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

The Added Value of Apparent Diffusion Coefficient and Histogram Analysis in Assessing Treatment Response of Locally Advanced Cervical Cancer

OBJECTIVE

The aim of the study is to assess the diagnostic performance of quantitative analysis of diffusion-weighted imaging in assessing treatment response in cervical cancer patients.

METHODS

A retrospective analysis was done for 50 patients with locally advanced cervical cancer who received concurrent chemoradiotherapy and underwent magnetic resonance imaging and diffusion-weighted imaging. Treatment response was classified into 4 categories according to RECIST criteria 6 months after therapy completion. Apparent diffusion coefficient (ADC) values were measured using both region of interest (ROI) ADC and whole lesion (WL) ADC histogram for all cases at both baseline pretreatment and posttreatment Magnetic resonance imaging studies. Changes in ADC values were calculated and compared between groups.

RESULTS

The percentage change of ROI-ADCmean at a cutoff value of >20 had excellent discrimination of responders versus nonresponders, while the percentage change of WL-ADCmean, ADCmin, and ADCmax at cutoff values of >12.5, >35.8, and > 19.6 had acceptable discrimination of responders versus nonresponders. Logistic regression analysis revealed that only baseline WL ADCmin was a statistically significant independent predictor of response. Cancer cervix patients with baseline ADCmin < or equal to 0.73 have 12.1 times higher odds of exhibiting a response.

CONCLUSIONS

The percentage change of ROI-ADCmean and WL histogram ADCmean values after concurrent chemoradiotherapy can predict response. Pretreatment WL histogram ADCmin was a statistically significant independent predictor of posttherapy response.

Surgery-based radiation-free multimodality treatment for locally advanced cervical cancer

The current review described a 55-year woman using 28 months to finish her surgery-based radiation-free multimodality treatment journey to fight International Federation of Gynaecology & Obstetrics (FIGO) 2018 clinical stage IIA2 (cT2aN0M0) squamous cell carcinoma (SCC) of the cervix. She received six cycles of perioperative adjuvant therapy, including three cycles of neoadjuvant therapy (NAT) and three cycles of postoperative adjuvant therapy by using combination of dose-dense chemotherapy (CT, weekly paclitaxel 80 mg/m2+triweekly cisplatin 40 mg/m2), immunotherapy (IO, triweekly pembrolizumab 200 mg) and half-dose anti-angiogenic agent (triweekly bevacizumab 7.5 mg/kg) plus interval radical surgery (radical hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + para-aortic lymph node sampling) and following maintenance therapy with monthly 22 cycles of half-dose of IO (pembrolizumab 100 mg) and concomitant 4 cycles of single-agent CT (paclitaxel 175 mg/m2) and 18 cycles of half-dose anti-angiogenic agent (bevacizumab 7.5 mg/kg). During the cervical SCC fighting journey, two unwanted adverse events (AEs) occurred. One was pseudo-progressive disease during the NAT treatment and pathology-confirmed upgrading FIGO stage IIIC1p (ypT2a1N1M0) after radical surgery and the other was the occurrence of hypothyroidism during the post operative adjuvant therapy. Based on this case we presented, we review the recent trend in the management of women with locally advanced cervical cancer (LACC) using the radiation-free but surgery-based multimodality strategy and highlight the strengths and limitations about perioperative adjuvant therapy with dose-dense CT + IO + half-dose anti-angiogenic agent and maintenance treatment of half-dose IO combining with short-term single agent CT and following long-term half-dose anti-angiogenic agent. All underscore the possibility that women with LACC have an opportunity to receive surgery-based RT-free multi-modality strategy to manage their diseases with satisfactory results. Additionally, the evolving role of IO plus CT with/without anti-angiogenic agent functioning as either primary treatment or adjuvant therapy for the treatment of advanced CC has been in process continuously. Moreover, the patient's positive response to IO, pembrolizumab as an example, both during the primary and maintenance therapy, highlights the importance of integrating IO into CT regimens for CC, especially in cases where conventional therapies, RT as an example, are insufficient or who do not want to receive RT-based treatment. The sustained disease-free status of the patient over several years reinforces the potential of IO to significantly increase long-term survival outcomes in CC patients, particularly for those with LACC.

Meta-analysis of the efficacy of neoadjuvant chemotherapy for locally advanced cervical cancer

BACKGROUND

Neither improvements in surgical techniques and methods nor advances in radiotherapy equipment and techniques have significantly improved cervical cancer survival rates for quite some time.

AIM

By comparing the effectiveness of neoadjuvant chemotherapy in the treatment of locally advanced cervical cancer, this study aimed to explore effective treatment methods for locally advanced cervical cancer, and provide a theoretical basis to guide clinical practice.

METHODS

A search of PubMed, Embase, Scopus, Web of Science and Cochrane databases was undertaken to identify randomized controlled trials on the efficacy of neoadjuvant chemotherapy for locally advanced cervical cancer, where the intervention in the experimental group was neoadjuvant chemotherapy. Based on the inclusion and exclusion criteria, the studies were evaluated for quality according to the Cochrane Quality Rating Scale. Baseline information, intervention information and outcome indicators of the included studies were extracted. Meta-analysis was performed using RevMan 5.4.

RESULTS

Significant differences in overall survival [relative risk (RR) 1.63, 95 % confidence interval (CI) 0.69-2.57; p = 0.0007] and complete remission rate (RR 0.37, 95 % CI -0.49 to 1.23; p = 0.041) were found between the two groups. Heterogeneity of the objective response rate showed p < 0.0001 and I2 = 99 % (I2 = 99 > 50 % and p > 0.1 for the Q-test suggested strong heterogeneity). The fixed effects model was chosen for the integration statistic [standardized mean difference (SMD) 0.81, 95 % CI -0.21 to 1.83; p = 0.12]; the difference was not significant (p > 0.05). Heterogeneity of the adverse effects of neoadjuvant chemotherapy showed p < 0.0001 and I2 = 98 % (I2 = 98 %>50 % and p > 0.1 for the Q-test suggested strong heterogeneity). The fixed effects model was chosen for the integration statistic (SMD -0.023, 95 % CI -0.95 to 0.49; p = 0.53); the difference was not significant (p > 0.05).

CONCLUSIONS

The use of neoadjuvant chemotherapy for the treatment of locally advanced cervical cancer improved the objective response rate and the complete remission rate of patients, but failed to improve overall survival and adverse effects.

Nodal staging score for adequacy of nodal staging in cervical cancer

Background

Cervical cancer remains the fourth most common female malignancy with increasing newly cases around the world. It is of clinical value to precisely evaluate whether false negative nodal existed and develop a nodal staging model in cervical cancer.

Materials and methods

Clinical data of cervical cancer patients was retrieved from the Surveillance, Epidemiology, and End Results database. Probability of missing nodal disease and nodal staging score (NSS) was computed to assess the nodal status of each individual.Prognostic value of NSS was assessed.

