Image-guided, intensity-modulated radiation therapy in definitive radiotherapy for 1433 patients with cervical cancer

Dosimetric effects of bladder volume changes in MR-guided radiotherapy for cervical cancer

PURPOSE

Bladder volume variations during radiotherapy can significantly influence dose distribution to both target volumes and surrounding organs-at-risk (OARs). This study aims to assess the dosimetric impact of variable bladder volume on the clinical target volume (CTV) and OARs in cervical cancer patients undergoing MR-guided radiotherapy.

METHOD

A total of 27 cervical cancer patients were included in this study: 12 received radical radiotherapy, and 15 underwent postoperative radiotherapy. All patients were treated with the Elekta Unity MR-linac system. The dose requirement was 95-100% of the prescribed dose to the PTV(45 Gy/25 sessions/5 weeks). Daily images were acquired at the time of treatment using the MR-linac. For this study, MR images from the first three treatments of each patient were selected to contour the CTV and OAR (bladder, small bowel, rectum, right and left lateral femoral heads), and the treatment plan was recalculated using the Monaco TPS. The dosimetric effects of bladder volume changes on the CTV and OAR were analyzed by SPSS.

RESULT

Regarding the dosimetric effects on the CTV, in the postoperative radiotherapy group, D98 and D95 of the CTV decreased as the bladder filled. In contrast, for patients undergoing radical radiotherapy, the mean dose of the CTV increased from 5223.55 cGy to 5273.93 cGy as the bladder filled. For the dosimetric effects on the bladder, in the postoperative radiotherapy group, V30 and V20 of the bladder decreased as the bladder filled. In the radical radiotherapy group, the minimum dose of the bladder decreased with increasing bladder volume, but the maximum dose increased from 5347.68 cGy to 5581.63 cGy. For the rectum and small bowel, in the postoperative radiotherapy group, changes in bladder volume did not significantly affect the dose of the small bowel and rectum. However, in the radical radiotherapy group, the minimum and mean doses to the rectum and the D2 of the small bowel decreased with bladder filling.

CONCLUSION

This study evaluated the dosimetric and volumetric impact of bladder filling on the Clinical Target Volume (CTV) and Organs at Risk (OAR) using daily magnetic resonance (MR) images from the MR-linac. The findings indicate that variations in bladder filling significantly affect dose distribution to both the CTV and OAR.

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.

A Novel Scoring System to Predict Acute Radiation Enteritis Recovery in Cervical Cancer Patients Undergoing Concurrent Chemoradiotherapy: A Southwest China Cohort Study

Purpose

To establish a pragmatic and effective predictive model for monitoring the recovery of radiation enteritis (RE) in cervical cancer patients undergoing concurrent chemoradiotherapy (CCRT).

Methods

This study included 105 cervical cancer patients undergoing CCRT. We assessed baseline clinicopathologic characteristics, evaluated the effects of CCRT on circulating immune cells, tumor biomarkers, and inflammatory cytokines, and developed a predictive scoring system, the Immune-Tumor-Score (ITS), using the LASSO-Cox regression model. The model performance of LASSO-Cox and nomogram was compared via ROC curve and calibration curve.

Results

The median age of the patients was 55 years, with 53.3% having a normal BMI and 46.7% having positive lymph nodes. Post-CCRT, significant decreases were observed in lymphocyte counts, T-cell subpopulations, and tumor markers (CA125, TPA, SCCA, CYFRA21). The CD4/CD8 ratio and IL10 levels were significantly higher post-CCRT, while inflammation indexes (NLR, ELR) increased, and LMR decreased. The ITS, derived from 11 significant parameters, effectively predicted RE recovery, outperforming a traditional nomogram. Higher ITS scores correlated with shorter RE recovery times, as validated by Kaplan-Meier analyses and ROC curves (AUC = 0.822).

Conclusion

The ITS system provides a robust and reliable tool for predicting RE recovery in cervical cancer patients undergoing CCRT, surpassing traditional models in accuracy and reliability. This tool enables better patient management by allowing for timely interventions and personalized treatment strategies. Future research should focus on validating these findings in larger cohorts and integrating additional clinical parameters to enhance the predictive power of the ITS.

Application of Recombinant Human Superoxide Dismutase in Radical Concurrent Chemoradiotherapy for Cervical Cancer to Prevent and Treat Radiation-induced Acute Rectal Injury: A Multicenter, Randomized, Open-label, Prospective Trial

PURPOSE

The purpose of this study was to evaluate the efficacy of recombinant human superoxide dismutase (rhSOD) enemas in radiation-induced acute rectal injury (RARI) in patients with locally advanced cervical cancer.

METHODS AND MATERIALS

In this phase 3, randomized, open-label trial (NCT04819685) conducted across 14 medical centers in China from June 2021 to August 2023, all patients received concurrent chemoradiation therapy (CCRT). The experimental group was treated with a rhSOD enema during chemoradiation therapy, and the control group had no enema. The Common Terminology Criteria for Adverse Events (version 5.0) was used to evaluate radiation therapy-induced side effects. Endoscopic appearance was assessed using the Vienna Rectoscopy Score. The primary endpoint in the acute phase was the occurrence rate and duration of grade ≥1 (≥G1) diarrhea during CCRT. Secondary endpoints included the occurrence rate and duration of ≥G2 and ≥G3 diarrhea, ≥G1 and ≥G2 diarrhea lasting at least 3 days, and damage to the rectal mucosa due to radiation therapy measured by endoscopy.

RESULTS

Two hundred and eighty-three patients were randomly divided into the experimental (n = 141) or control group (n = 142). The mean number of ≥G1 and ≥G2 diarrhea days were significantly lower in the experimental group than in the control group (3.5 and 0.8 days vs 14.8 and 4.5 days, respectively; P < .001). The incidence of ≥G2 diarrhea decreased from 53.6% to 24.1% when rhSOD enemas were used. Use of antidiarrheals was lower in the experimental group (36.2% vs 55.7%, P < .001). Three patients felt intolerable or abdominal pain after rhSOD enema. RARI grades in the experimental group tended to be lower than those in the control group (P = .061). Logistic regression analysis revealed that rhSOD enema was associated with a lower occurrence rate of ≥G1/2 diarrhea for at least 3 days (P < .001).

CONCLUSIONS

The results of this study suggest that rhSOD enema is safe and significantly reduces the incidence, severity, and duration of RARI, protecting the rectal mucosa.

Weekly Image Guidance in Patients With Cervical Cancer Treated With Intensity-Modulated Radiation Therapy: Results of a Large Cohort Study

BACKGROUND

Image guidance is recommended for patients undergoing intensity-modulated radiation therapy (IMRT) for cervical cancer. In this study, we evaluated the feasibility of a weekly image guidance pattern and analyzed the long-term outcomes in a large cohort of patients.

METHODS

The study enrolled patients with Stage IB-IVA cervical cancer who received definitive radiotherapy or concurrent chemoradiotherapy. IMRT was delivered at a dose of 50.4 Gy in 28 fractions, with weekly cone-beam computed tomography (CBCT). Physicians advised patients on rectum and bladder preparation to help them prepare on nonimaging guidance days. When significant tumor regression was observed, a second computed tomography simulation and replanning were performed.

RESULTS

The median follow-up periods were 63.4 months. The incidence rates of loco-regional and distant failure were 9.9% and 13.6%. The 5-year overall survival (OS), disease-free survival (DFS), loco-regional relapse-free survival (LRFS), and distant metastasis-free survival (DMFS) rates were 80.1%, 72.9%, 78.3%, and 74.8%, respectively. For patients with different stages, the 5-year OS, DFS, LRFS, and DMFS rates were statistically significant. For patients with and without positive regional lymph nodes, the 5-year OS, DFS, LRFS, and DMFS rates were 64.5% and 86.0%, 56.8% and 78.8%, 62.7% and 84.3%, and 58.8% and 81.0%, respectively. Multivariate analysis showed that age, histology, tumor size, cancer stage, pretreatment squamous cell carcinoma antigen level, and para-aortic metastatic lymph nodes were independent prognostic factors of OS. Fifty-six (4.0%) patients experienced late Grade 3/4 chronic toxicities.

CONCLUSIONS

IMRT with weekly CBCT is an acceptable image guidance strategy in countries with limited medical resources.

Automatic segmentation of high-risk clinical target volume and organs at risk in brachytherapy of cervical cancer with a convolutional neural network

PURPOSE

This study aimed to design an autodelineation model based on convolutional neural networks for generating high-risk clinical target volumes and organs at risk in image-guided adaptive brachytherapy for cervical cancer.

MATERIALS AND METHODS

A novel SERes-u-net was trained and tested using CT scans from 98 patients with locally advanced cervical cancer who underwent image-guided adaptive brachytherapy. The Dice similarity coefficient, 95th percentile Hausdorff distance, and clinical assessment were used for evaluation.

RESULTS

The mean Dice similarity coefficients of our model were 80.8%, 91.9%, 85.2%, 60.4%, and 82.8% for the high-risk clinical target volumes, bladder, rectum, sigmoid, and bowel loops, respectively. The corresponding 95th percentile Hausdorff distances were 5.23mm, 4.75mm, 4.06mm, 30.0mm, and 20.5mm. The evaluation results revealed that 99.3% of the convolutional neural networks-generated high-risk clinical target volumes slices were acceptable for oncologist A and 100% for oncologist B. Most segmentations of the organs at risk were clinically acceptable, except for the 25% sigmoid, which required significant revision in the opinion of oncologist A. There was a significant difference in the clinical evaluation of convolutional neural networks-generated high-risk clinical target volumes between the two oncologists (P<0.001), whereas the score differences of the organs at risk were not significant between the two oncologists. In the consistency evaluation, a large discrepancy was observed between senior and junior clinicians. About 40% of SERes-u-net-generated contours were thought to be better by junior clinicians.

