Locally advanced cervical cancer: A study of 5-year outcomes

Characteristics, treatment patterns, and outcomes in patients with high-risk locally advanced cervical cancer

OBJECTIVE

To characterize the real-world treatment patterns and outcomes of patients with high-risk locally advanced cervical cancer (HR-LACC).

METHODS

This retrospective study identified and randomly selected adults diagnosed between 2010 and 2018 from the ConcertAI Oncology Dataset. For patients initially treated with concurrent chemoradiotherapy (CCRT), we estimated real-world progression-free survival (rwPFS) among those with persistent disease, real-world time on CCRT, and recurrence-free survival (rwRFS) using Kaplan-Meier methods.

RESULTS

The cohort included 300 patients. Median age at diagnosis was 51 years. 53.7 % were White and 30.0 % were Black; 52.0 % were premenopausal; 89.3 % had squamous cell histology; 75.3 % had stage III disease, and 92.7 % had no evidence of performance status impairment. Initial treatment included CCRT (N = 229), surgery (N = 28), antineoplastics only (N = 11), and radiation only (N = 5). Twenty-seven patients were untreated. Baseline characteristics for the CCRT-first patients were similar to the overall cohort; their median real-world time on treatment was 1.6 months; 78.2 % received cisplatin for a median of 1.2 months; 28.4 % received antineoplastics after CCRT, and 11.8 % initiated a second antineoplastic therapy. Of the CCRT-first patients, 27/143 with a complete response had subsequent recurrent disease (median rwRFS not reached). 179 patients had persistent disease, among whom median (95 % confidence interval [CI]) rwPFS was 29.7 (16.9-59.3) months.

CONCLUSION

In this study of United States-based clinical practices, most HR-LACC patients received CCRT as initial treatment. Many patients developed persistent disease after CCRT indicating a need for improved first treatment and maintenance options.

Analysis of Correlation Between LncRNA TDRG1 Expression and its Prognosis in Cervical Carcinoma Tissues

To explore and analyze the correlation between LncRNA TDRG1 expression degree and the prognosis of cervical carcinoma tissues. The cervical cancer tissues and para-carcinoma tissues of 106 patients with cervical carcinoma surgically removed in our hospital were chosen as specimens. LncRNA TDRG1 expression in cervical carcinoma tissues and para-carcinoma tissues was inspected by real-time fluorescence quantitative PCR, and the correlation between LncRNA TDRG1 and the clinicopathological parameters and disease prognosis was analyzed. The relative expression of LncRNA TDRG1 in cervical carcinoma tissues was critically gone up (P < 0.05) compared to para-carcinoma tissues. The relative expression of LncRNA TDRG1 in cervical carcinoma was correlated with FIGO staging, lymph node metastasis, infiltrating depth of cervical basal, and the differentiation of cancer cells (P < 0.05). According to the results of the Kaplan-Meier curve and Log-rank test, the overall survival conditions of subjects with low-lncRNA TDRG1 were superior to that of those with high-lncRNA TDRG1 expression (P < 0.05). The expression of LncRNA TDRG1 in cervical carcinoma tissues and the clinicopathological features in predicting the overall survival (OS) in sufferers with cervical carcinoma were investigated by the Cox regression model. LncRNA TDRG1 expression in cervical carcinoma tissues is tightly associated with the progression and prognosis of cervical carcinoma, which may be a latent biological indicator for clinical diagnosis and prognosis of cervical carcinoma.

Radiochemotherapy and interstitial brachytherapy for cervical cancer: clinical results and patient-reported outcome measures

OBJECTIVE

To evaluate clinical results and long-term patient-reported outcome measures (PROMs) on quality of life in cervical cancer patients following radiochemotherapy (RCT) and brachytherapy (BT) as definitive treatment.

MATERIALS AND METHODS

Between 2003 and 2023, a total of 132 patients with advanced cervical cancer were evaluated for possible treatment. Patients treated by postoperative RCT, palliative radiotherapy, and those treated for recurrent disease were excluded. Thus, 46 patients receiving standard RCT and BT as their curative treatment were included in this study. PROMs were assessed prospectively by patients' self-completion of the EORTC-QLQ-C30 and EORTC-QLQ-CX24 questionnaires.

RESULTS

Five-year overall survival (OS), distant metastases-free survival (DMFS), and pelvic tumor-free survival rates (PTFS) were 53%, 54%, and 83%, respectively. A significant impact on OS was seen for FIGO (International Federation of Gynecologic Oncology) stage (IIB-IIIA: 79% vs. IIIB-IVA: 33%, p = 0.015), for overall treatment time (OTT; 50-65 d: 64% vs. > 65 d: 38%, p = 0.004), and for rectal D2cc (≤ 73 Gy: 50% vs. > 73 Gy: 38%, p = 0.046). The identical parameters were significantly associated with DMFS (FIGO stage: p = 0.012, OTT: p = 0.008, D2cc: p = 0.024). No parameters with a significant influence on PTFS were seen. In multivariate analysis, an impact of FIGO stage on OS (p = 0.05) and DMFS (p = 0.014) was detected, and of rectal D2cc on DMFS (p = 0.031). The overall QoL score was 63/100. Cognitive function was the least impaired (84/100), while role functioning was the worst (67/100). On the symptom scale, insomnia (46/100), fatigue (41/100), dyspnea (32/100), pain (26/100), and financial difficulties (25/100) were scored the worst. According to EORTC-QLQ-CX24, peripheral neuropathy (36/100) and lymphedema (32/100) occurred most frequently. Impaired sexual/vaginal functioning (32/100) and body image (22/100) were also frequently recorded.

