Isolated paraaortic lymph node recurrence after definitive irradiation for cervical carcinoma

18F-FDG PET/CT guided salvage radiotherapy strategies for lymph-nodal relapses in gynecological cancers: SBRT vs ENRT

OBJECTIVE

To identify outcome differences between extended nodal radiotherapy (ENRT) with simultaneous integrated boost (SIB) and stereotactic body radiotherapy (SBRT), performed with advanced radiotherapy techniques, both of which were 18F-Fluoro-Deoxy-Glucose (FDG) PET/CT guided, for lymph-node (LN) relapses of gynecological tumors, and to identify the most important determining factors.

METHODS

Records of gynecologic patients treated in a single-institution with FDG PET/CT guided intensity-modulated radiotherapy (IMRT), image-guided radiotherapy (IGRT), or SBRT, were reviewed, and only patients at first salvage radiotherapy for LN relapses were considered. Local relapse-free- (LRFS), regional relapse-free- (RRFS), distant metastasis-free- (DMFS), disease-free-(DFS) and overall-survival (OS), as well as acute and late toxicity (with CTCAE v5.0 score), were determined.

RESULTS

Fifty-eight patients (23 ENRT+SIB; 35 SBRT) treated for 178 LNs from February 2007-April 2023, were identified. Median biological equivalent dose (BED10) delivered to PET-positive LNs was 76.5 Gy (Interquartile range-IQR- 74.4;78.7) for ENRT, and 72 Gy (IQR 59.5;75.6) for SBRT. Median follow-up was 81.1(IQR 48.5; 117.2) and 37.0 (IQR 21.3; 58.4) months for ENRT and SBRT, respectively. Thirty-six-month estimated LRFS was 90.2% for ENRT and 82.6% for SBRT; RRFS was 69% and 63.4%, DMFS 26.1% and 44.3%, and OS 73.7% and 60.4%; no statistically significant differences were found between the two groups (logrank test, p= 0.29). ENRT recorded more acute (p⩽0.033), but not late, toxicities.

CONCLUSIONS

ENRT+SIB and SBRT for gynecological LN tumor relapses obtain similar results in terms of disease-free and OS, with fair toxicity. Prospective studies with higher patient numbers are needed.

The impact of different clinicopathologic factors and salvage therapies on cervical cancer patients with isolated para-aortic lymph node recurrence

BACKGROUND

Cervical cancer patients with isolated para-aortic lymph nodes (PALN) recurrence were mainly associated with treatment failure. For these patients, radiotherapy, chemotherapy, surgery ± adjuvant therapy or chemoradiotherapy may be advised, however, no specific therapy has been proposed yet. This study aimed to explore factors influencing the prognosis of cervical cancer cases with isolated PALN recurrence and to find out an effective salvage therapy.

METHODS

Cervical cancer cases with isolated PALN recurrence who received therapies in Zhejiang Cancer Hospital between January 2013 and June 2021 were analyzed retrospectively.

RESULTS

Carcinoembryonic antigen (CEA) level > 10 ng/mL and positron emission tomography/computed tomography (PET/CT) imaging method used to detect the recurrence were found to be associated with the local control rate. PALN (positive), squamous-cell carcinoma-antigen (SCC-Ag) level (> 10 ng/mL) upon initial diagnosis, and CEA level (> 10 ng/mL), number of metastatic lymph nodes (several) at recurrence were associated with worse survival. Compared with surgery ± adjuvant therapy, chemotherapy (CT) alone or sequential chemoradiotherapy (SCRT) was associated with worse PFS or OS. Concurrent chemoradiotherapy (CCRT) after PALN recurrence could reduce the risk of the second recurrence. 3-year OS of cases after surgery ± adjuvant therapy was the highest (65%), followed by CCRT (45.7%), SCRT (38.9%), radiotherapy (RT) (33.3%), and CT (20.6%).

CONCLUSION

In cervical cancer patients with isolated PALN recurrence, chemoradiotherapy or surgery ± adjuvant therapy may be preferred as the salvage treatment.

Clinical Outcomes of Stereotactic Body Radiotherapy (SBRT) for Oligometastatic Patients with Lymph Node Metastases from Gynecological Cancers

BACKGROUND

To evaluate clinical outcomes of stereotactic body radiation therapy (SBRT) as a local treatment for lymph node metastases from gynecological cancers.

METHODS

Between November 2007 and October 2021, we retrospectively analyzed 29 lymph node metastases in 22 oligometastatic/oligoprogressive patients treated with SBRT. The Kaplan-Meier method was used to estimate the rates survival. Univariate analysis for prognostic factors were performed with the log-rank test, and Cox proportional hazards regression was used to estimate hazard ratios (HR).

RESULTS

Median age was 62 years (IQR, 50-80 years). Median follow-up was 17 months (IQR 10.5-31 months). The median survival was 22 months (CI 95%: 4.2-39.7, IQR: 12.5-34.5 months). Six months, one year and two year overall survival (OS) were 96.6%, 85.2%, and 48.7%, respectively. Median local control (LC) was not reached. Six months, 1one year and 2 year were 93.1%, 87.9%, and 79.9%, respectively. Distant metastasis free survival (DMFS) at one year, and two year was 53% and 37.1%, respectively Four patients (18%) experienced acute G1-G2 toxicities. No G3-4 acute toxicity was reported, and no late toxicity was observed.

CONCLUSIONS

SBRT for lymph node recurrence offers excellent in-field tumor control with safe profile and low toxicities. Size, number of oligometastases, and time primary tumor to RT seem to be significant prognostic factors.

Laparoscopic management of isolated nodal recurrence in gynecological malignancies is safe and feasible even for large metastatic nodes up to 8 cm: A prospective case series

BACKGROUND

The surgical treatment of isolated lymph node recurrence (ILNR) of gynecological malignancies is still debated. The feasibility and effectiveness of minimally invasive lymphadenectomy have been reported by few studies; however, it remains unclear what the upper tumor size limit is for a minimally invasive approach. We prospectively analyzed cases of ILNR treated by laparoscopy in our unit while focusing on the safety and feasibility of resecting large tumors suspected of recurrence using a minimally invasive approach.

MATERIALS AND METHODS

We carried out a prospective observational case-series study. We included all consecutive patients with ILNR from gynecological cancers who underwent minimally invasive lymphadenectomy at our unit from June 2013 to June 2021 to assess the safety and feasibility of such a surgical approach. We also evaluated the oncological outcome in terms of further recurrence, site of recurrence, and survival.

RESULTS

Twenty-seven patients with ILNR due to gynecological malignancies were included (ovarian cancer, 12; uterine malignancies, 12; cervical cancer, 3). Three had remarkably large LNs up to 8 cm: these emblematic cases have been reported in detail with accompanying videos of the surgical procedure. The most frequent site of ILNR was aortic (67%). Recurrent LNs were completely resected in all cases; none of the procedures was converted to open surgery. The median follow-up duration was 24 months. Ten patients (37%) had a new recurrence. To date five patients (18.5%) have succumbed, four (14.8%) are alive with evidence of disease, and 18 (66.7%) are alive with no evidence of disease.

CONCLUSIONS

Minimally invasive surgery for ILNR in gynecological malignancies may be an option feasible, safe, and effective in terms of oncological outcomes, even for large tumors. It also allows quicker recovery with early initiation of appropriate postoperative systemic chemotherapy, in the context of an optimal multimodal therapeutic approach.

Dose escalated simultaneous integrated boost of gross nodal disease in gynecologic cancers: a multi-institutional retrospective analysis and review of the literature

PURPOSE

Typical doses of 45-50.4 Gy used to treat regional nodes have demonstrated inadequate control of gross nodal disease (GND) in gynecologic cancer, and accelerated repopulation may limit the efficacy of a sequential boost. We reviewed outcomes of patients treated with a simultaneous integrated boost (SIB) at 2.25 Gy per fraction to positron emission tomography (PET) avid GND to evaluate toxicity and tumor control using this dose-escalated regimen.

