Neoadjuvant chemotherapy with cisplatin, vincristine, and bleomycin and radical surgery in early-stage bulky cervical carcinoma

Neoadjuvant docetaxel combined with cisplatin and followed by radical surgery for the treatment of locally advanced (stage IB2 - IIB) cervical cancer: preliminary results of a single-institution experience

OBJECTIVES

We aimed to determine the efficacy and toxicity of treating locally advanced cervical cancer (LACC) with a neoadjuvant chemotherapy (NAC) regimen combining docetaxel and cisplatin followed by radical surgery.

METHODS

We retrospectively reviewed the clinical records of patients with stage IB2 - IIB (tumor diameter ≥ 4 cm) disease admitted between January 2007 and July 2009 who, before radical hysterectomy and pelvic lymph node dissection, received two to three courses of an NAC regimen comprising docetaxel (75 mg/m²) and cisplatin (70 - 75 mg/m²).

RESULTS

Fifty-two patients with LACC received 109 cycles of NAC. The objective response rate was 86.5% (26.9% CR and 17.3% pathological CR). Stage IB2 disease had a more favorable response to NAC (95.7%, p = 0.019). Deep stromal invasion and lymph-vascular space metastasis rates were significantly lower in NAC responders (p = 0.033) than in nonresponders (p = 0.012). Most side effects of NAC were mild or moderate. Log-rank test showed the 2-year overall survival and progression-free survival rates were 100 and 90.3% for NAC responders, compared with only 57.1% (p = 0.000) and 68.6% for nonresponders (p = 0.012), respectively.

CONCLUSION

Neoadjuvant docetaxel combined with cisplatin yielded a high response rate with well tolerable toxicity for LACC and could decrease pathological risk factors in NAC responders.

Neoadjuvant chemotherapy in bulky stage IB-IIA cervical cancer: results of a quick course with vincristine, bleomycin, and cisplatin

We retrospectively analyzed 51 consecutive patients with bulky International Federation of Gynecology and Obstetrics stage IB-IIA cervical cancer who were treated with vincristine (1 mg/m), bleomycin (25 mg/m; days 1-3), and cisplatin (50 mg/m) every 10 days between 1995 and 2005 to assess the efficacy and the safety of a quick course of neoadjuvant chemotherapy. A clinical response occurred in 37 patients (72.5%), including 7 patients (13.7%) with a complete response and 30 patients (58.8%) with a partial response; 13 patients (25.5%) had a stable disease, and 1 patient (2.0%) had a progressive disease. Among the 50 patients who were surgically explored, 42 patients had a radical hysterectomy with pelvic and para-aortic lymphadenectomy; radical surgery was aborted in 8 patients because of paracervical and para-aortic lymph node involvement. Hematologic toxicity was the most common adverse event with anemia occurring most frequently, followed by leukopenia. Importantly, pulmonary toxicity occurred in 7 patients, 2 of whom died of complications from pulmonary fibrosis 1 and 3 months after radical surgery. With a median follow-up of 53 months (range, 2-129 months), the estimated 2- and 5-year survival rates were 74.9% and 61.3%, respectively. In conclusion, the survival benefit of a quick course of neoadjuvant chemotherapy consisting of vincristine, bleomycin, and cisplatin may be uncertain despite the significant clinical response in bulky International Federation of Gynecology and Obstetrics stage IB2-IIA cervical cancer. Special care is required to monitor bleomycin-induced pulmonary toxicity.

Neoadjuvant chemotherapy and radical surgery compared to radical surgery alone in bulky stage IB-IIA cervical cancer

AIM

The aim of this study was evaluation of the efficacy of neoadjuvant chemotherapy (NACT) and radical hysterectomy on long-term survival in stage IB-IIA locally advanced cervical cancer as compared with radical surgery alone.

METHODS

We reviewed all patients with cervical cancer stage IB-IIA who were treated with two treatment modalities, i.e. NACT followed by radical hysterectomy and lymphadenectomy, and radical hysterectomy alone between March 1996 and March 2004. There were 22 patients in the NACT group (group 1) and 160 patients in the immediate radical surgery group (group 2). All patients in group 1 were followed for more than 108months, and long-term survival and factors affecting recurrence were evaluated.

RESULTS

Nineteen patients in the NACT arm underwent radical surgery. Pelvic lymph node metastasis was found in 8 patients in this group and in 36 in the radical surgery group. Eighteen patients in the NACT group and 96 patients in the radical surgery group were scheduled for adjuvant postoperative chemoradiation. During the 9-year follow-up, recurrence rate was 47.1% and 30.2% in NACT and control groups, respectively. In the NACT group lymph node metastasis was a significant independent risk factor for recurrence. Overall survival in the NACT arm was not statistically significantly lower than the control arm (p=0.06).

