Multimodal treatment with neoadjuvant intraarterial chemotherapy and radical surgery in patients with stage IIIB-IVA cervical cancer. A preliminary study

The comparative study for survival outcome of locally advanced cervical cancer treated by neoadjuvant arterial interventional chemotherapy or intravenous chemotherapy followed by surgery or concurrent chemoradiation

OBJECTIVE

This study aimed to compare the survival outcome of 3 different treatment groups (arterial interventional chemotherapy or intravenous chemotherapy or concurrent chemoradiotherapy) for locally advanced cervical cancer.

METHODS

A total of 187 patients with pathological stage IB3-IIB cervical cancer (cervical squamous cell carcinoma, adenosquamous carcinoma, or adenocarcinoma) hospitalized in the First Affiliated Hospital of Zhengzhou University from January 2013 to May 2019 were included. Therefore, this article is a retrospective study. We collected data from all eligible patients. And all according to the treatment methods at that time, they were divided into three subgroups: (1) 40 patients who received neoadjuvant arterial interventional chemotherapy + surgery + postoperative chemotherapy (IA-NAC + RS), (2) 63 patients who received neoadjuvant intravenous chemotherapy + surgery + postoperative chemotherapy (IV-NAC + RS), (3) 84 patients who only received concurrent chemoradiotherapy (CCRT). Notably, 108 of these patients met the 5-year follow-up period, and 187 patients met the 3-year follow-up period only. Consequently, we compared 5-year survival and 3-year survival separately. The prognosis (5-year survival and 3-year survival) of the three groups and the chemotherapy efficacy, intraoperative blood loss, operation time, and postoperative pathological risk factors of different subgroups were compared.

RESULTS

(1) There were no significant differences in the 3-year overall survival (OS) rate, 3-year progression-free survival (PFS) rate, 5-year OS rate, and 5-year PFS rate among the three subgroups (p > 0.05). (2) The chemotherapy response rates of IA-NAC+RS group (37.5%) and IV-NAC+RS group (25.4%) were comparable (p > 0.05). (3) The intraoperative blood loss in the IA-NAC+RS group (average 92.13±84.09 mL) was significantly lower than that in the IV-NAC+RS group (average 127.2±82.36 mL) (p < 0.05). (4) The operation time of the IA-NAC+RS group (average 231.43±63.10 min) and the IV-NAC+RS group (average 219.82±49.11 min) were comparable (p > 0.05). (5) There were no significant differences between the IA-NAC+RS group and IV-NAC+RS group in pathological lymph node metastasis, parametrial invasion, and involvement of lymphovascular space (p > 0.05).

CONCLUSIONS

Neoadjuvant chemotherapy combined with surgery had the same long-term survival benefit as concurrent chemoradiotherapy.

The Safety and Efficacy of Intra-Arterial versus Intravenous Neoadjuvant Chemotherapy in Patients with Locally Advanced Cervical Cancer: A Meta-Analysis

Objective

The aim of this study was to evaluate the safety and efficacy of intra-arterial versus intravenous neoadjuvant chemotherapy for the management of patients with locally advanced cervical cancer.

Methods

The PubMed, EMBASE, PMC, Web of Science, and Cochrane databases were searched to identify correlational studies published in English. Prospective controlled studies that evaluated the treatment effect of intra-arterial neoadjuvant chemotherapy or intravenous neoadjuvant chemotherapy in patients with locally advanced cervical cancer were pooled for a meta-analysis.

Results

A total of three eligible studies with 112 patients with locally advanced cervical cancer were eventually included in this analysis. The baseline regimen of neoadjuvant chemotherapy was platinum-based chemotherapy. The total clinical response rate was 71.4%, and the overall pathological complete response (CR) rate was 11.5%. The grade 3/4 toxicity rate was 27.2%. In the intra-arterial group, the response rate was 83.1% (CR, 22.0%; partial response (PR), 61.0%), which was significantly higher than 58.5% (CR, 11.3%; PR, 47.2%) in the intravenous group (P=0.01). The pathological CR rate was 15.5% in the intra-arterial group, which was higher than 6.5% in the intravenous group. The grade 3/4 toxicity rate was 17.2% in the intra-arterial group, which was higher than the rate of 13.8% in the intravenous group.

Conclusion

Platinum-based neoadjuvant chemotherapy was well tolerated in patients with locally advanced cervical cancer and showed moderate response activity. Compared to intravenous neoadjuvant chemotherapy, intra-arterial neoadjuvant chemotherapy had an evident advantage in terms of the clinical response while maintaining a similar toxicity rate. The clinical efficacy of intra-arterial neoadjuvant chemotherapy deserves further evaluation.

