Martínez-Monge R, García-Foncillas J, Azinovic I, Aristu J, López-García G, Brugarolas A. Pilot study of concurrent cisplatin, 5-fluorouracil, and external beam radiotherapy prior to radical surgery +/- intraoperative electron beam radiotherapy in locally advanced cervical cancer. Gynecol Oncol 1999; 74:30-7. [PMID: 10385548 DOI: 10.1006/gyno.1999.5424] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE The purpose of this study was to describe the feasibility of a combined preoperative chemoradiation program followed by radical surgery in advanced cervical cancer. MATERIALS AND METHODS From February 1988 to April 1997, 40 patients with carcinoma of the cervix were treated with preoperative external beam radiotherapy to 45 Gy in 5 weeks. Patients received concurrent continuous infusion cisplatin (20 mg/m2) and 5-fluorouracil (1500 mg) chemotherapy during the first (days 1-4) and fifth (days 22-25) weeks of the radiation course. Radical surgery was performed 4-6 weeks after the completion of the preoperative treatment. Intraoperative radiotherapy was given to 20 patients, based on intraoperative assessment. RESULTS Toxicity associated with chemoradiation was usually mild except in two patients who presented WHO grade 4 bone marrow aplasia. Three patients developed postoperative ureterovaginal fistula, and five patients developed long-term hydronephrosis that needed ureteral stenting. Clinical response was observed in 95% of the patients (55% complete response). The analysis of the surgical specimens revealed complete pathological response in 67.5% of the cases and partial pathological response in 32.5%. As expected, the degree of pathological response was predicted by the degree of clinical response (P = 0.001). Nine-year local control, distant metastases-free survival, disease-free survival, and overall survival were 86, 84, 81, and 85%, respectively. Patients displaying a complete pathological response had statistically significant improved local control (P = 0.004), distant metastases-free survival (P = 0.009), disease-free survival (P = 0.002), and overall survival (P = 0.038). CONCLUSIONS Cisplatin plus 5-fluorouracil preoperative chemoradiation is active and usually well tolerated in locally advanced carcinoma of cervix, inducing a high rate of clinical and pathological complete responses. When this therapy is followed by radical surgery, the local control rates are excellent, even in patients with advanced stages or poor response. These improved local control rates may be achievable only through extensive surgical resection, with a parallel increase in the complication rates.
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Affiliation(s)
- M Jurado
- Department of Oncology, Clínica Universitaria, Universidad de Navarra, Pamplona, 31080, Spain
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Mundt AJ, Connell PP, Campbell T, Hwang JH, Rotmensch J, Waggoner S. Race and clinical outcome in patients with carcinoma of the uterine cervix treated with radiation therapy. Gynecol Oncol 1998; 71:151-8. [PMID: 9826453 DOI: 10.1006/gyno.1998.5203] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The aim of this study was to examine factors underlying differences in outcome between African-American (AA) and Caucasian (C) patients undergoing radiation therapy (RT). METHODS Patient, tumor, treatment characteristics, and the outcome of 316 AA and 94 C cervical cancer patients who underwent RT were compared. Median follow-up was 72.4 months. RESULTS AA patients had a trend to a poorer 8-year cause-specific survival (47.9 vs 60.6%) (P = 0.10) compared to C patients with a significant difference seen in stage IIB-IVA disease (34.3 vs 59.5%) (P = 0.04). Several factors correlated with poor outcome were present in the AA group including lower mean hemoglobin levels during RT (P = 0.001), lower median income (P = 0.001), and less frequent intracavitary RT (P = 0.09). In addition, while uncommon in C patients, health problems were major reasons for treatment protraction and inability to undergo intracavitary RT in the AA patients. Multivariate analysis demonstrated that race was not an independent prognostic factor after controlling for difference in patient, tumor, and treatment factors. CONCLUSIONS AA cervical cancer patients possess multiple factors that adversely impact upon the efficacy of RT. These findings may add further insight into the observed differences in outcome of cervical cancer patients based on race.
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Affiliation(s)
- A J Mundt
- Section of Gynecologic Oncology, University of Chicago Hospitals, Chicago, Illinois, 60637, USA.
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Minagawa Y, Kigawa J, Irie T, Okada M, Kanamori Y, Terakawa N. Radical surgery following neoadjuvant chemotherapy for patients with stage IIIB cervical cancer. Ann Surg Oncol 1998; 5:539-43. [PMID: 9754763 DOI: 10.1007/bf02303647] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND We conducted a phase II trial of radical surgery following neoadjuvant chemotherapy in patients with stage IIIB cervical cancer. METHODS A total of 26 patients with stage IIIB cervical cancer were entered in this study. Patients were treated with a chemotherapeutic regimen consisting of intraarterial infusion of cisplatin and intravenous infusion of other anticancer agents, to a maximum of 3 courses. If the results of the evaluation indicated that surgery was feasible, radical surgery, including complete removal of pelvic vessels, partial resection of adjacent organs, and pelvic and paraaortic lymphadenectomy, was performed. Patients whose tumors showed no response received radiotherapy. We evaluated operability, survival rate, toxicities, and complications. Additionally, we examined prognostic variables by multivariate analysis in the patients treated by radical surgery. RESULTS Eighteen patients (69.2%) underwent radical surgery. The remaining eight patients received radiation therapy. The 3-year disease-free survival rate was 72.2% in patients who received surgery and 25.0% in those who received radiotherapy. Multivariate analysis did not show any independent prognostic factors in the patients who underwent surgery. CONCLUSION Radical surgery following neoadjuvant chemotherapy may be feasible in two thirds of patients with stage IIIB cervical cancer; therefore, phase III trials can be recommended.