CONCLUSION

The high-risk clinical target volumes and organs at risk of cervical cancer generated by the proposed convolutional neural networks model can be used clinically, potentially improving segmentation consistency and efficiency of contouring in image-guided adaptive brachytherapy workflow.

The safety and efficacy of volumetric modulated Arc therapy combined with computer tomography-guided adaptive brachytherapy for locally advanced cervical cancer: a single institution experience

BACKGROUND

Volumetric modulated arc therapy (VMAT) is a novel form of IMRT, which can deliver more accurate dose distribution and shorten treatment time. Compared to MRI-guided adaptive brachytherapy, which is recommended as gold standard imaging for cervical cancer contours, CT-guided adaptive brachytherapy (CTGAB) is more available, more widespread, and more affordable in many centers. This study aims to retrospectively analyze the efficacy and the safety of VMAT combined with CTGAB for patients with locally advanced cervical cancer.

METHODS AND MATERIALS

This study retrospectively analyzed 102 patients with locally advanced cervical cancer who underwent VMAT and CTGAB. Clinical outcomes including local control (LC), overall survival (OS) and progression-free survival (PFS), tumor response to treatment evaluated by the Response Evaluation Criteria in Solid Tumors (RECIST) (version 1.1), and toxicities including gastrointestinal toxicity, urinary toxicity and hematologic toxicity evaluated by the Common Terminology Criteria for Adverse Events (CTCAE) (version 5.0) were analyzed. The Kaplan-Meier method was used to calculate LC, OS, and PFS.

RESULTS

Median follow-up time was 19 months. Complete response (CR), partial response (PR), stable disease (SD), and progressive disease (PD) occurred in 68 (66.7%), 24 (23.5%), 4 (3.92%), and 6 (5.88%), respectively. The 2-year and 3-year OS were 89.6% and 83%, respectively. The 2-year and 3-year PFS were 84.2% and 74.3%, respectively. The 2-year and 3-year LC were 90.1% and 79.3%, respectively. The average cumulative D2cm3 in the rectum, the bladder, the colon, and the small intestine were 78.07 (SD: 0.46) Gy, 93.20 (SD: 0.63) Gy, 63.55 (SD: 1.03) Gy and 61.07 (SD: 0.75) Gy, respectively. The average cumulative D90% of the high-risk clinical target volume (HR-CTV) was 92.26 (SD: 0.35) Gy. Grade ≥ 3 gastrointestinal and urinary toxicities occurred in 4.9% and 0.98%, respectively. 1.96% of patients were observed grade ≥ 4 gastrointestinal toxicities and none of the patients observed grade ≥ 4 urinary toxicities.

CONCLUSION

VMAT combined with CTGAB for locally advanced cervical cancer was an effective and safe treatment method, which showed satisfactory LC, OS, PFS, and acceptable toxicities.

Risk of Secondary Malignancies After Pelvic Radiation: A Population-based Analysis

Background and objective

Radiation therapy has increasingly been used in the management of pelvic malignancies. However, the use of radiation continues to pose a risk of a secondary malignancy to its recipients. This study investigates the risk of secondary malignancy development following radiation for primary pelvic malignancies.

Methods

A retrospective cohort review of the Surveillance, Epidemiology, and End Results database from 1975 to 2016 was performed. Primary pelvic malignancies were subdivided based on the receipt of radiation, and secondary malignancies were stratified as pelvic or nonpelvic to investigate the local effect of radiation.

Key findings and limitations

A total of 2 102 192 patients were analyzed (1 189 108 with prostate, 315 026 with bladder, 88 809 with cervical, 249 535 with uterine, and 259 714 with rectal/anal cancer). The incidence rate (defined as cases per 1000 person years) of any secondary malignancies (including but not limited to secondary pelvic malignancies) was higher in radiation patients than in nonradiation patients (incidence rate ratio [IRR] 1.04, confidence interval [CI] 1.03-1.05), with significantly greater rates noted in radiation patients with prostate (IRR 1.22, CI 1.21-1.24), uterine (IRR 1.34), and cervical (IRR 1.80, CI 1.72-1.88) cancer. While the overall incidence rate of any secondary pelvic malignancy was lower in radiation patients (IRR 0.79, CI 0.78-0.81), a greater incidence was still noted in the same cohorts including radiation patients with prostate (IRR 1.42, CI 1.39-1.45), uterine (IRR 1.15, CI 1.08-1.21), and cervical (IRR 1.72, CI 1.59-1.86) cancer.

Conclusions and clinical implications

Except for localized cervical cancer, when put in the context of median overall survival, the impact of radiation likely does not carry enough weight to change practice patterns. Radiation for pelvic malignancies increases the risk for several secondary malignancies, and more specifically, secondary pelvic malignancies, but with a relatively low absolute risk of secondary malignancies, the benefits of radiation warrant continued use for most pelvic malignancies. Practice changes should be considered for radiation utilization in malignancies with excellent cancer-specific survival such as cervical cancer.

Patient summary

The use of radiation for the management of pelvic malignancies induces a risk of secondary malignancies to its recipients. However, the absolute risk being low, the benefits of radiation warrant its continued use, and a change in practice patterns is unlikely.

Pelvic target volume inter-fractional motion during radiotherapy for cervical cancer with daily iterative cone beam computed tomography

BACKGROUND

Tumor regression and organ movements indicate that a large margin is used to ensure target volume coverage during radiotherapy. This study aimed to quantify inter-fractional movements of the uterus and cervix in patients with cervical cancer undergoing radiotherapy and to evaluate the clinical target volume (CTV) coverage.

METHODS

This study analyzed 303 iterative cone beam computed tomography (iCBCT) scans from 15 cervical cancer patients undergoing external beam radiotherapy. CTVs of the uterus (CTV-U) and cervix (CTV-C) contours were delineated based on each iCBCT image. CTV-U encompassed the uterus, while CTV-C included the cervix, vagina, and adjacent parametrial regions. Compared with the planning CTV, the movement of CTV-U and CTV-C in the anterior-posterior, superior-inferior, and lateral directions between iCBCT scans was measured. Uniform expansions were applied to the planning CTV to assess target coverage.

RESULTS

The motion (mean ± standard deviation) in the CTV-U position was 8.3 ± 4.1 mm in the left, 9.8 ± 4.4 mm in the right, 12.6 ± 4.0 mm in the anterior, 8.8 ± 5.1 mm in the posterior, 5.7 ± 5.4 mm in the superior, and 3.0 ± 3.2 mm in the inferior direction. The mean CTV-C displacement was 7.3 ± 3.2 mm in the left, 8.6 ± 3.8 mm in the right, 9.0 ± 6.1 mm in the anterior, 8.4 ± 3.6 mm in the posterior, 5.0 ± 5.0 mm in the superior, and 3.0 ± 2.5 mm in the inferior direction. Compared with the other tumor (T) stages, CTV-U and CTV-C motion in stage T1 was larger. A uniform CTV planning treatment volume margin of 15 mm failed to encompass the CTV-U and CTV-C in 11.1% and 2.2% of all fractions, respectively. The mean volume change of CTV-U and CTV-C were 150% and 51%, respectively, compared with the planning CTV.

CONCLUSIONS

Movements of the uterine corpus are larger than those of the cervix. The likelihood of missing the CTV is significantly increased due to inter-fractional motion when utilizing traditional planning margins. Early T stage may require larger margins. Personal radiotherapy margining is needed to improve treatment accuracy.

Long-term assessment of clinical parameters and positron emission tomography parameters in predicting recurrence in uterine cervical cancer patients receiving definitive chemoradiotherapy

OBJECTIVE

The objective of this study was to assess the prognostic value of clinical factors and metabolic parameters measured using fluorodeoxyglucose PET (FDG-PET/CT) in predicting disease recurrence, as well as distant metastasis-free survival (DMFS), local recurrence-free survival (LRFS), and overall survival (OS) in patients with uterine cervical cancer who received definitive chemoradiotherapy.

METHODS

The clinical data and FDG-PET parameters, including standardized uptake value (SUV), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of 194 patients with biopsy-confirmed squamous cell carcinoma of cervical cancer were retrospectively analyzed. Univariate and multivariate analyses were used to ascertain prognostic factors associated with DMFS, LRFS, and OS.

RESULTS

With a median follow-up of 12.5 years, 96 patients (49.5%) presented with disease recurrence, at a median of 9.9 months after chemoradiotherapy. Patients who experienced recurrence had significantly higher values for all FDG-PET parameters compared to patients who did not. In multivariate regression analysis, lymph node metastasis, MTV, and SUV mean were significantly correlated with distant metastasis, while local recurrence was only predicted by SUV max . Lymph node metastasis, high MTV, SUV mean , and TLG predicted shorter DMFS, while only the primary tumor SUV max predicted LRFS. Age, regional nodal metastasis, and higher MTV independently predicted shorter OS in multivariate analysis.

CONCLUSION

We found that metabolic parameters derived from FDG-PET/CT could serve as surrogates for disease recurrence in patients with cervical cancer who were treated with definitive chemoradiotherapy. Patients at high risk of distant metastasis could be defined using SUV mean and MTV, and for local recurrence, by using SUV max .

Analysis of nutritional risk, skeletal muscle depletion, and lipid metabolism phenotype in acute radiation enteritis

BACKGROUND

Radiation enteritis, which often occurs during radiation-induced acute intestinal symptoms (RIAIS), is the most common and important complication during radiotherapy for cervical cancer. RIAIS caused by abdominal and pelvic radiotherapy will affect nutrient intake, digestion, absorption, and metabolism, leading to malnutrition or poorer nutritional status. In patients with malignant tumors, malnutrition can adversely affect the curative effect and response of radiotherapy by reducing radiosensitivity, affecting the precision of radiotherapy placement and increasing the incidence of radiotherapy-related adverse reactions.