The Surgical Morbidity And Oncological Outcome Of Total Laparoscopic Radical Trachelectomy Versus Total Laparoscopic Radical Hysterectomy For Early Stage Cervical Cancer: A Retrospective Study With 11-Year Follow-Up

Objective

The objective of this study was to evaluate the surgical morbidity and oncological outcome of total laparoscopic radical trachelectomy (TLRT) and total laparoscopic radical hysterectomy (TLRH) in patients with early-stage cervical cancer.

Methods

We performed a retrospective study to compare the outcomes of patients with stage IB1 cervical cancer who underwent TLRT to patients treated with TLRH from January 2005 to December 2016.

Results

Forty-six patients underwent TLRT and 73 patients underwent TLRH between January 2005 and December 2016. The median age was 30 (19-40) years for TLRT group compared to 43 (31-65) years for TLRH group. No significant difference was found for the tumor size, histology, and pathology grade between TLRT group and TLRH group. In the TLRT group, the median operative time was 200 mins (range, 150-360 mins) and the median blood loss was 200 mL (range, 50-400mL). In the TLRH group, the median operative time was 240 mins (range, 180-380) and the median blood loss was 250mL (range, 10-1500mL). The median follow-up time was 80 months for TLRT group and 72 months for TLRH group. No patient in TLRT group developed recurrence. However, there were 2 recurrences diagnosed in the TLRH group.

Conclusion

TLRT appears to have equal surgical morbidity and oncological outcome to TLRH in stage IB1 cervical cancer. Intraoperative complications did not differ significantly between these two groups. However, postoperative complications were fewer observed in TLRT. Because of the natural limitations of the retrospective study, the clinical value should be confirmed by multi-institutional prospective trial in the future.

Comparison of Neoadjuvant Intraarterial Chemotherapy Versus Concurrent Chemoradiotherapy in Patients With Stage IIIB Uterine Cervical Cancer

Background

The purpose of this study was to compare the long-term survival of patients with stage IIIB squamous cell carcinoma of the cervix treated with neoadjuvant intraarterial chemotherapy (IA-NAC) versus those treated with concurrent chemoradiotherapy (CCRT).

Methods

We retrospectively reviewed the clinical records of 38 patients with stage IIIB squamous cell carcinoma of the cervix admitted between January 1994 and December 1999 who received IA-NAC followed by abdominal radical hysterectomy (ARH) or radiotherapy (RT). IA-NAC consisted of bilateral infusion via the internal iliac artery of cisplatin, bleomycin and pirarubicin for 2-3 courses. A historical control group of 64 patients who underwent primary CCRT from January 2000 to September 2007 was used for comparison.

Results

In the IA-NAC group, 12 patients (31.6%) with operable tumors underwent ARH, and the remaining 26 patients (68.4%) received RT. The response rates were 86.8% (12 complete response + 21 partial response) for IA-NAC and 98.4% (26 complete response + 37 partial response) for CCRT (P = 0.077), respectively. The 5-year overall survival and disease-free survival rates were 62.4 and 44.5% for IA-NAC and 51.1 and 46.9% for CCRT (P = 0.247 and 0.776), respectively. The 5-year overall survival and disease-free survival rates were 75.0 and 58.3% for the patients receiving IA-NAC followed by ARH, and 55.3 and 37.6% for the patients receiving IA-NAC followed by RT (P = 0.368 and 0.262), respectively.

Conclusions

In the present study, IA-NAC followed by ARH or RT and primary CCRT showed similar survival rates for stage IIIB squamous cell carcinoma of the cervix.

Neoadjuvant intraarterial chemotherapy for stage IIB-IIIB cervical cancer in Japanese women

Chemoradiotherapy is currently the main treatment for locally advanced cervical cancer, but neoadjuvant intraarterial chemotherapy (IA-NAC) has been reported to achieve favorable results. This study investigated the efficacy of several different IA-NAC regimens. The subjects were 55 patients with stage IIB-IIIB cervical cancer who received IA-NAC between January 1991 and April 2006. IA-NAC was administered for a total of 1-3 courses at 3-week intervals, with three different regimens being employed in chronological order. The response rate achieved with IA-NAC was 90.2% for squamous cell carcinoma, 60% for adenosquamous carcinoma and 42.9% for adenocarcinoma. Surgery was performed after IA-NAC in 36 patients, and radiotherapy alone was performed in 19 patients. The 5-year survival rate was 72.9% for patients with squamous cell carcinoma and 50% for those with adenocarcinoma or adenosquamous carcinoma. PAMF therapy (cisplatin, epirubicin, mitomycin-C and 5-fluorouracil) achieved a response rate of ≥90% for squamous cell carcinoma, as did CDDP + THP therapy (cisplatin plus pirarubicin), while PACF therapy (cisplatin, epirubicin, cyclophosphamide and 5-flurouracil) achieved a better response rate for adenosquamous carcinoma and adenocarcinoma. Grade 3 or 4 hematological toxicity was significantly more common with PAMF therapy. In conclusion, IA-NAC improved the survival of patients with squamous cell carcinoma. CDDP + THP therapy achieved a high response rate with little hematologic toxicity. PACF therapy achieved a significantly higher response rate in patients with adenosquamous carcinoma or adenocarcinoma. Therefore, IA-NAC may be a therapeutic option for locally advanced cervical cancer, particularly using the above-mentioned regimens.