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Affiliation(s)
- Y Minagawa
- Department of Obstetrics and Gynecology, Tottori University School of Medicine, Nishimachi, Japan
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Sweeney PJ, Nicolae D, Ignacio L, Chen L, Roach M, Wara W, Marcus KC, Vijayakumar S. Effect of subcutaneous recombinant human erythropoietin in cancer patients receiving radiotherapy: final report of a randomized, open-labelled, phase II trial. Br J Cancer 1998; 77:1996-2002. [PMID: 9667681 PMCID: PMC2150364 DOI: 10.1038/bjc.1998.331] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The purpose of this study was to determine the safety, efficacy and impact on quality of life of recombinant human erythropoietin (r-HuEPO) for cancer patients undergoing radiotherapy (RT). An open-labelled randomized design was used, with patients randomized to either treatment or control arms. Patients in the treatment arm received r-HuEPO given by subcutaneous injection at a dose of 200 units kg(-1) day(-1) plus oral iron supplements (ferrous sulphate 325 mg p.o. t.i.d.). Entry was restricted to patients with carcinoma of the lung, uterine cervix, prostate or breast who presented for RT with anaemia parameters reflective of 'the anaemia of chronic disease'. Radiotherapy policies (portals, doses, fraction size, etc.) were determined by the site and stage of disease. Complete blood counts (CBCs) were obtained weekly. The target level of haemoglobin was 15 g dl(-1) for men and 14 g dl(-1) for women. Quality of life (QOL) was assessed weekly by using an analogue scale to judge energy, activities of daily living and overall quality of life. Forty-eight patients were entered in the study, 24 in the treatment arm and 24 in the control arm. The prerandomization demographic characteristics and mean laboratory values were comparable in both arms. The mean haemoglobin at completion was 13.6 g dl(-1) for r-HuEPO-treated patients compared with 11.0 g dl(-1) for control subjects (P = 0.0012). Patients who received r-HuEPO demonstrated a mean weekly haemoglobin increase of 0.41 g dl(-1) compared with a decrease in mean haemoglobin level in controls for 6 of the 7 weeks of the study (mean weekly decrease of 0.073 g dl(-1)). Target levels of haemoglobin were achieved by 41.6% of r-HuEPO-treated patients compared with none of the control subjects. The mean platelet count declined in both arms of the study with RT but the decline from pretreatment was less rapid in r-HuEPO-treated patients (11.2% decrease) compared with controls (26.3% decrease) and was statistically significant during weeks 4-6. Toxicity was minor with only mild irritation at the injection site. Mean quality of life end points were superior in the treatment arm but not statistically significant. r-HuEPO had a beneficial effect on weekly haemoglobin levels in patients undergoing RT with response rates similar to other studies. There was also a less rapid decline in weekly platelet counts in r-HuEPO-treated patients compared with control subjects. Further studies are needed to address the optimum dose and scheduling as well as the impact of r-HuEPO on clinical outcomes.
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Affiliation(s)
- P J Sweeney
- Department of Radiation and Cellular Oncology, University of Chicago, IL, USA
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Koumantakis E, Haralambakis Z, Koukourakis M, Mazonakis M, Haldeopoulos D, Papageorgiou N, Livas V, Froudarakis G, Varveris H. A pilot study on concurrent platinum chemotherapy and intracavitary brachytherapy for locally advanced cancer of the uterine cervix. Br J Radiol 1998; 71:552-7. [PMID: 9691902 DOI: 10.1259/bjr.71.845.9691902] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
This study aims to evaluate the feasibility, toxicity and efficacy of concurrent chemotherapy with platinum compounds and brachytherapy, for locally advanced carcinoma of the cervix (Stages IIA/B, IIIA). The hypothesis was that synchronous chemo-brachytherapy may be sufficient to cause down-staging of the tumour, to render it operable, and hopefully improve the prognosis. 36 women with locally advanced cervical cancer were treated with concomitant brachytherapy and chemotherapy before surgery and/or definitive external radiotherapy. All patients received two caesium-137 Selectron MDR applications, 1 week apart. The dose calculated to point A for each implant was 20-25 Gy. Chemotherapy consisting of continuous cisplatin infusion (50 mg m2) and of carboplatin (300 mg m-2) was given simultaneously with intracavitary irradiation during the first and second application, respectively. The combined therapy was followed when feasible by radical hysterectomy, pelvic lymphadenectomy and pelvic radiotherapy. Patients deemed ineligible for surgery because of poor response were given full dose external radiotherapy. 31/36 patients were treated by Wertheim hysterectomy of whom 10 had negative lymph nodes and resection margins. Definitive external radiotherapy was given in the remaining five patients. Overall, 83% were disease free at 2.8 years mean follow-up. The most frequent acute side-effects of chemobrachytherapy were nausea and vomiting. No renal toxicity was observed. Thrombocytopenia was seen in five patients and was responsible for delayed surgery in four patients. Concerning late effects, two patients developed grade 2 intestinal sequelae, two mild frequency and two vaginal stenosis. One rectovaginal and one vesicovaginal fistula developed in two patients; and a third patient had a fistula associated with tumour recurrence. Concurrent brachytherapy and chemotherapy with platinum compounds is well tolerated and effective in reducing tumour bulk before definitive local treatment (surgery or external radiotherapy), in patients with locally advanced carcinoma of the uterine cervix.
