Radiation therapy with or without weekly cisplatin for bulky stage 1B cervical carcinoma: follow-up of a Gynecologic Oncology Group trial

Less than whole uterus irradiation for patients with locally advanced cervical cancer

INTRODUCTION

Current consensus guidelines for definitive cervical cancer intensity modulated radiation therapy (IMRT) recommend inclusion of the entire uterus within the clinical target volume, however this is debated. We aimed to evaluate outcomes of patients with cervical cancer who were treated with less than whole uterus irradiation.

METHODS

We identified 109 patients with FIGO Stage IB-IVA cervical cancer treated definitively with concurrent chemoradiation, including IMRT and brachytherapy, from 2010 to 2022 at a single institution where the practice was to include the gross cervix tumor with an internal target volume with differences in bladder filing accounted for, plus additional 5 mm planning target volume (PTV) margin. Local, regional, and distant recurrences were analyzed using competing risk methods, and a Wilcoxon rank sum test was performed to assess differences in dose to organs at risk based on the proportion of the uterus included in the PTV, with the median proportion of the uterus included (75 %) used as the cut-point.

RESULTS

The median follow-up time was 65 months (range 3-352 months). The 2-year cumulative incidence of LR for the entire cohort was 4.2 % (95 % confidence interval [CI] 1.3-9.7). Compared with patients who had ≥ 75 % of the uterus included in the PTV, patients who had < 75 % of the uterus included in the PTV had significantly lower bowel D200cc (p = 0.02). The cumulative incidence of local failure (LR) was not significantly different between the two groups.

CONCLUSIONS

Including less than the whole uterus for definitive cervix cancer IMRT does not seem to compromise local control. Less than whole uterus irradiation could be considered for carefully selected cervix cancer patients to decrease bowel dose and possible treatment-related toxicity.

Recent breakthroughs in the management of locally advanced and recurrent/metastatic cervical cancer

Cervical cancer continues to be a global threat affecting individuals in resource poor communities disproportionately. The treatment paradigm for this disease is ever evolving with recent innovations propelling oncologic outcomes to a new frontier offering survival benefits for patients struggling with locally advanced disease and metastatic/recurrent carcinoma. Immunologic checkpoint inhibitors and anti-body drug conjugates represent two novel drug classes that have demonstrable activity in this disease, particularly in the first-line and second-line treatment paradigm for recurrence. The tolerability of these novel medicines and associated durable responses underscore regulatory approval by the U.S. Food and Drug Administrations and their implementation in clinic.

Post-transplant malignancy: Focusing on virus-associated etiologies, pathogenesis, evidence-based management algorithms, present status of adoptive immunotherapy and future directions

Modern immunosuppression has led to a decrease in rejection rates and improved survival rates after solid organ transplantation. Increasing the potency of immunosuppression promotes post-transplant viral infections and associated cancers by impairing immune response against viruses and cancer immunoediting. This review reflects the magnitude, etiology and immunological characteristics of various virus-related post-transplant malignancies, emphasizing the need for future research. A multidisciplinary and strategic approach may serve best but overall literature evidence targeting it is sparse. However, the authors attempted to provide a more detailed update of the literature consensus for the prevention, diagnosis, management and surveillance of post-transplant viral infections and associated malignancies, with a focus on the current role of adoptive immunotherapy and the way forward. In order to achieve long-term patient and graft survival as well as superior post-transplant outcomes, collaborative research on holistic care of organ recipients is imperative.

Immunotherapies landscape and associated inhibitors for the treatment of cervical cancer

Cervical cancer ranks as the fourth most common form of cancer worldwide. There is a large number of situations that may be examined in the developing world. The risk of contracting HPV (Human Papillomavirus) due to poor sanitation and sexual activity is mostly to blame for the disease's alarming rate of expansion. Immunotherapy is widely regarded as one of the most effective medicines available. The immunotherapy used to treat cervical cancer cells relies on inhibitors that block the immune checkpoint. The poly adenosine diphosphate ribose polymer inhibited cervical cancer cells by activating both the programmed death 1 (PD-1) and programmed death ligand 1 (CTLA-1) checkpoints, a strategy that has been shown to have impressive effects. Yet, immunotherapy directed towards tumors that have already been invaded by lymphocytes leaves a positive imprint on the healing process. Immunotherapy is used in conjunction with other treatments, including chemotherapy and radiation, to provide faster and more effective outcomes. In this combination therapy, several medications such as Pembrolizumab, Durvalumab, Atezolizumab, and so on are employed in clinical trials. Recent developments and future predictions suggest that vaccinations will soon be developed with the dual goal of reducing the patient's susceptibility to illness while simultaneously strengthening their immune system. Many clinical and preclinical studies are now investigating the effectiveness of immunotherapy in slowing the progression of cervical cancer. The field of immunotherapy is expected to witness more progress toward improving outcomes. Immunotherapies landscape and associated inhibitors for the treatment of Cervical Cancer.

Combination of image-guided IMRT and IGBT in locally advanced carcinoma cervix: Prospective evaluation of toxicities and clinical outcomes from a tertiary cancer center in India

Purpose

We aimed to assess the toxicity profile and clinical outcome in patients with locally advanced cervical cancer (LACC) treated with a combination of image-guided intensity-modulated radiation therapy (IG-IMRT) and image-guided brachytherapy (IGBT).

Material and methods

25 LACC patients were recruited in this single-arm prospective study. Whole pelvis IG-IMRT was delivered (45 Gy with simultaneously integrated nodal boost of 55 Gy in 25 fractions), with concurrent weekly cisplatin (40 mg/m2). Patients received IGBT of 7 Gy each in 4 fractions to high-risk clinical target volume (HR-CTV). First fraction was done under MRI, and subsequent fractions were performed under CT guidance. Primary endpoint was acute toxicity, and secondary endpoints were 2-year loco-regional control and late toxicity.

Results

The median age was 52 years, and FIGO 2018 stage distribution was IIA2, IIB, IIIB, and IIIC1 in 12%, 40%, 20%, and 28% patients, respectively. All patients received concurrent chemotherapy with median number of 5 cycles (range, 4-5 cycles). Grade 1 and 2 diarrhea, and grade 1 cystitis was reported in 4 (16%), 3 (12%), and 2 (8%) patients, respectively. Grade 1 and 2 anemia, and grade 1 and 2 dermatitis were observed in 3 (12%) and 2 (8%), and 3 (12%) and 3 (12%) patients, respectively. No patient reported grade 3-4 acute toxicity. At median follow-up of 29.5 months (range, 25-37 months), late grade 1 bladder toxicity was observed in 1 (4%) patient. Loco-regional control at 1 and 2 years were 96% and 92%, respectively.

Conclusions

The combination of IG-IMRT and IGBT yielded excellent outcomes in terms of acute toxicity and loco-regional control.

Evaluation of doses to pelvic lymph node regions from image-guided high-dose-rate interstitial brachytherapy for carcinoma of the uterine cervix

Purpose

Interstitial brachytherapy (ISBT) is indicated for intact cervical carcinoma (IN-CC) if intracavitary brachytherapy (ICRT) is not feasible and also in vault carcinoma (VA-C). We aimed to evaluate the doses to pelvic lymph node regions in IN-CC and VA-C treated with ISBT.