AIM

To analyze nutritional risk, skeletal muscle depletion, and lipid metabolism phenotype in acute radiation enteritis.

METHODS

Fifty patients with cervical cancer received external beam radiotherapy, and 15 patients received brachytherapy after external beam radiotherapy. Body weight, body composition parameters, nutritional risk screening (NRS) 2002 score, and blood biochemical indices of patients with cervical cancer during periradiation were tested by a one-way repeated measures analysis of variance. Metabolomics analysis was used to identify characteristic lipid metabolism pathways. Clinical factors that affect linoleic acid changes were screened using the generalized evaluation equation.

RESULTS

Among the 50 patients, 37 had RIAIS, including 34 patients with grade 1-2 RIAIS and 3 patients with grade 3 RIAIS. The NRS 2002 score of patients who underwent cervical cancer radiotherapy continued to increase during the periradiation period, and 42 patients who underwent cancer radiotherapy had nutritional deficits (NRS 2002 score ≥ 3 points) at the end of radiotherapy. Correlation analyses revealed that body weight and body mass index changes were closely associated with body fat content (R2 = 0.64/0.51). The results of the univariate analysis showed that radiotherapy time, percentage reduction of serum albumin, and percentage reduction of serum prealbumin were the key factors affecting skeletal muscle exhaustion (P < 0.05). Metabolomic analysis of fecal supernatants of cervical cancer patients during the periradiation period revealed the involvement of linoleic acid, cholic acid, arachidonic acid, and N-acetyl-L-benzene alanine in the metabolic pathway of linoleic acid.

CONCLUSION

Cervical cancer radiotherapy patients faced nutritional risks, decreased serum albumin synthesis, and increased risk of skeletal muscle exhaustion. Linoleic acid was a biomarker of high nutritional risk.

Risk Factors for Nodal Failure in Patients with FIGO IIIC Cervical Cancer Receiving Definitive Image-Guided Radiotherapy

BACKGROUND

Nodal failure is a major failure pattern for patients with FIGO IIIC cervical cancer, which is further associated with worse survival. This study was designed to investigate risk factors for nodal failure in FIGO IIIC cervical cancer patients.

METHODS

The characteristics of positive lymph nodes (LNs) and relevant clinical factors of 162 FIGO IIIC cervical cancer patients were collected. The chi-square test and logistic regression model were used to identify risk factors for nodal failure.

RESULTS

In total, 368 positive LNs were identified, including 307 pelvic LNs and 61 para-aortic LNs. The nodal failure rates for all LNs, pelvic LNs, and para-aortic LNs were 9.2%, 7.8%, and 16.4%, respectively. After 20 fractions of RT, a nodal short diameter (D20F) ≥ 0.95 cm and a ratio of nodal shrinkage (ΔV20F) < 0.435 resulted; <4 cycles of chemotherapy indicated higher nodal failure rates for all LNs. For pelvic LNs, ΔV20F < 0.435 and <4 cycles of chemotherapy were associated with a higher incidence of nodal failure. For para-aortic LNs, ΔV20F < 0.435 was the only risk factor for nodal failure.

CONCLUSIONS

Para-aortic LNs were more likely to experience nodal failure than pelvic LNs. Nodal shrinkage during radiotherapy and cycles of chemotherapy were associated with nodal failure in patients with FIGO IIIC cervical cancer.

Optimal cisplatin cycles in locally advanced cervical carcinoma patients treated with concurrent chemoradiotherapy

PURPOSE

To analyze the effect of cisplatin cycles on the clinical outcomes of patients with locally advanced cervical cancer (LACC) treated with concurrent chemoradiotherapy (CCRT).

METHODS

This study included 749 patients with LACC treated with CCRT between January 2011 and December 2015. A receiver operating characteristic (ROC) curve was used to analyze the optimal cut-off of cisplatin cycles in predicting clinical outcomes. Clinicopathological features of the patients were compared using the Chi-square test. Prognosis was assessed using log-rank tests and Cox proportional hazard models. Toxicities were compared among different cisplatin cycle groups.

RESULTS

Based on the ROC curve, the optimal cut-off of the cisplatin cycles was 4.5 (sensitivity, 64.3%; specificity, 54.3%). The 3-year overall, disease-free, loco-regional relapse-free, and distant metastasis-free survival for patients with low-cycles (cisplatin cycles < 5) and high-cycles (≥ 5) were 81.5% and 89.0% (P < 0.001), 73.4% and 80.1% (P = 0.024), 83.0% and 90.8% (P = 0.005), and 84.9% and 86.8% (P = 0.271), respectively. In multivariate analysis, cisplatin cycles were an independent prognostic factor for overall survival. In the subgroup analysis of high-cycle patients, patients who received over five cisplatin cycles had similar overall, disease-free, loco-regional relapse-free, and distant metastasis-free survival to patients treated with five cycles. Acute and late toxicities were not different between the two groups.

CONCLUSION

Cisplatin cycles were associated with overall, disease-free, and loco-regional relapse-free survival in LACC patients who received CCRT. Five cycles appeared to be the optimal number of cisplatin cycles during CCRT.

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.

Clinical research of the value of high-risk CTV setting on intensity-modulated radiotherapy for stage IIB-IVA cervical cancer

BACKGROUND

This study aims to evaluate the clinical efficacy and side effects of setting up a high-risk clinical target volume (CTV-hr) alongside simultaneous integrated boost intensity-modulated radiotherapy (IMRT-SIB) in patients diagnosed with stage IIB-IVA cervical cancer.

METHODS

This study retrospectively analysed patients with stage IIB-IVA cervical cancer who received radical radiotherapy at the Affiliated Hospital of Qingdao University between November 2014 and September 2019. The patients were divided into experimental and control groups based on whether CTV-hr was set. All patients received a combined treatment of radiotherapy and chemotherapy. The dosage for paclitaxel was 135 mg/m², while for cisplatin it was 75 mg/m² or for carboplatin it was AUC 4-6, given in a cycle of 21 days. Radiotherapy (RT) included external beam radiation therapy (EBRT) and intracavitary brachytherapy (ICBT). In the control group, positive lymph nodes (GTV-n) were treated at a dose of 58-62 Gy/26-28 fractions(f), while clinical target volumes (CTV) were treated with a dose of 46-48 Gy/26-28f. The experimental group received a simultaneous integrated boost (SIB) to CTV-hr at a dose of 54-56 Gy/26-28f, with the same CTV and GTV-n as the control group. Both groups were combined with brachytherapy with a total dose (EQD2, the equivalent dose in 2 Gy/f) of 80-90 Gy. The study measured objective remission rate (ORR), 3-year progression-free survival (PFS) rate, 3-year overall survival (OS) rate, recurrence rate, and side effects as endpoints.

RESULTS

The study enrolled 217 patients, with 119 in the experimental group and 98 in the control group. Results showed that the experimental group had a higher 3-year OS rate (87.4% vs. 71.4%, p = 0.001) and 3-year PFS rate (72.3% vs. 51.0%, p = 0.000) compared to the control group. Additionally, the experimental group had significantly lower rates of overall recurrence (26.1% vs. 50.0%, p = 0.003), in-field recurrence (15.1% vs. 36.7%, p = 0.000), and out-field recurrence(13.4% vs. 35.7%, p = 0.000) compared to the control group. All observed differences were found to be statistically significant. However, the experimental and control groups had no statistically significant difference in ORR and radiological side effects, such as radiation cystitis and enteritis (p > 0.05).

CONCLUSIONS

Setting CTV-hr and performing IMRT-SIB on patients with stage IIB-IVA cervical cancer effectively increased the 3-year OS rate, 3-year PFS rate and reduced recurrence rate, with no significant differences in side effects.

Fatty acid metabolism: A new therapeutic target for cervical cancer

Cervical cancer (CC) is one of the most common malignancies in women. Cancer cells can use metabolic reprogramming to produce macromolecules and ATP needed to sustain cell growth, division and survival. Recent evidence suggests that fatty acid metabolism and its related lipid metabolic pathways are closely related to the malignant progression of CC. In particular, it involves the synthesis, uptake, activation, oxidation, and transport of fatty acids. Similarly, more and more attention has been paid to the effects of intracellular lipolysis, transcriptional regulatory factors, other lipid metabolic pathways and diet on CC. This study reviews the latest evidence of the link between fatty acid metabolism and CC; it not only reveals its core mechanism but also discusses promising targeted drugs for fatty acid metabolism. This study on the complex relationship between carcinogenic signals and fatty acid metabolism suggests that fatty acid metabolism will become a new therapeutic target in CC.

Establishment of a prediction model for severe acute radiation enteritis associated with cervical cancer radiotherapy

BACKGROUND

Cervical cancer is one of the most common gynecological malignant tumors. Radiation enteritis (RE) leads to radiotherapy intolerance or termination of radiotherapy, which negatively impacts the therapeutic effect and seriously affects the quality of life of patients. If the incidence of RE in patients can be predicted in advance, and targeted clinical preventive treatment can be carried out, the side effects of radiotherapy in cervical cancer patients can be significantly reduced. Furthermore, accurate prediction of RE is essential for the selection of individualized radiation dose and the optimization of the radiotherapy plan.

AIM

To analyze the relationships between severe acute RE (SARE) of cervical cancer radiotherapy and clinical factors and dose-volume parameters retrospectively.