Comparative study of neoadjuvant chemotherapy before radical hysterectomy and radical surgery alone in stage IB2-IIA bulky cervical cancer

OBJECTIVE

To compare the efficacy of neoadjuvant chemotherapy with paclitaxel plus platinum followed by radical hysterectomy with radical surgery alone in patients with stage IB2-IIA bulky cervical cancer.

METHODS

From November 1999 to September 2007, stage IB2-IIA cervical cancers with tumor diameter >4 cm, as measured by MRI, were managed with two cycles of preoperative paclitaxel and platinum. As a control group, we selected 35 patients treated with radical surgery alone.

RESULTS

There were no significant between group differences in age, tumor size, FIGO stage, level of SCC Ag, histopathologic type and grade. Operating time, estimated blood loss, the number of lymph nodes yielded and the rate of complications were similar in the two groups. In surgical specimens, lymph-vascular space invasion (LVSI), nodal metastasis and parametrial involvement did not differ significantly between the two groups. In the neoadjuvant group, pathologic tumor size was significantly smaller and fewer patients had deep cervical invasion. Radiotherapy, alone and in the form of concurrent chemoradiation, was administered to more patients treated with radical surgery alone (82.9% vs. 52.9%, p=0.006). No recurrence was observed in patients who could avoid adjuvant radiotherapy owing to improved risk factors after neoadjuvant chemotherapy. There were no significant differences in 5-year disease free and overall survival.

CONCLUSION

As neoadjuvant chemotherapy would improve pathologic prognostic factors, adjuvant radiotherapy can be avoided, without worsening the prognosis, in patients with locally advanced bulky cervical cancer. Neoadjuvant chemotherapy would be improving the quality of life after radical hysterectomy in patients with bulky cervical cancer.

Long-term follow-up of neoadjuvant intraarterial chemotherapy using an original four-lumen double-balloon (4L-DB) catheter for locally advanced uterine cervical cancer

BACKGROUND

We report the therapeutic potential, longterm survival, and toxicity of neoadjuvant intraarterial chemotherapy (NAIC) using an original four-lumen double-balloon (4L-DB) catheter followed by radical hysterectomy and/or radiotherapy in patients with locally advanced cervical cancer.

METHODS

Sixty patients with stage IIB-IVA cervical squamous cell cancer were treated with NAIC which included cisplatin (60-70 mg/m(2), day 1), mitomycin-C (10-20 mg/m(2), day 1), and pirarubicin hydrochloride (THP; 10-20 mg/m(2), day 1) for two courses every 21 days.

RESULTS

The median follow up among surviving patients was 93.7 months. Among 60 eligible patients, 22 had a complete response (CR; 36.7%) including 12 with a pathologic CR (20.0%). Thirty-six patients had a partial response (60.0%), and stable disease was observed in only 2 patients (3.3%). Moreover, we found that the platinum concentration in the cervix was correlated with the clinical response (P < 0.001). The 10-year progression-free survival (PFS) and 10-year survival were 90.9% and 90.9%, respectively, in patients with stage IIB disease and 66.0% and 70.7%, respectively, in patients with stage III disease. Leukopenia occurred in 86.7% of patients, but it was not very severe (grade 3, 4 in 13.3% of patients).

CONCLUSION

Our results with NAIC using the 4L-DB catheter in locally advanced cervical cancer demonstrate that a high platinum concentration has beneficial effects on primary lesions and improves long-term progression-free and overall survival.

Explanation for the failure of neoadjuvant chemotherapy to improve outcomes after radiotherapy for locally advanced uterine cervical cancer from the standpoint of the tumor regression rate

PURPOSE

Treatment outcomes for patients with locally advanced cervical cancer are no better with neoadjuvant chemotherapy (NAC) combined with radiotherapy (RT) than with RT alone. We investigated the reason for this failure from the standpoint of the tumor regression rate (RR).