CONCLUSION

In patients with advanced cervical cancer, a combination of RCT and BT remains an excellent treatment option. In terms of patient-reported long-term quality of life, specific support is needed to alleviate symptoms including lymphedema, peripheral neuropathy, and impaired sexual activity.

Optimization and Validation of a Harmonized Protocol for Generating Therapeutic-Grade Dendritic Cells in a Randomized Phase II Clinical Trial, Using Two Varied Antigenic Sources

Autologous dendritic cell (DC)-based immunotherapy is a cell-based advanced therapy medicinal product (ATMP) that was first introduced more than three decades ago. In the current study, our objective was to establish a harmonized protocol using two varied antigenic sources and a good manufacturing practice (GMP)-compliant, manual method for generating clinical-grade DCs at a limited-resource academic setting. After obtaining ethical committee-approved informed consent, the recruited patients underwent leukapheresis, and single-batch DC production was carried out. Using responder-independent flow cytometric assays as quality control (QC) criteria, we propose a differentiation and maturation index (DI and MI, respectively), calculated with the QC cut-off and actual scores of each batch for comparison. Changes during cryopreservation and personnel variation were assessed periodically for up to two to three years. Using our harmonized batch production protocol, the average DI was 1.39 and MI was 1.25. Allogenic responder proliferation was observed in all patients, while IFN-gamma secretion, evaluated using flow cytometry, was detected in 10/36 patients and significantly correlated with CD8+ T cell proliferation (p value-0.0002). Tracking the viability and phenotype of cryopreserved MDCs showed a >90% viability for up to three years, while a mature DC phenotype was retained for up to one year. Our results confirm that the manual/semi-automated protocol was simple, consistent, and cost-effective, without the requirement for expensive equipment and without compromising on the quality of the final product.

Overexpression of SOCS2 Inhibits EMT and M2 Macrophage Polarization in Cervical Cancer via IL-6/JAK2/STAT3 Pathway

OBJECTIVE

SOCS2 is a member of the suppressor of cytokine signaling (SOCS) protein family associated with the occurrence and development of multiple cancers. This study revealed the expression and molecular mechanisms of SOCS2 in cervical cancer.

METHODS

In this study, RT-qPCR, Western Blot, and immunohistochemistry were used to detect the expression level of SOCS2 in cervical cancer tissues and tumor cells. We overexpressed SOCS2 in SiHa cells via lentivirus. In-vitro experiments were used to investigate the changes in cervical cancer cell proliferation, migration, and invasion ability before and after SOCS2 overexpression. Western Blot was used to detect the expression of IL-6/JAK2/STAT3 pathway and EMTrelated proteins. M0 macrophages were co-cultured with the tumor-conditioned medium. The effect of SOCS2 on macrophage polarization was examined by RT-qPCR.

RESULTS

SOCS2 expression level was significantly downregulated in cervical cancer tissues. SOCS2 was negatively correlated with CD163+M2 macrophages. Overexpression of SOCS2 inhibited the proliferation, migration, and invasion of cervical cancer cells. The expressions of Twist- 2, N-cadherin, and Vimentin were decreased, while the expression of E-cadherin was increased. Moreover, the expression of IL-6, p-JAK2, and p-STAT3 were decreased. After the addition of RhIL-6, the expression of E-cadherin protein in the LV-SOCS2 group was reversed. CM in the LV-SOCS2 group inhibited the polarization of M2 macrophages.

CONCLUSION

SOCS2 acts as a novel biological target and suppressor of cervical cancer through IL- 6/JAK2/STAT3 pathway.

Determinants of late-stage cervical cancer presentation in Ethiopia: a systematic review and meta-analysis

INTRODUCTION

Behind breast, colorectal, and lung cancers, cervical cancer is the fourth most common cancer affecting females. Despite, it is a preventable form of cancer both the incidence and mortality figures reflect it as a major reproductive health problem. Late-stage cervical cancer diagnosis is associated with complicated clinical presentation which can result in short survival time and increased mortality. Several factors contribute to the late-stage presentation of cervical cancer patients. In Ethiopia nationally summarized evidence on the level and the factors contributing to late-stage cervical cancer diagnosis is scarce. Therefore, this systematic review and meta-analysis aimed to assess the pooled prevalence of late-stage cervical cancer diagnosis and its determinants in Ethiopia.

METHOD

A systematic review and meta-analysis were conducted using PRISMA guidelines. Comprehensive literature was searched in PubMed, Embase, Google Scholar, and African Online Journal to retrieve eligible articles. A weighted inverse variance random effect model was used to estimate pooled prevalence. Cochrane Q-test and I2 statistics were computed to assess heterogeneity among studies. Funnel plot and Egger's regression test were done to assess publication bias.

