Matched-case comparison for the efficacy of neoadjuvant chemotherapy before surgery in FIGO stage IB1-IIA cervical cancer

Management of Bulky Tumors in Cervical Cancer: Limits of the Surgical Approach

The standard treatment for cervical tumors larger than 4 cm, known as bulky tumors, currently involves concurrent chemoradiotherapy followed by vaginal brachytherapy. However, radical surgery is an alternative option in some cases, particularly for those in which a combination of risk factors is not anticipated. Recent studies show that neoadjuvant chemotherapy may help reduce tumor size in these bulky tumors, enabling subsequent surgical intervention reducing the adverse effects derived from radiotherapy. Evidence about fertility sparing surgery in patients with bulky tumors is limited, although some retrospective studies reported good oncological outcomes when adequate tumor reduction is achieved through neoadjuvant chemotherapy. Moreover, the administration of adjuvant radiotherapy after radical surgery in patients with tumor sizes ≥ 4 cm in the final pathological report, combined with other intermediate risk factors for recurrence, remains a topic of debate. Current evidence indicates no significant differences in overall survival or disease-free survival between follow-up alone and the use of adjuvant radiotherapy in these cases, although further research is needed to refine treatment strategies for these patients. This narrative review aims to summarize the available evidence on the comprehensive management of bulky cervical tumors, addressing relevant issues and controversies in the field.

Initial treatment for FIGO 2018 stage IIIC cervical cancer based on histological type: A 14-year multicenter study

BACKGROUND

To compare the oncological outcomes of radical chemotherapy (R-CT), abdominal radical hysterectomy (ARH), and neoadjuvant chemotherapy and radical surgery (NACT) for International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IIIC cervical cancer, according to histological types: squamous cell carcinoma (SCC) and adenocarcinoma (AC)/adenosquamous cell carcinoma (ASC).

METHODS

A comparison of 5-year overall survival (OS) and disease-free survival (DFS) was performed for the SCC and AC/ASC subgroups for the three initial treatments, assessed using Kaplan-Meier and Cox proportional hazards regression analysis and validated using propensity score matching (PSM).

RESULTS

The study included 4086 patients: R-CT, n = 1913; ARH, n = 1529; and NACT, n = 644. AC/ASC had a lower survival rate (63.7%) than SCC (73.6%) and a higher recurrence and mortality rate (36.3% and 26.4%, respectively). The 5-year OS and DFS rates were different in the SCC group for R-CT, ARH, and NACT (OS: 69.8% vs. 80.8% vs. 73.0%, p < 0.001; DFS: 66.7% vs. 70.7% vs. 56.4%, p < 0.001), also in the AC/ASC group (OS: 46.1% vs. 70.6% vs. 55.6%, p < 0.001; DFS: 42.7% vs. 64.6% vs. 40.8%, p < 0.001). As for initial treatment, survival outcomes were worse for AC/ASC treated with R-CT and ARH than for SCC (both p < 0.05), with no group differences between the two treated with NACT.

CONCLUSION

Initial treatment influences oncological prognosis for patients with FIGO 2018 stage IIIC cervical cancer. ARH is an alternative treatment for stage IIIC cervical SCC and AC/ASC, and NACT needs to be chosen with caution, moreover, R-CT for AC/ASC requires careful selection.

Machine learning applied to MRI evaluation for the detection of lymph node metastasis in patients with locally advanced cervical cancer treated with neoadjuvant chemotherapy

PURPOSE

Concurrent cisplatin-based chemotherapy and radiotherapy (CCRT) plus brachytherapy is the standard treatment for locally advanced cervical cancer (LACC). Platinum-based neoadjuvant chemotherapy (NACT) followed by radical hysterectomy is an alternative for patients with stage IB2-IIB disease. Therefore, the correct pre-treatment staging is essential to the proper management of this disease. Pelvic magnetic resonance imaging (MRI) is the gold standard examination but studies about MRI accuracy in the detection of lymph node metastasis (LNM) in LACC patients show conflicting data. Machine learning (ML) is emerging as a promising tool for unraveling complex non-linear relationships between patient attributes that cannot be solved by traditional statistical methods. Here we investigated whether ML might improve the accuracy of MRI in the detection of LNM in LACC patients.

METHODS

We analyzed retrospectively LACC patients who underwent NACT and radical hysterectomy from 2015 to 2020. Demographic, clinical and MRI characteristics before and after NACT were collected, as well as information about post-surgery histopathology. Random features elimination wrapper was used to determine an attribute core set. A ML algorithm, namely Extreme Gradient Boosting (XGBoost) was trained and validated with tenfold cross-validation. The performances of the algorithm were assessed.

RESULTS

Our analysis included n.92 patients. FIGO stage was IB2 in n.4/92 (4.3%), IB3 in n.42/92 (45%), IIA1 in n.1/92 (1.1%), IIA2 in n.16/92 (17.4%) and IIB in n.29/92 (31.5%). Despite detected neither at pre-treatment and post-treatment MRI in any patients, LNM occurred in n.16/92 (17%) patients. The attribute core set used to train ML algorithms included grading, histotypes, age, parity, largest diameter of lesion at either pre- and post-treatment MRI, presence/absence of fornix infiltration at pre-treatment MRI and FIGO stage. XGBoost showed a good performance (accuracy 89%, precision 83%, recall 78%, AUROC 0.79).