MATERIALS AND METHODS

A total of 48 patients with clinical stage IIB-IVA cervical squamous cell carcinoma were treated clinically with cisplatin-based NAC plus RT (n = 15) or RT alone (n = 33). The RR was defined as the slope of a tumor shrinkage curve derived with magnetic resonance images. The local control rate (LCR) and disease-free rate (DFR) were estimated by clinical stage (IIB vs. III-IVA), pretreatment volume (< or = median vs. > median), lymph node status (negative vs. positive), treatment type, overall treatment time (< or =8 weeks vs. >8 weeks), and RR (< or = median vs. > median) using univariate and multivariate analyses.

RESULTS

RR during NAC or during NAC and RT (n = 15) was not significantly higher than RR by RT alone (n = 33). Low RR and positive nodal status were significantly powerful prognostic factors for both the LCR and DFR, whereas the others were not.

CONCLUSION

Although effective in reducing tumor volume prior to RT, NAC showed no overall effect in increasing the RR, which was shown to be the most powerful prognostic factor.

Randomized study of preoperative chemotherapy versus primary surgery for stage IB cervical cancer

AIM

To determine the most effective treatment and long-term outcome of patients with stage IB carcinoma of the cervix.

METHODS

From January 1999 to December 2001, 106 women with cervical cancer stage IB received neoadjuvant chemotherapy (n = 52) or primary surgery (n = 54). These were randomly assigned. Clinical effects and pathological changes were simultaneously recorded.

RESULTS

The overall clinical response rate was 84.6% and included a complete response (CR) in four patients (7.7%), partial response (PR) in 40 patients (76.9%), and stable disease (SD) in the remaining eight patients (15.4%). Surgery revealed positive nodes in 9.6% neoadjuvant chemotherapy group patients and in 29.6% primary surgery group patients (P = 0.014). Similar results occurred with vascular space involvement: 27.8% in the primary surgery group compared to 9.6% in the neoadjuvant chemotherapy group (P = 0.024). However, parametrial infiltration was found in 7.4% of the patients in the primary surgery group, while only 3.8% showed it in the neoadjuvant chemotherapy group (P = 0.679). The overall 5-year survival rate was significantly higher for all patients who received neoadjuvant chemotherapy (84.6%) than for the control group (75.9%) (P = 0.0112). The median survival time in patients with complete response and partial response to chemotherapy (83.3 months) was significantly higher than that of patients with stable disease to chemotherapy (55.2 months) (P = 0.0049). 27.3% of patients developed recurrent disease within 5 years of the primary treatment. The women with recurrence included partial response in six patients (60.0%), and stable disease in four patients (40.0%). For the other patients there was partial response and complete response in 38 patients (90.5%), and stable disease in the remaining four patients (9.5%) (P = 0.035).

CONCLUSION

Neoadjuvant chemotherapy can effectively eliminate the pathological risk factors and improve long-term survival in patients with locally advanced cervical cancer.

Neoadjuvant chemotherapy with cisplatin, aclacinomycin A, and mitomycin C for cervical adenocarcinoma - a preliminary study

Between 1989 and 2002, 28 patients with locally advanced cervical adenocarcinoma (bulky IB-IIIB) were recruited for a pilot study aimed at evaluation of the effectiveness of neoadjuvant chemotherapy with cisplatin, aclacinomycin-A, and mitomycin-C (PAM), followed by radical surgery. This regimen was administrated intra-arterially or intravenously. In addition to patients treated with PAM, we retrospectively analyzed the prognoses of 26 patients in stage I and II, who had been treated between 1975 and 1981 with radical surgery with/without radiation therapy. Twenty-eight patients received PAM therapy as neoadjuvant chemotherapy, and 75.0% of the 16 intra-arterially infused patients showed a response, as did 66.7% of the 12 intravenously infused patients. There was a significant difference in the 5-year prognosis of stage II (PAM group, 72.9%; without-PAM group, 36.4%). The results suggest that, as the free space in the parametrium is widened by neoadjuvant chemotherapy with PAM, it is possible that the tumor could be completely resected by radical hysterectomy. Thus, neoadjuvant chemotherapy with PAM is expected to improve the survival rate of patients with advanced cervical adenocarcinoma by the preliminary study. However, the survival rates of stage II with lymph node metastasis in the without-PAM group seem low, and we must also consider that the various technologies to evaluate and treat the cervical adenocarcinomas, e.g. computed tomography, magnetic resonance imaging, and surgical equipments, had improved during 1989-2002 than was the scenario during 1975-1981, and these improvements contributed to better prognosis. A prospective-randomized study is needed to assess the value of this approach compared with standard management.

Correlation between responsiveness of neoadjuvant chemotherapy and apoptosis-associated proteins for cervical adenocarcinoma

OBJECTIVE

Adenocarcinoma of the uterine cervix appears to be increasing in prevalence and it has been suggested that these tumors tend to be less sensitive to radiation therapy and to chemotherapy than squamous carcinomas. In the present study, 29 patients with locally advanced cervical adenocarcinoma (bulky IB-IVB) were treated with neoadjuvant chemotherapy (NAC) using cisplatin, aclacinomycin-A and mitomycin-C, followed by radical surgery or irradiation.