MATERIALS AND METHODS

A total of 83 patients with gynecologic cancer and PET avid inguinal, pelvic, or para-aortic lymphadenopathy were treated using intensity-modulated radiation therapy (IMRT) with SIB. Primary cancers were mostly cervical (51%) and endometrial (34%), and included patients who received concurrent chemotherapy (59%) and/or brachytherapy boost (78%).

RESULTS

Median follow-up from radiation completion was 12.6 months (range, 2.7 to 92.9 months). Median dose to elective lymphatics was 50.4 Gy (range, 45 to 50.4 Gy) at 1.8 Gy/fraction. Median SIB dose and volume were 63 Gy (range, 56.3 to 63 Gy) and 72.8 mL (range, 6.8 to 1,134 mL) at 2-2.25 Gy/fraction. Nodal control was 97.6% in the SIB area while 90.4% in the low dose area (p = 0.013). SIB radiotherapy (RT) field failure-free, non-SIB RT field failure-free, and out of RT field failure-free survival at 4 years were 98%, 86%, and 51%, respectively. Acute and late grade ≥3 genitourinary toxicity rates were 0%. Acute and late grade ≥3 gastrointestinal toxicity rates were 7.2% and 12.0%, respectively.

CONCLUSION

Dose escalated SIB to PET avid adenopathy results in excellent local control with acceptable toxicity.

Intensity modulated radiotherapy in carcinoma cervix with metastatic para-aortic nodes: an institutional experience from a Regional Cancer Centre of Eastern India

Background

Cervical cancer is a major health problem, especially in developing countries like India. Extended field radiotherapy (EFRT) for cancer cervix treatment remains a challenging task for radiation oncologists. In the last decade studies have shown that EFRT using intensity modulated radiotherapy (IMRT) is feasible in treating gynaecological malignancies but there is a dearth of literature on this specific topic from this part of the world where patient profile differs greatly in several aspects from that of the western world. The aim of the study was evaluation of treatment response and toxicity profile in cases of carcinoma cervix with metastatic para-aortic nodes treated with intensity modulated radiotherapy technique.

Materials and methods

In this retrospective study the treatment records of 45 para-aortic node positive cervical cancer patients treated with EFRT (IMRT) and concurrent cisplatin were analysed for evaluation of loco-regional control and toxicities.

Results

Forty-four patients received full course of treatment. Among those 44 patients, 93.2% achieved complete response. Overall, the treatment was tolerated well and toxicities were within acceptable limits. Acute grade 3–4 toxicities were observed mostly in the form of anaemia and leucopenia. Most common late toxicities were those of small and large intestine.

Conclusion

EFRT with concurrent chemotherapy was successfully delivered for para-aortic nodes positive cervical cancer patients in Indian scenario where under-nutrition, infection, anaemia and several other factors adversely influence treatment outcome. Pelvic and para-aortic control rates were satisfactory. The technique was associated with an acceptable acute and late toxicity profile.

Patterns of Treatment Failure after Concurrent Chemoradiotherapy or Adjuvant Radiotherapy in Patients with Locally Advanced Cervical Cancer

OBJECTIVE

To identify patterns of therapy failure after radiotherapy in Chinese patients with locally advanced cervical cancer (LACC).

METHODS

A retrospective study was conducted at a Chinese hospital from June 2012 to July 2018. All analyses were done using SPSS 26.

RESULTS

105 patients with treatment failure were included. After a median follow-up of 27 months (range 10-82), the 3-year survival rate after therapy failure was 19.4%. In multivariate analysis, squamous cell carcinoma antigen (SCC-Ag) <4 ng/mL (p < 0.001) and disease-free interval >12 months (p = 0.013) showed significant survival benefits. We identified 3 types of failure: distant lymph node metastasis (n = 50), hematogenous metastasis (n = 53) and pelvic failure (n = 48). Most metastatic para-aortic lymph nodes (PALN) were inferior to the level of left renal hilum (84.8%, n = 28). A total of 80% of patients with supraclavicular lymph nodes (SCLN) metastasis ignored imaging on supraclavicular region. For solitary SCLN or lung metastasis, the prognosis was better than that combined with other sites failure, respectively (p = 0.005; p = 0.001). Many patients with central sites recurrence received insufficient doses of intracavitary brachytherapy (IBT) for low tolerance to pain.

CONCLUSION

The distribution of metastatic PALN is asymmetrical and optimizing clinical target volume to minimize toxicity of para-aortic radiation is necessary. The effect of ultrasonography as preliminary screening and follow-up means on SCLN metastasis can be expected. Pain management and psychological interventions are essential for patients receiving IBT.

Molecular landscape of recurrent cervical cancer

Cervical cancer (CC) is a major gynecological problem in developing and underdeveloped countries. Despite the significant advancement in early detection and treatment modalities, several patients recur. Moreover, the molecular mechanisms responsible for CC recurrence remains obscure. The patients with CC recurrence often show poor prognosis and significantly high mortality rates. The clinical management of recurrent CC depends on treatment history, site, and extent of the recurrence. Owing to poor prognosis and limited treatment options, recurrent CC often presents a challenge to the clinicians. Several in vitro, in vivo, and patient studies have led to the identification of the critical molecular changes responsible for CC recurrence. Both aberrant genetic and epigenetic modifications leading to altered cell signaling pathways have been reported to impact CC recurrence. Researchers are currently trying to dissect the molecular pathways in CC and translate these findings for better management of disease. This article attempts to review the existing knowledge of disease relapse, accompanying challenges, and associated molecular players in CC.

Pharmacological Treatment of Patients with Metastatic, Recurrent or Persistent Cervical Cancer Not Amenable by Surgery or Radiotherapy: State of Art and Perspectives of Clinical Research

Cervical cancer patients with distant or loco-regional recurrences not amenable by surgery or radiotherapy have limited treatment options, and their 5-year overall survival (OS) rates range from 5% to 16%. The purpose of this paper is to assess the results obtained with chemotherapy and biological agents in this clinical setting. Several phase II trials of different cisplatin (CDDP)-based doublets and a phase III randomized trial showing a trend in response rate, progression-free survival, and OS in favor of CDDP + paclitaxel (PTX) compared with other CDDP-based doublets have been reviewed. The factors predictive of response to chemotherapy as well as the benefits and risks of the addition of bevacizumab to CDDP + PTX have been analyzed. The FDA has recently approved pembrolizumab for patients with recurrent or metastatic cervical cancer in progression on or after chemotherapy whose tumors were PD-L1 positive. Interesting perspectives of clinical research are represented by the use of immune checkpoint inhibitors alone or in addition to chemotherapy, whereas PARP inhibitors and PI3K inhibitors are still at the basic research phase, but promising.

Stereotactic Ablative Radiotherapy for Recurrent or Metastatic Gynecological Cancer: Extending Lives?

OPINION STATEMENT

Recent phase II clinical trials suggest that stereotactic ablative radiation therapy (SABR) can potentially improve survival for patients with oligometastatic cancer. However, these studies have mostly enrolled primaries other than gynecologic malignancies. While level I evidence is limited, recent publications exploring the use of SABR for oligometastatic gynecologic cancers have indicated a potential role for this treatment in para-aortic lymph node recurrences, and in visceral and brain metastases. The use of SABR for recurrences in the pelvis presents a number of challenges as these patients have often received previous radiation treatment. In these settings, care must be taken to avoid trespassing normal tissue tolerance with SABR leading to toxicity, especially as the potential benefit of SABR in this setting is not based on high-level evidence. Although SABR is feasible and in general safe for oligometastatic gynecologic malignancies, insufficient data are available to indicate whether it is associated with improved survival. Clinical judgment that incorporates patient and tumor factors is needed to determine if SABR is appropriate for selecting patients. Future directions include combining SABR with novel systemic therapies, determining optimal sequencing of treatments, and generating more robust randomized data pertaining to the use of SABR for oligometastatic gynecologic cancers.