CONCLUSION

NACT did not improve long-term overall survival of bulky early-stage cervical cancer patients compared to primary radical surgery.

XRCC1 R399Q polymorphism is associated with response to platinum-based neoadjuvant chemotherapy in bulky cervical cancer

OBJECTIVES

The aim of the study was to assess whether the genetic polymorphisms were associated with the tumor response in patients treated with platinum-based neoadjuvant chemotherapy (NAC) for bulky cervical cancer.

METHODS

We retrospectively reviewed the clinical data and recruited paraffin-embedded, formalin-fixed tissues of 36 patients with bulky cervical carcinoma. All patients underwent two or three cycles of platinum-based NAC followed by radical hysterectomy. We determined the genotypes of each single nucleotide polymorphism (SNP) of ERCC1, ERCC2, GGH, GSTP1, MTHFR, SLC19A1 and XRCC1 using single base primer extension assay.

RESULTS

The response to platinum-based NAC was higher in patients with SNP of XRCC1 R399Q (P=0.015), and there was a significant increased chance of treatment response in women with the G/G genotype (OR 38.0; 95% CI 1.66-870.45; P=0.023). The probability of response was also higher in patients with SNP of SLC19A1 6318C/T (P=0.032). There were dose-dependent influence of the number of alleles on the response to platinum-based chemotherapy (chi2 test for linear-by-linear association; P=0.009 for XRCC1 R399Q and P=0.017 for SLC19A1 6318C/T, respectively). Moreover, the multifactor dimensionality reduction (MDR) analysis documented that the combinations of XRCC1 R399Q and GGH-401C/T genetic polymorphisms were significantly associated with response to chemotherapy (P<0.0001).

CONCLUSIONS

Genetic polymorphism of XRCC1 R399Q is associated with response to platinum-based NAC in bulky cervical cancer, and MDR analysis documented association between gene-gene interaction of XRCC1 R399Q and treatment response.

Gynecological cancers in developing countries: the challenge of chemotherapy in low-resources setting

The epidemiologic pattern of cancers in developing countries differs in many aspects from that of industrialized nations. Cancer natural history, microbiologic environment, patient's immune system, and drug availability may differ as well. Four of five new cases of cervical cancer and most of cervical cancer deaths occur in developing countries. Where chemoradiation and supportive care facilities are unavailable, it would be logical to consider an inexpensive effective drug. In locally advanced cases, neoadjuvant chemotherapy followed by surgery should be considered the treatment of choice. For ovarian cancer, it may be reasonable to maintain a secure supply of platinum and/or taxanes. For endometrial cancer, platinum compounds are proved active chemotherapic single agents. Oral medroxyprogesterone acetate (MPA) may represent a good chance for treating an advanced or recurrent disease. For vulvar/vaginal cancer, the role of chemotherapy alone is currently considered limited, and it is mostly used as palliative treatment in advanced or recurrent cases. Whenever possible, standard western chemotherapic regimens should be applied in developing countries as well. When standard therapies are unavailable, drugs of choice should be easily accessible, inexpensive, and effective. The most commonly used drugs are cisplatin, cyclophosphamide, and MPA.

The role of chemotherapy in locally advanced, metastatic and recurrent cervical cancer

Cervical cancer is among the major health problems world-wide although advances in screening programs. Surgery and radiotherapy are the treatment modalities of choice for early and locally advanced cervical cancer. However, the role of chemotherapy in this setting has been better investigated in the latest years. To improve loco-regional control in locally advanced disease, authors have tested both neo-adjuvant chemotherapy and concurrent chemoradiotherapy. From 1999 NCI clinical announcement, concurrent cisplatin-based chemoradiation is considered the treatment of choice for cervical cancer patients requiring radiation therapy. Neo-adjuvant chemotherapy is reaching encouraging results in IB bulky-IIA cervical cancer, but further investigation are ongoing in locally advanced cervical setting. The optimal treatment for patients with metastatic or recurrent cervical cancer is still undefined and chemotherapy is used with palliation intent. Cisplatin remains the most active cytotoxic agents, although combinations of cisplatin with paclitaxel, topotecan, vinorelbine, have shown encouraging results in phase II and in early phase III studies. This paper reviews the role of chemotherapy in the management of patients with locally advanced, metastatic and recurrent cervical cancer. Studies discussed in this paper were selected trough a search in the med-line database performed in October 2003.