Results

A total of 9056 individuals were in this study, with 5115 squamous cell carcinoma, 2791 adenocarcinoma, 512 adenosquamous carcinoma, and 638 other type individuals. A beta-binomial model was used to compute the probability of nodal disease in four histological types, respectively. False negative probability drastically decreased as more nodes examined. To reach 0.05 of false negative probability, it required at least 17 lymph nodes in squamous cell carcinoma patients,18 in adenocarcinoma, 12 in adenosquamous carcinoma patients and 14 in other types. To reach 0.95 of NSS, it took 10 lymph nodes in squamous cell carcinoma, 6 in adenocarcinoma, 10 in adenosquamous carcinoma and 7 in other types. Significant prognostic values of NSS quartiles subsets were found in all four histological sets.

Conclusion

NSS tool enables adequate nodal staging of cervical cancer with significant prognostic value. Exact number of lymph nodes required for surgery in cervical cancer is specified based on histologic type.

The prognostic value of radiological and pathological lymph node status in patients with cervical cancer who underwent neoadjuvant chemotherapy and followed hysterectomy

To investigate the prognostic value of lymph node status in patients with cervical cancer (CC) patients who underwent neoadjuvant chemotherapy (NACT) and followed hysterectomy. Patients in two referral centers were retrospectively analyzed. The baseline tumor size and radiological lymph node status (LNr) were evaluated on pre-NACT MRI. Tumor histology, differentiation and pathological lymph node status (LNp) were obtained from post-operative specimen. The log-rank test was used to compare survival between patient groups. Cox proportional hazards regression models were employed to estimate the hazard ratio (HR) of various factors with progression-free survival (PFS) and overall survival (OS). A total of 266 patients were included. Patients with 2018 FIGO IIIC showed worse PFS compared to those with FIGO IB-IIB (p < 0.001). The response rate in patients with LNp(-) was 64.1% (134/209), significantly higher than that of 45.6% (26/57) in patients with LNp( +) (p = 0.011). Multivariate Cox analysis identified the main independent predictors of PFS as LNp( +) (HR = 3.777; 95% CI 1.715-8.319), non-SCC (HR = 2.956; 95% CI 1.297-6.736), poor differentiation (HR = 2.370; 95% CI 1.130-4.970) and adjuvant radiation (HR = 3.266; 95% CI 1.183-9.019). The interaction between LNr and LNp regarding PFS were significant both for univariate and multivariate (P = 0.000171 and 1.5357e-7 respectively). In patients with LNr( +), a significant difference in PFS was observed between patients with LNp(-) and LNp( +) (p = 0.0027). CC patients with FIGO 2018 stage IIIC who underwent NACT and followed hysterectomy had worse PFS compared to those with IB-IIB. LNp( +), non-SCC, poor differentiation and adjuvant radiation were independent risk factors for PFS. The adverse prognostic value of LNp( +) was more significant in patients with LNr( +).

Neoadjuvant chemotherapy plus camrelizumab for locally advanced cervical cancer (NACI study): a multicentre, single-arm, phase 2 trial

BACKGROUND

Locally advanced cervical cancer constitutes around 37% of cervical cancer cases globally and has a poor prognosis due to limited therapeutic options. Immune checkpoint inhibitors in the neoadjuvant setting could address these challenges. We aimed to investigate the efficacy and safety of neoadjuvant chemo-immunotherapy for locally advanced cervical cancer.

METHODS

In this single-arm, phase 2 trial, which was done across eight tertiary hospitals in China, we enrolled patients aged 18-70 years with untreated cervical cancer (IB3, IIA2, or IIB/IIIC1r with a tumour diameter ≥4 cm [International Federation of Gynecology and Obstetrics, 2018]) and an Eastern Cooperative Oncology Group performance status of 0 or 1. Eligible patients underwent one cycle of priming doublet chemotherapy (75-80 mg/m2 cisplatin, intravenously, plus 260 mg/m2 nab-paclitaxel, intravenously), followed by two cycles of a combination of chemotherapy (cisplatin plus nab-paclitaxel) on day 1 with camrelizumab (200 mg, intravenously) on day 2, with a 3-week interval between treatment cycles. Patients with stable disease or progressive disease received concurrent chemoradiotherapy, and patients with a complete response or partial response proceeded to radical surgery. The primary endpoint was the objective response rate, by independent central reviewer according to Response Evaluation Criteria in Solid Tumours, version 1.1. Activity and safety were analysed in patients who received at least one dose of camrelizumab. This study is registered with ClinicalTrials.gov, NCT04516616, and is ongoing.

FINDINGS

Between Dec 1, 2020, and Feb 10, 2023, 85 patients were enrolled and all received at least one dose of camrelizumab. Median age was 51 years (IQR 46-57) and no data on race or ethnicity were collected. At data cutoff (April 30, 2023), median follow-up was 11·0 months (IQR 6·0-14·5). An objective response was noted in 83 (98% [95% CI 92-100]) patients, including 16 (19%) patients who had a complete response and 67 (79%) who had a partial response. The most common grade 3-4 treatment-related adverse events during neoadjuvant chemo-immunotherapy were lymphopenia (21 [25%] of 85), neutropenia (ten [12%]), and leukopenia (seven [8%]). No serious adverse events or treatment-related deaths occurred.

INTERPRETATION

Neoadjuvant chemo-immunotherapy showed promising antitumour activity and a manageable adverse event profile in patients with locally advanced cervical cancer. The combination of neoadjuvant chemo-immunotherapy with radical surgery holds potential as a novel therapeutic approach for locally advanced cervical cancer.

FUNDING

National Key Technology Research and Development Program of China and the National Clinical Research Center of Obstetrics and Gynecology.

Efficacy of high-dose-rate brachytherapy with different radiation source activities among cervical cancer patients and risk factors for long-term outcomes: A 6-year retrospective study

PURPOSE

This study aimed to assess the impact of dose rates due to natural decay of Iridium-192 sources and the risk factors of clinical outcomes for cervical cancer patients treated with high-dose-rate (HDR) brachytherapy.

METHODS AND MATERIALS

Four ninety-four patients were divided into relatively-high-radioactive (rHR), relatively-medium-radioactive (rMR), and relatively-low-radioactive (rLR) groups for retrospective treatment response comparison. The short-term outcomes were evaluated using the 1-month /3-month follow-up results based on RECIST 1.1. Local recurrence-free survival (LRFS) and metastatic recurrence-free survival (MRFS) were selected as long-term outcomes. A class of transformation models with adaptive lasso was applied to assess the risk factors of long-term outcomes.

