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Qin Y, Guan P, Li D, He H, He W, Tan L, Deng X, Liao B, Wen Q, Zhang Z. Successful inguinal interstitial brachytherapy in metastatic cervical carcinoma: a case report. Front Oncol 2024; 13:1330681. [PMID: 38288097 PMCID: PMC10822930 DOI: 10.3389/fonc.2023.1330681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/28/2023] [Indexed: 01/31/2024] Open
Abstract
Background Treatment of metastatic cervical cancer is a tricky issue. Currently, the National Comprehensive Cancer Network (NCCN) guideline recommends chemotherapy combined with bevacizumab for recurrent or metastatic cervical cancer. Still, the recurrence rate is high and the survival rate is low after standard treatment. We urgently need to achieve a multimodal therapy approach for recurrent or metastatic cervical cancer. Case description We report the case of a patient with stage IB2 cervical squamous carcinoma who developed multiple metastases within a short term after receiving first-line standard treatment, and she underwent interstitial brachytherapy after systemic therapy with an encouraging outcome. The patient developed suspected inguinal lymph node metastases after 9 months at the end of first-line therapy and multiple metastases in the inguinal lymph nodes, anterior abdominal wall, and right lung after 17 months. As the patient had residual inguinal lymph nodes after systemic therapy, she received 3D-printed template-guided interstitial brachytherapy to the inguinal lymph nodes and maintenance therapy. By Sep 2023, she had achieved a good treatment outcome with a progression-free survival (PFS) of 36 months. Conclusion Based on our patient response, when multiple metastases develop in the short term in early-stage cervical squamous carcinoma after first-line therapy, we may consider implementing local therapy combined with systemic therapy.
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Affiliation(s)
- Yi Qin
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, Sichuan, China
| | - Ping Guan
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, Sichuan, China
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dan Li
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, Sichuan, China
| | - Huailin He
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, Sichuan, China
| | - Wenfeng He
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, Sichuan, China
| | - Longjing Tan
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, Sichuan, China
| | - Xiangyu Deng
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, Sichuan, China
| | - Bizhen Liao
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qinglian Wen
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhenhua Zhang
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, Sichuan, China
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Ma X, Fang J, Zhang L, Huang Y, Shen H, Ma X, Zhang S, Zhang B. Efficacy and safety of adjuvant chemotherapy for locally advanced cervical cancer: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2023; 184:103953. [PMID: 36889613 DOI: 10.1016/j.critrevonc.2023.103953] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/31/2023] [Accepted: 02/27/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Locally advanced cervical cancer (LACC) is generally treated using concurrent chemo-radiotherapy (CCRT); yet, the effectiveness of adjuvant chemotherapy (ACT) following CCRT remains controversial. METHODS The databases Embase, Web of Science, and PubMed were analyzed for relevant research. Primary endpoints included overall survival (OS) and progression-free survival (PFS). RESULTS Fifteen trials with 4041 patients were included. Pooled HRs for PFS and OS were 0.81 (95 % CI: 0.67-0.96) and 0.69 (95 % CI: 0.51-0.93), respectively. However, subgroup analyses indicated that in randomized trials and trials with larger sample sizes (n > 100) as well as ACT cycles ≤ 3, ACT was not linked with improved PFS and OS. Moreover, ACT induced a greater rate of hematologic toxicities (P < 0.05). CONCLUSION Higher quality of evidence suggests that ACT could not yield additional survival benefits for LACC; however, identifying high-risk patients who may benefit from ACT is required to design further clinical trials and better inform treatment decisions.
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Affiliation(s)
- Xiao Ma
- Department of Radiology, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Jin Fang
- Department of Radiology, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Lu Zhang
- Department of Radiology, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Yao Huang
- Department of Radiology, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Hui Shen
- Department of Radiology, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Xiaohua Ma
- Department of Medical Ultrasonics, Hongqi Hospital of Mudanjiang Medical University, Mudanjiang, Heilongjiang, China
| | - Shuixing Zhang
- Department of Radiology, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China.
| | - Bin Zhang
- Department of Radiology, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China.
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Kavuma A, Luutu I, Kibudde S, Kanyike D. A Retrospective Analysis of the Impact of HIV Infection on Outcomes of Locally Advanced Cervical Cancers Treated With Either Conventional or Hypofractionated Radiotherapy: The Uganda Experience. JCO Glob Oncol 2022; 8:e2100360. [PMID: 35696625 PMCID: PMC9225504 DOI: 10.1200/go.21.00360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We annually treat more than 800 new patients with cervical cancer, where the majority (approximately 60%) have locally advanced disease and approximately 40% of them are infected with HIV. To optimally care for this large number of patients in low-income settings is difficult. From July 2011, we started using 45.0 Gy/15# hypofractionated radiotherapy (HFRT) as a substitute to 50.0 Gy/25# conventional fractionated radiotherapy (CFRT), for the treatment of locally advanced cervical cancer (LACC). This study aims at comparing the 5-year treatment outcomes between patients with LACC, known HIV serostatus, and treated with either CFRT or HFRT. METHODS A retrospective study was conducted according to demographic/clinical data, radiotherapy fractionations, and outcomes. Factors considered were FIGO stages IIB-IIIB, known HIV serostatus, and had completed external-beam radiotherapy and intracavitary brachytherapy. The primary end point was overall survival; the secondary end points were toxicity and compliance. RESULTS The study included 221 patients. Squamous cell carcinomas were 95.1% and adenocarcinomas 2.3%. The median age was 45.0 (interquartile range, 38.0-52.0) years. Stages IIB, IIIA, and IIIB were 38.9%, 6.3%, and 54.8%, respectively. HIV-positive and HIV-negative were 87 (39.4%) and 134 (60.6%), respectively. Chemoradiation was administered in 100 (45.2%), and 52 (52.0%) completed chemotherapy. CFRT/HFRT were 116 (52.5%)/105 (47.5%). At 24 months, the overall response was 54.1% for HIV-negative compared with 45.0% for HIV-positive ( P value .262). There was no significant differences in acute/late toxicity grades ≥ 2 for HIV-negative/positive treated with HFRT/CFRT. At 60 months, the survival probabilities were 45.7% and 27.7% for HIV-negative and HIV-positive treated with CFRT ( P value = .006), whereas it was 44.2% and 30.7% for HIV-negative and HIV-positive treated with HFRT ( P value = .048), respectively. CONCLUSION For the treatment of LACC with known HIV serology, there was no significant statistical difference in terms of response, toxicity, and compliance between CFRT and HFRT. However, the difference in overall survival between HIV-negative and HIV-positive was significant.
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Affiliation(s)
- Awusi Kavuma
- Department of Radiotherapy, Uganda Cancer Institute, Kampala, Uganda
| | - Israel Luutu
- Department of Radiotherapy, Uganda Cancer Institute, Kampala, Uganda
| | - Solomon Kibudde
- Department of Radiotherapy, Uganda Cancer Institute, Kampala, Uganda
| | - Daniel Kanyike
- Department of Radiotherapy, Uganda Cancer Institute, Kampala, Uganda
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Kavuma A, Luutu I, Kibudde S, Bangidde C. A retrospective review of conventional versus hypo-fractionated pelvic radiotherapy for locally advanced cervical cancer, in limited-resource countries: The Uganda experience. SOUTH AFRICAN JOURNAL OF ONCOLOGY 2021. [DOI: 10.4102/sajo.v5i0.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background: Cervical cancer incidence in Uganda is 54.8 per 100 000 population. We annually treat over 800 new cervical cancers (40% of the workload), which is challenging to treat such numbers in limited resources settings. From July 2011, we commenced the use of hypo-fractionated radiotherapy (HFRT) of 45 Gy/15 fraction (#) as an alternative to conventional fractionated radiotherapy (CFRT) of 50 Gy/25#, for treatment of locally advanced cervical cancer (LACC).Aim: To compare the 5-year follow-up treatment outcomes between CFRT and HFRT.Settings: The study analysed patients treated at the Uganda Cancer Institute – a limited resource institution.Methods: This was a non-randomised, retrospective study, where 414 patients’ files were reviewed according to demographic, clinical, radiotherapy fractionations and outcomes. Inclusion criteria were International Federation of Gynecology and Obstetrics stages IIB–IIIB cervical cancer cases and had completed external beam radiotherapy and intracavitary radiotherapy.Results: Squamous cell carcinomas were 93.6% and adenocarcinomas were 3.0%. The median age was 49.5 (interquartile range [IQR]: 40.0–56.0) years. Stages IIB/IIIA/IIIB were 36.2%, 8.2%, 55.6%, respectively. Human immunodeficiency virus serology was positive, negative, and unknown in 70 (16.9%), 116 (28.0%) and 228 (55.1%), respectively. Concurrent chemo-radiation was administered in 182 (44.0%) patients. Conventional fractionated radiotherapy and HFRT were 221 (53.4%) and 193 (46.6%), respectively. At 6 months, the overall response rate was 73.3% for CFRT compared with 67.6% for HFRT (p = 0.085), whilst the grades 0–1 toxicities were 94.5% and for 94.7% CFRT and HFRT, respectively (p = 0.080). At 60 months, the survival probabilities were 44.9% for CFRT and 46.6% for HFRT (p = 0.293).Conclusion: There is no significant statistical difference between CFRT and HFRT for the treatment of LACC. The HFRT could be considered for high volume limited resource settings.
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Horeweg N, Mittal P, Gradowska PL, Boere I, Chopra S, Nout RA. Adjuvant Systemic Therapy after Chemoradiation and Brachytherapy for Locally Advanced Cervical Cancer: A Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:1880. [PMID: 33919905 PMCID: PMC8070970 DOI: 10.3390/cancers13081880] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/24/2021] [Accepted: 04/06/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Standard of care for locally advanced cervical cancer is chemoradiation and brachytherapy. The addition of adjuvant systemic treatment may improve overall survival. A systematic review and meta-analysis was conducted to summarize evidence on survival outcomes, treatment completion and toxicity. METHODS PubMed, EMBASE and Web of Science were systematically searched for relevant prospective and retrospective studies. Two authors independently selected studies, extracted data and assessed study quality. Pooled hazard ratios for survival endpoints were estimated using random effect models. Weighted averages of treatment completion and toxicity rates were calculated and compared by the Fisher exact test. RESULTS The search returned 612 articles; 35 articles reporting on 29 different studies on adjuvant chemotherapy or immunotherapy were selected for systematic review. Twelve studies on an adjuvant platinum-pyrimidine antagonist or platinum-taxane were included for meta-analysis. The pooled hazard ratios for overall survival were 0.76 (99%CI: 0.43-1.34, p = 0.22) and 0.47 (99%CI: 0.12-1.86, p = 0.16) for the addition of, respectively, a platinum-pyrimidine antagonist or platinum-taxane to chemoradiation and brachytherapy. Completion rates were 82% (95%CI: 76-87%) for platinum-pyrimidine antagonist and 74% (95%CI: 63-85%) for platinum-taxane. Severe acute hematological and gastro-intestinal toxicities were significantly increased by adding adjuvant chemotherapy to chemoradiation and brachytherapy. CONCLUSIONS The addition of adjuvant platinum-pyrimidine antagonist or platinum-taxane after chemoradiation and brachytherapy does not significantly improve overall survival, while acute toxicity is significantly increased. These adjuvant treatment strategies can therefore not be recommended for unselected patients with locally advanced cervical cancer.