RESULT

Overall, 726 articles were retrieved and finally 10 articles were included in this review. The pooled prevalence of late-stage cervical cancer diagnosis in Ethiopia was 60.45% (95%CI; 53.04%-67.85%). Poor awareness about cervical cancer and its treatment (AOR = 1.55, 95% CI: (1.03 - 2.33, longer delay to seek care (AOR = 1.02, 95% CI: (1.01 - 1.03)) and rural residence (AOR = 2.07, 95% CI:( 1.56 - 2.75)) were significantly associated to late-stage diagnosis.

CONCLUSION

In Ethiopia, six in every ten cervical cancer cases are diagnosed at the late stage of the disease. Poor awareness about cervical cancer and its treatment, long patient delay to seek care, and rural residence were positively associated with late-stage diagnosis. Therefore intervention efforts should be made to improve public awareness about cervical cancer, minimize patient delay to seek care, and expand screening services specifically in the rural residing segment of the population to detect the disease early and improve survival.

Transitioning India to advanced image based adaptive brachytherapy: a national impact analysis of upgrading National Cancer Grid cervix cancer guidelines

Background

High-dose-rate image guided brachytherapy (IGBT) for cervical cancer leads to improved local control and reduced toxicity and is a critical component of treatment. However, transition to IGBT requires capacity upscaling. An institutional activity mapping and national impact analysis of such a transition were undertaken to understand feasibility.

Methods

Between September 2020 and March 2021, activity mapping was conducted in a high-volume centre that triaged cervical cancer patients for brachytherapy into four workflows; A: two-dimensional (2D) X-Ray point A-based intracavitary brachytherapy, B: CT point A-based intracavitary brachytherapy, C: MRI/CT-volume based intracavitary brachytherapy, D: MRI/CT volume-based intracavitary +/- interstitial brachytherapy. Clinical process time mapping was performed, and case scenarios for transition were modelled at the institutional and national levels based on available incidence and infrastructure levels. Treatment capacity changes were calculated, and potential strategies for workflow reorganisation were proposed.

Findings

Eighty-four patients were included in the study. The total time taken for the workflows A, B, C, and D were 176 min (57-208), 224 min (74-260), 267 min (101-302), and 348 min (232-383), respectively. The transition from workflow A to D through sequential steps led to 35%, 49%, and 64% loss of treatment capacity in the index institution. Solutions such as 10-hour or 12-hour overlapping shifts increased treatment capacity by 25% and 50% and performing single implants and delivering multiple fractions increased capacity by 100%. Twenty-three Indian states and Union Territories are predicted to be able to transition to advanced workflows. For four Indian states, it may be detrimental considering the current infrastructure level, and eight Indian states lacked brachytherapy access. Further financial investment is required in the latter 12 states for transition to advanced workflows.

Interpretation

Our study demonstrates that unplanned transition to IGBT can lead to treatment capacity loss and increase in waiting lists to access treatment. The proposed solutions of workflow reorganisation, using strategies such as single brachytherapy applicator implant and delivering multiple treatment fractions can improve access to treatment for women with cervix cancer in resource-strained and high patient-volume settings. We recommend state-wise solutions for the upscale from conventional 2D workflows to IGBT, subject to the availability of skilled personnel, infrastructure and training. Financial investments may be needed in some states to achieve this goal.

Funding

International Atomic Energy Agency (IAEA) supported the salary of VH through project E33042 that focussed on implementation strategies of image guided brachytherapy.

SERPINB7 as a prognostic biomarker in cervical cancer: Association with immune infiltration and facilitation of the malignant phenotype

Purpose

The purpose of this study was to investigate the expression patterns, predictive significance, and roles in the immune microenvironment of Serpin Family-B Member 7 (SERPINB7) in cervical squamous cell carcinoma and endocervical adenocarcinoma (CESC).

Methods

The expression of SERPINB7 and its prognostic relevance were evaluated using RNA-seq data from The Cancer Genome Atlas. SERPINB7 regulation of CESC cell growth and metastasis was investigated using MTT, scratch, and Transwell assays. In vivo effects of SERPINB7 were examined in xenograft model mice and differentially expressed genes (DEGs) associated with SERPINB7 were identified to explore its functional role in oncogenesis. Associations between SERPINB7 levels, chemosensitivity, and immune infiltration were assessed, and mutations and methylation of SERPINB7 were evaluated using the cBioPortal and MethSurv databases, respectively.

Results

SERPINB7 was up-regulated in CESC samples as well as in other tumors, and patients with higher SERPINB7A mRNA levels exhibited shorter overall survival. The area under the curve for the use of SERPINB7 in CESC diagnosis was above 0.9, and the gene was shown to regulate tumor cell proliferation and metastasis in vitro and in vivo. Overall, 398 DEGs enriched in key CESC progression-related signaling pathways were identified. SERPINB7 expression was additionally correlated with intratumoral immune infiltration and immune checkpoint activity. Patients expressing higher SERPINB7 levels exhibited distinct chemosensitivity profiles, and methylation of the SERPINB7 gene was linked to CESC patient prognostic outcomes.

