The 5-year overall survival of cervical cancer in stage IIIC-r was little different to stage I and II: a retrospective analysis from a single center

Comparison of oncological outcomes between radical hysterectomy and radiochemotherapy for International Federation of Gynecology and Obstetrics 2018 stage IIIC1 cervical adenocarcinoma: A retrospective multicenter cohort study

BACKGROUND

To compare oncological outcomes of radical hysterectomy (RH) and radiochemotherapy (R-CT) for stage IIIC1 (FIGO 2018) cervical adenocarcinoma patients.

METHODS

Based on the Chinese Cervical Cancer Clinical Diagnosis and Treatment Project Database, we retrospectively reviewed 236 cases of FIGO stage IIIC1 cervical adenocarcinoma diagnosed between 2005 and 2019. The 5-year overall survival (OS) and 5-year disease-free survival (DFS) rates were compared between the two treatment groups using multivariate Cox regression models and the log-rank test, both in the overall study population and after propensity score matching (PSM).

RESULTS

From 63 926 patients, we selected 236 cases, including 203 in the RH group and 33 in the R-CT group. In the overall study population, R-CT was associated with significantly worse 5-year OS (51.8% vs. 67.2%, p < 0.05) and 5-year DFS (43.1% vs. 60.1%, p < 0.05) compared to RH. Multivariate analysis revealed that R-CT was an independent risk factor for 5-year DFS (hazard ratio [HR] = 2.226, 95% confidence interval [CI] 1.141-4.343, p < 0.05) but not for 5-year OS (HR = 1.834, 95% CI: 0.829-4.061, p > 0.05) in FIGO stage IIIC1 cervical adenocarcinoma. After matching (n = 26 in R-CT group vs. 73 in RH group), the R-CT group showed significantly lower 5-year OS (50.3% vs. 77.4%, p < 0.05) and DFS (38.2% vs. 65.0%, p < 0.05) compared to the RH group. In the matched cohort, R-CT remained an independent risk factor for 5-year DFS (HR = 2.299, 95% CI: 1.113-4.750, p < 0.05) but not for 5-year OS (HR = 1.926, 95% CI: 0.792-4.682, p > 0.05).

CONCLUSION

Among patients with stage FIGO 2018 IIIC1 cervical cancer adenocarcinoma, R-CT was not associated with better oncological outcomes than RH. Radiotherapy should not be the only recommended treatment.

Construction and evaluation of a prognostic model for cervical cancer based on dynamic hematological and clinical features

OBJECTIVES

This study aims to investigate the prognostic significance of dynamic hematological and clinical characteristics and to construct nomograms to predict overall survival (OS) in patients with cervical carcinoma who underwent radical radiotherapy.

METHODS

The study analyzed patients with cervical cancer who underwent radical radiotherapy at The University of Hong Kong-Shenzhen Hospital between January 2015 and June 2022 and were staged as IB1 to IVA according to the International Federation of Gynecology and Obstetrics (FIGO) 2018 staging system. We identified predictive factors through univariate and multivariate cox regression analyses. Two multivariate analyses integrating different groups of variables were conducted independently. Concordance index (C-index), receiver operating characteristic (ROC), and Kaplan-Meier curves were used to evaluate the nomograms. Bootstrap validation was performed to determine the accuracy of the nomogram using 1000 resamples. The performances of proposed nomograms and FIGO 2018 staging system were compared to assess the prognostic value of hematological and inflammatory markers.

RESULTS

One hundred fifty-nine patients were included in this retrospective analysis. The median follow-up time was 41.37 months, and the 3-year OS rate was 82.6%. The first multivariate analysis of pre-treatment clinical factors and all hematological variables showed that FIGO2018 staging, and pre-treatment albumin levels were associated with 3-year OS. The final multivariate analysis incorporating all clinical factors, hematological variables, and inflammatory markers identified the following prognostic factors: FIGO2018 staging, rate of tumor shrinkage before brachytherapy, pre-treatment albumin levels, treatment times, minimum neutrophils during treatment, concurrent chemotherapy cycles, and lymphopenia grade. Calibration plots showed agreement between the OS predicted by the nomograms and actual OS. Kaplan-Meier curves demonstrated that patients in the high-risk group had shorter OS than those in the low-risk group (P ≤ 0.001). The C-index for the two nomograms was superior to that of the current FIGO2018 staging system, with values of 0.709 (95% Confidence Interval [CI], 0.622-0.795) and 0.803 (95% CI, 0.729-0.877), compared to 0.593 (95% CI, 0.508-0.678) for the FIGO system.

