Neoadjuvant chemotherapy in cervical cancer: a new trend

Local Disease-Free Survival and Disease-Free Survival in Locally Advanced Cervical Cancer Diagnosed and Treated in Bihor County, Romania

INTRODUCTION

Cervical cancer is the fourth most dangerous malignancy worldwide in women and is diagnosed at the advanced stages in most cases. Oncological and surgical modalities when precisely employed together can prove to be helpful for determining the proper diagnosis and treatment strategies. Neoadjuvant chemotherapy (NACT) has been found to have a role in reducing tumor size and has evolved as a treatment regimen for locally advanced cervical cancer (LACC). The present study aimed to analyze the treatment strategies either with neoadjuvant platinum-based chemotherapy (NACT) administration or not and pathological responses in patients with LACC.

METHODS

We reviewed 100 patients of LACC from October 2018 to December 2022 at Bihor County Emergency Clinical Hospital. About 43 patients underwent radiation therapy in addition to NACT administration (NACT+/other) and 57 underwent other treatment regimens without neoadjuvant treatment (NACT-/ other). Various demographic parameters, FIGO staging, histological status, surgical interventions, and survival rate (local disease-free survival (LDFS) and disease-free survival (DFS)) were accessed in both groups. Statistical analysis was performed to analyze the significance of various parameters studied.

RESULTS

The mean age range of the studied sample was 57.05 ± 12.51 in NACT+/other and 60.4±12.32 in NACT-/other. Among 100 patients, 90 cases of squamous carcinoma, eight of adenocarcinoma, and two cases of adenosquamous carcinoma were analyzed and treated. At stage IIIC1, 11 patients were accessed while 15 patients were at clinical stage IIIC2, and among these, 25.58% received neoadjuvant oncological treatment and very limited mediastinal disease. DFS rates are greater in the patients who have undergone surgery in the NACT+/other group, while in the LDFS, there is better survival in the case of surgery without any NACT treatment (NACT-/other).

CONCLUSIONS

The effect of NACT can be suggested as another important treatment strategy and result in a good response in terms of DFS and LDFS in patients with LACC. This approach aims to reduce tumor size preoperatively, facilitating surgical removal and potentially improving patient outcomes compared to other treatment modalities. Thus, it can be concluded that NACT may be considered an important strategy to be opted for the treatment of LACC.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evaluation of early regression index as response predictor in cervical cancer: A retrospective study on T2 and DWI MR images

BACKGROUND AND PURPOSE

Early Regression Index (ERI_TCP) is an image-based parameter based on tumor control probability modelling, that reported interesting results in predicting pathological complete response (pCR) after pre-operative chemoradiotherapy (CRT) in rectal cancer. This study aims to evaluate this parameter for Locally Advanced Cervical Cancer (LACC), considering not only T2-weighted but also diffusion-weighted (DW) Magnetic Resonance (MR) images, comparing it with other image-based parameters such as tumor volumes and apparent coefficient diffusion (ADC).

MATERIALS AND METHODS

A total of 88 patients affected by LACC (FIGO IB2-IVA) and treated with CRT were enrolled. An MRI protocol consisting in two acquisitions (T2-w and DWI) in two times (before treatment and at mid-therapy) was applied. Gross Tumor Volume (GTV) was delineated and ERI_TCP was calculated for both imaging modalities. Surgery was performed for each patient after nCRT: pCR was considered in case of absence of any residual tumor cells. The predictive performance of ERI_TCP, GTV volumes (calculated on T2-w and DW MR images) and ADC parameters were evaluated in terms of area (AUC) under the Receiver Operating Characteristic (ROC) curve considering pCR and two-years survival parameters as clinical outcomes.

RESULTS

ERI_TCP and GTV volumes calculated on DW MR images (ERI_DWI and V_{mid_DWI}) significantly predict pCR (AUC = 0.77 and 0.75 respectively) with results superior to those observed considering T2-w MR images or ADC parameters. Significance was also reported in the prediction of 2-years local control and disease free-survival.

CONCLUSION

This study identified ERI_TCP and V_mid as good predictor of pCR in case of LACC, especially if calculated considering DWI. Using these indicators, it is possible to early identify not responders and modifying the treatment, accordingly.