Conclusion

SERPINB7 was found to be a crucial regulator of CESC progression, prognosis, and the tumor immune microenvironment, highlighting its potential as a diagnostic and prognostic biomarker and target for CESC immunotherapy.

Geographic and demographic distribution and access to brachytherapy in India with its implications on cancer care

PURPOSE

Geographic access to medical care varies for nearly every specialty in India. Given the special nature of its treatments, which sometimes necessitate numerous visits over a lengthy period, and the substantial-high fixed cost infrastructure requirements for radiation facilities, radiation oncology is particularly prone to regional inequities in access to care. Brachytherapy (BT) is emblematic of several of these access difficulties since it necessitates specialized equipment, the capacity to maintain a radioactive source, and particular skill sets. The study was conducted to report the availability of BT treatment units in relation to state-level population, overall cancer incidence, and gynecologic cancer incidence.

METHODS AND MATERIALS

The availability of BT resources at the state level in India was and the population of each state was estimated using data from the Government of India's Census. The number of cancer cases was approximated for each state and union territory. The total number of gynecological cancers that required BT was determined. The BT infrastructure was also compared to those of other nations in terms of the number of BT units available per million people and for various malignancies.

RESULTS

A heterogeneous geographic distribution of BT units was noted across India. India has one BT unit for every 42,93,031 population. The maximum deficit was seen in Uttar Pradesh, Bihar, Rajasthan, and Odisha. Among the states having BT units, the maximum units per 10,000 cancer patients was noted in Delhi (7), Maharashtra (5) and Tamil Nadu (4) and the least was noted in the Northeastern states (<1), Jharkhand, Odisha, and Uttar Pradesh. In BT of gynecological malignancies alone an infrastructural deficit ranging from 1 to 75 units were noted across the states. It was noted that only 104 out of the 613 medical colleges in India had BT facilities. On comparing the BT infrastructure status with other countries India had one BT machine for every 4,181 cancer patients when compared to United States (1 every 2,956 patients), Germany (2,754 patients), Japan (4,303 patients), Africa (10,564) and Brazil (4,555 patients).

CONCLUSION

The study identified the deficits of BT facilities in terms of geographic and demographic aspects. This research provides a roadmap for the development of BT infrastructure in India.

Barriers to early diagnosis of cervical cancer: a mixed-method study in Côte d'Ivoire, West Africa

BACKGROUND

Cervical cancer, a major public health problem in many developing countries, is usually associated with a poor survival related to an advanced disease at diagnosis. In Côte d'Ivoire and other developing countries with high cervical cancer prevalence, little is known about factors associated with advanced cervical cancer stages in a context of limited access to screening services.

METHODS

From May to July 2019, we conducted a cross-sectional study using a mixed, quantitative and qualitative method. Information on socio-demographic and history of the disease was extracted from a rapid case ascertainement study performed by the cancer registry of Côte d'Ivoire that enrolled all women diagnosed with cervical cancer between July 2018 and June 2019. In-depth semi-structured interviews were conducted among a subset of these women (12 women) and six healthcare providers to further capture barriers to early cervical cancer diagnosis. Factors associated with an advanced stage III, IV (according to FIGO classification) were estimated by a logistic regression model. Qualitative data were analyzed using a thematic analysis technique guided by the treatment pathway model and triangulated with quantitative data.

RESULTS

In total, 95 women with cervical cancer [median age = 51 (IQR 42-59)] years, were included. Among them, 18.9% were living with HIV and only 9.5% were covered by a health insurance. The majority (71.5%) were diagnosed with advanced cervical cancer. Being HIV-uninfected (aOR = 5.4; [1.6-17.8], p = 0.006) and being uninsured (aOR = 13.1; [2.0-85.5], p = 0.007) were independently associated with advanced cervical cancer in multivariable analysis. Qualitative data raised additional factors potentially related to advanced cervical cancer stages at diagnosis, including the lack of patient information on cervical cancer by healthcare providers and inadequate national awareness and screening campaigns.

CONCLUSION

In a context of challenges in access to systematic cervical cancer screening in Côte d'Ivoire, access to health insurance or integrated healthcare program appear to be key determinants of early diagnosis of cervical cancer.

Validation of the 2018 FIGO Staging System for Predicting the Prognosis of Patients With Stage IIIC Cervical Cancer

Background

Risk stratification of patients with cervical cancer accompanied by positive lymph nodes (stage IIIC) (the 2018 International Federation of Gynecology and Obstetrics [FIGO] new staging system) yields a clinically heterogeneous group. In this study, we investigated the prognostic performance of the 2018 FIGO staging system for stage IIIC cervical cancer.

Methods

The study included patients with stage III cervical cancer based on the 2018 FIGO staging system, who visited Chongqing University Cancer Hospital between January 2011 and December 2014. Kaplan-Meier curves were generated to evaluate overall survival (OS), which was compared using the log-rank test. The Cox proportional hazard regression model was used for multivariable analysis.