Time-Dependent Squamous Cell Carcinoma Antigen in Prediction of Relapse and Death of Patients With Cervical Cancer

OBJECTIVE

The aim of the study was to develop a methodology to identify the best use of a longitudinally measured biomarker in relevance to prognosis.

MATERIALS AND METHODS

Data of squamous cell carcinoma antigen (SCC-Ag) from 770 patients with cervical squamous cell carcinoma (SCC) were used. The pretreatment, nadir, and time-dependent SCC-Ag values were analyzed in relevance to disease relapse and death with univariate and multivariate analysis side by side with a variety of available clinicopathologic factors. The predictive power of the significant variates was evaluated by C-index with 5-fold cross validation.

RESULTS

The pretreatment, nadir, and time-dependent SCC-Ag were all significant risk factors for both relapse and death in the univariate analysis (p < .05), and the time-dependent SCC-Ag had the highest C-index in both events. The nadir and time-dependent SCC-Ag were both independently significant in response to relapse with International Federation of Gynecology and Obstetrics (FIGO) stage as the covariate, and the latter had a higher C-index (0.745). Only the time-dependent SCC-Ag was independently significant together with FIGO stage in response to death with the C-index at 0.844.

CONCLUSIONS

Increases in the serum level of SCC-Ag in cervical SCC patients suggest a higher risk of both relapse and death. The best use of serial SCC-Ag measurements is to include the time-dependent value in prognostic assessment with FIGO stage also accounted for. Cervical SCC patients should be followed up on their levels of SCC-Ag, and prognostic evaluation should be updated with recent measurements.

Comparison of salvage therapies for isolated para-aortic lymph node recurrence in patients with uterine cervical cancer after definitive treatment

Background

Some studies have demonstrated that concurrent chemo-radiotherapy is an effective salvage treatment for isolated para-aortic lymph node (PALN) recurrence.

However, no studies have compared multi-treatment modalities, such as radiation therapy (RT), concurrent chemoradiotherapy (CCRT), surgery, chemotherapy, and best supportive care (BSC), across a sufficient number of patients with PALN recurrence. We thus aimed to evaluate the clinical outcomes of multi-treatment modalities for isolated PALN recurrence in uterine cervical cancer.

Methods

Records of 50 patients who were first diagnosed with isolated PALN recurrence after definitive cervical cancer treatment from 2002 to 2016 at our institution were reviewed retrospectively. The initial definitive cervical cancer therapies included RT alone, CCRT, or surgery with or without post-operative RT. The median follow-up time was 33 months. The median age at recurrence diagnosis was 57 years (range, 26–84 years). The median duration between the end of initial treatment and recurrence was 10 months (range, 1–91 months). The median maximum metastatic lesion size was 17 mm (range, 8–60 mm). Twenty-four patients had one or two PALN metastases, while 26 had 3 or more. Eighteen patients were treated for recurrence with RT alone, seven with CCRT, three with surgery, 17 with chemotherapy, and five with BSC. Potential prognostic factors included histopathology, initial FIGO stage, initial treatment, age at recurrence, tumor markers (serum SCC-Ag and CEA) at recurrence, time to recurrence, maximum size of the metastatic lesion, number of metastases, and the recurrence treatment method.

Results

The 3-year overall survival (OS) rates of all patients were 47.0%. The 3-year OS rate of patients who underwent CCRT for recurrence was 85.7%; surgery, 66.7%; chemotherapy, 48.8%; RT, 41.3%; and BSC, 0% (p = 0.014). Univariate analysis revealed that only the recurrence treatment method was significantly associated with OS. The 3-year local control rate (LCR) and progression free survival (PFS) rate for CCRT were 100 and 71.4%; for surgery, 100 and 66.7%; for chemotherapy, 33.6 and 13.7%; and for RT, 55.5 and 14.1%, respectively (LCR: p = 0.028, PFS: p = 0.059). The number of metastatic lesions, SCC-Ag levels and recurrence treatment method were significantly associated with LCR. Age at recurrence, SCC-Ag levels, and number of metastatic lesions were significantly associated with PFS.

Conclusions

Although our patient cohort size was small, our results suggest that CCRT may be effective in preventing local disease recurrence in the PALN and may improve OS.

Para-aortic lymph node recurrence after curative radiotherapy for cervical cancer

OBJECTIVE

The para-aortic lymph nodes are one of the most common sites in recurrent cervical cancer. However, treatment strategies for para-aortic lymph node recurrence have not yet been established.This study aimed to evaluate the prognostic factors and treatment outcomes in patients with para-aortic lymph node recurrence after curative radiotherapy for cervical cancer.

METHODS

We retrospectively reviewed patients who developed para-aortic lymph node recurrence following curative radiation therapy for cervical cancer from January 2001 and December 2014 at the Samsung Medical Center. Prognostic factors for overall survival after recurrence were analyzed by univariate and multivariate analyses.

RESULTS

A total of 67 patients were included in the analysis. After a median follow-up of 24.0 months (range 4-155), the 3-year overall survival rate was 42.7%. 32 patients had isolated para-aortic lymph node recurrence (group 1), 21 patients had para-aortic lymph node recurrence combined with other lymph node recurrence (group 2), and 14 patients developed para-aortic lymph node recurrence with distant organ metastasis (group 3). The 3-year overall survival rates in groups 1, 2, and 3 were 60.8%, 42.1%, and 7.7%, respectively (p<0.001). In multivariate analysis, histologic type of squamous cell carcinoma (p=0.028), non-symptomatic recurrence (p=0.024), isolated para-aortic lymph node recurrence (p=0.008), and disease-free interval (p=0.008) were significant factors for survival. Among the patients with isolated para-aortic lymph node recurrence, survival rates differed significantly according to disease-free interval; the 3-year overall survival in patients with disease-free interval ≥12 months and disease-free interval <12 months was 69.6% and 37.5%, respectively (p<0.001).

CONCLUSIONS

In patients with para-aortic lymph node recurrence from cervical cancer, histologic type, presence of symptoms, extent of disease, and disease-free interval were the prognostic factors for survival. Patients with isolated para-aortic lymph node recurrence with disease-free interval ≥12 months had higher survival outcomes at 3 years.

Diagnostic value of 18F-FDG PET/MRI in recurrent pelvis malignancies of female patients: a systematic review and meta-analysis

The aim of this study was to assess the diagnostic performance of fluorine-18-fluorodeoxyglucose (F-FDG) PET/MRI for suspected recurrence of pelvis malignancies of female patients using a meta-analysis. We performed a systematical literature search for relevant studies in PubMed, Cochrane Library, Google Scholar, and several Chinese databases. Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) was used to assess the quality of all included studies. Pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were calculated per patient and per lesion. Summary receiver operating characteristic curves were also constructed. All procedures involving human participants in this study were performed in conformity with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments. Finally, seven articles comprising 257 patients and 695 lesions were included in this meta-analysis. On patient-based analysis, the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of F-FDG PET/MRI in detecting recurrence of pelvis malignancies were 0.96 [95% confidence interval (CI): 0.93-0.99], 0.95 (95% CI: 0.87-0.99), 9.85 (95% CI: 4.62-21.00), 0.07 (95% CI: 0.04-0.13), and 201.41 (95% CI: 62.89-645.03), respectively. On lesion-based analysis, the corresponding estimates were 0.99 (95% CI: 0.97-1.00), 0.94 (95% CI: 0.89-0.97), 17.11 (95% CI: 4.46-65.60), 0.02 (95% CI: 0.01-0.05), and 1125.24 (95% CI: 211.46-5987.79), respectively. The results of our meta-analysis indicate that F-FDG PET/MRI has excellent diagnostic performance in restaging female patients with suspected recurrence of gynecological pelvic malignancies.

Evaluation of T2-W MR imaging and diffusion-weighted imaging for the early post-treatment local response assessment of patients treated conservatively for cervical cancer: a multicentre study

Objectives

To compare MR imaging with or without DWI and clinical response evaluation (CRE) in the local control evaluation of cervical carcinoma after radiotherapy.