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Affiliation(s)
- Nanda Horeweg
- Department of Radiation Oncology, Leiden University Medical Center, 2333ZA Leiden, The Netherlands
| | - Prachi Mittal
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Parel, Homi Bhabha National Institute, Mumbai 400094, India;
| | - Patrycja L. Gradowska
- Department of Hematology—HOVON Data Center, Erasmus MC Cancer Institute, P.O. box 2040, 3000CA Rotterdam, The Netherlands;
| | - Ingrid Boere
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, P.O. box 2040, 3000CA Rotterdam, The Netherlands;
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Centre, Parel, Homi Bhabha National Institute, Mumbai 400094, India;
| | - Remi A. Nout
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, P.O. box 2040, 3000CA Rotterdam, The Netherlands;
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Ballari N, Rai B, Bahl A, Mittal BR, Ghoshal S. Prospective observational study evaluating acute and delayed treatment related toxicities of prophylactic extended field volumetric modulated arc therapy with concurrent cisplatin in cervical cancer patients with pelvic lymph node metastasis. Tech Innov Patient Support Radiat Oncol 2021; 17:48-56. [PMID: 33748442 PMCID: PMC7970137 DOI: 10.1016/j.tipsro.2021.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 02/10/2021] [Accepted: 02/15/2021] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To evaluate the treatment related acute and delayed toxicities of extended field Volumetric modulated arc therapy (VMAT) with concurrent chemotherapy in patients of locally advanced cervical cancer with pelvic lymph nodes. MATERIAL AND METHODS From 2014 to 2016, 15 patients of locally advanced cervical cancer with Fluoro-deoxyglucose positron emission tomography (FDG-PET) positive pelvic lymph nodes were treated with extended field Simultaneous integrated boost (SIB)-VMAT 45 Gy/55 Gy/25#/5weeks and concurrent cisplatin. Acute toxicities were documented according to common terminology criteria for adverse events version 4 (CTCAE v.4). Dose volume parameters and patient characteristics were analyzed for association with toxicities. RESULTS Median age of patients at diagnosis was 48 years. 40% (6 patients) were stage IIB & 60% (9 patients) were stage IIIB. Median number of involved pelvic lymph nodes was 2 (range, 1-4), commonest location was external iliac lymph node region (86%). Median number of concurrent chemotherapy cycles received was five. Treatment was well tolerated and there were no grade ≥ 3 acute toxicities. Commonest acute toxicities observed were vomiting (≥grade2 -13.3%) followed by & nausea (grade ≥ 2 in 6%) and were associated with volume of bowel bag receiving 45 Gy. Constitutional symptoms (≥grade 2) were observed in 6% patients and had no dosimetric associations. At a median follow up of 43 months, delayed ≥ grade1, 2, 3 toxicity were observed in 80%, 0%, and 0% respectively with diarrhea being the commonest. CONCLUSION Prophylactic para aortic extended field VMAT with concurrent chemotherapy for locally advanced cervical cancer is well tolerated with acceptable acute toxicity profile. Significant grade 3 acute/delayed toxicities were not observed in this cohort of patients.
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Affiliation(s)
- N Ballari
- Departments of Radiotherapy, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - B Rai
- Departments of Radiotherapy, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - A Bahl
- Departments of Radiotherapy, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - B R Mittal
- Nuclear Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - S Ghoshal
- Departments of Radiotherapy, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Wu N, Su X, Song H, Li Y, Gu F, Sun X, Li X, Cheng G. A Multi-Institutional Retrospective Analysis of Oncologic Outcomes for Patients With Locally Advanced Cervical Cancer Undergoing Platinum-Based Adjuvant Chemotherapy After Concurrent Chemoradiotherapy. Cancer Control 2021; 28:1073274821989307. [PMID: 33593091 PMCID: PMC8482744 DOI: 10.1177/1073274821989307] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Objective: To evaluated the oncologic outcomes associated with platinum-based adjuvant chemotherapy following concurrent chemoradiotherapy (CCRT) in the management of patients with locally advanced cervical cancer (LACC). Methods: A total of 695 patients with FIGO stage IB2, IIA2, IIB-IVA LACC treated at 6 medical facilities were enrolled and divided into 2 groups: 478 were assigned to CCRT alone (CCRT group) and 217 to adjuvant chemotherapy after CCRT (CCRT-ACT group). The treatment outcomes were retrospectively compared and reported after the propensity score matching (PSM) analysis. Results: With a median follow-up of 56.4 months, no statistically significant differences were found in overall survival (OS), disease-free survival (DFS), progression-free survival (PFS) and distance metastasis-free survival (DMFS) between 2 groups. In CCRT-ACT group, patients with lymph nodes involvement or squamous cell carcinoma (SCC) had significantly longer DMFS, but no significant benefit in survival outcomes were observed with more than 2 cycles of adjuvant chemotherapy. Moreover, patients with a high level of CA125 (>20.5U/mL) or SCC-Ag (>22.8μg/L) had a relatively better DFS or PFS, and grade 3-4 acute hematological toxicity, late urinary and lower gastrointestinal complications and diarrhea symptom were more frequent in CCRT-ACT group. Conclusions: Adjuvant chemotherapy after CCRT has a potential role in further improving disease control for LACC patients with lymph nodal-metastasis or SCC with a high level of CA125 or SCC-Ag. Due to increased treatment-related complications and diarrhea symptom affecting the quality of life, post-CCRT adjuvant chemotherapy with excessive cycles was not be considered as the most appropriate choice in general.
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Affiliation(s)
- Ning Wu
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Xing Su
- Department of Radiation Oncology, Beijing Cancer Hospital, Beijing, China
| | - Honglin Song
- Department of Gynecologic Oncology, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Ying Li
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fei Gu
- Department of Radiation Oncology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xiaoge Sun
- Department of Radiation Oncology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Xiaofan Li
- Department of Radiation Oncology, Beijing Cancer Hospital, Beijing, China
| | - Guanghui Cheng
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun, China
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Liu X, Wang W, Meng Q, Zhang F, Hu K. Extended-field intensity-modulated radiation therapy combined with concurrent chemotherapy for cervical cancer with para-aortic lymph nodes metastasis. Jpn J Clin Oncol 2019; 49:263-269. [PMID: 30668725 DOI: 10.1093/jjco/hyy184] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/09/2018] [Accepted: 11/16/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE This study was conducted to evaluate the efficacy and toxicity of extended-field intensity-modulated radiation therapy combined with concurrent chemotherapy in patients with cervical cancer with positive para-aortic lymph nodes (PALN). METHODS From September 2007 to December 2014, a total of 59 patients who had cervical cancer with para-aortic lymph node metastasis were treated with concurrent chemoradiotherapy at our institution. A dose of 45-50.4 Gy in 25-28 fractions with extended-field intensity-modulated radiation therapy was prescribed to planning target volume, and a dose of 30-36 Gy in 5-6 fractions was prescribed to Point A with high-dose-rate brachytherapy. A concurrent first-line cisplatin-based chemotherapy regimen was used. RESULTS The median duration of follow-up was 32.1 months (range, 3.2-103.7 months). The 2- and 3-year overall survival, disease-free survival and local control rates were 69.0 and 52.8%, 45.0 and 41.3% and 83.4 and 81.0%, respectively. Distant metastasis was the major pattern of treatment failure, which occurred in 26 patients (44.1%). The incidence of Grade 3 or greater acute hematologic, gastrointestinal and genitourinary toxicity was 50.9, 1.7 and 3.4%, respectively. Only one patient had both Grade 3 late gastrointestinal and genitourinary toxicity. CONCLUSIONS The study found that extended-field intensity-modulated radiation therapy combined with concurrent chemotherapy was safe and effective in patients who had cervical cancer with positive PALN.
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Affiliation(s)
- Xiaoliang Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Weiping Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Qingyu Meng
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fuquang Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Gupta M, Chopra S, Kunder S, Dheera A, Sampathirao D, Engineer R, Ghosh J, Gurram L, Mahantshetty U, Gupta S, Shrivastava S. Early toxicity and treatment outcomes of extended field-intensity modulated radiotherapy for cervical cancer patients with para-aortic nodal metastasis. Ecancermedicalscience 2019; 13:957. [PMID: 31645885 PMCID: PMC6759319 DOI: 10.3332/ecancer.2019.957] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Indexed: 11/06/2022] Open
Abstract
Objective Extended-field radiotherapy (EFRT) with concurrent chemotherapy represents standard treatment in cervical cancer patients with para-aortic lymph nodal (PALN) metastasis. While EFRT with Intensity Modulated RT (IMRT) has been demonstrated to reduce toxicities, the dose thresholds for minimizing acute toxicity is not clear. The present study was undertaken to report the early toxicity with extended-field intensity-modulated radiotherapy (EF-IMRT) for carcinoma of the cervix in our cohort of patients and determine dose-volume parameters that predict ≥grade II haematological toxicity and diarrhoea. Methodology This was a retrospective study of consecutive cervical cancer patients with PALN metastasis treated with EF-IMRT. Patients received rotational IMRT +/- neoadjuvant chemotherapy (NACT) and/or concurrent chemotherapy (45–50 Gy/25#/5 weeks) followed by high-dose rate brachytherapy. Acute haematological and gastrointestinal toxicity (diarrhoea and vomiting) was correlated with doses received by bowel and marrow. Receiver operator characteristics curves were used for deriving thresholds that predict for increased toxicity and tested on univariate and multivariate analysis. Finally, disease free and overall survival (DFS and OS) was calculated. Results A total of 43 patients were included. One-fourth of the patients (11/43) received NACT and 88% received concurrent chemotherapy. Within the upfront EF-IMRT cohort, 22.6% and 9.7% patients developed grade ≥III haematological (HT) and gastrointestinal (GI) toxicity respectively, with an increase in HT (≥ grade III HT =67%) in patients receiving NACT (p = 0.007). In the entire cohort bone marrow Volume receiving 10 Gy (V10>) 90% correlated with an increase in ≥ grade III HT (p = 0.05). No dose volume thresholds could be validated for GI toxicity. The OS and DFS at 2 years was 56% and 54%, respectively. Conclusion EF-IMRT is a feasible option for cervical cancer patients with PALN involvement and is associated with acceptable grade III toxicity. Future studies need to focus on minimizing HT toxicity.
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Affiliation(s)
- Meetakshi Gupta
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, India
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Kharghar, Navi Mumbai, India
| | - Shreya Kunder
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, India
| | - A Dheera
- Department of Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, India
| | - Devaraju Sampathirao
- Department of Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, India
| | - Jaya Ghosh
- Department of Medical Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Kharghar, Navi Mumbai, India
| | - Lavanya Gurram
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, India
| | - Umesh Mahantshetty
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, India
| | - Sudeep Gupta
- Department of Medical Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Kharghar, Navi Mumbai, India
| | - Shyam Shrivastava
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, India
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Ali N, Valimohammad AT, Abbasi AN, Mansha MA, Hafiz A, Qureshi BM. Chemoradiation and the Role of Adjuvant Chemotherapy in Lymph Nodal-Metastatic Cervical Cancer. J Glob Oncol 2018; 4:1-4. [PMID: 30241186 PMCID: PMC6180839 DOI: 10.1200/jgo.2017.009852] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To report the long-term outcome in lymph nodal–metastatic cervical
squamous cell cancer after chemoradiation followed by adjuvant
chemotherapy. Patients and Methods Between 2010 and 2013, five patients were diagnosed with advanced cervical
cancer with clinically involved para-aortic lymph nodes (ie, International
Federation of Gynecology and Obstetrics stage IVB). These patients were
treated with concurrent chemoradiation therapy followed by adjuvant
chemotherapy. Concurrent chemoradiation consisted of cisplatin given once
per week concomitantly with extended-field radiation therapy followed by
high-dose-rate brachytherapy. Adjuvant chemotherapy comprised four courses
of carboplatin and paclitaxel given every three weeks. The primary outcomes
were local and distant failures. Results None of the patients had local recurrence or distal failure after a minimum
follow-up time of 3 years. Conclusion Adjuvant chemotherapy after chemoradiation has a probable role in the
management of lymph nodal–metastatic cervical cancer.
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Affiliation(s)
- Nasir Ali
- All authors: Aga Khan University Hospital, Karachi, Pakistan
| | | | | | | | - Asim Hafiz
- All authors: Aga Khan University Hospital, Karachi, Pakistan
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Management of Para-aortic Lymph Node Disease in Patients With Cervical Cancer: What Is the Best Approach? Int J Gynecol Cancer 2018; 27:543-549. [PMID: 28107261 DOI: 10.1097/igc.0000000000000914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Cervical cancer remains a prevalent and deadly disease in low-income countries, especially among young and otherwise healthy women. Multimodality treatment has led to a significant improvement in outcomes for patients with locally advanced disease, and this is mainly because of the incorporation of platinum-based chemoradiotherapy in current treatment protocols. However, locally advanced tumors are associated with a greater risk for para-aortic lymph node (PALN) involvement, which is an important adverse prognostic factor. Most staging techniques have low accuracy for detection of disease in this area, which could lead to understaging and undertreatment. Meanwhile, patients with PALN disease are underrepresented in trials addressing the treatment of advanced cervical cancer and a few studies have been directed at this population. The aim of this review is to analyze the current data regarding staging and treatment of cervical cancer with PALN disease to determine which strategy is best when managing these patients.
