Comparison between conventional surgery plus postoperative adjuvant radiotherapy and concurrent chemoradiation for FIGO stage IIB cervical carcinoma: a retrospective study

Pharmacotherapy for cervical cancer: current standard of care and new perspectives

INTRODUCTION

Cervical cancer, while highly preventable, remains an international public health challenge especially in under resourced regions. Although early-stage cervix confined cancers are often amenable to surgical resection, larger tumors deemed locally advanced cervical cancer (LACC) necessitate systemic therapy as part of chemoradiation therapy. Moreover, systemic therapy is the standard therapeutic approach for those presenting with primary metastasis or recurrence.

AREAS COVERED

While several agents have been approved to treat recurrent cervical cancer including checkpoint inhibitors as well as both biomarker agnostic and specific antibody drug conjugates, the development of agents added to chemoradiation has been less fruitful. Until recently, the addition of novel therapies to chemoradiation has been negative in terms of improving outcomes; however, results of a recent Phase III clinical trial (NCT04221945) in LACC demonstrated that the addition of pembrolizumab to standard of care chemoradiation was associated with an improvement in progression-free survival and resulted in an FDA approval for this therapy. This observation led to the first change in treating LACC since the early 2000s.

EXPERT OPINION

Improvements in systemic therapy both alone and in combination with chemoradiation for cervical cancer have been realized. Ongoing research is needed for therapeutic options following immunotherapy.

Patterns of use of primary and first-line chemotherapy for recurrence among patients with cervical cancer

BACKGROUND

Little is known about real-world patterns of chemotherapy use in patients with cervical cancer.

OBJECTIVE

To examine the patterns of chemotherapy use in patients with cervical cancer METHODS: We identified patients with cervical cancer in the IBM MarketScan Database who underwent primary hysterectomy or radiation therapy between 2011 and 2020 and described their treatment in the primary setting and at first recurrence.

RESULTS

We identified 5390 patients: 2667 (49.5%) underwent primary hysterectomy and 2723 (50.5%) primary radiotherapy. Among patients who underwent primary hysterectomy, 979 (36.7%) received adjuvant radiation, and 617 (23.1%) received primary chemotherapy. The most common chemotherapy regimens were single-agent platinum (51.7%), platinum combination therapy (42.9%), and non-platinum (3.4%). Among patients treated with primary radiation, 73.6% received primary/concurrent chemotherapy, either platinum alone (66.4% of those who received chemotherapy), platinum combinations (32.2%), or non-platinum (1.4%). The median duration of primary chemotherapy was 1.2 months. Therapy for recurrent cervical cancer was initiated in 959 patients. The most common regimens were platinum combination (63.9%), non-platinum cytotoxic agents (16.5%), single-agent platinum (14.9%), targeted therapy with bevacizumab (6.0%), and immunotherapy with pembrolizumab (3.2%). Overall, the proportion of patients treated with single-agent platinum therapy increased from 17.4% in 2011 to 32.1% in 2019, while platinum combinations decreased from 64.1% to 41.5% over the same years. Use of non-platinum agents increased from 18.5% in 2011 to 32.9% in 2018 and 26.4% in 2019.

CONCLUSIONS

Platinum-based chemotherapy is the most commonly used therapy in patients with cervical cancer in the primary setting and at the time of recurrence. The rate of use of non-platinum agents at first recurrence has increased over time.

A case report of lung metastasis in a cervical cancer presenting as a consolidation

Cervical cancer is a preventable cancer in the United States. We discuss a case of a 43-year-old woman who presented with signs and symptoms of Cerebrovascular accident (CVA) as well as shortness of breath and chest tightness. Upon investigation, it was concluded that she had developed multiple brain infarcts, pulmonary embolism, and deep venous thrombosis in both lower extremities. However, after her pulmonary symptoms worsened, further investigations revealed an uncommon occurrence of infiltrative lung metastasis. This finding was particularly surprising as she had recently been diagnosed with squamous cell carcinoma of the cervix. It is important to note that patients who have not undergone regular cervical cancer screening can remain without symptoms until the disease has reached an advanced stage, as is the case with this patient. Various screening methods, such as Pap smear cytology, human papillomavirus (HPV) DNA testing, and visual inspection tests, are available to detect and prevent cervical cancer.

Using Radiomics and Machine Learning Applied to MRI to Predict Response to Neoadjuvant Chemotherapy in Locally Advanced Cervical Cancer

Neoadjuvant chemotherapy plus radical surgery could be a safe alternative to chemo-radiation in cervical cancer patients who are not willing to receive radiotherapy. The response to neoadjuvant chemotherapy is the main factor influencing the need for adjunctive treatments and survival. In the present paper we aim to develop a machine learning model based on cervix magnetic resonance imaging (MRI) images to stratify the single-subject risk of cervical cancer. We collected MRI images from 72 subjects. Among these subjects, 28 patients (38.9%) belonged to the "Not completely responding" class and 44 patients (61.1%) belonged to the 'Completely responding' class according to their response to treatment. This image set was used for the training and cross-validation of different machine learning models. A robust radiomic approach was applied, under the hypothesis that the radiomic features could be able to capture the disease heterogeneity among the two groups. Three models consisting of three ensembles of machine learning classifiers (random forests, support vector machines, and k-nearest neighbor classifiers) were developed for the binary classification task of interest ("Not completely responding" vs. "Completely responding"), based on supervised learning, using response to treatment as the reference standard. The best model showed an ROC-AUC (%) of 83 (majority vote), 82.3 (mean) [79.9-84.6], an accuracy (%) of 74, 74.1 [72.1-76.1], a sensitivity (%) of 71, 73.8 [68.7-78.9], and a specificity (%) of 75, 74.2 [71-77.5]. In conclusion, our preliminary data support the adoption of a radiomic-based approach to predict the response to neoadjuvant chemotherapy.