METHODS

We included 50 cervical cancer patients who received volumetric modulated arc therapy (VMAT) from September 2017 to June 2018 in the Department of Radiotherapy at The First Affiliated Hospital Soochow University. Clinical and dose-volume histogram factors of patients were collected. Logistic regression analysis was used to evaluate the predictive value of each factor for SARE. A nomogram to predict SARE was developed (SARE scoring system ≥ 3 points) based on the multiple regression coefficients; validity was verified by an internal verification method.

RESULTS

Gastrointestinal and hematological toxicity of cervical cancer VMAT gradually increased with radiotherapy and reached the peak at the end of radiotherapy. The main adverse reactions were diarrhea, abdominal pain, colitis, anal swelling, and blood in the stool. There was no significant difference in the incidence of gastrointestinal toxicity between the radical and postoperative adjuvant radiotherapy groups (P > 0.05). There were significant differences in the small intestine V₂₀, V₃₀, V₄₀, and rectal V₄₀ between adjuvant radiotherapy and radical radiotherapy after surgery (P < 0.05). Univariate and multivariate analyses revealed anal bulge rating (OR: 14.779, 95%CI: 1.281-170.547, P = 0.031) and disease activity index (DAI) score (OR: 53.928, 95%CI: 3.822-760.948, P = 0.003) as independent predictors of SARE.

CONCLUSION

Anal bulge rating (> 0.500 grade) and DAI score (> 2.165 points) can predict SARE. The nomogram shows potential value in clinical practice.

Comparative Analysis of 60Co and 192Ir Sources in High Dose Rate Brachytherapy for Cervical Cancer

High-dose-rate (HDR) brachytherapy (BT) is an essential treatment for cervical cancer, one of the most prevalent gynecological malignant tumors. In HDR BT, high radiation doses can be delivered to the tumor target with the minimum radiation doses to organs at risk. Despite the wide use of the small HDR 192Ir source, as the technique has improved, the HDR 60Co source, which has the same miniaturized geometry, has also been produced and put into clinical practice. Compared with 192Ir (74 days), 60Co has a longer half-life (5.3 years), which gives it a great economic advantage for developing nations. The aim of the study was to compare 60Co and 192Ir sources for HDR BT in terms of both dosimetry and clinical treatment. The results of reports published on the use of HDR BT for cervical cancer over the past few years as well as our own research show that this treatment is safe and it is feasible to use 60Co as an alternative source.

Clinical performance evaluation of O-Ring Halcyon Linac: A real-world study

BACKGROUND

Radiation therapy, especially the development of linear accelerators, plays a key role in cancer management. The fast-rotating coplanar O-ring Halcyon Linac has demonstrated many advantages. The previous literature has mainly focused on the machine parameters and plan quality of Halcyon, with a lack of relevant research on its clinical application.

AIM

To evaluate the clinical performance of the O-ring Halcyon treatment system in a real-world application setting.

METHODS

Data from sixty-one patients who were treated with the Halcyon system throughout the entire radiotherapy process in Peking Union Medical College Hospital between August 2019 and September 2020 were retrospectively reviewed. We evaluated the target tumour response to radiotherapy and irradiation toxicity from 1 to 3 mo after treatment. Dosimetric verification of Halcyon plans was performed using a quality assurance procedure, including portal dosimetry, ArcCHECK and point dose measurements for verification of the system delivery accuracy.

RESULTS

Of the 61 patients in the five groups, 16, 12, 7 and 26 patients had complete response, partial response, progressive disease and stable disease, respectively. No increase in the irradiated target tumour volume was observed when separately evaluating the local response. Regarding irradiation toxicity, no radiation-induced deaths were observed. Thirty-eight percent (23/61 patients) had no radiation toxicity after radiotherapy, 56% (34/61 patients) experienced radiation toxicity that resolved after treatment, and 6% (4/61 patients) had irreversible adverse reactions. The average gamma passing rates with a 2% dose difference and 2-mm distance to agreement for IMRT/VMAT/SRT plans were ArcCHECK at 96.4% and portal dosimetry at 96.7%, respectively. All of the validated clinical plans were within 3% for point dose measurements, and Halcyon’s ArcCHECK demonstrated a high pass rate of 99.1% ± 1.1% for clinical gamma passing criteria of 3%/3 mm.

CONCLUSION

The O-ring Halcyon Linac could achieve a better therapeutic effect on the target volume by providing accurate treatment delivery plans with tolerable irradiation toxicity.

Nomograms Predicting Survival of Cervical Cancer Patients Treated With Concurrent Chemoradiotherapy Based on the 2018 FIGO Staging System

Background

In 2018, a revised staging system was released for cervical cancer, which defined pelvic and paraaortic lymph node metastasis as stages IIIC1 and IIIC2, respectively. In this study, we constructed and validated nomograms to predict the 3- and 5-year survival of patients with cervical cancer based on the revised International Federation of Gynecology and Obstetrics (FIGO) staging system.

Methods

We retrospectively examined patients with 2009 FIGO stage IB–IVA cervical cancer who were treated at our institute between 2011 and 2015. Patients were randomized into the model development and validation cohorts (2:1). Univariate and multivariate analyses were conducted for the model development cohort to identify prognostic factors. In the multivariate analysis, nomograms were built to predict overall survival (OS) and disease-free survival (DFS) using significant variables. The nomograms were assessed based on the discrimination and calibration in both cohorts. Discrimination was assessed using the concordance index. Calibration was performed by comparing the mean nomogram estimated survival and the mean observed survival.

Results

We included 1,192 patients, with 795 and 397 patients in the model development and validation cohorts, respectively. In the model development cohort, the median follow-up period was 49.2 months. After multivariate analysis, age, histology, 2018 FIGO stage, and pelvic lymph node number were independent factors for OS. Histology, 2018 FIGO stage, squamous cell carcinoma antigen, and pelvic lymph node number were significant predictors of DFS. The nomograms constructed to predict OS and DFS were based on these factors. In both model cohorts, the concordance index for the nomogram-predicted OS and DFS was 0.78 and 0.75 and 0.74 and 0.67, respectively. The calibration curve revealed good agreement between the nomogram predictions and actual values.

Conclusion

We constructed robust nomograms to predict the OS and DFS of patients with cervical cancer undergoing treatment with concurrent chemoradiotherapy based on the 2018 FIGO staging system.

Comparing dosimetric and cancer control outcomes after intensity‑modulated radiation therapy and tomotherapy for advanced cervical cancer

Concurrent chemoradiation therapy (CCRT) is the standard treatment for locally advanced cervical cancer. The present study aimed to compare the therapeutic responses, toxicities and dosimetric parameters between intensity-modulated radiation therapy (IMRT) and tomotherapy (TOMO) in patients with advanced cervical cancer. This retrospective study included 310 patients with stage IIB-IIIB cervical cancer who underwent CCRT, with 155 patients in each group. Intracavitary brachytherapy was performed after a course of external beam radiation therapy (EBRT), or in the last week of pelvic EBRT. The treatment planning aim at point A (defined as a reference location 2 cm above the vaginal fornix and 2 cm beside the mid axis of the uterus) was >85 Gy in an equivalent dose at 2 Gy. There was no statistical difference with regard to clinicopathological characteristics between the two groups (P>0.05). Improved dose conformity and dose homogeneity (P<0.05) were observed in TOMO planning. TOMO provided more efficacious critical organ sparing than IMRT when assessing the percentage of normal tissue receiving at least 20 Gy (V20) for the bladder, the percentage of normal tissue receiving at least 40 Gy (V40) for the femoral head, and the V40 and V20 for the rectum (P<0.05). TOMO demonstrated a greater ability to protect the ovary (P<0.05). The acute radiation toxicity of proctitis and leukopenia were significantly lower in the TOMO group (P<0.05). The chronic radiation toxicity of radiation enterocolitis and cystitis was lower in the TOMO group (P<0.05). Thus, TOMO provided better critical organ sparing than IMRT. The radiation toxicities were acceptable. Therefore, TOMO appears to be a good option for the treatment of stage IIB-IIIB cervical cancer.

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.

Usefulness of Short-Term Imaging and Squamous Cell Carcinoma Antigen to Early Predict Response to Concurrent Chemoradiotherapy in Patients With Cervical Cancer

OBJECTIVE

The objective is to investigate the factors that can predict early treatment response in patients receiving concurrent chemoradiotherapy (CCRT) for cervical cancer.

METHODS

We assessed clinical factors and treatment response in patients who underwent CCRT for cervical cancer at four time points: initial, 2.5 weeks, 6 weeks after starting CCRT, and 3 months after completing CCRT. The final treatment response was determined by positron emission tomography-computed tomography (PET-CT) 3 months after completion of CCRT. Patients were divided into two groups according to the final treatment response: complete response (CR) group or non-CR group. And the early CCRT response prediction model was developed using stepwise multivariate logistic regression analysis.

RESULTS

Of the 62 patients who underwent CCRT for cervical cancer, 57 patients who completed all 4 time points examinations were included in the analyses and classified as CR (n = 32) and non-CR (n = 25) group. Tumor volume and serum squamous cell carcinoma antigen (SCC Ag) of the initial, 2.5 weeks, and 6 weeks after CCRT were significantly associated with the final treatment response. For the early treatment response prediction model, we selected patient age, tumor volume, and SCC Ag measured at initial and 2.5 weeks of CCRT as variables, and the equation of the final model was yielded. Using a cutoff of 0.433, this model had a sensitivity of 72.0%, a specificity of 84.4%, and a probability of 0.8225 (P < .0001).

CONCLUSION

Short-term (at 2.5 weeks after starting CCRT) measurements of tumor volume and serum SCC Ag were significant predictors of response to CCRT in patients with cervical cancer.