Material and methods

Ten patients (6 IN-CC, 4 VA-C) were chosen for this dosimetric study. IN-CC had a central tandem in addition to the needles. External iliac (EI-N), internal iliac (II-N), obturator (OB-N) and sacral (SA-N) groups of lymph nodes were delineated. A dose of 10 grays (Gy) and 8 Gy each × 2 fractions was prescribed to the target in IN-CC and VA-C respectively. Doses received by 100%, 90% and 50% volume (D100, D90, D50) and D2cc, D1cc, D0.1cc were evaluated. Doses to lymph nodal groups in IN-CC vs. VA-C were compared using Student's t-test.

Results

For 20 implants, the median number of needles was 18 (range, 16-20). Mean D90 and D2cc of the combined bilateral OB-N, II-N, EI-N and SA-N groups were 33.62 ±3.46% and 102.94 ±10.71%, 6.98 ±0.65% and 39.69 ±3.64%, 5.1 ±0.51% and 15.4 ±0.8%, 7.76 ±0.95% and 15.36 ±1.09% of the prescribed doses respectively. Patients with a central tandem (IN-CC) received significantly higher doses to external, internal iliac and sacral group of lymph nodes (p < 0.001) as compared to VA-C.

Conclusions

In patients with cervical carcinoma treated with ISBT, pelvic lymph node groups received significant doses. The dose contribution to pelvic lymph nodes is higher in patients with intact cervical cancer where a central tandem is used as compared to post-operative patients.

Inter-observer variation of target volume delineation for CT-guided cervical cancer brachytherapy

Purpose

Delineation is a critical and challenging step in radiotherapy planning. Differences in delineation among observers are common, despite the presence of contouring guidelines. This study aimed to identify the inter-observer variability in the target volume delineation of computed tomography (CT)-guided brachytherapy for cervical cancer.

Material and methods

Four radiation oncologists (ROs) with different expertise levels delineated high-risk (HR) and intermediate-risk (IR) clinical target volume (CTV) according to GYN GEC-ESTRO recommendations, in a blinded manner on every CT set of ten locally advanced cervical cancer cases. The most experienced RO's contours were determined as the index and used for comparison. Dice similarity coefficient (DSC) and pairwise Hausdorff distance (HD) metrics were applied to compare the overlap and gross deviations of all contours.

Results

Median DSC for HR-CTV and IR-CTV were 0.73 and 0.76, respectively, and a good concordance was achieved for both in majority of contours. While there was no difference in DSC measurements for HR-CTV among the three ROs, RO-3 provided improved DSC values for IR-CTV (p = 0.01). Median HD95 was 5.02 mm and 6.83 mm, and median HDave was 1.69 mm and 2.21 mm for HR-CTV and IR-CTV, respectively. There was no significant difference among ROs in HR-CTV for HD95 or HDave; however, IR-CTV value was significantly improved according to RO-3 (p = 0.01). Case-by-case HD analysis showed no significant inter-observer variations, except for two cases.

Conclusions

The inter-observer agreement is generally high for target volumes in CT-guided brachytherapy for cervical cancer. The agreement is lower for IR-CTV than HR-CTV. The individual characteristics of each case and different expertise levels of the ROs may have caused the differences. Despite the good concordance for delineation, dosimetric consequences can still be clinically significant.

Characterization of Uterine Cervix Cancers in Women from Appalachian Kentucky

Uterine cervix cancer (UCCx) is clinically and socioeconomically diverse among women in the United States (US), which obscures the discovery of effective radiochemotherapy approaches for this disease. UCCx afflicts 7.5 per 100,000 American women nationally but 11.7 per 100,000 women in Appalachian Kentucky (AppKY), when age-adjusted to the 2000 US standard population. Epidemiological chart review was performed on 212 women with UCCx treated at the University of Kentucky (UKY) between January 2001 and July 2021. Demographics, tumor characteristics, and relative radiochemotherapy dose and schedule intensity were compared among AppKY and non-AppKY cohorts as well as Surveillance, Epidemiology, and End Results (SEER) data. One hundred thirty-eight (65%) of 212 women seeking radiochemotherapy treatment for UCCx resided in AppKY. Most (80%) sought external-beam radiochemotherapy close to their AppKY residence. Brachytherapy was then most frequently (96%) conducted at UKY. Cancer stage at diagnosis was significantly more advanced in AppKY residents. Women residing in AppKY had a median 10-week radiochemotherapy course, longer than an 8-week guideline. Estimated survival in women residing in AppKY was 8% lower than US national averages. In summary, this study identified an increased percentage of advanced-stage UCCx cancer at diagnosis arising in AppKY residents, with a confounding population-specific delay in radiochemotherapy schedule intensity lowering survival.

Risk Stratification of Early-Stage Cervical Cancer with Intermediate-Risk Factors: Model Development and Validation Based on Machine Learning Algorithm

Background

Adjuvant therapy for patients with cervical cancer (CC) with intermediate‐risk factors remains controversial. The objectives of the present study are to assess the prognoses of patients with early‐stage CC with pathological intermediate‐risk factors and to provide a reference for adjuvant therapy choice.

Materials and Methods

This retrospective study included 481 patients with stage IB–IIA CC. Cox proportional hazards regression analysis, machine learning (ML) algorithms, Kaplan‐Meier analysis, and the area under the receiver operating characteristic curve (AUC) were used to develop and validate prediction models for disease‐free survival (DFS) and overall survival (OS).

Results

A total of 35 (7.3%) patients experienced recurrence, and 20 (4.2%) patients died. Two prediction models were built for DFS and OS using clinical information, including age, lymphovascular space invasion, stromal invasion, tumor size, and adjuvant treatment. Patients were divided into high‐risk or low‐risk groups according to the risk score cutoff value. The Kaplan‐Meier analysis showed significant differences in DFS (p = .001) and OS (p = .011) between the two risk groups. In the traditional Sedlis criteria groups, there were no significant differences in DFS or OS (p > .05). In the ML‐based validation, the best AUCs of DFS at 2 and 5 years were 0.69/0.69, and the best AUCs of OS at 2 and 5 years were 0.88/0.63.

Conclusion

Two prognostic assessment models were successfully established, and risk grouping stratified the prognostic risk of patients with CC with pathological intermediate‐risk factors. Evaluation of long‐term survival will be needed to corroborate these findings.

Implications for Practice

The Sedlis criteria are intermediate‐risk factors used to guide postoperative adjuvant treatment in patients with cervical cancer. However, for patients meeting the Sedlis criteria, the choice of adjuvant therapy remains controversial. This study developed two prognostic models based on pathological intermediate‐risk factors. According to the risk score obtained by the prediction model, patients can be further divided into groups with high or low risk of recurrence and death. The prognostic models developed in this study can be used in clinical practice to stratify prognostic risk and provide more individualized adjuvant therapy choices to patients with early‐stage cervical cancer.

Adjuvant treatment for patients with cervical cancer remains controversial. This article assesses the prognosis of early‐stage cervical cancer with pathological intermediate‐risk factors and provides a reference for choice of adjuvant therapy.