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Affiliation(s)
- E Koumantakis
- Department of Obstetrics and Gynecology, Iraklion University Hospital, Crete, Greece
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Mayr NA, Yuh WT, Zheng J, Ehrhardt JC, Sorosky JI, Magnotta VA, Pelsang RE, Hussey DH. Tumor size evaluated by pelvic examination compared with 3-D quantitative analysis in the prediction of outcome for cervical cancer. Int J Radiat Oncol Biol Phys 1997; 39:395-404. [PMID: 9308943 DOI: 10.1016/s0360-3016(97)00318-0] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE Tumor size estimated by pelvic examination (PE) is an important prognostic factor in cervical cancer treated with radiation therapy (RT). Recent histologic correlation studies also showed that magnetic resonance (MR) imaging provides highly accurate measurements of the actual tumor volume. The purpose of this study was to: (a) compare the accuracy of PE and MR in predicting outcome, and (b) correlate tumor measurements by PE versus MR. METHODS AND MATERIALS Tumor measurements were performed prospectively in 43 patients with advanced cervical cancer. MR and PE were performed at the same time intervals: (a) at the start of RT, (b) after 20-24 Gy/2-2.5 weeks, (c) after 40-50 Gy/4-5 weeks, and (d) at follow-up (1-2 months after RT completion). PE measured tumor diameters in anteroposterior, lateral, and craniocaudal direction, and PE-derived tumor size was computed as maximum diameter, average diameter, and ellipsoid volume. MR-derived tumor size was calculated by summation of the tumor areas in each section and multiplication by the section thickness. Tumor regression during RT was calculated for each method as percentage of initial volume. The measurements were correlated with local failure and disease-free survival. Median follow-up was 29 months (range: 9-56 months). RESULTS Prediction of local control: Overall, tumor regression rate (rapid versus slow) was more precise than the initial tumor size in the prediction of outcome. MR provided a more accurate and earlier prediction of local control (at 2-2.5 weeks, and at 4-5 weeks of RT) than PE (only at follow-up). Based on the initial tumor size, MR was also better than PE in predicting disease-free survival and local control, particularly in large (> or = 100 cm3) tumors. Size correlation: Tumor size (maximum diameter, average diameter, volume) by PE and MR did not correlate well (r = 0.51, 0.61, and 0.58, respectively). When using MR measurements as a reference, PE tended to overestimate intermediate-size (40-99 cm3) tumors. CONCLUSION This preliminary study suggests that increased precision of tumor volume measurement leads to more accurate and earlier prediction of outcome in cervical cancer. MR tumor volumetry may be useful as an adjunct to PE in selected cases, and holds the potential to impact therapeutic decision-making.
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Affiliation(s)
- N A Mayr
- Division of Radiation Oncology, The University of Iowa College of Medicine, Iowa City 52242, USA
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Ogino I, Okamoto N, Andoh K, Kitamura T, Okajima H, Matsubara S. Analysis of prognostic factors in stage IIB-IVA cervical carcinoma treated with radiation therapy: value of computed tomography. Int J Radiat Oncol Biol Phys 1997; 37:1071-7. [PMID: 9169815 DOI: 10.1016/s0360-3016(96)00599-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE To define the influence of the tumor size measured by computed tomography (CT) and lymph node involvement detected by CT in patients treated with radiation therapy for Stage IIB-IVA carcinoma of intact uterine cervix. METHODS AND MATERIALS This was a retrospective analysis of 233 patients with uterine cervical cancer managed with both external irradiation and high-dose-rate intracavitary brachytherapy (HDR-ICR) at Kanagawa Cancer Center. The results were analyzed for the end points of absolute survival (AS), disease-free survival (DFS), pelvic control (PC), and central control (CC). The parameters of stage, CT-measured anterior-posterior (AP) cervix size, and CT-detected lymph node metastases were evaluated using univariate and multivariate analysis. RESULTS The stage, AP cervix size, and lymph node involvement were significant pretreatment factors in univariate analysis with respect to AS, DFS, PC, and CC. Multivariate analysis confirmed that significant risk was associated with certain prognostic parameters. Those in terms of AS, in order of decreasing significance, were lymph node involvement, AP cervix size, age, and total HDR-ICR dose. When DFS was studied, lymph node involvement and AP cervix size were demonstrated to have a significant effect. Stage and lymph node involvement significantly affected PC. CONCLUSION Because the International Federation of Gynecological Obstetrics staging system fails to incorporate important prognostic information about tumor volume and lymph node involvement, CT-detected lymph node metastases as well as CT-measured cervix size should be determined as complementary additional prognostic measures.
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Affiliation(s)
- I Ogino
- Department of Radiology, Yokohama City University, Kanazawa-ku, Japan
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Griebel J, Mayr NA, de Vries A, Knopp MV, Gneiting T, Kremser C, Essig M, Hawighorst H, Lukas PH, Yuh WT. Assessment of tumor microcirculation: a new role of dynamic contrast MR imaging. J Magn Reson Imaging 1997; 7:111-9. [PMID: 9039600 DOI: 10.1002/jmri.1880070115] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
With the advances in MR techniques, information related to tumor microcirculation now can be obtained in the clinical setting. This information can be valuable in the assessment of tumor blood supply/oxygenation status and tumor response to therapy. In this article, we review the tracer-kinetic modeling for tumor microcirculatory parameters derived from dynamic contrast MR imaging and report several preliminary results from both an animal model and early experience with human tumors. Despite the application of different MR protocols and tracer-kinetic models, the initial results of these pioneer studies consistently support the role of MR-derived microcirculatory tumor parameters, in providing prognostic information to assess and predict the response of cancers to cytotoxic therapy.
