Concurrent chemoradiation in locally advanced carcinoma cervix patients

Accelerated Radiotherapy Alone Versus Chemoradiation in Locally Advanced Carcinoma Cervix: Long-Term Outcomes

Introduction Chemoradiation (CRT) is the standard of care for the treatment of carcinoma cervix, more benefits of CRT are seen in the early stage as compared to a locally advanced stage. Altered fractionation such as accelerated radiotherapy (ART) in locally advanced carcinoma cervix has not been explored much. Here, we have reported the long-term outcome of ART in comparison to conventional CRT in locally advanced cervical cancer patients. Methods From September 2011 to January 2014, 191 patients with locally advanced squamous cell carcinoma of the uterine cervix, FIGO stage IIB - IIIB were included in this study. They were randomized into two arms: the CRT arm (95 patients) versus the ART arm (96 patients). During external beam radiotherapy (EBRT), the patients in the CRT arm received conventional radiotherapy 50 Gy/25 fractions, 2 Gy/fraction, 5 fractions/week with cisplatin 40 mg/m2/week while patients in the ART arm received 50 Gy/25 fractions, 2 Gy/fraction, 6 fractions per week (Monday to Saturday) radiation alone. This was followed by three insertions of 6.5 Gy per fraction of high dose rate (HDR) brachytherapy at one-week intervals in both arms to keep the total treatment time 50 days in the CRT arm versus 45 days in the ART arm. Results The median follow-up of the study population was 57 months (range: 4-108 months). The patients with no residual disease (NRD) after EBRT and complete response (CR) at first follow-up were statistically less in the ART arm as compared to the CRT arm (30.2% versus 53.7% and 42.7% versus 63.2%; p = 0.006 and p = 0.024, respectively). However, there was no statistical difference in response at six months. High-grade acute toxicities hematological (9.5%) and gastrointestinal (15.8%) were more prevalent in the CRT arm in comparison to the ART arm, with no statistical significance (p>0.05) and Grade 1/2 genitourinary toxicity was significantly higher in the CRT arm. Late toxicities in both groups were equivalent. Recurrence, distant type of recurrence, and time to recurrence were similar in both groups. Five-year rates of overall survival (OS) and disease-free survival (DFS) were 51.2% versus 37.2% (p = 0.087) and 57.1% versus 46.3% (p = 0.223) in the CRT arm versus ART arm, respectively. Conclusion ART is a compelling alternative to concurrent chemoradiotherapy for locally advanced cervical cancer, particularly in patients with significant comorbidities, elderly women, and those in higher stages where concurrent chemotherapy's efficacy diminishes. It should be strongly considered when chemotherapy is contraindicated.

Efficacy and Safety Evaluation of the Various Therapeutic Options in Locally Advanced Cervix Cancer: A Systematic Review and Network Meta-Analysis of Randomized Clinical Trials