Results

A total of 418 patients were eligible for analysis. The 5-year OS was 54.1% for stage IIIC1, 43.3% for stage IIIA, 40.6% for stage IIIB, and 23.1% for stage IIIC2 (P < .001). Multivariable analysis revealed that compared with stages IIIA (hazard ratio [HR] 1.432, 95% confidence interval [CI] 0.867-2.366, P = .161) and IIIB (HR 1.261, 95% CI 0.871-1.827, P = .219), stage IIIC1 cancer was not significantly associated with an increased mortality risk. Stage IIIC2 was independently associated with an increased mortality risk compared with stages IIIA (HR 2.958, 95% CI 1.757-4.983, P < .001) and IIIB (HR 2.606, 95% CI 1.752-3.877, P < .001). We stratified patients with stage IIIC1 based on the T stage. The 5-year OS was significantly longer in patients with stage IIIC1 (T1) than in those with stage IIIA (P = .004) or IIIB (P < .001). Analysis of multiple factors revealed that the mortality risk was 2.75-fold higher in patients with stage IIIC1pN>2 than in patients with stage IIIC1pN1-2 (HR 2.753, 95% CI 1.527-4.965, P = .001).

Conclusions

Patients with stage IIIC1 cervical cancer showed heterogeneous clinical characteristics that reflected variable prognoses, depending on the T stage and the extent of pelvic lymph node metastases.

Eight Aging-Related Genes Prognostic Signature for Cervical Cancer

This study searched for aging-related genes (ARGs) to predict the prognosis of patients with cervical cancer (CC). All data were obtained from Molecular Signatures Database, Cancer Genome Atlas, Gene Expression Integration, and Genotype Organization Expression. The R software was used to screen out the differentially expressed ARGs (DE-ARGs) between CC and normal tissues. A protein-protein interaction network was established by the DE-ARGs. The univariate and multivariate Cox regression analyses were conducted on the first extracted Molecular Complex Detection component, and a prognostic model was constructed. The prognostic model was further validated in the testing set and GSE44001 dataset. Prognosis was analyzed by Kaplan-Meier curves, and accuracy of the prognostic model was assessed by receiver operating characteristic area under the curve analysis. An independent prognostic analysis of risk score and some clinicopathological factors of CC was also performed. The copy-number variant (CNV) and single-nucleotide variant (SNV) of prognostic ARGs were analyzed by the BioPortal database. A clinical practical nomogram was established to predict individual survival probability. Finally, we carried out cell experiment to further verify the prognostic model. An eight-ARG prognostic signature for CC was constructed. High-risk CC patients had significantly shorter overall survival than low-risk patients. The receiver operating characteristic (ROC) curve validated the good performance of the signature in survival prediction. The Figo_stage and risk score served as independent prognostic factors. The eight ARGs mainly enriched in growth factor regulation and cell cycle pathway, and the deep deletion of FN1 was the most common CNV. An eight-ARG prognostic signature for CC was successfully constructed.

Dysregulated RUNX1 Predicts Poor Prognosis by Mediating Epithelialmesenchymal Transition in Cervical Cancer

OBJECTIVE

Runt-related transcription factor 1 (RUNX1) has been proven to be over-expressed and vital in many malignancies. However, its role in cervical cancer is still unclear.

METHODS

Some online databases (Oncomine, GEPIA, UALCAN, LinkedOmics, and others) were used to explore the expression level, prognostic significance, and gene mutation characteristics of RUNX1 in cervical cancer. The protein levels of RUNX1 in cervical cancer were measured by immunohistochemistry (IHC). The functional changes of cervical cancer cells were measured in vitro after decreasing RUNX1.

RESULTS

Bioinformatic results revealed that RUNX1 was upregulated in cervical cancer compared to normal tissues. Moreover, over-expression of RUNX1 was significantly correlated with cervical cancer patients' clinical parameters (e.g., individual cancer stages, patients' age, nodal metastasis status, and others). Meanwhile, functional enrichment analysis of RUNX1-related genes indicated that RUNX1 was mainly involved in the epithelial-mesenchymal transition (EMT) process in cervical cancer. Furthermore, RUNX1 may be upregulated by hsamiR-616-5p and hsa-miR-766 identified by miRDB, TargetScan, and miRWalk. Finally, RUNX1 was upregulated in cervical cancer compared to normal tissues by IHC in collected cervical cancer samples. The invasion and migration abilities of cervical cancer cells were significantly reduced by repressing EMT after knocking down RUNX1 in vitro.

CONCLUSION

RUNX1 was highly expressed in cervical cancer, and upregulated RUNX1 could significantly promote the invasive abilities of cervical cancer cells by inducing EMT. Therefore, RUNX1 may be a potential biomarker for early diagnosis and targeted therapy of cervical cancer.

A Retrospective Study of Chemotherapy and 3D-Image-Guided Afterloading Intracavitary Radiotherapy in Locally Advanced Cervical Cancer

Aim

To investigate the value of neoadjuvant chemotherapy combined with 3D-image-guided afterloading intracavitary radiotherapy in locally advanced cervical cancer (LACC).