CONCLUSIONS

We developed an accurate model to predict LNM in LACC patients in NACT, based on a ML algorithm requiring few easy-to-collect attributes.

Treatment of FIGO 2018 stage IIIC cervical cancer with different local tumor factors

BACKGROUND

To compare the oncological outcomes of patients with FIGO 2018 stage IIIC cervical cancer (CC) involving different local tumor factors who underwent abdominal radical hysterectomy (ARH), neoadjuvant chemotherapy and radical surgery (NACT), or radical chemoradiotherapy (R-CT).

METHODS

Based on tumor staging, patients with stage IIIC were divided into T1, T2a, T2b, and T3 groups. Kaplan-Meier and Cox proportional hazards regression analysis were used to compare their overall survival (OS) and disease-free survival (DFS) of 5 years.

RESULTS

We included 4,086 patients (1,117, 1,019, 869, and 1,081 in the T1, T2a, T2b, and T3 groups, respectively). In the T1 group, NACT was correlated with a decrease in OS (hazard ratio [HR] = 1.631, 95% confidence interval [CI]: 1.150-2.315, P = 0.006) and DFS (HR = 1.665, 95% CI: 1.255-2.182, P < 0.001) than ARH. ARH and NACT were not correlated with OS (P = 0.226 and P = 0.921) or DFS (P = 0.343 and P = 0.535) than R-CT. In the T2a group, NACT was correlated with a decrease in OS (HR = 1.454, 95% CI: 1.057-2.000, P = 0.021) and DFS (HR = 1.529, 95% CI: 1.185-1.974, P = 0.001) than ARH. ARH and NACT were not correlated with OS (P = 0.736 and P = 0.267) or DFS (P = 0.714 and P = 0.087) than R-CT. In the T2b group, NACT was correlated with a decrease in DFS (HR = 1.847, 95% CI: 1.347-2.532, P < 0.001) than R-CT nevertheless was not correlated with OS (P = 0.146); ARH was not correlated with OS (P = 0.056) and DFS (P = 0.676). In the T3 group, the OS rates of ARH (n = 10), NACT (n = 18), and R-CT (n = 1053) were 67.5%, 53.1%, and 64.7% (P = 0.941), and the DFS rates were 68.6%, 45.5%, and 61.1%, respectively (P = 0.761).

CONCLUSION

R-CT oncological outcomes were not entirely superior to those of NACT or ARH under different local tumor factors with stage IIIC. NACT is not suitable for stage T1, T2a, and T2b. Nevertheless ARH is potentially applicable to stage T1, T2a, T2b and T3. The results of stage T3 require confirmation through further research due to disparity in case numbers in each subgroup.

Neoadjuvant chemotherapy followed by radical surgery reduces radiation therapy in patients with stage IB2 to IIA2 cervical cancer

BACKGROUND

To investigate whether carboplatin-liposomal paclitaxel neoadjuvant chemotherapy (NACT) benefits patients with locally advanced cervical cancer (LACC) through avoiding or delaying postoperative radiation.

METHODS

A total of 414 patients with cervical cancer of International Federation of Gynecology and Obstetrics (FIGO 2009) stages IB2-IIA2 were included in the retrospective cohort study, who had received carboplatin-liposomal paclitaxel chemotherapy followed by radical surgery (NACT group) or primary radical surgery (PRS group) between 2007 and 2017 at our hospital. The baseline clinicopathological characteristics at diagnosis, postoperative pathological risk factors, and oncological outcomes after surgery, including postoperative radiation (as adjuvant treatment or treatment of recurrent diseases), progression-free survival (PFS), and overall survival (OS), were compared between the groups. Before treatment, the patients in the NACT group had significantly more advanced tumor stages and larger tumor sizes than those in the PRS group.

RESULTS

The NACT reduced the tumor volumes remarkedly with a response rate of 62.4%, and the tumors in the NACT group were smaller than those in the PRS group when the patients were subjected to radical surgery. Furthermore, postoperative pathology examination revealed less frequent deep stromal invasion in the NACT group than in the PRS group. According to the presence of pathological risk factors for recurrence, 54.82% of women in the NACT group needed adjuvant radiotherapy, while 60.87% in the PRS group, and in fact, 33.00% of NACT patients and 40.09% of PRS patients received adjuvant radiation. In addition, 8.12% of NACT patients and 9.68% of PRS patients underwent radiotherapy after relapse. The cumulative postoperative radiation rate was significantly lower in the NACT group (P = 0.041), while the differences in 5-year OS and PFS were not statistically significant between the groups.

CONCLUSIONS

NACT reduces the pathological risk factors and the use of radiation without compromising survival in patients with LACC, which may protect younger patients from radiation-related side effects and subsequently improve the quality of life.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN24104022.