RESULTS

No significant difference was identified in short- or long-term outcomes of different radioactive groups. Subgroup analyses demonstrated similar findings. In multivariate factor analysis, advanced stage was significantly associated with higher risk of local recurrence and metastatic recurrence (HR = 1.66, 95%confidence interval [CI] = 1.14-2.43, p = 0.008; HR = 1.57, 95%CI = 1.23-2.00, p < 0.001). Significant associations were observed between local recurrence and pathology, and between metastatic recurrence and pre-treatment serum indices, respectively (HR = 8.62, 95%CI = 2.28-32.60, p = 0.002; HR = 1.98, 95%CI=1.20-2.26, p = 0.008).

CONCLUSIONS

Overall, there was no significant difference in long- or short-term efficacy of the HDR brachytherapy among the groups with different levels of activity of radiation sources. Stage, pathology, and pretreatment serum indices were crucial factors that affected the long-term outcomes.

Neoadjuvant Chemotherapy plus Radical Surgery in Locally Advanced Cervical Cancer: Retrospective Single-Center Study

BACKGROUND

Several pretreatment variables have been found to correlate with the clinical outcome of patients treated with NACT plus radical hysterectomy, such as FIGO stage, tumor size, and lymph node status.

METHODS

A single-center retrospective observational study to evaluate the use of NACT in LACC, particularly in the lymph-node-positive subpopulation. The study, conducted at the Maternal and Child Department of "Cannizzaro Hospital" in Catania, included patients treated between 2009 and 2019. Multivariate analysis was performed to analyze responses to NACT according to clinicopathologic parameters. Kaplan-Meyer disease-free survival (DFS) and overall survival (OS) curves were generated according to different lymph node status subgroups.

RESULTS

A total of 151 consecutive patients were enrolled in the study. Significant independent risk factors for response to NACT were preoperative tumor diameter, parametrium involvement, and lymphoma vascular space invasion (LVSI). T initial diameter at NMR was found to be the independent prognostic predictor for general (p = 0.024) and lymph node (LND) response (p = 0.028). Tumors between 2 and 6 cm have a better response to NACT than tumors > 6 cm, and LVSI absence was an independent prognostic factor for LND response to NACT. Survival DFS and OS curves were significant for positive vs. negative pathologic LND.

CONCLUSIONS

Neoadjuvant chemotherapy followed by surgery cannot be considered a standard of care in patients with locally advanced cervical cancer, particularly in the subgroup with pre-NACT imaging suspected for LND metastases.

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.

The long-term outcomes of clinical responders to neoadjuvant chemotherapy followed by radical surgery in locally advanced cervical cancer

OBJECTIVE

To compare the long-term oncological outcome of neoadjuvant chemotherapy before radical surgery (NCRS) and definitive chemoradiotherapy (DR) for stage IB2 and IIA2 cervical squamous cell carcinoma.

METHODS

The clinical outcome of 480 patients with stage IB2 and IIA2 cervical cancer (308 clinical responders, 111 clinical non-responders, 61 unclear) who underwent NCRS (and subgroup assessments) were compared with those of 233 patients who underwent DR.

RESULTS

The clinical response rate was 73.5% in the NCRS group. Multivariate COX regression analyses revealed that NCRS was not correlated with the 5-year overall survival (OS) rate (p = 0.067) or disease-free survival (DFS) rate (p = 0.249). In a subgroup of NCRS, the clinical response group was also shown to be a protective independent factor of 5 year OS rate compared to the DR group (aHR, 0.403; 95% CI, 0.209-0.777), but had no correlation with the 5 year DFS rate (p = 0.089). On the other hand, the clinical non-response group had no correlation with the 5 year OS rate (p = 0.780) or DFS rate (p = 0.669).

CONCLUSION

Clinical responders who underwent NCRS exhibited a better oncological outcome compared to those who underwent DR. International Clinical Trials Registry Platform Search Port, http://apps.who.int/trialsearch/ ; CHiCTR1800017778.

Cemiplimab as Second-Line Therapy for Patients with Recurrent Cervical Cancer: A United States-based Cost-effectiveness Analysis

INTRODUCTION

The efficacy of cemiplimab in recurrent cervical cancer has been demonstrated in the clinical trial EMPOWER-Cervical 1. However, its high price makes patients and clinicians hesitate to use it. Therefore, we designed a study to evaluate its cost-effectiveness.

METHODS

We developed a Markov model based on phase III clinical trials to calculate the cost, life years (LYs), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) over 20 years with a willingness-to-pay (WTP) threshold of $150,000/QALY. The economic data included were obtained from official US government websites and published literature. Sensitivity analysis was used to determine the uncertainties associated with the model, and a subgroup analysis was performed.

RESULTS

Compared with chemotherapy, cemiplimab produced an additional 0.597 QALYs (0.751 LYs), resulting in an ICER of $111,211.471/QALY in the United States. The cost of cemiplimab is the most influential factor in the model. The results of these models were robust in all sensitivity analyses. From the American public payers' perspective, subgroup analysis showed cemiplimab was a cost-effective regimen in patients with squamous cell carcinoma, adenocarcinoma, or programmed cell death ligand 1 (PD-L1) ≥ 1%.

CONCLUSION

From the American public payers' perspective, cemiplimab is a cost-effective treatment option for second-line treatment of recurrent cervical cancer. Meanwhile, cemiplimab was a cost-effective treatment for patients with PD-L1 ≥ 1 and all histological types.

MRI Texture Analysis for Preoperative Prediction of Lymph Node Metastasis in Patients with Nonsquamous Cell Cervical Carcinoma

RATIONALE AND OBJECTIVES

To preoperatively predict lymph node metastasis (LNM) in patients with cervical nonsquamous cell carcinoma (non-SCC) based on magnetic resonance imaging (MRI) texture analysis.

MATERIALS AND METHODS

This retrospective study included 104 consecutive patients (mean age of 47.2 ± 11.3 years) with stage IB-IIA cervical non-SCC. According to the ratio of 7:3, 72, and 32 patients were randomly divided into the training and testing cohorts. A total of 272 original features were extracted. In the process of feature selection, features with intraclass correlation coefficients (ICCs) less than 0.8 were eliminated. The Pearson correlation coefficient (PCC) and analysis of variance (ANOVA) were applied to reduce redundancy, overfitting, and selection biases. Further, a support vector machine (SVM) with linear kernel function was applied to select the optimal feature set with a high discrimination power.

RESULTS

The T2WI + DWI-based, T2WI + DWI + CE-T1WI-based and T2WI + DWI + LNS-MRI (LN status on MRI)-based SVM models yielded an AUC and accuracy of 0.78 and 0.79; 0.79 and 0.69; 0.79 and 0.81 for predicting LNM in the training cohort, and 0.82 and 0.78; 0.82 and 0.69; 0.79 and 0.72 in the testing cohort. The T2WI + DWI-based, T2WI + DWI + CE-T1WI-based and T2WI + DWI + LNS-MRI-based SVM models performed better than morphologic criteria of LNS-MRI and yield similar discrimination abilities in predicting LNM in the training and testing cohorts (all p-value > 0.05). In addition, the T2WI + DWI-based and T2WI + DWI + LNS-MRI-based SVM models showed robust performance in the AC and ASC subgroups (all p-value > 0.05).