METHODS

To predict the prognosis and response to the chemotherapy, the expression of apoptosis associated-proteins, p53, p21WAF1/CIP1, Bcl-2 and activated caspase-3 was evaluated for tumor samples by immunohistochemistry.

RESULTS

Of the analyzed clinicopathological factors, the overexpression of p53 was frequently observed in endocervical-type adenocarcinoma, nonresponders to chemotherapy and the grade 0 histologic effect of the chemotherapy. Positive staining of Bcl-2 was frequently observed in the early stage and had a better prognosis than for patients with the negative staining; however, there was no correlation between responders and nonresponders to chemotherapy. The expression of p21WAF1/CIP1 and caspase-3 was not correlated to the clinicopathological factors.

CONCLUSION

In this study, the overexpression of p53 was found to be a factor to predict the chemoresistance and positive expression of Bcl-2 indicated as a better prognostic value. For p21WAF1/CIP1 and caspase-3, further analysis is necessary.

The role of radical hysterectomy and neoadjuvant chemotherapy in carcinoma of the cervix

The patient presenting with a bulky stage IB2 cervical cancer is a therapeutic challenge. None of the current surgical or radiation treatment strategies satisfactorily leads to a high rate of disease-free survival and a low risk of treatment-related complications including ovarian failure and psychosexual deficits. Neoadjuvant chemotherapy may allow for reductions in tumor bulk, thereby rendering radiation therapy more effective or surgery more feasible. Impressive clinical response rates to cisplatin-based neoadjuvant chemotherapy have been achieved with acceptable toxicity. Approximately 20% of patients achieve a complete clinical response, and many also experience a complete pathologic response. There are still too few comparative studies and phase III trials to assess the effectiveness of neoadjuvant chemotherapy and radical surgery relative to standard treatments.

Phase I-II study of neoadjuvant chemoradiotherapy followed by radical surgery in locally advanced cervical cancer

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.

Neoadjuvant chemotherapy in gynecologic oncology

The use of neoadjuvant chemotherapy in conjunction with surgery in squamous carcinoma of the uterine cervix can reduce the surgical treatment extent (to be confirmed) in small-volume tumors (diameter < 4 cm) and increase overall survival and disease-free interval in localized median-volume tumors (< or = 8 cm) and improve the quality of life of patients with large, locally advanced tumors, due to longer disease-free period. These issues have yet to be completely resolved (three randomized trials have confirmed these data), but in the meantime, neoadjuvant chemotherapy could be used as an alternative treatment in locally advanced tumors or large localized tumors. It is necessary to use high-dose chemotherapy to achieve a good tumor response and satisfactory "down-staging." Surgical treatment after neoadjuvant chemotherapy seems to be the most appealing option, especially in patients with poor response to chemotherapy. The proper extension of surgery after neoadjuvant chemotherapy is an unexplored matter for the gynecologic oncologist, and no trial has been developed to address this issue, but it seemingly must be performed according to the initial size and extension of the tumor (prior to neoadjuvant chemotherapy) despite the tumor response to it.

Super high-dose intraarterial cisplatin infusion under percutaneous pelvic perfusion with extracorporeal chemofiltration for advanced uterine cervical carcinoma: II. Its impact on clinical response and subsequent surgery

The present pilot study was conducted to investigate the clinical efficacy of super high-dose intraarterial cisplatin infusion with percutaneous pelvic perfusion under extracorporeal chemofiltration (PPPEC) for locally advanced uterine cervical carcinoma. Cisplatin (140-240 mg/m2) was infused in uterine arteries in a neoadjuvant setting in 20 patients under the PPPEC system twice during a 2-week interval. Fourteen of 17 patients in whom reduction of the disease (tumor downstaging) was confirmed underwent radical surgery. Despite the tumor downstaging, the remaining three patients had poor PS and the other three showed insufficient stage regression. Clinical responses, histologic responses, and surgical review were studied. The rate of overall tumor response (complete response plus partial response), tumor downstaging, overall histologic response, and radical surgery performance after the second course of PPPEC were 95.0%, 85.0%, 95.0%, and 70.0%, respectively. Curative surgery, defined as negative carcinoma cells in surgical margins, was achieved in 85.7% of the cases, whereas the rate of complete surgery defined as negative carcinoma cells both in surgical margins and regional lymph nodes was 42.9%. With 42 months of median follow-up time, 3 of the 14 surgical patients died of the original disease, and the remaining 9 patients are in recurrence-free survival, whereas 2 patients are alive with disease. PPPEC achieved a high frequency of rapid tumor downstaging of locally advanced uterine cervical carcinoma without severe adverse effects and resulted in the favorable performance of the subsequent radical surgery and prognosis.