Methods

In a multicentre university setting, we prospectively included 107 patients with primary cervical cancer treated with radiotherapy. Sensitivity and specificity for CRE and MR imaging (with pre-therapy MR imaging as reference) (2 readers) were evaluated using cautious and strict criteria for identifying residual tumour. Nested logistic regression models were constructed for CRE, subsequently adding MR imaging with and without DWI as independent variables, as well as the pre- to post-treatment change in apparent diffusion coefficient (delta ADC).

Results

Using cautious criteria, CRE and MR imaging with DWI (reader 1/reader 2) have comparable high specificity (83% and 89%/95%, respectively), whereas MR imaging without DWI showed significantly lower specificity (63%/53%) than CRE. Using strict criteria, CRE and MR imaging with DWI both showed very high specificity (99% and 92%/95%, respectively), whereas MR imaging without DWI showed significantly lower specificity (89%/77%) than CRE. All sensitivities were not significantly different. Addition of MR imaging with DWI to CRE has statistically significant incremental value in identifying residual tumour (reader 1: estimate, 1.06; p = 0.001) (reader 2: estimate, 0.62; p = 0.02). Adding the delta ADC did not have significant incremental value in detecting residual tumour.

Conclusions

DWI significantly increases the specificity of MR imaging in the detection of local residual tumour. Furthermore, MR imaging with DWI has significant incremental diagnostic value over CRE, whereas adding the delta ADC has no incremental diagnostic value.

Key Points

• If MR imaging is used for response evaluation, DWI should be incorporated

• MR imaging with DWI has diagnostic value comparable/complementary to clinical response evaluation

• Inter-reader agreement is moderate to fair for two experienced radiologist readers

• Quantitative measurements of ADC early post-therapy have limited diagnostic value

Management of Para-aortic Lymph Node Disease in Patients With Cervical Cancer: What Is the Best Approach?

Cervical cancer remains a prevalent and deadly disease in low-income countries, especially among young and otherwise healthy women. Multimodality treatment has led to a significant improvement in outcomes for patients with locally advanced disease, and this is mainly because of the incorporation of platinum-based chemoradiotherapy in current treatment protocols. However, locally advanced tumors are associated with a greater risk for para-aortic lymph node (PALN) involvement, which is an important adverse prognostic factor. Most staging techniques have low accuracy for detection of disease in this area, which could lead to understaging and undertreatment. Meanwhile, patients with PALN disease are underrepresented in trials addressing the treatment of advanced cervical cancer and a few studies have been directed at this population. The aim of this review is to analyze the current data regarding staging and treatment of cervical cancer with PALN disease to determine which strategy is best when managing these patients.

Stereotactic Radiotherapy for Oligometastases in Lymph Nodes-A Review

In recent years, the concept of oligometastases has become accepted and reports on stereotactic body radiotherapy as a treatment method have been published. Lesions in the brain, lung, and liver have been reported as target lesions. However, lymph node oligometastases could be a good candidate for stereotactic body radiotherapy as well. In this study, the usability of stereotactic body radiotherapy for oligometastases to lymph nodes is assessed by researching for each primary site. As a result, we could consider that stereotactic body radiotherapy could be almost well applied for lymph node oligometastases from the breast, gynecological organs, and prostate. However, doubts remain concerning the usefulness of stereotactic body radiotherapy for cervical node metastases from head and neck cancer or for mediastinal node metastases from lung or esophageal cancer since late toxicities have occurred with a large radiation dose at hypofractionation to major vessels or the central respiratory tract, especially in patients with irradiation histories. In addition, high-dose irradiation is required to control lymph node metastases from colorectal cancer due to its radioresistance, and severe late adverse events would therefore occur in adjacent organs such as the gastrointestinal tract. In cases of lymph node oligometastases with a primary tumor in the stomach or esophagus, stereotactic body radiotherapy should be used limitedly at present because this patient population is not so large and these metastases are often located close to organs at risk. Because of the varied status of recurrence and varied conditions of patients, it is difficult to determine the optimal dose for tumor control. It might be reasonable to determine the treatment dose individually based on dose constraints of adjacent organs. The oligometastatic state is becoming more frequently identified with more sensitive methods of detecting such oligometastases. In addition, there seems to be another type of oligometastases, so-called induced oligometastases, following successful systemic treatment. To determine the optimal indication of stereotactic body radiotherapy for lymph node oligometastases, further investigation about the mechanisms of oligometastases and further clinical studies including a phase III study are needed.

The value of squamous cell carcinoma antigen (SCCa) to determine the lymph nodal metastasis in cervical cancer: A meta-analysis and literature review

BACKGROUND

The diagnostic power of CT or MRI on the lymph node status was limited. Supplement measurements were needed to assist the diagnosis of lymph node metastasis. The SCCa was reported to be close related to lymph node status. But currently the clinical value of serum SCCa measurement in lymph node status has not been clearly defined. This meta-analysis was to investigate this topic on a large scale.

METHOD

Searching the Pubmed, Embase, Cochrane library, CNKI and Wanfang database for SCC-Ag/SCCA/SCC-antigen and cervical cancer/tumor/carcinoma/neoplasm published in any language from Jan 1 1990 to Aug 1 2017. QUADAS (quality assessment of diagnostic accuracy studies) was used to evaluate the quality of the articles. An eligible set of data should include true positive, true negative, false positive and false negative number. Every set of data was extracted and analyzed by STATA 14.0. The forest plot and bivariate boxplot were utilized to evaluate the heterogeneity. The funnel graph was used to test the publication bias. The SROC curve was draw via random effect model and HSROC model.

RESULT

17 sets of data and 3985 patients were included for the diagnostic meta-analysis. There was heterogeneity, which was partially from SCCa cut-off value. The pooled sensitivity was 0.70 and specificity was 0.63. AUC was 0.73. Eight articles provided the relative risk value of lymphatic metastasis when SCCa increased. The relative risk of lymph node metastasis increased ranging from 2.3-40 as with different SCCa cut off value.

CONCLUSION

The diagnostic value of SCCa for lymph nodal metastasis was medium and it was strongly related to lymph node status. Thus SCCa could assist imaging tests to detect lymph node metastasis. Besides, it was correlated with para-aortic lymph node metastasis.

Prognostic Importance of the Site of Recurrence in Patients With Metastatic Recurrent Cervical Cancer

PURPOSE

The clinical characteristics and outcomes of patients with metastatic recurrent cervical cancer remain poorly understood. The goals of the present study were to investigate the survival outcomes according to the recurrence site in a large cohort of cervical cancer patients.

METHODS AND MATERIALS

Of 1322 patients with primary cervical cancer from 2000 to 2013, 205 with recurrence after primary or adjuvant postoperative radiation were enrolled retrospectively. Aggressive salvage therapy (AST), which was defined as salvage therapy that aimed not only to relieve symptoms but also to ablate recurrent tumors by the single or combined application of surgical resection of local recurrence, metastasectomy, or metastasis-directed irradiation, followed by chemotherapy, was performed according to our institutional guidelines. The patterns of recurrence, application rate and mode of AST, and survival outcomes were evaluated retrospectively under approval from the institutional review board.

RESULTS

Regarding the pattern of recurrence, distant-only (DO) recurrence was most common (59.5%), followed by combined (21.5%), central (cervix or vaginal stump; 10.7%), and pelvic (pelvic lymph nodes or pelvic side wall; 8.3%) recurrence. Two subgroups (distant lymph nodes and lung parenchyma) of the DO group demonstrated remarkably good prognosis and were categorized as type A DO; the other subgroups were labeled type B DO. Patients with type A DO recurrence constituted 36% of all recurrences and 83.8% of them received AST. The 5-year overall survival rates were significantly greater in the type A DO group than in the other groups (44.8% in the type A DO group, 12.6% in the pelvic group, and 6.8% in the type B DO group).

CONCLUSIONS

We identified a patient subgroup with favorable outcomes after salvage therapy, type A DO, defined as recurrence in the distant lymph nodes only or in the lung parenchyma only. A future prospective trial is needed to investigate whether AST improves survival in this group.