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

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

Sorafenib Nanomicelles Effectively Shrink Tumors by Vaginal Administration for Preoperative Chemotherapy of Cervical Cancer

To investigate the potential of sorafenib (SF) in preoperative chemotherapy for cervical cancer to reduce tumor volume, sorafenib micelles (SF micelles) with good stability and high drug loading were designed. SF micelles were prepared by film hydration followed by the ultrasonic method. The results showed that the SF micelles were spherical with an average particle size of 67.18 ± 0.66 nm (PDI 0.17 ± 0.01), a considerable drug loading of 15.9 ± 0.46% (w/w%) and satisfactory stability in buffers containing plasma or not for at least 2 days. In vitro release showed that SF was gradually released from SF micelles and almost completely released on the third day. The results of in vitro cellular intake, cytotoxicity and proliferation of cervical cancer cell TC-1 showed that SF micelles were superior to sorafenib (Free SF). For intravaginal administration, SF micelles were dispersed in HPMC (SF micelles/HPMC), showed good viscosity sustained-release profiles in vitro and exhibited extended residence in intravaginal in vivo. Compared with SF micelles dispersed in N.S. (SF micelles/N.S.), SF micelles/HPMC significantly reduced tumor size with a tumor weight inhibition rate of 73%. The results suggested that SF micelles had good potential for preoperative tumor shrinkage and improving the quality life of patients.

Comparison of therapeutic effects of chemo-radiotherapy with neoadjuvant chemotherapy before radical surgery in patients with bulky cervical carcinoma (stage IB3 & IIA2)

Background

Cervical cancer is one of the most common malignancies among women. Appropriate and timely treatment of these patients can reduce the complications and increase their survival. The objective of this study was to compare neoadjuvant chemotherapy plus radical hysterectomy (NACTRH) and chemo-radiotherapy (CRT) in patients with bulky cervical cancer (stage IB3 & IIA2).

Material and methods

The medical records of patients with bulky cervical cancer (stage IB3 & IIA2) that received NACTRH or CRT between 2007 and 2017 were evaluated for therapeutic effects. Demographic characteristics, complications of chemo-radiotherapy and neoadjuvant chemotherapy, were collected in a researcher-made questionnaire. Our primary outcome was comparison of overall survival (OS), and disease-free survival (DFS) between two groups receiving NACTRH and CRT modalities.

Results

One-hundred and twenty three patients were enrolled in the study. The median age and the proportion of patients with stage IIA2 were higher in the CRT group compared to the NACTRH group (p < 0.05). The medians (95% CI) OS were 3.64 (3.95–6.45) and 3.9 (3.53–4.27) years in the NACTRH and CRT groups, respectively (P = 0.003). There were 16 (34.8%) and 22 (43.1%) recurrences in the NACTRH and CRT group, respectively (P = 0.4). The median (95% CI) DFS was 4.5 (3.88–5.12) years in the NACTRH group and 3.6 (2.85–4.35) years in the CRT group (P = 0.004). The 3-year OS rate in NACTRH and CRT groups were 97 and 90% respectively. The 3-year DFS rate in NACTRH and CRT groups were 88 and 66% respectively.

Conclusions

NACTRH is associated with a higher OS and DFS compared to CRT.

Gene expression changes in cervical squamous cancers following neoadjuvant interventional chemoembolization

BACKGROUND

The efficacy of therapy for cervical cancer is related to the alteration of multiple molecular events and signaling networks during treatment. The aim of this study was to evaluate gene expression alterations in advanced cervical cancers before- and after-trans-uterine arterial chemoembolization- (TUACE).

METHODS

Gene expression patterns in three squamous cell cervical cancers before- and after-TUACE were determined using microarray technique. Changes in AKAP12 and CA9 genes following TUACE were validated by quantitative real-time PCR.

RESULTS

Unsupervised cluster analysis revealed that the after-TUACE samples clustered together, which were separated from the before-TUACE samples. Using a 2-fold threshold, we identified 1131 differentially expressed genes that clearly discriminate after-TUACE tumors from before-TUACE tumors, including 209 up-regulated genes and 922 down-regulated genes. Pathway analysis suggests these genes represent diverse functional categories. Results from real-time PCR confirmed the expression changes detected by microarray.