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Oh J, Seol KH, Lee HJ, Choi YS, Park JY, Bae JY. Prophylactic extended-field irradiation with concurrent chemotherapy for pelvic lymph node-positive cervical cancer. Radiat Oncol J 2017; 35:349-358. [PMID: 29262671 PMCID: PMC5769878 DOI: 10.3857/roj.2017.00367] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 08/19/2017] [Accepted: 09/01/2017] [Indexed: 01/22/2023] Open
Abstract
Purpose This study aimed to evaluate whether prophylactic extended-field pelvic radiotherapy (EF-PRT) yields better results than standard whole pelvic radiotherapy (WPRT) in patients with pelvic lymph node-positive cervical cancer treated with concurrent chemoradiotherapy (CCRT). Materials and Methods A total of 126 cases of stage IB-IVA cervical cancer that had pelvic lymph node involvement in magnetic resonance imaging and were treated with CCRT between 2000 and 2016 were reviewed. None of the patients had paraaortic lymph node (PALN) metastases. The patients were classified to two groups, namely, those treated with EF-PRT, including prophylactic para-aortic radiotherapy, and those treated only with WPRT. The median dose to the PALN area in patients treated with EF-PRT was 45 Gy. All patients received concurrent cisplatin-based chemotherapy. Results Overall, 52 and 74 patients underwent EF-PRT and WPRT, respectively. Patient characteristics and irradiated dose were not significantly different, except the dose to the para-aortic area, between the two groups. The median follow-up period was 75.5 months (range, 5 to 195 months). The 10-year cumulative recurrence rate of PALN for EF-PRT vs. WPRT was 6.9% and 10.1% (p = 0.421), respectively. The 10-year disease-free survival and overall survival for EF-PRT vs. WPRT were 69.7% vs. 66.1% (p = 0.748) and 71.7% vs. 72.3% (p = 0.845), respectively. Acute gastrointestinal complications were significantly higher in EF-PRT (n = 21; 40.4%) than WPRT (n = 26; 35.1%) (p = 0.046). Late toxicities were not significantly different in both groups. Conclusion In this study, prophylactic radiotherapy for PALN does not have an additional benefit in patients with pelvic lymph node-positive cervical cancer treated with CCRT.
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Affiliation(s)
- Jinju Oh
- Department of Obstetrics and Gynecology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Ki Ho Seol
- Department of Radiation Oncology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Hyun Joo Lee
- Department of Obstetrics and Gynecology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Youn Seok Choi
- Department of Obstetrics and Gynecology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Ji Y Park
- Department of Pathology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jin Young Bae
- Department of Obstetrics and Gynecology, Catholic University of Daegu School of Medicine, Daegu, Korea
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Yan K, Ramirez E, Xie XJ, Gu X, Xi Y, Albuquerque K. Predicting severe hematologic toxicity from extended-field chemoradiation of para-aortic nodal metastases from cervical cancer. Pract Radiat Oncol 2017; 8:13-19. [PMID: 28865761 DOI: 10.1016/j.prro.2017.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 06/01/2017] [Accepted: 07/03/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of this study was to determine factors predictive for severe hematologic toxicity (HT) in cervical cancer patients with para-aortic lymph node metastasis treated with concurrent cisplatin chemoradiation to an extended field (EFCRT). METHODS AND MATERIALS Thirty-eight patients with cervical cancer and para-aortic lymph node metastasis who underwent EFCRT were analyzed. Active bone marrow was defined as the region within irradiated total bone marrow (BMTOT) with a standard uptake value on 18F-fluorodeoxyglucose positron emission tomography/computed tomography greater than the mean standard uptake value for BMTOT. Serial weekly blood counts from the beginning to the end of radiation treatment were evaluated for HT using Common Terminology Criteria for Adverse Events, version 4.0. RESULTS Nineteen patients had grade 3 or higher hematologic toxicity (HT3+), not including lymphocyte toxicity. Obese patients (n = 12) were less likely to get HT3+ (P = .03) despite getting equivalent doses of chemotherapy. Volumes of BMTOT and active bone marrow receiving doses of 20, 30, and 45 Gy and body mass index significantly predicted HT3+. Patients who had HT3+ had prolonged treatment time (62 vs 53 days, P < .001). CONCLUSIONS For patients receiving EFCRT, bone marrow irradiation parameters and patient body mass index were associated with HT3+. A simplified nomogram has been created to predict HT3+ in these patients, allowing the potential to explore bone marrow-sparing delivery techniques.
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Affiliation(s)
- Kevin Yan
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ezequiel Ramirez
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Xian-Jin Xie
- Division of Biostatistics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Xuejun Gu
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yin Xi
- Division of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kevin Albuquerque
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas.
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Lee J, Lin JB, Chang CL, Jan YT, Sun FJ, Wu MH, Chen YJ. Prophylactic lower para-aortic irradiation using intensity-modulated radiotherapy mitigates the risk of para-aortic recurrence in locally advanced cervical cancer: A 10-year institutional experience. Gynecol Oncol 2017; 146:20-26. [PMID: 28457584 DOI: 10.1016/j.ygyno.2017.04.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 04/20/2017] [Accepted: 04/22/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the effects of prophylactic sub-renal vein radiotherapy (SRVRT) using intensity-modulated radiotherapy (IMRT) for cervical cancer. METHODS A total of 206 patients with FIGO stage IB2-IVA cervical cancer and negative para-aortic lymph nodes (PALNs) who underwent pelvic IMRT (PRT) or SRVRT between 2004 and 2013 at our institution were reviewed. SRVRT cranially extended the PRT field for PALNs up to the left renal vein level. The prescribed dose was consistent 50.4Gy in 28 fractions. RESULTS Overall, 110 and 96 patients underwent PRT and SRVRT, respectively. The SRVRT group had more advanced disease based on FIGO stage and positive pelvic lymph nodes (PLNs). The median follow-up time was 60months (range, 7-143). For the total study population, the 5-year PALN recurrence-free survival (PARFS) and overall survival (OS) for PRT vs. SRVRT were 87.6% vs. 97.9% (p=0.03) and 74.5% vs. 87.8% (p=0.04), respectively. In patients with FIGO III-IVA or positive PLNs, the 5-year PARFS and OS for PRT vs. SRVRT were 80.1% vs. 96.4% (p=0.02) and 58.1% vs. 83.5% (p=0.012), respectively. However, there were no significant differences in these outcomes for patients with FIGO IB-IIB and negative PLNs. In a multivariate analysis, only SRVRT was associated with better PARFS (HR, 0.21; 95% CI, 0.06-0.78; p=0.02). The SRVRT did not significantly increase severe late toxicities. CONCLUSION Prophylactic SRVRT using IMRT reduced PALN recurrence with tolerable toxicities, supporting the application of risk-based radiation fields for cervical cancer.
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Affiliation(s)
- Jie Lee
- Department of Radiation Oncology, MacKay Memorial Hospital, Taipei, Taiwan; Department of Medicine, MacKay Medical College, Taiwan; Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Jhen-Bin Lin
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, Taiwan
| | - Chih-Long Chang
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Ya-Ting Jan
- Department of Radiology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Fang-Ju Sun
- Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan; MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
| | - Meng-Hao Wu
- Department of Radiation Oncology, MacKay Memorial Hospital, Taipei, Taiwan; Department of Medicine, MacKay Medical College, Taiwan.
| | - Yu-Jen Chen
- Department of Radiation Oncology, MacKay Memorial Hospital, Taipei, Taiwan; Department of Medicine, MacKay Medical College, Taiwan.
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Lee J, Lin JB, Sun FJ, Chen YJ, Chang CL, Jan YT, Wu MH. Safety and efficacy of semiextended field intensity-modulated radiation therapy and concurrent cisplatin in locally advanced cervical cancer patients: An observational study of 10-year experience. Medicine (Baltimore) 2017; 96:e6158. [PMID: 28272204 PMCID: PMC5348152 DOI: 10.1097/md.0000000000006158] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Patients with locally advanced cervical cancer (LACC) are at risk of para-aortic lymph node (PALN) metastasis. Pelvic concurrent chemoradiotherapy, the current standard treatment for LACC, has a PALN failure rate of 9% according to the Radiation Therapy Oncology Group Trial 90-01, suggesting that it may not completely eliminate all microscopic tumors in the PALNs. To minimize the toxicities associated with conventional prophylactic extended-field radiotherapy, our institute use prophylactic semiextended field radiotherapy that includes only the PALNs below the level of the renal vessels. Use of intensity-modulated radiotherapy (IMRT) is another means of reducing the incidence of toxicity. This study evaluated the safety and efficacy of prophylactic semiextended field IMRT (SEF-IMRT) and concurrent cisplatin chemotherapy in patients with LACC.We retrospectively assessed survival and toxicity in 76 patients with stage IB2-IVA cervical cancer and negative PALNs who received prophylactic SEF-IMRT and concurrent weekly cisplatin (40 mg/m) between 2004 and 2013. The region targeted by SEF-IMRT included the PALNs below the level of the renal vessels, and the prescribed dose was 50.4 Gy in 28 fractions. Brachytherapy was administered at a dose of 30 Gy in 6 fractions. Survival outcomes were calculated by using the Kaplan-Meier method, and acute and late toxicities were scored according to the Common Terminology Criteria for Adverse Events, version 3.0.All patients completed the planned SEF-IMRT, as well as brachytherapy. Acute grade ≥3 gastrointestinal, genitourinary, and hematologic toxicities were observed in 2, 0, and 41 patients, respectively. The median follow-up time after SEF-IMRT was 55 (range, 11-124) months. Eight patients developed out-field distant recurrences without PALN failure, and 1 patient experienced out-field PALN failure with simultaneous distant metastasis. No patients had late genitourinary toxicities, and 3 patients had late grade 3 gastrointestinal toxicities. The 5-year overall survival, disease-free survival, local failure-free survival, regional failure-free survival, PALN failure-free survival, and distant metastasis-free survival rates were 85.0%, 84.4%, 96.0%, 97.3%, 98.6%, and 88.4%, respectively.For patients with LACC, prophylactic PALN irradiation up to the level of the renal vessels reduced PALN recurrence and resulted in favorable outcomes with few severe toxicities.
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Affiliation(s)
- Jie Lee
- Department of Radiation Oncology, MacKay Memorial Hospital
- Department of Medicine, MacKay Medical College, Taipei
| | - Jhen-Bin Lin
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua
| | - Fang-Ju Sun
- Department of Medical Research, MacKay Memorial Hospital
- MacKay Junior College of Medicine, Nursing and Management
| | - Yu-Jen Chen
- Department of Radiation Oncology, MacKay Memorial Hospital
- Department of Medicine, MacKay Medical College, Taipei
| | - Chih-Long Chang
- Department of Medicine, MacKay Medical College, Taipei
- Department of Obstetrics and Gynecology
| | - Ya-Ting Jan
- Department of Radiology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Meng-Hao Wu
- Department of Radiation Oncology, MacKay Memorial Hospital
- Department of Medicine, MacKay Medical College, Taipei
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Abstract
OBJECTIVE The aim of this study was to identify prognostic factors and establish a model for predicting life expectancy in International Federation of Gynecology and Obstetrics stage IVB cervical cancer patients. METHODS The baseline characteristics and outcome data of patients with stage IVB cervical cancer between May 1994 and October 2014 were collected and retrospectively reviewed. A Cox proportional hazards regression model was used to identify independent predictors of survival in stage IVB cervical cancer patients. RESULTS A total of 107 patients were included in our database. The median overall survival (OS) period was 16 months. Multivariate analysis revealed that the metastatic site (hazards ratio, 3.09; 95% confidence interval, 1.94-4.88; P < 0.0001) and a white blood cell (WBC) count exceeding 10,000/μL (hazards ratio, 2.02; 95% confidence interval, 1.19-3.30; P = 0.0102) were significant prognostic factors in terms of OS. Patient survival was inversely correlated with the number of these prognostic factors possessed. When the patients were divided into 3 prognostic groups, the median OS of the patients with 0, 1, or 2 poor prognostic factors was 26, 12, and 7 months, respectively. Among the patients with WBC counts of less than 10,000/μL, treatment with radiotherapy resulted in improved survival compared with chemotherapy or palliative care alone. In contrast, radiotherapy had minimal effects on survival in patients with WBC counts of greater than 10,000/μL. CONCLUSIONS The metastatic site and an elevated WBC count are significant prognostic factors in patients with stage IVB cervical cancer. Our prognostic model composed of these 2 clinical variables might enable physicians to predict survival more accurately.