Survival benefit of surgery with postoperative radiotherapy in locally advanced cervical adenocarcinoma: a population-based analysis

BACKGROUND

The incidence of cervical adenocarcinoma (AC) has experienced a considerable increase in recent decades. Despite this, our understanding of the optimal management of locally advanced cervical AC remains limited. The present study sought to compare the clinical outcomes of radical hysterectomy with postoperative radiotherapy (PORT) and primary radiotherapy (RT) in patients with locally advanced cervical AC using the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

The data were extracted from the SEER database utilizing the SEER ∗ STAT software (version 8.4.0.1). The study included patients diagnosed with locally advanced cervical AC between 2004 and 2017 with adequate information available for analysis. Patients were assigned to either the Surgery + PORT or Primary RT group based on treatment modality, and their clinical characteristics were compared. Propensity score matching (PSM) was utilized to adjust for differences in baseline characteristics between groups. The primary endpoints of the study were overall survival (OS) and cancer-specific survival (CSS).

RESULTS

Of the 1363 patients who met the inclusion criteria, 302 (22.16%) underwent Surgery + PORT, while 1061 patients received Primary RT. The two groups differed significantly in terms of age, year of diagnosis, tumor size, grade, stage, T/N stage, and chemotherapy. PSM was performed to balance the baseline characteristics between the two groups, resulting in 594 patients being analyzed. After PSM, the Surgery + PORT group exhibited significantly improved survival rates. The 5-year OS rates were 69.7% (95% CI: 63.3%-76.9%) for the Surgery + PORT group and 60.9% (95% CI: 56.0%-66.3%) for the group receiving Primary RT (p = 0.002). The 5-year CSS rates for the two groups were 70.7% (95% CI: 64.3%-77.8%) and 66.2% (95% CI: 61.3%-71.5%), respectively (p = 0.049). Multivariate analysis revealed that Surgery + PORT was an independent favorable prognostic factor for OS (HR = 0.60, p = 0.001) and CSS (HR = 0.69, p = 0.022). Although the combined approach of surgery and PORT resulted in a favorable impact on OS in patients aged 65 years or older (HR = 0.57, p = 0.048), it did not result in a statistically significant improvement in CSS in the same age group (HR = 0.56, p = 0.087). Similarly, the combined treatment did not yield a statistically significant increase in either OS (HR = 0.78, p = 0.344) or CSS (HR = 0.89, p = 0.668) in patients with tumors larger than 60 mm.

CONCLUSION

The present study demonstrated that Surgery + PORT was associated with improved OS and CSS in patients with locally advanced cervical AC when compared to Primary RT. As such, Surgery + PORT may be a preferable therapeutic option for carefully selected patients with cervical AC. These findings offer valuable insight into the management of locally advanced cervical AC and may assist in personalized treatment decisions.

Current Therapeutic Approaches in Cervical Cancer Based on the Stage of the Disease: Is There Room for Improvement?

Cervical cancer continues to be among the most common malignancies in women, and in recent decades, important measures have been taken to reduce its incidence. The first and most important steps to achieve this goal are oriented toward prevention through screening programs and vaccination, mainly against oncogenic human papillomavirus (HPV) strains 16 and 18. The therapeutic approach is based on the diagnosis and treatment guidelines for cervical cancer, which establish for each stage (FIGO, TNM) specific conduct. These guidelines summarize quite precisely the elements of therapeutic practice, but, in some places, they leave optional variants based on which nuanced approaches could be established. Adherence to these guidelines, which include the performing of minor or major surgery, with or without chemotherapy and radiation therapy, combined with advanced imaging investigations, has been able to lead to a substantial increase in survival. The purpose of this literature review is to discuss the diagnosis and treatment options in cervical cancer depending on the histological type, FIGO staging, and patient performance index, taking into account the hospital resources available in middle-income countries (percentage of gross domestic product allocated to health services around 5.5%, in the case of Romania).

Modulated electrohyperthermia in locally advanced cervical cancer: Results of an observational study of 95 patients

Most federation of gynecology and obstetrics stage II or higher locally advanced cervical cancer (LACC) patients are treated with concurrent chemoradiotherapy (CCRT); however, recurrence is high, and the prognosis is poor. In this observational retrospective study, data from LACC patients treated with CCRT alone or combined with modulated electrohyperthermia (mEHT) were collected from 2011 to 2018. Ninety-five LACC patients, including 53 (%) treated with CCRT alone and 42 (%) treated with CCRT + mEHT, were enrolled. The complete remission rate significantly increased with CCRT + mEHT compared with CCRT alone among LACC cases with lymph node metastasis (45% vs 71%, P = .0377). Additionally, at the last follow-up point, the no-evidence-of-disease rate significantly improved with CCRT + mEHT compared with CCRT (58% vs 82%, P = .0315). Disease-free survival increased in the CCRT + mEHT group with lymph node metastasis (P = .04). The addition of mEHT to CCRT led to a better therapeutic response in LACC with regional lymph node metastasis without severe complications.

Is postoperative radiotherapy (PORT) a viable option in high-risk early-stage cervical cancer after upfront or downstaged radical surgery? A comparative study

BACKGROUND

Radical surgery for cervical cancer has inherent benefits, and as upfront or post neoadjuvant chemotherapy (NACT), is extendable to locally advanced cancer cervix (LACC), with postoperative radiotherapy (PORT) for high-risk factors. Objective of the study was to compare the effectiveness and survival between non-PORT and PORT in high-risk early stages.

MATERIALS AND METHODS

Radical hysterectomies conducted between January 2014 and December 2017 were evaluated and followed till December 2019. Clinical, surgical-pathologic characteristics, and oncological outcomes were compared between non-PORT and PORT groups. A similar comparison was made between alive and dead patients within each group. The impact of PORT was assessed.