CONCLUSIONS

Gene expression signature significantly changes during TUACE therapy of cervical cancer. Theses alterations provide useful information for the development of novel treatment strategies for cervical cancers on the molecular level.

Multi-institutional phase II study of neoadjuvant irinotecan and nedaplatin followed by radical hysterectomy and the adjuvant chemotherapy for locally advanced, bulky uterine cervical cancer: A Kansai Clinical Oncology Group study (KCOG-G1201)

AIM

A multi-institutional phase II trial was conducted to determine the efficacy and toxicity of neoadjuvant chemotherapy with irinotecan and nedaplatin followed by radical hysterectomy and adjuvant chemotherapy for locally advanced, bulky stage IB2-IIB cervical cancer.

METHODS

Patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB2-II, bulky type (>4 cm in diameter) squamous cell carcinoma of the uterine cervix were enrolled. Irinotecan (60 mg/m² ) was administered intravenously on days 1 and 8 and nedaplatin (80 mg/m² ) was also administered on day 1 of every 21-day cycle. After two cycles of chemotherapy, a radical hysterectomy was performed. Until 6 weeks after the surgery, three to five cycles of the regimen were added as adjuvant chemotherapy. The primary endpoint was the 2-year relapse-free survival rate. The response rates and toxicities were evaluated as secondary endpoints.

RESULTS

Thirty-two patients from seven institutions were enrolled in this study. The median age was 48 years (range 25-75 years). The average follow-up period was 37.8 months (15-71 months). Twenty-three patients completed the regimen as planned. The objective response rate (complete response + partial response) for the neoadjuvant chemotherapy regimen was 81.2%. The 2-year and 5-year relapse-free-survival rates were 87.5% and 78.8%, respectively. The incidence of grade 3/4 neutropenia was 6.3% and 34.4% during neoadjuvant and adjuvant treatment, respectively. All other toxicities were well tolerated.

CONCLUSION

Our treatment showed efficacy and tolerability for patients with locally advanced, bulky stage IB2-IIB cervical cancer. This suggests that treatment has the potential to improve the prognosis compared to concurrent chemo-radiotherapy.

Early response to neoadjuvant chemotherapy can help predict long-term survival in patients with cervical cancer

It is still controversial whether cervical cancer patients with clinical responses after neoadjuvant chemotherapy (NACT) have a better long-term survival or not. This study was designed to investigate the effect of the clinical response on the disease-free survival (DFS) of cervical cancer patients undergoing NACT. A total of 853 patients from a retrospective study were used to evaluate whether the clinical response was an indicator for the long-term response, and 493 patients from a prospective cohort study were used for further evaluation. The survival difference was detected by log-rank test, univariate and multivariate Cox regression and a pooled analysis. The log-rank test revealed that compared with non-responders, the DFS of responders was significantly higher in the retrospective data (P = 0.007). Univariate Cox regression showed that the clinical response was an indicator of long-term survival in the retrospective study (HR 1.83, 95% CI 1.18-2.85, P = 0.007). In a multivariate Cox model, the clinical response was still retained as an independent significant prognostic factor in the retrospective study (HR 1.59, 95% CI 1.01-2.50, P = 0.046). The result was also validated in the prospective data with similar results. These findings implied that the clinical response can be regarded as an independent predictor of DFS.

The association between short-term response and long-term survival for cervical cancer patients undergoing neoadjuvant chemotherapy: a system review and meta-analysis