Clinical outcome of FIGO 2018 stage IB3/IIA2 cervical cancer treated by neoadjuvant chemotherapy followed by radical surgery due to lack of radiotherapy equipment: A retrospective comparison with concurrent chemoradiotherapy

This study aimed to assess neoadjuvant chemotherapy's clinical outcomes such as efficacy, toxicity, and survival outcomes followed by radical hysterectomy ((NACT-RS) among women with cervical cancer stage IB3 and IIA2, by comparing concurrent chemoradiotherapy (CCRT) and NACT-RS. The study retrospectively reviewed patients with (2018 FIGO) stage IB3 and IIA2 cervical cancer who received preoperative neoadjuvant chemotherapy followed by NACT-RS or concurrent chemoradiotherapy (CCRT). The outcome measures were the 5-year survival and complication rates between the two groups. The median follow-up was 75 months. In total, 218 patients had stage IIA2, 136 patients had stage IB3, 201 patients received CCRT, and 153 patients received preoperative NACT-RS. In the CCRT group, the incidence of early complications (myelosuppression, gastrointestinal and urinary) was higher compared with that in the NACT-RS group (76.1 vs. 26.1%; p < 0.001, respectively). There was no significant difference between the two study groups concerning late complications. Five-year PFS was 79.9% and 85.5% in the NACT-RS and CCRT groups, respectively (p = 0.093). Five-year OS was 86.9% and 85.5% in the NACT-RS and CCRT groups, respectively (p = 0.97). In the multivariate clinicopathologic characteristics analysis for OS, initial tumor size > 4.3 cm (HR 5.11; p < 0.001), AC/ASC (HR 1.89; p = 0.02), histologic grade 2-3 (HR 2.25; p = 0.04), and 2018 FIGO stage IIA2 (HR 8.67; p < 0.001) were independent risk factors. The survival of patients with stage IB3 and IIA2 cervical cancer treated with NACT-RS was similar to that of patients treated with CCRT without increasing side effects.

The Effect of Neoadjuvant Chemotherapy on Lymph Node Metastasis of FIGO Stage IB1-IIB Cervical Cancer: A Systematic Review and Meta-Analysis

Objectives

This study aimed to assess the effect of neoadjuvant chemotherapy (NACT) on the rate of lymph node metastasis (LNM) in FIGO stage IB1-IIB cervical cancer patients and compare the LNM between NACT plus surgery and surgery only.

Methods

We identified 34 eligible studies in PubMed, Web of Science, Cochrane Library, and EMBASE from inception to July 27, 2019. Data analyses were performed by Stata (version 13) and Revman (version 5.3).

Results

In these 34 included studies, the pooled incidence of LNM was estimated as 23% (95% CI, 0.20-0.26; I² = 79.6%, P<0.001). In the subgroup analysis, we identified five factors, including study type, year of publication, continents from which patients came, histological type and the FIGO stage. When taking FIGO stage into consideration, the LNM rate was 13% in stage IB (95% CI: 0.10-0.15; I² = 5.5%, P=0.385), 23% in stage IIA (95% CI: 0.18-0.28; I² = 0%, P=0.622), and 27% in stage IIB (95% CI: 0.20-0.33; I² = 0%, P=0.898), respectively. Through the comparison between NACT plus surgery and surgery only based on the six randomized controlled trials, the incidence of positive lymph nodes was lower in patients receiving NACT plus surgery than surgery only (RR=0.57, 95% CI: 0.39-0.83; I² = 60.5%, P=0.027). The 5-year OS was higher in the NACT + surgery group than surgery-only group (RR=1.13, 95% CI: 1.03-1.23; I² = 0.0%, P=0.842).

Conclusions

Among cervical cancer in stage IB1-IIB, the preoperative NACT plus radical surgery resulted in a 23% probability of LNM, which was lower than those receiving radical surgery only. In stage IIA and IIB, the effect of NACT to reduce LNM was more obvious.

Effect of neoadjuvant chemotherapy followed by surgery for FIGO stage I-II cervical cancer: a meta-analysis

OBJECTIVE

In this meta-analysis, we aimed to evaluate the oncological outcomes of preoperative neoadjuvant chemotherapy followed by radical surgery compared with radical surgery alone for treatment of International Federation of Gynecology and Obstetrics (FIGO) stage I-II cervical cancer.

METHOD

We searched for studies comparing the safety and efficacy of neoadjuvant chemotherapy plus surgery versus surgery alone in treatment outcomes of locally advanced cervical cancer. Meta-analysis was used to calculate the pooled odds ratios with corresponding 95% confidence intervals (CI).

RESULTS

Sixteen studies were included in our analysis. Pooled analysis of overall survival rate [odds ratio (OR) = 1.09, 95% CI: 0.83-1.43] and progression-free survival rate (OR = 1.10, 95% CI: 0.77-1.57) showed that preoperative neoadjuvant chemotherapy did not have a benefit compared with surgery alone in terms of survival rates. The pooled results for postoperative parameters indicated that preoperative neoadjuvant chemotherapy followed by radical surgery was associated with a high rate of vascular space involvement (OR = 0.25, 95% CI: 0.17-0.35) and parametrial infiltration (OR = 0.60, 95% CI: 0.45-0.79).