RESULTS

Of 178 radical surgeries, early-LACC constituted 70%. Most (37%) of the patients belonged to stage 1b2, while stage 2b formed 5%. Mean age of patients was 46.5 years; 69% were below 50 years of age. Abnormal bleeding (41%) was the predominant symptom, followed by postcoital (20%) and postmenopausal bleeding (12%). Upfront surgeries formed 70.2%, and the average waiting period was 1.93 months (range: 1-10 months). PORT patients were 97 (54.5%) in number and the remaining formed the non-PORT group. Mean follow-up was 34 months, with 118 (66%) alive patients. Significant adverse prognostic factors were tumors >4 cm (44.4% patients), positive margins (10%), lymphatic vascular space invasion (LVSI; 42%), malignant nodes (33%), multiple metastatic nodes averaging seven (range: 3-11), and delayed (>6 months) presentation, but not deep stromal invasion (77% patients) and positive parametrium (8.4% patients). PORT overcame the adverse effects of tumors >4 cm, multiple metastatic nodes, positive margins, and LVSI. Total recurrences (25%) were balanced for both groups, but recurrences within 2 years were significantly more for PORT. Two-year overall survival (78%) and recurrence-free survival (72%), median overall survival (21 months), and median recurrence-free interval (19 months) were significantly better for PORT, with the complication rates being similar.

CONCLUSION

PORT had significantly better oncological outcomes compared to non-PORT. Multimodal management is worthwhile.

The Association of Preoperative PET-CT and Survival in Patients with Resectable Cervical Cancer

PURPOSE

No randomized study with a long-term follow-up has investigated the effect of pretreatment 18-fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸FDG-PET-CT) on the survival of patients with stage IB-IIA cervical cancer receiving curative surgery. Therefore, in this propensity score-matched, population-based cohort study, we investigated the effect of preoperative ¹⁸FDG-PET-CT on the survival outcomes of patients with potentially resectable cervical cancer.

PATIENTS AND METHODS

We included 2550 patients with stage IB-IIA cervical cancer receiving curative surgery with complete data on clinical stages. The patients were categorized into two 1:4 propensity, score-matched groups depending on whether they underwent pretreatment ¹⁸FDG-PET-CT, and their outcomes were compared.

RESULTS

We included 2030 and 520 patients with cervical cancer in the non-pretreatment and pretreatment PET-CT groups, respectively. Multivariable analyses revealed that the most prominent correlation between preoperative PET-CT and all-cause death was observed in the patients with stage IB-IIA cervical cancer receiving surgery (aHR [95% CI]: 1.16 [0.83-1.63]; p = 0.3752).

CONCLUSIONS

Preoperative ¹⁸FDG-PET-CT was not associated with longer survival in the patients with clinical stage IB-IIA cervical cancer receiving curative surgery.

Debulking hysterectomy followed by chemoradiotherapy versus chemoradiotherapy for FIGO stage (2019) IB3/II cervical cancer

BACKGROUND

With an estimated 570,000 new cases reported globally in 2018, and increasing numbers of new cases in countries without established human papillomavirus (HPV) vaccination programmes, cervical cancer is the third most common cancer in women worldwide. The majority of global disease burden (around 85%) is in low-and middle-income countries (LMICs), with estimates of cervical cancer being the second most common cancer in women in such regions. As it commonly affects younger women, cervical cancer has the greatest impact on years of life lost (YLL) and adverse socioeconomic outcomes compared to all other cancers in women. Management of cervical cancer depends on tumour stage. Radical hysterectomy with lymphadenectomy is the standard primary treatment modality for International Federation of Gynecology and Obstetrics (FIGO) stage (2019) 1B1 to 1B3 disease. However, for larger primary tumours, radical hysterectomy is less commonly recommended. This is mainly due to a high incidence of unfavourable histopathological parameters, which require adjuvant concurrent chemoradiotherapy (CCRT) (chemotherapy given with radiotherapy treatment). CCRT is the standard of care and is widely used as first-line treatment for cervical cancer considered to be not curable with surgery alone (i.e.those with locally advanced disease). However, a sizable cohort of women managed with primary CCRT will have residual disease within the cervix following treatment. Debulking' hysterectomy to remove (debulk) the primary tumour in locally advanced disease, prior to CCRT, may be an alternative management strategy, avoiding the potential need for surgery for residual cervical disease following CCRT, which may be more extensive, or have increased morbidity due to CCRT. However, this strategy may subject more women to unnecessary surgery and its inherent risks.

OBJECTIVES

To assess the efficacy and harms of debulking hysterectomy (simple or radical) followed by chemoradiotherapy (CCRT) versus CCRT alone for FIGO (2019) stage IB3/II cervical cancer.

SEARCH METHODS

We systematically searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 4), MEDLINE via Ovid (1946 to 12 April 2021) and Embase via Ovid (1980 to 12 April 2021). We also searched other registers of clinical trials, abstracts of scientific meetings and reference lists up to 12 April 2021.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs), quasi-RCTs or non-randomised studies (NRSs) comparing debulking hysterectomy followed by CCRT versus CCRT alone for locally advanced FIGO (2019) stage IB3/II cervical malignancy.

DATA COLLECTION AND ANALYSIS

We applied Cochrane methodology, with two review authors independently assessing whether potentially relevant studies met the inclusion criteria. We planned to apply standard Cochrane methodological procedures to analyse data and risk of bias.

MAIN RESULTS

We did not find any evidence for or against debulking hysterectomy followed by CCRT versus CCRT alone for FIGO (2019) stage IB3/II cervical cancer. We did not identify any studies assessing the validity of debulking hysterectomy for these women.  AUTHORS' CONCLUSIONS: There was no evidence for or against debulking hysterectomy followed by CCRT versus CCRT alone for FIGO (2019) stage IB3/II cervical cancer.