Comparison of survival, acute toxicities, and dose-volume parameters between intensity-modulated radiotherapy with or without internal target volume delineation method and three-dimensional conformal radiotherapy in cervical cancer patients: A retrospective and propensity score-matched analysis

BACKGROUND

To evaluate whether the use of the internal target volume (ITV) delineation method improves the performance of intensity-modulated radiotherapy (IMRT) and three-dimensional conformal radiotherapy (3DCRT) in terms of survival, acute toxicities, and dose-volume parameters.

METHODS

A total number of 477 cervical cancer patients who received concurrent chemoradiotherapy (CCRT) from January 2012 to December 2016 were retrospectively analyzed. They were divided into four groups: the non-ITV (N-ITV) + IMRT, ITV + IMRT, N-ITV + 3DCRT, and ITV + 3DCRT groups, with 76, 41, 327, and 33 patients, respectively. Survival analysis was performed with the Kaplan-Meier and the log-rank tests, and acute toxicity analysis was performed with the chi-squared test and the binary logistic regression test. Using the propensity score matching (PSM) method, 92 patients were matched among the four groups, and their dose-volume parameters were assessed with the Kruskal-Wallis method.

RESULTS

The median follow-up time was 49 months (1-119) for overall survival (OS). The 5-year OS rate was 66.4%. The ITV delineation method was an independent prognostic factor for OS (HR [95% CI]: 0.52 [0.27, 0.98], p = 0.044) and progression-free survival (PFS) (HR [95% CI]: 0.59 [0.36, 0.99], p = 0.045). The ITV + IMRT group had the lowest incidence rate (22%) and the N-ITV + IMRT group had the highest incidence rate of grade ≥3 hematological toxicity (HT) (46.1%) among the four groups. The pelvic bone marrow relative V10, V20, and V30 in the N-ITV + IMRT group was higher than those in the ITV + IMRT and N-ITV + 3DCRT groups (p < 0.05).

CONCLUSIONS

The use of ITV for IMRT treatment planning was associated with improved overall survival and progression-free survival, with lower HT rate.

A comparative study of smica in various body fluids of diagnosed cervical cancer patients and healthy women

Objective

Cervical cancer (CC) is a major public health problem in women, and its early detection can help reduce morbidity and mortality. The objective of this study was to compare serum levels of soluble MHC class I-related chain A (sMICA) levels in various body fluids between women diagnosed with CC and healthy women.

Methods

A case-control study was conducted at a tertiary care hospital and a cancer center in Kolhapur, India. Overall, 150 individuals (100 CC patients and 50 healthy women) participated after providing informed written consent. Demographic data, histopathology history, parity, and tumor, node, and metastasis (TNM) staging data were collected. Pap smears, saliva, blood, and urine samples were collected. Pap smears were examined microscopically, and sMICA levels in all samples were determined by enzyme-linked immunoassay (ELISA).

Results

The mean age of women with cervical cancer was 49.86±8.18 years. Squamous cell carcinoma (70%) was the most common histological variant in CC patients. Serum soluble sMICA levels differed significantly with parity and TNM staging (P<0.05). Mean levels of sMICA were significantly different in samples (CC cases vs. healthy patients; saliva: 166.721±108.718 vs. 0.039±0.005 pg/mL; urine: 82.921±45.580 vs. 0.010±0.005 pg/mL; serum: 35.756±10.799 vs. 0.039±0.005 pg/mL, P<0.001).

Conclusion

Levels of sMICA in body fluids can be considered as a diagnostic or prognostic tool to determine disease progression or tumor regression.

Clinical value of serum biomarkers, squamous cell carcinoma antigen and apolipoprotein C-II in follow-up of patients with locally advanced cervical squamous cell carcinoma treated with radiation: A multicenter prospective cohort study

There are currently no reliable, established serum biomarkers to predict the prognosis of radiotherapy for advanced cervical cancer. We aimed to identify serum biomarkers for survival after radiotherapy for cervical cancer. In this multicenter prospective cohort study, the usefulness of pre- and posttreatment serum protein levels of potential biomarkers, including squamous cell carcinoma antigen (SCC-Ag), apolipoprotein C-II (ApoC-II), matrix metalloproteinase (MMP)1, and MMP2, were evaluated together with clinical factors in 145 cervical cancer patients in order to determine their suitability to predict survival. Progression-free survival (PFS) was the primary endpoint, and overall survival (OS), pelvic PFS (PPFS), and distant metastasis-free survival (DMFS) were the secondary endpoints. Blood samples were collected before and 1 month after radiotherapy to measure serum biomarker levels. ApoC-II was measured using a monoclonal antibody-based enzyme-linked immunosorbent assay, which was developed for this purpose. Kaplan-Meier method, log-rank test, and univariate and multivariate Cox proportional hazards models were used for statistical analyses. In multivariate analysis, larger tumor size was independently associated with shorter PFS, OS, PPFS, and DMFS, while longer overall treatment time was independently associated with shorter PPFS. Higher pretreatment SCC-Ag (P < 0.001) was associated with shorter DMFS. Higher posttreatment SCC-Ag (P = 0.017) was also associated with shorter DMFS. Pretreatment ApoC-II was associated with PPFS in univariate analysis (P = 0.048), but not in multivariate analysis. Patients with pretreatment ApoC-II levels ≤ 25.8 μg/ml had shorter PPFS than those with pretreatment ApoC-II levels > 25.8 μg/ml (P = 0.023, log-rank test). Pre- and posttreatment serum SCC-Ag and pretreatment serum ApoC-II levels may be important biomarkers to predict survival outcomes of patients with cervical cancer after radiotherapy. Pre- and posttreatment SCC-Ag and pretreatment ApoC-II might be useful in clinical settings for screening patients to improve treatment strategies in cervical cancer.

Planning CT-guided robust and fast cone-beam CT scatter correction using a local filtration technique

PURPOSE

Cone-beam CT (CBCT) has been widely utilized in image-guided radiotherapy. Planning CT (pCT)-aided CBCT scatter correction could further enhance image quality and extend CBCT application to dose calculation and adaptive planning. Nevertheless, existing pCT-based approaches demand accurate registration between pCT and CBCT, leading to limited imaging performance and increased computational cost when large anatomical discrepancies exist. In this work, we proposed a robust and fast CBCT scatter correction method using local filtration technique and rigid registration between pCT and CBCT (LF-RR).

METHODS

First of all, the pCT was rigidly registered with CBCT, then forward projection was performed on registered pCT to create scatter-free projections. The raw scatter signals were obtained via subtracting the scatter-free projections from the measured CBCT projections. Based on frequency and intensity threshold criteria, reliable scatter signals were selected from the raw scatter signals, and further filtered for global scatter estimation via local filtration technique. Finally, corrected CBCT was reconstructed with the projections generated by subtracting the scatter estimation from the raw CBCT projections using FDK algorithm. The LF-RR method was evaluated via comparison with another pCT-based scatter correction method based on Median and Gaussian filters (MG method).

RESULTS

Proposed method was first validated on an anthropomorphic pelvis phantom, and showed satisfied performance on scatter removal even when anatomical mismatches were intentionally created on pCT. The quantitative analysis was further performed on four clinical CBCT images. Compared with the uncorrected CBCT, CBCT corrected by MG with rigid registration (MG-RR), MG with deformable registration (MG-DR), and LF-RR reduced the CT number error from 79 ± 35 to 25 ± 18 , 17 ± 13 and 7 ± 3 HU for adipose and from 115 ± 61 to 36 ± 22 , 30 ± 24 , 7 ± 3 HU for muscle, respectively. After correction, the spatial non-uniformity (SNU) of CBCT corrected with MG-RR, MG-DR and LF-RR was 51 ± 13 , 60 ± 21 , and 21 ± 9 HU for adipose, and 50 ± 22 , 57 ± 41 , and 25 ± 6 HU for muscle, respectively. Meanwhile, the contrast-to-noise ratio (CNR) between muscle and adipose was increased by a factor of 2.70, 2.89 and 2.56, respectively. Using the LF-RR method, the scatter correction of 656 projections can be finished within 10 s and the corrected volumetric images (200 slices) can be obtained within 2 min.

CONCLUSION

We developed a fast and robust pCT-based CBCT scatter correction method which exploits the local-filtration technique to promote the accuracy of scatter estimation and is resistant to pCT-to-CBCT registration uncertainties. Both phantom and patient studies showed the superiority of the proposed correction in imaging accuracy and computational efficiency, indicating promisingfuture clinical application.

The 100 Most Cited Papers in Radiotherapy or Chemoradiotherapy for Cervical Cancer: 1990-2020

Objective

This work aims to analyze the 100 most cited papers in radiotherapy or chemoradiotherapy for cervical cancer.

Methods

The 100 most cited papers in radiotherapy or chemoradiotherapy between 1990 and 2020 were identified with Thompson Reuters Web of Science citation indexing on August 24, 2020. The publication years, source titles, countries/regions, total citations, and average citations per year were extracted from the Web of Science. The research type and research domain were classified by the authors.

Results

These 100 papers were cited a total of 28,714 times, and the median number of citations was 169.5 (ranging from 116 to 1,700 times). The most cited paper was “Concurrent cisplatin-based radiotherapy and chemotherapy for locally advanced cervical cancer” by Rose et al., with a total citation of 1,700 times. The International Journal of Radiation Oncology Biology Physics (40 papers), Radiotherapy and Oncology (14 papers), and the Journal of Clinical Oncology (12 papers) published the largest number of papers. USA (47 papers), Austria (18 papers), Canada (13 papers), and England (13 papers) contributed the largest number of papers. Image-guided adaptive brachytherapy (IGABT) had the largest number of papers (25 papers). Concurrent chemotherapy was the most cited research domain, with 10,663 total citations and 592.4 citations per paper.

Conclusion

In the present study, we conducted a bibliometric analysis of the 100 most cited papers in radiotherapy or concurrent chemoradiotherapy for cervical cancer in the past 30 years. IGABT and concurrent chemotherapy were the most cited research domains.