CONCLUSIONS

This meta-analysis indicated that surgery following neoadjuvant chemotherapy for FIGO stage I-II cervical cancer and surgery alone had similar oncological outcomes.

Effect of neoadjuvant chemotherapy followed by radical surgery for FIGO stage IB2/IIA2 cervical cancer: A multi-center retrospective clinical study

This study compared the efficacy of neoadjuvant chemotherapy (NACT) followed by radical surgery (RS) vs primary surgical treatment (PST) in patients diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage IB2/IIA2 cervical cancer.Data of 303 cervical cancer patients who received primary therapy for stage IB2/IIA2 cervical cancer at 7 medical centers in Beijing, China between January 1, 2009 and December 31, 2016 and followed through December 31, 2017 were collected retrospectively. The response rates, surgical characteristics, and overall survival (OS) durations of patients who received NACT followed by RS were compared to those of patients who received PST.An improved short-term complete response rate was observed among patients who received intra-arterial chemotherapy compared with patients who had intravenous chemotherapy (18.3% vs 4.1%, Pdifference = .020). Patients who received NACT were more likely to undergo laparoscopic surgery and to have a lower blood loss volume (555.4 ± 520.2 ml vs PST, 682.5 ± 509.8 ml; P = .036) and increased estimated operative time (249.9 ± 101.9 vs PST, 225.1 ± 76.5 min; P = .022). No differences in high-risk factors (HRFs), the effects of supplemental treatment, or 5-year OS were observed between patients who received NACT and PST.Our findings indicate that patients who received NACT for FIGO stage IB2/IIA2 cervical cancer were more likely to undergo laparoscopic surgery. These findings have important implications regarding treatment with curative intent for stage IB2/IIA2 cervical cancer and warrant a further analysis of treatment strategies to ensure adequate treatment and patient-centered care.

Adenocarcinoma of the uterine cervix: Pathologic features, treatment options, clinical outcome and prognostic variables

Adenocarcinoma accounts for 10-25% of all cervical cancers, and its relative and absolute rate has raised over the past decades. Most, but not all the authors, reported that adenocarcinoma has a greater propensity to lymph node, ovarian and distant metastases and a worse prognosis compared with squamous cell carcinoma. However, whether histologic type is an independent prognostic factor is still a debated issue. Moreover, adenocarcinoma is a very heterogenous disease, including different histological subtypes. Whereas radical hysterectomy and definitive radiotherapy achieve the same clinical outcome in early stage squamous cell carcinoma, surgery seems to obtain better survival compared with definitive radiotherapy in early stage adenocarcinoma. Chemoradiation is the standard treatment for locally advanced cervical cancer regardless of histologic type, although several retrospective studies showed that patients with adenocarcinoma were more likely to die than those with squamous cell carcinoma both before and after concurrent chemoradiation era. The prognostic relevance of biological variables, such as cyclin-dependent kinase inhibitors, p53, cyclooxygenase-2 [COX-2], cell surface tyrosine-kinases and programmed death-ligand [PD-L1], is still under investigation. Palliative chemotherapy is the only treatment option for persistent or recurrent cervical adenocarcinoma not amenable with surgery and radiotherapy. The use of immune checkpoint inhibitors as well as a therapeutic strategy targeting cell surface tyrosine kinases should be adequately explored in this clinical setting.

Optimal pathological response indicated better long-term outcome among patients with stage IB2 to IIB cervical cancer submitted to neoadjuvant chemotherapy

The role of pathological response in long-term outcome is still unclear in cervical cancer patients treated with neoadjuvant chemotherapy (NACT) in China. This study aimed to investigate the effect of optimal pathologic response (OPR) on survival in the patients treated with NACT and radical hysterectomy. First, 853 patients with stage IB2-IIB cervical cancer were included in a retrospective analysis; a Cox proportional hazards model was used to investigate the relationship between pathological response and disease-free survival (DFS). In the retrospective database, 64 (7.5%) patients were found to have achieved an OPR (residual disease <3 mm stromal invasion); in the multivariate Cox model, the risk of death was much greater in the non-OPR group than in the OPR group (HR, 2.61; 95%CI, 1.06 to 6.45; P = 0.037). Next, the role of OPR was also evaluated in a prospective cohort of 603 patients with cervical cancer. In the prospective cohort, 56 (9.3%) patients were found to have achieved an OPR; the log-rank tests showed that the risk of recurrence was higher in the non-OPR patients than in the OPR group (P = 0.05). After combined analysis, OPR in cervical cancer was found to be an independent prognostic factor for DFS.