Nonadherence to Multimodality Cancer Treatment Guidelines in the United States

Purpose

Our purpose was to identify patients with cancer who do not receive guideline-concordant multimodality treatment and to identify factors that are associated with nonreceipt of guideline-concordant multimodality treatment.

Methods and Materials

Five cancers for which the multimodal guideline-concordant treatment (with surgery, chemotherapy, and radiation therapy) is clearly defined in national guidelines were selected from the National Cancer Database: (1) nonmetastatic anal cancer, (2) locally advanced cervical cancer, (3) nonmetastatic nasopharynx cancer, (4) locally advanced rectal cancer, and (5) locally advanced non-small cell lung cancer. Multivariable logistic regression was used to determine the odds ratios (with 95% confidence intervals) of receiving the guideline-concordant treatment versus not, adjusting for common confounding variables.

Results

178,005 patients with cancer were included: 32,214 anal, 54,485 rectal, 13,179 cervical, 5061 nasopharyngeal, and 73,066 lung. Overall, 162,514 (91%) received guideline-concordant treatment and 15,491 (9%) did not. Twenty-one percent of patients with cervical cancer, 10% of patients with rectal cancer, 7% of patients with lung cancer, 5% of patients with anal cancer, and 3% of patients with nasopharynx cancer did not receive guideline-concordant treatment. In general, patients who were older, with comorbid conditions, and who were evaluated at low-volume facilities (odds ratios > 1 with P < .05) were less likely to receive guideline-concordant treatment.

Conclusions

Nearly 1 in 10 patients in this cohort are not receiving appropriate multimodal cancer therapy. There appear to be significant disparities in receipt of guideline-concordant treatment based on primary tumor site, age, comorbidities, and reporting facility.

Current Management of Locally Advanced and Metastatic Cervical Cancer in the United States

Despite decreases in incidence in the twentieth century, cervical cancer continues to be a highly morbid disease in the United States. For those diagnosed with locally advanced disease, single-agent cisplatin-based chemotherapy concurrent with radiation remains the mainstay of treatment. For patients with metastatic, progressive, and recurrent disease, treatment typically consists of combination chemotherapy and incorporation of bevacizumab, and recent data show benefits with the addition of upfront immunotherapy in women whose cancer expresses programmed death ligand-1. The physical sequelae of locally advanced cervical cancer treatments stem largely from irradiation of the pelvis, and treatment of these is aimed at identifying reversible or treatable causes of symptoms and palliating those with irreversible causes. From a psychologic standpoint, patients with cervical cancer face the stigma of having a preventable cancer caused by a sexually transmitted infection and the ramifications of sexual dysfunction. Clinicians must invite honest dialogue to be able to address specific survivorship issues.

A Rare Case of Clear Cell Cervical Carcinoma to a Woman, 50 Years After Diethylstilbestrol Exposure for Lactation Suppression

A 73-year-old lady presented with post-menopausal bleeding and a suspicious-looking endocervical polyp. She had a loop biopsy of the cervix that showed clear cell cervical carcinoma, and she was referred to our Gynaecology oncology team for further management. Following imaging for staging and an MDT discussion, she had a total abdominal radical hysterectomy that confirmed the diagnosis. The diagnosis of clear cell adenocarcinoma of the cervix is rare, accounting for 4% of cervical carcinomas. However, it is often correlated with diethylstilbestrol (DES) exposure in utero. It is well documented that daughters of mothers who received DES during pregnancy are at a higher risk of adenocarcinomas in the genital tract. In our case, the patient had been administered DES for lactation suppression 50 years earlier. After reviewing the relevant literature, we present the case of our patient, the management of this uncommon case, and help identify possible correlation/long-term implications to patients who received DES.

The Effect of Neoadjuvant Chemotherapy Combined With Brachytherapy Before Radical Hysterectomy on Stage IB2 and IIA Cervical Cancer: A Retrospective Analysis

Objective

This study aims to retrospectively evaluate and compare the clinical efficacy in patients with stage IB2 and IIA cervical cancer, who treated with neoadjuvant chemotherapy combined with brachytherapy or not before radical hysterectomy.

Methods

The data of patients who have diagnosed with stage IB2 and IIA cervical cancer between January 2010 and December 2013 were retrieved through the Hospital Information System (HIS) of Gansu Provincial Maternal and Child Health Hospital. Patients were divided into two groups: neoadjuvant chemotherapy combined with brachytherapy followed by radical hysterectomy group (NACT+BT Group) and direct radical hysterectomy group (RH Group). The rate of adjuvant radiotherapy, progression-free survival (PFS), and overall survival (OS) were compared between the two groups.

Results

A total of 183 patients were included in this study with 82 in the NACT+BT group and 101 in the RH group. The median follow up duration was 44.9 months for the NACT+BT group and 38.1 months for the RH group. The 5-year PFS for NACT+BT Group was 93.8%, which was significantly higher compared to the RH group (77.2%, P= 0.0202). The rate of postoperative adjuvant pelvic radiotherapy was significantly lower in the NACT+BT group compared to the RH group (30.49% vs 79.21%; P <0.05). COX multivariate analysis showed that NACT+BT increased PFS by 29% compared with RH treatment, and Positive margin decreased PFS and OS by by 4.7 and 6.87 times, respectively.

Conclusion

Neoadjuvant chemotherapy combined with brachytherapy followed by radical hysterectomy (NACT+BT) can extend PFS, reduce postoperative pathological risk, and postoperative adjuvant pelvic radiotherapy compared to the direct radical hysterectomy (RH).