Survival and Control Prognosticators of Recurrent Gynecological Malignancies of the Pelvis and Para-aortic Region Treated with Stereotactic Body Radiation Therapy

Purpose

To define prognostic factors associated with improved survival and local control (LC) for gynecologic cancer recurrences limited to the pelvis and para-aortic (PA) region using stereotactic body radiation therapy (SBRT).

Methods

Between 2/2008 and 7/2014, 30 women (35 targets) with pelvic or PA recurrence of endometrioid (n = 12), cervical (n = 11), ovarian (n = 3), uterine-serous (n = 2), or carcinosarcoma (n = 2) cancer were treated with SBRT. Eleven recurrences were located in the central pelvis, 11 along the pelvic sidewall (PSW), and 13 in the PA region.

Results

Five-year survival for all patients was 42% with a median survival of 43.4 months. Multivariate analysis revealed better performance status (PS), and smaller clinical tumor volume was significant for improved survival (p < 0.05).

Conclusion

SBRT is a local therapy for recurrent gynecological malignancies in the pelvis and PA region with curative potential. SBRT is especially effective for LC when targeting PSW or PA recurrence and for patients with a cervical/endometrioid uterine primary. Survival is improved for patients with better PS and smaller recurrence volume prior to SBRT.

Clinical value of routine serum squamous cell carcinoma antigen in follow-up of patients with locally advanced cervical cancer treated with radiation or chemoradiation

Objective

The objective of this study was to evaluate the clinical benefits of routine squamous cell carcinoma antigen (SCC-Ag) monitoring of patients with locally advanced cervical squamous cell carcinoma treated with radiation or chemoradiation.

Methods

A total of 53 patients with recurrent cervical squamous cell carcinoma treated with radiotherapy or chemoradiation were enrolled in this study. A retrospective review of medical records was conducted. The role of routine monitoring of serum SCC-Ag was evaluated in terms of cost effectiveness and effect on survival after diagnosis of recurrence.

Results

Serum SCC-Ag abnormality (≥2.5 ng/mL) was observed in 62.3% of patients when recurrent disease was diagnosed. The first indicator of relapse was abnormal serum SCC-Ag level in 21 patients (39.6%), 10 of whom had asymptomatic recurrent disease amenable to salvage therapy. Adding SCC-Ag measurement to the basic follow up protocol improved the sensitivity for detecting recurrence (The sensitivity of the basic protocol vs. addition of SCC-Ag: 49.1% vs. 88.7%, P<0.001). Twenty-three patients who were candidates for salvage therapy with curative intent showed better survival compared with those who were not candidates for therapy (5-year survival: 36.6% vs. 0%, P=0.012).

Conclusion

Surveillance with routine serum SCC-Ag monitoring can better detect asymptomatic recurrent disease that is potentially amenable to salvage therapy with curative intent. Early diagnosis of recurrent disease that can be treated with salvage therapy may lead to better survival.

Extended field radiotherapy with or without chemotherapy in patients with cervical cancer and positive para-aortic lymph nodes: a single institution retrospective review

BACKGROUND

Positive para-aortic lymph node (PALN) at diagnosis in cervical cancer patients confers an unfavorable prognosis. This study reviewed the outcomes of extended field radiotherapy (EFRT) and concurrent chemotherapy with extended field RT (CCEFRT) in patients with positive PALN at diagnosis.

MATERIALS AND METHODS

Medical records of 407 cervical cancer patients between 1st January 2002 to 31st December 2012 were reviewed. Some 32 cases with positive PALN were identified to have received definitive extended field radiotherapy with or without chemotherapy. Treatment outcomes, clinicopathological factors affecting survival and radiotherapy related acute and late effects were analyzed.

RESULTS

Totals of 13 and 19 patients underwent EFRT and CCEFRT respectively during the period of review. The median follow-up was 70 months. The 5-year overall survival (OS) was 40% for patients who underwent CCEFRT as compared to 18% for patients who had EFRT alone, with median survival sof 29 months and 13 months, respectively. The 5-years progression free survival (PFS) for patients who underwent CCEFRT was 32% and 18% for those who had EFRT. Median PFS were 18 months and 12 months, respectively. Overall treatment time (OTT) less than 8 weeks reduced risk of death by 81% (HR=0.19). Acute side effects were documented in 69.7% and 89.5% of patients who underwent EFRT and CCEFRT, respectively. Four patients (12.5%) developed radiotherapy late toxicity and there was no treatment-related death observed.

CONCLUSIONS

CCEFRT is associated with higher 5-years OS and median OS compared to EFRT and with tolerable level of acute and late toxicities in selected patients with cervical cancer and PALN metastasis.

Prolonged survival in a patient with isolated skull recurrence of cervical carcinoma - Case report and review of the literature

A 58 years old woman was diagnosed with squamous cell carcinoma of the uterine cervix FIGO stage IIB and was treated by concomitant radio-chemotherapy followed by simple hysterectomy. Several months later a single metastasis to the skull was diagnosed. The patient underwent craniotomy and radiotherapy and achieved a prolonged disease free survival of 20 months.

Bone metastases from cervical carcinoma are usually part of widespread metastatic disease. Skull metastases are extremely rare. Selected cases of solitary bone metastases can be treated radically and achieve long term disease free survival.

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Cervical carcinoma can rarely spread to the bones of the skull.

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Symptoms include headache and a palpable mass.

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Radical therapy with surgery and radiotherapy for an isolated bone recurrence can result in prolonged disease free survival.

Utility of serum squamous cell carcinoma antigen levels at the time of recurrent cervical cancer diagnosis in determining the optimal treatment choice

OBJECTIVE

To investigate the utility of serum squamous cell carcinoma antigen (SCC-Ag) levels upon the diagnosis of recurrent cervical cancer for decision making in patient management.

METHODS

Clinical records from 167 cervical cancer patients who developed recurrence between April 1996 and September 2010 were reviewed. A Cox proportional hazards regression model was used to investigate the prognostic significance of serum SCC-Ag levels at the time of recurrence. The effects of various salvage treatments on survival outcomes of recurrent cervical cancer were examined with respect to serum SCC-Ag levels.

RESULTS

Serum SCC-Ag levels were elevated (>2.0 ng/mL) in 125 patients (75%) when recurrence was diagnosed. These patients exhibited significantly shorter postrecurrence survival than those with normal SCC-Ag levels (log-rank; p=0.033). Multivariate analyses revealed that an elevated serum SCC-Ag level was an independent prognostic factor for poor postrecurrence survival. In patients with SCC-Ag levels <14.0 ng/mL, radiotherapy or surgery resulted in improved survival compared with chemotherapy or supportive care. In contrast, in patients with SCC-Ag levels of ≥14.0 ng/mL, salvage treatment with radiotherapy had only a minimal impact on postrecurrence survival.

CONCLUSION

The serum SCC-Ag level measured when cervical cancer recurrence is diagnosed can be useful for deciding upon the appropriate salvage treatment.

Prognostic value of different patterns of squamous cell carcinoma antigen level for the recurrent cervical cancer

Purpose

In some unusual cases, in patients with cervical cancer, an elevation of squamous cell carcinoma antigen (SCC-Ag) was not observed at diagnosis but was observed on recurrence, or vice versa. The objective of this study was to identify patient-, disease-, and treatment-related factors associated with this unusual level of SCC-Ag, and to determine whether SCC-Ag is a useful tumor marker in such patients.

Materials and Methods

Among 129 patients with recurrence, 14 who showed a normal SCC-Ag level at diagnosis but an elevated level at recurrence were classified as group I; 22 patients with an elevated SCC-Ag level at diagnosis but not at recurrence were classified as group II; and 76 patients with an elevated SCC-Ag level at both diagnosis and recurrence were classified as group III.