Serum conversion pattern of SCC-Ag levels between pre- and post-chemoradiotherapy predicts recurrence and metastasis in cervical cancer: a multi-institutional analysis

The value of squamous-cell carcinoma antigen (SCC-Ag) as a tumor marker for cervical cancer is controversial because it is not elevated (> 2 ng/mL) in a quarter of patients at diagnosis. Two hundred ninety one IB-IVA cervical squamous cell-carcinoma patients who underwent definitive chemoradiotherapy (CRT) were included in four tertiary institutions. Serum conversion pattern between pre- and post-treatment SCC-Ag levels was categorized into the following three arms: (1) Consistent Seronegative arm (both ≤ 2 ng/mL); (2) Negative Conversion arm (from > 2 ng/mL to ≤ 2 ng/mL); and (3) Consistent Seropositive arm (both > 2 ng/mL). Median follow-up time was 40.3 months. For Consistent Seronegative (N = 67), Negative Conversion (N = 165), and Consistent Seropositive (N = 59) arms, the 3-year recurrence-free survival (RFS) rates were 79.4%, 62.0%, and 48.4% (P < 0.001) and the 3-year overall survival (OS) rates were 86.3%, 80.6%, and 58.7% (P = 0.001), respectively. The serum conversion pattern of SCC-Ag between pre- and post-treatment was the most significant and potent prognostic factor of RFS (P = 0.001) and OS (P = 0.007) on the multivariate analysis. Simply checking whether SCC-Ag level is above or below 2 ng/mL before and after definitive CRT can provide clinicians with a simple rule-of-thumb for prediction of disease outcome in cervical cancer patients.

Radioterapia y 5-fluorouracilo-cisplatino en el tratamiento del cáncer de cuello uterino de alto riesgo

Objetivo: evaluar la eficacia de la combinación de radioterapia y 5-fluorouracilo-cisplatino en el tratamiento del cáncer de cuello uterino de alto riesgo. Materiales y métodos: estudio retrospectivo en el que se revisaron los datos de pacientes tratadas en el periodo enero 2009 a diciembre 2019 en el Hospital Central “Dr. Urquinaona”, Maracaibo, Venezuela. Se revisaron los registros clínicos de todas las pacientes sometidas a histerectomía radical y linfadenectomía pélvica bilateral que recibieron quimio-radioterapia concurrente adyuvante con 5-fluorouracilo-cisplatino (grupo de tratamiento) y se compararon con quienes no fueron manejadas con este régimen, las que no recibieron ningún tratamiento adyuvante o solo fueron tratadas con radioterapia (grupo control). Se evaluaron las características generales, efectos adversos del tratamiento, recurrencias de la enfermedad y supervivencia. Resultados: para el análisis final quedaron 164 pacientes, de las cuales 115 (70,1%) fueron del grupo de tratamiento y 49 (29,9%) del control. No se encontraron diferencias estadísticamente significativas en las características clínicas entre ambos grupos (p = ns); sí las hubo en la frecuencia de recurrencias a distancia (p = 0,0056). La supervivencia libre de progresión y la global de ambos grupos no mostraron diferencias significativas (p = 0,2678 y p = 0,3452). Conclusión: no existen beneficios evidentes del uso de 5-fluorouracilo-cisplatino desde el punto de vista de progresión o supervivencia general, en pacientes con carcinoma cuello uterino de alto riesgo.

Hysterectomy for Recurrent/Residual Cervical Cancer Following Definitive Radiotherapy

BACKGROUND/AIM

Radical hysterectomy has been used for local recurrent or persistent (LR) cervical cancer after radiotherapy (RT), but the rate of serious complications is high and tolerance is low. This study determined the efficacy, safety, and prognostic factors of adjuvant simple hysterectomy in LR cervical cancer post-RT.

PATIENTS AND METHODS

A total of 21 patients who underwent hysterectomy for LR cervical cancer post-RT in our Department between May 2007 and September 2018 were included in the study. Primary, definitive RT was performed. Histological response by definitive RT in the extirpated uterus was classified on the basis of histological response criteria: effect (Ef) 0-3.

RESULTS

The 5-year overall survival (OS) and disease-free survival (DFS) rates were 51.9% and 50.1%, respectively. Ef 1 was significantly associated with poorer prognosis compared to Ef 2 or Ef 3.

CONCLUSION

Adjuvant hysterectomy could be a treatment of choice for LR cervical cancer post-RT.

Analysis of radiotherapy-induced alteration of CD8+ T cells and PD-L1 expression in patients with uterine cervical squamous cell carcinoma

Radiotherapy induces an immune response in the cancer microenvironment that may influence clinical outcome. The present study aimed to analyse the alteration of CD8⁺ T-cell infiltration and programmed death-ligand 1 (PD-L1) expression following radiotherapy in clinical samples from patients with uterine cervical squamous cell carcinoma. Additionally, the current study sought to analyse the association between these immune responses and clinical outcomes. A total of 75 patients who received either definitive chemoradiotherapy or radiotherapy were retrospectively analyzed. CD8⁺ T-cell infiltration and PD-L1 expression were determined by immunohistochemistry using biopsy specimens before radiotherapy (pre-RT) and after 10 Gy radiotherapy (post-10 Gy). The PD-L1⁺ rate was significantly increased from 5% (4/75) pre-RT to 52% (39/75) post-10 Gy (P<0.01). Despite this increase in the PD-L1⁺ rate post-10 Gy, there was no significant association between both pre-RT and post-10 Gy and overall survival (OS), locoregional control (LC) and progression-free survival (PFS). On the other hand, the CD8⁺ T-cell infiltration density was significantly decreased for all patients (median, 23.1% pre-RT vs. 16.9% post-10 Gy; P=0.038); however, this tended to increase in patients treated with radiotherapy alone (median, 17.7% pre-RT vs. 24.0% post-10 Gy; P=0.400). Notably, patients with high CD8⁺ T-cell infiltration either pre-RT or post-10 Gy exhibited positive associations with OS, LC and PFS. Thus, the present analysis suggested that CD8⁺ T-cell infiltration may be a prognostic biomarker for patients with cervical cancer receiving radiotherapy. Furthermore, immune checkpoint inhibitors may be effective in patients who have received radiotherapy, since radiotherapy upregulated PD-L1 expression in cervical cancer specimens.

Overcoming Radiation Resistance by Iron-Platinum Metal Alloy Nanoparticles in Human Copper Transport 1-Overexpressing Cancer Cells via Mitochondrial Disturbance

BACKGROUND

Radiation therapy remains an important treatment modality in cancer therapy, however, resistance is a major problem for treatment failure. Elevated expression of glutathione is known to associate with radiation resistance. We used glutathione overexpressing small cell lung cancer cell lines, SR3A-13 and SR3A-14, established by transfection with γ-glutamylcysteine synthetase (γ-GCS) cDNA, as a model for investigating strategies of overcoming radiation resistance. These radiation-resistant cells exhibit upregulated human copper transporter 1 (hCtr1), which also transports cisplatin. This study was initiated to investigate the effect and the underlying mechanism of iron-platinum nanoparticles (FePt NPs) on radiation sensitization in cancer cells.

MATERIALS AND METHODS

Uptakes of FePt NPs in these cells were studied by plasma optical emission spectrometry and transmission electron microscopy. Effects of the combination of FePt NPs and ionizing radiation were investigated by colony formation assay and animal experiment. Intracellular reactive oxygen species (ROS) were assessed by using fluorescent probes and imaged by a fluorescence-activated-cell-sorting caliber flow cytometer. Oxygen consumption rate (OCR) in mitochondria after FePt NP and IR treatment was investigated by a Seahorse XF24 cell energy metabolism analyzer.