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Li H, Wu X, Cheng X. Advances in diagnosis and treatment of metastatic cervical cancer. J Gynecol Oncol 2016; 27:e43. [PMID: 27171673 PMCID: PMC4864519 DOI: 10.3802/jgo.2016.27.e43] [Citation(s) in RCA: 299] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 04/26/2016] [Accepted: 04/27/2016] [Indexed: 01/20/2023] Open
Abstract
Cervical cancer is one of the most common cancers in women worldwide. The outcome of patients with metastatic cervical cancer is poor. We reviewed the relevant literature concerning the treatment and diagnosis of metastatic cervical cancer. There are two types of metastasis related to different treatments and survival rates: hematogenous metastasis and lymphatic metastasis. Patients with hematogenous metastasis have a higher risk of death than those with lymphatic metastasis. In terms of diagnosis, fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) and PET-computed tomography are effective tools for the evaluation of distant metastasis. Concurrent chemoradiotherapy and subsequent chemotherapy are well-tolerated and efficient for lymphatic metastasis. As for lung metastasis, chemotherapy and/or surgery are valuable treatments for resistant, recurrent metastatic cervical cancer and chemoradiotherapy may be the optimal choice for stage IVB cervical cancer. Chemotherapy and bone irradiation are promising for bone metastasis. A better survival is achieved with multimodal therapy. Craniotomy or stereotactic radiosurgery is an optimal choice combined with radiotherapy for solitary brain metastases. Chemotherapy and palliative brain radiation may be considered for multiple brain metastases and other organ metastases.
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Affiliation(s)
- Haoran Li
- Department of Gynecological Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Xiaohua Wu
- Department of Gynecological Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Xi Cheng
- Department of Gynecological Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.
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LIU YUNQIN, YU JINMING, QIAN LITING, ZHANG HONGYAN, MA JUN. Extended field intensity-modulated radiotherapy plus concurrent nedaplatin treatment in cervical cancer. Oncol Lett 2016; 11:3421-3427. [PMID: 27123128 PMCID: PMC4841108 DOI: 10.3892/ol.2016.4416] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 02/26/2016] [Indexed: 11/10/2022] Open
Abstract
The present study assessed the efficacy and toxicity of definitive extended-field intensity-modulated radiotherapy (EF-IMRT) plus concurrent chemotherapy in cervical cancer. A total of 48 patients with cervical cancer received the planning target volume between 39.6 and 50.4 Gy in 1.8-2.0 Gy daily fractions, while the enlarged pelvic and/or para-aortic nodes were treated with a total dose of 55-60 Gy in 2.0-2.4 Gy daily fractions using simultaneous integrated boost-IMRT. All patients underwent high dose-rate brachytherapy. Concurrent to EF-IMRT, nedaplatin was administered weekly at a median dose of 30 mg/m2 (range, 25-40 mg/m2) for 5 weeks with a total of 150 mg/m2. Of the 48 patients, 46 patients exhibited initial complete responses and 2 patients had partial responses, with a response rate of 100%. After 4-24 months of treatment, 12 patients (27.08%) had local and/or distant failure and 39 patients (81.25%) were alive at the last follow-up. The 12-month overall survival (OS) and disease-free survival (DFS) were 87.5 and 75.8%, respectively, while the 24-month OS and DFS were 69.7 and 49.7%, respectively. Grade ≥3 acute neutropenia and thrombcytopenia occurred in 20 (41.7%) and 4 (8.3%) patients, respectively, while 2 patients (4.2%) developed grade ≥3 diarrhea and 2 (4.2%) had grade ≥3 late toxicities. However, no patients exhibited grade ≥3 vomiting. Thus, concurrent nedaplatin chemotherapy with definitive EF-IMRT was effective and relatively safe for treating patients with cervical cancer. Furthermore, EF-IMRT was able to deliver ≤60 Gy to enlarged para-aortic and/or pelvic nodes using simultaneous integrated boost without increased acute and late gastrointestinal toxicity.
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Affiliation(s)
- YUNQIN LIU
- Department of Radiation Oncology, Shandong Tumor Hospital, Shandong Medical University, Jinan, Shandong 250117, P.R. China
- Department of Radiation Oncology, Anhui Cancer Hospital, Anhui Medical University, Hefei, Anhui 230001, P.R. China
- Department of Radiation Oncology, Anhui Provincial Hospital, Anhui Medical University, Hefei, Anhui 230001, P.R. China
| | - JINMING YU
- Department of Radiation Oncology, Shandong Tumor Hospital, Shandong Medical University, Jinan, Shandong 250117, P.R. China
- Correspondence to: Dr Jinming Yu, Department of Radiation Oncology, Shandong Tumor Hospital, Shandong Medical University, 440 Jiyan Road, Jinan, Shandong 250117, P.R. China, E-mail:
| | - LITING QIAN
- Department of Radiation Oncology, Anhui Cancer Hospital, Anhui Medical University, Hefei, Anhui 230001, P.R. China
- Department of Radiation Oncology, Anhui Provincial Hospital, Anhui Medical University, Hefei, Anhui 230001, P.R. China
| | - HONGYAN ZHANG
- Department of Radiation Oncology, Anhui Cancer Hospital, Anhui Medical University, Hefei, Anhui 230001, P.R. China
- Department of Radiation Oncology, Anhui Provincial Hospital, Anhui Medical University, Hefei, Anhui 230001, P.R. China
| | - JUN MA
- Department of Radiation Oncology, Anhui Cancer Hospital, Anhui Medical University, Hefei, Anhui 230001, P.R. China
- Department of Radiation Oncology, Anhui Provincial Hospital, Anhui Medical University, Hefei, Anhui 230001, P.R. China
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Perioperative morbidity and rate of upstaging after laparoscopic staging for patients with locally advanced cervical cancer: results of a prospective randomized trial. Am J Obstet Gynecol 2015; 213:503.e1-7. [PMID: 25986030 DOI: 10.1016/j.ajog.2015.05.026] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Revised: 03/30/2015] [Accepted: 05/13/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The International Federation of Gynecology and Obstetrics (FIGO) staging for cervical cancer is based on clinical examination. Previous studies have demonstrated significant upstaging with surgical staging. However, no randomized trial has ever shown a survival benefit when radiation combined with chemoradiation (RCTX) is modified according to surgical staging. The objective of the study was to evaluate the feasibility and outcomes of surgical staging prior to radical RCTX treatment among patients with locally advanced cervical cancer in the setting of a larger, prospective, randomized study (the Uterus-11 study of the German Gynecologic Oncology Group). STUDY DESIGN Between 2009 and 2013, 255 patients with advanced cervical cancer (FIGO IIB-IVA) were randomized to surgical staging and RCTX (arm A) or RCTX (arm B). RCTX in both arms included pelvic external beam radiotherapy with weekly cisplatin at 40 mg/m(2) and brachytherapy. Extended-field radiation was performed in cases of confirmed paraaortic metastases. RESULTS One hundred thirty patients were randomized to surgical staging; 121 were eligible for this analysis. The mean patient age was 47.2 years, and the mean body mass index was 26.2 kg/m(2); the FIGO stages were IIB, IIIA, IIIB, and IVA in 85 (70.2%), 4 (3.3%), 29 (24%), and 3 (2.5%) patients, respectively. Arm A and arm B were similar with respect to Karnofsky performance status, histology, comorbidities, and lymphovascular space involvement. The surgical approach was transperitoneal laparoscopy in nearly all patients (93.4%), with no operative mortality. One patient (0.8%) had a conversion to laparotomy; 2 patients had more than 500 mL blood loss; the early postoperative complication rate was 7.3%. A mean of 19 pelvic and 17 paraaortic nodes were removed, with means of 2.4 and 1.3 positive nodes, respectively. RCTX began between 7 and 21 days after surgery. Operative staging led to upstaging in 40 of 121 (33%). CONCLUSION Surgical staging in patients with locally advanced cervical cancer is safe and does not delay primary RCTX in a randomized study.
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Hwang L, Bailey A, Lea J, Albuquerque K. Para-aortic nodal metastases in cervical cancer: a blind spot in the International Federation of Gynecology and Obstetrics staging system: current diagnosis and management. Future Oncol 2015; 11:309-22. [PMID: 25591841 DOI: 10.2217/fon.14.200] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
In cervical cancer, para-aortic nodal (PALN) metastases at presentation is a strong indicator of poor prognosis. Despite this, International Federation of Gynecology and Obstetrics staging system does not require evaluation of lymph node involvement and does not incorporate clinically detected PALN into the staging system. In the USA, despite screening, a significant number of women still present at an advanced stage often with nodal metastases. While the presence of PALN metastases often indicates occult systemic disease, it is possible with modern therapies to provide long-term control of disease in a percentage of patients. We review the epidemiology, diagnosis and treatment of PALN metastases in cervical cancer outlining advances in modern imaging and combined modality therapies (surgery, chemotherapy and radiation therapy).
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Affiliation(s)
- Lindsay Hwang
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX 75390 9183, USA
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Fujiwara M, Isohashi F, Mabuchi S, Yoshioka Y, Seo Y, Suzuki O, Sumida I, Hayashi K, Kimura T, Ogawa K. Efficacy and safety of nedaplatin-based concurrent chemoradiotherapy for FIGO Stage IB2-IVA cervical cancer and its clinical prognostic factors. JOURNAL OF RADIATION RESEARCH 2015; 56:305-314. [PMID: 25428244 PMCID: PMC4380049 DOI: 10.1093/jrr/rru101] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 09/23/2014] [Accepted: 10/05/2014] [Indexed: 06/04/2023]
Abstract
Cisplatin-based concurrent chemoradiotherapy (CCRT) is a standard treatment for cervical cancer, but nedaplatin-based CCRT is not routinely administered. We evaluated the efficacy and safety of nedaplatin-based CCRT (35 mg/m(2) weekly) and analyzed prognostic factors for survival among 52 patients with International Federation of Gynecology and Obstetrics (FIGO) Stage IB2-IVA cervical cancer treated from 1999 to 2009. Patients were treated with a combination of external beam radiotherapy of 40-56 Gy (in 20-28 fractions) and 13.6-28.8 Gy (in 2-4 fractions) of high-dose-rate (HDR) intracavitary brachytherapy or 18 Gy (in 3 fractions) of HDR interstitial brachytherapy. Overall survival (OS), progression-free survival (PFS), and local control (LC) were estimated using the Kaplan-Meier method. The Cox proportional hazard model was used for multivariate analysis. Acute and late toxicities were evaluated using the Common Terminology Criteria for Adverse Events version 4.0. The median follow-up period was 52 months. The median patient age was 63 years. The 5-year OS, PFS and LC rates were 78%, 57% and 73%, respectively. Multivariate analysis showed that histologic type, maximum tumor diameter, and pretreatment hemoglobin level were independent risk factors for PFS. Regarding adverse effects, 24 patients (46%) had acute Grade 3-4 leukopenia and 5 (10%) had late Grade 3 gastrointestinal toxicities. No patient experienced renal toxicity. Nedaplatin-based CCRT for FIGO Stage IB2-IVA cervical cancer was efficacious and safe, with no renal toxicity. Histologic type, maximum tumor diameter, and pretreatment hemoglobin level were statistically significant prognostic factors for PFS.