Results

In univariate analysis, unusual SCC-Ag showed statistically significant relationships with pathology and biochemical response to treatment. However, in the multivariate analysis, none of the clinicopathologic factors showed a statistical relationship with unusual levels of SCC-Ag. The 5-year disease-free survival rates for groups I, II, and III were 7.1%, 9.1%, and 0% (p=0.418), and the 5-year overall survival rates were 34.3%, 58.4%, and 33.3% (p=0.142), respectively.

Conclusion

The value of SCC-Ag has been confirmed in all patients; thus, check of SCC-Ag level at follow-up should be considered. Although no statistically significant differences were observed among the groups, we conclude that patients with a high initial SCC-Ag and elevated SCC-Ag at relapse have poor prognosis due to high SCC-Ag level.

Laparoscopic transperitoneal infrarenal para-aortic lymphadenectomy in patients with FIGO stage IB1-II B cervical carcinoma

These authors suggest that laparoscopic transperitoneal infrarenal lymphadenectomy for cervical cancer is a feasible, safe procedure.

Background and Objectives:

This study aimed to evaluate the safety, feasibility, and clinical outcomes of laparoscopic transperitoneal infrarenal para-aortic lymphadenectomy in patients with FIGO stage IB1-IIB cervical carcinoma.

Methods:

Between August 1999 and April 2009, we performed 59 laparoscopic transperitoneal lymphadenectomies; specifically, 12 procedures were performed up to the level of the left renal vessels, and 47 procedures were performed up to the level of the inferior mesenteric artery. We retrospectively analyzed the pathology reports and clinical data and compared the 2 groups. The data were analyzed with a nonparametric Mann-Whitney test, Kaplan-Meier log-rank test, and Pearson's correlation analysis.

Results:

The 2 groups did not significantly differ with respect to histologic type (P=.093), clinical stage (P=.053), tumor size (P=.383), time interval to start adjuvant therapy postoperatively (P=.064), and type of adjuvant therapy (P=.407). The blood loss (P=.131), operative time (P=.200), mean hospital stay (P=.417), and postoperative self-voiding (P=.306) did not significantly differ between the groups, with the exception of the number of harvested lymph nodes (P=.001). The disease-free survival was better in the group that underwent infrarenal para-aortic lymphadenectomy than the group that did not (P=.017); however, the 2 groups did not differ with respect to overall survival (P=.115).

Conclusion:

We suggest that laparoscopic transperitoneal infrarenal lymphadenectomy for cervical cancer is feasible and safe. The rate of positive lymph nodes in infrarenal lymphadenectomy is very rare in patients with locally advanced cervical carcinoma. Infrarenal lymphadenectomy in patients with cervical cancer did not provide additional survival benefits in this study.

Stereotactic body radiotherapy for metachronous multisite oligo-recurrence: a long-surviving case with sequential oligo-recurrence in four different organs treated using locally radical radiotherapy and a review of the literature

Stereotactic body radiotherapy (SBRT) for oligometastases represents a recent trend in radiation oncology. While abundant data are available regarding the use of SBRT for the treatment of lung or liver oligometastases from various retrospective series and prospective trials, relatively little information has been accumulated for the treatment of oligometastases at sites other than the lungs and liver, particularly for sequential oligometastases in multiple organs. Oligometastases with primary lesions controlled is called “oligo-recurrence.” We describe herein the case of a lung cancer patient who developed repeated oligo-recurrence at multiple sites that were each controlled by radical radiotherapy and achieved long-term survival and discuss the merits of locally aggressive radiotherapy for this type of disease condition with reviewing the literature. Although further investigation should be undertaken to clarify the benefits, objectives, and methods of SBRT for the treatment of oligometastases, we believe utilization of SBRT may be worthwhile for patients with remote metastases who hope for treatment to acquire better local control and possible longer survival.

Cancer of the pelvis: definitive three-dimensional conformal radiotherapy for patients with isolated recurrence in the para-aortic lymph nodes

The purpose of this study was to evaluate the outcome of definitive three-dimensional conformal radiotherapy (RT) for isolated para-aortic lymph node (LN) recurrence in patients with controlled primary cancer of the pelvis. Twenty-four consecutive patients with isolated para-aortic LN recurrence were retrospectively analyzed. The patients were included in this study if they were eligible to receive definitive RT for abdominal para-aortic LN recurrence with controlled primary cancer of the pelvis without other distant/recurrent diseases. The median time between the front-line therapy and RT for isolated para-aortic LN metastases was 21 months. Nineteen (79%) patients had an objective tumor response. In-field failure occurred in four patients (17%), while failure outside of the irradiated field was recognized in 12 patients (50%). The overall survival, progression-free survival and local control rates at 5 years were 56%, 29% and 72%, respectively. Statistically significant prognostic factors of the overall survival rate in the univariate analyses were an objective tumor response (P = 0.0098) and the time between front-line therapy and RT (P = 0.033). The maximum tumor size was a significant prognostic factor of the overall survival rates in the multivariate analyses (P = 0.046). The toxicities were mild; leukopenia of Grade 3 was detected in one patient, and no Grade 3 or higher non-hematological toxicity was observed. In conclusion, definitive three-dimensional RT for isolated abdominal para-aortic LN recurrence in patients with controlled primary cancer of the pelvis may be feasible, and can provide a relatively longer-term survival. The results justify further investigation of higher dose RT using modern RT planning techniques.

Salvage radiotherapy for lymph node recurrence after radical surgery in cervical cancer

OBJECTIVE

This study was to evaluate the treatment outcomes and prognostic factors of patients treated with salvage radiotherapy for the treatment of isolated lymph node recurrence of cervical cancer.

METHODS

Between 1990 and 2009, 22 cervical cancer patients with lymph node recurrence who had previously undergone radical hysterectomy and pelvic lymph node dissection were treated with salvage radiotherapy with (n=18) or without (n=4) chemotherapy. Of the 22 patients, 10 had supraclavicular lymph node recurrence, 9 had para-aortic lymph node, and 3 had inguinal lymph node. The median total radiotherapy dose was 60 Gy (range, 40 to 70 Gy). Initial pathologic findings, latent period to lymph node recurrence and other clinical parameters such as squamous cell carcinoma antigen (SCC-Ag) level and concurrent chemotherapy were identified as prognostic factors for survival.

RESULTS

The median follow-up period after salvage radiotherapy was 31.2 months (range, 12.1 to 148.9 months). The 5-year progression-free and overall survival rates of all patients were 32.7% and 30.7%, respectively. Concurrent chemoradiotherapy (p=0.009) and longer latent period to lymph node recurrence (>18 months vs. ≤18 months, p=0.019) were significant predictors of progression-free survival and SCC-Ag level at the time of recurrence (>8 ng/dL vs. ≤8 ng/dL, p=0.008) and longer latent period to lymph node recurrence (p=0.040) for overall survival. Treatment failure after salvage radiotherapy occurred in 14 (63.6%) for the 22 patients (in field, 2; out of field, 10; both in and out field, 2). Grade 3 acute skin (n=2) and hematologic toxicity (n=1) developed in 3 patients.

CONCLUSION

For isolated lymph node recurrence of cervical cancer, salvage radiotherapy with concurrent chemotherapy should be considered, especially in patients with a long-term progression-free period.

Pretreatment carcinoembryonic antigen level is a risk factor for para-aortic lymph node recurrence in addition to squamous cell carcinoma antigen following definitive concurrent chemoradiotherapy for squamous cell carcinoma of the uterine cervix

Background

To identify pretreatment carcinoembryonic antigen (CEA) levels as a risk factor for para-aortic lymph node (PALN) recurrence following concurrent chemoradiotherapy (CCRT) for cervical cancer.

Methods

From March 1995 to January 2008, 188 patients with squamous cell carcinoma (SCC) of the uterine cervix were analyzed retrospectively. No patient received PALN irradiation as the initial treatment. CEA and squamous cell carcinoma antigen (SCC-Ag) were measured before and after radiotherapy. PALN recurrence was detected by computer tomography (CT) scans. We analyzed the actuarial rates of PALN recurrence by using Kaplan-Meier curves. Multivariate analyses were carried out with Cox regression models. We stratified the risk groups based on the hazard ratios (HR).