Controversy exists regarding whether a short-term response has an impact on the long-term survival of cervical cancer patients undergoing neoadjuvant chemotherapy (NACT). This study was designed to identify the predictive role of an early response by pooling the results of previous studies. The PubMed and Embase databases were searched through July 2016, and the associations between an early response and disease-free survival (DFS) were pooled by hazard ratio (HR) using random effects models. Six studies involving 490 cervical cancer patients, with 336 responders and 154 non-responders, were finally included in the meta-analysis. The HR for 1-year DFS between early responders and non-responders was 0.25 (95% CI 0.10-0.58, P = 0.001). The HRs for 2-, 3-, 4-, and 5-year DFS were 0.28 (95% CI 0.15-0.56), 0.27 (95% CI 0.16-0.45), 0.29 (95% CI 0.17-0.50) and 0.33 (95% CI 0.20-0.54), respectively. No obvious heterogeneity was found among the studies, with I² = 0, and a sensitivity analysis showed that all pooled results were robust with logHR confidence limits < 0. An early response was associated with DFS, and responders achieved a significantly higher survival rate than non-responders. This finding should be validated in future prospective studies.

Meta-analysis showing that early response to neoadjuvant chemotherapy predicts better survival among cervical cancer patients

This study was designed to identify the prognostic value of early response to neoadjuvant chemotherapy (NACT) for long-term survival of cervical cancer patients. We searched Pubmed and EMBASE for studies published through July 2016 on outcomes of cervical patients that received NACT. Eight studies involving 825 cervical cancer patients were ultimately included in our meta-analysis. We pooled the hazard ratios (HR) according to random-effects models and used funnel plots with Egger's and Begg's tests to explore potential publication bias. The HR between early response and 1-year overall survival (OS) was 3.60 (95% CI 1.93–6.72; I² = 0). Similar results were found in the analysis of 3-year OS (HR 3.34; 95% CI 2.28–4.90; I² = 0) and 5-year OS (HR 3.44; 95% CI 2.40–4.94; I² = 0). Sensitivity analysis showed that all of the pooled results were robust, and all logHRs had confidence limits > 0. Our findings indicate that early response is associated with long-term survival, and responders achieved a higher survival rate than non-responders.

Practice guidelines for management of cervical cancer in Korea: a Korean Society of Gynecologic Oncology Consensus Statement

Clinical practice guidelines for gynecologic cancers have been developed by academic society from several countries. Each guideline reflected their own insurance system and unique medical environment, based on the published evidence. The Korean Society of Gynecologic Oncology (KSGO) published the first edition of practice guidelines for gynecologic cancer treatment in late 2006; the second edition was released in July 2010 as an evidence-based recommendation. The Guidelines Revision Committee was established in 2015 and decided to develop the third edition of the guidelines in an advanced format based on evidence-based medicine, embracing up-to-date clinical trials and qualified Korean data. These guidelines cover strategies for diagnosis and treatment of primary and recurrent cervical cancer. The committee members and many gynecologic oncologists derived key questions through discussions, and a number of relevant scientific literature were reviewed in advance. Recommendations for each specific question were developed by the consensus conference, and they are summarized here, along with the details. The objective of these practice guidelines is to establish standard policies on issues in clinical practice related to the management in cervical cancer based on the results in published papers to date and the consensus of experts as a KSGO Consensus Statement.

Squamous cell carcinoma antigen expression in tumor cells is associated with the chemosensitivity and survival of patients with cervical cancer receiving docetaxel-carboplatin-based neoadjuvant chemotherapy

The present study examined the association between squamous cell carcinoma antigen (SCCA) expression and the response of patients with cervical cancer to docetaxel-carboplatin (DC) combination chemotherapy, in order to determine the prognostic potential of SCCA expression. A total of 21 patients were enrolled with stage IB2 or stage IIA2 SCC. Of these, 9 patients had chemotherapy-sensitive cancer (2 cases with a complete response and 7 cases with a partial response) and 12 patients had chemotherapy-resistant cancer (12 cases of stable disease and no cases of progressive disease). Patients were treated with two cycles of DC chemotherapy (docetaxel 75 mg/m² plus cisplatin 25 mg/m²) with 21-day intervals, followed by radical surgery. SCCA expression levels prior to and following chemotherapy were evaluated using immunohistochemistry. Following DC chemotherapy, the SCCA expression levels decreased in the patients with chemotherapy-sensitive cancer, but not in those with chemotherapy-resistant cancer (P=0.042). Significant survival differences between the SCCA-positive and -negative patients following chemotherapy (P=0.009) was observed. However, no statistically significant difference in survival between patients with chemotherapy-sensitive and chemotherapy-resistant cancer, or between patients with SCCA-positive and -negative expression prior to chemotherapy was observed. Overall, the chemotherapy sensitivity of patients with cervical cancer was associated with decreased SCCA expression levels following DC chemotherapy. Therefore, SCCA expression levels following DC chemotherapy may potentially be used in the clinical prognosis for cervical cancer patients who receive DC chemotherapy and subsequent radical surgery.