Methods

Patients with cervical cancer admitted to our hospital from January 1, 2020 to January 1, 2021 were retrieved and analyzed. Cases treated with neoadjuvant chemotherapy and 3D-image-guided afterloading intracavitary radiotherapy were assigned into the observation group (OG), while cases with neoadjuvant chemotherapy alone were assigned into the control group (CG). The short-term effects were determined by RECIST 1.1. Total effective rate (TR) = complete remission (CR) + partial remission (PR). The serum levels of squamous epithelial cell carcinoma antigen (SCC-Ag), glycoantigen 125 (CA125), carcinoembryonic antigen (CEA), and vascular endothelial growth factor (VEGF) were assessed. In view of the difference between tumor markers and diameters before and after treatment, the correlation between them was analyzed by Pearson test. The adverse events were compared, and the amount of operative bleeding and operation time were evaluated. Cox regression analysis was conducted to assess the influencing factors of 1-year disease-free survival time.

Results

Sixty-seven patients were retrieved, including 30 cases in the OG and 37 cases in the CG. There were no significant differences in age, pathological type, tumor size, FIGO stage, past medical history, or smoking history between the two groups (P > 0.05). The TR of patients in the OG was higher than that in the CG (P < 0.05). The SCC-Ag, CA125, CEA, and VEGF levels in the OG decreased markedly after treatment (P < 0.001). The difference in SCC-Ag, CA125, CEA, and VEGF was positively correlated with the difference in tumor diameter before and after treatment (P < 0.05). The incidence of adverse events revealed no obvious difference between the OG and CG (P > 0.05). Cox regression analysis showed that FIGO stage and treatment regimens were independent prognostic factors for 1-year disease-free survival (P < 0.05).

Conclusion

Neoadjuvant chemotherapy combined with 3D-image-guided afterloading intracavitary radiotherapy can improve the TR rate and 1-year disease-free survival of LACC patients without increasing the incidence of adverse events.

Clinical profile and outcomes in cervical cancer: An audit from a tertiary cancer center

Background

Carcinoma cervix contributes to a major proportion of cancer treatment in tertiary oncology centers. The outcomes are dependent on multiple factors. We conducted an audit to establish the pattern of treatment practiced for carcinoma cervix at the institute and suggest changes thereof to improve the quality of care.

Methodology

A retrospective observational study of 306 diagnosed cases of carcinoma cervix was carried out for the year 2010. Data was collected with regards to diagnosis, treatment, and follow-up. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 20.

Results

Out of 306 cases, 102 (33.33%) patients received only radiation therapy and 204 (66.66%) patients received concurrent chemotherapy. The most common chemotherapy used was weekly cisplatin 99 (48.52%), followed by weekly carboplatin 60 (29.41%) and three weekly cisplatin 45 (22.05%). Disease-free survival (DFS) at 5 years was 36.6% with patients of overall treatment time (OTT) of <8 weeks and >8 weeks showing DFS of 41.8% and 34% (P = 0.149), respectively. Overall survival (OS) was 34%. Concurrent chemoradiation improved overall survival by a median of 8 months (P = 0.035). There was a trend towards improved survival with three weekly cisplatin regimen, however, insignificant. Stage correlated with improved overall survival significantly with stage I and II showing 40% and stage III and IV showing 32% (P < 0.05) OS. Acute toxicity (grade I-III) was higher in the concurrent chemoradiation group (P < 0.05).

Conclusion

This audit was a first of its kind in the institute and threw light on the treatment and survival trends. It also revealed the number of patients lost to follow-up and prompted us to review the reasons for it. It has laid the foundation for future audits and recognized the importance of electronic medical records in the maintenance of data.

Construction of hypoxia-immune-related prognostic model and targeted therapeutic strategies for cervical cancer

Emerging evidence indicates that hypoxia and immunity play important roles in tumorigenesis and development. However, the hypoxia-immune-related prognostic risk model has not been established in cervical cancer (CC). We aimed to construct a hypoxia-immune-based prognostic risk model with potential application in CC patient prognosis and predicting response to targeted therapy. The RNA-seq data and corresponding clinical information were retrieved from The Cancer Genome Atlas (TCGA) database. Hypoxia and immune status of CC patients were evaluated using the Consensus Clustering method and single sample gene set enrichment analysis (ssGSEA), respectively. The univariate Cox regression, least absolute shrinkage and selection operator (LASSO) and multivariate Cox regression were applied to establish the prognostic risk model of CC. The chemotherapy response for six chemotherapeutic agents of each CC patient was calculated according to the Genomics of Drug Sensitivity in Cancer (GDSC). And the Connectivity Map (CMap) database was performed to screen candidate small molecule drugs. In this study, we identified 7 gene signatures (P4HA2, MSMO1, EGLN1, ZNF316, IKZF3, ISCU, MYO1B) with prognostic values. And the survival time of patients with low-risk was significantly longer than those with high-risk. Meanwhile, CC patients in the high-risk group yielded higher sensitivity to five chemotherapeutic agents. And we listed ten candidate small-molecules drugs that exhibited a high correlation with the prognosis of cervical cancer. Thus, the prognostic model can accurately predict the prognosis of patients with CC and may be helpful for the development of new hypoxia-immune prognostic markers and therapeutic strategies for CC.