Neoadjuvant chemotherapy for locally advanced cervical cancer

Neoadjuvant chemotherapy followed by surgery (NCS) has not been fully evaluated clinically. Currently, the main regimen of neoadjuvant chemotherapy (NAC) used in NCS includes cisplatin. The antitumor effects of NAC reduce lymph node metastasis and the tumor diameter in patients prior to surgery, and this can reduce the number of high risk patients who require postoperative radiation therapy. Many randomized controlled trials (RCTs) have examined the long-term prognosis of NCS compared to primary surgery, but the utility of NCS remains uncertain. The advent of concurrent chemoradiotherapy (CCRT) has markedly improved the outcome of radiotherapy (RT), and CCRT is now used as a standard method in many cases of advanced bulky cervical cancer. NCS gives a better treatment outcome than radiation therapy alone, but it is important to verify that NCS gives a similar or better outcome compared to CCRT.

Adenocarcinoma of the cervix: should we treat it differently?

Worldwide, cervical cancer is a leading cause of mortality among women, causing 265,653 deaths annually. Squamous cell carcinoma (SCC) accounts for 75% of cervical cancer cases in the USA, while adenocarcinoma (AC) accounts for 25%. The incidence of SCC is decreasing in the USA, yet AC is increasing. Many differences exist between cervical SCC and AC including anatomic origin, risk factors, prognosis, dissemination, sites of recurrence, and rates of metastasis. Despite differences, current treatment algorithms do not distinguish between cervical SCC and AC. To date, prospective research directed toward AC is limited. We review published differences in response to neoadjuvant chemotherapy and concomitant chemotherapy with radiation, the role of adjuvant radical hysterectomy, and optimal chemotherapy for cervical AC. Cervical AC is sufficiently distinct from SCC to warrant specific treatment recommendations; however, lack of data evaluating AC limit recommendations. Additional prospective AC cervix specific research is needed.

Could the extent of lymphadenectomy be modified by neoadjuvant chemotherapy in cervical cancer? A large-scale retrospective study

Background

The effect of neoadjuvant chemotherapy (NACT) on topographical distribution patterns of lymph node metastasis in cervical cancer was unknown.

Methods

Patients with FIGO stage IB1-IIB who underwent radical surgery with or without NACT were enrolled (3527 patients). A matched-case comparison design was used to compare the effects of NACT on lymph node metastasis.

Results

We analyzed groups of 167 and 140 patients who were diagnosed with lymph node metastasis in the matched primary surgery group and NACT group, respectively, and no significant difference was observed (p = 0.081). The incidence of lymph node metastasis was significantly decreased in the NACT-responsive group compared to the non-responsive group (18.4% vs. 38.6%, P<0.001). The metastatic rates for every lymph node group also declined in the NACT-responsive group except for the deep inguinal and the para-aortic lymph node groups. Clinical response, deep stromal, parametrial and lymph vascular invasions were independent risk factors for lymph node metastasis in the NACT group. Furthermore, deep stromal invasion and lymph vascular invasion, but not the response to NACT, were independently associated with upper LNM. The number of lymph nodes involved, response to NACT, tumor histology and a positive vaginal margin were independent prognostic factors affecting DFS or OS rates in node-positive patients treated with NACT plus radical surgery.

Conclusion

The frequency and topographic distribution of LNM are not modified by NACT, and clinical non-responders showed more involved LNs. A systemic and extensive lymphadenectomy should be performed in patients treated with NACT plus surgery regardless of the response to NACT.

The efficacy of neoadjuvant chemotherapy in different histological types of cervical cancer

OBJECTIVE

To determine whether the efficacy of neoadjuvant chemotherapy (NACT) is different among cervical cancer types, squamous cell carcinoma (SCC) and non-SCC, including adenocarcinoma of the cervix (ACC) and adenosquamous carcinoma (ASC).

METHODS

We searched PubMed, MEDLINE, ScienceDirect, Springerlink and CNKI for studies published between Jan 1987 and Sep 2012 and evaluated the studies published in English and Chinese on NACT and cervical carcinoma based on specific inclusion and exclusion criteria. Because there was a relative lack of relevant randomized controlled trials (RCTs), we included 2 RCTs and 9 observational studies in our analysis. Meta-analysis was applied to calculate the efficacy of NACT in different histological types of cervical cancer with 95% confidence intervals. The risk of bias was assessed by Begg's adjusted rank correlation test and Egger's regression asymmetry tests.

RESULTS

As many as 11 articles, 2 RCTs and 9 observational studies, were selected according to the eligibility criteria for a total of 1559 participants. For the short-term efficacy of NACT, either in terms of CR+PR or CR only, there was no difference between SCC and non-SCC when the data were pooled (P>0.05) in stratified studies based on the International Federation of Gynecology and Obstetrics (FIGO) stage (P>0.05) or histological type (P>0.05) or in observational studies (P>0.05). Nevertheless, SCC was associated with a higher short-term response rate than non-SCC in RCTs [6.57 (95%CI 1.72-25.12) in CR+PR]. For the long-term outcome of NACT, patients with SCC experienced a significant 5-year overall survival (OS) and progress-free survival (PFS) when compared to patients with non-SCC in pooled [1.47 (95%CI 1.06-2.06)] and observational studies [1.96 (95%CI 1.61-2.38)] other than RCTs (P>0.05). Moreover, this difference was especially obvious when the subgroup analysis was restricted to patients in stages above IIB [2.06 (95%CI 1.79-2.36)] rather than in stages IB-IIB [1.33 (95%CI 0.99-1.79)].