RESULTS

These hCtr1-overexpressing cells exhibited elevated resistance to IR and the resistance could be overcome by FePt NPs via enhanced uptake of FePt NPs. Overexpression of hCtr1 was responsible for the increased uptake/transport of FePt NPs as demonstrated by using hCtr1-transfected parental SR3A (SR3A-hCtr1-WT) cells. Increased ROS and drastic mitochondrial damages with substantial reduction of oxygen consumption rate were observed in FePt NPs and IR-treated cells, indicating that structural and functional insults of mitochondria are the lethal mechanism of FePt NPs. Furthermore, FePt NPs also increased the efficacy of radiotherapy in mice bearing SR3A-hCtr1-WT-xenograft tumors.

CONCLUSION

These results suggest that FePt NPs can potentially be a novel strategy to improve radiotherapeutic efficacy in hCtr1-overexpressing cancer cells via enhanced uptake and mitochondria targeting.

Organ preserving radiation strategies for penile cancer

INTRODUCTION

The majorities of penile cancers are of squamous cell origin and thus are amenable to treatment and cure by radiation. Despite the move toward penile sparing strategies, radiation remains an under-utilized and often neglected option. This paper will review the various radio-therapeutic approaches for penile cancer and the literature supporting their use. English, French and Spanish literature on penile cancer was reviewed for the past 5 decades and classified according to modality: external beam radiotherapy, interstitial brachytherapy and surface mold brachytherapy. Many series span several decades and include a wide range of stages, especially for external beam radiotherapy. Penile preservation obviously will depend on dose prescription and stage at treatment. Nonetheless, in general, penile sparing with external beam ranges from 36% to 66% at 5 years. For the selected patients appropriate for interstitial brachytherapy penile sparing is 77% to 87% at 5 years, decreasing to 70% at 10 years. Mold therapy is selected for those with very superficial disease and penile sparing is consequently higher.

CONCLUSIONS

The development of centers of excellence for the management of this uncommon disease is encouraged. The required surgical and radiotherapy skill sets cannot be expected to be available in all centers. A multidisciplinary evaluation of each patient will facilitate selection of optimal management from the outset.

Dosimetric comparison of two different applicators and rectal retraction methods used in inverse optimization-based intracavitary brachytherapy for cervical cancer

Purpose

The purpose of this study was to evaluate the dosimetric differences between two different applicators and rectal-retraction methods used in image-guided brachytherapy (IGBT) for locally advanced cervical cancer (LACC).

Material and methods

Ten patients with LACC treated with definitive chemoradiotherapy and inverse optimization-based IGBT were included in this study. In each patient, at least one fraction of IGBT was performed using tandem-ovoids (TO) with vaginal gauze packing (VGP) or tandem-ring (TR) with rectal-retractor (RR). High-risk clinical target volume (CTV_HR) and intermediate-risk CTV (CTV_IR) were defined as CTVs, and bladder, rectum, sigmoid, small bowel, urethra, and vaginal mucosa were defined as organs at risk (OARs). All patients received 50.4 Gy external beam radiotherapy (EBRT) in 28 fractions. After EBRT, 28 Gy high-dose-rate (HDR) IGBT in 4 fractions was delivered to central disease. A plan comparison was performed using dose-volume histogram (DVH) and treatment planning parameters for CTVs and OARs.

Results

There were no significant differences in D₉₀ values of CTV_HR. In terms of rectum dose, TR with RR was found to be significantly better than TO with VGP (p < 0.0001 for D_2cm3 and p < 0.013 for V_5Gy). Although, there were no statistically significant differences in D_2cm3 value of bladder, sigmoid, small bowel, upper vaginal mucosa, and urethra, mean value of D_2cm3 for all defined OARs were found lower in TR than in TO. Bladder V_7Gy, upper vaginal mucosa V_7Gy, middle and lower vaginal mucosa D_2cm3 values were all found to be significantly lower for TR than for TO (p < 0.035). CTV_HR and CTV_IR volumes contoured in TR were approximately 11% and 9% smaller than TO, respectively.

Conclusions

The results showed that there were no statistically differences in D₉₀ value of CTV_HR and CTV_IR. However, all DVH parameters for OARs in TR with RR were found to be better than in TO with VGP.

Radiopharmaceuticals for Persistent or Recurrent Uterine Cervix Cancer

Uterine cervix cancers pose therapeutic challenges because of an overactive ribonucleotide reductase, which provides on-demand deoxyribonucleotides for DNA replication or for a DNA damage repair response. Ribonucleotide reductase overactivity bestows cancer cell resistance to the effects of radiotherapy and chemotherapy used to treat disease; but nevertheless, this same biologic overexpression provides opportune vulnerabilities relatively specific to uterine cervix cancers for new therapeutic strategies to take advantage. The discovery of human epidermal growth factor receptor 2 (ErbB2 or HER2) overexpression on metastatic uterine cervix cancer cells provides an opportunity for clinical trials of targeted radiopharmaceuticals in combination with DNA damage response modifying drugs. The National Cancer Institute's clinical trial infrastructure and its experimental therapeutics portfolio can now offer clinical trial evaluation of molecularly-targeted and tolerated radiopharmaceutical-drug combinations for women with persistent or recurrent metastatic uterine cervix cancer. This article discusses the current thinking of the National Cancer Institute in regard to attractive radiopharmaceutical strategies for this disease and others.

Human papillomavirus infection in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These guidelines from the American Society of Transplantation Infectious Diseases Community of Practice update the epidemiology and management of human papillomavirus (HPV) infections in organ transplant recipients. HPV is one of the most common sexually transmitted infections and is associated with cancers of the anogenital region. Increasing evidence suggests an association with head and neck cancers as well. Solid organ transplant recipients have a higher risk of HPV infection than the general population. Infection manifests as premalignant lesions, warts, or cancer of the cervix, penis, vulva, scrotum, and anal canal. Most are asymptomatic initially, so diagnosis can be difficult without screening. A vaccine is available though not effective in preventing all cancer-causing strains. Organ transplant recipients should be screened for HPV-associated cancers and appropriate therapy initiated in a timely manner. Further studies are warranted to delineate the most effective screening methods and therapeutic modalities, including whether changes in immunosuppression are effective in attenuating disease.

Primary Clear Cell Adenocarcinoma of the Cervix: A Clinical Analysis of 18 Cases without Exposure to Diethylstilbestrol

Objectives

Cervical clear cell adenocarcinoma (CCAC) is a rare malignant tumor with independent biological behavior in the female reproductive system. In this report, we collect the clinical and histopathological characteristics of 18 CCAC patients without exposure to diethylstilbestrol (DES) and conduct relevant clinical analysis.

Methods

We retrospectively analyzed the clinical data of 18 patients with CCAC who were diagnosed and treated from January 2009 to August 2017 in the Second Hospital of Jilin University.