Pre-treatment hematological parameters as a cost effective predictive marker for response to concurrent chemo radiation in locally advanced cervical cancer

INTRODUCTION

Locally advanced cervical cancer is still a major cause of mortality in developing countries. Recently, personalized medicine has changed the treatment paradigm for many solid cancers but no robust biomarkers has yet been validated for predicting response to chemo radiation in cervical cancer patients.

AIM

To assess the role of hematological parameters as a cost-effective predictive marker of response to concurrent chemo radiation in cervical cancer patients.

MATERIALS AND METHOD

This is a retrospective analysis of 90 cervical cancer patients treated with concurrent chemo radiation in a tertiary cancer center. Clinical details of the patients were extracted from the case records. For end point evaluation, the pre-treatment levels of hemoglobin, neutrophil, lymphocyte, platelet, platelet lymphocyte ratio (PLR) and neutrophil lymphocyte ratio (NLR) were compared and statistically analyzed between responders and non-responders. The optimal cutoff values of hematological parameters were estimated by the receiver operating characteristics (ROC) curve.

RESULT

Out of 90 patients, 60 (66.66%) were complete responders and remaining 30 (33.33%) were non-responders. The mean value of platelet, NLR, and PLR was significantly higher in the non-responder group. ROC curve analysis showed the optimal cut-off value of pre-treatment Hb, PLT, NLR and PLR to be 11 gm/dl, 3, 177 × 109/L, and 70 respectively.

CONCLUSION

Our study suggests that simple hematological markers like NLR, PLT count and PLR could be used as a cost effective pretreatment predictive marker for response to chemo radiation in cervical cancer patients.

Patterns of care and clinical outcomes in stage IVA cervical cancer: 14-year experience from a tertiary care centre in South India

Aim:

To analyse the patterns of care and clinical outcomes of patients diagnosed with cervical cancer International Federation of Gynecology and Obstetrics (FIGO) stage IVA treated at a tertiary care centre in South India.

Materials and methods:

The electronic medical records of 2,476 patients diagnosed with cervical cancer at a tertiary care institution between January 2005 and December 2018 were reviewed. Among them, 96 patients diagnosed with histologically proven carcinoma cervix stage IVA established by either cystoscopy or proctoscopy were included. Four patients who did not receive treatment at the study centre were excluded and 92 patients were available for final analysis.

Results:

The median follow-up period was 12 months (2–131 months). Of the 92 patients, 59 patients (64·13%) received radiation therapy (RT) alone, 22 patients (23·9%) received chemoradiation (CRT), three patients (3·26%) received neoadjuvant chemotherapy (NACT) followed by RT, one (1·08%) received NACT followed by CRT, four patients (4·35%) received chemotherapy alone, while three (3·26%) were offered best supportive care. The median progression-free survival (PFS) was 12 months (95% CI: 9·6–14·4 months) and median overall survival (OS) was 25 months (95% CI: 16·6–33·4 months). The 2-year and 3-year PFS was 30 and 20%, respectively, and the OS was 50 and 32%, respectively.

Conclusion:

The management of stage IVA cervical cancer needs to be individualised to achieve a fine balance between local control, toxicity, and quality of life. RT is the mainstay of treatment with concurrent chemotherapy in carefully selected patients. Involvement of palliative care team early in the course of treatment adds a holistic approach to the continuum of oncological care.

Changes in the diversity of local cervical bacteria in women with cervical cancer receiving antineoplastic treatment

Background

Some studies show changes in the microbiota in people undergoing antineoplastic treatment. Currently, there is not enough evidence of this effect in the treatment of cervical cancer (CC). The objective was to determine changes in the diversity of local cervical bacteria in women with CC receiving chemotherapy, radiotherapy, and brachytherapy.

Materials and Methods

A descriptive, longitudinal, and prospective study was conducted in 68 women with locally advanced CC with a treatment plan based on the administration of chemotherapy, external beam radiotherapy, and brachytherapy. Cervical-vaginal fluid samples were taken during antineoplastic treatment. The samples were used to isolate bacterial strains. The bacteria were identified at the molecular level by comparing sequences of the 16S ribosomal RNA gene.

Results

The bacteria identified belonged to three phyla: Firmicutes, Proteobacteria, and Actinobacteria. Nine genera and 25 species of bacteria were identified. The most frequent species were Staphylococcus epidermidis, Corynebacterium amycolatum, and Enterococcus faecalis. There were statistically significant differences when comparing bacterial diversity found in the different stages of treatment (≤0.05). Bacterial diversity decreased as antineoplastic treatment progressed and increased at the end of therapy.

Conclusion

Antineoplastic treatments generate changes in the diversity of local cervical bacterial communities of women with CC.

