Impact of para-aortic recurrence risk-guided intensity-modulated radiotherapy in locally advanced cervical cancer with positive pelvic lymph nodes

Predictors of para-aortic lymph node metastasis based on pathological diagnosis via surgical staging in patients with locally advanced cervical cancer: A multicenter study

Para-aortic lymph node (PALN) metastasis of patients with locally advanced cervical cancer (LACC) is associated with multiple risk factors. This study aimed to identify risk factors and develop a predictive model for PALN metastasis based on the pathological diagnosis via surgical staging to determine the patient-population suitable for extended-field irradiation (EFRT) and clarify the prognosis of patients with LACC. Five parameters were identified as predictors by logistic regression analysis. The predictive model was displayed as a nomogram and then modified into a simple scoring system. The concordance indices for the prediction nomogram were 0.939 in the training cohort, and 0.954 in the validation cohort, respectively. The scoring system consisted of tumor size, histological type, number of pelvic lymph nodes (PLNs), common iliac lymph node, and shorter diameter of the largest PLN. With a cutoff value of 8 points, the sensitivity and specificity of the predictive model were 91.04 % and 85.37 %, respectively, in the training cohort, and 89.47 % and 84.68 %, respectively, in the validation cohort. Using this system, patients were divided into high- and low-risk groups. Patients in the high-risk group showed a greater likelihood of PALN metastasis and worse PFS and OS than those in the low-risk group. The predictive model displays promise for the pathological diagnosis of PALN via surgical staging, offering good accuracy. It provides a non-invasive, practical tool to guide precise radiation strategy and stratify prognosis of patients with LACC.

The value of PFS36 as a primary endpoint for radiotherapy trials in patients with LACC: individual patient data from the Chinese NCC and validation from 26 RCTs

Objective

A conventional endpoint for locally advanced cervical cancer (LACC) clinical trials is overall survival (OS) with five years of follow-up. The primary hypothesis was that progression-free survival (PFS) with three years of follow-up (PFS36) would be an appropriate primary surrogate endpoint.

Materials and methods

The primary hypothesis, which was developed from our data, was further investigated using phase III randomized controlled trials and then externally validated using retrospective studies up to 2023. Correlation analysis at the treatment-arm level was performed between 2-, 3-, 4-, and 5-year PFS rates and 5-year OS.

Results

A total of 613 patients with histologically confirmed cervical cancer who underwent radiotherapy or chemoradiation at our institute between January 2010 and December 2013 were eligible. The recurrence rates for years 1 through 5 were 12.9%, 7.3%, 3%, 2.3%, and 1.8%, respectively. Patients who did not achieve PFS36 had a 5-year OS rate of 30.3%. However, patients who achieved PFS36 had a 5-year OS rate of 98.2%. Further data were extracted from 26 randomized phase III trials on LACC. The trials included 55 arms, with a pooled sample size of 7,281 patients. Trial-level surrogacy results revealed that PFS36 (r2, 0.732) was associated with 5-year OS. The correlation between PFS36 and OS was externally validated using independent retrospective data.

Conclusion

A significant positive correlation was found between PFS36 and OS at 5 years of follow-up both within patients and across trials. These results suggest that PFS36 is an appropriate endpoint for LACC clinical trials of radiotherapy-based regimens.

Spectral computed tomography in the assessment of metastatic lymph nodes in cervical cancer patients treated with definitive radiotherapy: a single-center, prospective study

Identifying metastatic lymph nodes (LNs) in patients with cervical cancer treated with definitive radiotherapy may inform treatment strategy and determine prognosis, but available methods have limitations, especially in developing regions. Herein, we aimed to evaluate the performance of quantitative parameters in spectral computed tomography (CT) scanning in this context, focusing on its complementary role alongside conventional diagnostic approaches like 18-fluorine-fuorodeoxyglucose positron emission tomography computed tomography (18 F FDG-PET/CT). Patients with cervical cancer, who underwent pretreatment spectral CT simulation scanning and planned radiotherapy, were enrolled in this prospective study. The LNs were categorized as "metastatic" and "non-metastatic", based on a procedure that included 18 F FDG-PET/CT as well as CT, magnetic resonance imaging, Node Reporting and Data System and follow-up results. Iodine concentrations (IC), normalized IC (NIC), effective atom number (effZ), and spectral curve slope (λHU) in the arterial (AP) and venous (VP) phases, were compared between metastatic and non-metastatic LNs. IC were derived from iodine-based material decomposition through manual delineation and normalized to the iodine concentration in the adjacent artery (NIC). effZ and λHU were calculated based on the effective atom number image and virtual monochromatic images. Univariate and multivariate logistic regression analyses were used to determine spectral CT factors independently associated with LNs metastasis, and their diagnostic efficacies were assessed using the area under the curve (AUC) analysis. The diagnostic efficiency of 18 F FDG-PET/CT and spectral CT was compared. A total of 115 metastatic and 97 non-metastatic LNs were detected, and spectral CT parameters (IC, NIC, effZ, λHU) significantly differed between the two groups. In univariate and multivariable logistic regression analysis, λHU in the AP and NIC in the VP were independent predictors for metastatic LNs and their combination improved AUC to 0.923, with a sensitivity of 84.4%, and a specificity of 85.6%. Spectral CT could achieve similar sensitivity as 18 FFDG-PET/CT in total LNs, and, more importantly, a higher sensitivity (95.5% vs. 59.1%) and diagnostic accuracy (92.9% vs. 67.9%) for para-aortic LNs. Quantitative spectral CT parameters can help distinguish metastatic from non-metastatic LNs in patients with cervical cancer treated with definitive radiotherapy. Combination of λHU in AP and NIC in VP further improves diagnostic performance. Spectral CT, while promising, complements rather than replaces PET/CT, especially for diagnosing para-aortic LNs, where PET/CT may have limitations. It could be a valuable adjunct to conventional imaging, particularly in settings with limited access to advanced tools.

Current Paradigm and Future Directions in the Management of Nodal Disease in Locally Advanced Cervical Cancer

Approximately 36% of patients with cervical cancer present with regional nodal metastasis at diagnosis, which is associated with adverse survival outcomes after definitive treatment. In the modern era of chemoradiotherapy (CRT) and image-guided adaptive brachytherapy (IGABT), where excellent local control is achieved for patients with locally advanced cervical cancer (LACC), nodal failure remains a major challenge to cure. To optimize treatment outcomes for node-positive LACC and reduce the incidence of nodal failure, various treatment approaches have been explored, including methods of surgical nodal staging or dissection, RT dose escalation strategies, such as intensity-modulated radiotherapy (IMRT) with simultaneous integrated boost (SIB) to involved nodes, and elective treatment of subclinical para-aortic (PAO) disease. Additionally, there is growing interest in emerging precision RT techniques, such as magnetic resonance-guided radiotherapy (MRgRT) and proton therapy, which may allow for further improvement in the therapeutic ratio. This review outlines the various methods of detection of nodal metastasis, treatment options for node-positive LACC, techniques of nodal radiotherapy and their clinical evidence in efficacy and toxicity profiles. Furthermore, recent advances in systemic therapy and promising novel therapeutic directions that may shape the management of node-positive LACC are discussed.

Study protocol of Elective Para-aortic and pelvic versus Pelvic only Irradiation in pelvic node positive Cervical cancer: a multicentric open labelled phase III randomised controlled trial (EPIC Study)

INTRODUCTION

The revision of International Federation of Gynaecology and Obstetrics staging in 2018 with recommendations to include cross-sectional imaging and a separate stage for node positive disease have opened a lot of uncertainties in implementing the correct treatment approach in these patients. While studies have suggested higher chances of occult para-aortic lymph node (PALN) even with advanced imaging, especially in pelvic node positive disease which tend to recur after pelvic radiation therapy. This study intends to study these patients and isolate the subset who will benefit most from elective PALN irradiation.

METHODS AND ANALYSIS

This is an ongoing multicentric phase III randomised controlled trial with a sample size of 274 subjects in two arms (137 in each arm) to determine the superiority of limited elective para-aortic irradiation compared with no irradiation. Arm one includes radiation to the lower PALN and pelvis; Arm two includes radiation to the pelvis. Concurrent chemotherapy followed by brachytherapy is standard in both arms. Patients with cervical cancer and radiologically positive pelvic LNs aged>18 years and<70 years are screened for the study. The primary endpoint of this study is 3-year disease-free survival. The secondary endpoints include 3-year para-aortic recurrence-free survival, 3-year distant metastasis-free survival, 3-year overall survival, acute and late toxicity, quality of life. Translational study to evaluate systemic immune response by FAPI-PETCT (fibroblast activator protein inhibitor positron emission tomography) and assessment of p16, L1 cell adhesion molecule (L1CAM) and protein death ligand-1 (PDL-1) expression by immunohistochemistry.

ETHICS AND DISSEMINATION

The study has been approved by the institutional ethics committee and will be routinely monitored according to standard guidelines. The results of the study will be published in peer-reviewed scientific journals, presented at conferences and submitted to regulatory authorities.

TRIAL REGISTRATION NUMBER

The study was registered on 17 January 2022 under CTRI/2022/01/039495 (http://ctri.nic.in).