CONCLUSION

The T2WI + DWI-based, T2WI + DWI + CE-T1WI-based and T2WI+DWI+LNS-MRI-based SVM models showed similar good discrimination ability and performed better than the morphologic criteria of LNS-MRI in predicting LNM in patients with cervical non-SCC. The inclusion of the CE-T1WI sequence and morphologic criteria of LNS-MRI did not significantly improve the performance of the T2WI + DWI-based model. The T2WI + DWI-based and T2WI + DWI + LNS-MRI-based SVM models showed robust performance in the subgroup analysis.

Neoadjuvant chemotherapy followed by surgery in cervical cancer: past, present and future

BACKGROUND

Cisplatin-based concurrent chemoradiation is the standard treatment for locally advanced cervical cancer. In view of the difficulties associated with implementation of standard radiation protocols in low- and middle-income countries and the associated toxicities of chemoradiation, neoadjuvant chemotherapy followed by surgery has been tried as an alternative treatment for locally advanced cervical cancer.

METHODS

A comprehensive review was undertaken of the existing literature, caveats and potential avenues of neoadjuvant chemotherapy followed by surgery compared with chemoradiation in locally advanced cervical cancer.

RESULTS

Randomized studies conducted in the pre-chemoradiation era comparing neoadjuvant chemotherapy followed by surgery with definitive radiotherapy alone showed favorable outcomes with the chemo-surgical approach. However, contemporary studies evaluating the role of neoadjuvant chemotherapy followed by surgery have failed to establish this approach as the standard. About 25-30% of patients who undergo neoadjuvant chemotherapy remain inoperable and require definitive chemoradiation. A similar proportion of patients would require adjuvant (chemo)radiation after neoadjuvant chemotherapy followed by surgery, resulting in excessive morbidity. Evaluation of time trends across the past few decades reveals that the advancements in delivery of radiation (external beam and brachytherapy) have translated into improvement in outcomes for locally advanced cervical cancer, while a similar trend was not observed for surgery or chemotherapy.

CONCLUSION

Neoadjuvant chemotherapy followed by surgery cannot be considered a standard of care in patients with locally advanced cervical cancer. This approach needs further clinical research to generate robust high-quality evidence especially for the sub-sets that might potentially benefit in terms of survival, toxicity and quality of life, against the gold standard treatment of concomitant chemoradiation.

Neoadjuvant Chemotherapy Prior Fertility-Sparing Surgery in Women with FIGO 2018 Stage IB2 Cervical Cancer: A Systematic Review

Simple Summary

In order to provide our contribution to the knowledge of women affected by IB2 cervical cancer, who wish to preserve fertility, we revised and updated the available literature in the debated issue of neoadjuvant chemotherapy prior to fertility-sparing treatment. The effectiveness of preoperative chemotherapy in tumors larger than 2 cm virtually proposes a conservative opportunity to a broader group of women, while keeping low, and hopefully absent, the risk of local and distant relapse. Available studies of neoadjuvant chemotherapy to the fertility-sparing approach have shown that a suboptimal response at surgery seems to be an independent prognostic factor in poorer survival, and, therefore, the careful selection of patients and the surgical approach after neoadjuvant chemotherapy remains crucial. Finally, we proposed an algorithm to be helpful in the decision-making process of that subgroup of patients.

Abstract

Nowadays, the optimal management of patients with cervical cancers measuring 2–4 cm desiring to maintain fertility is still uncertain. In this systematic review, we assessed the reliability of neoadjuvant chemotherapy (NACT) prior to fertility-sparing (FS) surgery in International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IB2 cervical cancer, in terms of pathologic response, oncological and obstetric outcomes. The review of the literature was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data, using MEDLINE and PubMed, were searched for from 1 January 2005 up to 1 December 2020. We identified 20 articles and 114 women with IB2 disease, possible candidates for NACT prior to FS surgery. However, uterine conservation was achieved only in 76.7% of them. Patients reached optimal pathological response to NACT in 60.9% of cases and a TIP (cisplatin, ifosfamide and paclitaxel) regime was related to the best response. Suboptimal response to NACT appeared to be an independent negative prognostic factor. Up to 9.2% of patients recurred with a median 7.4-months DFS, and 4.6% of patients died of disease. Fifty percent of women tried to conceive after treatment and NACT prior to conization appeared to be the most promising alternative to upfront radical trachelectomy in terms of obstetric outcomes. In conclusion, NACT prior to FS surgery is an option, but the literature about this issue is still weak and FS should be carefully discussed with patients.

The Outcome of Locally Advanced Cervical Cancer in Patients Treated with Neoadjuvant Chemotherapy Followed by Radical Hysterectomy and Primary Surgery

Background:

In recent years, before radical hysterectomy, neoadjuvant chemotherapy (NACT) has been administered to patients with locally advanced cervical cancer to shrink large tumors. It has been reported that this treatment significantly reduces the need for radiotherapy after surgery. The current study aimed to assess the outcome (survival, recurrence, and the need for adjuvant radiotherapy) of locally advanced cervical cancer in patients treated with NACT followed by radical hysterectomy and primary surgery.

Methods:

In a retrospective cohort study, the records of 258 patients with cervical cancer (stage IB2, IIA, or IIB), who referred to Imam Khomeini Hospital (Tehran, Iran) from 2007 to 2017 were evaluated. The patients were assigned into two groups; group A (n=58) included patients, who underwent radical hysterectomy and group B (n=44) included those, who underwent a radical hysterectomy after NACT. The outcome measures were the recurrence rate, five-year survival rate, and the need for adjuvant radiotherapy.

Results:

The median for overall survival time in group A and B was 113.65 and 112.88 months, respectively (P=0.970). There was no recurrence among patients with stage IB2 cervical cancer in group B, while the recurrence rate in group A was 19.5% with a median recurrence time of 59.13 months. Lymph node involvement was the only factor that affected patients’ survival. The need for postoperative adjuvant radiotherapy in group B was lower than in group A (P=0.002).

Conclusion:

NACT before the hysterectomy was found to reduce the need for postoperative radiotherapy in patients with locally advanced cervical cancer according to disease stages. As a direct result, adverse side effects and the recurrence rate were reduced, and the overall survival rate of patients with stage IIB cervical cancer was increased.

Whole-tumor histogram analysis of apparent diffusion coefficient for differentiating adenosquamous carcinoma and adenocarcinoma from squamous cell carcinoma in patients with cervical cancer

BACKGROUND

Differentiating adenosquamous carcinoma (ASC) and adenocarcinoma (AC) from squamous cell carcinoma (SCC) precisely is crucial for treatment strategy and prognosis prediction in patients with cervical cancer (CC).

PURPOSE

To differentiate ASC and AC from SCC in patients with CC using the apparent diffusion coefficient (ADC) histogram analysis.