Treatment options in locally advanced cervix cancer (LACC) have evolved around radiation therapy (RT) and/or chemotherapy (CT), hypoxic cell sensitizers, immunomodulators (Imm), and locoregional moderate hyperthermia (HT). A systematic review and network meta-analysis was conducted to synthesize the evidence for efficacy and safety in terms of long-term locoregional control (LRC), overall survival (OS), and grade ≥3 acute morbidity (AM) and late morbidity (LM). Five databases were searched, and 6285 articles (1974-2018) were screened per the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Fifty-nine randomized trials in untreated LACC without surgical intervention were shortlisted. These used 13 different interventions: RT alone and/or neoadjuvant CT (NACT), adjuvant CT (ACT), concurrent chemoradiation therapy (CTRT) (weekly cisplatin [CDDP]/3-weekly CDDP/combination CT with CDDP/non-CDDP-based CT), hypoxic cell sensitizers, Imm, or HT. Odds ratios (ORs) using random effects network meta-analysis were estimated. Interventions for each endpoint were ranked according to their corresponding surface under cumulative ranking curve values. Of the 9894 patients evaluated, the total events reported for LRC, OS, AM, and LM were 5431 of 8197, 4482 of 7958, 1710 of 7183, and 441 of 6333, respectively. ORs and 95% credible intervals (CrIs) for the 2 best strategies were HT + RT versus CTRT + ACT (OR, 1.23; 95% CrI, 0.49-3.19) for LRC, CTRT (3-weekly CDDP) versus HTCTRT (OR, 1.14; 95% CrI, 0.35-3.65) for OS, RT + ACT versus RT (OR, 0.01; 95% CrI, 0.00-1.04) for AM, and NACT + RT + ACT versus RT + Imm (OR, 0.42; 95% CrI, 0.02-7.39) for LM. The 3 interventions with the highest cumulative surface under cumulative ranking curve values for all 4 endpoints were HTRT, HTCTRT, and CTRT (3-weekly CDDP). Articles with low risk of bias and those published during 2004 to 2018 also retained these interventions as the best. Two-step cluster analysis grouped these 3 modalities in a single distinctive cluster. HTRT, HTCTRT, and CTRT with 3-weekly CDDP were identified as therapeutic modalities with the best comprehensive impact on key clinical endpoints in LACC. This warrants a phase 3 randomized trial among these strategies for a head-to-head comparison and additional validation.

Effects of Treatment of Uterine Cervical Carcinoma Monitored by Magnetic Resonance Imaging - Sarajevo Experience

GOAL

The goal of this study was the determination of the effects in treatment of early stage (

MATERIAL AND METHODS

The study was a prospective, comparative, analytical, and observational and included 74 patients with cervical cancer (PH confirmed). All 74 patients have initially gone through the pre-therapeutic MRI to determine the tumour FIGO stage. At a renewal of the initial MRI findings, patients were divided into two study groups: group A and group B. Group A consisted from 39 patients with early-stage cervical carcinoma (

RESULTS

An analysis of treatment outcomes in group A showed that most patients had no local recurrence or residuum disease in 89.7%, while local recurrence was observed in only 10.3% cases. An analysis of treatment outcomes in group B showed that most patients had complete regression after local chemoradiotherapy in 68.8%, while 25.7% of patients had local progression of the disease, while the 5.7% cases recorded partial local tumour regression(p<0.05). It has been shown that a complete local regression was more frequent in the case of squamous cell carcinoma in 74.2% vs 25% in adenocarcinoma cases. Also local and partial regression was observed more frequently in the case of squamous cell carcinoma in 6.5% compared to 0% in adenocarcinoma, while progression was more common in adenocarcinoma at 75% compared to 19.4% for squamous cell (p<0.05). MRI results showed positive outcome of treatment group A and B in our study, showed a statistically significant difference in favour of group A (89.7%) compared to group B 68.8% (p<0.05).

CONCLUSION

The results obtained from our studies show that early stage cervical cancer ( Collapse

Key Words

• FIGO stage
• MRI
• cervical cancer
• oncology treatment
• surgical treatment

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Affiliation(s)

Amela Sofic Clinic of Radiology, Clinical center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
Azra Husic-Selimovic Institute of Gastroenterohepatology, Clinical center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
Nermina Beslic Clinic of Nuclear medicine, Clinical center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
Azra Rasic Oncology Clinic, Clinical center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
Dzenana Begic Oncology Clinic, Clinical center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
Anja Tomic-Cica Clinic of obstetrics and gynecology, Clinical center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
Nejira Imsirevic Institute of Gastroenterohepatology, Clinical center University of Sarajevo, Sarajevo, Bosnia and Herzegovina

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Concurrent chemoradiotherapy vs. radiotherapy alone in locally advanced cervix cancer: A systematic review and meta-analysis