Results

A total of 18 patients were enrolled. The age of patients ranged from 37 to 74 years with the peak incidence between 45 and 55 years. The median age was 53 years. The most common symptom was vaginal bleeding (66.7%, 12/18). The most common type of lesion was the endocervical type (66.7%, 12/18). The negative rate of human papillomavirus (HPV) examination was 88.9% (8/9). Based on the staging criteria of the International Federation of Gynecology and Obstetrics (FIGO) cervical cancer clinical stage in 2018, 55.6% patients were stage I (n=10), 16.7% were stage II (n=3), 22.2% were stage III (n=4), and 5.6% were stage IV (n=1). Seventeen patients underwent surgery; 64.7% (11/17) of cases showed infiltration of the entire layer of the cervix, pelvic lymph node (PLN) metastasis was observed in 4 patients (26.7%, 4/15), endometrium metastasis was observed in 4 patients (25%, 4/16), and 13 patients (72.2%, 13/18) were diagnosed at an early stage (stage IB1-IIA2). Fifteen patients' immunohistochemistry indicated that napsin A, CK7, CK (AE1/AE3), and PAX-8 were positive, and p53, p16, ER, and vimentin were expressed to different degrees. Follow-up data were obtained in 13 patients (72.2%, 13/18). One patient died of recurrence 5 months after surgery, and the other patients' progression-free survival (PFS) ranged from 9 to 59 months. Tumor size (>4 cm), tumor stage (FIGO IIA2-IV), PLN, and endometrium metastasis had negative effects on PFS (P < 0.05).

Conclusions

CCAC is a highly invasive malignant tumor, whose pathogenesis may not be associated with HPV infection. Radical hysterectomy combined with chemotherapy (paclitaxel + platinum) has the ideal short-term curative effect. In the future, larger samples of clinical data are required to confirm these insights.

Dose to pelvic lymph nodes in image based high dose rate brachytherapy of carcinoma cervix

Aim

The aim of this study is to analyse the dosimetry to the pelvic lymph nodes and its correlation to point B using CT based high dose rate brachytherapy of carcinoma cervix.

Background

Conventionally, dose to pelvic lymph nodes from intracavitary brachytherapy was reported by point B and by the reference points of the lymphatic trapezoid.

Materials and methods

30 consecutive CT based high dose rate applications were reviewed between February and March 2016. The high risk clinical target volume and the organs at risk and the pelvic nodal groups were contoured. DVH parameters for the right and left obturator nodal group, right and left external iliac nodal group and right and left internal iliac nodal group were recorded. Right and left point B doses were also recorded.

Results

On analysis of the combined dose, it was found that all the DVH parameters were significantly different from point B, except the D100 obturator and D2cc internal iliac lymph node. There was a significant correlation between all DVH parameters and point B, except D2cc, D1cc and D0.1cc of external iliac. The obturator group received the highest dose contribution from brachytherapy. The mean D90 dose received per fraction for the obturator, external iliac and internal iliac nodes was 2.7 Gy, 1.17 Gy and 1.41 Gy, respectively.

Conclusions

There is a significant dose contribution to the pelvic lymph nodal groups during intracavitary brachytherapy. There is a low degree of correlation between point B dose and dosimetric parameters of the individual nodal groups. Hence, it is important to analyse the dose delivered to individual nodal groups during intracavitary brachytherapy, at least in patients with enlarged lymph nodes to calculate the cumulative dose delivered.

MicroRNA-7-5p Promotes Cisplatin Resistance of Cervical Cancer Cells and Modulation of Cellular Energy Homeostasis by Regulating the Expression of the PARP-1 and BCL2 Genes

Background

Resistance to cisplatin results in recurrence or relapse of cervical cancer in women. An understanding of the mechanisms of cisplatin resistance will be important to improve the efficacy of cisplatin treatment. The aim of this study was to investigate the role of microRNA-7-5p (mir-7-5p) in cisplatin-resistant cervical cancer cells in vitro.

Material/Methods

The expression levels of miR-7-5p were detected in cisplatin-resistant cervical cancer cells, HeLa, and SiHa cells (HPV16-positive), and in clinical tissue samples, using miR-7-5p inhibition and a luciferase reporter assay. Fifteen paired cervical cancer tissue samples and adjacent normal cervical tissues were obtained from 15 patients who underwent surgery for cervical cancer. Western blot and flow cytometry were used to investigate cell apoptosis. The expression of mir-7-5p was detected by quantitative real-time reverse transcription-polymerase chain reaction (qRT-PCR).

Results

The level of miR-7-5p was increased in cisplatin-resistant HeLa and SiHa cervical cancer cells. Increased expression of miR-7-5p inhibited DNA repair by modulating the expression of poly (ADP-ribose) polymerase 1 (PARP-1), reducing energy consumption, and promoting autophagy via suppression of the expression of Bcl-2. These findings supported that increasing energy generation and reducing energy consumption, resulted in miR-7-5p maintaining energy homeostasis during cisplatin treatment.

Conclusions

The findings of this study showed that there was a protective role of miR-7-5p in cervical cancer cells treated with cisplatin and that miR-7-5p expression maintained energy homeostasis in cisplatin-resistant cervical cancer cells. However, miR-7-5p reduced energy consumption via inhibiting PARP-1 expression, and miR-7-5p increased energy generation by suppressing the expression of Bcl-2.

Twenty-first century cervical cancer management: A historical perspective of the gynecologic oncology group/NRG oncology over the past twenty years

Since 1970, the Gynecologic Oncology Group (GOG) has been at the forefront of evaluating and helping to implement ground breaking and paradigm changing research in the management of cervical cancer. While the most dramatic example of this impact was a series of clinical trials published in 1999 that evaluated chemoradiation therapy versus radiation therapy alone for patients with various clinical scenarios, including both locally advanced as well as post radical hysterectomy patients, investigation has continued to further refine and improve therapy. In 2014, based on the results of GOG protocol 240, bevacizumab became the first approved targeted therapy in a gynecologic cancer in the United States. Most recently, clinical trial work from the GOG is changing the standard of care for all clinical scenarios. Finally, an emphasis on survivorship and special populations are now top priorities.

Triapine Radiochemotherapy in Advanced Stage Cervical Cancer

Clinical ribonucleotide reductase (RNR) inhibitors have reinvigorated enthusiasm for radiochemotherapy treatment of patients with regionally advanced stage cervical cancers. About two-thirds of patients outlive their cervical cancer (1), even though up to half of their tumors retain residual microscopic disease (2). The National Cancer Institute Cancer Therapy Evaluation Program conducted two prospective trials of triapine–cisplatin–radiation to improve upon this finding by precisely targeting cervical cancer’s overactive RNR. Triapine’s potent inactivation of RNR arrests cells at the G1/S cell cycle restriction checkpoint and enhances cisplatin–radiation cytotoxicity. In this article, we provide perspective on challenges encountered in and future potential of clinical development of a triapine–cisplatin–radiation combination for patients with regionally advanced cervical cancer. New trial results and review presented here suggest that a triapine–cisplatin–radiation combination may offer molecular cell cycle target control to maximize damage in cancers and to minimize injury to normal cells. A randomized trial now accrues patients with regionally advanced stage cervical cancer to evaluate triapine’s contribution to clinical benefit after cisplatin–radiation (clinicaltrials.gov, NCT02466971).