Predictive Model of Paraaortic Lymph Node Involvement in cN0 Locally Advanced Cervical Cancers: PET/CT Technology Matters

Background: The aim is to propose a model for predicting occult paraaortic lymph node (PALN) involvement in locally advanced cervical cancer (LACC) patients by including parameters such as reconstruction detection technology (use of time-of-flight) and parameters related to the primary tumor. This model will then be compared with the scores used in routine clinical practice; Methods: This retrospective observational cohort study included patients diagnosed with LACC who underwent 18F-FDG PET/CT prior to PALN surgical staging between February 2012 and May 2020. The following parameters were collected on PET/CT: tumor SUVmax, tumor MTV, number of common and distal pelvic node involvements. A multivariate regression analysis estimating the probability of PALN involvement was performed, with optimal thresholds determined via ROC curves; Results: In total, 71 patients met the inclusion criteria. Occult PALN involvement was detected in 12.7% of patients. A derived multivariate PET model selected four variables: number of common and distal iliac lymph nodes (OR 5.9 and 2.7, respectively), tumor-to-liver SUV ratio (OR 0.9) and the use of time-of-flight technology (OR 21.4 if no time-of-flight available). At the optimal threshold, a sensitivity of 77.8% and specificity of 88.7% was found. The model's performances varied significantly between patients whose PET/CT used time-of-flight and those whose PET/CT did not. No significant differences were found between our model and the one used in clinical practice (p = 0.55); Conclusions: This study shows that PET/CT technology influences the ability to detect occult PALN involvement in LACC. This parameter should be considered in the regular revision of PET-based scores.

Variability of treatment of locally advanced cervical cancer: How French multidisciplinary teams follow European guidelines?

INTRODUCTION

Cervical cancer is a global public health concern. Despite ESGO recommendations and FIGO classification changes, management of locally advanced cervical cancer (LACC) remains debated in France. Our study aimed to review LACC treatment practices and assess adherence to ESGO recommendations among different practitioners.

METHODS

From February 2021 to August 2022, we conducted a survey among gynecologic oncology surgeons, radiation oncologists, and medical oncologists practicing in France and managing LACC (FIGO stages IB3-IVA) according to the 2018 FIGO classification. We analyzed responses against the 2018 ESGO recommendations as a "gold standard."

RESULTS

Among 115 respondents (56% radiation oncologists, 30% surgeons, 13% medical oncologists), 48.6% of gynecologic surgeons didn't perform para-aortic lymphadenectomy (PAL) with significant radiologic pelvic involvement. PAL, when indicated by PET-CT, was more common in university hospitals (66.7% of surgeons). Surgeons in university hospitals also followed ESGO recommendations more closely. Overall, compliance with all ESGO recommendations was low: 5.7% of surgeons, 21.5% of radiation oncologists, and 60% of medical oncologists. Prophylactic para-aortic irradiation, per ESGO, was more frequent in comprehensive cancer centers (52% of radiation oncologists).

CONCLUSION

Adherence to ESGO recommendations for LACC treatment appears low in France, particularly in surgery, with limited PAL in cases of lymph node negativity on PET-CT. However, these recommendations are more often followed by surgeons in university hospitals and radiation oncologists in cancer centers. Adherence to these recommendations may impact patient survival and warrants evaluation of care quality, justifying the organization of LACC management in expert centers.

Comparative Analysis of Oncologic Outcomes in Patients with Squamous Cell Carcinoma of the Uterine Cervix with High-Risk Features for Para-Aortic Recurrence: Prophylactic Extended-Field versus Pelvic Chemoradiotherapy

Purpose

To compare the oncologic outcomes of prophylactic extended-field radiation therapy (EFRT) and whole pelvic radiation therapy (WPRT) in cervical patients at high risk of para-aortic lymph node (PALN) recurrence.

Patients and Methods

From July 1999 to May 2022, a total of 115 patients with cervical cancer and high-risk features of PALN recurrence based on tumor markers, positive LNs and extensive parametrial invasion were retrospectively analyzed. All patients had received EFRT or WPRT at a dose of 39.6-45 Gy and concurrent chemotherapy. In EFRT, coverage was extended to include the para-aortic region below the level of the left renal vein or T12.

Results

Twenty-eight and 87 patients underwent EFRT and WPRT, respectively. For patients who survived, the median follow-up time was 60.8 months (range 9.2-131.6 months) in the EFRT group and 115.9 months (range 16.9-212.1 months) in the WPRT group. The 5-year overall survival (OS) and pelvic, extrapelvic and PALN recurrence rates were 87.7% vs 60.8% (p=0.019), 10.9% vs 25.3% (p=0.119), 18.1% vs 45.8% (p=0.011), and 0% vs 30.4% (p=0.005), respectively, between the EFRT and WPRT groups. Multivariate analysis revealed that EFRT and 2018 FIGO stage IV disease status were significant predictors of OS and extrapelvic recurrence.

Conclusion

Compared to WPRT, EFRT significantly improved OS and reduced extrapelvic and PALN recurrence in patients with cervical cancer with high-risk recurrence features.

Treatment Strategies Guided by [18F]FDG-PET/CT in Patients with Locally Advanced Cervical Cancer and [18F]FDG-Positive Lymph Nodes

BACKGROUND

Modern treatment guidelines for women with advanced cervical cancer recommend staging using 2-deoxy-2-[18F]fluoro-D-glucose positron emission computed tomography ([18F]FDG-PET/CT). However, the risk of false-positive nodes and therapy-related adverse events requires caution in treatment planning. Using data from the Netherlands Cancer Registry (NCR), we estimated the impact of [18F]FDG-PET/CT on treatment management in women with locally advanced cervical cancer, i.e., on nodal boosting, field extension, and/or debulking in cases of suspected lymph nodes.

METHODS

Women diagnosed between 2009 and 2017, who received chemoradiotherapy for International Federation of Gynaecology and Obstetrics (2009) stage IB2, IIA2-IVB cervical cancer with an [18F]FDG-positive node, were retrospectively selected from the NCR database. Patients with pathological nodal examination before treatment were excluded. The frequency of nodal boosting, extended-field radiotherapy, and debulking procedures applied to patients with [18F]FDG-positive lymph nodes was evaluated.

RESULTS

Among the 434 eligible patients with [18F]FDG-positive nodes, 380 (88%) received interventions targeting these lymph nodes: 84% of these 380 patients received nodal boosting, 78% extended-field radiotherapy, and 12% debulking surgery. [18F]FDG-positive nodes in patients receiving these treatments were more likely to be classified as suspicious than inconclusive (p = 0.009), located in the para-aortic region (p < 0.001), and larger (p < 0.001) than in patients who did not receive these treatments.

CONCLUSION

While existing guidelines advocate [18F]FDG-PET/CT-guided treatment planning for the management of advanced cervical cancer, this study highlights that not all cases of [18F]FDG-positive nodes received an intervention, possibly due to the risk of false-positive results. Improvement of nodal staging may reduce suboptimal treatment planning.

Tata Memorial Centre Evidence Based Use of Nuclear medicine diagnostic and treatment modalities in cancer

ABSTRACT

PET/CT and radioisotope therapy are diagnostic and therapeutic arms of Nuclear Medicine, respectively. With the emergence of better technology, PET/CT has become an accessible modality. Diagnostic tracers exploring disease-specific targets has led the clinicians to look beyond FDG PET. Moreover, with the emergence of theranostic pairs of radiopharmaceuticals, radioisotope therapy is gradually making it's way into treatment algorithm of common cancers in India. We therefore would like to discuss in detail the updates in PET/CT imaging and radionuclide therapy and generate a consensus-driven evidence based document which would guide the practitioners of Oncology.

Predicting Lymph Node Metastasis From Primary Cervical Squamous Cell Carcinoma Based on Deep Learning in Histopathologic Images

We developed a deep learning framework to accurately predict the lymph node status of patients with cervical cancer based on hematoxylin and eosin-stained pathological sections of the primary tumor. In total, 1524 hematoxylin and eosin-stained whole slide images (WSIs) of primary cervical tumors from 564 patients were used in this retrospective, proof-of-concept study. Primary tumor sections (1161 WSIs) were obtained from 405 patients who underwent radical cervical cancer surgery at the Fudan University Shanghai Cancer Center (FUSCC) between 2008 and 2014; 165 and 240 patients were negative and positive for lymph node metastasis, respectively (including 166 with positive pelvic lymph nodes alone and 74 with positive pelvic and para-aortic lymph nodes). We constructed and trained a multi-instance deep convolutional neural network based on a multiscale attention mechanism, in which an internal independent test set (100 patients, 228 WSIs) from the FUSCC cohort and an external independent test set (159 patients, 363 WSIs) from the Cervical Squamous Cell Carcinoma and Endocervical Adenocarcinoma cohort of the Cancer Genome Atlas program database were used to evaluate the predictive performance of the network. In predicting the occurrence of lymph node metastasis, our network achieved areas under the receiver operating characteristic curve of 0.87 in the cross-validation set, 0.84 in the internal independent test set of the FUSCC cohort, and 0.75 in the external test set of the Cervical Squamous Cell Carcinoma and Endocervical Adenocarcinoma cohort of the Cancer Genome Atlas program. For patients with positive pelvic lymph node metastases, we retrained the network to predict whether they also had para-aortic lymph node metastases. Our network achieved areas under the receiver operating characteristic curve of 0.91 in the cross-validation set and 0.88 in the test set of the FUSCC cohort. Deep learning analysis based on pathological images of primary foci is very likely to provide new ideas for preoperatively assessing cervical cancer lymph node status; its true value must be validated with cervical biopsy specimens and large multicenter datasets.

18F-FDG PET/MRI and 18F-FDG PET/CT for the Management of Gynecological Malignancies: A Comprehensive Review of the Literature

OBJECTIVE

Positron emission tomography with 2-deoxy-2-[fluorine-18] fluoro- D-glucose integrated with computed tomography (18F-FDG PET/CT) or magnetic resonance imaging (18F-FDG PET/MRI) has emerged as a promising tool for managing various types of cancer. This review study was conducted to investigate the role of 18F- FDG PET/CT and FDG PET/MRI in the management of gynecological malignancies.