CONCLUSION

Although no significant differences exist in the short-term efficacy of NACT, the histological type may be used to predict the long-term efficacy of NACT in patients with cervical cancer, especially those with FIGO stages above IIB.

Efficacy of neoadjuvant cisplatin and 5-flourouracil prior to surgery in FIGO stage IB2/IIA2 cervical cancer

Cervical cancer is currently the first or second leading cause of cancer-related mortality among women in developing countries. This study was conducted in order to determine whether neoadjuvant cisplatin and 5-flourouracil (NAPF) prior to surgery is superior to primary surgical treatment (PST) as a treatment option for patients with International Federation of Gynaecology and Obstetrics (FIGO) stage IB2/IIA2 cervical cancer. A retrospective review of 195 patients with early-stage bulky cervical cancer was performed. The patients were divided into two groups, according to whether they received NAPF prior to surgery. The surgical profiles and complications, risk factors of recurrence and survival were compared between the groups. The response rate to NAPF was found to be 61.2%. There were no differences in operative time and intra-operative complications between the two groups, whereas the estimated blood loss in the NAPF and PST groups were 620.1±394.9 and 434.8±233.7 ml, respectively (P=0.000). When compared with PST, NAPF remarkably reduced tumor size (22.5 vs. 93.3%, P=0.000). Furthemore, the ratio of deep stromal invasion was significantly lower in responders to NAPF compared with that in non-responders (46.7 vs. 76.3%, respectively; P=0.004) and in the PST group (46.7 vs. 70.0%, respectively; P=0.004). No reduction of high-risk factors (HRFs) was observed. The NAPF group, even the responder subgroup, exhibited no significant improvement in progression-free survival (PFS) and overall survival (OS) compared to the PST group. In conclusion, despite the reduction of intermediate-risk factors (IRFs), neoadjuvant chemotherapy (NAC) with the NAPF regimen prior to radical surgery (RS) did not improve the prognosis in patients with FIGO stage IB2/IIA2 cervical cancer.

Impact of Chemoradiation on Prognosis in Stage IVB Cervical Cancer with Distant Lymphatic Metastasis

PURPOSE

The purpose of this study was to determine whether chemoradiation (CCR) is efficient for improving prognosis, compared with systemic chemotherapy (SC), in patients with stage IVB cervical cancer who have distant lymphatic metastasis.

MATERIALS AND METHODS

Among 2,322 patients with cervical cancer between January 2000 and March 2010, 43 patients (1.9%) had stage IVB disease. After exclusion of 19 patients due to insufficient data and hematogenous metastasis, 24 patients (1%) who received CCR (n=10) or SC (n=14) were enrolled. We compared tumor response, progression-free survival (PFS) and overall survival (OS), and disease recurrence between CCR and SC.

RESULTS

Complete response rates were 60% and 0% after CCR and SC (p<0.01). Grade 3 or 4 leukopenia was more common in patients treated with CCR (24.4% vs. 9.1%, p=0.03), whereas grade 3 or 4 neuropenia was more frequent in those treated with SC (28.4% vs. 11.1%, p=0.03). Development of grade 3 proctitis occurred as a late radiotherapy (RT)-related toxicity in only one patient (10%) treated with CCR. In addition, squamous cell carcinoma and CCR were favorable prognostic factors for improvement of PFS (adjusted hazard ratios [HRs], 0.17 and 0.12; 95% confidence intervals [CIs], 0.04 to 0.80 and 0.03 to 0.61), and only CCR was significant for improvement of OS (adjusted HR, 0.15; 95% CI, 0.02 to 0.90). However, no differences in the rate and pattern of disease recurrence were observed between CCR and SC.

CONCLUSION

CCR may be more effective than SC for improving survival, and can be regarded as a feasible method with some caution regarding late RT-related toxicity for treatment of stage IVB cervical cancer with distant lymphatic metastasis.

Is neoadjuvant chemotherapy followed by radical surgery more effective than radiation therapy for stage IIB cervical cancer?

OBJECTIVE

The primary objective of the study was to compare the survival rate of patients who had received neoadjuvant chemotherapy with that of patients who had received radiation therapy for stage IIB cervical cancer. The secondary objective was to analyze the effect of neoadjuvant chemotherapy on pathological prognostic factors.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of patients who had received therapy for stage IIB cervical cancer. Based on the primary therapy, 192 patients were divided into 2 groups; patients in the neoadjuvant chemotherapy group (n =103) underwent a type III radical hysterectomy after completion of the neoadjuvant chemotherapy. Patients in the other group (n = 89) were treated with radiation alone or a combination of chemotherapy and radiotherapy.

RESULTS

After neoadjuvant chemotherapy, the level of squamous cell carcinoma antigen, tumor size, lymph node involvement, and parametrium involvement were significantly decreased. However, 90.3% of the patients who had received neoadjuvant chemotherapy needed to have adjuvant therapy after radical surgery because of poor pathological prognostic factors. The rate of disease-free survival did not differ significantly between the 2 groups. However, the overall survival rate was significantly lower in the neoadjuvant chemotherapy group for patients who were 60 years or older (P = 0.03). The rates of disease-free survival and overall survival for patients who had a good (complete or partial) response to the neoadjuvant chemotherapy were not significantly higher than the rates for patients in the radiation therapy group.