Radiotherapy approaches for locally advanced penile cancer: neoadjuvant and adjuvant

PURPOSE OF REVIEW

As penile cancer is an uncommon malignancy in the Western society, randomized trials to address the controversies in management have not previously been undertaken. The incorporation of multidisciplinary approaches in the management of advanced penile carcinoma has largely borrowed evidence from analogous malignancies in the anogenital region. This review is being undertaken in preparation for the international launch of InPACT, the International Penile Advanced Cancer Trial, a collaborative effort from European and North American trialists.

RECENT FINDINGS

The literature supporting the development of this trial is reviewed, along with the trial design, goals, and endpoints. Level one evidence of the benefits of combined chemo-radiotherapy in the management of squamous cell carcinoma of the cervix, oropharynx, vulva, and anal canal has led to the introduction of this approach for advanced penile cancer. InPACT will compare chemo-radiotherapy to the traditional surgical approach, with or without neoadjuvant chemotherapy.

SUMMARY

InPACT will define the roles and optimal sequencing of surgery, chemotherapy, and radiotherapy in advanced penile cancer. In the meantime, this collaborative effort among the major research consortiums of Europe and North America lends credibility to the application of this evidence to the penile site.

A Medicare cost analysis of MRI- versus CT-based high-dose-rate brachytherapy of the cervix: Can MRI-based planning be less costly?

PURPOSE

While some institutions deliver multiple fractions per implant for MRI-based planning, it is common for only one fraction to be delivered per implant with CT-based cervical brachytherapy. The purpose of this study was to compare physician costs, hospital costs, and overall costs for cervical cancer patients treated with either CT-based or MRI-based high-dose-rate (HDR) cervical brachytherapy to determine if MRI-based brachytherapy as described can be financially feasible.

METHODS AND MATERIALS

We identified 40 consecutive patients treated with curative intent cervical brachytherapy. Twenty patients underwent CT-based HDR brachytherapy with five fractions delivered in five implants on nonconsecutive days in an outpatient setting with the first implant placed with a Smit sleeve under general anesthesia. Twenty patients received MRI-based HDR brachytherapy with four fractions delivered in two implants, each with MRI-based planning, performed 1-2 weeks apart with an overnight hospital admission for each implant. We used Medicare reimbursements to assess physician costs, hospital costs, and overall cost.

RESULTS

The median cost of MRI-based brachytherapy was $14,248.75 (interquartile range [IQR]: $13,421.32-$15,539.74), making it less costly than CT-based brachytherapy with conscious sedation (i.e., $18,278.85; IQR: $17,323.13-$19,863.03, p < 0.0001) and CT-based brachytherapy with deep sedation induced by an anesthesiologist (i.e., $27,673.44; IQR: $26,935.14-$29,511.16, p < 0.0001). CT-based brachytherapy with conscious sedation was more costly than CT-based brachytherapy with deep sedation (p < 0.001).

CONCLUSIONS

MRI-based brachytherapy using the described treatment course was less costly than both methods of CT-based brachytherapy. Cost does not need to be a barrier for MRI-based cervical brachytherapy, especially when delivering multiple fractions with the same application.

Sarcopenia Is an Important Prognostic Factor in Patients With Cervical Cancer Undergoing Concurrent Chemoradiotherapy

Objective

This study aimed to investigate the correlation of sarcopenia findings with prognostic factors in patients with cervical cancer (CC) undergoing concurrent chemoradiotherapy (CCRT).

Methods

We retrospectively collected data on body composition and clinicopathological features from the medical records of 60 patients with CC who underwent CCRT and analyzed correlations between prognosis and changes in body composition as measured by computed tomography (skeletal muscle and iliopsoas muscle [IM]). Statistical analyses were performed using the Mann-Whitney U test. Progression-free survival (PFS) and overall survival (OS) were analyzed using the Kaplan-Meier method. Cox proportional hazard regression was used for univariate and multivariate analyses.

Results

The median follow-up for all patients who were alive at the last follow-up was 33.5 months (range, 1–104 months). The PFS and OS rates were worse for patients with at least 15.0% than for those with less than 15.0% loss of skeletal muscle and IM from baseline (P < 0.001 for both). Furthermore, multivariate analyses showed that at least 15.0% loss of IM was an independent prognostic factor for PFS and OS (P = 0.002 for both).

Conclusions

Sarcopenia (≥15.0% loss of IM from baseline) was revealed to be an important prognostic factor in patients with CC undergoing CCRT.

Alcohol Abuse Decreases Pelvic Control and Survival in Cervical Cancer: An Opportunity of Lifestyle Intervention for Outcome Improvement

PURPOSE

We examined the incidence and the effect of alcohol abuse on pelvic control (PC), disease-free survival (DFS), and overall survival (OS) in locally advanced cervical cancer patients undergoing definitive radiation therapy (RT).

METHODS

Between 2007 and 2013, 95 patients treated with RT were reviewed, and the tumor characteristics, the RT dose, the treatment time, chemotherapy, and the number of cycles were recorded. The association between alcohol abuse and DFS, OS, and the duration of PC was analyzed using multivariable Cox proportional hazards models.

RESULTS

Of the 95 patients with an average age of 54.8 years (range, 27 to 91 y), 30% were FIGO stage 1B1, 1B2, 2A, 52% stage 2B, 3A; and 18% stage 3B; 86% of the patients were treated with weekly cisplatin chemotherapy. Alcohol history showed that 10 (10.5%) patients met the CDC criteria for heavy alcohol use. With a mean follow-up time of 2 years, 85 patients (88.5%) achieved PC and 86 patients (90.5%) were free of distant metastasis. A total of 82 patients (86.3%) were alive at the last follow-up. When controlling for the total treatment time, excessive alcohol abuse was significantly associated with a decrease in DFS (P=0.005; hazard ratio [HR], 6.19; 95% confidence interval [CI]: 1.73, 22.18), OS (P=0.001; HR, 6.68; 95% CI: 2.10, 21.26), and PC (P=0.029; HR, 3.10; 95% CI: 1.13, 8.56) on univariable analysis. On multivariable analysis, excessive alcohol abuse was significantly associated with a decrease in DFS (P=0.005; HR, 10.57; 95% CI: 2.07, 53.93) and OS (P=0.001; HR, 10.80; 95% CI: 2.57, 45.40).

CONCLUSIONS

In this small hypothesis-generating series of patients with heavy alcohol use, the data support the association that heavy alcohol use increases the risk of cancer recurrence and mortality. Additional research is required to better define the patient- and treatment-related factors that may be targeted for intervention.

Contemporary role of radiotherapy in the management of penile cancer

Penile cancer is a rare clinical entity that contributes to significant patient morbidity and mortality. Human papilloma virus (HPV) plays an important role in the carcinogenesis of penile squamous cell carcinoma (SCC), is associated with improved clinical outcomes, and is predictive for response to treatment with chemotherapy and radiotherapy. Historically, treatment consisted of radical surgery with partial or total penectomy. While effective for local control, surgical resection can impart significant physical, psychological and sexual dysfunction for afflicted men. Organ preservation strategies offer significant quality of life advantages over standard surgery and can be utilized without compromising oncological control. As an alternative or adjunct to surgical resection, radiation therapy can be used for organ preservation strategies successfully in up to 70% of patients. A variety of treatment techniques can be employed depending on the location and burden of disease. Limited disease can be amenable to treatment with interstitial brachytherapy, surface mold plesiotherapy or external beam radiotherapy. For locally advanced presentations, or for patients not amenable to surgical resection, excellent clinical outcomes can be achieved using a combination of chemotherapy and radiation therapy. Here, we discuss the management of penile SCC using modern radiation therapy treatment techniques, the expected clinical outcomes for organ preservation, as well as the management of side-effects and toxicities. While large randomized trials are being developed, the management of penile cancer is informed from the management of other of other anogenital malignancies, which we also review.