SEARCH STRATEGY

We searched for relevant articles in the three databases PubMed/MEDLINE, Scopus, and Web of Science.

SELECTION CRITERIA

All studies reporting data on the FDG PET/CT and FDG PET MRI in the management of gynecological cancer, performed anywhere in the world and published exclusively in the English language, were included in the present study.

DATA COLLECTION AND ANALYSIS

We used the EndNote software (EndNote X8.1, Thomson Reuters) to list the studies and screen them on the basis of the inclusion criteria. Data, including first author, publication year, sample size, clinical application, imaging type, and main result, were extracted and tabulated in Excel. The sensitivity, specificity, and diagnostic accuracy of the modalities were extracted and summarized.

MAIN RESULTS

After screening 988 records, 166 studies published between 2004 and 2022 were included, covering various methodologies. Studies were divided into the following five categories: the role of FDG PET/CT and FDG-PET/MRI in the management of: (a) endometrial cancer (n = 30); (b) ovarian cancer (n = 60); (c) cervical cancer (n = 50); (d) vulvar and vagina cancers (n = 12); and (e) gynecological cancers (n = 14).

CONCLUSIONS

FDG PET/CT and FDG PET/MRI have demonstrated potential as non-invasive imaging tools for enhancing the management of gynecological malignancies. Nevertheless, certain associated challenges warrant attention.

Prophylactic Extended-Field Irradiation Versus Pelvic Irradiation in Patients With Cervical Cancer With 2018 FIGO Stage IIIC1 Disease

PURPOSE

The aim of this study was to compare the survival rates and toxicities of prophylactic extended-field radiation therapy (EFRT) and pelvic radiation therapy (PRT) among patients with cervical cancer with 2018 International Federation of Gynecology and Obstetrics (FIGO) stage IIIC1 disease.

METHODS AND MATERIALS

We retrospectively analyzed patients with 2018 FIGO stage IIIC1 disease who were treated with definitive concurrent chemoradiotherapy at our institute between 2011 and 2015. A dose of 50.4 Gy in 28 fractions was delivered to the pelvic region (by PRT) or the pelvic plus para-aortic lymph node region (by EFRT) with intensity modulated radiation therapy. The first-line regimen of concurrent chemotherapy was weekly cisplatin.

RESULTS

A total of 280 patients were included, with 161 patients treated with PRT and 119 patients treated with EFRT. After propensity score matching (1:1), 71 pairs of patients were selected. The respective 5-year rates of the patients treated with PRT and EFRT were 61.9% and 85.0% for overall survival (P = .025) and 53.0% and 77.9% for disease-free survival (DFS) (P = .004), respectively, after matching. In the subgroup analysis, patients were grouped into a high-risk group (122 patients) and a low-risk group (158 patients) based on 3 factors: positive common iliac lymph nodes, ≥3 pelvic lymph nodes, and 2014 FIGO stage IIIB disease. In both the high-risk and low-risk groups, EFRT significantly improved DFS compared with PRT. The rates of grade ≥3 chronic toxicities were 1.2% and 5.9% in the PRT and EFRT groups, respectively (P = .067).

CONCLUSIONS

In comparison to PRT, prophylactic EFRT was associated with improved overall survival, DFS, and para-aortic lymph node control in patients with cervical cancer with FIGO stage IIIC1 disease. The incidence of grade ≥3 toxicities was higher in the EFRT group than in the PRT group, although the difference was not significant.

Improvement in radiation techniques for locally advanced cervical cancer during the last two decades

Since the National Cancer Institute (NCI) alert of concurrent chemoradiotherapy, radiotherapy has been changed from external beam radiotherapy plus brachytherapy to platinum-based concurrent chemoradiotherapy. Therefore, concurrent chemoradiotherapy plus brachytherapy has become a standard treatment for locally advanced cervical cancer. Simultaneously, definitive radiotherapy has been changed gradually from external beam radiotherapy plus low-dose-rate intracavitary brachytherapy to external beam radiotherapy plus high-dose-rate intracavitary brachytherapy. Cervix cancer is uncommon in developed countries; hence, international collaborations have been critical in large-scale clinical trials. The Cervical Cancer Research Network (CCRN), created from the Gynecologic Cancer InterGroup (GCIG), has investigated various concurrent chemotherapy regimens and sequential methods of radiation and chemotherapy. Most recently, many clinical trials of combining immune checkpoint inhibitors with radiotherapy have been ongoing for sequential or concurrent settings. During the last decade, the method of standard radiation therapy has changed from three-dimensional conformal radiation therapy to intensity-modulated radiation therapy for external beam radiotherapy and from two-dimensional to three-dimensional image-guided approaches for brachytherapy. Recent improvements include stereotactic ablative body radiotherapy and MRI-guided linear accelerator (MRI-LINAC) using adaptive radiotherapy. Here we review the current progress of radiation therapy during the last two decades.

Controversies in the Staging of Patients with Locally Advanced Cervical Cancer

Approximately 10-25% of patients with locally advanced cervical cancer harbor metastases to the para-aortic lymph nodes. Staging of patients with locally advanced cervical cancer can be performed with imaging techniques, such as PET-CT; however, false negative rates can be as high as 20%, especially for patients with pelvic lymph node metastases. Surgical staging can identify patients with microscopic lymph nodes metastases and aid in accurate treatment planning with the administration of extended-field radiation therapy. Data from retrospective studies investigating the impact of para-aortic lymphadenectomy on the oncological outcomes of patients with locally advanced cervical cancer are mixed, while data from randomized controlled trials do not demonstrate a progression-free survival benefit. In the present review, we explore controversies in the staging of patients with locally advanced cervical cancer and summarize the available literature.

PARa-aOrtic LymphAdenectomy in locally advanced cervical cancer (PAROLA trial): a GINECO, ENGOT, and GCIG study

BACKGROUND

Positron emission tomography/computed tomography (PET/CT) fails to detect approximately 25% of aortic lymph node metastasis in patients with PET/CT stage IIIC1 cervical cancer. Surgical staging could lead to treatment modification and to improved para-aortic and distant control.

PRIMARY OBJECTIVES

To demonstrate if chemoradiation with tailored external beam radiation field based on surgical staging and pathologic examination of the para-aortic lymph node is associated with improved 3-year disease-free survival compared with patients staged with PET/CT staging only.

STUDY HYPOTHESIS

Surgical staging followed by tailored chemoradiation will improve disease-free survival while avoiding unnecessary prophylactic extended-field chemoradiation in patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIIC1 cervical cancer.

TRIAL DESIGN

This is an international multicenter, randomized, phase III study. Eligible patients will be randomized 1:1 between PET/CT staging followed by chemoradiation (control arm), or surgical staging followed by tailored chemo-radiation (experimental arm). Randomization will be stratified by tumor stage according to TNM classification, center, and adjuvant treatment.

MAJOR INCLUSION/EXCLUSION CRITERIA

Main inclusion criteria are histologically proven PET/CT FIGO stage IIIC1 cervical cancer. Main exclusion criteria include unequivocal positive common iliac or para-aortic lymph node at pre-therapeutic imaging PET/CT.

PRIMARY ENDPOINTS

The primary endpoint is disease-free survival defined as the time from randomization until first relapse (local, regional, or distant), or death from any cause.

SAMPLE SIZE

510 eligible patients ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS: The estimated date for completing accrual will be Q2 2027. The estimated date for presenting results will be Q4 2030.

TRIAL REGISTRATION NUMBER

NCT05581121.

Clinical analysis of prophylactic para-aortic intensity-modulated radiation in cervical cancer

AIM

This study aimed to compare the survival and toxicity of patients with International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB1-IIIC cervical cancer without common iliac node metastasis treated with extended-field intensity-modulated radiotherapy (EF-IMRT) or pelvic IMRT (P-IMRT).

MATERIALS AND METHODS

Thirty-one patients treated with EF-IMRT and 37 patients who underwent P-IMRT were analysed retrospectively. Both groups were treated with high-dose-rate ¹⁹²Ir two-dimensional brachytherapy and concurrent chemotherapy. The chi-square test and Kaplan-Meier method were used to compare toxicity and survival between the two groups.

RESULTS

The median follow-up time of EF-IMRT group and P-IMRT group was 22 and 30 months, respectively. The 3-year overall survival (OS), progression-free survival (PFS), and para-aortic lymph node metastasis-free survival (PAMFS) in the EF-IMRT group and P-IMRT group were 87% versus 74.6%, 83.6% versus 61.7%, and 96% versus 80.5%, respectively. Treatment regimens, tumour size, and radiation time were independent prognostic factors of OS and PFS. Treatment regimens, tumour size, and total equivalent dose in 2 Gy/f (EQD2) of point A were independent prognostic factors of PAMFS. Five patients in the EF-IMRT group and 14 patients in P-IMET group experienced treatment failure. The cumulative incidence of grade 3 and 4 acute leukopenia in the EF-IMRT group was 51.6%, in comparison with 27.03% in the pelvic group. No difference was found in thrombocytopenia between two groups.

CONCLUSIONS

Patients with FIGO 2009 stage IB1-IIIC cervical cancer without common iliac node metastases may be benefit from EF-IMRT. Notably, EF-IMRT exhibits increased toxicity incidence; however, this remains within an acceptable range.

Concurrent definitive chemoradiation incorporating intensity-modulated radiotherapy followed by adjuvant chemotherapy in high risk locally advanced cervical squamous cancer: a phase II study

BACKGROUND

Although the prognosis of locally advanced cervical cancer has improved dramatically, survival for those with stage IIIB-IVA disease or lymph nodes metastasis remains poor. It is believed that the incorporation of intensity-modulated radiotherapy into the treatment of cervical cancer might yield an improved loco-regional control, whereas more cycles of more potent chemotherapy after the completion of concurrent chemotherapy was associated with a diminished distant metastasis. We therefore initiated a non-randomized prospective phaseII study to evaluate the feasibility of incorporating both these two treatment modality into the treatment of high risk locally advanced cervical cancer.