Long-Term Toxicity and Efficacy of Intensity-Modulated Radiation Therapy in Cervical Cancers: Experience of a Cancer Hospital in Pakistan

PURPOSE

To report the chronic toxicity and disease outcomes attributable to intensity-modulated radiation therapy (IMRT) in patients with cervical cancer.

METHODS AND MATERIALS

Between January 2014 and December 2018, a retrospective review of medical records of patients with cervical cancer who received radiation therapy with IMRT was performed. Disease and treatment-related details were documented. Follow-up notes were reviewed, and severity of late toxicities was recorded. Overall survival (OS) and disease-free survival (DFS) at 3 years were estimated.

RESULTS

A total of 222 patients’ records were reviewed. Mean age was 50.7 years. Median follow-up duration was 33 months (range, 2-70 months). The most common toxicity was vaginal stricture (grade 2, n = 59, 26.6%; grade 3, n = 4, 1.80%), followed by proctitis (grade 2, n = 24; 10.8%; grade 3, n = 7; 3.20%). Seven patients (grade 2, n = 5, 2.3%; grade 3, n = 2; 0.90%) developed cystitis, and only 5 (grade 2; 2.3%) were found to have colitis. None of the patients had grade 4 or grade 5 toxicities. There was a significant difference in late complications in patients with nodal disease or those who underwent prior surgery (P < .05). Three-year OS and DFS rates were 79.7% and 81.9%, respectively. Patients with tumor size > 5 cm and those with pelvic lymph node metastasis had poor survival rates (P < .05).

CONCLUSION

IMRT is an effective and well-tolerated technique that should be considered in patients with lymph node disease and in postoperative patients. There is an inverse relationship between tumor size and nodal involvement with respect to OS and DFS.

Prognostic value of post-radiation serum squamous cell carcinoma antigen and primary tumor regression for cervical squamous cell carcinoma

OBJECTIVE

In this study, we determined the prognostic values of magnetic resonance imaging (MRI)-based primary tumor regression and serum squamous cell carcinoma antigen (SSCC-Ag) levels 4 weeks after definitive radiotherapy (RT) in cervical squamous cell carcinoma (CSCC) patients.

METHODS

This was a retrospective study involving 218 patients with histologically confirmed CSCC (stages IB-IVA). All the patients received definitive RT. Pre- and post-RT pelvic MRI and SSCC-Ag levels were measured. Locoregional control (LRC), distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival (OS) were evaluated, and possible OS prognostic factors were analyzed.

RESULTS

The median follow-up time was 25.57 (1.73-58.93) months. Thirty-six and 68 patients died and experienced recurrence, respectively, and the primary tumors of 130 (59.6%) and 88 (40.4%) patients exhibited complete response (CR) and non-CR, respectively. The 3-year OS, DFS, LRC, and DMFS rates were significantly higher in the CR than in the non-CR patients (85.2% vs. 67.9%, 78.9% vs. 39.0%, 93.4% vs. 63.8%, and 83.4% vs. 54.5%, respectively; p< 0.05). The 3-year OS, DFS, LRC, and DMFS rates were significantly lower in the patients with high post-RT SSCC-Ag levels than in those with low post-RT SSCC-Ag levels (38.0% vs. 83.9%, 21.2% vs. 66.3%, 73.0% vs. 84.9%, and 26.5% vs. 79.0%, respectively; p<0.05). Multivariate analyses indicated that SSCC-Ag levels were an independent OS predictor (HR: 5.749, 95% CI: 2.598-12.723, p< 0.001).

CONCLUSION

Post-RT SSCC-Ag levels are OS independent prognostic factors in CSCC patients receiving RT. Timely and optimized treatment plans for CSCC patients after 4 weeks of RT are necessary when patients with persistent tumor and/or positive SSCC-Ag.

Adaptive Radiotherapy in the Management of Cervical Cancer: Review of Strategies and Clinical Implementation

The complex and varied motion of the cervix-uterus target during external beam radiotherapy (EBRT) underscores the clinical benefits afforded by adaptive radiotherapy (ART) techniques. These gains have already been realised in the implementation of image-guided adaptive brachytherapy, where adapting to anatomy at each fraction has seen improvements in clinical outcomes and a reduction in treatment toxicity. With regards to EBRT, multiple adaptive strategies have been implemented, including a personalised internal target volume, offline replanning and a plan of the day approach. With technological advances, there is now the ability for real-time online ART using both magnetic resonance imaging and computed tomography-guided imaging. However, multiple challenges remain in the widespread dissemination of ART. This review investigates the ART strategies and their clinical implementation in EBRT delivery for cervical cancer.

Oncologic outcomes in the era of modern radiation therapy using FIGO 2018 staging system for cervical cancer

BACKGROUND

The recently published ASTRO cervical cancer guidelines recommend the use of modern radiotherapy. Imaging is now incorporated in the updated FIGO 2018 staging with a new stage IIIC. This study aims to evaluate the oncologic outcomes and predictors of survival using FIGO 2018 staging in a cohort of patients treated in an era of high-precision image-guided radiotherapy.

METHODS

We performed a retrospective cohort study of 216 adult cervical cancer patients treated with definitive chemoradiotherapy between 2010 and 2018. Eligible patients had non-metastatic cervical cancer treated at a single academic institution. All patients had pre-treatment MRI and CT/PET. Treatment protocol consisted of external beam intensity-modulated radiotherapy and 3D image-guided brachytherapy. Kaplan-Meier curves were used for survival analysis. Multivariate cox proportional-hazards model was performed to identify potential prognostic factors.

RESULTS

Median age at diagnosis was 50 and median BMI was 26.4 kg/m². Median follow-up time was 44.3 months. Five-year overall survival (OS), disease-free survival and loco-regional disease-free survival rates were 76.8%, 68.5% and 82.6%, respectively. FIGO 2018 showed better OS discrimination compared to FIGO 2009 classification. OS was increasingly worse with positive pelvic and para-aortic nodes (p < 0.001). In a multivariate prediction model, performance status (p = 0.044) and FIGO 2018 classification (stage III p = 0.016; stage IVA p = 0.010) were predictors of mortality; FIGO 2018 classification (stage III p = 0.003; stage IVA p = 0.001) was a predictor of any recurrence; MRI tumor diameter (p ≤ 0.001) and nodal metastases (p = 0.024) were predictors of loco-regional recurrence.

CONCLUSIONS

Integration of state-of-the-art imaging in cervical cancer staging and in radiotherapy planning leads to good loco-regional control rates, however distant recurrence remains an important issue. FIGO 2018 staging better reflects patient prognosis, highlighting the need for new treatment strategies for stage IIIC cervical cancer.

Combined dynamic contrast enhanced MRI parameter with clinical factors predict the survival of concurrent chemo-radiotherapy in patients with 2018 FIGO IIICr stage cervical cancer

PURPOSE

Combined clinical prognostic factors and magnetic resonance imaging (MRI) parameters on predicting the prognosis after concurrent chemo-radiotherapy (CCRT)in patients with 2018 International Federation of Gynecology and Obstetrics (FIGO) IIICr stage patients.

METHODS

A total of 117 patients with cervical cancer (2018 FIGO stage IIICr) who underwent CCRT were enrolled from Dec.2014 to Jul.2017. 47 patients developed outcome events, including 32 recurrences and 15 deaths. Clinical and MR parameters of primary tumors were analyzed, including apparent diffusion coefficient (ADC) values (ADC_mean, ADC_min, and ADC_max) and dynamic contrast-enhanced MRI (DCE-MRI) parameters (K^trans, K_ep, V_e) were recorded. The short diameters of visible lymph nodes in the MRI and enhanced computed tomography (CT) images were measured. Progression-free survival (PFS) was compared by Kaplan-Meier analysis and independent predictors were identified using cox regression analysis.

RESULTS

The median PFS was 35 months (6-68 month). The 1-year and 3-year PFS rates were was 90.4 %, 74.4 %, respectively. Multivariate analysis showed that 2018 FIGOIIIC2r stage (HR 2.701,95 %CI1.259to. 5.797; p = 0.011), K^trans(HR 0.353;95 %CI 0.189 to 0.659; p = 0.001) and ADC_min (HR0.423,95 %CI0.229to0.783; p = 0.006) were highly correlated with poor PFS.

CONCLUSION

In conclusion, we have identified IIIC2r stage, K^trans value and ADC_min value as the most important factors in evaluating the survival rate and prognosis of patients with stage IIICr cervical cancer. For stage IIIC1r subgroup, K^trans, ADC_min value and site of positive lymph node >2 were independent prognostic factors.

Systemic Inflammatory Score predicts Overall Survival in patients with Cervical Cancer

Background: To evaluate the prognostic value of the systemic inflammatory score (SIS) in cervical cancer patients.

Methods: A total of 264 patients with FIGO stage (2009) IB-IIA cervical cancer undergoing radical resection from January 2014 to December 2017 were recruited. The optimal cutoff values for inflammatory biomarkers were calculated by X-tile software. The prognostic factors were investigated using univariate and multivariate Cox analyses. Time-dependent receiver operating characteristic (time-ROC) analysis and the concordance index (C-index) were used to compare the prognostic impact of factors.

Results: In total, 264 patients with cervical cancer were included in the study. The optimal cutoff value for lymphocyte-to-monocyte ratio (LMR) was 4.1. In multivariate analysis, FIGO stage, lymphovascular invasion, lymph node metastasis, preoperative serum albumin (Alb), and LMR were independent prognostic factors (P<0.05). Then, we combined preoperative Alb and LMR to establish the SIS. Multivariate analysis showed that the SIS was an independent factor that affected survival (P<0.05). When stratified by FIGO stage, significant differences in survival were also found for patients with different SISs (P<0.05). When the SIS and FIGO stage were combined, the time-ROC curve was superior to that of FIGO stage only. The C-index of the model combining the SIS and FIGO stage was 0.786 (95% CI 0.699-0.873), which was significantly higher than that of the model with FIGO stage only (0.676, 95% CI 0.570-0.782, P=0.0049).