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Affiliation(s)
- Masateru Fujiwara
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 5650871, Japan
| | - Fumiaki Isohashi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 5650871, Japan
| | - Seiji Mabuchi
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 5650871, Japan
| | - Yasuo Yoshioka
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 5650871, Japan
| | - Yuji Seo
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 5650871, Japan
| | - Osamu Suzuki
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 5650871, Japan
| | - Iori Sumida
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 5650871, Japan
| | - Kazuhiko Hayashi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 5650871, Japan
| | - Tadashi Kimura
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 5650871, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 5650871, Japan
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Marnitz S, Schram J, Budach V, Sackerer I, Vercellino GF, Sehouli J, Köhler C. Extended field chemoradiation for cervical cancer patients with histologically proven para-aortic lymph node metastases after laparaoscopic lymphadenectomy. Strahlenther Onkol 2014; 191:421-8. [PMID: 25413986 DOI: 10.1007/s00066-014-0785-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 10/31/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND PURPOSE The purpose of this work was to evaluate the use of extended-field chemoradiation (EFRT) with concomitant chemotherapy in patients with histologically confirmed para-aortic metastases after laparoscopic para-aortic and pelvic lymphadenectomy (LAE) with regard to oncologic results and treatment-related toxicity. PATIENTS AND METHODS A total of 44 women with squamous cell carcinoma (82 %) and adenocarcinoma (18 %) of the cervix in FIGO stages IIA (n = 3), IIB (n = 29); IIIB (n = 9), and IVA (n = 3) and histologically proven para-aortic metastases underwent EFRT and chemotherapy. Laparoscopic LAE was performed in 40 patients. Patients underwent chemoradiation with conventional fractionation of 1.8-50.4 Gy to the para-aortic and pelvic region. In addition, MRI-guided brachytherapy was performed to the cervix with 5-6 single doses of 5 Gy for a total dose of 25-30 Gy. RESULTS The mean number of harvested lymph nodes was 17 in the pelvic as well as para-aortic regions, respectively. Laparoscopic intervention did not delay chemoradiation. Follow-up was 6-76 months (mean 25.1 months). There was no grade 4 or 5 acute radiation toxicity. In all, 8, 4, and 11 % grade 1, 2, and 3 gastrointestinal late toxicities and 7, 11, and 19 % grade 1, 2 and 3 genitourinary late toxicities were recorded. Despite the excellent locoregional (pelvic) control rates of 89.1 and 82.8 % after 2 and 5 years, respectively, the overall survival rates were 68.4 and 54.1 % after 2 and 5 years, respectively. Of the 44 patients, 43 remained tumor free in the para-aortic region. CONCLUSION In patients with proven para-aortic disease, excellent pelvic and para-aortic control could be achieved by laparoscopic LAE followed by EFRT. More than half of the patients were long-term survivors. The high risk of distant metastases should be addressed by further improving systemic treatment.
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Affiliation(s)
- Simone Marnitz
- Department of Radiation Oncology, Charité University Medicine, Augustenburger Platz 1, 13353, Berlin, Germany,
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Yap ML, Cuartero J, Yan J, Pintilie M, Fyles A, Levin W, Manchul L, Milosevic M. The role of elective para-aortic lymph node irradiation in patients with locally advanced cervical cancer. Clin Oncol (R Coll Radiol) 2014; 26:797-803. [PMID: 25194726 DOI: 10.1016/j.clon.2014.08.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 06/16/2014] [Accepted: 07/07/2014] [Indexed: 11/18/2022]
Abstract
AIMS Pelvic lymph node positivity in cervical cancer is known to be an adverse prognostic factor and is associated with an elevated risk of clinically occult para-aortic lymph node metastases. The purpose of this study was to examine the benefit of elective para-aortic lymph node radiotherapy (PART) in patients with no clinical or radiographic evidence of para-aortic lymph node metastases receiving concurrent cisplatin chemotherapy. MATERIALS AND METHODS Patients treated with radiotherapy and concurrent cisplatin for cervical cancer from 1999 to 2009 were identified in two prospective databases. All patients received external beam pelvic radiotherapy (PRT) to a median dose of 50 Gy concurrently with weekly cisplatin 40 mg/m(2). This was followed by pulse dose rate intracavitary brachytherapy to a median dose of 40 Gy. Patients at high risk of occult para-aortic metastases also received PART to a median dose of 40 Gy. RESULTS There were 228 patients suitable for analysis; the median follow-up was 4.6 years. The addition of PART to PRT was not associated with a significant difference in disease-free survival (hazard ratio 1.1, confidence interval 0.7-1.8, P = 0.75) or overall survival (hazard ratio 1.6, confidence interval 0.9-2.7, P = 0.11) on multivariate analysis. There was no significant difference in the rate of para-aortic relapse with PART versus PRT (hazard ratio 2.01, confidence interval 0.79-5.12, P = 0.14). The 3 year grade 3-4 late toxicities were 11% for the PART group versus 8% for PRT (hazard ratio 1.39, confidence interval 0.58-3.37, P = 0.47). CONCLUSIONS These results suggest that cervical cancer patients treated with radiotherapy and concurrent cisplatin do not benefit from elective PART.
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Affiliation(s)
- M L Yap
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - J Cuartero
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - J Yan
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - M Pintilie
- Division of Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Dalla Lana School of Public Health Sciences, University of Toronto, Toronto, Ontario, Canada
| | - A Fyles
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - W Levin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - L Manchul
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - M Milosevic
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Ontario, Canada.
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Park SG, Kim JH, Oh YK, Byun SJ, Kim MY, Kwon SH, Kim OB. Is Prophylactic Irradiation to Para-aortic Lymph Nodes in Locally Advanced Cervical Cancer Necessary? Cancer Res Treat 2014; 46:374-82. [PMID: 25043821 PMCID: PMC4206071 DOI: 10.4143/crt.2013.084] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 10/31/2013] [Indexed: 11/23/2022] Open
Abstract
Purpose This study evaluated the efficacy of extended field irradiation (EFI) in patients with locally advanced cervical cancer without para-aortic nodal involvement. Materials and Methods A total of 203 patients with locally advanced cervical cancer (International Federation of Gynecology and Obstetrics [FIGO] stage, IB2-IIIB) treated with radiotherapy at Keimyung University Dongsan Medical Center from 1996 to 2010 were retrospectively analyzed. The median patient age was 59 years (range, 29 to 83 years). None of the patients had para-aortic node metastases. Of the 203 patients, 88 underwent EFI and 115 underwent irradiation of the pelvis only. Concurrent chemoradiotherapy (CCRT) was administered to 133 patients. EFI field was used for treatment of 26 patients who received radiotherapy alone and 62 who received CCRT. Results The median follow-up period was 60 months. The 2- and 5-year overall survival (OS) rates were 87.8% and 73.5%, respectively, and the 2- and 5-year disease-free survival rates were 81.7% and 75.0%, respectively, however, no survival differences were observed between the two treatment field groups. EFI tended to increase OS in the radiotherapy alone group, but not in the CCRT group. Conclusion These findings suggest that EFI does not have a significant effect in patients with locally advanced cervical cancer, especially in patients receiving CCRT. Conduct of additional studies will be required in order to confirm these findings.
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Affiliation(s)
- Seung Gyu Park
- Department of Radiation Oncology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Jin Hee Kim
- Department of Radiation Oncology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Young Kee Oh
- Department of Radiation Oncology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Sang Jun Byun
- Department of Radiation Oncology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Mi Young Kim
- Department of Radiation Oncology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Sang Hoon Kwon
- Department of Obstetrics and Gynecology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Ok Bae Kim
- Department of Radiation Oncology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
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Low-Dose, Prophylactic, Extended-Field, Intensity-Modulated Radiotherapy Plus Concurrent Weekly Cisplatin for Patients With Stage IB2-IIIB Cervical Cancer, Positive Pelvic Lymph Nodes, and Negative Para-aortic Lymph Nodes. Int J Gynecol Cancer 2014; 24:901-7. [DOI: 10.1097/igc.0b013e31829f4dc5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ObjectiveThe objective of this study was to assess prospectively the clinical outcomes of low-dose prophylactic extended-field, intensity-modulated radiotherapy (IMRT) plus concurrent weekly cisplatin for patients with stage IB2-IIIB cervical cancer, positive pelvic lymph nodes (PLNs), and negative para-aortic lymph nodes (PALNs).MethodsThirty-two patients with stage IB2-IIIB cervical cancer with positive PLN and negative PALN were included prospectively. All lymph nodes were assessed with positron emission tomography. The PALN field, including lymphatics from the superior border of L1 to the L4-L5 interphase, was irradiated concurrently with pelvic IMRT with a prescribed dose of 40 Gy in 25 fractions. Chemotherapy consisted of cisplatin delivered weekly at a dose of 40 mg/m2. Using historical controls treated with pelvic radiotherapy, the survival curves were compared to assess the difference between the 2 treatment periods.ResultsThirty-one patients completed the allocated extended-field IMRT, and all finished the planned pelvic IMRT and brachytherapy. Acute ≥ grade 3 gastrointestinal, genitourinary, and hematologic toxicities were seen in 2, 1, and 18 patients, respectively. During a median follow-up of 33 months, 5 patients developed out-field distant recurrences. One patient had a late grade 3 gastrointestinal complication, and 1 patient had genitourinary toxicity. The 3-year actuarial overall survival, disease-free survival, and distant metastasis–free survival for the study cohort and historic controls were 87% versus 62% (P = 0.02), 82% versus 54% (P = 0.02), and 79% versus 57% (P = 0.01), respectively.ConclusionsExtended-field IMRT of 40 Gy to the PALN plus concurrent cisplatin can effectively eradicate subclinical disease at the PALN and improve the outcome for patients with PLN-positive stage IB2-IIIB cervical cancer.
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Leblanc E, Narducci F, Bresson L, Durand-Labrunie J, Taieb S, Vanlerenberghe E, Farre I, Nickers P. A new laparoscopic method of bowel radio-protection before pelvic chemoradiation of locally advanced cervix cancers. Surg Endosc 2014; 28:2713-8. [PMID: 24789127 DOI: 10.1007/s00464-014-3533-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 04/01/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chemoradiation therapy (CRT) has become the mainstay of locally advanced cervical carcinomas (LACC). However, the price to pay is a significant rate of both early and late colo-rectal toxicities, which may impact on survivors' quality of life. To reduce the incidence of such complications, we suggest a simple technique of pelvic radioprotection. MATERIALS AND METHODS An omental flap is created which is placed to fill the Douglas pouch to both increase the space between rectum and uterine cervix and prevent small bowel to fall in and to be exposed to radiation. In addition, a long sigmoid loop is retracted and fixed in the left paracolic gutter to prevent its irradiation as well. RESULTS From May 2011 to May 2012, 51 successive LACC patients were offered this procedure in addition of a laparoscopic staging. All but 2 with too small an omentum benefitted from omentoplasty, while sigmoidopexy was performed in all but one patient with a long and free sigmoid loop. No immediate adverse effect was observed. The volume of retro-uterine omental flap averaged 7.17 ± 3.79 cm(3). Sequential measurements of the utero-rectal space throughout CRT duration showed a real and durable increase in the distance between these organs, resulting in a drop in the dose of irradiation to recto-sigmoid. With 10 ± 4.5-month median follow-up, we did not observe any rectal or small bowel early or late adverse effects of CRT. CONCLUSIONS Although this series is preliminary, this simple procedure, feasible by laparoscopy (or laparotomy), seems effective to prevent recto-sigmoid as well as small bowel from radio-induced complications due to pelvic CRT.
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Affiliation(s)
- E Leblanc
- Department of Gynecologic Oncology, Centre Oscar Lambret, Lille, France,
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Zuliani AC, Esteves SCB, Teixeira LC, Teixeira JC, de Souza GA, Sarian LO. Concomitant cisplatin plus radiotherapy and high-dose-rate brachytherapy versus radiotherapy alone for stage IIIB epidermoid cervical cancer: a randomized controlled trial. J Clin Oncol 2014; 32:542-7. [PMID: 24449243 DOI: 10.1200/jco.2013.50.1205] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The benefits of chemoradiotherapy (CRT) for cervical cancer compared with radiation (RT) alone seem to diminish in later-stage disease. However, these modalities have not been directly compared for disease-free interval (DFI) and overall survival (OS) of women with stage IIIB cervical cancer. PATIENTS AND METHODS We conducted a randomized controlled clinical trial comparing DFI and OS of 147 women with stage IIIB squamous cervical cancer who received either cisplatin plus RT (CRT) or RT alone (72 patients in the CRT group and 75 patients in the RT-only group). RESULTS The CRT group had significantly better DFI (hazard ratio [HR], 0.52; 95% CI, 0.29 to 0.93; P = .02). However, patients in the CRT group did not have significantly better OS than those in the RT-only group (HR, 0.67; 95% CI, 0.38 to 1.17; P = .16). Toxicity was graded according to criteria of the Radiation Therapy Oncology Group. The organs affected (excluding hematologic effects) did not differ significantly between groups. Also, late toxicity events and organs affected were not significantly disproportionate between the study groups. CONCLUSION For stage IIIB cervical cancer, the addition of cisplatin offers a small but significant benefit in DFI, with acceptable toxicity.