OBJECTIVES

To determine whether the incorporation of intensity-modulated radiotherapy and the addition of adjuvant paclitaxel plus cisplatin regimen into the treatment policy for patients with high risk locally advanced cervical cancer might improve their oncologic outcomes.

STUDY DESIGN

Patients were enrolled if they had biopsy proven stage IIIA-IVA squamous cervical cancer or stage IIB disease with metastatic regional nodes. Intensity-modulated radiotherapy was delivered with dynamic multi-leaf collimators using 6MV photon beams. Prescription for PTV ranged from 45.0 ~ 50.0 Gy at 1.8 Gy ~ 2.0 Gy/fraction in 25 fractions. Enlarged nodes were contoured separately and PTV-nodes were boosted simultaneously to a total dose of 50.0-65 Gy at 2.0- 2.6 Gy/fraction in 25 fractions. A total dose of 28 ~ 35 Gy high-dose- rate brachytherapy was prescribed to point A in 4 ~ 5 weekly fractions using an iridium- 192 source. Concurrent weekly intravenous cisplatin at 30 mg/m² was initiated on the first day of radiotherapy for over 1-h during external-beam radiotherapy. Adjuvant chemotherapy was scheduled within 4 weeks after the completion of concurrent chemo-radiotherapy and repeated 3 weeks later. Paclitaxel 150 mg/m² was given as a 3-h infusion on day1, followed by cisplatin 35 mg/m² with 1-h infusion on day1-2 (70 mg/m² in total).

RESULTS

Fifty patients achieved complete response 4 weeks after the completion of the treatment protocol, whereas 2 patients had persistent disease. After a median follow-up period of 66 months, loco-regional (including 2 persistent disease), distant, and synchronous treatment failure occurred in 4,5, and 1, respectively. The 5-year disease-free survival, loco-regional recurrence-free survival, distant-metastasis recurrence-free survival was 80.5%, 90.3%, and 88.0%, respectively. Four of the patients died of the disease, and the 5-year overall survival was 92.1%. Most of the toxicities reported during concurrent chemo-radiotherapy were mild and transient. The occurrence of hematological toxicities elevated mildly during adjuvant chemotherapy, as 32% (16/50) and 4% (2/50) patients experienced grade 3-4 leukopenia and thrombocytopenia, respectively. Grade 3-4 late toxicities were reported in 3 patients.

CONCLUSIONS

The incorporation of intensity-modulated radiotherapy and adjuvant paclitaxel plus cisplatin chemotherapy were highly effective and well-tolerated in the treatment of high-risk locally advanced cervical cancer. The former yields an improved loco-regional control, whereas distant metastases could be effectively eradicated with mild toxicities when adjuvant regimen was prescribed.

Prophylactic extended-field irradiation for locally advanced cervical cancer

Concomitant chemoradiotherapy is the standard treatment for locally advanced cervical cancer. Pelvic irradiation is commonly recommended for patients with negative para-aortic lymph nodes(PALNs). However, owing to the development of imaging-guided brachytherapy, distant failure has become the main failure pattern. The PALNs are a vital site of distant metastasis, and the para-aortic region may contain occult microscopic metastases that are barely detected owing to imaging technology restriction. The prognostic of patients who experienced PALN failure is dismal. Typically, there are four ways to decrease PALN failure. First, surgical staging can be performed to assess the occurrence of metastasis in the para-aortic region; however, the application of surgical staging is decreasing owing to controversial survival benefits and accompanying complications of surgery. Second, regular imaging surveillance and timely salvage of early recurrences could reduce PALN failure. Third, better systemic adjuvant therapy could be recommended since it has enormous potential to reduce distant metastases and improve overall survival. Fourth, performing prophylactic extended-field irradiation (EFI), including pelvic and para-aortic region irradiation, can sterilize occult microscopic metastases in the para-aortic region and improve survival. Prior investigations have revealed that prophylactic EFI could reduce PALN failure as well as distant metastasis and present the benefit of survival. Yet, owing to the serious morbidity induced by enlarged irradiation field in the era of conventional irradiation techniques, further research on EFI is stagnated. Nowadays, with the development of new technologies, intensity modulated radiation therapy can deliver a higher dose to tumors with acceptable toxicity. Prophylactic EFI regained attention. However, the inclusion criteria of prophylactic EFI in existing studies reveal great discrepancies. Thus, it is urgent to precisely identify indications for better survival and lower complications in patients with cervical cancer. In this review, we identify indications and summary guidelines for prophylactic EFI, which may provide a foundation for further trials and clinical applications.

Intensity-Modulated Radiotherapy and Three-Dimensional Conformal Radiotherapy Combined with Intracavitary Posterior Radiotherapy for the Treatment of Medium-Term and Advanced Cervical Cancer: Efficacy, Safety and Prognostic Factors

Objective

To explore the efficacy, safety, and prognostic factors of intensity modulated radiation therapy (IMRT) and three dimensional conformal radiation therapy (3D-CRT) combined with intracavitary posterior radiotherapy for medium-term and advanced cervical cancer.

Methods

Retrospectively analyze the clinical data of 104 patients with medium-term and advanced cervical cancer who were treated in the radiotherapy department of our hospital from September 2015 to March 2017. According to the different radiotherapy techniques, they were divided into the IMRT combined with intracavitary posterior radiotherapy group (n = 52) and the 3D-CRT combined with intracavitary posterior radiotherapy group (n = 52). Observe and compare the short-term efficacy, occurrence of adverse reactions and overall survival rate of the two groups. The clinicopathological characteristics of the survival group and the death group were compared, and univariate analysis and multiple logistic regression models were used to analyze the relationship between the clinicopathological characteristics and the patient’s prognosis.

Results

The total effective rate of IMRT combined with intracavitary posterior radiotherapy group was 96.15%, which was higher than that of 3D-CRT combined with intracavitary posterior radiotherapy group (88.46%), but the difference was not statistically significant (p > 0.05). The incidence of digestive system injury, thrombocytopenia, and radiation proctitis in the IMRT combined intracavitary posterior radiotherapy group was lower than that of the 3D-CRT combined intracavitary posterior radiotherapy group, and the differences were statistically significant (p < 0.05). The prognosis and survival of the two groups of patients were similar, and the difference was not statistically significant (p > 0.05). Pathological classification, clinical stage, and lymph node metastasis are independent influencing factors of 3-year prognosis in patients with medium-term and advanced cervical cancer (p < 0.05).

Conclusion

IMRT combined with intracavitary posterior radiotherapy is equivalent to 3D-CRT combined with intracavitary posterior radiotherapy, but it can reduce the incidence of adverse reactions in patients with medium-term and advanced cervical cancer, and has higher safety. Pathological typing, clinical staging, Lymph node metastasis were independent factor affecting the prognosis of patients. In clinical treatment, IMRT combined with intracavitary posterior radiotherapy is more recommended as a treatment plan for patients with medium-term and advanced cervical cancer.

The prognostic significance of pretreatment squamous cell carcinoma antigen levels in cervical cancer patients treated by concurrent chemoradiation therapy and a comparison of dosimetric outcomes and clinical toxicities between tomotherapy and volumetric modulated arc therapy

Background

To analyze the prognostic factors associated with stage IB-IVA cervical cancer in patients who underwent concurrent chemoradiation therapy (CCRT) and to compare the clinical toxicities and dosimetric parameters of organs at risk between the different radiotherapy techniques.

Methods

This retrospective study enrolled 93 patients with stage IB-IVA cervical cancer who underwent definitive CCRT between April 2009 and December 2017. Nine patients (9.7%) received 3DCRT, 43 patients (46.2%) underwent VMAT, and 41 patients (44.1%) received tomotherapy, and all of them followed by brachytherapy using a 2D planning technique. The treatment outcomes and related prognostic factors were analyzed. We also compared the clinical toxicities and dosimetric parameters between the different techniques used for the last 30 patients.

Results

With a median follow-up of 52.0 months, the 5-year overall survival (OS), progression-free survival (PFS), locoregional recurrence–free survival (LRRFS), and distant metastases–free survival (DMFS) were analyzed. In a Cox proportional hazards regression model, pretreatment SCC Ag > 10 ng/mL was a significant prognostic factor for PFS (hazard ratio [HR] 2.20; 95% confidence interval [CI] 1.03–4.70; P = 0.041), LRRFS (HR, 3.48; 95% CI 1.07–11.26; P = 0.038), and DMFS (HR 2.80; 95% CI 1.02–7.67; P = 0.045). Increasing the rectal volume receiving a radiation dose exceeding 30 Gy (V₃₀ of rectum; odds ratio [OR] 1.15; 95% CI 1.10–1.30; P = 0.03) was associated with a higher possibility of ≥ Grade 2 acute radiation therapy (RT)-related diarrhea. The median rectal V₃₀ values were 56.4%, 97.5%, and 86.5% for tomotherapy, 3-dimensional conformal radiation therapy (3DCRT), and volumetric modulated arc therapy (VMAT), respectively (P < 0.001). In addition, the chance of experiencing ≥ Grade 2 acute diarrhea were 10.0%, 66.7%, and 54.5% for tomotherapy, 3DCRT, and VMAT, respectively (P = 0.029).

Conclusions

Patients with pretreatment SCC Ag ≤ 10 ng/mL have better PFS, LRRFS, and DMFS than those with pretreatment SCC Ag > 10 ng/mL. The rectal V₃₀ is a significant predictor of severe acute diarrhea. Tomotherapy significantly decreased the rectal V₃₀, reducing the severity of acute RT-related diarrhea during external beam RT.