MATERIAL AND METHODS

A total of 118 patients with histologically diagnosed ASC, AC, and SCC were included. The ADC histogram parameters were extracted from ADC maps. Receiver operating characteristic analysis was performed to evaluate the diagnostic performance of each ADC histogram parameter in differentiating the subtypes of CC. The predictors for histologic subtypes were further selected using univariate and multivariate logistic regression analyses.

RESULTS

The ADC_mean, ADC_max, ADC_P10, ADC_P25, ADC_P75, ADC_P90, ADC_median, and ADC_mode of the ASC were significantly lower than those of the AC; and ADC_kurtosis and ADC_skewness of the ASC were lower than those of the SCC. The ADC_mean, ADC_max, ADC_P10, ADC_P25, ADC_P75, ADC_P90, ADC_median, and ADC_mode of AC were significantly higher than those of the SCC. The ADC_P10 and ADC_P10 + diameter yielded the AUCs of 0.753 and 0.778 in differentiating ASC from AC. The ADC_median and ADC_median + diameter yielded the AUCs of 0.807 and 0.838 in differentiating AC from SCC. The ADC_skewness yielded the AUC of 0.713 in differentiating ASC from SCC.

CONCLUSION

The ADC_P10 and ADC_P10 + diameter, ADC_median, and ADC_median + diameter performed well in differentiating ASC from AC and AC from SCC, respectively. However, ADC_skewness exhibited a limited ability in differentiating ASC from SCC.

Neoadjuvant chemotherapy increases the 5-year overall survival of patients with resectable cervical cancer: A systematic review and meta-analysis

Cervical cancer is a global health challenge in women. Neoadjuvant chemotherapy (NACT) is a recent prospect for alternative cervical cancer treatments. This study investigated the efficacy of NACT against resectable cervical cancer based on the medium and long-term survival of patients with the disease. We searched through PubMed, Web of Science, EBSCO and Cochrane Library for relevant reports published by June 2020. The primary outcomes were 3-year and 5-year progression-free survival (PFS) and overall survival (OS) of patients with resectable cervical cancer. Overall, 22 publications encompassing 5627 patients fulfilled the inclusion criteria. We found NACT not to affect both 3-year PFS and OS as well as 5-year PFS of patients with resectable cervical cancer. However, NACT significantly improves the 5-year OS of patients with resectable cervical cancer (HR = 0.83, 95% CI: 0.73-0.94, p = 0.013). Subgroup analysis (RCTs, non-RCTs, NACT + surgery + AT vs. surgery + AT, NACT + surgery + AT vs. CCRT/RT/CRT) further revealed NACT had no significant effect on 5-year PFS of patients with resectable cervical cancer, converse to the 5-year OS subgroup analysis, which validated the beneficial effect of NACT in patients with resectable cervical cancer. In addition, the effect of NACT was most significant in the non-RCTs subgroup (p = 0.012). NACT may improve the long-term prognosis of patients with resectable cervical cancer. However, further large-scale multicenter studies are needed to validate this finding.

Optimal treatment in locally advanced cervical cancer

Introduction: Locally advanced cervical cancer (LACC) (International Federation of Gynecology and Obstetrics (FIGO) 2009/2018 - stages IB2-IVA/IB3-IVA, respectively) is treated using a multimodal approach that includes chemoradiotherapy followed by brachytherapy.Areas covered: This review provides an overview of the progress made over the past decade in the treatment of LACC. Prognostic factors, FIGO classification and the role of imaging staging will be discussed. Efficacy of external-beam radiotherapy, brachytherapy and chemotherapy will be detailed. Indications for para-aortic staging lymphadenectomy and adjuvant hysterectomy, as well as follow-up and special population, will be covered.Expert opinion: The initial workup is one of the most crucial steps in the optimal care of patients, which should be realized by a multidisciplinary expert team. With the implementation of modern conformal radiotherapy techniques, the local control rate has been optimized. Nevertheless, 40% of patients experience recurrence with distant metastasis and a dismal prognosis. Currently, a clear benefit of neo- and adjuvant chemotherapy has not been established. The future likely involves (1) improved selection of patients for whom treatment intensification is justified, (2) a combination of new drugs with chemoradiation that are currently being tested in trials, and (3) the development of tailored treatment based on molecular characteristics.

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.

Epidemiological guideline influence on the therapeutic trend and patient outcome of uterine cervical cancer in Japan: Japan society of gynecologic oncology guideline evaluation committee project

OBJECTIVE

The Japan Society of Gynecologic Oncology published its first clinical guidelines for uterine cervical cancer in 2007 which has been revised twice in 2011 and 2017. The aim of this study was to investigate the influence of the first guideline publication on the therapeutic trend and patient outcome by analyzing uterine cervical cancer cases registered to the cancer registry organized by the Japan Society of Obstetrics and Gynecology.

METHODS

Data of uterine cervical cancer cases registered to the cancer registry from 2000 to 2012 were provided. Epidemiological and clinical trend were analyzed by the Chi-squared test with subsequent standardized residual analysis. Overall survival among the patients registered between 2004 and 2009 was analyzed using the Fine and Gray competing risk model.

RESULTS

68,707 cases were registered during the study period. A trend analysis revealed that the guideline publication may have led to a decrease in neoadjuvant chemotherapy in parallel with an increase in radiation therapy mainly in stage II and III patients undergoing primary treatment. A survival analysis indicated that the introduction of the guideline may have improved overall survival among stage III uterine cervical cancer patients, even though a significant difference was not observed in all of the cases.

CONCLUSIONS

This study demonstrated the potential influence of the guideline publication on the clinical trend and patient outcome. As this is the first assessment of the guideline for uterine cervical cancer in Japan, continuous evaluation is necessary to further comprehend the significance of this guideline.

CCDC7 Activates Interleukin-6 and Vascular Endothelial Growth Factor to Promote Proliferation via the JAK-STAT3 Pathway in Cervical Cancer Cells

Objective

Tumor growth is one of the most lethal attributes of human malignancy. The expression of CCDC7, a novel gene which has multiple functions, has been shown to be associated with tumor growth and poor prognosis in patients with cancer. However, the specific functions of CCDC7 remain unclear. Here, we investigated the molecular mechanisms underlying the effects of CCDC7 on proliferation in cervical cancer.

Materials and Methods

The MTT and EdU assays were performed to evaluate the function of CCDC7. The immunohistochemical, quantitative real-time PCR (qRT-PCR), ELISA and Western blot assay were used to detect the gene and protein expression in tissues and cells. A xenograft test was conducted to detect the impact of CCDC7 on tumor development in vivo .