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Affiliation(s)
- J Griebel
- Institute of Radiobiology, GSF-National Research Center for Environment and Health, Neuherberg, Germany
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Corn BW, Schnall MD, Milestone B, King S, Hauck W, Solin LJ. Signal characteristics of tumors shown by high-resolution endorectal coil magnetic resonance imaging may predict outcome among patients with cervical carcinoma treated with irradiation: A preliminary study. Cancer 1996. [DOI: 10.1002/(sici)1097-0142(19961215)78:12<2535::aid-cncr13>3.0.co;2-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Mayr NA, Yuh WT, Magnotta VA, Ehrhardt JC, Wheeler JA, Sorosky JI, Davis CS, Wen BC, Martin DD, Pelsang RE, Buller RE, Oberley LW, Mellenberg DE, Hussey DH. Tumor perfusion studies using fast magnetic resonance imaging technique in advanced cervical cancer: a new noninvasive predictive assay. Int J Radiat Oncol Biol Phys 1996; 36:623-33. [PMID: 8948347 DOI: 10.1016/s0360-3016(97)85090-0] [Citation(s) in RCA: 171] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE This study investigated sequential changes in tumor blood supply using magnetic resonance (MR) perfusion imaging and assessed their significance in the prediction of outcome of patients with advanced cervical cancer. The purpose of this project was to devise a simple, noninvasive method to predict early signs of treatment failure in advanced cervical cancer treated with conventional radiation therapy. METHODS AND MATERIALS Sixty-eight MR perfusion studies were performed prospectively in 17 patients with squamous carcinomas (14) and adenocarcinomas (3) of the cervix, Stages bulky IB (1), IIB (5), IIIA (1), IIIB (8), and IVA (1), and recurrent (1). Four sequential studies were obtained in each patient: immediately before radiation therapy (pretherapy), after a dose of 20-22 Gy/ approximately 2 weeks (early therapy), after a dose of 40-45 Gy/ approximately 4-5 weeks (midtherapy), and 4-6 weeks after completion of therapy (follow-up). Perfusion imaging of the tumor was obtained at 3-s intervals in the sagittal plane. A bolus of 0.1 mmol/kg of MR contrast material (gadoteridol) was injected intravenously 30 s after beginning image acquisition at a rate of 9 ml/s using a power injector. Time/signal-intensity curves to reflect the onset, slope, and relative signal intensity (rSI) of contrast enhancement in the tumor region were generated. Median follow-up was 8 months (range 3-18 months). RESULTS Tumors with a higher tissue perfusion (rSI > or = 2.8) in the pretherapy and early therapy (20-22 Gy) studies had a lower incidence of local recurrence than those with a rSI of < 2.8, but this was not statistically significant (13% vs. 67%; p = 0.05). An increase in tumor perfusion early during therapy (20-22 Gy), particularly to an rSI of > or = 2.8, was the strongest predictor of local recurrence (0% vs. 78%; p = 0.002). However, pelvic examination during early therapy (20-22 Gy) commonly showed no appreciable tumor regression. The slope of the time/signal-intensity curve obtained before and during radiation therapy also correlated with local recurrence. Follow-up perfusion studies did not provide information to predict recurrence. CONCLUSION These preliminary results suggest that two simple MR perfusion studies before and early in therapy can offer important information on treatment outcome within the first 2 weeks of radiation therapy before response is evident by clinical examination. High tumor perfusion before therapy and increasing or persistent high perfusion early during the course of therapy appear to be favorable signs. High perfusion suggests a high blood and oxygen supply to the tumor. The increase in tumor perfusion seen in some patients early during radiation therapy suggests improved oxygenation of previously hypoxic cells following early cell kill. Radiation therapy is more effective in eradicating these tumors, resulting in improved local control. Our technique may be helpful in identifying early-while more aggressive therapy can still be implemented-those patients who respond poorly to conventional radiation therapy.
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Affiliation(s)
- N A Mayr
- Division of Radiation Oncology, University of Iowa College of Medicine, Iowa City, USA
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Mayr NA, Magnotta VA, Ehrhardt JC, Wheeler JA, Sorosky JI, Wen BC, Davis CS, Pelsang RE, Anderson B, Doornbos JF, Hussey DH, Yuh WT. Usefulness of tumor volumetry by magnetic resonance imaging in assessing response to radiation therapy in carcinoma of the uterine cervix. Int J Radiat Oncol Biol Phys 1996; 35:915-24. [PMID: 8751400 DOI: 10.1016/0360-3016(96)00230-1] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE Clinical evaluation of tumor size in cervical cancer is often difficult, and clinical signs of radiation therapy failure may not be present until well after completion of treatment. The purpose of this study is to investigate early indicators of treatment response using magnetic resonance (MR) imaging for quantitative assessment of tumor volume and tumor regression rate before, during, and after radiation therapy. METHODS AND MATERIALS Thirty-four patients with cervical cancer Stages IB [5], IIB [8], IIIA [1], IIIB [14], IVA [3], IVB [1], and recurrent [2] were studied prospectively with four serial MR examinations obtained at the start of radiation therapy, at 2-2.5 weeks (20-24 Gy), at 4-5 weeks (40-50 Gy), and 1-2 months after treatment completion. Tumor volume was assessed by three-dimensional volumetric measurements using T2-weighted images of each MR examination. The volume regression rate was generated based on the four sequential MR studies. These findings were correlated with local control, metastasis rate, and disease-free survival. Median follow-up was 18 months (range: 9-43 months). RESULTS The tumor regression rate after a dose of 40-50 Gy correlated significantly with treatment outcome. The actuarial 2-year disease-free survival was 88.4% in patients with tumors regressing to < 20% of the initial volume compared with 45.4% in those with > or = 20% residual (p = 0.007). The incidence of local recurrence was 9.5% (2 out of 21) and 76.9% (10 out of 13), respectively (p < 0.001). Analysis by initial tumor volume showed that this observation was valid in patients with initial volumes between 40 and 100 cm3. Analysis by FIGO stage confirmed this observation in all patients except those with Stage IB. CONCLUSION Sequential tumor volumetry using MR imaging appears to be a sensitive measure of the responsiveness of cervical cancer to irradiation. Treatment response can be assessed as early as during the course of radiation therapy by measurement of initial tumor volume and regression rate at 40-50 Gy. In patients with large (> 40 cm3) and advanced (Stage > or = IIIA) tumors, this technique may be helpful in supplementing the clinical examination for response assessment. The identification of patients at high risk for treatment failure may ultimately lead to improved clinical outcome.