Trial registration This study was approved by the institutional review board at Kaohsiung Medical University Hospital. The registration number is KMUHIRB-E(I)-20190054 and retrospectively registered on 2019/3.

Optimal prophylactic para-aortic radiotherapy in locally advanced cervical cancer: anatomy-based versus margin-based delineation

OBJECTIVE

Precise delineation of the para-aortic nodal region is critical for the optimal therapeutic ratio of prophylactic para-aortic radiotherapy. We aimed to evaluate the para-aortic control and patient-reported gastrointestinal toxicity in patients with locally advanced cervical cancer who received anatomy-based or margin-based prophylactic para-aortic radiotherapy.

METHODS

We analyzed 160 patients with locally advanced cervical cancer who received prophylactic extended-field radiotherapy between January 2014 and November 2019 at two tertiary centers. Para-aortic nodal regions were delineated based on the anatomic principle-based atlas or marginal expansion from the aorta and inferior vena cava. The Patient-Reported Outcome version of the Common Terminology Criteria for Adverse Events was used to assess acute gastrointestinal toxicity, and a score of ≥3 was defined as severe gastrointestinal toxicity.

RESULTS

Seventy-six (47.5%) and 84 (52.5%) patients received anatomy-based and margin-based prophylactic para-aortic radiotherapy, respectively. The median follow-up was 40.1 months (IQR 25.5-58.9). Para-aortic nodal failures occurred in one (1.3%) patient in the anatomy-based para-aortic radiotherapy group and in one (1.2%) patient in the margin-based para-aortic radiotherapy group (p=1.00). There was no in-field or marginal para-aortic nodal failure. The 3-year para-aortic recurrence-free survival for anatomy-based and margin-based para-aortic radiotherapy was 98.6% and 98.8%, respectively (p=0.94). Patients who received anatomy-based para-aortic radiotherapy reported less severe acute gastrointestinal toxicity than those who received margin-based para-aortic radiotherapy (13.2% vs 29.8%, p=0.01). A comparison of gastrointestinal toxicities showed that patients who received anatomy-based para-aortic radiotherapy reported significantly less severe gastrointestinal toxicity than those who received margin-based para-aortic radiotherapy in terms of frequency of diarrhea (7.9% vs 20.2%, p=0.03), severity of abdominal pain (3.9% vs 14.3%, p=0.03), and interference of abdominal pain (2.6% vs 11.9%, p=0.03).

CONCLUSION

Anatomy-based prophylactic para-aortic radiotherapy achieved excellent para-aortic control and a lower incidence of severe patient-reported gastrointestinal toxicity. These findings suggest that anatomy-based delineation optimizes clinical outcomes of prophylactic para-aortic radiotherapy in locally advanced cervical cancer.

Combined modality management of advanced cervical cancer including novel sensitizers

The management of advanced cervical cancer has evolved with time. Combined modality treatments for cervical cancer have been shown to improve clinical outcomes for these patients. The role of surgery is reviewed in this article for specific situations such as the treatment of bulky lymph nodes and even in the metastatic setting. External beam radiotherapy and brachytherapy techniques have improved which has decreased patient toxicity. Systemic therapy such as chemotherapy, immunotherapy, and novel sensitizing agents have been extensively studied and have shown promising results. The combination of these three different modalities of treatment can be tailored to each specific patient to achieve the best outcomes. We review the recent advances and various international guidelines for the management of cervical cancer in this article.

A Novel Risk Factor for Para-Aortic Lymph Node Recurrence After Definite Pelvic Radiotherapy in Stage IIIB Cervical Cancer

Background: Studies determining which patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIIB disease benefit from prophylactic extended-field irradiation (EFRT), which can reduce para-aortic lymph node (PALN) failure rates, are limited. The study was designed to evaluate the value of the controlling nutritional status (CONUT) score as a risk factor for predicting PALN recurrence and identifying potential indications of prophylactic EFRT. Methods: From 2010 to 2015, a retrospective review was conducted among patients with FIGO stage IIIB cervical cancer who were treated with definitive pelvic radiotherapy or concurrent chemoradiotherapy. We analyzed para-aortic lymph node metastasis-free survival (PALNMFS) using Kaplan-Meier curves. Multivariate analyses were performed using Cox regression models. Results: A total of 116 patients with FIGO stage IIIB cervical cancer were included in the study and the median follow-up was 42.2 months (range: 3.5-104.2 months). Multivariate analysis revealed that the CONUT score (HR: 3.141; 95% CI: 2.321-5.436; P < .001) and ≥3 pelvic lymph node metastases (HR: 2.235; 95% CI: 1.428-11.242; P < .001) were independent risk predictors of PALNMFS. Compared with the low CONUT group (score<3), the high CONUT group (score≥3) was associated with a significantly worse 3-year disease-free survival rate (46.9 vs 69.5%, P = .001), a significantly lower 3-year overall survival rate (68.5 vs 79.7%, P = .016) and a significantly lower PALNMFS rate (74.8 vs 96.4%, P < .001). Conclusions: A high CONUT score (score≥3) and ≥3 pelvic metastatic lymph nodes were significant predictors of PALNMFS after pelvic radiation in FIGO stage IIIB cervical cancer patients. Patients with these risk factors might benefit from prophylactic EFRT.

A modified delineation method of para-aortic nodal clinical target volume in patients with locally advanced cervical cancer

PURPOSE

To validate the nodal center coverage (NCC) of the three mainstream delineation methods of para-aortic nodal clinical target volume (CTV) and propose a modified delineation method of para-aortic nodal CTV in prophylactic extended-field irradiation (EFI) of cervical cancer.

METHODS

A total of 106 patients with para-aortic lymph nodes (PALNs) identified on PET/CT were included at Peking Union Medical College Hospital between 2011 and 2020. PALNs were classified as left lateral para-aortic (LLPA), aorto-caval (AC), and right para-caval (RPC). Distances from the nodal center to the aorta and inferior vena cava (IVC) were measured. The NCC of the three mainstream delineation methods of para-aortic nodal CTV (CTV-K, CTV-S, and CTV-D) and a modified CTV (CTV-M) was calculated. Radiotherapy plans were created based on 4 CTVs for 10 selected patients who received prophylactic EFI. The chi-squared test and the Student's t-test were performed.

RESULTS

We identified 344 PALNs (216 LLPA, 101 AC, and 27 RPC) in 106 patients. Mean distance from the nodal center to the aorta was 9.6 mm in the LLPA and 7 mm in the AC and from the nodal center to the IVC was 5.6 mm in the AC and 5.6 mm in the RPC. CTV-D improved the NCC of 98% compared with 92% for CTV-K (p = 0.002) and 95% for CTV-S (p = 0.046). CTV-M provided the same satisfactory NCC as CTV-D (97% vs. 98%, p = 0.485). The V_50Gy to the duodenum, the D_mean to the bilateral kidneys, and the V_45Gy to the small bowel were significantly lower on the CTV-M-based plan than on the CTV-D-based plan (p = 0.001, 0.011, and 0.001, respectively).

CONCLUSION

CTV-D provided more satisfactory NCC than CTV-K and CTV-S. CTV-M provided the same satisfactory NCC as CTV-D and reduced the dose to the critical structures.

Clinical Observation of Prophylactic Extended-Field Intensity-Modulated Radiation Therapy with Synchronous Chemotherapy in Locally Advanced Cervical Cancer

BACKGROUND We aimed to evaluate the value of prophylactic extended-field intensity-modulated radiation therapy (IMRT) in the treatment of locally advanced cervical cancer with multiple pelvic lymph node metastases (≥2) and negative common iliac and paraaortic lymph nodes. MATERIAL AND METHODS Thirty-four patient with newly diagnosed cervical cancer (IB1-IVA) and multiple pelvic lymph node metastases (≥2) confirmed by computed tomography and magnetic resonance imaging were randomly divided into an extended-field group (17 patients) and a pelvic-field group (17 patients). In the extended-field group, we added the drainage area of paraaortic lymph nodes on the pelvic field. The pelvic field was administered Dt 45.0 to 50.4 Gy, while the drainage area of paraaortic lymph nodes was administered Dt 40.0 to 45.0 Gy. Both groups were given Irl92 intracavitary radiotherapy after 3 weeks of external irradiation. The total dose of point A was 25.0 to 30.0 Gy, fractional 6.0 to 7.0 Gy. All patients had concurrent platinum-based chemotherapy once weekly until the end of radiotherapy. RESULTS No paraaortic lymph node metastasis was found in the extended-field group (P=0.0184), and disease-free survival (DFS) was prolonged (P=0.0286). Adverse effects in patients with III-IV degree myelosuppression were increased in the extended-field group (P=0.0324). However, all patients recovered after symptomatic treatment. CONCLUSIONS Prophylactic extended-field IMRT with chemotherapy reduced the metastasis rate of paraaortic lymph nodes and prolonged the DFS in patients with locally advanced cervical cancer and multiple pelvic lymph node metastases (≥2), while the toxic adverse effects were tolerated.

Higher Dose to Organs at Risk: The Unintended Consequences of Intravenous Contrast Use in Computed Tomography Simulation for Cervical Cancer

PURPOSE

To compare the volumes of interest and doses to the organs at risk on contrast and noncontrast scans in patients with cervical cancer who underwent prophylactic extended-field radiation therapy (EFRT).

METHODS AND MATERIALS

We reviewed twenty cervical cancer patients treated with prophylactic EFRT at Peking Union Medical College Hospital between March 2021 and April 2021. Each patient underwent noncontrast and contrast scans during simulation. All structures were contoured, and radiation therapy plans were created based on both scans. Student t test and Pearson correlation coefficient test were performed.