CONCLUSION

We developed and validated nomograms to predict OS in cervical cancer patients staged IB1 to IVA who underwent radical radiotherapy RT. The prognostic significance of dynamic changes in blood and inflammatory markers has been confirmed. The proposed nomogram exhibits robust predictive capabilities for estimating OS in these patients, facilitating risk stratification and individualized treatment.

Survival outcomes of 2018 FIGO stage IIIC versus stages IIIA and IIIB in cervical cancer: A systematic review with meta-analysis

OBJECTIVE

To assess the difference in survival outcomes between stage IIIC and stages IIIA and IIIB in the 2018 FIGO cervical cancer staging system.

METHODS

The PubMed, EMBASE, MEDLINE and Web of Science were searched for articles published from November 1, 2018 to January 31, 2023. Articles published in English were considered. The included studies compared the survival outcomes of patients with cervical cancer in FIGO 2018 stage IIIC with those in stages IIIA and IIIB. Studies focused on rare histopathological types were excluded. The statistical analyses were performed using Stata 17 software. The endpoints were overall survival (OS) and progression-free survival (PFS).

RESULTS

Ten retrospective cohort studies were eligible, involving 2113 (6.2%), 9812 (28.6%), 44 (0.1%), 10 171 (29.7%), 11 677 (34.1%) and 445 (1.3%) patients in stage IIIA, IIIB, IIIA&B, IIIC, IIIC1, and IIIC2, respectively. In the OS group, stage IIIC/C1 was significantly associated with superior survival compared with stage IIIA (hazard risk [HR] 0.62, 95% confidence interval [CI] 0.41-0.93, P = 0.022; I2 = 92.9%) and stage IIIB(A&B) (HR 0.56, 95% CI 0.44-0.71, P < 0.001; I2 = 94.0%). The FIGO 2018 stage IIIC2 was not associated with an increased mortality risk compared with stage IIIA and stage IIIB(A&B). In the PFS group, the outcome of FIGO 2018 stage IIIC/C1 was similar to stage IIIA (HR 0.66, 95% CI 0.27-1.64, P = 0.371; I2 = 65.6%), but better than stage IIIB(A&B) (HR 0.75, 95% CI 0.68-0.83, P < 0.001; I2 = 0.0%). The FIGO 2018 stage IIIC2 has similar PFS outcomes to stage IIIA and stage IIIB(A&B).

CONCLUSION

Our findings demonstrate that survival outcomes of stage IIIC are no worse than those of stage IIIA and stage IIIB in the 2018 FIGO cervical cancer staging system. In cervical cancer, FIGO 2018 stage IIIC1 has significantly better OS outcomes than stage IIIA and stage IIIB.

Integrated pretreatment diffusion kurtosis imaging and serum squamous cell carcinoma antigen levels: a biomarker strategy for early assessment of radiotherapy outcomes in cervical cancer

OBJECTIVE

This study aims to explore the utility of pretreatment DKI parameters and serum SCC-Ag in evaluating the early therapeutic response of cervical cancer to radiotherapy.

MATERIALS AND METHODS

A total of 33 patients diagnosed with cervical cancer, including 31 cases of cervical squamous cell carcinoma and two cases of adenosquamous carcinoma, participated in the study. All patients underwent conventional MRI and DKI scans on a 3T magnetic resonance scanner before radiotherapy and after ten sessions of radiotherapy. The therapeutic response was evaluated based on the Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1. Patients were categorized into a response group (RG), comprising Complete Remission (CR) and Partial Remission (PR), and a non-response group (NRG), comprising Stable Disease (SD) and Progressive Disease (PD). LASSO was employed to select pretreatment DKI parameters, and ROC curves were generated for the selected parameters and serum SCC-Ag.