American Brachytherapy Task Group Report: A pooled analysis of clinical outcomes for high-dose-rate brachytherapy for cervical cancer

PURPOSE

Advanced imaging used in combination with brachytherapy (BT) has revolutionized the treatment of patients with cervical cancer. We present a comprehensive review of the literature for definitive radiation with high-dose-rate (HDR) BT. In addition, we investigate potential outcome improvement with image-based brachytherapy (IBBT) compared to studies using traditional Point A dosing. This review extensively investigates acute and late toxicities.

METHODS AND MATERIALS

This study reviews the literature from 2000 to 2015 with an emphasis on modern approaches including concurrent chemotherapy (chemoRT), radiation, and HDR BT and IBBT. Descriptive statistics and pelvic control (PC), disease-free survival (DFS), and overall survival (OS) outcomes were calculated using weighted means to report pooled analysis of outcomes.

RESULTS

Literature search yielded 16 prospective, 51 retrospective studies that reported survival outcomes, and 13 retrospective studies that focused on acute and late toxicity outcomes regardless of applicator type. There are 57 studies that report Point A dose specification with 33 having chemoRT, and 10 studies that use IBBT, 8 with chemoRT. Patients receiving radiation and chemoRT with HDR BT in the prospective studies, with >24 months followup, rates of PC were: for RT: 73%, SD: 11; CRT: 82%, SD: 8; DFS-RT: 55%, SD: 10; CRT: 65%, SD: 7; OS-RT: 66%, SD: 7; CRT: 70%, SD: 11. In the retrospective studies, the PC rates (weighted means) for the radiation and chemoradiation outcomes are 75% vs. 80%, and for DFS, the values were 55% vs. 63%, respectively. Comparing patients receiving chemoRT and IBBT to traditional Point A dose specification, there is a significant improvement in PC (p < 0.01) and DFS (p < 0.01) with IBBT. The range of genitourinary late toxicity reported for radiation was Grade 3: 1-6% and for chemoRT 2-20%. The range of late gastrointestinal toxicity for radiation was Grade 3: 4-11% and for chemoRT, 1-11%. For the late gynecologic toxicity, only 1 of the 16 prospective trials report a Grade 1-2 of 17% for radiation and 9% for chemoRT effects.

CONCLUSIONS

We present concise outcomes of PC, DFS, OS, and toxicity for cervical cancer patients treated with chemoradiation and HDR BT. Our data suggest an improvement in outcomes with the use of IBBT compared with traditional Point A dose prescriptions. In conclusion, HDR BT is a safe, effective modality when combined with IBBT.

Cervical cancer: A global health crisis

Cervical cancer is the fourth most common malignancy diagnosed in women worldwide. Nearly all cases of cervical cancer result from infection with the human papillomavirus, and the prevention of cervical cancer includes screening and vaccination. Primary treatment options for patients with cervical cancer may include surgery or a concurrent chemoradiotherapy regimen consisting of cisplatin-based chemotherapy with external beam radiotherapy and brachytherapy. Cervical cancer causes more than one quarter of a million deaths per year as a result of grossly deficient treatments in many developing countries. This warrants a concerted global effort to counter the shocking loss of life and suffering that largely goes unreported. This article provides a review of the biology, prevention, and treatment of cervical cancer, and discusses the global cervical cancer crisis and efforts to improve the prevention and treatment of the disease in underdeveloped countries. Cancer 2017;123:2404-12. © 2017 American Cancer Society.

How one institution overcame the challenges to start an MRI-based brachytherapy program for cervical cancer

Purpose

Adaptive magnetic resonance imaging (MRI)-based brachytherapy results in improved local control and decreased high-grade toxicities compared to historical controls. Incorporating MRI into the workflow of a department can be a major challenge when initiating an MRI-based brachytherapy program. This project aims to describe the goals, challenges, and solutions when initiating an MRI-based cervical cancer brachytherapy program at our institution.

Material and methods

We describe the 6-month multi-disciplinary planning phase to initiate an MRI-based brachytherapy program. We describe the specific challenges that were encountered prior to treating our first patient.

Results

We describe the solutions that were realized and executed to solve the challenges that we faced to establish our MRI-based brachytherapy program. We emphasize detailed coordination of care, planning, and communication to make the workflow feasible. We detail the imaging and radiation physics solutions to safely deliver MRI-based brachytherapy. The focus of these efforts is always on the delivery of optimal, state of the art patient care and treatment delivery within the context of our available institutional resources.

Conclusions

Previous publications have supported a transition to MRI-based brachytherapy, and this can be safely and efficiently accomplished as described in this manuscript.

The Glasgow Prognostic Score Determined During Concurrent Chemoradiotherapy Is an Independent Predictor of Survival for Cervical Cancer

OBJECTIVE

The Glasgow prognostic score (GPS) determined at pretreatment is important in the prediction of prognosis in various cancers. We investigated if the GPS used both at pretreatment and during concurrent chemoradiotherapy (CCRT) could predict the prognosis of patients with cervical cancer.

METHODS

We collected GPS and clinicopathological data from the medical records of 91 patients who underwent CCRT for cervical cancer; their GPSs at pretreatment and during CCRT were retrospectively analyzed for correlations with recurrence and survival. Statistical analyses were performed using the Mann-Whitney U test. Disease-free survival (DFS) and overall survival (OS) were analyzed using the Kaplan-Meier method. Cox's proportional hazard regression was used for univariate and multivariate analyses.

RESULTS

The median follow-up for all patients who were alive at the time of last follow-up was 38.0 months (range, 1-108 months). The DFS and OS rates of patients with a high GPS during CCRT (GPS 1 + 2; 55 patients; 60.4%) were significantly shorter than those for patients with a low GPS (GPS 0; 36 patients; 39.6%) (DFS, P < 0.001; OS, P < 0.001). Furthermore, multivariate analyses showed that high GPS during CCRT was an independent prognostic factor of survival for OS (P = 0.008).

CONCLUSIONS

During CCRT, a high GPS was revealed to be an important predictor of survival for cervical cancer.

Concurrent cisplatin-based chemoradiotherapy versus exclusive radiotherapy in high-risk cervical cancer: a meta-analysis

Objective

To evaluate the efficacy and safety of cisplatin-based concurrent chemoradiotherapy (DDP-CCRT) in patients with high-risk cervical carcinoma (CC) compared with exclusive radiotherapy (RT).

Materials and methods

Databases were searched for randomized controlled trials (RCTs) and cohort studies comparing DDP-CCRT with RT alone. Risk of bias assessment for RCTs was performed using the Cochrane Collaboration’s tool, and the Newcastle–Ottawa quality scale was used to perform quality assessment for cohort studies. Meta-analysis was conducted using Review Manager 5 and Stata 12.0 software.