Results

Both pretreatment CEA levels ≥ 10 ng/mL and SCC-Ag levels < 10 ng/mL (p < 0.001, HR = 8.838), SCC-Ag levels ≥ 40 ng/mL (p < 0.001, HR = 12.551), and SCC-Ag levels of 10-40 ng/mL (p < 0.001, HR = 4.2464) were significant factors for PALN recurrence. The corresponding 5-year PALN recurrence rates were 51.5%, 84.8%, and 27.5%, respectively. The 5-year PALN recurrence rate for patients with both low (< 10 ng/mL) SCC and CEA was only 9.6%. CEA levels ≥ 10 ng/mL or SCC-Ag levels ≥ 10 ng/mL at PALN recurrence were associated with overall survival after an isolated PALN recurrence. Pretreatment CEA levels ≥ 10 ng/mL were also associated with survival after an isolated PALN recurrence.

Conclusions

Pretreatment CEA ≥ 10 ng/mL is an additional risk factor of PALN relapse following definitive CCRT for SCC of the uterine cervix in patients with pretreatment SCC-Ag levels < 10 ng/mL. More comprehensive examinations before CCRT and intensive follow-up schedules are suggested for early detection and salvage in patients with SCC-Ag or CEA levels ≥ 10 ng/mL.

The role of squamous cell carcinoma antigen as a prognostic and predictive factor in carcinoma of uterine cervix

Purpose

Although the role of squamous cell carcinoma antigen (SCC-Ag) as a predictive and prognostic factor for uterine cervical cancer has been identified in previous studies, 1) the effective patient group of screening for recurrence with SCC-Ag, 2) the relationship between SCC-Ag and recurrence site, and 3) the relationship between the change of SCC-Ag and treatment outcome or recurrence have not been described.

Materials and Methods

The study included 506 patients with histologically proven uterine cervical cancer between January 1994 and December 2010. We determining the serum SCC-Ag level before treatment and after treatment, and conducted a retrospective review of the patients' records. We evaluated the sensitivity and specificity of SCC-Ag for the detection of tumor recurrence by comparing biochemical recurrence with clinical recurrence.

Results

The pretreatment SCC-Ag level and the proportion of patients over 1.5 ng/mL were higher in poor prognostic patient group. In the univariate and multivariate analysis, pretreatment SCC-Ag showed a statistically significant correlation with tumor size, International Federation of Gynecology and Obstetrics (FIGO) stage, pathology. In patients with biochemical recurrence vs. those without, 5-year DFS and OS were 27.6 vs. 92.7% (p ≤ 0.001) and 53.7 vs. 92.5% (p ≤ 0.001), respectively.

Conclusion

Our study reconfirmed the known function of pretreatment SCC-Ag, but could not confirm the function of biochemical response as a predictive factor for treatment and as a prognostic factor. There was no statistically significant relationship between SCC-Ag level and recurrence site. We confirmed the role of SCC-Ag as a follow-up tool for recurrence of disease and which patient groups SCC-Ag was more useful for.

Efficacy of 18F-FDG PET/CT in the evaluation of patients with recurrent cervical carcinoma

PURPOSE

Only a limited number of studies have evaluated the efficacy of 18F-FDG PET/CT for recurrent cervical carcinoma, which this study seeks to expand upon.

METHODS

This is a retrospective study of 30 women with cervical carcinoma who had a surveillance PET/CT after initial therapy. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated using a 2 × 2 contingency table with pathology results (76%) or clinical follow-up (24%) as the gold standard. The Wilson score method was used to perform 95% confidence interval estimations.

RESULTS

The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of PET/CT for the detection of local recurrence at the primary site were 93, 93, 93, 86, and 96%, respectively. The same values for the detection of distant metastases were 96, 95, 95, 96, and 95%, respectively. Seventy-one percent of the scans performed in symptomatic patients showed true-positive findings. In comparison, 44% of scans performed in asymptomatic patients showed true-positive findings. But, all patients subsequently had a change in their management based on the PET/CT findings such that the effect was notable. The maximum standardized uptake value ranged from 5 to 28 (average: 13 ± 7) in the primary site and 3 to 23 (average: 8 ± 4) in metastases which were significantly different (p = 0.04).

CONCLUSION

This study demonstrates favorable efficacy of 18F-FDG PET/CT for identification of residual/recurrent cervical cancer, as well as for localization of distant metastases.

Brachytherapy reirradiation with hyaluronate gel injection of paraaortic lymphnode metastasis of pancreatic cancer: paravertebral approach--a technical report with a case

Paraaortic lymph nodal (PALN) recurrence is not a rare scenario of abdominal malignancies including pancreas cancer, even after radiotherapy. The role and indication of reirradiation is limited because it is often associated with significant late toxicity in the surrounding normal organs. We developed a new approach and technique of brachytherapy to overcome this difficult situation, with a paravertebral approach and hyaluronate gel injection (HGI). We encountered a patient with pancreatic cancer who developed PALN metastasis as in-field recurrence, 6 months after resection of pancreatic cancer with 50 Gy of preoperative radiotherapy. The applicator brachytherapy needles and gel injection needles were advanced by percutaneous paravertebral approach under local anesthesia, and by injection of a hyaluronate gel to separate the surrounding small intestines and the target. A single fraction of 18 Gy was delivered to the tumor (75.6 Gy equivalent in conventional schedule calculated with LQ model at α/β = 3) and total estimated D2cc (the minimum dose to the most irradiated volume of 2 cc, calculated at α/β = 2) in the small intestines was 61.6 GyE with HGI and 80.6 GyE without. No complications have been observed for six months. Three months later, FDG accumulation had disappeared, the tumor size was reduced, and serum CA-19-9 value decreased from 5150 U/mL to 36.6 U/mL (normal range < 37.5). Conclusively, the brachytherapy with the HGI procedure by paravertebral approach was thought safe and effective in reirradiation of PALN recurrence.

Stereotactic body radiotherapy (SBRT): Technological innovation and application in gynecologic oncology

OBJECTIVES

Stereotactic body radiotherapy (SBRT) is a novel form of noninvasive, highly conformal radiation treatment that delivers a high dose to tumor. The advantage of the technique resides in its ability to provide a high dose to tumor but spare normal tissues to an extent not previously possible. In this paper we will provide an introduction and review of this technology with regard to its use in gynecologic malignancies. Preliminary results from our experience are presented for the purpose of illustrating the range of SBRT applications in gynecologic oncology.

METHODS

A comprehensive literature review was conducted and our experience from the past three years was reviewed.

RESULTS

Six case series are published that report results of SBRT for gynecologic malignancies. Sixteen gynecologic patients have been treated with SBRT at our institution. Treatment sites include pelvic and periaortic nodes (9 patients), oligometastatic disease (2), and cervical or endometrial primary tumors when other conventional external radiation or brachytherapy techniques were unsuitable (5). Preliminary follow-up at a median of 11 months (range, 0.3-33 months) demonstrates 79% locoregional control, 43% distant failure, and 50% overall survival.

CONCLUSIONS

SBRT boosts to macroscopic periaortic node recurrences and other sites seem to provide local control and a possibility of long-term disease-free survival in carefully selected patients. Previously this had been difficult to achieve with conventional radiotherapy because of the proximity of periaortic nodes to small bowel. SBRT also offers a novel approach for minimally invasive treatment in the management of gynecological cancer where current surgical and radiotherapy techniques are unsuitable.

Intensity-modulated radiation therapy versus para-aortic field radiotherapy to treat para-aortic lymph node metastasis in cervical cancer: prospective study

AIM

To compare dosimetry, efficacy, and toxicity of intensity-modulated radiation therapy (IMRT) with para-aortic field radiotherapy in patients with para-aortic lymph node (PALN) metastasis of cervical cancer.