RESULTS

Compared with the noncontrast scan, on the contrast scan, the mean volume of the inferior vena cava expanded by 44% (P ≤ .001), and the mean volume of the para-aortic nodal clinical target volume increased by 17% (P ≤ .001). For the second portion of the duodenum, the V30 (38.2% vs 43.8%, P = .038), V35 (27.6% vs 35.1%, P = .002), V40 (18.3% vs 26.3%, P = .014), V45 (11.2% vs 18.5%, P = .008), and V50 (4.2% vs 9.1%, P = .005) were significantly lower on the noncontrast scan than on the contrast scan. For the third portion of the duodenum, the V45 (78.4% vs 81.6%, P = .03) and V50 (59.7% vs 67%, P ≤ .001) were significantly lower on the noncontrast scan than on the contrast scan. For the right kidney, the V5, V10, V15, V20, and V25 on the contrast and noncontrast scans were 85.4% versus 79.8% (P = .013), 52.5% versus 45.6% (P = .021), 25.6% versus 20.1% (P = .003), 11.1% versus 7.5% (P = .001), and 3.8% versus 2.3% (P = .027), respectively.

CONCLUSIONS

Compared with the noncontrast scan, expansion of the inferior vena cava on the contrast scan can lead to excessive contouring and an overdose to the duodenum and right kidney in cervical cancer patients treated with prophylactic EFRT.

Implications of the new FIGO staging and the role of imaging in cervical cancer

International Federation of Gynecology and Obstetrics (FIGO) staging, which is the fundamentally important cancer staging system for cervical cancer, has changed in 2018. New FIGO staging includes considerable progress in the incorporation of imaging findings for tumour size measurement and evaluating lymph node (LN) metastasis in addition to tumour extent evaluation. MRI with high spatial resolution is expected for tumour size measurements and the high accuracy of positron emmision tomography/CT for LN evaluation. The purpose of this review is firstly review the diagnostic ability of each imaging modality with the clinical background of those two factors newly added and the current state for LN evaluation. Secondly, we overview the fundamental imaging findings with characteristics of modalities and sequences in MRI for accurate diagnosis depending on the focus to be evaluated and for early detection of recurrent tumour. In addition, the role of images in treatment response and prognosis prediction is given with the development of recent technique of image analysis including radiomics and deep learning.

Association of bowel radiation dose-volume with skeletal muscle loss during pelvic intensity-modulated radiotherapy in cervical cancer

BACKGROUND

Radiation-induced bowel damage may compromise nutrient absorption and digestion and affect body composition during pelvic radiotherapy in patients with locally advanced cervical cancer (LACC). This study aimed to evaluate the relationship between bowel radiation dose-volume and body composition changes during pelvic radiotherapy.

METHODS

Data of 301 LACC patients treated with chemoradiotherapy were analyzed. Changes in skeletal muscle index (SMI) and density (SMD), and total adipose tissue index (TATI) were measured from computed tomography images at the L3 vertebral level. A reduction in SMI, SMD, or TATI of ≥10% was classified as "loss." Bowel V45 indicates the bowel volume (mL) receiving a radiation dose of ≥45 Gy. The relationship between body composition and bowel V45 was analyzed using logistic regression models.

RESULTS

After treatment, 61 (20.3%), 81 (26.9%), and 97 (32.2%) patients experienced SMI, SMD, and TATI loss, respectively. Increased bowel V45 was independently associated with increased odds of SMI loss (odds ratio [OR]: 1.012; 95% confidence interval [CI]: 1.007-1.018; p<0.001) and TATI loss (OR: 1.006; 95% CI: 1.001-1.010; p=0.01), but not with SMD loss (OR: 1.005; 95% CI: 1.000-1.009; p=0.054). The cut-off value with the highest accuracy for predicting SMI loss was V45 ≥222 mL; a higher rate of SMI loss was noted in 40.0% of patients with V45 ≥222 mL than in 13.7% of patients with V45 <222 mL (p<0.001).

CONCLUSIONS

Higher bowel dose-volume was significantly associated with muscle loss during pelvic radiotherapy. Bowel dose-volume consideration is required in individualized nutritional counseling and supportive care in clinical practice.

Patterns of definitive radiotherapy practice for cervical cancer in South Korea: a survey endorsed by the Korean Radiation Oncology Group (KROG 20-06)

Objective

The Korean Radiation Oncology Group conducted a nationwide questionnaire survey to evaluate the patterns of clinical practice for patients with cervical cancer receiving definitive radiation therapy (RT) in South Korea.

Methods

Practicing radiation oncologists from 93 centers in South Korea were administered a questionnaire survey via e-mail. The survey focused on demographic characteristics, diagnostic evaluation, indications for definitive RT, RT techniques, RT field and dose prescription, lymph node (LN) boost RT, brachytherapy, and chemotherapy.

Results

The response rate was 62.4% (58/93 institutions). Of the 2,134 patients treated at the radiation oncology department in 2019, 48.8% underwent definitive RT. The selection of patients for definitive concurrent chemoradiation therapy and RT field, and RT dose prescription varied greatly. The upper border of the pelvis was commonly used as the bony landmark for external beam RT (81%–88% of respondents). Most (96.6%) centers performed LN boost RT with median total doses of 59 Gy and 59.2 Gy for pelvic and retroperitoneal LN, respectively. With 50% of the centers offering brachytherapy, image-guided brachytherapy and volume-based prescription were applied in 48.3% and 37.9%, respectively. Upfront concurrent chemoradiation therapy with varying prescription doses was considered by 60.4% respondents in cases of supraclavicular LN metastasis.

Conclusion

Most differences were noted in the indications for treatment, RT field, and prescription dose. This finding can serve as a reference for establishing practical RT guidelines for the management of locally advanced cervical cancer.

Intensity-modulated radiation therapy (IMRT)-based concurrent chemoradiotherapy (CCRT) with Endostar in patients with pelvic locoregional recurrence of cervical cancer: Results from a hospital in the Qinghai-Tibet Plateau

The treatment of recurrent cervical cancer, especially pelvic locoregional recurrence, is very challenging for gynecologic oncologists. This study investigated the efficacy and safety of intensity-modulated radiation therapy (IMRT)-based concurrent chemoradiotherapy (CCRT) with Endostar, a novel modified recombinant human endostatin, in patients with pelvic locoregional recurrence of cervical cancer following surgical treatment.This phase 2 study was conducted between May 2018 and May 2019 at a single center in the Qinghai-Tibet Plateau and enrolled 31 patients with pelvic locoregional recurrence of cervical cancer following surgical treatment. All patients were treated with IMRT-based CCRT for 6 weeks and intravenous infusions of Endostar (15 mg/m), which were administered on days 1 to 7 of CCRT, followed by rest for 4 weeks. After resting, chemotherapy with cisplatin (70 mg/m) plus paclitaxel (135-175 mg/m) was given every 3 weeks for a total of 4 treatments.Thirty-one patients were evaluable for the primary endpoint. The mean age was 50.03 years (SD 7.72). The objective response rate was 67.74% and the disease control rate was 83.87% (48.39% achieved a complete response, 19.35% a partial response, 16.13% had disease stabilization, and 16.13% had progressive disease). The most common adverse events were nausea, vomiting, alopecia, neutropenia, and leukopenia; most events were grade 1 or 2 in intensity. Grade 3 toxicities included thrombocytopenia and neutropenia in 2 patients each, and leukopenia in 4 patients. No cases of grade 4 acute toxicity were observed.IMRT-based CCRT with Endostar infusions is effective and safe. Our results support the use of this treatment for patients with pelvic locoregional recurrence of cervical cancer following surgical treatment.

Management of cervical cancer during the corona virus disease-19 (COVID-19) era

COVID-19 pandemic has had a catastrophic impact on the society, economy and heath-care system all over the globe with virus showing no signs of losing potency. As the situation appears to worsen, extra burden on other specialities like oncology seems to increase. Specific recommendations are necessary for management of cervical cancer in the current context. All concerned specialities must work together in the best interest of the patient. Attempts should be made at managing cervical cancer while limiting the viral spread among the patients and health-care workers without the loss of opportunity. Surgical intervention for early cervical cancer should be postponed or alternative modalities be considered. In a locally advanced disease, concurrent chemoradiation is the treatment of choice. In addition, the following under mentioned suggestions aim to discuss ways of minimizing infection spread, workload rationalization and providing guidance for management of cervical cancer in the presence of COVID-19 infection.

Antineoplastic potential and chemical evaluation of essential oils from leaves and flowers of Tagetes ostenii Hicken

Breast and cervical cancer represent a major problem of women's global public health. Here, we investigated the chemical composition of essential oils from leaves and flowers of T. ostenii and the antineoplastic potential in a cervical cancer and breast cancer cell line, SiHa and MCF-7; and non-tumoral cells, HaCat. The chemical analysis revealed a predominance of oxygenated monoterpenes in both essential oils. The IC50 after 24 h of treatment was 72 ng/mL for EO 1 and 83 ng/mL for EO 2 in SiHa cells. For MCF-7 the IC50 was 174.3 ng/mL for EO 1. For HaCat cells it was 54.45 ng/mL for EO 1 and 20.83 ng/mL for EO 2. A synergistic effect with both essential oils and cisplatin was also verified. SiHa cells had their wound healing capacity reduced after 48 h of treatment with EO 2 and both essential oils were able to significantly inhibit the adhesion process and clonogenic ability after 24 h of treatment. Our results suggest a long-lasting inhibitory activity in SiHa cells because of the low recovery capacity of cells after treatment withdrawal. Flow cytometer with annexin V/propidium iodide demonstrated a majority cell death through late apoptosis after 24, 48 and 72 hours of treatment.