RESULTS

Significant differences were observed in pretreatment MD, Da, Dr, MK, Ka, Kr, and SCC-Ag between the RG and NRG groups (P < 0.01). However, no significant differences were noted for FA and FAK (P = 0.441&0.928). The two selected parameters (MD and MK) demonstrated area under the curve (AUC), sensitivity, and specificity of 0.810, 0.769, 0.850 and 0.827, 0.846, 0.750, respectively. The combination of MD and MK exhibited an improved AUC of 0.901, sensitivity of 0.692, and specificity of 1.000, with a higher Youden index compared to the individual parameters. Conversely, the AUC, sensitivity, and specificity of the combination of MD, MK, and SCC-Ag were 0.852, 0.615, and 1.000, with a Youden index of 0.615.

CONCLUSION

Pretreatment MD, MK, and SCC-Ag demonstrate potential clinical utility, with the combined application of MD and MK showing enhanced efficacy in assessing the early therapeutic response of cervical cancer to radiotherapy. The addition of SCC-Ag did not contribute further to the assessment efficacy.

Average log change rate of pretreatment squamous cell carcinoma antigen after concurrent chemoradiotherapy in stage IIIC1 cervical squamous cell carcinoma

We aimed to determine whether pretreatment squamous cell carcinoma antigen (SCC-Ag) levels and the average logarithmic change in SCC-Ag levels (Δ log SCC-Ag Δ time ) after concurrent chemoradiotherapy (CCRT) could predict treatment outcomes in patients with stage IIIC1 cervical squamous cell carcinoma (SCC). We analyzed 168 patients with stage IIIC1 cervical SCC who underwent primary CCRT and collected data on age, local extension, treatment details, hematological parameters, and tumor markers such as SCC-Ag and carcinoembryonic antigen 21-1 (Cyfra). Predictive performances of pretreatment SCC-Ag levels andΔ log SCC-Ag Δ time were assessed using receiver operating characteristic curves. Survival analysis was performed using the Cox regression model and Kaplan-Meier plots. The combination of pretreatment SCC-Ag levels andΔ log SCC-Ag Δ time showed higher area under the curve values than pretreatment SCC-Ag levels alone (area under the curve; 95% confidence interval [CI] 0.708 [0.581-0.836] vs. 0.666 [0.528-0.804], respectively). Pretreatment SCC-Ag (≥ 5 ng/ml and Cyfra levels (≥ 3.15 ng/ml) andΔ log SCC-Ag Δ time (≥ - 1.575) were significant predictors of disease-specific survival. The 5-year disease-specific survival rates significantly differed among the low-, intermediate-, and high-risk groups. Risk stratification using both pretreatment SCC-Ag levels andΔ log SCC-Ag Δ time may predict treatment outcomes of patients with stage IIIC1 SCC.

Clinicopathological and radiological stratification within FIGO 2018 stages improves risk-prediction in cervical cancer

OBJECTIVE

Assess the added prognostic value of the updated International Federation of Gynecology and Obstetrics (FIGO) 2018 staging system, and to identify clinicopathological and radiological biomarkers for improved FIGO 2018 prognostication.

METHODS

Patient data were retrieved from a prospectively collected patient cohort including all consenting patients with cervical cancer diagnosed and treated at Haukeland University Hospital during 2001-2022 (n = 948). All patients were staged according to the FIGO 2009 and FIGO 2018 guidelines based on available data for individual patients. MRI-assessed maximum tumor diameter and stromal tumor invasion, as well as histopathologically assessed lymphovascular space invasion were applied to categorize patients according to the Sedlis criteria.

RESULTS

FIGO 2018 stage yielded the highest area under the receiver operating characteristic (ROC) curve (AUC) (0.86 versus 0.81 for FIGO 2009) for predicting disease-specific survival. The most common stage migration in FIGO 2018 versus FIGO 2009 was upstaging from stages IB/II to stage IIIC due to suspicious lymph nodes identified by PET/CT and/or MRI. In FIGO 2018 stage III patients, extent and size of primary tumor (p = 0.04), as well as its histological type (p = 0.003) were highly prognostic. Sedlis criteria were prognostic within FIGO 2018 IB patients (p = 0.04).