Phase I/II study of intravenous nedaplatin and intraarterial cisplatin with transcatheter arterial embolization for patients with locally advanced uterine cervical carcinoma

BACKGROUND

Nedaplatin, a platinum analog with less renal toxicity and similar efficacy for cervical carcinoma, recently has been shown to have a synergistic effect on cervical carcinoma lines in combination with cisplatin. To determine the clinical efficacy of this combination in patients with cervical carcinoma, the authors conducted a Phase I/II study of intravenous nedaplatin and intraarterial cisplatin combined with transcatheter arterial embolization (TAE).

METHODS

Eligibility criteria were as follows: cervical carcinoma (Stages IB2-IV; International Federation of Gynecology and Obstetrics), 16-70 years of age, performance status between 0 and 2, and adequate bone marrow, renal, and hepatic function. Nedaplatin (40-70 mg/m2) was administered intravenously on Day 1 followed by intraarterial administration of cisplatin (70 mg/m2) on Day 3 via both uterine arteries by using the Seldinger method. This then was followed by TAE. This course of treatment was repeated every 3 weeks for 3 cycles.

RESULTS

Patient data were as follows: age 37-68 (median, 55 years) and Stages IB2:4, IIA:3, IIB:2, IIIA:1, IIIB:3, IVA:2 carcinoma. The response to therapy was defined by magnetic resonance imaging as follows: partial response in 60% (9 of 15) of patients, complete response in 40% (6 of 15) of patients, and an overall response rate of 100% (95% confidence interval, 78-100%). Myelosuppression was manageable. Grade 3/4 renal toxicity was observed in 2 patients who received 70 mg/m2 of nedaplatin. Thirteen patients received radical hysterectomy, 1 patient received lymph node sampling, and 11 patients received adjuvant radiotherapy or chemotherapy.

CONCLUSIONS

The maximum tolerable dose was 70 mg/m2 nedaplatin, and the dose-limiting toxicity was renal toxicity. The recommended dose was 60 mg/m2 nedaplatin intravenously followed by 70 mg/m2 cisplatin intraarterially. Intravenous nedaplatin followed by intraarterial cisplatin with TAE appears to be very effective for locally advanced cervical carcinoma.

Neoadjuvant intraarterial infusion chemotherapy in patients with stage IB2-IIIB cervical cancer

OBJECTIVES

The purpose of this study was determine the effect of neoadjuvant intraarterial chemotherapy (NAIC) on the prognosis of patients with locally advanced cervical cancer.

METHODS

From January 1992 to December 1997, 26 previously untreated patients with stage IB2-IIIB cervical cancer were enrolled in the study. NAIC was administered for more than two courses every 3 weeks using a combination of 17.5 mg/m(2) bleomycin, 7 mg/m(2) mitomycin-C, and 75 mg/m(2) cisplatin via the bilateral internal iliac artery. Pathologic findings were evaluated with histologic examinations of surgical specimens. A nonrandomized control group of 120 patients who underwent conventional treatment between 1980 and 1991 was used for comparison.

RESULTS

Nineteen (73.1%) of the 26 patients responded to initial chemotherapy, permitting a radical hysterectomy with pelvic lymphadenectomy in 14 patients. The remaining 5 patients received radiotherapy. One of 7 nonresponders was able to undergo radical surgery. Pathologic complete responses were found in 4 of the 15 patients who underwent radical surgery. The incidence of lymph node metastasis, parametrial infiltration, and vascular space involvement in the 15 patients who received NAIC followed by radical surgery was significantly lower than that in the control group (13.3, 6.7, and 13.3% vs 54.2, 43.8, and 60.4%). The overall 5-year estimated survival rate was significantly higher for all 26 patients who received NAIC (80.0%) than for the control group (59.6%). In stage II and III, the 5-year survival rate for patients who received NAIC was significantly higher than that in the control group (83.3 and 77.8% vs 68.1 and 49.8%).

CONCLUSIONS

These preliminary results suggest that NAIC is able to eliminate effectively the pathologic risk factors in the pelvic cavity, to improve the operability in patients with stage IIIB cervical cancer, considered inoperable, and to improve the prognosis of patients with locally advanced cervical cancer.