Prophylactic Extended-Field Irradiation in Patients With Cervical Cancer: A Literature Review

Currently, the standard radiation field for locally advanced cervical cancer patients without evidence of para-aortic lymph node (PALN) metastasis is the pelvis. Due to the low accuracy of imaging in the diagnosis of PALN metastasis and the high incidence of PALN failure after pelvic radiotherapy, prophylactic pelvic and para-aortic irradiation, also called extended-field irradiation (EFI), is performed for patients with cervical cancer. In the era of concurrent chemoradiotherapy, randomized controlled trials are limited, and whether patients with cervical cancer can benefit from prophylactic EFI is still controversial. With conformal or intensity-modulated radiation therapy, patients tolerate prophylactic EFI very well. The severe toxicities of prophylactic EFI are not significantly higher than those of pelvic radiotherapy. We recommend delivering prophylactic EFI to cervical cancer patients with common iliac lymph nodes metastasis. Clinical trials are needed to investigate whether patients with ≥3 positive pelvic lymph nodes and FIGO stage IIIB disease can benefit from prophylactic EFI. According to the distribution of PALNs, it is reasonable to use the renal vein as the upper border of the radiation therapy field for patients treated with prophylactic EFI. The clinical target volume expansion of the node from the vessel should be smaller in the right para-caval region than in the left lateral para-aortic region. The right para-caval region above L2 or L3 may be omitted from the PALN target volume to reduce the dose to the duodenum. More clinical trials on prophylactic EFI in cervical cancer are needed.

How should we stage and tailor treatment strategy in locally advanced cervical cancer? Imaging versus para-aortic surgical staging

Para-aortic lymph node status at initial assessment is the most important prognostic factor and a key point for the therapeutic strategy in patients with locally advanced cervical cancer. Undiagnosed lymph node metastasis is a major clinical problem as the finding of positive para-aortic lymph nodes leads to treatment modification, with a possible impact on disease free survival. When aortic lymph node disease is discovered, radiotherapy is extended to the para-aortic area, and other treatment modalities may be considered. Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) is the most accurate imaging examination to assess para-aortic extension in patients with locally advanced cervical cancer. The gold standard to identify para-aortic extension remains histologic evaluation of the lymph nodes. Indeed, PET/CT fails to detect approximately 10-15% of patients with negative PET/CT aortic nodes who have lymph node metastasis on pathologic staging. Patients with positive pelvic lymph nodes have para-aortic extension in 25-30% of cases, and surgical staging will lead to treatment modification and probably to improved para-aortic and distant control. Surgical staging also avoids unnecessary toxicity associated with extended field radiation in approximately 75% of patients with pelvic lymph node metastasis. The best modality to identify para-aortic extension is histological evaluation of the lymph nodes, but the survival benefit of surgical staging remains controversial. On the other hand, current studies include a majority of patients without pelvic lymph node spread, who are likely to be those who will benefit the least from surgical staging.

Risk factors associated with Para-Aortic Lymph Node Failure after pelvic irradiation in patients with Cervical Cancer

Objective: Previous studies have shown that prophylactic extended-field irradiation can reduce para-aortic lymph node failure (PALNF) rates in patients with cervical cancer. As such, this type of irradiation may particularly benefit patients with a high risk of PALNF. In the present study, we analyzed the risk factors for PALNF in patients with cervical cancer treated with pelvic irradiation in order to identify potential indications of prophylactic extended-field irradiation.

Methods: We evaluated patients with 2018 FIGO stage IB3-IIIC1 cervical cancer who were treated with definitive pelvic radiotherapy or concurrent chemoradiotherapy at our institution between 2011 and 2014. Univariate and multivariate analyses were performed to identify risk factors for PALNF.

Results: We included 572 patients in the study. The median follow-up period was 37.9 months. Eighteen patients (3.1%) first site of tumor relapse was the para-aortic lymph nodes, and thus showed PALNF. Using multivariate Cox regression analysis, we identified two significant risk factors for PALNF: tumor extension to the pelvic wall (hazard ratio, HR 3.60, p=0.026) and ≥ 2 pelvic MLNs (HR 5.30, p=0.005). For patients with and without risk factors, the 3-year overall survival, disease-free survival, and PALNF rates were 77.3% and 90.1% (p<0.001), 56.4% and 83.1% (p<0.001), and 12.0% and 2.3% (p<0.001), respectively.

Conclusion: Tumor extension to the pelvic wall and ≥ 2 pelvic MLNs are positively associated with PALNF after pelvic irradiation in patients with cervical cancer. Further trials will be required to validate whether patients with these two risk factors may benefit from prophylactic extended-field irradiation.

Lymph Node Number Predicts the Efficacy of Adjuvant Chemoradiotherapy in Node-Positive Endometrial Cancer Patients

This study aimed to evaluate the value of lymph node (LN) number as a predictor for adjuvant treatment in node-positive endometrial cancer. Data of 441 patients diagnosed with International Federation of Gynaecology and Obstetrics (FIGO) stage IIIC endometrial cancer and who underwent adjuvant chemotherapy alone or chemoradiotherapy between 2009 and 2015 from the Taiwan Cancer Registry were reviewed. The patients were stratified based on the number of positive LN as follows: 1, 2-5, and ≥ 6. The overall survival (OS) was analysed using the Kaplan-Meier method and the Cox proportional hazards model. In multivariable analysis, chemoradiotherapy was independently associated with improved OS (hazard ratio [HR]: 0.62, 95% confidence interval [CI]: 0.43-0.90; p = 0.01) compared with chemotherapy alone. Patients with ≥ 6 positive LNs were associated with a worse OS (HR: 2.22, 95% CI: 1.25-3.95; p = 0.006) and those with 2-5 LNs were not associated with a worse OS (HR: 1.56, 95% CI: 0.94-2.59; p = 0.09) compared to patients with one LN. When stratified based on LN number, chemoradiotherapy was found to significantly improve the 5-year OS of patients with ≥ 6 positive LNs compared to chemotherapy alone (35.9% vs. 70.0%, p < 0.001). No significant differences between chemotherapy alone and chemoradiotherapy were observed in 5-year OS among patients with one LN (73.1% vs. 80.8%, p = 0.31) or 2-5 positive LNs (71.4% vs. 75.7%, p = 0.68). Lymph node number may be used to identify node-positive endometrial cancer patients who are likely to have improved OS with intensification of adjuvant therapy.

Muscle Loss after Chemoradiotherapy as a Biomarker of Distant Failures in Locally Advanced Cervical Cancer

This study aimed to evaluate whether computed tomography (CT)-based muscle measurement predicts distant failure in patients with locally advanced cervical cancer (LACC). Data from 278 patients with LACC who underwent chemoradiation therapy (CCRT) between 2004 and 2017 were analysed. Changes in the skeletal muscle index (SMI), skeletal muscle density, and total adipose tissue index during CCRT were calculated from CT images taken at the baseline and after CCRT. The predictive capability of CT-based muscle measurement for distant failure was evaluated using Cox proportional hazards regression, Harrell’s concordance index (C-index), and time-dependent receiver operating characteristic curves. SMI loss ≥ 5% was independently associated with worse distant recurrence-free survival (DRFS) (HR: 6.31, 95% CI: 3.18–12.53; p < 0.001). The addition of muscle change to clinical models, including International Federation of Gynaecology and Obstetrics (FIGO) stage, lymph nodes, pathology, and squamous cell carcinoma-antigen, achieved higher C-indices (0.824 vs. 0.756; p < 0.001). Models including muscle change had superior C-indices than those including weight change (0.824 vs. 0.758; p < 0.001). The area under the curve for predicting 3-year DRFS was the highest for the muscle-loss model (0.802, muscle-loss model; 0.635, clinical model; and 0.646, weight-loss model). Our study demonstrated that muscle loss after CCRT was independently associated with worse DRFS and that integrating muscle loss into models including classical prognostic factors improved the prediction of distant failure.

Prophylactic Extended-Field Irradiation for Patients With Cervical Cancer Treated With Concurrent Chemoradiotherapy: A Propensity-Score Matching Analysis

Supplemental digital content is available in the text.

Objective

The aim of the study was to evaluate the efficacy and toxicity of prophylactic extended-field radiation therapy (RT) for cervical cancer patients treated with concurrent chemoradiotherapy (CCRT).

Methods

Records of patients with cervical cancer without para-aortic metastatic lymph nodes who were treated with definitive RT or CCRT between January 2011 and December 2014 were reviewed. Patients were classified into the pelvic RT and extended-field RT groups. An additional dose of 50.4 Gy in 28 fractions was delivered to para-aortic lymph node regions for patients in the extended-field RT group. Cox regression and propensity-score matching (1:1) were used to compare the overall survival (OS), disease-free survival (DFS), distant failure, and para-aortic lymph node failure (PALNF) between the pelvic RT and extended-field RT groups.

Results

A total of 778 patients were analyzed. Of them, 624 patients were treated with pelvic RT and 154 patients received extended-field RT. The median follow-up period was 37.5 months. In multivariate analysis, extended-field RT was an independent prognostic factor of distant failure (hazard ratio [HR] = 0.49, 95% confidence interval [CI] = 0.26–0.90, P = 0.023) and PALNF (HR = 0.012, 95% CI = 0.00–0.49, P = 0.019). However, it was not significant in predicting OS (P = 0.546) and DFS (P = 0.187). With propensity-score matching, 108 pairs of patients were selected. The 3-year OS, DFS, local control, distant failure, and PALNF rates in the pelvic RT and extended-field RT groups were 87.1% and 85.7% (P = 0.681), 71.0% and 80.6% (P = 0.199), 86.6% and 85.0% (P = 0.695), 21.7% and 7.0% (P = 0.016), and 6.6% and 0% (P = 0.014), respectively. The incidences of grade 3 or greater chronic toxicities were 3.5% and 6.5% in the pelvic RT and extended-field RT groups, respectively (P = 0.097).