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Zhang G, He F, Fu C, Zhang Y, Yang Q, Wang J, Cheng Y. Definitive extended field intensity-modulated radiotherapy and concurrent cisplatin chemosensitization in the treatment of IB2-IIIB cervical cancer. J Gynecol Oncol 2014; 25:14-21. [PMID: 24459576 PMCID: PMC3893669 DOI: 10.3802/jgo.2014.25.1.14] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 11/14/2013] [Accepted: 11/21/2013] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess the toxicity of delivering extended field intensity-modulated radiotherapy (EF-IMRT) and concurrent cisplatin chemotherapy for locally advanced cervical carcinoma. METHODS Forty-five patients who underwent EF-IMRT and concurrent cisplatin chemotherapy for the treatment of stage IB2 to IIIB cervical cancer were retrospectively reviewed. The clinical target volume included all areas of gross and potentially microscopic disease and regional lymph node regions. All patients underwent high-dose-rate brachytherapy. The acute and late toxicity were scored using the Common Terminology Criteria for Adverse Events and the Radiation Therapy Oncology Group late radiation morbidity scoring criteria, respectively. RESULTS The median follow-up was 28 months (range, 5 to 62 months). Forty-two patients had a complete response, and three had a persistent disease. Of those 42 patients, 15 patients (35.7%) had recurrence. The regions of recurrence were in-field in 2 patients and out-field in 13 patients. Acute grade ≥3 gastrointestinal, genitourinary and hematologic toxicity occurred in 3, 1, and 9 patients, respectively. Three patients (6.7%) suffered from late grade 3 toxicities. Seven patients experienced ovarian transposition, 5 of those patients (71%) maintained ovarian function. Thirty-eight patients (84.4%) were alive at the last follow-up. CONCLUSION Concurrent cisplatin chemotherapy with EF-IMRT was safe. The acute and late toxicities are acceptable. EF-IMRT provides an opportunity to preserve endocrine function for patients with ovarian transposition.
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Affiliation(s)
- Guangyu Zhang
- Department of Radiation Oncology, Qilu Hospital of Shandong University, Jinan, China
| | - Fangfang He
- Department of Radiation Oncology, Qilu Hospital of Shandong University, Jinan, China
| | - Chunli Fu
- Department of Geriatrics, Qilu Hospital of Shandong University, Jinan, China
| | - Youzhong Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, China
| | - Qiuan Yang
- Department of Radiation Oncology, Qilu Hospital of Shandong University, Jinan, China
| | - Jianbo Wang
- Department of Radiation Oncology, Qilu Hospital of Shandong University, Jinan, China
| | - Yufeng Cheng
- Department of Radiation Oncology, Qilu Hospital of Shandong University, Jinan, China
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Anker CJ, O'Donnell K, Boucher KM, Gaffney DK. Effect of brachytherapy technique and patient characteristics on cervical cancer implant dosimetry. Med Dosim 2013; 38:430-5. [PMID: 23973016 DOI: 10.1016/j.meddos.2013.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 05/16/2013] [Accepted: 06/12/2013] [Indexed: 11/25/2022]
Abstract
Our purpose was to evaluate the relationship between brachytherapy technique and patient characteristics on dose to organs-at-risk (OARs) in patients undergoing high dose rate (HDR) brachytherapy for cervical cancer. From 1998 to 2008, 31 patients with cervical cancer with full dosimetric data were identified who received definitive external-beam radiation and HDR brachytherapy with tandem and ovoid applicators. Doses were recorded at point A, the International Commission on Radiation Units and Measurements (ICRU)-38 rectal point, the ICRU-38 bladder point, the vaginal surface, and the pelvic sidewall. Generalized estimating equations were used to determine the significance of changes in OAR to point A dose ratios with differences in brachytherapy technique or patient characteristics. Patients underwent a median of 5 brachytherapy procedures (range, 3 to 5), with a total of 179 procedures for 31 patients. For all brachytherapy treatments, the average ratios between the doses for the rectal, bladder, vaginal surface, and pelvic sidewall reference points to those at point A were 0.49, 0.59, 1.15, and 0.17, respectively. In general, decreased OAR dose was associated with a lower stage, younger age, increased ovoid size, increased tandem length, and earlier implant number. Increased tandem curvature significantly increased bladder dose and decreased rectal dose. Intravenous anesthesia usage was not correlated with improved dosimetry. This study allowed identification of patient and procedure characteristics influencing OAR dosing. Although the advent of 3-dimensional (3D) image-guided brachytherapy will bring new advances in treatment optimization, the actual technique involved at the time of the brachytherapy implant procedure will remain important.
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Affiliation(s)
- Christopher J Anker
- Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah, Salt Lake City, UT.
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Kim JY, Kim JY, Kim JH, Yoon MS, Kim J, Kim YS. Curative Chemoradiotherapy in Patients With Stage IVB Cervical Cancer Presenting With Paraortic and Left Supraclavicular Lymph Node Metastases. Int J Radiat Oncol Biol Phys 2012; 84:741-7. [DOI: 10.1016/j.ijrobp.2012.01.070] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Revised: 01/13/2012] [Accepted: 01/22/2012] [Indexed: 10/28/2022]
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Extended-Field Intensity-Modulated Radiotherapy and Concurrent Cisplatin-Based Chemotherapy for Postoperative Cervical Cancer With Common Iliac or Para-Aortic Lymph Node Metastases: A Retrospective Review in a Single Institution. Int J Gynecol Cancer 2012; 22:1220-5. [DOI: 10.1097/igc.0b013e3182643b7c] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ObjectiveRetrospectively, to assess the toxicity of delivering postoperative extended-field intensity-modulated radiotherapy (EF-IMRT) and concurrent cisplatin chemotherapy for patients with cervical cancer with a pathologically confirmed positive common iliac node and/or a para-aortic node.MethodsEach patient received postoperative EF-IMRT and concurrent cisplatin chemotherapy. The clinical target volume included regional lymph node regions (obturator; common, internal, and external iliac nodal regions; presacral region; and para-aortic regions) and the upper 2.0 cm of the vagina and paravaginal soft tissue lateral to the vagina. The acute and late toxicity were scored using the Common Terminology Criteria for Adverse Events (CTCAE) and the Radiation Therapy Oncology Group late radiation morbidity scoring criteria, respectively.ResultsFifty-eight patients were treated with postoperative EF-IMRT and concurrent cisplatin chemotherapy. The median follow-up was 34 months. Eighteen patients (31%) had recurrence. The region of recurrence was in-field in 2 patients (3.4%) and out-field in 16 patients (27.6%). Acute grade 3 or higher gastrointestinal, genitourinary, and hematologic toxicity occurred in 2, 1, and 11patients, respectively. Three patients (5.1%) had late grade 3 toxicities. Thirteen patients experienced ovarian transposition; of these, 10 patients (77%) maintained ovarian function. Forty-one patients (71%) were alive at the last follow-up.ConclusionsConcurrent cisplatin chemotherapy with postoperative EF-IMRT was safe and well tolerated. The acute and late toxicities are acceptable. The locoregional control rates are hopeful, although distant metastases continue to be the primary mode of failure. Postoperative EF-IMRT provides an opportunity to preserve endocrine function for patients with ovarian transposition.
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Marnitz S, Budach V, Weisser F, Burova E, Gebauer B, Vercellino FG, Köhler C. Rectum separation in patients with cervical cancer for treatment planning in primary chemo-radiation. Radiat Oncol 2012; 7:109. [PMID: 22788414 PMCID: PMC3503658 DOI: 10.1186/1748-717x-7-109] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Accepted: 03/14/2012] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To proof feasibility of hydrogel application in patients with advanced cervical cancer undergoing chemo-radiation in order to reduce rectal toxicity from external beam radiation as well as brachytherapy. MATERIAL AND METHODS Under transrectal sonographic guidance five patients with proven cervical cancer underwent hydro gel (20 cc) instillation into the tip of rectovaginal septum adherent to posterior part of the visible cervical tumor. Five days after this procedure all patients underwent T2 weighted transversal and sagittal MRI for brachytherapy planning. MRI protocol included T2 weighted fast spin echo (FSE) imaging in sagittal, coronal and para-axial orientation using an 1.5 Tesla MRI. Separation of anterior rectal wall and cervix was documented. RESULTS Hydrogel application was uneventful in all patients and no toxicity was reported. Separation ranged from 7 to 26 mm in width (median 10 mm). The length of the separation varied between 18 and 38 mm (median 32 mm). In all patients displacement was seen in the posterior vaginal fornix, and/or at the deepest part of uterine cervix depending on the extension of the cul-de-sac in correlation to the posterior wall of the uterus. In patients with bulky tumor and/or deep (vaginal) extend of peritoneal cavity tumour was seen mainly cranial from the rectovaginal space and therefore above the hydrogeI application. Only in the extra-peritoneal (lower) part of the cervix a good separation could be achieved between the rectum and cervix. CONCLUSION Hydrgel instillation in patients with cervial cancer undergoing chemoradiation is safe and feasible. Because of the loose tissue of the cul-de-sac and its intra- and extraperitoneal part, hydrogel instillation of 20 cc did not result in a sufficient separation of the cervix from anterior wall.
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Affiliation(s)
- Simone Marnitz
- Department of Radiooncology, Charité University Medicine, Augustenburger Platz 1, 13353, Berlin, Germany.
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Kim HS, Kim MK, Kim HJ, Han SS, Kim JW. Phase II Study of Consolidation Chemotherapy after Adjuvant or Primary Concurrent Chemoradiation Using Paclitaxel and Carboplatin to Treat High-Risk Early-Stage or Locally Advanced Cervical Cancer. Cancer Res Treat 2012; 44:97-103. [PMID: 22802747 PMCID: PMC3394869 DOI: 10.4143/crt.2012.44.2.97] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Accepted: 03/07/2012] [Indexed: 11/21/2022] Open
Abstract
Purpose This study investigated the efficacy and toxicity associated with consolidation chemotherapy using paclitaxel and carboplatin after concurrent chemoradiation (CCR) in cervical cancer patients. Materials and Methods From a total of 37 patients, 19 with International Federation of Gynecology and Obstetrics (FIGO) stage IB1-IIA cervical cancer (group 1) underwent surgery followed by consolidation chemotherapy after CCR, and 18 with stage IIB-IVA disease (group 2) received consolidation chemotherapy after primary CCR. Three cycles of chemotherapy using paclitaxel (135 mg/m2) and carboplatin (AUC 5.0) were administered every 3 weeks for CCR therapy, and three cycles of consolidation chemotherapy using paclitaxel (175 mg/m2) and carboplatin (AUC 5.0) were used every 3 weeks after CCR. Results The complete and partial response rates were 77.8% and 22.2% in group 2. Moreover, the 3-year progression-free and overall survival rates were 62.7% and 90.9% in group 1, and 51.9% and 60% in group 2, respectively. The most common grade 3 or 4 hematologic toxicities observed were leukopenia (group 1, 10.5%; group 2, 13.0%) and neutropenia (group 1, 7.0%; group 2, 14.8%), and grade 3 or 4 diarrhea (group 1, 1.8%) and febrile illness (group 2, 1.9%) were the most frequently observed non-hematologic toxicities. When we compared these results with previous reports, consolidation chemotherapy after CCR using paclitaxel and carboplatin revealed a relatively lower complete response rate (77.8% vs. 87-100%, respectively) and shorter progression-free survival (51.9-62.7% vs. 81-86%, respectively) and overall survival (60-90.9% vs. 81-95%, respectively) in spite of similar toxicity findings. Conclusion Due to low efficacy results, consolidation chemotherapy using paclitaxel and carboplatin after CCR is not a feasible treatment regimen for high-risk early-stage or locally advanced cervical cancer.