Conclusions: The preoperative SIS is a simple and useful prognostic factor for postoperative survival in patients with cervical cancer. It might assist in the identification of high-risk patients among patients with the same FIGO stage.

Association of pretreatment SUVmax of cervix and SCC-antigen with FIGO2018 stage in Stage IIB-IVB squamous cervical cancer and relationship to prognosis

OBJECTIVE

To evaluate the association of pretreatment maximum standardized ¹⁸ F-fluorodeoxyglucose uptake value (SUV_max ) of cervix and serum squamous cell carcinoma antigen (SCC-ag) with FIGO2018 stage and prognosis among women with Stage IIB-IVB squamous cervical cancer.

METHODS

Retrospective study of 116 women with FIGO2018 Stage IIB-IVB cervical cancer treated in Hangzhou, China, 2013-2015. The relationship between pretreatment SUV_max or SCC-ag and prognostic factors was evaluated by univariate and multivariate analyses.

RESULTS

Women were stratified by mean SUV_max and mean SCC-ag. There was a significant difference between low (<12.9) and high (≥12.9) SUV_max groups in menopause (P = 0.004), FIGO2018 stage (P = 0.015), and survival rate (P < 0.001). The low group had better overall and progress-free survival by Kaplan-Meier evaluation (both P = 0.022). High SCC-ag (≥14.6 ng/mL) was associated with FIGO2018 stage (P = 0.038) and distant metastasis (P = 0.011). There was a significant correlation between SUV_max and serum SCC-ag (P = 0.026). In multivariate Cox regression analyses, FIGO2018 stage (P = 0.019) and SUV_max of cervix (P = 0.015) were independent predictors of poor outcome in squamous cervical cancer.

CONCLUSION

Both SUV_max of cervix and SCC-ag were associated with FIGO2018 stage in squamous cervical cancer. Pretreatment high SUV_max of cervix and advanced FIGO2018 stage might indicate a poor prognosis.

Aberrant methylation of GADD45A is associated with decreased radiosensitivity in cervical cancer through the PI3K/AKT signaling pathway

Epigenetic inactivation of GADD45A is a common occurrence in different types of cancer. However, little is known regarding its association with radiosensitivity in cervical cancer (CC). Thus, the present study aimed to investigate the association between aberrant GADD45A methylation and radiosensitivity in CC. SiHa, HeLa and CaSki CC cells were treated with 5-azacytidine (5-azaC), with or without irradiation. The expression levels of GADD45A and AKT related molecules were detected via reverse transcription-quantitative PCR and western blot analyses. The methylation status of GADD45A was assessed via methylation-specific PCR and cell proliferation assays, while clonogenic assays and flow cytometric analysis were performed to assess the function of the genes (GADD45A and AKT) in the CC cell lines. The results demonstrated that methylation of GADD45A was significantly higher in the radioresistant tissues (63.16%) compared with the radiosensitive samples (33.33%). In addition, the surviving fraction of SiHa cells following irradiation with 2 Gy was demonstrated to be highest amongst the three CC cells (CaSki, 57±9.5%; HeLa, 70±4% and SiHa, 75±10%). The survival rate of SiHa cells following treatment with 5-azaC and ionizing radiation (IR) significantly decreased as the radiation dose increased, compared with treatment with IR alone. Following overexpression of GADD45A or treatment with 5-azaC, the radiosensitivity of SiHa cells significantly increased compared with both the control vector and PBS treated groups. In addition, the AKT inhibitor, MK-2206, increased the radiosensitivity of SiHa cells. Notably, aberrant methylation of GADD45A was associated with decreased radiosensitivity in CC, and the PI3K/AKT signaling pathway was essential for radioresistance, which was mediated through downregulation of GADD45A.

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.

Radiotherapy for Cervical Cancer in Patients with Systemic Lupus Erythematosus

OBJECTIVE

To determine the toxicity and efficacy of radiotherapy for cervical cancer in patients with systemic lupus erythematosus (SLE).

METHODS

Medical records of patients with SLE who received radiation for cervical cancer from January 2011 to January 2019 were reviewed. For definitive radiotherapy, a dose of 50.4 Gy in 28 fractions was delivered by intensity-modulated radiation therapy (IMRT) combined with high-dose-rate brachytherapy of 28 to 30 Gy in 5 fractions. A dose of 45 to 50.4 Gy in 25-28 fractions was delivered for postoperative radiation. All patients were in remission with or without a low dosage of prednisone or immunosuppressive medication. Survival data were analyzed with the Kaplan-Meier method. The incidence of severe toxicities among patients was compared with the chi-square test or Fisher's exact test.

RESULTS

Twelve patients with SLE were included in this study. Definitive radiotherapy was delivered in 7 patients with FIGO (2009) stage II-III disease. Five patients with FIGO I disease received postoperative radiation. The median follow-up time was 22.1 months. The 3-year overall survival (OS) and 3-year progression-free survival (PFS) were 77.8% and 83.3%, respectively. One patient of definitive radiotherapy and one patient of postoperative radiation died due to distant metastasis of cervical cancer. Grade 3 or higher acute and chronic reactions occurred in 58.3% and 8.3% patients, respectively. Acute grade 3 or higher toxicity correlated with the presence of chemotherapy (p = 0.045).

CONCLUSION

Modern radiotherapy for cervical cancer was well tolerated in SLE patients with remission and provided a favorable outcome.

Impact of radiation source activity on short- and long-term outcomes of cervical carcinoma patients treated with high-dose-rate brachytherapy: A retrospective cohort study

OBJECTIVE

High-dose-rate (HDR) afterloading brachytherapy using Iridium-192 source involves large radiation activity varieties due to fast decay. It was unknown but clinically desirable to evaluate its impacts on patient outcomes to support more informed decisions.

METHODS

Data of 510 cervical carcinoma (CC) patients were retrospectively included. High-radioactive (HR) and low-radioactive (LR) groups were statistically defined per patient-specific average mean-dose-rate (MDR) of all fractions. The cutoffs were calculated using R-3.6.1 packages based on significance of correlation with binary outcome or survival time. Categorized 1-month and 3-month follow-up results were analyzed as short-term outcomes. Long-term outcomes were evaluated using local recurrence-free survival (LRFS) and metastatic recurrence-free survival (MRFS). Propensity-score-matched (PSM) pairs were generated to reduce bias.

RESULTS

The median follow-up time was 47.1 months (interquartile range: 33.9 months-66.4 months), involving MDR varieties of up to 9 folds ranging from 6059.99 cGy/h to 54013.66 cGy/h due to 17 source replacements at intervals ranging from 93 days-199 days. Both short-term (1-month: p = 0.22; 3-month: p = 0.79) and long-term (LRFS: p = 0.10; MRFS: p = 0.46) outcomes showed no significant difference between HR and LR. Subgroup analysis displayed significantly better results in LR for stage I-II (3-month, p = 0.02) and stage II (LRFS, p = 0.04) patients. Both LRFS and MRFS of LR were significantly non-inferior to HR (p ≤ 0.02).

CONCLUSIONS

LR is clinically non-inferior or partially superior to HR for CC treatment using HDR, which dispels concerns of potentially undermined patient outcomes when source replacement is delayed.

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.

Adjuvant chemotherapy after radiotherapy or concurrent chemoradiotherapy for pelvic lymph node-positive patients with locally advanced cervical cancer: a propensity score matching analysis

Objective

The benefit of adjuvant chemotherapy after definitive chemoradiotherapy in patients with pelvic lymph node-positive cervical cancer has been poorly studied. This study aimed to test the hypothesis that the addition of adjuvant chemotherapy to definitive radiotherapy or concurrent chemoradiotherapy improves survival in patients with pelvic lymph node-positive cervical squamous cell carcinoma.

Methods

This retrospective study enrolled patients with stage IB–IVA pelvic lymph node-positive cervical squamous cell carcinoma, without para-aortic lymph node metastases and initially treated with definitive radiotherapy or concurrent chemoradiotherapy between March 2007 and February 2018. Patients were classified into the adjuvant chemotherapy (5-fluorouracil or paclitaxel, plus cisplatin) and no-adjuvant chemotherapy groups. Treatment outcomes were compared between the two groups before and after 1:1 ratio propensity score matching.

Results

Medical records of 951 patients were reviewed and 792 patients were excluded. Finally, 159 patients were enrolled for analysis. Of these, 42 patients received a median of two cycles (range, 1–6) of adjuvant chemotherapy and 117 patients under observation after primary treatment. The median follow-up period was 33.8 months (range, 2.9–113.0). Before propensity score matching, no significant difference was observed in survivals between the two groups (P>0.05). After propensity score matching, 37 pairs of patients were selected. The 3-year rates of progression-free survival, overall survival, local control, and distant metastasis-free survival in the adjuvant chemotherapy and no-adjuvant chemotherapy groups were 80.2% and 60.4% (P=0.07), 83.0% and 63.7% (P=0.17), 94.0% and 81.9% (P=0.12), and 85.9% and 60.1% (P=0.04), respectively. The incidences of grade 3–4 acute and late toxicities were comparable between the two groups (P>0.05).

Discussion

Adjuvant chemotherapy significantly improved 3-year distant metastasis-free survival in patients with pelvic lymph node-positive cervical squamous cell carcinoma. Further prospective studies are needed to provide supportive evidence for the therapeutic efficacy of adjuvant chemotherapy.