Results

In immunohistochemical analysis of 193 cases, normal cervical tissue and cervical cancer tissue show that CCDC7 expression is closely correlated with the development of cervical cancer and was positively correlated with the clinical stage and histological grade. Overexpression or knockdown of CCDC7 affected cell proliferation in cervical cancer cells in vitro. In a nude mouse xenograft model in vivo, knockdown of CCDC7 inhibited cell proliferation and tumor growth. Furthermore, CCDC7 overexpression upregulated interleukin (IL)-6 and vascular endothelial growth factor (VEGF) at mRNA and protein levels, and treatment with recombinant IL-6 or VEGF proteins also increased CCDC7 expression. In a case set of 80 patients with cervical cancer, we found that CCDC7, IL-6, and VEGF affected patient prognosis. Finally, inhibition of various signaling pathways using specific inhibitors indicated that CCDC7 blocked the decrease in cell proliferation observed following suppression of the JAK-STAT3 pathway, suggesting that CCDC7 functioned via this critical signaling network.

Conclusion

Those findings indicated that CCDC7 may be a novel target for the treatment of cervical cancer and may have applications as a predictive marker for tumor growth in cervical carcinoma.

Management of Stage IIB Cervical Cancer: an Overview of the Current Evidence

PURPOSE OF REVIEW

To review and discuss the present evidence of surgery- and radiation-based treatment strategies for stage IIB cervical cancer.

RECENT FINDINGS

Recently, two randomized controlled trials compared the efficacy of neoadjuvant chemotherapy followed by radical hysterectomy (NACT + RH) with that of concurrent chemoradiotherapy (CCRT) for stage IB3-IIB cervical cancer. When these studies were combined (N = 1259), NACT + RH was associated with a shorter disease-free survival [hazard ratio (HR) 1.36, 95% confidence interval (CI) 1.13-1.64], but with a similar overall survival (HR 1.11, 95% CI 0.90-1.36) when compared with the findings for CCRT. Stage-specific analysis for stage IIB cervical cancer demonstrated that disease-free survival was significantly worse with NACT + RH than with CCRT (HR 1.90, 95% CI 1.25-2.89); however, no significant difference was observed for stage IB3-IIA cervical cancer. Based on the results of recent level I evidence, the standard treatment for stage IIB cervical cancer remains CCRT.

Combined dynamic DCE-MRI and diffusion-weighted imaging to evaluate the effect of neoadjuvant chemotherapy in cervical cancer

PURPOSE

To prospectively investigate changes in quantitative parameters of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and the apparent diffusion coefficient (ADC) of diffusion-weighted imaging (DWI) in patients with cervical cancer before and after neoadjuvant chemotherapy (NACT).

METHODS

Thirty-eight patients with cervical cancer underwent DCE-MRI and DWI 1 week before and 4 weeks after NACT. The patients were classified into 2 groups: significant reaction (sCR) group and the non-sCR group. DCE-MRI parameters and ADC values were measured and compared between the 2 groups.

RESULTS

Before NACT, the mean K^trans value was higher, but the mean V_e was lower, in the sCR group compared with the non-sCR group; these differences were statistically significant (p<0.05). After NACT, the mean K^trans value and the delta (i.e., changed) value of K^trans were significantly lower in the sCR group compared with the non-sCR group (p<0.05). However, the mean ADC and the delta value of the mean ADC between the 2 groups were slightly higher in the sCR group compared with the non-sCR group (p<0.05). The area under the curve of pre-mean K^trans, DK^trans, and pre-mean K^trans combined with post-mean ADC values were 0.801, 0.955, and 0.878, respectively (p<0.05). The optimal cutoff values for distinguishing sCR from non-sCR were pretreatment K^trans (0.7020 min^-1) and DK^trans (0.0437 min^-1).

CONCLUSIONS

Quantitative parameters (pre-mean K^trans, DK^trans, and pre-mean K^trans) combined with post-mean ADC could predict treatment efficacy more precisely. However, quantitative DCE-MRI combined with DWI could not significantly improve prognostic efficacy.

Expression of thioredoxin 1 and peroxiredoxins in squamous cervical carcinoma and its predictive role in NACT

BACKGROUND

This study aims to investigate the expression of thioredoxin 1, peroxiredoxin 1 and peroxiredoxin 2 in bulky cervical squamous carcinoma and its predictive role in cisplatin-based neoadjuvant chemotherapy.

METHODS

Initially, the expression of thioredoxin 1, peroxiredoxin 1 and peroxiredoxin 2 protein was analyzed in 13 human cervical squamous cancer tissues and their paired adjacent non-cancerous tissues by western-blotting and immunohistochemistry. Then, correlation between the expression of thioredoxin 1, peroxiredoxin 1, peroxiredoxin 2 and responses to cisplatin-based neoadjuvant chemotherapy was analyzed in 35 paired tumor samples (pre- and post-chemotherapy) from bulky cervical squamous cancer patients by immunohistochemistry.

RESULTS

A clinical response occurred in 48.6% (17/35) of patients, including 14.3% (5/35) with a complete response and 34.3% (12/35) with a partial response. The expression of thioredoxin 1, peroxiredoxin 1 and peroxiredoxin 2 was much higher in cervical squamous cancer tissues compared with paired adjacent non-cancerous tissues by western-blotting and immunohistochemistry. Additionally, the expression of thioredoxin 1, peroxiredoxin 1 and peroxiredoxin 2 was significantly up-regulated in post-chemotherapy tissues compared to pre-chemotherapy cervical cancer tissues. High levels of thioredoxin 1, peroxiredoxin 1 and peroxiredoxin 2 were associated with a poor chemotherapy response in cervical squamous cancer patients.

CONCLUSIONS

Thioredoxin 1, peroxiredoxin 1 and peroxiredoxin 2 are frequently over-expressed in cervical squamous cancer. High expression levels of these proteins were related to a poor response to cisplatin-based neoadjuvant chemotherapy. The present study is the first report that thioredoxin peroxidase system may serve as a prediction of the responses to neoadjuvant chemotherapy in cervical squamous cancer.

Clinicopathological characteristics of patients with mucinous adenocarcinoma of the uterine cervix: A retrospective study of 21 cases

OBJECTIVES

Few studies in the literature take into account the WHO's 2014 redefinition of the characteristics of mucinous adenocarcinoma of the uterine cervix. Our objective was to describe the characteristics of a group of these patients.

MATERIAL AND METHODS

This was a retrospective descriptive study of patients diagnosed between 1 January 2005 and 31 May 2016 in three hospitals in Lyon, France. All the cases of cervical adenocarcinoma were reanalysed by an expert in gynaecological pathology to retain the mucinous subtypes as defined in the 2014 WHO classification. We analysed their clinical and pathological characteristics.