The detection of sentinel lymph nodes in laparoscopic surgery for uterine cervical cancer using 99m-technetium-tin colloid, indocyanine green, and blue dye

OBJECTIVE

Our objective was to determine the feasibility and detection rates and clarify the most effective combination of injected tracer types for sentinel lymph node (SLN) mapping in uterine cervical cancer in patients who have undergone laparoscopic surgery or neoadjuvant chemotherapy (NAC).

METHODS

A total of 119 patients with cervical cancer underwent SLN biopsy at radical hysterectomy using three types of tracers. The various factors related to side-specific detection rate, sensitivity, and false negative (FN) rate were analyzed.

RESULTS

The SLN detection rates using 99m-technetium ((99m)Tc)-tin colloid, indigo carmine, and indocyanine green (ICG) were 85.8%, 20.2%, and 61.6%, respectively. The patients with ≥2-cm-diameter tumors and those who received NAC had lower detection rates than those with <2-cm-diameter tumors (75.7% vs. 91.5%, p<0.01) and those who did not receive NAC (67.9% vs. 86.3%, p<0.01), respectively. Laparoscopic procedures had a higher detection rate than laparotomy (100.0% vs. 77.1%, p<0.01). No factors significantly affected the sensitivity; however, the patients with ≥2-cm-diameter tumors (86.0% vs. 1.4%, p<0.01), NAC (19.4% vs. 2.2%, p<0.01), and those who underwent laparotomy (7.4% vs. 0%, p<0.01) had an unfavorable FN rate.

CONCLUSION

Among the examined tracers, (99m)Tc had the highest detection of SLN mapping in patients with uterine cervical cancer. Patients with local advanced cervical cancer with/without NAC treatment might be unsuited for SLN mapping. SLN mapping is feasible and results in an excellent detection rate in patients with <2-cm-diameter cervical cancer. Laparoscopic surgery is the best procedure for SLN detection in patients with early-stage disease.

A randomized controlled trial comparing four versus six courses of adjuvant platinum-based chemotherapy in locally advanced cervical cancer patients previously treated with neo-adjuvant chemotherapy plus radical surgery

OBJECTIVES. The aim of this study was to compare 4 versus 6 courses of adjuvant chemotherapy after neoadjuvant chemotherapy plus radical surgery in terms of overall survival (OS), disease-free survival (DFS), recurrence rate and toxicity profile. METHODS. We randomly assigned 200 patients with IB2-IIB cervical cancer to receive 4 (Group A) or 6 (Group B) courses of cisplatin 100 mg/mq and paclitaxel 175 mg/mq every 21 days. RESULTS. At 4-years follow-up, the comparison of recurrence rate (p = 1; RR = 1.005; 95% CI = 0.87 to 1.161), OS (p = 0.906) and DFS (p = 0.825) did not show statistically significant differences between the two groups. Data analysis showed statistically significant differences between the two groups in term of episodes of leukopenia (p = 0.0072; RR = 1.513; 95% CI = 1.127-2.03), anemia (p = 0.048; RR = 1.188; CI = 1.012-1.395) and febrile neutropenia (p = 0.042; RR = 1.119; 95% CI = 1.014-1.235), in favor of Group A. As regards non-hematological toxicities, there were no statistically significant differences in terms of gastrointestinal symptoms (p = 0.49; RR = 1.046; CI = 0.948-1.153. On the contrary, there was a statistically significant difference regarding neurological symptoms (p=0.014; RR=1.208; CI=1.046-1.395), that were less frequent in Group A (13%) than in Group B (28%). CONCLUSIONS. Adjuvant treatment with 4 or 6 courses of platinum-based chemotherapy showed similar results in terms of OS and DSF, with a favorable toxicity profile in favor of the first regimen.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Neoadjuvant chemotherapy plus radical surgery followed by chemotherapy in locally advanced cervical cancer

OBJECTIVES

To evaluate the efficacy, in terms of safety, overall survival and progression free survival of neoadjuvant chemotherapy followed by radical surgery plus adjuvant chemotherapy in patients affected by locally advanced cervical cancer (stage IB2-IIB) with or without node metastases.