Combination therapy with irinotecan and cisplatin as neoadjuvant chemotherapy in locally advanced cervical cancer

To evaluate the response rate and toxicity of the combination of irinotecan (CPT-11) and cisplatin in a neoadjuvant setting, a phase II study was conducted regarding the regimen of this combination in patients with locally advanced cervical cancer. Eligibility included patients with previously untreated stage Ib2, IIb, or IIIb squamous cell carcinoma with good performance status. CPT-11 (60 mg m(-2)) was administered intravenously on days 1, 8 and 15, followed by cisplatin (60 mg m(-2)) given intravenously on day 1. Treatment was repeated every 4 weeks for a total of two or three cycles. Among 23 eligible patients (median age: 59 years), three showed complete response (13%), 15 showed partial response (65%), for an overall response rate of 78% (95% confidence interval 58-90%). Stable disease was observed in four cases (17%) and progressive disease in one (4%). The median time to failure and median survival time have not yet been reached. Of the 52 treatment cycles administered, diarrhoea and grade 3 or 4 neutropenia were observed in 10% and 75% respectively. There were no therapy-related deaths. The combination of CPT-11 with cisplatin is a promising regimen for neoadjuvant chemotherapy in locally advanced cervical cancer. The toxicities of this regimen are well tolerated.

Tumor response to neoadjuvant chemotherapy correlates with the expression of P-glycoprotein and PCNA but not GST-pi in the tumor cells of cervical carcinoma

OBJECTIVE

To identify the clinicopathological and chemoresistant factors predicting the response to neoadjuvant chemotherapy and the patient prognosis in high-risk cervical carcinomas.

METHODS

We retrospectively reviewed 47 patients with locally advanced or bulky cervical carcinoma treated with two courses of intraarterial infusion of cisplatin, doxorubicin, mitomycin C, and 5-fluorouracil (5-FU), followed by radical hysterectomy at our hospital between 1988 and 1995. Expressions of the chemoresistance-related proteins, such as P-glycoprotein, glutathione S-transferase pi (GST-pi), and proliferating cell nuclear antigen (PCNA) in the tumor cells, were examined by immunohistochemistry using pretreatment biopsy specimens. These results were compared with the chemotherapeutic response, which was evaluated by magnetic resonance imaging (MRI) and histopathology. Outcome of the patients was also studied.

RESULTS

Chemotherapeutic effect of either complete (CR) or partial (PR) response on MRI was obtained in 36 of the 47 (86%) patients. Poor response to chemotherapy was significantly correlated with P-glycoprotein expression (P < 0.005) and low PCNA labeling (P < 0. 05), but not GST-pi expression in the tumor cells. Independent prognostic factors for patient survival were parametrial involvement and lymph node metastasis. Neither the expression of GST-pi nor PCNA was correlated with the patient survival.

CONCLUSION

Assessment of the expression of P-glycoprotein and PCNA is potentially useful for the prediction of tumor response to neoadjuvant chemotherapy for cervical carcinomas.

Neoadjuvant chemotherapy with mitomycin C, etoposide, and cisplatin for adenocarcinoma of the cervix

Between May 1990 and February 1995, 16 patients with adenocarcinoma or adenosquamous carcinoma of the uterine cervix were prescribed neoadjuvant chemotherapy consisting of cisplatin (50 mg/m2) on day 1, mitomycin C (10 mg/m2) on day 1, and etoposide (100 mg/m2) on days 1, 3, and 5 (MEP). In 2 patients stage was IB1, 5 were in stage IB2, 1 was in stage IIA, 5 were in stage IIB, 2 were in stage IIIB, and one was in stage IVB. A median of three courses of chemotherapy was given (range two to five). Of the 16 patients, 3 had a complete response and 5 had a partial response (response rate, 50%). Following termination of this chemotherapy, 12 patients with stage I or stage II carcinoma underwent radical hysterectomy. Three were given adjuvant radiotherapy because of positive pelvic nodes. One stage IIB patient, 1 stage IIIB patient and 1 stage IVB patient underwent standard radiotherapy and 1 stage IIIB patient underwent chemotherapy with another regimen because MEP therapy was without effect. Histopathological examinations revealed that changes as a result of the chemotherapy correlated well with clinical responses. Moderate or marked pathological changes occurred in 3 with a clinically complete response. The mean survival period of responders was 47.5 months while that of nonresponders was 28.3 months. Side effects of chemotherapy with MEP were within acceptable limits. The dose-limiting toxicity was myelosuppression and for only 1 patient the dose was reduced because of thrombocytopenia. Our preliminary study indicates that this chemotherapy regimen is effective for subjects with adenocarcinoma of the cervix. A prospective cooperative group trial on this regimen is ongoing.

Neoadjuvant intraarterial chemotherapy followed by radical hysterectomy and/or radiotherapy for locally advanced cervical cancer

OBJECTIVES

We assessed neoadjuvant intraarterial chemotherapy (NAC) followed by radical hysterectomy and/or radiotherapy in patients with locally advanced cervical cancer.