CONCLUSIONS

Although neoadjuvant chemotherapy improved pathological prognostic factors in patients with stage IIB cervical cancer, it was not sufficiently effective to decrease adjuvant therapy. Neoadjuvant chemotherapy also did not improve the rate of patient survival compared to the rate of patient survival in the radiation therapy group.

Neoadjuvant chemotherapy followed by fertility-sparing surgery for women with stage IB1 cervical cancer

Fertility-sparing surgery was optimal to patients with tumor diameter smaller than 2 cm. For patients with larger tumors, neoadjuvant chemotherapy can debulk the tumor and offer the chance of surgery. We report 2 cases of stage IB1 cervical cancer treated by neoadjuvant chemotherapy and fertility-sparing surgery. Relevant literature was reviewed. Its safety, efficacy, and reproductive outcome need to be validated in the future.

Neoadjuvant chemotherapy for locally advanced cervical cancer reduces surgical risks and lymph-vascular space involvement

Neoadjuvant chemotherapy (NACT), which can reduce the size and therefore increase the resectability of tumors, has recently evolved as a treatment for locally advanced cervical cancer. NACT has been reported to decrease the risk of pathologic factors related to prognosis of cervical cancer. To further assess the effects of NACT on surgery and the pathologic characteristics of cervical cancer, we reviewed 110 cases of locally advanced cervical cancer treated with radical hysterectomy with or without NACT at the People's Hospital of Peking University between January 2006 and December 2010. Of 110 patients, 68 underwent platinum-based NACT prior to surgery (NACT group) and 42 underwent primary surgery treatment (PST group). Our results showed 48 of 68 (70.6%) patients achieved a complete response or partial response to NACT. Estimated blood loss, operation time, and number of removed lymph nodes during surgery, as well as complication rates during and after surgery were not significantly different between the NACT group and the PST group. The rates of deep stromal invasion, positive parametria, positive surgical vaginal margins, and lymph node metastasis were not significantly different between the two groups. However, the rate of lymph-vascular space involvement (LVSI) was significantly lower in the NACT group than in the PST group (P = 0.021). In addition, the response rate of NACT was significantly higher in the patients with chemotherapeutic drugs administrated via artery than via vein. Our results suggest that NACT is a safe and effective treatment for locally advanced cervical cancer and significantly decreases the rate of LVSI.

Development of criteria for ovarian preservation in cervical cancer patients treated with radical surgery with or without neoadjuvant chemotherapy: a multicenter retrospective study and meta-analysis

BACKGROUND

There is no consensus on the selection criteria for ovarian preservation in cervical cancer, and the role of neoadjuvant chemotherapy (NACT) on ovarian metastasis (OM) is also unknown.

METHODS

A total of 1,889 cervical cancer patients with International Federation of Gynecology and Obstetrics (FIGO) stages IB to IIB who underwent radical hysterectomy, pelvic lymphadenectomy, and bilateral salpingo-oophorectomy with or without NACT were enrolled. Clinicopathologic variables were studied by univariate and multivariate analyses. Meta-analyses of published data for risk factors of OM were also performed.

RESULTS

Twenty-two (1.2%) of 1,889 patients were diagnosed as OM: 12 squamous cell carcinomas (SCC, 0.7%), five adenocarcinomas (2.7%), four adenosquamous carcinomas (5.6%), and one small cell carcinoma (7.7%). Multivariate analysis revealed that lymph node metastasis (LNM; odds ratio 5.75, 95% confidence interval 2.16-15.28), corpus uteri invasion (CUI; 5.53, 2.11-14.53), parametrial invasion (PMI; 8.24, 3.01-22.56), and histology and NACT (0.40, 0.13-1.22) were associated with OM. Furthermore, OM in patients with SCC was associated with PMI (5.67, 1.63-19.72), CUI (3.25, 0.88-12.01), and LNM (9.44, 2.43-36.65). FIGO stage (IIB vs. IB; 31.78, 1.41-716.33), bulky tumor size (12.71, 1.31-123.68), PMI (51.21, 4.10-639.19), NACT (0.003, 0.00-0.27), and CUI (44.49, 2.77-714.70) were independent clinicopathologic factors for OM in adenocarcinomas. In the meta-analysis, we identified six risk factors for OM: LNM, CUI, PMI, adenocarcinoma, large tumor size, and lymphovascular space involvement.

CONCLUSIONS

Ovarian preservation surgery may be safe in SCC patients without suspicious LNM, PMI, and CUI, and in adenocarcinomas in patients who received NACT without FIGO stage IIB disease, bulky tumor size (>4 cm), suspicious PMI, and CUI.

Surgical-pathologic risk factors of pelvic lymph node metastasis in stage Ib1-IIb cervical cancer

OBJECTIVE

To study the distribution characteristics and risk factors of cervical cancer lymph node metastasis (LNM).