RESULTS

Among the 82 cases of cervical adenocarcinoma, 21 (26%) were diagnosed as mucinous. Ten were gastric type, of which four were in the extremely well differentiated form of minimal deviation adenocarcinomas, six were intestinal type, two were signet-ring cell type, and three were not otherwise specified. The patients' mean age was 42 years and 18 patients were premenopausal. The revealing symptom was metrorrhagia in eight cases (38%) and mucinous vaginal discharge in four (19%). Fifteen (72%) of the cervical smear were abnormal. Five (31%) of the 16 patients with gastric or intestinal type adenocarcinoma had a specific radiological presentation: multiple cysts of the uterine isthmus, visible on ultrasound and with T2 hyperintensity on MRI.

CONCLUSION

Mucinous adenocarcinoma is a rare form of cervical cancer that can be confused with other pathological types. It can be detected using cervical smears and should be suspected in cases of mucinous discharge and characteristic MRI features.

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.

Systemic therapy for cervical carcinoma - current status

Two major treatment modalities in cervical cancer are radiation therapy (RT) and surgery. Chemotherapy continues to be the main form of systemic therapy adjunctive to definitive local therapies, and is used for palliation. Platinum-based regimens, administered concurrently with both definitive and postoperative RT, were demonstrated to provide significant survival benefits, whereas the beneficial effect of concurrent chemoradiotherapy in later-stage disease was smaller. The role of chemotherapy in addition to RT in IB1/IIA1 cervical cancer patients not undergoing surgery remains undefined. Likewise, the role of chemotherapy in combination with postoperative RT for patients with intermediate-risk factors for recurrence has not yet been verified. The recent standard for chemoradiotherapy is cisplatin alone administered weekly. Other cisplatin-based or non-cisplatin-based regimens have not been subjected to large clinical studies. The benefits of consolidation chemotherapy after chemoradiation for locally advanced cervical cancer are still undetermined. Neoadjuvant cisplatin-based chemotherapy followed by surgery has shown survival benefits, however its role in the era of chemoradiotherapy remains unclear. The combination of cisplatin and paclitaxel is considered a standard regimen in the palliative setting. There is no standard of care for second-line systemic therapy in advanced cervical cancer. Bevacizumab combined with palliative chemotherapy (cisplatin/paclitaxel or topotecan/paclitaxel) in the first-line treatment for recurrent/metastatic cervical cancer significantly improves overall survival when compared to chemotherapy alone. The role of immunotherapy in cervical cancer remains to be established. The optimal combined modality treatment including systemic therapy for cervical tumors of non-squamous histology remains a matter of debate. Ongoing accumulation of data on genomic and proteomic characteristics provides insight into the molecular heterogeneity of cervical cancer and paves the way for developing molecularly targeted therapies.

Predictive role of galectin-1 and integrin α5β1 in cisplatin-based neoadjuvant chemotherapy of bulky squamous cervical cancer

Although galectin-1 and integrin α5β1 confer chemoresistance to certain types of cancer, whether their expression predicts the response to cisplatin-based neoadjuvant chemotherapy (NACT) in squamous cervical cancer remains unclear. Paired tumor samples (pre- and post-chemotherapy) were obtained from 35 bulky squamous cervical cancer patients treated with cisplatin-based NACT and radical hysterectomy at our hospital between January 2007 and August 2014. The expression of galectin-1 and integrin α5β1 in tumor cells and stromal cells was analyzed by immunohistochemistry. The correlation between galectin-1/integrin α5β1 and apoptosis-associated markers was investigated by using the The Cancer Genome Atlas (TCGA) RNA-sequencing data. Seventeen patients were identified as chemotherapy responders and 18 as non-responders. Galectin-1 and integrin α5β1-positive immunostaining was more frequently observed in stromal cells than its in tumor cells. The expression of galectin-1 and integrin α5β1 in stromal and tumor cells was significantly down-regulated in postchemotherapy cervical cancer tissues. High levels of galectin-1 and integrin α5β1 in stromal were associated with a negative chemotherapy response in squamous cervical cancer patients treated with cisplatin-based NACT. Additionally, the expression of galectin-1 and integrin α5 correlated negatively with caspase 3/caspase 8 by using the TCGA RNA-sequencing data. Galectin-1 and integrin α5β1 expression in stromal may serve as a prediction of the responses to cisplatin-based NACT for patients with bulky squamous cervical cancer. Galectin-1 and integrin α5β1 may be implicated in the development of chemoresistance in cervical cancer via suppressing apoptosis.

[Cervical cancer : Update on morphology]

The World Health Organization (WHO) classification from 2014 differentiates between different subtypes of mucinous adenocarcinoma of the uterine cervix. A gastric subtype was recently described that showed no association with high-risk human papillomavirus (HPV) infections, has a poor prognosis, is mainly diagnosed in women of Asian origin and can occur in patients with Peutz-Jeghers syndrome. Although no clear grading system has been recommended in the WHO classification, it is likely that grading of adenocarcinomas of the uterine cervix will partly be based on the different patterns of invasion. Deep stromal infiltration of macroinvasive carcinomas is defined as an infiltration of >66 % of the cervical stroma. In the near future a maximum tumor size of 2 cm could act as a discriminator for planning of less radical surgery. Parameters of the histopathological report that are relevant for the prognostic assessment as well as the choice of adjuvant treatment and function as quality indicators during certification are described. The histological type of an adenocarcinoma alone is of no predictive or prognostic relevance for patients undergoing primary surgical treatment, neoadjuvant chemotherapy, combined chemo-radiotherapy or treatment with angiogenesis inhibitors. Currently, molecular parameters and biomarkers are of no relevance.

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.

Biology and treatment of cervical adenocarcinoma

Uterine cervical adenocarcinoma (ADC) has been increasing in its prevalence world widely despite the decrease of squamous cell carcinoma (SCC). It comprises nearly 20-25% of the all cervical malignancy in developed countries. The worse biological behavior had been reported in patients with intermediate- and high risk factors after surgery, and in advanced stage over Ⅲ, radiotherapy (RT) alone and concurrent chemo-radiotherapy (CCRT) with cisplatin was not always effective. As for chemotherapy (CT), the induction CT has not established, as well. Further molecular targeted therapy (MTT) has been studied. The targets of oncogenic driver mutations were vascular endothelial growth factor (VEGF) in SCC, or tyrosine kinase (TK) of endothelial growth factor receptor 2 (EGFR2, Her2/neu)-Ras-MAPK-ERK pathway. Bevacizumab (Bev, anti-VEGF monoclonal antibody) is considered as one of key agent with paclitaxel and carboplatin in SCC, but not for ADC. This article focuses on up-to-date knowledge of biology and possible specific therapeutic directions to explore in the management of cervical ADC.

Oncologic Outcomes of Stage IVB or Persistent or Recurrent Cervical Carcinoma Patients Treated With Chemotherapy at Siriraj Hospital: Thailand's Largest Tertiary Referral Center

Objectives

To determine response rate and survival outcomes of chemotherapeutic treatment in stage IVB, persistent, or recurrent cervical carcinoma patients.