The Role of microRNAs in the Cisplatin- and Radio-Resistance of Cervical Cancer

Cervical cancer is the fourth leading cause of cancer-related death among women worldwide. The chemotherapeutical agent cisplatin, a small platinum-based compound, is considered as the standard therapy for locally advanced cervical cancer or recurrent cancers, sometimes in combination with radiotherapy or other drugs. However, drug resistance and radio-resistance phenomena could reduce the life expectancy of cervical cancer patients. Resistance mechanisms are complex and often involve multiple cellular pathways in which microRNAs (miRNAs) play a fundamental role. miRNAs are a class of endogenous non-coding small RNAs responsible for post-transcriptional gene regulation. Convincing evidence demonstrates that several deregulated miRNAs are important regulators in the onset of drug and radioresistance in cervical cancer, thus underlying their potential applications in a clinical setting. In this review, we summarized the mechanisms by which miRNAs affect both cisplatin and radioresistance in cervical cancer. We also described the regulatory loops between miRNAs and lncRNAs promoting drug resistance. Besides, we reported evidence for the role of miRNAs in sensitizing cancer cells to cisplatin-based chemotherapy, and provided some suggestions for the development of new combined therapies for cervical cancer.

Prognosis of bulky pTIIB cervical cancer treated by radical hysterectomy comparing adenocarcinoma with squamous cell carcinoma using propensity score matching

OBJECTIVE

To investigate whether radical hysterectomy (RAH) can effectively treat true Stage IIB (pTIIB) cervical adenocarcinoma (AC) because FIGO (clinical) Stage IIB cervical cancer is rarely treated with RAH and radiotherapy has unfavorable effects on AC.

METHODS

We retrospectively analyzed data for 82 patients with Stage pTIIB cervical cancer who underwent RAH at our institution between January 1997 and December 2017. The end points were disease-free survival (DFS) and overall survival (OS) among squamous cell carcinoma (SCC) (n = 60) and AC (n = 22) patients. Kaplan-Meier survival analysis with and without propensity score matching was conducted to identify the impact of RAH.

RESULTS

Para-aortic lymph node metastasis and tumor diameter were significant factors for recurrence, and adjuvant chemotherapy prevented recurrence on multivariate analysis. After propensity score matching, there was no significant difference in DFS and OS between the groups. Five-year DFS and OS of the SCC group were 0.505 (95% confidence interval [CI] 0.268-0.702) and 0.619 (95% CI 0.351-0.803), respectively, and those of the AC group were 0.444 (95% CI 0.232-0.638) and 0.602 (95% CI 0.351-0.782), respectively.

CONCLUSION

Bulky Stage pTIIB cervical cancer is hard to cure, but RAH plus adjuvant therapy might be an option for radio-resistant pTIIB cervical AC.

Tailored radical hysterectomy for locally advanced cervical cancer

OBJECTIVE

The survival and prognostic factors for locally advanced cervical cancer treated with nerve-sparing Okabayashi-Kobayashi radical hysterectomy have not been elucidated. We aimed to evaluate the oncological outcomes of those patients after radical hysterectomy with adjuvant chemotherapy.

METHODS

This retrospective cohort study was conducted from January 2002 to December 2011. Treatment was conducted at a single tertiary center in northern Japan. We used the Okabayashi-Kobayashi radical hysterectomy with lymphadenectomy. We applied unilateral nerve preservation for stage IIA/IIB cancer if there was a one-sided extension of the disease outside the cervix. Indication for adjuvant therapy was based on Sedlis criteria. High-risk was defined as evidence of lymph node metastasis, pathological parametrial invasion, and a positive/close surgical margin. The choice of adjuvant therapy was chemotherapy which consisted of paclitaxel and cisplatin.

RESULTS

The study included 76 early-stage IB1 (≤4 cm) and IIA1 cervical cancer and 45 locally advanced stage IB2 (>4 cm), IIA2, and IIB disease treated consecutively. The median follow-up was 106 (range: 6-203) months. There were 18 (15%) patients with recurrence, with five of 76 in the early-stage (7%) and 13 of 45 in the locally advanced disease (29%) (P<0.001). For locally advanced cervical cancer, pT classification (P<0.001), lymph node metastasis (P=0.007), and histology (P=0.05) were associated with locoregional recurrence. The five-year locoregional recurrence rate in the locally advanced disease was 20% and 5% in the early-stage disease (P=0.01). The five-year disease-free survival in the locally advanced cervical cancer was 71% and 93% in the early-stage disease (P<0.001). The overall survival in locally advanced disease depended on the adeno-type histology and lymph node metastasis.

CONCLUSION

The tailored use of nerve-sparing Okabayashi-Kobayashi radical hysterectomy with adjuvant chemotherapy based on tumor histology and lymph node metastasis may be a possible option as a treatment of locally advanced cervical cancer in selected patients.

A Rare Case of Clear Cell Adenocarcinoma of the Cervix with No Intrauterine Diethylstilbestrol Exposure

Cervical cancer is the fourth most common cancer in females. Clear cell adenocarcinoma of the cervix is an uncommon histological variant and is usually seen with intrauterine exposure to diethylstilbestrol. A 28-year-old female with no intrauterine exposure to diethylstilbestrol presented with postcoital bleeding. A pelvic exam revealed a cervical mass. Imaging confirmed the cervical mass and positron emission tomography scan showed an increased uptake in the cervical mass as well as the para-aortic and pelvic lymph nodes. Biopsy showed a clear cell carcinoma of the cervix. She was treated with cisplatin and paclitaxel for eight cycles and concurrent radiation therapy. She had a complete response to therapy and has been in complete remission nine months from the end of therapy. There are no clear guidelines for the treatment of clear cell carcinoma with current therapy based on the treatment of squamous and non-clear cell adenocarcinoma. Cisplatin and paclitaxel could be an option, given the successful treatment of the patient in our case.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Concurrent Chemo- Radiobrachytherapy with Cisplatin and Medium Dose Rate Intra- Cavitary Brachytherapy for Locally Advanced Uterine Cervical Cancer

Objective:

Cervical carcinoma is the third most common gynecologic cancer, after ovarian and uterine cancers in Iran. The aim of this study was to evaluate the efficacy (response rate) and toxicity of adding Medium Dose Rate (MDR) brachytherapy with concurrent chemotherapy to External Beam Radiotherapy (EBRT) for the treatment of locally advanced uterine cervical carcinoma.