Human papillomavirus genotyping by a polymerase chain reaction-based genechip method in cervical carcinoma treated with neoadjuvant chemotherapy plus radical surgery

The aim of this study was to evaluate the accuracy of human papillomavirus (HPV) genotyping by a polymerase chain reaction (PCR)-based genechip method and to determine the prognostic value of HPV genotype in bulky stage IB or IIA cervical carcinoma treated with neoadjuvant chemotherapy (NAC) and radical surgery. A total of 149 patients had adequate tissue for the study. The SPF1/GP6+ primers were used to amplify a 184 bp fragment. The amplimers were submitted for direct sequencing and hybridization with a genechip using revert-blot detection of 39 types of HPV DNA in a single reaction. Two runs of PCR with respective hybridization were performed for each tumor. The complete concordance of HPV genotyping was 80.5% (120/149) of the paired genechip results. The kappa coefficient was 0.634 (P < 0.0001). HPV DNA sequences were detected in 100% of the specimens, among which 67.8% harbored single type and 32.2% contained multiple types. HPV-16 was detected in 98.7%, HPV-18 in 22.8%, HPV-31 in 0.7%, HPV-45 in 1.3%, HPV-52 in 2.0%, HPV-58 in 6.7%, HPV-59 in 4.7%, and HPV-67 in 0.7%. In multivariate analyses, the HPV genotype [HPV-18 or HPV-16 and HPV-18 only versus all others: relative risk (RR), 2.33; 95% CI, 1.17-4.64; P = 0.016] and pre-NAC tumor size (>5 versus </=5 cm: RR, 2.25; 95% CI, 1.13-4.48; P = 0.021) were significantly related to overall survival. This PCR-based genechip method is sensitive and reproducible for HPV genotyping. The association of HPV-18 or HPV-16 and HPV-18 with poor outcome in cervical carcinoma treated with NAC plus radical surgery is confirmed.

Treatment of stage IB2 (bulky) cervical carcinoma

Tumour size is an important prognostic factor in patients with stage IB cervical cancer. The patient with stage IB2 (bulky) cervical cancer represents a therapeutic challenge. Neither radical hysterectomy nor primary radiation therapy are sufficiently effective and are associated with significant treatment-related complications including ovarian failure and psychosexual deficits. A number of phase III studies have explored alternative management approaches in this patient population. It appears that extrafascial hysterectomy following radiation therapy does not improve overall survival relative to radiation therapy alone. Consistent with results seen in locally advanced cervical carcinoma, chemoradiation therapy is superior to radiation therapy alone as primary treatment for stage IB2 cervical cancer and as adjuvant therapy for surgically treated patients with high-risk factors for recurrence. Neoadjuvant chemotherapy has resulted in high clinical response rates and operability rates. There are two phase III trials suggesting an improvement in survival with neoadjuvant chemotherapy followed by radical hysterectomy versus either surgery (and selected postoperative radiation) or radiation therapy alone. These emerging treatments should be scrutinized in prospective controlled trials.

Neoadjuvant chemotherapy for cervical cancer

None of the current surgical or radiation treatment strategies for cervical cancer satisfactorily leads to a high disease-free survival and a low risk for treatment-related complications in patients with bulky or locally-advanced disease. Neoadjuvant chemotherapy (NACT) prior to surgery or radiation therapy has been studied as a means to reduce tumour bulk and thereby rendering subsequent therapy more effective. Impressive clinical response rates to cisplatin-based NACT have been achieved with acceptable toxicity and survival. Of the patients treated, approximately 20% will achieve a complete clinical response and many of these patients will prove to have a complete pathological response. Although there are too few randomised controlled studies to determine the effectiveness of NACT approaches, relative to standard treatments.

Prognostic value of age and histologic type in neoadjuvant chemotherapy plus radical surgery for bulky (>/=4 cm) stage IB and IIA cervical carcinoma

The purpose of this study was to investigate pretreatment variables related to prognosis and to evaluate long-term outcome in patients with bulky early-stage cervical carcinoma who were enrolled into a protocol treatment of neoadjuvant chemotherapy (NAC) followed by radical surgery. Between 1988 and 1999, 162 women with previously untreated bulky (>/=4 cm) stage IB or IIA carcinoma of the uterine cervix registered to receive cisplatin, vincristine, and bleomycin for three cycles followed by radical hysterectomy and pelvic lymphadenectomy, were enrolled into this study. The 5-year relapse-free (RFS) and overall survival (OS) rates of the whole series were 65% and 69%, respectively. In multivariate analyses, age (< 35 vs. >/= 35-year-old: relative risk [RR], 2.06; 95% confidence interval [CI], 1.02-4.14; P = 0.043) and histologic type (adeno-adenosquamous vs. squamous carcinoma: RR, 2.60; 95% CI, 1.26-5.39; P = 0.010) were independent variables associated with RFS, and age (< 35 vs. >/= 35-year-old: RR, 2.53; 95% CI, 1.24-5.14; P = 0.010) and pre-NAC tumor size (> 5 vs. = 5 cm: RR, 2.06; 95% CI, 1.09-3.90; P = 0.027) were significantly related to OS. Narrowing down patient selection to squamous carcinoma and age older than 35 years with stratification of tumor size (break point of 5 cm) is recommended in future trials involving cisplatin-based NAC plus radical surgery.