Conclusions

Prophylactic extended-field RT was associated with decreased distant failure and PALNF and showed a trend in improving DFS in patients with cervical cancer treated with CCRT.

The Effect of Body Mass Index and Weight Change on Late Gastrointestinal Toxicity in Locally Advanced Cervical Cancer Treated With Intensity-modulated Radiotherapy

OBJECTIVE

To evaluate the effects of body mass index (BMI) and weight change during radiotherapy on the development of toxicity in patients with locally advanced cervical cancer (LACC) treated with intensity-modulated radiotherapy (IMRT).

METHODS

A total of 245 patients were analyzed after undergoing definitive IMRT treatment between 2004 and 2015 for stage IB2 to stage IVA LACC. The patients were divided into 3 groups: underweight (BMI <18.5 kg/m), normal weight (BMI 18.5-24.9 kg/m), and overweight (BMI ≥25.0 kg/m). The relationships between toxicity, clinical factors, and the bowel dose-volume histogram were analyzed. V45 indicated the bowel volume that received a radiation dose of 45 Gy.

RESULTS

The median follow-up period was 63 months. The V45 was similar among the 3 groups. The 5-year rates of grade 3 or higher late gastrointestinal toxicities were 18.6%, 4.0%, and 4.2% for the underweight, normal weight, and overweight groups, respectively (P = 0.002). In the multivariable analysis, underweight (hazard ratio, 13.99; 95% confidence interval, 3.22-60.82; P < 0.001) and weight loss (> -5%) (hazard ratio, 5.91; 95% confidence interval, 1.75-19.98; P = 0.004) were significant predictors of grade 3 or higher-grade late gastrointestinal toxicities.

CONCLUSION

A BMI of less than 18.5 kg/m and weight loss (> -5%) were associated with a higher risk of grade ≥3 or higher late gastrointestinal toxicity in patients with LACC treated with definitive IMRT. Future research on the development of a standardized and structured approach to improve the therapeutic ratio for the supportive care of patients with LACC is needed.

Efficacy and toxicity of chemoradiation with image-guided adaptive brachytherapy for locally advanced cervical cancer

OBJECTIVE

To evaluate the efficacy and toxicity of primary chemoradiation with image-guided adaptive brachytherapy for locally advanced cervical cancer and to identify predictors of treatment failure and toxicity.

METHODS

Retrospective analysis of 155 stage IB-IVA cervical cancer patients treated from 2008 to 2016 with chemoradiation and image-guided adaptive brachytherapy. Treatment consisted of external beam radiotherapy (45 - 48.6 Gy in 1.8 - 2 Gy fractions) with concurrent weekly cisplatin (40 mg/m², 5 - 6 cycles) and image-guided adaptive brachytherapy (3-4 × 7 Gy high dose rate) using intracavitary or combined intracavitary-interstitial techniques according to GEC-ESTRO (Group Européen de Curiethérapie and the European Society for Radiotherapy and Oncology) recommendations. Incidences of all outcomes were calculated using Kaplan-Meier's methodology. Risk factors for treatment failure and toxicity were identified using Cox's proportional hazards model and the Kruskal-Wallis H-test respectively.

RESULTS

Median follow-up was 57 months. Five-year local control was 90.4 %. Five-year para-aortic lymph node metastasis-free and distant metastasis-free survival were 85.3 % and 70.2 % respectively. Tumor size and lymph node metastasis were independent risk factors for treatment failure. Cumulative incidences of severe late bladder, rectal, bowel, and vaginal toxicity were 0.8%, 3.3%, 3.6%, and 1.4% respectively at 5 years of follow-up. Combined intracavitary-interstitial brachytherapy techniques were associated with less vaginal morbidity.

CONCLUSIONS

Primary chemoradiation with image-guided adaptive brachytherapy for locally advanced cervical cancer is a highly effective local and loco-regional treatment. However, survival is compromised by the occurrence of distant metastasis. Patients with large tumors and nodal involvement at diagnosis are at increased risk and may benefit from intensified treatment. Severe late gastrointestinal and urogenital toxicity is limited and may be further reduced by increasing conformity, using combined intracavitary-interstitial techniques and lowering doses to organs at risk.

The role of para-aortic nodal irradiation in cervical cancer

The current standard of care for locally advanced cervical cancer is whole pelvis and para-aortic radiation when indicated, delivered concomitantly with chemotherapy and brachytherapy. Para-aortic node involvement is a predictor of survival in locally advanced disease but presence of metastases is difficult to determine because the currently available imaging methods lack enough sensitivity to be able to detect accurately para-aortic metastases when surgical staging is not feasible. The objective of this review is to describe the current status of para-aortic lymph node irradiation in locally advanced cervical cancer. It includes analysis of the diagnostic imaging and surgical approaches for assessment of para-aortic lymph node dissemination, together with indications for radiotherapy and radiotherapeutic techniques.

Radiographic Number of Positive Pelvic Lymph Nodes as a Prognostic Factor in Cervical Cancer Treated With Definitive Concurrent Chemoradiotherapy or Intensity-Modulated Radiotherapy

Background: This study aims to assess the prognostic significance of radiographic numbers of positive pelvic lymph nodes (PLNs) in patients with cervical cancer treated with definitive concurrent chemoradiotherapy (CCRT) or intensity-modulated radiotherapy (IMRT).

Methods: We conducted a retrospective study that included 164 eligible adult patients with cervical cancer who were treated with definitive CCRT or IMRT at our institution from 2009 to 2016. After exclusion of 50 patients, a total of 114 patients whose clinicopathological data and follow-up were finally analyzed. The radiographic numbers of positive PLNs were assessed by pretreatment magnetic resonance imaging (MRI) or computed tomography (CT). The criterion for a positive lymph node was defined as a short-axis diameter >1 cm. Using the Kaplan–Meier method and the Cox proportional hazards regression model, we assessed the overall survival (OS), cancer-specific survival (CSS), distant metastasis-free survival (DMFS), and locoregional relapse-free survival (LRFS).

Results: The median follow-up duration was 40 (range: 2–100) months. For patients with 0, 1–2, and ≥3 positive PLNs, the estimated 3-year OS were 85.4% vs. 82.4% vs. 59.7% (p = 0.035), CSS were 90.1% vs. 86.1% vs. 62.9% (p = 0.010), DMFS were 89.4% vs. 91.3% vs. 49.6% (p < 0.001), and LRFS were 77.8% vs. 73.4% vs. 70% (p = 0.690). Per the multivariate Cox regression, positive PLNs ≥3 (HR, 2.51; 95% CI: 1.09–5.80; p = 0.031) and non-squamous cell carcinoma type (HR, 2.82; 95% CI: 1.19–6.69; p = 0.018) were unfavorable factors for the OS. Besides, positive PLNs ≥3 was the independent factor for the CSS (HR, 3.38; 95% CI: 1.32–8.67; p = 0.011) and DMFS (HR, 6.83; 95% CI: 2.62–17.83; p < 0.001). The patients that were treated without intracavitary brachytherapy exhibited inferior LRFS (HR, 13.15; 95% CI: 2.66–65.10; p = 0.002).

Conclusions: The radiographic number of positive PLNs (≥ 3) is an independent prognostic factor for OS, CSS, and DMFS in patients treated with definitive CCRT or IMRT.

Intensity-modulated radiation therapy for definitive treatment of cervical cancer: a meta-analysis

Background

To compare the efficacies and toxicities of intensity-modulated radiotherapy (IMRT) with three-dimensional conformal radiotherapy (3D-CRT) or conventional two-dimensional radiotherapy (2D-RT) for definitive treatment of cervical cancer.

Methods

A meta-analysis was performed using search engines, including PubMed, Cochrane Library, Web of Science, and Elsevier. In the meta-analysis, odds ratios (ORs) were compared for overall survival (OS), disease-free survival (DFS), and acute and chronic toxicities.

Results

Included data were analysed using RevMan 5.2 software. Six studies encompassing a total of 1008 patients who received definitive treatment (IMRT = 350, 3-DCRT/2D-RT = 658) were included in the analysis. A comparison of 3-year OS and 3-year DFS revealed no significant differences between IMRT and 3D-CRT or 2D-RT (3-year OS: OR = 2.41, 95% confidence interval [CI]: 0.62–9.39, p = 0.21; 3-year DFS: OR = 1.44, 95% CI: 0.69–3.01, p = 0.33). The incidence of acute gastrointestinal (GI) toxicity and genitourinary (GU) toxicity in patients who received IMRT was significantly lower than that in the control group (GI: Grade 2: OR = 0.5, 95% CI: 0.28–0.89, p = 0.02; Grade 3 or higher: OR = 0.55, 95% CI: 0.32–0.95, p = 0.03; GU: Grade 2: OR = 0.41, 95% CI: 0.2–0.84; p = 0.01; Grade 3 or higher: OR = 0.31, 95% CI: 0.14–0.67, p = 0.003). Moreover, the IMRT patients experienced fewer incidences of chronic GU toxicity than did the control group (Grade 3: OR = 0.09, 95% CI: 0.01–0.67, p = 0.02).

Conclusion

IMRT and conventional radiotherapy demonstrated equivalent efficacy in terms of 3-year OS and DFS. Additionally, IMRT significantly reduced acute GI and GU toxicities as well as chronic GU toxicity in patients with cervical cancer.