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Affiliation(s)
- N A Mayr
- Division of Radiation Oncology, University of Iowa College of Medicine, Iowa City, USA
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Kigawa J, Minagawa Y, Ishihara H, Itamochi H, Kanamori Y, Terakawa N. The role of neoadjuvant intraarterial infusion chemotherapy with cisplatin and bleomycin for locally advanced cervical cancer. Am J Clin Oncol 1996; 19:255-9. [PMID: 8638536 DOI: 10.1097/00000421-199606000-00009] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
To clarify the effect of neoadjuvant intraarterial infusion chemotherapy on the cure rate in advanced cervical cancer with bulky tumor, a total of 50 patients were examined prospectively. The clinical stage according to the International Federation of Gynecology and Obstetrics (FIGO) classification included 23 IIb, 6 IIIa, and 21 IIIb. These patients were randomly divided into the neoadjuvant intraarterial infusion chemotherapy group and the control group. There were no significant differences in mean age, FIGO clinical stage, and tumor histology between groups. Twenty-five patients in the former group were given 25 mg/m2 of cisplatin and 15 mg/m2 of bleomycin via each internal iliac artery. If the results of the evaluation indicated that surgery was feasible, radical surgery was performed. The patients whose tumors were inoperable received radiation therapy consisting of external irradiation and intracavitary irradiation. Twenty-five patients in the control group also underwent the same radiation therapy. The overall response rate was 80.0%. Eighteen of 20 responders underwent surgery. The 3-year survival rate was 85.7% for operated patients, 42.9% for patients receiving neoadjuvant intraarterial infusion chemotherapy followed by irradiation, and 49.5% for the control group. In the present study, neoadjuvant intraarterial infusion chemotherapy did not improve the prognosis of patients with advanced cervical cancer compared to radiation therapy alone, and only responders who underwent surgery obtained an advantage in survival.
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Affiliation(s)
- J Kigawa
- Department of Obstetrics and Gynecology, Tottori University School of Medicine, Yonago, Japan
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Thoms WW, Unger ER, Johnson PR, Spann CO, Hunter SH, Smith R, Horowitz IR, Icenogle JP, Vernon SD, Reeves WC. Cervical cancer survival in a high risk urban population. Cancer 1995; 76:2518-23. [PMID: 8625079 DOI: 10.1002/1097-0142(19951215)76:12<2518::aid-cncr2820761217>3.0.co;2-#] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cervical cancer remains an important public health problem, particularly for the urban minority population. To the authors' knowledge, determinants of cervical cancer survival have not been studied in this high risk population. METHODS This study included all 158 women diagnosed and treated for invasive cervical cancer from January 1, 1986, through December 31, 1992, at the Grady Memorial Hospital and Clinics (Atlanta, GA). Medical records were abstracted to determine age at diagnosis, race, International Federation of Gynecology and Obstetrics (FIGO) clinical stage, treatment, and survival. Pathologic material was reviewed to confirm the diagnosis. RESULTS Most patients (80%) were African American, and the stage distribution was similar for African American and white patients. Sixty-six (42%) had FIGO Stage I disease; 50%, Stage II or III; and 8%, Stage IV. Four-year actuarial survival differed significantly according to clinical stage (Ia = 94%, Ib = 79%, II = 39%, III = 26%, IV = 0%). Overall survival was lower for patients with glandular carcinomas than for those with squamous cell carcinomas (26% vs. 55%, P = 0.09). This difference was almost entirely due to increased mortality in patients with Stage Ib adenocarcinomas (53% vs. 88% for squamous cell carcinoma, Stage Ib, P = 0.03). CONCLUSIONS The major prognostic markers for cervical cancer survival in this high risk patient population were clinical stage and histology, factors identical to those identified for other populations.
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Affiliation(s)
- W W Thoms
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA
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Wheeler JA, Stephens LC, Tornos C, Eifel PJ, Ang KK, Milas L, Allen PK, Meyn RE. ASTRO Research Fellowship: apoptosis as a predictor of tumor response to radiation in stage IB cervical carcinoma. American Society for Therapeutic Radiology and Oncology. Int J Radiat Oncol Biol Phys 1995; 32:1487-93. [PMID: 7635794 DOI: 10.1016/0360-3016(95)00156-s] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE Levels of apoptosis predict for tumor responsiveness to radiation in various animal systems. To investigate the potential role of apoptosis as a predictor of response in human tumors, a retrospective review was undertaken of patients with adenocarcinoma of the cervix whose primary lesion at presentation measured at least 4 cm and who underwent definitive radiation therapy. A previous report had indicated that roughly half this group of patients should have a long-term relapse free survival. METHODS AND MATERIALS Pretreatment biopsy specimens of 44 patients with Stage IB adenocarcinoma of the cervix, whose primary lesion at presentation measured at least 4 cm in greatest dimension, were scored for apoptosis by two independent investigators without knowledge of the treatment outcome, and the results were averaged. Actuarial methods were used to assess overall survival, disease-free survival, determinate survival, and local control as a function of the baseline level of apoptosis. Patients ranged in age from 21 to 87 years and were treated with definitive radiotherapy between 1964 and 1989. Follow-up for the surviving patients ranged from 1 to 278 months, with a mean of 101 months. RESULTS Patients whose tumors had a baseline level of apoptosis above the median value (2%) had a better overall survival than those with lower levels of apoptosis (p = 0.056). A similar trend for disease-free survival (p = 0.32) and determinate survival (p = 0.27) did not reach statistical significance, perhaps because of the small number of patients. Because only 6 of the 44 patients (13%) had a local tumor failure, it was not possible to establish a correlation between the pretreatment level of apoptosis and the local tumor control by radiation. CONCLUSION The baseline level of apoptosis predicted for survival in patients with Stage IB cervical adenocarcinoma. Further investigation of the measurement of apoptosis as a potential predictive assay is warranted in other human tumor systems.