METHODS

This prospective study examined 60 patients with cervical cancer with PALN metastasis who underwent whole-pelvis radiotherapy followed by brachytherapy between November 1, 2004 and May 31, 2008. After 3 cycles of chemotherapy, patients were serially allocated into two groups and treated with IMRT or para-aortic field RT at doses of 58-68 Gy and 45-50 Gy, respectively. Treatment response was evaluated and toxicities were assessed. Patients in the IMRT group were treated with both para-aortic field RT and IMRT in order to compare the exposure dose of organs at risk.

RESULTS

In the IMRT group, the mean dose delivered to the planning target volume was 67.5 Gy. At least 99% of the gross tumor volume received effective coverage and radical dose (median, 63.5 Gy; range, 54.5-66) during treatment. IMRT plans yielded better dose conformity to the target and better sparing of the spinal cord and small intestine than para-aortic field RT. The IMRT patients experienced less acute and chronic toxicities. The IMRT group also had higher 2- and 3-year survival rates than the para-aortic RT group (2-year, 58.8% vs 25.0%, P = 0.019; 3-year, 36.4% vs 15.6%, P = 0.016). However, no significant difference was found in 1-year survival (67.7% vs 51.3%, P =0.201). The median survival in the IMRT group was 25 months (range, 3 to 37 months). The actuarial overall survival, disease-free survival, and locoregional control rates at 2 years were 67%, 77%, and 88%, respectively, in the IMRT group.

CONCLUSIONS

IMRT provides better clinical outcomes than para-aortic field radiotherapy in patients with PALN metastasis. However, cervical local and distal recurrence remain a problem. Long-term follow-up and studies involving more patients are needed to confirm our results.

The development of priority cervical cancer trials: a Gynecologic Cancer InterGroup report

Since the late 1990s, when a spate of US studies reported the benefit of chemoradiation for cervical cancer, there has been a dearth of clinical trials in cervical cancer. This requires to be addressed with urgency because this disease is responsible for a quarter of a million deaths globally each year, mostly in developing countries, but therapeutic advances are required in all health care settings. The Gynecologic Cancer InterGroup (GCIG) is a worldwide collaborative of leading national groups that develops and promotes multinational trials in gynecologic cancer. In recognition of the pressing need for action, the GCIG convened an international meeting with expert representations from most of the GCIG groups and selected large centers in low- and middle-income countries. The focus was to identify consensus on several concepts for clinical trials, which would be developed and promoted by the GCIG and launched with major international participation. The first half of the meeting was devoted to a resume of the current state of the knowledge and identifying the gaps most needing new evidence. The second half of the meeting was concerned with achieving consensus on the way forward. There were 2 principal outcomes. The first was a proposal to establish, under the umbrella of GCIG, a cervical cancer trials network of centers from countries currently outside GCIG (Eastern Europe, India, Thailand, Southern Africa, and South and Central America), which could increase international participation in trials, conducted within the principles of good clinical practice. The second was to identify the priorities for clinical trials. These included additional systemic therapy before or after chemoradiation; less radical surgery for small, early-stage tumors; the use of fewer fractions to improve cost-effectiveness of treatment in centers with limited resources; and chemotherapy to improve resectability of bulky tumors.

Use of serum squamous cell carcinoma antigen for follow-up monitoring of cervical cancer patients who were treated by concurrent chemoradiotherapy

Background

To investigate the significance of monitoring the levels of the serum squamous cell carcinoma antigen (SCC-Ag) for the detection of recurrent disease in patients with cervical cancer treated by concurrent chemoradiotherapy.

Methods

The records of 112 patients with cervical cancer were reviewed. Serum SCC-Ag levels were measured at regular follow-up visits. A SCC-Ag level of 2 ng/mL was considered the upper limit of normal. Biochemical failure was defined as two consecutively increasing SCC-Ag values above normal. Recurrent disease was confirmed by histologic and radiographic studies.

Results

Eighteen patients (16%) developed recurrent disease. Sixteen patients had initially elevated SCC-Ag, post-treatment normalization of SCC-Ag, and tumor recurrence. The SCC-Ag difference (ΔSCC-Ag), defined as the difference between the last value after two consecutively increases above normal and the value immediately before the elevation, had good clinical performance in predicting cancer recurrence. The cutoff value of ΔSCC-Ag was 0.95 ng/mL.

Conclusions

SCC-Ag is a relatively good method for the detection of disease recurrence in patients with cervical cancer who were treated by concurrent chemoradiotherapy.

Clinical outcome of hypofractionated stereotactic radiotherapy for abdominal lymph node metastases

PURPOSE

We report the medium-term clinical outcome of hypofractionated stereotactic body radiotherapy (SBRT) in a series of patients with either a solitary metastasis or oligometastases from different tumors to abdominal lymph nodes.

METHODS AND MATERIALS

Between January 2006 and June 2009, 19 patients with unresectable nodal metastases in the abdominal retroperitoneal region were treated with SBRT. Of the patients, 11 had a solitary nodal metastasis and 8 had a dominant nodal lesion as part of oligometastatic disease, defined as up to five metastases. The dose prescription was 45 Gy to the clinical target volume in six fractions. The prescription had to be downscaled by 10% to 20% in 6 of 19 cases to keep within dose/volume constraints. The first 11 patients were treated with three-dimensional conformal techniques and the last 8 by volumetric intensity-modulated arc therapy. Median follow-up was 1 year.

RESULTS

Of 19 patients, 2 had a local progression at the site of SBRT; both also showed concomitant tumor growth at distant sites. The actuarial rate of freedom from local progression was 77.8% ± 13.9% at both 12 and 24 months. Eleven patients showed progressive local and/or distant disease at follow-up. The 12- and 24-month progression-free survival rates were 29.5% ± 13.4% and 19.7% ± 12.0%, respectively. The number of metastases (solitary vs. nonsolitary oligometastases) emerged as the only significant variable affecting progression-free survival (p < 0.0004). Both acute and chronic toxicities were minimal.

CONCLUSIONS

Stereotactic body radiotherapy for metastases to abdominal lymph nodes was shown to be feasible with good clinical results in terms of medium-term local control and toxicity rates. Even if most patients eventually show progressive disease at other sites, local control achieved by SBRT may be potentially significant for preserving quality of life and delaying further chemotherapy.

Detection of hematogenous bone metastasis in cervical cancer: 18F-fluorodeoxyglucose-positron emission tomography versus computed tomography and magnetic resonance imaging

BACKGROUND

In this large-scale, retrospective study, the authors evaluated the diagnostic performances of computed tomography (CT), magnetic resonance (MR) imaging, and (18)F-fluorodeoxyglucose-positron emission tomography ((18)F-FDG-PET) in detecting hematogenous bone metastasis in patients with cervical cancer. The associated risk factors also were analyzed.

METHODS

Patients with invasive cervical cancer who had both (18)F-FDG-PET studies and CT or MR imaging studies were selected. Patients who had either International Federation of Gynecology and Obstetrics (FIGO) stage III/IV disease or positive lymph node metastasis at the time of primary staging and patients who had suspected recurrent disease were included in the analyses. The diagnostic performances of PET was compared with the performance of CT and MR imaging by using the area under the receiver-operating-characteristic curve (AUC). Both univariate and multivariate analyses were applied to assess the risk factors for hematogenous bone metastasis at primary staging.

RESULTS

PET was more sensitive than CT (P = .004) and was more specific than MR imaging (P = .04). The diagnostic performance of PET was significantly superior to the performance CT (AUC, 0.964 vs 0.662; P < .001) and MR (AUC, 0.966 vs 0.833; P = .033). Both FIGO stage and the extent of lymph node metastases were associated with hematogenous bone metastasis in univariate analysis. However, the extent of lymph node metastases was the only significant risk factor in multivariate analysis (P = .025).

CONCLUSIONS

The current study demonstrated the superiority of (18)F-FDG-PET over CT and MR imaging for detecting hematogenous bone metastasis in patients with advanced cervical cancer. Hematogenous bone metastasis in cervical cancer was associated with the extent of lymph node metastases rather than with FIGO stage.