Validation of the 2018 FIGO Staging System of Cervical Cancer for Stage III Patients with a Cohort from China

Purpose

To validate the 2018 revised FIGO cervical cancer staging system for stage III patients with a cohort from China.

Patients and Methods

Patients with stage III cervical cancer (FIGO 2018) treated with definitive radiotherapy at our institute were reviewed. Each patient was evaluated with both the 2014 and 2018 staging systems. Disease-free survival (DFS) was calculated with the Kaplan-Meier method. Receiver operative characteristic (ROC) curves for the predictive accuracy of DFS in patients with cervical cancer according to different FIGO staging systems were created.

Results

Between January 2008 and December 2014, a total of 586 patients with FIGO stage IIIC cervical cancer (2018) were treated with definitive radiotherapy at our institute. The 3-year DFS for patients according to FIGO stage (2014) were as follows: IB2 73.2%, IIA 63.7%, IIB 66.7%, IIIA 64.7%, and IIIB 59.6% (P=0.580). The 3-year DFS according to FIGO stage (2018) were IIIA 79.9%, IIIB 70.4%, IIIC1 66.3% and IIIC2 29.8% (P<0.001). The AUC values for DFS were 0.552 (95% CI: 0.503–0.600, P=0.037) and 0.623 (95% CI: 0.575–0.671, P<0.001) for the 2014 and 2018 FIGO staging systems, respectively.

Conclusion

The 2018 FIGO staging system of cervical cancer showed more distinction within stages and better predictive accuracy for DFS than the preceding staging system in patients with stage III disease from China.

Low Tesla magnetic resonance guided radiotherapy for locally advanced cervical cancer: first clinical experience

OBJECTIVE

Magnetic resonance-guided radiotherapy (MRgRT) represents an innovative approach for personalized radiotherapy treatments and its applications are being explored in various anatomical sites to fully understand its potential advantages. This study describes the first clinical experience of MRgRT application in patients with locally advanced cervical cancer (LACC) undergoing neoadjuvant chemoradiotherapy. The feasibility of the technique is evaluated and its toxicity profile and clinical outcomes are reported.

METHODS

Patients with LACC (International Federation of Gynecology and Obstetrics stage IIA-IVA) undergoing neoadjuvant chemoradiotherapy (CRT) on a 0.35T Tri-60-Co hybrid unit (ViewRay) were retrospectively compared with randomly selected patients treated with a standard linear accelerator. Total prescribed dose was 50.6 Gy (2.3 Gy/fraction) to planning target volume 1 (PTV1) and 39.6 Gy (1.8 Gy/fraction) to PTV2, delivered using a simultaneous integrated boost. Surgery was performed 8 weeks after the end of CRT. The effect of magnetic resonance guidance on replanning approaches, treatment-related toxicities, and pathologic response were assessed for each patient. Patient outcomes were noted and dosimetric comparisons performed between the 2 arms.

RESULTS

Nine patients with LACC treated from May 2018 to November 2018 were retrospectively enrolled and their records compared with the records of an equivalent cohort of randomly selected patients. Five replanning cases were performed in the MRgRT group and 0 in the linear accelerator group. Acute G1-G2 gastrointestinal toxicities were observed in 33.3% of MRgRT patients and in 55.5% of linear accelerator patients; acute G1-G2 genitourinary toxicities in 22.2% and 33.3%, respectively. No G3 toxicity was found except for neutropenia in 2 patients. No differences were observed in pathologic response between the 2 groups.

CONCLUSIONS

Despite the retrospective nature of the observations and the low number of enrolled patients, the application of MRgRT in LACC appears to be safe and feasible with a favorable toxicity profile and response rates comparable to gold standard, supporting the setup of larger prospective studies to investigate the potentialities of this new technology.

A Risk Stratification for Patients with Cervical Cancer in Stage IIIC1 of the 2018 FIGO Staging System

This retrospective study was designed to investigate the heterogeneity of patients with cervical cancer in stage IIIC1 (the 2018 International Federation of Gynecology and Obstetrics staging system, FIGO) and conduct a risk stratification for this group of patients. We reviewed clinical records of 325 patients with stage IIIC1 treated with definitive concurrent chemoradiotherapy in our institute between January 2008 and December 2014. The median follow-up duration was 28.4 months (range: 1.9–114.2 months). The 3-year DFS for the 325 eligible patients was 66.3%. Tumor size of ≥4 cm and number of pelvic lymph node metastasis ≥2 were identified as adverse prognostic factors for disease free survival (DFS) in cervical cancer patients with stage IIIC1 (2018). A risk stratification based on the number of identified prognostic factors for DFS was performed. The 3-year DFS for patients in low-risk (without prognostic factor), intermediate-risk (with one prognostic factor) and high-risk group (with two prognostic factors) was 92.1%, 70.0%, and 51.1%, respectively (P < 0.001). Our study confirms the heterogeneity of patients with cervical cancer in FIGO stage IIIC1 (the 2018 FIGO staging system). Tumor size and number of pelvic lymph node metastasis (PLNM) are significant prognostic factors for DFS in patients with FIGO stage IIIC1. The next revision of FIGO staging system for cervical cancer, especially for stage IIIC1, should focus on tumor size and number of pelvic lymph node metastasis.

Extended-field intensity-modulated radiation therapy combined with concurrent chemotherapy for cervical cancer with para-aortic lymph nodes metastasis

OBJECTIVE

This study was conducted to evaluate the efficacy and toxicity of extended-field intensity-modulated radiation therapy combined with concurrent chemotherapy in patients with cervical cancer with positive para-aortic lymph nodes (PALN).

METHODS

From September 2007 to December 2014, a total of 59 patients who had cervical cancer with para-aortic lymph node metastasis were treated with concurrent chemoradiotherapy at our institution. A dose of 45-50.4 Gy in 25-28 fractions with extended-field intensity-modulated radiation therapy was prescribed to planning target volume, and a dose of 30-36 Gy in 5-6 fractions was prescribed to Point A with high-dose-rate brachytherapy. A concurrent first-line cisplatin-based chemotherapy regimen was used.

RESULTS

The median duration of follow-up was 32.1 months (range, 3.2-103.7 months). The 2- and 3-year overall survival, disease-free survival and local control rates were 69.0 and 52.8%, 45.0 and 41.3% and 83.4 and 81.0%, respectively. Distant metastasis was the major pattern of treatment failure, which occurred in 26 patients (44.1%). The incidence of Grade 3 or greater acute hematologic, gastrointestinal and genitourinary toxicity was 50.9, 1.7 and 3.4%, respectively. Only one patient had both Grade 3 late gastrointestinal and genitourinary toxicity.

CONCLUSIONS

The study found that extended-field intensity-modulated radiation therapy combined with concurrent chemotherapy was safe and effective in patients who had cervical cancer with positive PALN.

Clinical Outcomes of Volumetric Modulated Arc Therapy Following Intracavitary/Interstitial Brachytherapy in Cervical Cancer: A Single Institution Retrospective Experience

Purpose: To evaluate treatment outcomes and toxicity in patients with cervical cancer (CC) treated with volumetric modulated arc therapy (VMAT), followed by three-dimensional high-dose-rate intracavity combined with interstitial brachytherapy (IC/IS BT) compared with intensity-modulated radiation therapy (IMRT) treatment.

Materials and Methods: A total of 398 patients with stage IA–IVB CC treated with definitive radiotherapy with or without chemotherapy were retrospectively analyzed (331 VMAT and 67 IMRT). A total prescription dose of 45–50 Gy was delivered to pelvic field with VMAT/IMRT in 25/28 fractions, with five fractions per week. Every patient further received IC/IS BT for four to six 6.0-Gy fractions. Local control (LC), disease-free survival (DFS), overall survival (OS), and distant metastasis-free survival (DMFS) rates were calculated. Acute hematotoxicity and late toxicity were recorded.

Results: The median follow-up period was 25.47 (range, 0.93–58.93) months for the VMAT and 35.07 (4.8–90.37) months for IMRT. The 3-year OS, DFS, LC, and DMFS rate were 80.5, 65.4, 88.7, and 78.1% in VMAT group, and 76.2, 76.4, 83.1, and 86.1% in the IMRT group, respectively. No significant differences were found between VMAT and IMRT groups for OS, DFS, LC, and DMFS rate. However, patients in the VMAT group had lower incidence of chronic enterocolitis complication (26.6 vs. 38.8%, p = 0.004). In addition, a total of 3 (0.9%) patients developed grade 3 chronic cystitis, and 7 (2.1%) patients developed grade 3 or greater chronic enterocolitis in VMAT group.

Conclusion: VMAT combined with IC/IS BT can result in satisfactory curative outcomes and low incidences of late radiation enterocolitis and cystitis in CC treatment.

The role of squamous cell carcinoma antigen (SCC Ag) in outcome prediction after concurrent chemoradiotherapy and treatment decisions for patients with cervical cancer

At present, the standard treatment approach for locally advanced cervical cancer is concurrent chemoradiotherapy (CCRT). An elevated pretreatment squamous cell carcinoma antigen (SCC Ag) level is associated with extensive tumors and poor survival for patients with cervical cancer treated with definitive CCRT. SCC Ag levels can be used to help physicians make decisions regarding surgery, avoiding the complications of double treatment modalities. Elevated SCC Ag is associated with radiotherapy resistance, and the rate of SCC Ag reduction during CCRT can predict tumor response after treatment. Moreover, the failure of SCC Ag levels to normalize posttreatment can predict tumor relapse, with a specificity higher than 70%, and adjuvant therapies should be considered for these patients. SCC Ag also plays an important role in the early detection of tumor relapse in patients with cervical cancer during follow-up after CCRT, with high sensitivity and good cost-effectiveness.