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Affiliation(s)
- J A Wheeler
- Department of Radiotherapy, University of Texas M. D. Anderson Cancer Center, Houston, USA
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Werner-Wasik M, Schmid CH, Bornstein L, Ball HG, Smith DM, Madoc-Jones H. Prognostic factors for local and distant recurrence in stage I and II cervical carcinoma. Int J Radiat Oncol Biol Phys 1995; 32:1309-17. [PMID: 7635770 DOI: 10.1016/0360-3016(94)00613-p] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE The effects of tumor size, parametrial involvement, and other variables on treatment outcome for patients with Federation Internationale de Gynecologie et d'Obstetrique (FIGO) Stage I or II cervical carcinoma, as well as treatment complications, were analyzed retrospectively. METHODS AND MATERIALS Records of 125 patients with FIGO Stage I or II carcinoma of the uterine cervix selected for curative radiotherapy between January 1980 and December 1990 were reviewed. Twelve patients (9.9%) underwent adjuvant extrafascial hysterectomy and 8 patients (6.4%) received chemotherapy. Median age was 55 years. Median follow-up time was 40 months, and minimum follow-up time was 24 months. The data were analyzed for site of first relapse, survival, overall incidence of complications, and incidence of grade 4 complications. RESULTS The overall 5-year survival was: Stage IA: 100%, Stage IB: 72%, Stage IIA: 90%, and Stage IIB: 72%. The 5-year survival with no evidence of disease (NED) was: Stage IA: 100%, Stage IB: 67%, Stage IIA: 90%, and Stage IIB: 50%. Patients with bulky (> 5 cm) tumors had a shorter overall and NED survival than patients with nonbulky tumors (53% vs. 83%; p = 0.0008 and 44% vs. 78%; p = 0.0001, respectively). Thirty-nine tumor recurrences (39 out of 125 = 31%) occurred and were scored as local (23 out of 125 = 18.3%), if initial failure had a local component, or distant (16 out of 125 = 12.7%), if initial failure was distant only. Patients with bulky (more than 5 cm) tumors (32 out of 125) were more likely to experience a recurrence (18 out of 32 = 56%) than patients with nonbulky tumors (21 out of 93 = 22%; p = 0.0004). The initial site of recurrence was more likely to be local for bulky tumors (14 out of 18 = 78%) than for nonbulky tumors (9 out of 21 = 43%; p = 0.03). The probability of a recurrence increased with the number of involved parametria (none: 20 out of 78 = 25%; one: 12 out of 34 = 35%; two: 7 out of 13 = 54%; p = 0.04 for linear trend), as did the probability that the initial failure was distant rather than local (none: 4 out of 20 = 20%; one: 7 out of 12 = 58%; two: 5 out of 7 = 71%; p = 0.01 for linear trend). Positive lymph nodes, vessel invasion, and low hemoglobin level all correlated with an increased risk of a recurrence (RR 2.41, p = 0.004; RR 2.20, p = 0.01; OR 2.02, p = 0.01, respectively). There were 46 complications among 37 (29%) patients. The incidence of grade 4 complications was 8.8% (11 out of 125). History of pelvic surgery and bulky tumor were significant predictors of a grade 4 complication (p < 0.0001 and 0.021, respectively). Also, a dose rate to point A of > 0.6 Gy/h increased the chance of a grade 4 complication (p = 0.007). CONCLUSION For patients with FIGO Stage I or II cervical carcinoma, tumor size was more predictive of local recurrence than was overall stage, and the extent of parametrial involvement was strongly predictive of distant recurrence, as was the stage. These findings suggest that tumor size and extent of parametrial involvement should be incorporated into the staging system. Patients with bulky tumors had a shorter survival and were more likely to experience a grade 4 toxicity of therapy. Dose rate to point A of > 0.6 Gy/h was associated with the increased risk of grade 4 complications.
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Zylberait D. [Chemotherapy and systemic treatments of cervical cancer]. Rev Med Interne 1995; 16:421-33. [PMID: 7652224 DOI: 10.1016/0248-8663(96)80733-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The prognosis of cervical cancer depends on nodal status and tumoral volume. Among patients with risk factors, chemotherapy seems promising, particularly with concomitant chemoradiation or neo adjuvant chemotherapy before surgery. The advent of treatments with combination of alpha interferon and 13 cis retinoid acid probably leads to a new therapeutic generation.
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Affiliation(s)
- D Zylberait
- Service d'oncologie médicale, centre hospitalier, Compiègne, France
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Shepherd SF, Collins CD, Fryatt IJ, Parsons CA, Blake PR. Computerized axial tomographic scan measurements as prognostic indicators in patients with cervical carcinoma. Br J Radiol 1995; 68:600-3. [PMID: 7627482 DOI: 10.1259/0007-1285-68-810-600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
This retrospective study of 56 patients with carcinoma of the uterine cervix treated with radical radiotherapy at the Royal Marsden Hospital, London, examined whether simple measurements of maximum tumour dimension from computerized axial tomographic (CT) scans have any prognostic significance. Our results indicate that tumour depth (i.e. maximum antero-posterior dimension) of 4 cm or more is associated with a statistically significant increased relative risk of death of 2.4 (95% CI 1.1-5.5; p = 0.045), as compared with tumours with a depth of less than 4 cm. In addition, there was a clear correlation between tumour depth and lymph node involvement (r = 0.36; p < 0.01), and tumour depth and width (r = 0.70; p < 0.005). We suggest that a measurement of maximum tumour depth from the staging CT scan in these patients provides valuable additional information about likely occult lymph node metastases and prognosis, over and above that suggested by the FIGO staging system alone.