Methods

Medical records of stage IVB or persistent or recurrent cervical carcinoma patients who received chemotherapy from January 2006 to December 2013 were retrospectively reviewed. Patients with neuroendocrine carcinoma and patients who received only 1 cycle of chemotherapy were excluded. The demographic data, tumor characteristics, chemotherapeutic agents, and response rate were reported. Factors associated with overall response rate from the first-round chemotherapeutic treatment were analyzed using χ² test. Kaplan-Meier method and Cox proportional hazards model were used for survival analysis.

Results

Of 286 cervical carcinoma patients, 47 patients had stage IVB and 239 patients had persistent or recurrent disease. One hundred sixty-nine patients (59.1%) had squamous cell carcinoma (SCC). A majority of disease sites (38.8%) had both local and distant metastases. Overall response rate for first-round chemotherapeutic treatment was 37.8%, with 23.1% of patients having a complete response and 14.7% of patients having a partial response. Regarding disease response, 32.2% of patients had stable disease and 30% had disease progression. Median overall survival (OS) and progression-free survival (PFS) for first-round chemotherapeutic treatment were 11.6 (range, 0.7–108.3) months and 5.6 (range, 0.7–102.2) months, respectively. Patients with distant metastasis had a shorter OS duration with an adjusted hazard ratio (HR) of 1.78, 95% confidence interval (CI) of 1.09 to 2.90; P = 0.02. Patients with a body mass index of 25 kg/m² or more had a longer PFS duration than those with a normal body mass index (adjusted HR, 0.72; 95% CI, 0.55–0.94; P = 0.018). Patients with non-SCC had a longer PFS duration than that of patients with SCC (adjusted HR, 0.77; 95% CI, 0.60–0.99; P = 0.041).

Conclusions

Response rates, median PFS, and median OS of cervical cancer patients treated by chemotherapy in our center were rather high when compared with those of previous gynecologic oncology group studies.

Different Prognostic Implications of 18F-FDG PET Between Histological Subtypes in Patients With Cervical Cancer

This study aimed to investigate whether the predictive values of intensity- and volume-based PET parameters are different between histological subtypes in patients with cervical cancer. Ninety patients, 65 with squamous cell carcinoma (SCC) and 25 with non-SCC (NSCC), who underwent pretreatment ¹⁸F-FDG PET/CT and pelvic MRI, were studied retrospectively. In addition to SUVmax and SUVmean, metabolic-tumor-volume (MTV) was determined by thresholding of 40% SUVmax and total-lesion-glycolysis (TLG) was calculated. Clinical factors and PET metabolic indices were compared between SCC and NSCC. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method with cut-offs determined by ROC analyses to stratify SCC and NSCC patients separately. Factors associated with survival were assessed with univariate and multivariate analyses using the Cox regression model. No significant differences were observed in clinical factors other than tumor size or ¹⁸F-FDG PET metabolic indices between SCC and NSCC. The Kaplan-Meier estimates of 2-year PFS and OS rates were 60% and 70% for SCC and 40% and 76% for NSCC, respectively. Multivariate analyses showed that MTV and TLG were the independent prognostic factors for PFS and OS in SCC; in contrast, SUVmax was the independent prognostic factor for PFS and OS in NSCC. Metabolic burden (MTV and TLG) could be beneficial for the prognostic prediction of cervical SCC patients; in contrast, metabolic intensity (SUVmax) could be beneficial for the prognostic prediction of NSCC patients. The different prognostic implications might be based on the differences of tissue integrity and histological heterogeneity between SCC and NSCC.

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.

Sex-determining region Y-related high mobility group box (SOX)-2 is overexpressed in cervical squamous cell carcinoma and contributes cervical cancer cell migration and invasion in vitro

Sex-determining region Y-related high mobility group box 2 (SOX-2) is a key pluripotency-associated transcription factor and may be implicated in the pathogenesis of cervical squamous cell carcinoma (SCC). The aim of this study was to explore SOX-2 expression in cervical SCC tissues and to examine whether and how SOX-2 regulates the malignant behaviors of cervical SCC cells in vitro. We here found that SOX-2 expression in the examined cervical SCC tissues was higher than that in the normal cervical and cervical intraepithelial neoplasia (CIN) tissues. Higher protein level of SOX-2 (nuclear positive staining cells ≥50 %) was detected in 34.9 % (29 out of 83 cases) of cervical SCC patients. We also noted that 100 % of well-differentiated and 66.7 % of moderately differentiated cervical SCCs showed lower SOX-2 expression (nuclear positive staining cells <50 %), while 58.8 % of poorly differentiated tumors had higher SOX-2 expression (P < 0.05). Furthermore, the migratory and invasive capabilities of SiHa cervical cancer cells were enhanced when SOX-2 was upregulated whereas suppressed when SOX-2 was downregulated. Also, the phosphorylation levels of protein kinase B (Akt) and extracellular regulated protein kinases (ERK) 1/2 were increased in SOX-2-overexpressed cancer cells but decreased in SOX-2-depleted cells. Additionally, LY294002 (Akt pathway inhibitor) or U0126 (ERK pathway inhibitor) significantly suppressed SOX-2-overexpression-induced migration and invasion in SiHa cells. Our results indicate that differentially expressed SOX-2 is associated with tumor differentiation (P < 0.05) and that SOX-2 contributes to the migratory and invasive behaviors of cervical SCC in vitro.

Fra-1 is downregulated in cervical cancer tissues and promotes cervical cancer cell apoptosis by p53 signaling pathway in vitro

Cervical cancer is a potentially preventable disease; however, it is the third most commonly diagnosed cancer and the fourth leading cause of cancer deaths in women worldwide. Cervical cancer is thought to develop through a multistep process involving virus, tumor suppressor genes, proto-oncogenes and immunological factors. It is known that human papillomavirus (HPV) infection is necessary but insufficient to cause malignancy. At present, the etiology of cervical carcinoma remains poorly understood. In this study, we found that the expression of FOS-like antigen-1 (Fra-1) gene was downregulated in cervical cancer compared with the adjacent non-cancerous tissues by RT-qPCR, immunohistochemistry (IHC) and western blotting techniques. To uncover the effect of Fra-1 on cervical cancer, we tested and confirmed that Fra-1 significantly inhibited the proliferation of HeLa cells by MMT assays in vitro. At the same time, overexpression of Fra-1 promoted apoptosis of HeLa cells. To explore the possible mechanism of Fra-1 in cervical cancer, we tested the expression levels of key molecules in p53 signaling pathway by western blotting technology. The results showed that p53 was downregulated in cervical cancer compared with the adjacent non-cancerous tissues, but MDM2 proto-oncogene, E3 ubiquitin protein ligase (MDM2) was upregulated in cervical cancer. In vitro, the p53 was upregulated and MDM2 was downregulated in HeLa cells with Fra-1 overexpression. In summary, our results suggested that Fra-1 expression is low in cervical cancer tissues and promotes apoptosis of cervical cancer cells by p53 signaling pathway.