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Affiliation(s)
- Hee Seung Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
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Is a low dose of concomitant chemotherapy with extended-field radiotherapy acceptable as an efficient treatment for cervical cancer patients with metastases to the para-aortic lymph nodes? Int J Gynecol Cancer 2012; 21:1465-71. [PMID: 21892097 DOI: 10.1097/igc.0b013e318226f657] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Extended-field radiotherapy (EFRT) with the concomitant administration of chemotherapy for patients with advanced cervical cancer has problems regarding its feasibility. The goal of the present study was to assess the tolerability and control rate of low-dose cisplatin with EFRT in patients with imaging-confirmed positive para-aortic lymph nodes (PALs). METHODS Sixteen patients with cervical cancer metastatic to the PALs treated with EFRT were evaluated. The patients included those with stages I to III disease according to the International Federation of Gynecology and Obstetrics with positive PALs diagnosed by computed tomographic imaging. The patients were treated with 25 to 30 mg/m weekly of cisplatin concurrently with radiation therapy. Doses of 48.6 to 51.0 Gy were delivered in 1.8-Gy fractions to the pelvis and included the PALs field. In addition, boost doses for the involved nodes of PALs were delivered contiguously for a total dose of 54 to 60 Gy. All patients were treated with a high dose rate of intracavitary brachytherapy combined with external irradiation. RESULTS All patients completed the radiation therapy. Grade 3 or 4 acute hematologic toxicity occurred in 7 patients, but there were no cases of grade 3 or 4 nonhematologic acute toxicity. As a late toxicity, 1 patient developed a grade 3 small bowel obstruction. No grade 4 or worse late toxicity occurred. The 4-year overall survival rate was 56.3%. The 4-year distant metastasis-free survival rate was 50%. Seven patients had no recurrence. Eight patients developed distant failures, and another had an isolated local intrapelvic recurrence. CONCLUSIONS A dose greater than 54 Gy for positive PALs in EFRT, in combination with intracavitary irradiation and low-dose weekly cisplatin administration, was safely completed by all of our patients. However, half of the patients had distant failure. This study provided relatively favorable local control and survival. Further considering modifications of the treatment should therefore be encouraged.
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Mendivil AA, Rettenmaier MA, Cox C, Abaid LN, Brown III JV, Micha JP, Lopez KL, Goldstein BH. Acute and Delayed Complications from Surgery and Adjuvant Radiotherapy in the Treatment of High-Risk Endometrial Cancer. Oncology 2011; 81:79-83. [DOI: 10.1159/000330821] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 07/01/2011] [Indexed: 12/12/2022]
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Choi CH, Lee YY, Kim MK, Kim TJ, Lee JW, Nam HR, Huh SJ, Lee JH, Bae DS, Kim BG. A matched-case comparison to explore the role of consolidation chemotherapy after concurrent chemoradiation in cervical cancer. Int J Radiat Oncol Biol Phys 2010; 81:1252-7. [PMID: 21075554 DOI: 10.1016/j.ijrobp.2010.07.2006] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Revised: 07/15/2010] [Accepted: 07/20/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE The aim of this study was to compare the efficacy and toxicity of consolidation chemotherapy after concurrent chemoradiation (CCRT) and CCRT alone in patients with locally advanced cervical carcinoma. METHODS AND MATERIALS Using medical records from January 2001 to December 2007, 39 patients treated with consolidation chemotherapy after CCRT (Group 1) were matched to 39 patients treated with CCRT alone (Group 2). Consolidation chemotherapy consisted of three additional cycles of chemotherapy with cisplatin 60 mg/m2 (Day 1) and 5-fluorouracil 1,000 mg/m2 per day (Days 1-5) given every 3 weeks. The primary endpoint was overall survival. RESULTS During a median follow-up period of 35 months (range, 8-96 months), 10 (25.6%) and 16 (41.0%) patients showed disease progression in Groups 1 and 2, respectively. Distant recurrence with or without locoregional/lymphogenous recurrence occurred more frequently in Group 2 than in Group 1 (23.1% vs. 7.7%, p=0.06). By contrast, there was no difference in locoregional or lymphogenous recurrence between the two groups. The rate of overall survival was higher in Group 1 than in Group 2 (92.7% vs. 69.9%, p=0.042), whereas the difference in progression-free survival between the groups was not statistically significant (70.1% vs. 55.1%, p=0.079). Although the difference was not statistically significant, neutropenia was more common in Group 1 than in Group 2 (10.9% vs. 4.7%, p=0.07). CONCLUSIONS Consolidation chemotherapy after CCRT may improve survival and reduce distant recurrence without additional toxicity compared to CCRT alone in patients with locally advanced cervical carcinoma.
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Affiliation(s)
- Chel Hun Choi
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Mabuchi S, Kimura T. Nedaplatin: a radiosensitizing agent for patients with cervical cancer. CHEMOTHERAPY RESEARCH AND PRACTICE 2010; 2011:963159. [PMID: 22312560 PMCID: PMC3265244 DOI: 10.1155/2011/963159] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 08/27/2010] [Indexed: 11/18/2022]
Abstract
Despite the recent advances in the management of cervical cancer using cisplatin-based concurrent chemoradiotherapy, substantial treatment failure still occurs, especially in advanced-stage patients and early-stage cervical cancer patients with high-risk prognostic factors. Therefore, efforts to further improve the survival and quality of life of these patients are necessary. Nedaplatin (cis-diammine-glycoplatinum), a derivative of cisplatin, was developed with the aim of producing a treatment with a similar effectiveness to cisplatin but decreased renal and gastrointestinal toxicities. Based on the promising results of preclinical studies, the clinical efficacy of nedaplatin as a radiosensitizing agent was evaluated in patients with cervical cancer. Retrospective analysis of nedaplatin-based concurrent chemoradiotherapy (CCRT) against cervical cancer suggested that nedaplatin-based CCRT can be considered as an alternative to cisplatin-based CCRT in both early-stage and advanced-stage cervical cancer patients. However, due to the lack of a randomized controlled study, nedaplatin-based CCRT has not been convincingly proven to be clinically effective in patients with cervical cancer. Further investigations in randomized controlled trials are therefore needed.
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Affiliation(s)
- Seiji Mabuchi
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Tadashi Kimura
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan
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Ntekim A, Adenipekun A, Akinlade B, Campbell O. High Dose Rate Brachytherapy in the Treatment of cervical cancer: preliminary experience with cobalt 60 Radionuclide source-A Prospective Study. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2010; 4:89-94. [PMID: 20838638 PMCID: PMC2934612 DOI: 10.4137/cmo.s5269] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Iridium-192 is widely used for high-dose rate brachytherapy. Co-60 source with similar geometric and dosimetric properties are now available. It has a longer half life but higher energy than Iridium-192. If Co-60 source can produce similar results, it will be more economical for low resource settings.
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Affiliation(s)
- Atara Ntekim
- Department of Radiation Oncology, University College Hospital Ibadan, Nigeria
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Beadle BM, Jhingran A, Yom SS, Ramirez PT, Eifel PJ. Patterns of regional recurrence after definitive radiotherapy for cervical cancer. Int J Radiat Oncol Biol Phys 2010; 76:1396-403. [PMID: 19581056 DOI: 10.1016/j.ijrobp.2009.04.009] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2009] [Revised: 03/20/2009] [Accepted: 04/03/2009] [Indexed: 02/03/2023]
Abstract
PURPOSE To determine the patterns of regional recurrence in patients treated with definitive radiotherapy (RT) for cervical cancer. METHODS AND MATERIALS The records of 198 patients treated with definitive RT for cervical cancer between 1980 and 2000 who experienced a regional recurrence without a central or distal vaginal recurrence were reviewed. All patients received a combination of external-beam RT and intracavitary brachytherapy. In the 180 patients with a documented location of regional recurrence, the relationship between the recurrence and the radiation fields was determined. RESULTS The median time to regional recurrence was 13 months (range, 2-85 months). Of the 180 patients who had an evaluable regional recurrence, 119 (66%) had a component of marginal failure; 71 patients recurred above-the-field, 2 patients occurred in the inguinal nodes, and 2 patients recurred above-the-field and in the inguinal nodes. In addition, 105 patients (58%) had a component of in-field failure; 59 patients recurred in-field only, 39 patients recurred in-field and above-the-field, 2 patients recurred in-field, above-the-field, and in the inguinal nodes, and 5 patients recurred in-field and in the inguinal nodes. The median survival after regional recurrence was 8 months (range, 0-194 months). CONCLUSIONS Most regional recurrences after definitive RT for cervical cancer include a component of marginal failure, usually immediately superior to the radiation field. These recurrences suggest a deficiency in target volume. Recurrences also occur in-field, suggesting a deficiency in dose. Developments in pretreatment staging, field delineation, dose escalation, and posttreatment surveillance may help to improve outcome in these patients.
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Affiliation(s)
- Beth M Beadle
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
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Tseng JY, Yen MS, Twu NF, Lai CR, Horng HC, Tseng CC, Chao KC, Juang CM. Prognostic nomogram for overall survival in stage IIB-IVA cervical cancer patients treated with concurrent chemoradiotherapy. Am J Obstet Gynecol 2010; 202:174.e1-7. [PMID: 19931041 DOI: 10.1016/j.ajog.2009.09.028] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Revised: 07/06/2009] [Accepted: 09/24/2009] [Indexed: 11/17/2022]
Abstract
OBJECTIVE On the basis of outcome data from concurrent chemoradiotherapy (CCRT) for locally advanced cervical squamous cell carcinoma, the authors developed a nomogram for predicting survival outcome. STUDY DESIGN Two hundred fifty-one eligible patients with International Federation of Gynecology and Obstetrics stage IIB-IVA squamous cell carcinoma of the uterine cervix who underwent CCRT were included for the construction of the nomogram. Predictor variables included age, serum squamous cell carcinoma antigen, tumor size, parametrium invasion, hydronephrosis, bladder/rectum invasion, and lymph node metastases. Internal validation of the nomogram was performed. RESULTS A nomogram for predicting the 5 year overall survival for these patients was constructed on the basis of a Cox regression model from 7 parameters. The concordance index was 0.69. CONCLUSION This nomogram is a predictive tool, upon external validation, that can be used to counsel patients in predicting outcomes. The discriminatory ability of the nomogram indicates that this population should not be considered homogeneous with respect to risk of death.
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Affiliation(s)
- Jen-Yu Tseng
- Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan
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Kim YS, Kim JH, Ahn SD, Lee SW, Shin SS, Nam JH, Kim YT, Kim YM, Kim JH, Choi EK. High-dose Extended-Field Irradiation and High-Dose-Rate Brachytherapy With Concurrent Chemotherapy for Cervical Cancer With Positive Para-Aortic Lymph Nodes. Int J Radiat Oncol Biol Phys 2009; 74:1522-8. [DOI: 10.1016/j.ijrobp.2008.10.024] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Revised: 10/04/2008] [Accepted: 10/08/2008] [Indexed: 10/21/2022]
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Ring KL, Young JL, Dunlap NE, Andersen WA, Schneider BF. Extended-field radiation therapy with whole pelvis radiotherapy and cisplatin chemosensitization in the treatment of IB2-IIIB cervical carcinoma: a retrospective review. Am J Obstet Gynecol 2009; 201:109.e1-6. [PMID: 19398095 DOI: 10.1016/j.ajog.2009.03.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2008] [Revised: 02/09/2009] [Accepted: 03/06/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This retrospective study evaluated the toxicity of extended-field radiation therapy (EFRT), whole pelvis radiotherapy, and concurrent chemotherapy in patients treated with IB2-IIIB cervical carcinoma. STUDY DESIGN Patients treated with EFRT, whole pelvis radiotherapy, and concurrent chemotherapy were analyzed for toxicity. Median prescribed dose to the whole pelvis was 45 Gy (45-50 Gy). Median prescribed dose to the paraaortic lymph nodes was 45 Gy (36-50). Thirty-five patients received cisplatin chemosensitization at a median dose of 40 mg/m(2) (40-51), with a median of 5 cycles (2-6). RESULTS Thirty-six patients were treated, 3 with positive paraaortic lymph nodes. The median follow-up interval was 32 months. Twenty-four patients (66.7%) had no evidence of disease at last follow-up. Thirteen patients (36.1%) had recurrence. Fifteen patients (41.7%) experienced acute grade 3 toxicity. CONCLUSION Increased toxicity in patients warrants careful patient selection.