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Affiliation(s)
- S F Shepherd
- Department of Radiotherapy, Royal Marsden Hospital, London, UK
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Abstract
BACKGROUND The poor survival of young patients with cervical cancer in a low income, disadvantaged community stimulated an investigation of pathologic and behavioral risk factors. METHODS The records of 1173 patients with cervical cancer diagnosed in 1967-1988 were evaluated with respect to age, stage, histology, and presenting symptoms. Histopathologic risk factors were evaluated in 196 patients with Stage IB disease treated by initial hysterectomy. Substance abuse behaviors were evaluated for 332 symptomatic patients with Stages IB-III disease diagnosed from 1976 to 1988. RESULTS There were no significant age-related differences in survival for patients without squamous cell carcinoma or those with Stage IA and asymptomatic Stage IB squamous cell carcinoma. Women age 70 years and older had a poorer survival rate than did younger women with Stages IB-III disease. Symptomatic patients with squamous cell carcinoma younger than age 50 years had a poorer survival than did patients age 50-69 years with Stages IB/IIA, IIB, and III disease. For patients with symptomatic Stage IB tumors, poor prognostic histopathologic factors were distributed equally among women younger than age 50 and those aged 50-69 years. Substance abuse was significantly more prevalent among younger patients, and patients who smoked or abused alcohol or drugs had significantly poorer survival than did nonsubstance abusers. However, in a multivariate analysis of age, stage, and substance abuse, young age remained a significantly poor prognostic factor. CONCLUSIONS Substance abuse may contribute to poor outcome of young patients with symptomatic squamous cell carcinoma but does not explain adequately their poor survival.
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Affiliation(s)
- E Serur
- Department of Obstetrics and Gynecology, State University of New York--Health Science Center, Brooklyn 11203, USA
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Affiliation(s)
- M E Crowther
- St. Bartholomew's Hospital, London, United Kingdom
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Eifel PJ, Morris M, Wharton JT, Oswald MJ. The influence of tumor size and morphology on the outcome of patients with FIGO stage IB squamous cell carcinoma of the uterine cervix. Int J Radiat Oncol Biol Phys 1994; 29:9-16. [PMID: 8175451 DOI: 10.1016/0360-3016(94)90220-8] [Citation(s) in RCA: 219] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE To define the influence of tumor size and morphology on rates of central tumor control (CTC), pelvic tumor control (PTC), and disease-specific survival (DSS) in patients treated with radiotherapy for squamous cell carcinoma of the intact uterine cervix. METHODS AND MATERIALS Records of 1526 patients treated with radiotherapy for FIGO Stage IB squamous cell carcinoma of the intact uterine cervix between 1960 and 1989 were retrospectively reviewed. The maximum tumor or cervical diameter was determined from clinical descriptions for 1494 patients. Tumors were divided into nine size categories. Tumors > or = 4 cm were further classified according to the dominant morphology (i.e., exophytic or endocervical). Median follow-up was 12.2 years. Five-year CTC, PTC, and DSS rates were calculated actuarially. RESULTS CTC, PTC, and DSS rates correlated strongly with tumor diameter (p < 0.0001). Overall, CTC, PTC, and DSS rates for patients with tumors < 5 cm were 99%, 97%, and 88%, respectively. For patients with tumors 5-7.9 cm these rates were 93%, 84%, and 69%, respectively. There were no significant differences in the rates of PTC, CTC, or DSS between subgroups of patients with lesions 5-7.9 cm in diameter. The rates of CTC (97%) and DSS (76%) for patients with 5-7.9 cm exophytic tumors were significantly better than those for patients with endocervical tumors of the same size (91% and 66%, respectively); there was no difference in the PTC rate. CONCLUSION Although the CTC rates were excellent for all patients with tumors < 8 cm in diameter, these rates for tumors < 5 cm (99%) and for exophytic tumors 5-7.9 cm (97%) make it difficult to justify the use of adjuvant hysterectomy. Although patients with tumors of 5-7.9 cm had consistently poorer PTC and DSS rates than did patients with smaller tumors, the control rates achieved with aggressive radiotherapy were still excellent. The strong correlation between tumor size and outcome suggests that tumor diameter should be assessed when tumors are clinically evaluated and staged and when treatment results are reported for patients with FIGO Stage IB carcinoma of the uterine cervix.
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Affiliation(s)
- P J Eifel
- Division of Radiotherapy, University of Texas M. D. Anderson Cancer Center, Houston 77030
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Kosary CL. FIGO stage, histology, histologic grade, age and race as prognostic factors in determining survival for cancers of the female gynecological system: an analysis of 1973-87 SEER cases of cancers of the endometrium, cervix, ovary, vulva, and vagina. SEMINARS IN SURGICAL ONCOLOGY 1994; 10:31-46. [PMID: 8115784 DOI: 10.1002/ssu.2980100107] [Citation(s) in RCA: 278] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The prognostic impact of FIGO stage, histology, histologic grade, age and race in survival for cancers of the female gynecological (cervix, endometrium, ovary, vulva, vagina) were examined using cases obtained from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program that were diagnosed between 1973 and 1987. Utilizing Cox proportional hazards modeling and relative survival rates analysis of 17,119 cases of cervical cancer indicated that the International Federation of Gynecology and Obstetrics (FIGO) stage, histology, histological grade, lymph node status, and age at diagnosis were all independently prognostic. No evidence was found of survival differences between squamous cell carcinoma and adenocarcinoma. Younger women were not found to have a poorer prognosis, survival declined with increased age. Analysis of 41,120 cases of endometrial cancer indicated that FIGO stage, histology, histologic grade, lymph node status, age at diagnostic, and race were all prognostic factors. Clear cell adenocarcinoma, leiomyosarcoma, and mixed mullerian tumors were all found to have poorer prognosis. Analysis of 21,240 cases of ovarian cancer indicated that FIGO stage, histology, histologic grade, lymph node status, age at diagnosis, presence of ascites, and race were all prognostically significant. Analysis of 2,575 cases of vulvar cancer indicated that FIGO stage, histology, histologic grade, age, and race were all prognostically significant. Analysis of 916 cases of vaginal cancer indicated that FIGO stage, histologic grade, lymph node status, and age are all prognostically significant. Additional analysis of the data by combinations of independent prognostic factors indicates that the interaction of factors may be more predictive of outcome than any one factor separately.