Methods:

This phase I-II study was conducted in 2007-2008 at the cancer institute, Tehran University of Medical Sciences. Patients were treated with pelvic EBRT (50 Gy in 25 Fraction) with concomitant chemotherapy to obtain tumor shrinkage and permit optimal intra-cavitary placement. One week after the completion of EBRT, patients were treated by 12 Gy MDR Intra-cavitary brachytherapy for two periods of one day with a one week interval and concomitant platinum based chemotherapy. Response rate was evaluated by gynecologic physical examination and pelvic MRI +- GD within three months of treatment. Acute and late toxicity were assessed using Radiation Therapy Oncology Group criteria.

Results:

A total of 33 patients with locally advanced cervical cancer were treated according to the above described treatment protocol. The patients mean age was 53.2 (range 31–78) years. Three months after the completion of treatment, the complete clinical, pathologic and radiologic response rate according to WHO-criteria was 81.8% (27 patients). Six cases had a partial response or stable disease. After 48 months, average disease free survival periods were 45.1, 23.0, 33.4 and 8 months for stage IIB, IIIA, IIIB and IVA lesions (according to The International Federation of Gynecology and Obstetrics staging system). The most frequently observed side effects were leukopenia, anemia, proctitis, cystitis, nausea and vomiting (mostly grade 1 and 2).

Conclusion:

Concomitant brachytherapy and chemotherapy with platinum compounds can be well tolerated and is effective in the treatment of locally advanced cervical cancer.

Bleeding after interstitial brachytherapy for cervical cancer requiring embolization

Cervical cancer is the third most common cancer among women worldwide and is usually managed with chemoradiation in advanced disease. This case presents a 41-year-old female with locally advanced cervical cancer who underwent combination intracavitary/interstitial brachytherapy after chemoradiation for local disease control. At her fifth brachytherapy session, one of the interstitial needles was malpositioned and lead to vascular injury with significant blood loss. She subsequently underwent emergent embolization of a branch of the right obturator artery with immediate clinical improvement and no complications. This is the first reported case of vascular injury from an interstitial brachytherapy needle that required arterial embolization for hemostasis.

Efficacy and toxicity of image-guided intensity-modulated radiation therapy combined with dose-escalated brachytherapy for stage IIB cervical cancer

Considering internal organ motion and tumor regression, it is controversial to use intensity-modulated radiation therapy (IMRT) in definitive radiotherapy for cervical cancer. In this study, we evaluated the efficacy and toxicity of IMRT combined with dose-escalated intracavitary brachytherapy (ICBT) for cervical cancer. In total, 373 consecutive FIGO-stage-IIB cervical cancer patients treated with IMRT combined with ICBT and concurrent chemotherapy were included in this study. A dose of 50.4 Gy in 28 fractions was delivered to the pelvis for IMRT. Weekly cone-beam computed tomography or daily megavoltage computed tomography was used for image guiding. For ICBT, 30–36 Gy in five to seven fractions were prescribed to point A. All patients received concurrent chemotherapy. The median follow-up duration was 32.5 months (range, 3.1–119.8 months). The three-year overall survival, disease-free survival and local control rates were 87.5%, 82.2% and 92.5%, respectively. Sixty patients (16.1%) experienced treatment failure, including 23 patients (6.2%) with pelvic relapse. The incidences of ≥grade 3 chronic gastrointestinal and genitourinary toxicity were 2.7% and 2.4%, respectively. These findings indicate that image-guided IMRT combined with dose-escalated ICBT results in good survival with acceptable toxicity in stage IIB cervical cancer patients.

B3GNT3 Expression Is a Novel Marker Correlated with Pelvic Lymph Node Metastasis and Poor Clinical Outcome in Early-Stage Cervical Cancer

BACKGROUND

The β1,3-N-acetylglucosaminyltransferase-3 gene (B3GNT3) encodes a member of the B3GNT family that functions as the backbone structure of dimeric sialyl-Lewis A and is involved in L-selectin ligand biosynthesis, lymphocyte homing and lymphocyte trafficking. B3GNT3 has been implicated as an important element in the development of certain cancers. However, the characteristics of B3GNT3 in the development and progression of cancer remain largely unknown. Thus, our study aimed to investigate the expression pattern and the prognostic value of B3GNT3 in patients with early-stage cervical cancer.

METHODS

The mRNA and protein levels of B3GNT3 expression were examined in eight cervical cancer cell lines and ten paired cervical cancer tumors, using real-time PCR and western blotting, respectively. Immunohistochemistry (IHC) was used to analyze B3GNT3 protein expression in paraffin-embedded tissues from 196 early-stage cervical cancer patients. Statistical analyses were applied to evaluate the association between B3GNT3 expression scores and clinical parameters, as well as patient survival.

RESULTS

B3GNT3 expression was significantly upregulated in cervical cancer cell lines and lesions compared with normal cells and adjacent noncancerous cervical tissues. In the 196 cases of tested early-stage cervical cancer samples, the B3GNT3 protein level was positively correlated with high risk TYPES of human papillomavirus (HPV) infection (P = 0.026), FIGO stage (P < 0.001), tumor size (P = 0.025), tumor recurrence (P = 0.004), vital status (P < 0.001), concurrent chemotherapy and radiotherapy (P = 0.016), lymphovascular space involvement (P = 0.003) and most importantly, lymph node metastasis (P = 0.003). Patients with high B3GNT3 expression had a shorter overall survival (OS) and disease-free survival (DFS) compared with those with low expression of this protein. Multivariate analysis suggested that B3GNT3 expression is an independent prognostic indicator for cervical cancer patients.