METHODS

Between June 2000 and February 2007, all patients with diagnosis of locally advanced cervical cancer referred to the Division of Gynecologic Oncology of the University Campus Bio-Medico of Rome were eligible for this protocol. All enrolled patients received 3 cycles of platinum-based chemotherapy every 3 weeks according to the scheme Cisplatin 100mg/mq and Paclitaxel 175 mg/mq. After neoadjuvant chemotherapy all patients with stable or progressive disease were excluded from the protocol, the others were submitted to classical radical hysterectomy, bilateral salpingo-oophorectomy and bilateral systematic pelvic lymphadenectomy and 4 cycles of adjuvant treatment with platinum based chemotherapy were executed.

RESULTS

Concerning intention to treat basis analysis, 5 year overall survival (OS) and disease-free survival (DFS) are 77% and 61%, respectively. The 5-year OS of patients with positive pelvic nodes and those with negative nodes metastases was respectively 60% and 87%. Concerning the according to protocol analysis, the 5-year OS and DFS are 81% and 70% respectively. The 5-year OS in patient with positive and negative lymph nodes is 75% and 88% respectively.

CONCLUSIONS

The adjuvant chemotherapy regimen after neoadjuvant chemotherapy and radical surgery represents a valid treatment for patients with locally advanced cervical cancer.

Short hairpin RNA targeting Twist1 suppresses cell proliferation and improves chemosensitivity to cisplatin in HeLa human cervical cancer cells

Development of multidrug resistance (MDR) remains a major hurdle to successful cancer chemotherapy and MDR1/P-gp overexpression is believed to be mainly responsible for MDR of tumor cells. Twist1, which is a highly conserved transcription factor that belongs to the family of basic helix-loop-helix proteins, has been shown to be a major regulator of the epithelial-mesenchymal transition (EMT), and therefore promotes carcinoma metastasis. Recently, a novel function of Twist1 was reported to confer radioresistance or chemoresistance in cervical cancer. However, mechanisms of such efficacy are not completely elucidated. In the present study, we firstly analyzed the relationship between Twist1 and MDR1/P-gp expression in human cervical cancer specimens and demonstrated a positive correlation between Twist1 and MDR1/P-gp expression in the same patient. Additionally, we provide the first evidence that silencing of Twist1 by RNAi downregulated MDR1/P-gp expression in HeLa cervical cancer cells, suppressed the cell proliferation, inhibited Rhodamine123 efflux activity of cells and sensitized cells to cisplatin treatment. Collectively, these findings suggest that Twist1-mediated modulation of MDR1/P-gp expression plays an important role in sensitization of cervical cancer cells to cisplatin, and also indicate a novel therapeutic strategy to overcome drug resistance through inactivation of Twist1 expression in cervical cancer.

Preoperative concomitant chemoradiotherapy in locally advanced cervical cancer: safety, outcome, and prognostic measures

OBJECTIVES

To evaluate the morbidity, and the therapeutic value of surgery after chemoradiation in a large series of locally advanced cervical cancers (LACC). The prognostic role of different clinico-pathological factors has been also evaluated.

METHODS

Between October 1997 and October 2006, 161 LACC patients were treated at both the Gynecologic Oncology Units of the Catholic University of Rome and Campobasso. Radiotherapy was administered to the whole pelvic region in combination with cisplatin and 5-fluorouracil. Radical surgery was performed 5-6 weeks after the end of the treatment.

RESULTS

A clinical complete/partial response was observed in 153 patients and radical surgery was performed in 152 cases. The overall rate of surgical complications was 33% with 15 (10%) patients experiencing severe toxicities. At pathological examination 111 of 152 patients (73%) showed absent/microscopic residual disease. With a median follow-up of 28 months, the 5-year disease free-survival (DFS) was 83% and the 5-year overall survival (OS) 90%. Advanced FIGO (Federation Internationale de Gynecolgie et d'Obstetrique) stage, pathological response and lymph node involvement were found significantly associated with clinical outcome.