CONCLUSIONS

Incorporation of cross-sectional imaging increases prognostic precision, as suggested by the FIGO 2018 guidelines. The 2018 FIGO IIIC stage could be refined by including the size and extent of primary tumor and histological type. The FIGO IB risk prediction could be improved by applying MRI-assessed tumor size and stromal invasion.

Clinical Outcomes and Prognostic Factors in Stage III C Cervical Cancer Patients Treated with Radical Radiotherapy or Radiochemotherapy

Objective: Since the update of the 2018 International Federation of Gynecology and Obstetrics (FIGO) staging criteria, there have been few reports on the prognosis of stage III C cervical cancer. Moreover, some studies have drawn controversial conclusions, necessitating further verification. This study aims to evaluate the clinical outcomes and determine the prognostic factors for stage III C cervical cancer patients treated with radical radiotherapy or radiochemotherapy. Methods: The data of 117 stage III C cervical cancer patients (98 III C1 and 19 III C2) who underwent radical radiotherapy or radiochemotherapy were retrospectively analyzed. We evaluated 3-year overall survival (OS) and disease-free survival (DFS) using the Kaplan-Meier method. Prognostic factors were analyzed using the Log-rank test and Cox proportional hazard regression model. The risk of para-aortic lymph node metastasis (LNM) in all patients was assessed through Chi-squared test and logistic regression analysis. Results: For stage III C1 and III C2 patients, the 3-year OS rates were 77.6% and 63.2% (P = .042), and the 3-year DFS rates were 70.4% and 47.4% (P = .003), respectively. The pretreatment location of pelvic LNM, histological type, and FIGO stage was associated with OS (P = .033, .003, .042, respectively); the number of pelvic LNM and FIGO stage were associated with DFS (P = .015, .003, respectively). The histological type was an independent prognostic indicator for OS, and the numbers of pelvic LNM and FIGO stage were independent prognostic indicators for DFS. Furthermore, a pelvic LNM largest short-axis diameter ≥ 1.5 cm and the presence of common iliac LNM were identified as high-risk factors influencing para-aortic LNM in stage III C patients (P = .046, .006, respectively). Conclusions: The results of this study validated the 2018 FIGO staging criteria for stage III C cervical cancer patients undergoing concurrent chemoradiotherapy. These findings may enhance our understanding of the updated staging criteria and contribute to better management of patients in stage III C.

The prognostic value of the presence of pelvic and/or para-aortic lymph node metastases in cervical cancer patients; the influence of the new FIGO classification (stage IIIC)

INTRODUCTION

One of the major changes in the revised (2018) FIGO-staging system is the addition of stage IIIC to the previously used 2009 system. We evaluated the prognostic value of positive pelvic and/or para-aortic lymph nodes in patients with cervical cancer.

METHODS

A nationwide retrospective cohort study was performed by analyzing data from the Netherlands Cancer Registry. All patients newly diagnosed with stage IB-IVA between 2005 and 2018 were identified. Three-year, 5-year and 15-year overall survival (OS) rates were estimated with the Kaplan-Meier method.

RESULTS

Of the included 6082 patients, 1740 patients (29%) had pelvic and/or para-aortic lymph node metastases. For patients with FIGO 2009 stage IB-IB1-IIA-IIA1 and stage IB2-IIA2-IIB with pelvic and/or para-aortic lymph node metastases the OS was significantly different (p < 0.001 and p = 0.009), with a 5-year OS of 77% and 67%, compared with 92% and 74% for women without lymph node metastases. For FIGO 2009 stage IIIA-IIIB-IVA with and without lymph node metastases, survival rates are not significantly different (p = 0.064). For FIGO 2018 stage IIIC the 3y-OS, 5y-OS and 15-year OS are 72%, 65% and 59% respectively. Survival rates of IIIC diagnosed based on imaging (IIICr) are significantly impaired compared to stage IIIC diagnosed based on pathology (IIICp) (p < 0.001).

CONCLUSION

Patients with FIGO 2009 stage IB-IIB cervical cancer with pelvic and/or para-aortic lymph node metastases have significantly impaired survival compared to patients without metastases. Survival rates of patients with FIGO 2009 stage IIIA-IVA are not affected by lymph node metastases.