The efficacy of concurrent chemoradiotherapy (CTRT) in locally advanced cervix cancer (LACC, stages IIB-IVA) is contentious. This is due to the variable extent of therapeutic benefit reported in different randomized clinical trials and meta-analyses that usually include all stages of cervix cancer. A systematic review and meta-analysis was therefore conducted to evaluate the efficacy of concurrent CTRT over radiotherapy (RT) alone, predominantly in LACC for the key endpoints; complete response (CR), long-term loco-regional control (LRC), overall survival (OS), grade III/IV acute and late toxicities. Six databases namely - PubMed, EMBASE, SCOPUS, Web of Science, Google Scholar and Cochrane library were explored and supplemented by hand-searching. Only prospective randomized trials conducted in LACC between concurrent CTRT and RT alone with no surgical interventions were included. Fourteen English language articles from 1788 citations were shortlisted for the final analysis. Of the 2445 patients evaluated (CTRT: n=1217; RT: n=1228), 95.7% had LACC and 96% had a squamous cell histology. Eight studies used cisplatin alone, 4 had cisplatin-based combination chemotherapy (CT) while 2 used mitomycin-C, either alone or in combination. CTRT improved the CR (+10.2%, p=0.027), LRC (+8.4%, p<0.001) and OS (+7.5%, p<0.001) over RT alone. However a 10.4% higher incidence of grade III/IV acute toxicities (p<0.001) was also evident with CTRT. Late toxicities in both groups were equivalent. Subgroup analysis and meta-regression did not reveal any significant advantage in outcomes between the 3 CTRT regimens. Thus, although concurrent CTRT provides conclusive therapeutic benefit over RT alone in LACC, the choice of CT agents should be based on their cost-effectiveness and the anticipated expenses for the management of any associated acute toxicities. This assumes importance particularly in resource-constrained low-middle-income countries with the highest burden of LACC, where majority of the patients meet the treatment costs as out-of-pocket expenses.

Concurrent Chemoradiation for Cancer of the Cervix: Results of a Multi-Institutional Study From the Setting of a Developing Country (India)

Purpose

The primary output of hospital-based cancer registries is data on cancer stage and treatment-based survival that can be used to evaluate patient care, but because there are many challenges in obtaining follow-up details, a separate study on patterns of care and patterns of survival for patients at selected sites was initiated under the National Cancer Registry Programme of India. This article presents the results for cervical cancer.

Patients and Methods

A standardized patient information form was used to record patient information, and data were entered into a central repository—the National Centre for Disease Informatics and Research. The study patients were from 12 institutions and were diagnosed between January 1, 2006, and December 31, 2008. Patterns of treatment were assessed for 7,336 patients, and patterns of survival were determined for 2,669 patients from six institutions, at least 70% of whom had data regarding follow-up as of December 31, 2012.

Results

Of 7,336 patients, 55.5% received optimal radiotherapy (RT). In all, 80.9% of patients had locally advanced cancers (stage IIB to IVA), 51.1% received RT alone, and 44.4% received concurrent chemoradiation (RTCT). In 1,753 patients with locally advanced cancers, significantly better survival was observed with RTCT than with RT alone (5-year cumulative survival, 70.2% v 47.3%; hazard ratio, 0.48; 95% CI, 0.41 to 0.56).

Conclusion

A conservative estimate indicates that, on an annual basis, 38,771 patients with cervical cancers in India alone do not get the benefit of RTCT and thus they have poorer survival. There is a need to reiterate the National Cancer Institute's alert that advised supplementing chemotherapy to radiation for locally advanced cancer of the cervix in the context of the developing world, where 84.3% of cancers of the cervix occur.

Serum zinc as a prognostic indicator in locally advanced cancer cervix patients receiving chemo-irradiation: A pilot study

Objective:

To evaluate the prognostic significance of serum Zinc (S.Zn) in locally advanced cancer cervix (LACC) patients treated with chemo-irradiation.