DESIGN

Retrospective study.

SETTING

Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology and Affiliated Hospital to Zunyi Medical College.

POPULATION

404 women diagnosed with cervical cancer FIGO stage Ib1-IIa who underwent primary radical surgery and 104 women with Ib2-IIb tumors treated with neoadjuvant chemotherapy (NACT) before surgery.

METHODS

Clinicopathological data were collected and analyzed.

MAIN OUTCOME MEASURES

Incidence of infiltration, metastasis and pelvic LNM.

RESULTS

In women without NACT, the incidence of infiltration, metastasis and LNM was 7.2, 17.6 and 15.8%, respectively. Metastasis and LNM were significantly associated with advanced FIGO stage and poorer histological grade. The incidence of multiple metastatic lymph nodes (MLNs), bilateral LNM, skip LNM, LNM in primary group and LNM in secondary group was 6.2, 3.0, 6.2%, 11.4 and 4.5%, respectively. Of the 111 MLNs, 13 (11.7%) were common iliac lymph nodes. In the NACT group, infiltration, metastasis and LNM were observed in 10 (9.6%), 24 (23.1%) and 21 (20.1%) of 104 women, respectively. Metastasis and LNM were significantly correlated with moderate cell differentiation.

CONCLUSION

High LNM risk is expected in tumors of IIa stage or higher and in moderately differentiated tumors. Skip metastasis and common iliac LNM are relatively common and therefore should not be neglected. Our results suggest that standardized and complete pelvic lymph node dissection under surgery is an important measure to ensure a therapeutic effect.

Matched-case comparison of neoadjuvant chemotherapy in patients with FIGO stage IB1-IIB cervical cancer to establish selection criteria

OBJECTIVE

Neoadjuvant chemotherapy (NACT) for cervical cancer still remains controversial. NACT was evaluated to establish selection criteria.

METHODS

A matched-case comparison was designed for the NACT group (n=707) and primary surgery treatment (PST; n=707) group to investigate short-term responses and high/intermediate risk factors (HRFs/IRFs). The 5-year disease-free survival (DFS) and overall survival (OS) rates were stratified by NACT response, HRFs/IRFs, International Federation of Gynecology and Obstetrics (FIGO) stage and tumour size, respectively.

RESULTS

The clinical and pathological response rates were 79.3% and 14.9% in the NACT group. In comparison to the PST group, IRFs but not HRFs were significantly decreased (P<0.05), and the 5-year DFS rate was significantly improved in the NACT group (88.4% versus 83.1%, P=0.021). Moreover, the 5-year DFS and OS rates were favourably increased in the clinical responders in comparison to the PST group and the clinical non-responders (P<0.05). Compared to those of clinical non-responders, the 5-year DFS and OS rates of clinical responders, with or without HRFs, were also significantly increased (P<0.01). In stage IB2, the 5-year DFS and OS rates were significantly increased, whereas operation duration declined in the NACT group (P<0.05). For patients with stage IB tumours of 2-5 cm, the 5-year DFS and OS rates of clinical responders were significantly improved (P<0.05).

CONCLUSIONS

NACT is a suitable option for patients with cervical cancer, especially for NACT responders and patients with stage IB, which provides a new concept of fertility preservation for young patients.

A prospective randomized controlled study on multiple neoadjuvant treatments for patients with stage IB2 to IIA cervical cancer

OBJECTIVE

Patients with stage IB2 to IIA cervical cancer have a poor survival regardless of what primary treatment is performed. We conducted a study to demonstrate whether neoadjuvant treatment could offer survival benefits to those patients.

METHODS

Between January 2006 and December 2009, 123 patients with stage IB2 to IIA cervical cancer were enrolled and randomly assigned to receive 1 of the following 4 treatments: radical surgery alone (arm RS), brachytherapy with a total dose of 15Gy to point A followed by radical surgery (arm BT), intravenous chemotherapy with cisplatin 50 mg/m plus 5-fluorouracil 750 mg/m at a 2-week interval for 2 courses followed by radical surgery (arm IVCT), or intra-arterial chemotherapy with the same regimen as the IVCT arm followed by radical surgery (arm IACT). Two weeks after neoadjuvant treatment, all patients underwent evaluation for response and operability. Those who were not amenable to surgery received concurrent chemoradiotherapy.

RESULTS

With a mean follow-up of 34.8 months, 120 patients were evaluable. Baseline characteristics were similarly distributed in the 4 arms. Clinical overall response rates were 61.3%, 42.9%, and 79.3% in the BT, IVCT, and IACT groups, respectively. Two patients achieved pathological complete response. Three-year progression-free survival rates were 70.7%, 66.3%, 81.5%, and 79.7% in the RS, BT, IVCT, and IACT arms, respectively (P = 0.354). Three-year overall survival was 73.3%, 68.3%, 82.9% and 80.4%, respectively (P = 0.431). Multivariate analysis showed that only lymph node status correlated with progression-free survival.

CONCLUSIONS

Neoadjuvant treatment had no significant impact on the outcomes of patients with stage IB2 to IIA cervical cancer.