CONCLUSIONS

Our study demonstrated that elevated B3GNT3 expression is associated with pelvic lymph node metastasis and poor outcome in early-stage cervical cancer patients. B3GNT3 may be a novel prognostic marker and therapeutic target for the treatment of cervical cancer.

Integration of PET/CT into the preoperative evaluation of patients with early cervical cancer does not decrease the proportion of patients with positive lymph nodes found after surgery

PURPOSE

The aim of this study was to evaluate whether preoperative positron emission tomography/computed tomography (PET/CT) in patients with early-stage cervical carcinoma reduced the proportion of patients with metastatic lymph nodes identified after surgery.

PATIENTS AND METHODS

This is a multicenter case-control study of 599 patients with early cervical cancer who underwent radical hysterectomy and pelvic lymphadenectomy at 1 of 10 gynecological oncology units in Israel. The patients were divided into 2 groups according to whether or not they underwent a preoperative PET/CT. The primary outcome was the proportion of patients with nodal involvement. The 2 groups were compared with regard to the clinical and histological variables.

RESULTS

Of the 599 patients who underwent surgery, 180 (36%) had preoperative PET/CT study. There were no significant differences between the PET/CT and control groups with regard to clinical and histological risk factors. The proportion of patients with involved nodes was similar in the control and PET/CT groups (20.8% vs 19%; P = 0.73) as well as the proportion of patients receiving adjuvant radiotherapy/chemoradiation (58.3% vs 55.1%; P = 0.55).

CONCLUSIONS

Preoperative PET/CT in patients with early cervical cancer does not reduce proportion of patients with metastatic nodal involvement and the employment of multimodality treatment. Prospective clinical trials comparing management based on PET/CT findings are warranted.

Adjuvant chemotherapy, a valuable alternative option in selected patients with cervical cancer

Radiotherapy is the standard treatment for cervical cancer, but causes radiotherapy-induced complications. Recently, chemotherapy has been more extensively utilized. Here, we perform a large-scale comparison of chemotherapy and radiotherapy. From 2002 to 2008, 2,268 patients were grouped according to adjuvant radiotherapy or chemotherapy before and/or after surgery, and we compared the 5-year overall survival (OS) and disease-free survival (DFS) rates, recurrence rates, side effects, quality of life (QoL), and sexual activity. There were no significant differences between the treatment groups for the 5-year OS and DFS rates (OS: p = 0.053, DFS: p = 0.095), although marginally improved outcomes were observed in the chemotherapy group (OS: 86.5% vs. 82.8%; DFS: 84.5% vs. 81.4%). However, patients with early-stage disease, clinical response, and younger age had increased 5-year OS and DFS rates following chemotherapy compared to radiotherapy (p<0.05). The chemotherapy group exhibited significantly lower 5-year recurrence and distant failure rates compared to the radiotherapy group (p<0.001 and p = 0.007, respectively). Nausea and vomiting were the most frequent short-term complications of chemotherapy, whereas bowel and urinary complications were more frequent in the radiotherapy group. Compared to the chemotherapy group, patients who received radiotherapy reported a lower QoL, less frequent sexual activity, and more severe menopausal symptoms (p<0.05). Cervical cancer patients treated with chemotherapy, especially those with early-stage disease, clinical responses, and younger ages, have more positive outcomes, fewer complications, better QoL and sexual activity, suggesting that chemotherapy may be a valuable alternative option for selected patients.

Patterns of care in patients with cervical cancer 2012: results of a survey among German radiotherapy departments and out-patient health care centers

BACKGROUND

Platinum-based primary or adjuvant chemoradiation is the treatment of choice for patients with cervical cancer. However, despite national guidelines and international recommendations, many aspects in diagnosis, therapy, and follow-up of patients with cervical cancer are not based on valid data.

METHODS

To evaluate the current patterns of care for patients with cervical cancer in Germany, a questionnaire with 25 items was sent to 281 radiooncologic departments and out-patient health care centers.

RESULTS

The response rate was 51%. While 87% of institutions treat 0-25 patients/year, 12 % treat between 26 and 50 and only 1% treat more than 50 patients/year. In 2011, the stage distribution of 1,706 treated cervical cancers were IB1, IB2, IIA, IIB, IIIA/IIIB, and IV in 11, 12, 11, 22, 28, and 16%, respectively. CT (90%) and MRI (86%) are mainly used as staging procedures in contrast to PET-CT with 14%. Interestingly, 27% of institutions advocate surgical staging prior to chemoradiation. In the majority of departments 3D-based (70%) and intensity-modulated radiotherapy (76%) are used for percutaneous radiation, less frequently volumetric arc techniques (26%). Nearly all colleagues (99.3%) apply conventional fractioning of 1.8-2 Gy for external-beam radiotherapy, in 19% combined with a simultaneous integrated boost. Cisplatinum mono is used as a radiosensitizer with 40 mg/m(2) weekly by 90% of radiooncologists. For boost application in the primary treatment, HDR (high-dose rate) brachytherapy is the dominant technique (84%). In patients after radical hysterectomy pT1B1/1B2, node negative and resection in sound margins adjuvant chemoradiation is applied due to the occurrence of 1-4 other risk factors in 16-97%. There is a broad spectrum of recommended primary treatment strategies in stages IIB and IVA.

CONCLUSION

Results of the survey underline the leading role but also differences in the use of chemoradiation in the treatment of cervical cancer patients in Germany.