CONCLUSIONS

We confirmed in a larger series the safety and efficacy of this multimodal approach in the treatment of LACC. The pathological assessment of response can allow not only a tailored surgery in selected patients, but also the identification of patients with higher risk of recurrence to be submitted to adjuvant therapies.

Radiochemotherapy combined with regional pelvic hyperthermia induces high response and resectability rates in patients with nonresectable cervical cancer ≥FIGO IIB “bulky”

PURPOSE

To evaluate preoperative radiochemotherapy combined with regional pelvic hyperthermia in patients with nonresectable cervical cancer >/= International Federation of Gynecology and Obstetrics (FIGO) IIB "bulky" in a Phase II study.

METHODS AND MATERIALS

Thirty-two patients with nonresectable FIGO IIB-IVA cervical cancer confined to the pelvis were treated with radiochemotherapy (5 x 1.8 Gy/wk, 45-50.4 Gy; cisplatin, 40 mg/m2/wk) and weekly regional pelvic hyperthermia (SIGMA-60 applicator, system BSD-2000; BSD Medical Corp., Salt Lake City, UT). Responders underwent hysterectomy if possible, whereas patients still unresectable received definitive hyperthermic radiochemotherapy. Feasibility, toxicity, as well as response and resectability, local progression free- and overall survival rates, were evaluated.

RESULTS

Thirty of 32 patients completed treatment. Grade III/IV toxicities (National Cancer Institute-Common Toxicity Criteria) were diarrhea (n = 5), weight loss >10 kg (n = 4), and nausea (n = 2). Twenty-four of 32 patients (75%) achieved a partial remission after 45-50 Gy, and 20 patients underwent hysterectomy (18 patients, R0; 8 patients pCR). Three-year overall survival was 60%, with moderate (13%) rates of severe late toxicity. R0-resected patients had a favorable chronic toxicity profile and an excellent prognosis (3-year survival rate: 93%). Response depended on thermal parameters (vaginal reference point), whereas response, R0-resection, and FIGO stage are significant prognostic factors for survival.

CONCLUSION

Preoperative hyperthermic radiochemotherapy (45-50 Gy) induces high response rates and enables curative surgery in a high proportion of patients with nonresectable cervical cancer. Therefore, the use of hyperthermia in conjunction with standard chemo-/radiotherapy +/- surgery may allow for more effective tumor treatment while decreasing the risk of complications in patients with locally advanced cervical cancer.

Preoperative chemoradiotherapy in locally advanced cervical cancer: Long-term outcome and complications

OBJECTIVE

To demonstrate the efficacy and feasibility of preoperative chemoradiotherapy in a consecutive series of 100 locally advanced cervical cancer (LACC) patients.

METHODS

Between October 1997 and December 2004, 100 LACC patients were consecutively staged and treated at the Catholic University of the Sacred Heart of Rome. Radiotherapy was administered to the whole pelvic region (1.8 Gy/day, totaling 39.6 Gy) in combination with cisplatin (20 mg/m(2)) and 5-FU (1000 mg/m(2)) (both on days 1-4 and 27-30). Radical surgery was performed 5-6 weeks after the end of the treatment.

RESULTS

A clinical complete or partial response was observed in 96 patients (56 and 40, respectively). Radical surgery was performed in 95 patients and an overall complication rate of 12.6% was observed in the early postoperative time. At pathological examination, 43 of 95 patients (45.2%) undergoing radical surgery showed complete response to treatment, 28 patients (29.5%) only had a microscopic disease, 18 patients (19%) had a partial response and 6 (6.3%) had no change of disease. With a median follow-up time of 25 months, the 5-year disease-free survival was 76% and the 5-year overall survival was 78%.

CONCLUSIONS

These data confirm the possibility of achieving encouraging rates of local control and OS in LACC patients submitted to chemoradiation plus surgery, with a low rate of toxicity and complications.