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Anker CJ, Cachoeira CV, Boucher KM, Rankin J, Gaffney DK. Does the entire uterus need to be treated in cancer of the cervix? Role of adaptive brachytherapy. Int J Radiat Oncol Biol Phys 2009; 76:704-12. [PMID: 19473779 DOI: 10.1016/j.ijrobp.2009.02.044] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2008] [Revised: 02/05/2009] [Accepted: 02/11/2009] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate local control and toxicity by use of a method of adaptive cervical brachytherapy (ACB). METHODS AND MATERIALS From 1998 to 2008, we identified 65 cervical cancer patients with FIGO (International Federation of Gynecology and Obstetrics) Stage IB1-IVA disease who received definitive external beam radiation therapy and high-dose rate brachytherapy with tandem and ovoid applicators. As tumors regressed, 45 of 65 patients had the tandem source retracted from the uterine fundus at successive brachytherapy insertions, thus decreasing the number of (192)Ir dwell positions. Tests of trend and Fisher's exact test were used to identify the effect of ACB on disease control and toxicity. Kaplan-Meier analyses were performed to evaluate disease control and late complications. RESULTS The median follow-up was 24.5 months. Of the patients, 92% received chemotherapy. The 3-year overall survival, 3-year disease-free survival, 3-year distant metastasis-free survival, and local control rates were 67%, 76%, 79%, and 97%, respectively. There was only 1 isolated local failure, and there were no local failures beyond 1 year. Distant failure was involved in 93% of recurrences. No significant trend was identified regarding the extent of retraction of the tandem source start position with either failure or toxicity. Acute and actuarial 3-year late Grade 3 toxicity or greater occurred in 24.6% and 17% of patients, respectively. CONCLUSIONS ACB determined by clinical response yielded excellent local control rates. These data indicate that ACB may be useful in decreasing late toxicities from high-dose rate brachytherapy. With the advent of three-dimensional image-guided brachytherapy, additional methods to adapt treatment technique to changes in tumor volume warrant investigation.
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Affiliation(s)
- Christopher J Anker
- Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah, Salt Lake City, UT 84112-5560, USA
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Current status and perspectives of brachytherapy for cervical cancer. Int J Clin Oncol 2009; 14:25-30. [PMID: 19225920 DOI: 10.1007/s10147-008-0865-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2008] [Indexed: 10/21/2022]
Abstract
Standard definitive radiotherapy for cervical cancer consists of whole pelvic external beam radiotherapy (EBRT) and intracavitary brachytherapy (ICBT). In Japan, high-dose-rate ICBT (HDR-ICBT) has been utilized in clinical practice for more than 40 years. Several randomized clinical trials demonstrated that HDR-ICBT achieved comparative outcomes, both for pelvic control and incidences of late complications, to low-dose-rate (LDR) ICBT. In addition, HDR-ICBT has some potential advantages over LDR-ICBT, leading to further improvement in treatment results. Prior to the current computer planning systems, some excellent treatment planning concepts were established. At present, systems modified from these concepts, or novel approaches, such as image-guided brachytherapy (IGBT) are under investigation. One serious problem to be solved in HDR-ICBT for cervical cancer is that of the discrepancy in standard treatment schedules for combination HDR-ICBT and EBRT between the United States and Japan. Prospective studies are ongoing to assess the efficacy and toxicity of the Japanese schedule.
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Prospective randomized comparison of monthly fluorouracil and cisplatin versus weekly cisplatin concurrent with pelvic radiotherapy and high-dose rate brachytherapy for locally advanced cervical cancer. Gynecol Oncol 2008; 108:195-200. [DOI: 10.1016/j.ygyno.2007.09.022] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2007] [Revised: 09/03/2007] [Accepted: 09/18/2007] [Indexed: 11/20/2022]
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Uno T, Mitsuhashi A, Isobe K, Yamamoto S, Kawakami H, Ueno N, Usui H, Tate S, Kawata T, Ito H. Concurrent daily cisplatin and extended-field radiation therapy for carcinoma of the cervix. Int J Gynecol Cancer 2008; 18:80-4. [PMID: 17466053 DOI: 10.1111/j.1525-1438.2007.00960.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The aim of this study was to assess acute toxicities of concurrent low-dose daily cisplatin and extended-field radiation therapy (EFRT) for carcinoma of the uterine cervix. Fifteen women with cervical cancer who were treated with concurrent daily low-dose cisplatin and EFRT were analyzed. Daily cisplatin dose was fixed to 8 mg/m(2), which was determined in the preceding phase I study using pelvic radiotherapy. Twelve patients underwent either combined external beam radiation therapy and intracavitary brachytherapy or external beam radiation therapy alone. Three other patients were treated with adjuvant chemoradiotherapy after surgery. A total dose of EFRT ranged from 40 to 45 Gy, with an additional boost to the gross tumor volume up to 50.4-55 Gy. A median total dose of cisplatin during entire radiation therapy course was 224 mg/m(2) (range, 200-240 mg/m(2)). In 14 of 15 patients (93%), daily cisplatin could be delivered continuously as planned without any modification. Administration of cisplatin had to be interrupted in only one patient for only 3 days. Fourteen patients developed grade 2 or worse leukopenia including five after treatment, grade 2 in four, grade 3 in eight, and grade 4 in two. Grade 3 thrombocytopenia was observed in three patients. Grade 2 or worse anemia was observed in 12. Three patients had grade 3 nonhematologic toxicities, diarrhea in two, and nausea/vomiting in one. Although moderate to severe hematologic toxicities are common, this study suggests that concurrent low-dose daily cisplatin and EFRT are feasible. A cumulative cisplatin dose of greater than 200 mg/m(2) during radiation therapy could be achieved by using daily cisplatin dose of 8 mg/m(2).
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Affiliation(s)
- T Uno
- Departments of Radiology and Obstetrics and Gynecology, Graduate School of Medicine, Chiba University, Chiba, Japan.
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Choi CH, Lee JW, Kim TJ, Kim WY, Nam HR, Kim BG, Huh SJ, Lee JH, Bae DS. Phase II Study of Consolidation Chemotherapy After Concurrent Chemoradiation in Cervical Cancer: Preliminary Results. Int J Radiat Oncol Biol Phys 2007; 68:817-22. [PMID: 17379437 DOI: 10.1016/j.ijrobp.2006.12.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2006] [Revised: 12/06/2006] [Accepted: 12/22/2006] [Indexed: 11/23/2022]
Abstract
PURPOSE Our aim was to determine the efficacy of consolidation chemotherapy after concurrent chemoradiation (CCRT) using high-dose-rate brachytherapy in patients with locally advanced cervical carcinoma. METHODS AND MATERIALS Patients with cervical carcinoma (FIGO stage IB2-IVA) were treated with external beam radiation therapy to the whole pelvis (50.4 Gy) and high-dose-rate brachytherapy (24 Gy to point A). Cisplatin 60 mg/m(2) (Day 1) and 5-fluorouracil 1000 mg/m(2) (Days 1-5) were given every 3 weeks starting concurrently with the radiation and followed by 3 more cycles of consolidation for a total of 6 cycles. RESULTS Thirty patients (94%) received 3 more cycles of post-CCRT consolidation chemotherapy and were evaluable for the toxicity and efficacy of consolidation. The most common toxicities of Grade 2 or higher were nausea or vomiting (47%) and anemia (33%). Late complications of the rectum and bladder occurred in 13% and 6% of the patients, respectively. The clinical complete response rate was 87% (95% CI, 75%-99%). During a median follow-up of 27 months (range, 6-58 months), 5 patients (17%) had recurrence; the sites of failure were 3 (10%) inside the radiation field and 2 (7%) outside the radiation field. The estimated 3-year progression-free survival rate was 83% (95% CI, 67%-99%) and overall survival rate was 91% (95% CI, 79%-100%). CONCLUSIONS Consolidation chemotherapy after CCRT is well tolerated and effective in patients with locally advanced cervical carcinoma. A prospective randomized trial to compare this treatment strategy with standard CCRT seems to be worthwhile.
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Affiliation(s)
- Chel Hun Choi
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Lee S, Shin HJ, Han IO, Hong EK, Park SY, Roh JW, Shin KH, Kim TH, Kim JY. Tumor carbonic anhydrase 9 expression is associated with the presence of lymph node metastases in uterine cervical cancer. Cancer Sci 2007; 98:329-33. [PMID: 17233814 PMCID: PMC11159029 DOI: 10.1111/j.1349-7006.2007.00396.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Tumor hypoxia has a pronounced effect on malignant progression and metastatic spread of human tumors. As carbonic anhydrases (CA) 9 and 12 are induced by the low-oxygen environment within tumors, we investigated the relationship between the expression of these two CA and the presence of metastatic lymph nodes (LN) in uterine cervical cancer. CA9/CA12 expression was evaluated histochemically in primary cervical cancer tissues of 73 patients who underwent laparoscopic LN staging and two patients with clinical staging before definitive radiotherapy at the National Cancer Center, Korea. We also evaluated CA9 expression in 33 patients with pathologically confirmed metastatic LN. CA9 expression in the primary tumors was significantly associated with LN metastasis (P = 0.03) and poorer disease-free survival (relative risk, 6.1; 95% confidence interval, 1.3-28.3, P = 0.02, multivariate analysis), whereas CA12 expression did not show such a relationship. In addition, 21 of 24 metastatic LN revealed similar CA9 expression (P = 0.001), suggesting that CA9-expressing tumor cells had a higher metastatic potential. CA9 was expressed in 45 of 75 (60%) primary tumors, with positive tumor cells observed predominantly in the area away from the blood vessels. In contrast, CA12 expression was observed in only 29 of 74 primary tumors (39%), without a specific pattern. These findings indicate that expression of CA9, but not CA12, in tumors is associated with the presence of LN metastases and poorer prognosis. Selective application of new treatment modalities based on CA9 expression to prevent LN metastases may improve overall treatment outcome in patients with uterine cervical cancer.
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Affiliation(s)
- Sun Lee
- Radiation Oncology, National Cancer Center, 809 Madu-dong, Ilsan-gu, Goyang-si, Gyeonggi-do, 411-769, Korea
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Salama JK, Mundt AJ, Roeske J, Mehta N. Preliminary outcome and toxicity report of extended-field, intensity-modulated radiation therapy for gynecologic malignancies. Int J Radiat Oncol Biol Phys 2006; 65:1170-6. [PMID: 16730136 DOI: 10.1016/j.ijrobp.2006.02.041] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2005] [Revised: 01/24/2006] [Accepted: 02/09/2006] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim of this article is to report a preliminary analysis of our initial clinical experience with extended-field intensity-modulated radiotherapy for gynecologic malignancies. METHODS AND MATERIALS Between November 2002 and May 2005, 13 women with gynecologic malignancies were treated with extended-field radiation therapy. Of the women, 7 had endometrial cancer, 4 cervical cancer, 1 recurrent endometrial cancer, and 1 suspected cervical cancer. All women underwent computed tomography planning, with the upper vagina, parametria, and uterus (if present) contoured within the CTV. In addition, the clinical target volume contained the pelvic and presacral lymph nodes as well as the para-aortic lymph nodes. All acute toxicity was scored according to the Common Terminology Criteria for Adverse Events (CTCAE v 3.0). All late toxicity was scored using the Radiation Therapy Oncology Group late toxicity score. RESULTS The median follow-up was 11 months. Extended-field intensity-modulated radiation therapy (IMRT) for gynecologic malignancies was well tolerated. Two patients experienced Grade 3 or higher toxicity. Both patients were treated with concurrent cisplatin based chemotherapy. Neither patient was planned with bone marrow sparing. Eleven patients had no evidence of late toxicity. One patient with multiple previous surgeries experienced a bowel obstruction. One patient with bilateral grossly involved and unresectable common iliac nodes experienced bilateral lymphedema. Extended-field-IMRT achieved good local control with only 1 patient, who was metastatic at presentation, and 1 patient not able to complete treatment, experiencing in-field failure. CONCLUSIONS Extended-field IMRT is safe and effective with a low incidence of acute toxicity. Longer follow-up is needed to assess chronic toxicity, although early results are promising.
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Affiliation(s)
- Joseph K Salama
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL 60637-1407, USA.
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