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.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Current developments in the treatment of newly diagnosed cervical cancer

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

Long-term survival following neoadjuvant chemotherapy and radical surgery in locally advanced cervical cancer

The aim of this study was to analyse the long-term survival and the relationships between prognostic factors at presentation, chemoresponsiveness and disease outcome in patients with locally advanced cervical cancer treated by neoadjuvant chemotherapy and radical surgery (RS). Two consecutive studies of neoadjuvant chemotherapy containing cisplatin, bleomycin plus/minus methotrexate followed by radical hysterectomy and systematic aortic and pelvic lymphadenectomy were carried out between January 1986 and September 1990 on 130 patients with > or = 4 cm stage IB2-III cervical cancer. Survival analysis was performed using the Kaplan and Meier test and Cox's multivariate regression analysis. 128 (98%) of the patients enrolled were evaluable for clinical response and survival, 83% (106) of the patients responded to chemotherapy, with a 15% complete response rate. Logistic regression analysis demonstrated that International Federation of Gynecology and Obstetrics (FIGO) stage, cervical tumour size, parametrial involvement and histotype are highly predictive of response. Responding patients underwent laparotomy, but 8% were not amenable for radical surgery. The 10-year survival estimates were 91%, 80% and 34.5% for stage IB2-IIA bulky, IIB and III, respectively (P < 0.001). After Cox's regression analysis, the parameters significantly associated with survival were the same factors predicting response to neoadjuvant chemotherapy. No stage IB2-IIA bulky patient has so far relapsed, while 12% stage IIB and 56% stage III patients recurred. The 10-year disease-free survival estimates are 91% and 44% for stage IB2-IIB and III, respectively (P < 0.001). Metastatic nodes and persistent tumour in the parametria were the only two independent factors for disease-free survival after multiple regression analysis. After a long-term follow-up (median follow-up 98 months (20-129+)), our results give new evidence of the prognostic value of response to neoadjuvant chemotherapy and of a possible therapeutic benefit of the sequential treatment adopted which, however, must be verified in a randomised setting.

Prognostic factors in patients with bulky stage IB or IIA cervical carcinoma undergoing neoadjuvant chemotherapy and radical hysterectomy

All patients with bulky (> or =4 cm) Stage Ib or IIa cervical carcinoma treated at Chang Gung Memorial Hospital between August 1988 and December 1991 using a strategy of neoadjuvant chemotherapy with cisplatin, vincristine, and bleomycin and radical hysterectomy were reviewed. Fifty-nine evaluable patients received 1 to 3 courses of chemotherapy, and 51 underwent subsequent hysterectomy. The remaining 8 patients, not completing planned surgery, were treated with definitive radiotherapy. The overall clinical response rate was 81.4% (48/59) with 18.6% complete response. Clinical response to chemotherapy was not different by stage, histologic type, tumor size, level of squamous cell carcinoma antigen, or DNA ploidy. However, tumors with DNA indices (DI) greater than 1.3 were associated with higher clinical response rates than tumors with DI < or = 1.3 (P = 0.043). Histologically proven pelvic node metastases was noted in 18.5% (10/54) who had laparotomy. Concomitant pregnancy and more than one node metastases had significant adverse influence on recurrence and death. The 5-year survival rate of those patients who received hysterectomy was 80.3%, while only 1 of the 8 patients without hysterectomy survived. Of the 7 patients received hysterectomy despite clinical poor response, only 2 had node metastases and 3 died, whereas all the 4 patients deterred hysterectomy for poor response died. This study demonstrates the value of DNA flow cytometry in predicting chemosensitivity. However, with a DI cutoff at 1.3, only 29.2% patients could be selected. Further studies are necessary to find additional indicators that predict histological response to select better candidates for this approach and to determine optimal adjunctive treatment in case that poor prognostic features are found.

[Chemotherapy and systemic treatments of cervical cancer]

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.