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Affiliation(s)
- C L Kosary
- Div. of Cancer Prevention and Control, National Cancer Institute, Bethesda, MD 20892
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Mendenhall WM, Sombeck MD, Freeman DE, Morgan LS. Stage IB and IIA-B carcinoma of the intact uterine cervix: Impact of tumor volume and the role of adjuvant hysterectomy. Semin Radiat Oncol 1994. [DOI: 10.1016/s1053-4296(05)80105-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Brizel DM, Klitzman B, Cook JM, Edwards J, Rosner G, Dewhirst MW. A comparison of tumor and normal tissue microvascular hematocrits and red cell fluxes in a rat window chamber model. Int J Radiat Oncol Biol Phys 1993; 25:269-76. [PMID: 8420874 DOI: 10.1016/0360-3016(93)90348-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
This laboratory has previously used a window chamber model to measure red blood cell velocity in mammary tumors and normal granulation tissues of the F-344 rat. Because red cell flux and hematocrit more accurately reflect the oxygen carrying potential of blood, we used this model to measure these parameters. Red blood cells were labelled with fluorescein isothiocyanate, and 0.2 ml. packed cells were injected intravenously into rats bearing an 8 to 10 day old R-3230 mammary carcinoma. beta-phycoerythrin (0.15 mg.) was also injected and served as a plasma dye to outline the blood vessels. A sample of peripheral blood was then taken and analyzed by flow cytometry to determine the labeled fraction of red blood cells. Flowing tumor and normal tissue vessels were recorded onto a VCR, and these video images were used to determine vascular length and diameter, RBC flux and velocity, and hematocrit. Median vessel diameter and loge (red blood cell flux) were significantly greater in tumors than in normal tissues (p = 0.007 and p < 0.025, respectively). After controlling for these variables, the median tumor hematocrit of 19% was not significantly greater than the median normal tissue hematocrit of 15%. This technique provides a nontoxic and reproducible method that is now being used to assist in the in vivo definition of tumor oxygenation.
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Affiliation(s)
- D M Brizel
- Dept. of Radiation Oncology, Duke University Comprehensive Cancer Center, Durham, NC 27710
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Touboul E, Lefranc JP, Blondon J, Ozsahin M, Roche B, Mauban S, Batel-Copel L, Schwartz LH, Schlienger M, Laugier A. Preoperative radiation therapy and surgery in the treatment of "bulky" squamous cell carcinoma of the uterine cervix (stage Ib, IIa, and IIb operable tumors). Radiother Oncol 1992; 24:32-40. [PMID: 1620885 DOI: 10.1016/0167-8140(92)90351-t] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Forty-two women with "bulky" squamous cell carcinoma of the uterine cervix, larger than 5 cm, were treated between 1982 and 1988. The median follow-up was 5 years (from 37 to 106 months). The age range was from 25 to 77 years (mean: 49). There were 14 stage Ib, 5 stage IIa, and 23 stage IIb operable patients. Forty grays were delivered at mid-plane of the pelvis (23 fractions in 31 days) using the four-field technique (6-18 MV). External beam radiation therapy was followed by 20 Gy of intracavitary radiation therapy. Forty-eight days later total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO) and bilateral pelvic lymphadenectomy were performed. The 3- and 5-year disease-free survival was 83 and 81%, respectively. The 5-year locoregional control rate was 83%. Thirteen patients suffered from mild to severe complications (31%) but there were only two long-term (5%) complications.
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Affiliation(s)
- E Touboul
- Service de Cancérologie-Radiothérapie A, C.H. Tenon, Paris, France
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Coleman DL, Gallup DG, Wolcott HD, Otken LB, Stock RJ. Patterns of failure of bulky-barrel carcinomas of the cervix. Am J Obstet Gynecol 1992; 166:916-20. [PMID: 1550164 DOI: 10.1016/0002-9378(92)91362-e] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE(S) This retrospective study was conducted to analyze the hypothesis that radiation therapy followed by extrafascial hysterectomy would improve survival in patients with bulky-barrel cervical carcinomas. STUDY DESIGN Forty-three patients with bulky-barrel carcinomas of the cervix were treated over a 14-year period. The majority of these were treated with approximately 4000 cGY external beam, followed by brachytherapy, followed by extrafascial hysterectomy. RESULTS Forty-seven percent of all patients are dead of disease; 2.3% are alive with disease. Of the total patients, 35% had diseased paraaortic nodes, and 80% of these are dead of disease. Of the patients dead of disease, 80% had distant metastases. Delayed complications included: vesicovaginal fistulas (n = 3), surgery for bowel obstruction (n = 3), rectovaginal fistula (n = 1), and vaginal vault necrosis (n = 3). CONCLUSION These data do not support an improvement in survival of patients with bulky-barrel-shaped lesions treated with irradiation plus adjunctive hysterectomy.
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Affiliation(s)
- D L Coleman
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta
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