METHODS

Over 5 years, 48 consecutive women with International Federation of Gynecology and Obstetrics stage IIb-IVa cervical cancer were enrolled. Treatment consisted of bilateral internal iliac artery infusion of cisplatin (100 mg/m2, day 1) or carboplatin (400 mg/m2, day 1) and peplomycin (20 mg/m2, day 1) for two courses separated by 3 weeks. Doxorubicin (30 mg/m2, day 1) was added for patients with adenocarcinoma. Stage III patients who responded to NAC and Stage IIb patients underwent radical hysterectomy with pelvic lymphadenectomy. Stage III patients not responding to NAC and all stage IVa patients were treated with pelvic radiotherapy.

RESULTS

Complete response was achieved in 5 (10.4%) of 48 patients, while a partial response was noted in 32 (66. 7%) and stable disease in 11 (22.9%). Of 25 patients with stage IIIb disease, 16 (64.0%) were able to undergo surgery. The 4-year disease-free survival (DFS) was 80.0% in patients with stage IIb and 62.3% in patients with stage III. In stage IIIb, the 4-year DFS in patients receiving surgery (75.2%) was higher than the DFS for those receiving radiotherapy (44.4%) (P < 0.05). Grade 3 or 4 leukopenia developed in 17 (35.4%) patients. Nausea and vomiting of grade 2 or higher occurred in 34 (70.8%). Creatinine clearance transiently decreased (>/= grade 2) in 16.6%. Patients negative for serum squamous cell carcinoma-associated antigen (SCC) responded better to NAC than to SCC-positive cases, and SCC-negative survival was significantly better than SCC-positive survival (P < 0.05).

CONCLUSIONS

Neoadjuvant intraarterial chemotherapy with platinum was safely performed, and a survival benefit followed radical surgery with or without radiotherapy after response to NAC.

Combination chemotherapy using intravenous nedaplatin (254-S) and intraarterial cisplatin (CDDP) with transcatheter arterial embolization (TAE) for a patient with uterine cervical cancer: a case report

A 45-year-old Japanese woman with a bulky (75 x 40 mm) stage 2a uterine cervical cancer was treated with 87 mg (50 mg/m2) of nedaplatin (254-S) intravenously and 120 mg (70 mg/m2) of cisplatin (CDDP) intraarterially with transcatheter arterial embolization (TAE). She received three courses of this combination chemotherapy and showed a complete response, as confirmed by magnetic resonance imaging. A radical hysterectomy was performed and the pathological findings revealed the absence of carcinoma cells. This type of combination chemotherapy seems to be effective for the treatment of locally advanced uterine cervical cancer.

Decrease in tumor volume and histologic response to intraarterial neoadjuvant chemotherapy in patients with cervical and endometrial adenocarcinoma

Our purpose was to evaluate the utility of clinicopathological and biological markers prior to treatment in predicting the immediate response to chemotherapy in cervical and endometrial adenocarcinomas. Twelve patients with locally advanced cervical adenocarcinomas and 16 patients with endometrial adenocarcinomas received intraarterial neoadjuvant chemotherapy (NAC) consisting of cisplatin and doxorubicin before surgical resection. The decrease in tumor volume on magnetic resonance imaging (MRI) ([tumor volume before NAC - tumor volume after NAC]/tumor volume before NAC x 100) and the histologic response to NAC were assessed. Five factors prior to NAC (nuclear grade, pretreatment tumor volume, PCNA index, p53 protein expression, and DNA ploidy) were analyzed for correlation with the decrease in tumor volume and histologic response in cervical and endometrial adenocarcinoma, respectively. In cervical adenocarcinoma, patients with higher PCNA index tumor (> or = 40.2%) showed a significantly greater decrease in tumor volume than those with lower PCNA index (P < 0.05). In patients with endometrial adenocarcinoma, those with a smaller tumors (< 30.3 cm3) showed a significantly greater decrease than those with a larger tumors (P < 0.001). Tumors with higher PCNA index (> or = 31.5%) and negative p53 protein expression appeared to respond better than other tumors, but the difference was not statistically significant. Nuclear grade and DNA ploidy were not correlated with decrease in tumor volume either in cervical adenocarcinoma or in endometrial adenocarcinoma. Four cases of effective histologic response (2 complete responses [no microscopic residual tumor] and 2 marked responses [no macroscopic residual tumor]) were noted only in patients with endometrial adenocarcinoma who had a smaller tumor, higher PCNA index, and negative p53 protein expression. Pretreatment tumor volume and PCNA index were the only significant predictive factors (P < 0.05). Results suggest that the PCNA index in cervical and endometrial adenocarcinomas and the pretreatment tumor volume in endometrial adenocarcinoma appeared to be potentially useful in predicting the immediate response to the chemotherapy.