Results

Finally, eight RCTs and three cohort studies containing 2,130 subjects were included. Analysis on total failures revealed a statistically significant difference in favor of DDP-CCRT (risk ratio =0.77, 95% confidence intervals [CIs]: 0.67–0.89). No significant heterogeneity was detected for pooled analysis concerning overall survival; the result of which demonstrated the superiority of DDP-CCRT over RT alone (hazard ratio =0.68, 95% CI: 0.57–0.80), and stable and established accumulative effects were observed in cumulative meta-analysis. Similar results were observed for progression-free survival (hazard ratio =0.63, 95% CI: 0.50–0.76). In terms of treatment-related Grade 3 and 4 adverse events, our pooled analysis with a fixed-effects model showed significantly enhanced toxicity in the DDP-CCRT group compared with that in the RT group (odds ratio =3.13, 95% CI: 2.37–4.13).

Conclusion

Solid and stable beneficial effects are associated with DDP-CCRT, and its superiority over comparative RT in patients with high-risk CC is confirmed. DDP-CCRT should be considered one of the frontline treatment options for high-risk CC patients without contraindications. However, enhanced toxicity associated with DDP-CCRT should never be ignored.

A practical review of magnetic resonance imaging for the evaluation and management of cervical cancer

Cervical cancer is a leading cause of mortality in women worldwide. Staging and management of cervical cancer has for many years been based on clinical exam and basic imaging such as intravenous pyelogram and x-ray. Unfortunately, despite advances in radiotherapy and the inclusion of chemotherapy in the standard plan for locally advanced disease, local control has been unsatisfactory. This situation has changed only recently with the increasing implementation of magnetic resonance image (MRI)-guided brachytherapy. The purpose of this article is therefore to provide an overview of the benefits of MRI in the evaluation and management of cervical cancer for both external beam radiotherapy and brachytherapy and to provide a practical approach if access to MRI is limited.

Urinary adverse effects of pelvic radiotherapy

Objective

Radiation is an integral part of the treatment of many pelvic tumors. The cellular death induced by radiotherapy (RT) benefits cancer control but can also result in adverse effects (AEs) on the organ being treated or those adjacent to it. RT for cancers of the pelvis (bladder, prostate, rectum, uterus or cervix) can result in AEs in the urinary tract. While the acute urinary AEs of pelvic RT are well described, late AEs are less well characterized. The burden of treatment for late AEs may be large given the prevalence of tumors in the pelvis and the high utilization of RT to treat them.

Review

For prostate cancer, grade 1 and 2 urinary AEs following external beam radiation therapy (EBRT) are reported to occur in 20-43% and 7-19%, respectively, with a follow up of 10 years. Three-year cumulative risk for grade ≥2 urinary AEs is 28-30%. Following brachytherapy (BT), rates of urinary AEs at 5 years are reported to be 36%, 24%, 6.2% and 0.1% for Radiation Therapy Oncology Group (RTOG) grade 1, 2, 3, and 4, respectively. For bladder cancer, with a median follow-up of 5 years, 7-12% of patients who receive RT experience urinary AEs of grade 3 or more. For cervical cancer, there remains a 0.25% per year risk of severe AEs for at least 25 years following RT, and ureteral stricture is a well-described AE. For endometrial cancer, severe urinary AEs are rare, but at 13 years of follow up, patients report a significantly worse quality of life with respect to urinary function. In rectal cancer, preoperative RT has a lower risk of AEs than postoperative RT, and few urinary AEs are reported in the literature.

Conclusions

Urinary AEs can manifest long after RT, and there is a paucity of studies describing rates of these long-term AEs. It is important that the possible complications of RT are recognized by providers and properly communicated to patients so that they are able to make informed decisions about their cancer treatment.

The safety of drug treatments for cervical cancer

INTRODUCTION

The treatment of some early-stage and most locally advanced disease cervical cancer patients consists of concurrent chemoradiation, while almost all with advanced disease require palliative chemotherapy.

AREAS COVERED

This review is aimed to analyze the safety issues emerging from trials of chemoradiation for early-stage high-risk disease and locally advanced stages, as well as safety issues of trials of palliative chemotherapy for advanced disease. Safety issues on fertility preservation are also discussed.

EXPERT OPINION

Cisplatin chemoradiation produces higher toxicity as compared to radiation alone, yet it is well-tolerated. Further advances would require (i) the development of more effective and tolerated combination chemoradiation regimens, (ii) demonstration of the efficacy and tolerability of adjuvant chemotherapy after cisplatin chemoradiation, and (iii) incorporation of targeted therapies into radiosensitizing regimens. A major problem continues to be the population of patients with advanced disease. The recent incorporation of bevacizumab into chemotherapy regimens represents a step forward; however, toxicity as well as economic issues may impede its wide acceptance worldwide. Preserving fertility in young women with cervical cancer is an issue that must be fully addressed. In this setting, neoadjuvant chemotherapy seems to increase fertlity rate without compromising oncological outcomes.

Concurrent Chemoradiation for Cancer of the Cervix: Results of a Multi-Institutional Study From the Setting of a Developing Country (India)

Purpose

The primary output of hospital-based cancer registries is data on cancer stage and treatment-based survival that can be used to evaluate patient care, but because there are many challenges in obtaining follow-up details, a separate study on patterns of care and patterns of survival for patients at selected sites was initiated under the National Cancer Registry Programme of India. This article presents the results for cervical cancer.

Patients and Methods

A standardized patient information form was used to record patient information, and data were entered into a central repository—the National Centre for Disease Informatics and Research. The study patients were from 12 institutions and were diagnosed between January 1, 2006, and December 31, 2008. Patterns of treatment were assessed for 7,336 patients, and patterns of survival were determined for 2,669 patients from six institutions, at least 70% of whom had data regarding follow-up as of December 31, 2012.

Results

Of 7,336 patients, 55.5% received optimal radiotherapy (RT). In all, 80.9% of patients had locally advanced cancers (stage IIB to IVA), 51.1% received RT alone, and 44.4% received concurrent chemoradiation (RTCT). In 1,753 patients with locally advanced cancers, significantly better survival was observed with RTCT than with RT alone (5-year cumulative survival, 70.2% v 47.3%; hazard ratio, 0.48; 95% CI, 0.41 to 0.56).

Conclusion

A conservative estimate indicates that, on an annual basis, 38,771 patients with cervical cancers in India alone do not get the benefit of RTCT and thus they have poorer survival. There is a need to reiterate the National Cancer Institute's alert that advised supplementing chemotherapy to radiation for locally advanced cancer of the cervix in the context of the developing world, where 84.3% of cancers of the cervix occur.

Image-Based Brachytherapy for the Treatment of Cervical Cancer

Cervical cancer is a disease that requires considerable multidisciplinary coordination of care and labor in order to maximize tumor control and survival while minimizing treatment-related toxicity. As with external beam radiation therapy, the use of advanced imaging and 3-dimensional treatment planning has generated a paradigm shift in the delivery of brachytherapy for the treatment of cervical cancer. The use of image-based brachytherapy, most commonly with magnetic resonance imaging (MRI), requires additional attention and effort by the treating physician to prescribe dose to the proper volume and account for adjacent organs at risk. This represents a dramatic change from the classic Manchester approach of orthogonal radiographic images and prescribing dose to point A. We reviewed the history and currently evolving data and recommendations for the clinical use of image-based brachytherapy with an emphasis on MRI-based brachytherapy.