Materials and Methods:

S.Zn values in 34 females with histopathologically (HP) proven LACC (>/= stage II B) were prospectively measured using atomic absorption spectrophotometer pre- and post-treatment. Thirty-four age- and sex-matched healthy individuals were also evaluated for the parameter during the course of the study. After completion of treatment, the patients were divided into 2 groups based on the response, 1 - Complete response (CR) and 2 - Partial/No response (PR/NR). These groups were compared based on the observations of the studied parameter.

Results:

The mean post-treatment S.Zn values were significantly higher in group 1 as compared to group 2 (P < 0.05).

Conclusion:

In our study, patients achieving CR had higher mean levels of S.Zn compared to patients achieving PR/NR. We advocate further in-depth studies to evaluate the role of S.Zn in the prognosis of LACC patients treated with chemo-irradiation.

Predictive value of diffusion-weighted magnetic resonance imaging during chemoradiotherapy for uterine cervical cancer

AIM

The purpose of this study was to evaluate the efficacy of diffusion-weighted (DW) magnetic resonance (MR) imaging to predict the tumor response to chemoradiotherapy (CRT) of uterine cervical cancer.

METHODS

Twenty-five consecutive patients with pathologically confirmed uterine cervical cancer underwent 1.5-T MR imaging including DW imaging before and during CRT. MR images were reviewed for the size and apparent diffusion coefficient (ADC). Pathological evaluation of the therapeutic effect was performed 3 months after finishing CRT, and we divided the subjects into two groups: complete remission (CR) (n=16) and residual tumor (n=9).

RESULTS

ADC was lower before CRT than during CRT (0.89 ± 0.12 and 1.25 ± 0.22 × 10⁻³ mm²/s, respectively) (P<0.01). ADC change between before and during CRT (ΔADC) showed a moderate positive correlation (r=0.435, P<0.05) with the tumor regression rates. ΔADC was higher in the CR group than in the residual tumor group (0.43 ± 0.23 and 0.25 ± 0.15 × 10⁻³ mm²/s, respectively) (P<0.05). The CR rates were higher in the high ΔADC group (ΔADC  ≥ 0.50) than in the low ΔADC group (ΔADC <0.49) (100% and 53%, respectively) but marginally significant (P=0.057). The local control rates were not statistically different between high and low ΔADC groups (83.3% and 73.7%, respectively) (P=0.602).

CONCLUSION

DW imaging including ADC measurement may be useful for prediction and early assessment of pathological response to CRT for uterine cervical cancer, but its impact on local disease-free survival was limited.

Chemoradiation and adjuvant chemotherapy in advanced cervical adenocarcinoma

PURPOSE

The optimal treatment of women with advanced adenocarcinoma of uterine cervix is still undefined. We compared concurrent chemoradiation (CCRT) and adjuvant cisplatin-based chemotherapy with CCRT alone for advanced cervical adenocarcinoma in a randomized trial at the Hunan Provincial Tumor Hospital in China.

METHODS

From 1998 to 2007, 880 patients with clinical FIGO stages IIB-IVA cervical adenocarcinoma were randomized to receive either CCRT or chemoradiation with one cycle of neo-adjuvant chemotherapy with Paclitaxel (135 mg/m(2))+Cisplatin (75 mg/m(2)) before receiving radiation and two cycles of consolidation chemotherapy with the same drugs after radiotherapy in 3-week intervals. The disease control and survival rates were calculated using the Kaplan-Meier method.

RESULTS

All patients completed the treatment plan. 340 patients have relapsed, with a median follow-up duration of 60 months. Patients who received chemoradiation with adjuvant chemotherapy showed a significantly longer disease-free (P<.05), cumulative survival (P<.05) and long-term local tumor control (P<.05). Patients who received CCRT alone had significantly more distant metastasis and pelvic failure than those who received chemoradiation with adjuvant chemotherapy (P<.05).

CONCLUSION

Incorporating neo-adjuvant and consolidation chemotherapy with Paclitaxel and Cisplatin into concomitant chemoradiation is highly effective, safe and may be a very promising treatment protocol for advanced cervical adenocarcinoma.