Aspects of Therapy for Cervical Cancer in Germany 2012 - Results from a Survey of German Gynaecological Hospitals

Introduction: In spite of the existence of guidelines and international recommendations, many aspects in the diagnosis, therapy and follow-up of patients with cervical cancer are not based on validated data. A broad spectrum of different opinions and procedures concerning the therapy for patients with cervical cancer is under controversial discussion by the responsible gynaecologists in German hospitals. Methods: The present study is intended to picture the current treatment situation for cervical cancer in Germany. For this purpose a specially developed questionnaire with questions divided into 19 subsections was sent to all 688 gynaecological hospitals in Germany. Results: The response rate to the questionnaire was 34 %. 91 % of the hospitals treated between 0 and 25 patients with cervical cancer per year. 7.5 % treated between 26 and 50 and 1.4 % of the hospitals more than 50 patients per year. The bimanual examination was the most frequently used staging method (98 %); PET-CT was the least used staging method (2.3 %). Interestingly 48 % of the hospitals used surgical staging. The great majority of the hospitals (71 %) used abdominal radical hysterectomy (Wertheim-Meigs operation) to treat their patients. TMMR via laparotomy was used by 13 %. 16 % of the hospitals performed laparoscopic or robot-assisted radical hysterectomies. The sentinel concept was hardly used even in the early stages. It must be emphasised that in 74 % of the hospitals radical hysterectomies were performed even in cases with positive pelvic lymph nodes and in 43 % also in cases with positive paraaortic lymph nodes. The therapy of choice for FIGO IIB cancers is primary radiochemotherapy (RCTX) in 21 % of the hospitals; operative staging followed by radiochemotherapy in 24 % and treatment by radical hysterectomy followed by adjuvant RCTX was employed in this situation by 46 % of the hospitals. In 15-97 % of the hospitals for node-negative and in sano resected patients in stage pT1B1/1B2 after radical hysterectomy, an adjuvant RCTX is recommended when further risk factors exist (LVSI, tumour > 4 cm, age < 40 years, adenocarcinoma, S3). Conclusion: A broad spectrum of differing staging and therapy concepts is in use for patients with cervical cancer in Germany. A standardisation of therapy is needed. An update of national guidelines could help to achieve more transparency and a standardisation of treatment for patients with cervical cancer.

Impact of the Addition of Concurrent Chemotherapy to Pelvic Radiotherapy in Surgically Treated Stage IB1-IIB Cervical Cancer Patients With Intermediate-Risk or High-Risk Factors: A 13-Year Experience

Objectives

To identify groups of patients who derive clinical benefit from postoperative adjuvant concurrent chemoradiotherapy (CCRT), we retrospectively investigated the survival outcomes of surgically treated early-stage cervical cancer patients.

Methods

We reviewed the medical records of 316 patients with FIGO stage IB1-IIB cervical cancer who had been treated with adjuvant radiotherapy (RT) (n = 124, RT group) or adjuvant CCRT (n = 192, CCRT group) after radical hysterectomy between January 1996 and December 2009. Of these, 187 patients displayed high-risk prognostic factors (high-risk group), and 129 displayed intermediate-risk prognostic factors (intermediate-risk group). Sixty patients with 1 intermediate-risk prognostic factor who received no adjuvant therapy were also identified and used as controls (NFT group). Survival was calculated using the Kaplan-Meier method and compared using the log-rank test.

Results

In the high-risk group, adjuvant CCRT was significantly superior to RT alone with regard to recurrence rate, progression-free survival (PFS), and overall survival. In the intermediate-risk group, CCRT was superior to RT with regard to recurrence rate and PFS in patents with 2 or more risk factors. Among the patients with only 1 intermediate-risk factor, although no survival benefit of CCRT over RT was observed, addition of adjuvant treatment resulted in significantly improved PFS compared with the NFT group in patients with deep stromal invasion (log-rank, P = 0.012).

Conclusions

Postoperative CCRT improved the prognosis of FIGO stage IB1-IIB cervical cancer patients in the high-risk group and patients who displayed 2 or more intermediate-risk factors. Patients who displayed deep stromal invasion alone also derived clinical benefit from adjuvant treatment.

Radical hysterectomy with adjuvant radiotherapy versus definitive radiotherapy alone for FIGO stage IIB cervical cancer

OBJECTIVES

The aim of this study was to compare the treatment outcomes and adverse effects of radical hysterectomy followed by adjuvant radiotherapy with definitive radiotherapy alone in patients with FIGO stage IIB cervical cancer.

METHODS

We retrospectively reviewed the medical records of FIGO stage IIB cervical cancer patients who were treated between April 1996 and December 2009. During the study period, 95 patients were treated with radical hysterectomy, all of which received adjuvant radiotherapy (surgery-based group). In addition, 94 patients received definitive radiotherapy alone (RT-based group). The recurrence rate, progression-free survival (PFS), overall survival (OS), and treatment-related complications were compared between the two groups.

RESULTS

Radical hysterectomy followed by adjuvant radiotherapy resulted in comparable recurrence (44.2% versus 41.5%, p=0.77), PFS (log-rank, p=0.57), and OS rates (log-rank, p=0.41) to definitive radiotherapy alone. The frequencies of acute grade 3-4 toxicities were similar between the two groups (24.2% versus 24.5%, p=1.0), whereas the frequencies of grade 3-4 late toxicities were significantly higher in the surgery-based group than in the RT-based group (24.1% versus 10.6%, p=0.048). Cox multivariate analyses demonstrated that treatment with surgery followed by adjuvant radiotherapy was associated with an increased risk of grade 3-4 late toxicities, although the statistical significance of the difference was marginal (odds ratio 2.41, 95%CI 0.97-5.99, p=0.059).

CONCLUSIONS

Definitive radiotherapy was found to be a safer approach than radical hysterectomy followed by postoperative radiotherapy with less treatment-related complications and comparable survival outcomes in patients with FIGO stage IIB cervical cancer.