Prevalence of HER2 overexpression and amplification in cervical cancer: A systematic review and meta-analysis

The reported rates of HER2 positivity in cervical cancer (CC) range from 0% to 87%. The importance of HER2 as an actionable target in CC would depend on HER2 positivity prevalence. Our aim was to provide precise estimates of HER2 overexpression and amplification in CC, globally and by relevant subgroups. We conducted a PRISMA compliant meta-analytic systematic review. We searched Medline, EMBASE, Cochrane database, and grey literature for articles reporting the proportion of HER2 positivity in CC. Studies assessing HER2 status by immunohistochemistry or in situ hybridization in invasive disease were eligible. We performed descriptive analyses of all 65 included studies. Out of these, we selected 26 studies that used standardized American Society of Clinical Oncology / College of American Pathologists (ASCO/CAP) Guidelines compliant methodology. We conducted several meta-analyses of proportions to estimate the pooled prevalence of HER2 positivity and subgroup analyses using geographic region, histology, tumor stage, primary antibody brand, study size, and publication year as moderators. The estimated pooled prevalence of HER2 overexpression was 5.7% (CI 95%: 1.5% to 11.7%) I2 = 87% in ASCO/CAP compliant studies and 27.0%, (CI 95%: 19.9% to 34.8%) I2 = 96% in ASCO/CAP non-compliant ones, p < 0.001. The estimated pooled prevalence of HER2 amplification was 1.2% (CI 95%: 0.0% to 5.8%) I2 = 0% and 24.9% (CI 95%: 12.6% to 39.6%) I2 = 86%, respectively, p = 0.004. No other factor was significantly associated with HER2 positivity rates. Our results suggest that a small, but still meaningful proportion of CC is expected to be HER2-positive. High heterogeneity was the main limitation of the study. Variations in previously reported HER2 positivity rates are mainly related to methodological issues.

Endostar, an Anti-angiogenesis Inhibitor, Combined with Chemoradiotherapy for Locally Advanced Cervical Cancer

This phase II randomized clinical trial aimed to assess the efficacy and toxicity of Endostar, an anti-angiogenesis inhibitor, combined with concurrent chemoradiotherapy (CCRT) for locally advanced cervical cancer (LACC). Patients with LACC were randomly assigned to either CCRT plus Endostar(CCRT+E arm) or CCRT alone (CCRT arm). All patients received pelvic intensity-modulated radiation therapy (IMRT)and brachytherapy. Weekly cisplatin was administered concurrently with IMRT. Patients in the CCRT+E arm also received concurrent Endostar every 3 weeks for 2 cycles. The primary endpoint was progression-free survival (PFS) and acute toxicities. The exploratory endpoint was the impact of vascular endothelial growth factor receptor-2 (VEGFR2) expression on long-term survival. A total of 116patientswere enrolled. Patients in the CCRT+E arm and in the CCRT arm had similar acute and late toxicity profile. The 1-and 2-year PFS were 91.4% vs. 82.1% and 80.8% vs. 63.5%（p=0.091）, respectively. The1-and 2-year distance metastasis-free survival （DMFS）were92.7% vs. 81.1% and 86.0% vs. 65.1%（p=0.031）, respectively. Patients with positive VEGFR2 expression had significant longer PFS and overall survival (OS), compared with those with negative VEGFR2 expression. Patients in the CCRT+E arm had significantly longer PFS, OS, and DMFS than those in the CCRT arm whenVEGFR2 expression was positive. In conclusion, CCRT plus Endostar significantly improved DMFS but not PFS over CCRT alone. The addition of Endostar could significantly improve survival for patients with positive VEGFR2 expression.

Identification of Biomarkers for Cervical Cancer Radiotherapy Resistance Based on RNA Sequencing Data

Cervical cancer as a common gynecological malignancy threatens the health and lives of women. Resistance to radiotherapy is the primary cause of treatment failure and is mainly related to difference in the inherent vulnerability of tumors after radiotherapy. Here, we investigated signature genes associated with poor response to radiotherapy by analyzing an independent cervical cancer dataset from the Gene Expression Omnibus, including pre-irradiation and mid-irradiation information. A total of 316 differentially expressed genes were significantly identified. The correlations between these genes were investigated through the Pearson correlation analysis. Subsequently, random forest model was used in determining cancer-related genes, and all genes were ranked by random forest scoring. The top 30 candidate genes were selected for uncovering their biological functions. Functional enrichment analysis revealed that the biological functions chiefly enriched in tumor immune responses, such as cellular defense response, negative regulation of immune system process, T cell activation, neutrophil activation involved in immune response, regulation of antigen processing and presentation, and peptidyl-tyrosine autophosphorylation. Finally, the top 30 genes were screened and analyzed through literature verification. After validation, 10 genes (KLRK1, LCK, KIF20A, CD247, FASLG, CD163, ZAP70, CD8B, ZNF683, and F10) were to our objective. Overall, the present research confirmed that integrated bioinformatics methods can contribute to the understanding of the molecular mechanisms and potential therapeutic targets underlying radiotherapy resistance in cervical cancer.

Effects of miR-202-5p silencing PIK3CA gene expression on proliferation, invasion, and epithelial-mesenchymal transition of cervical cancer SiHa cells through inhibiting PI3K/Akt/mTOR signaling pathway activation

To explore the mechanism of miR-202-5p targeting the expression of PIK3CA and mediating the activation of PI3K/Akt/mTOR signaling pathway on the proliferation, invasion, and epithelial-mesenchymal transition (EMT) of cervical cancer. The objects of study were 105 cases of cervical cancer and their corresponding normal tissues. qRT-PCR was used to detect the expression of miR-202-5p and PIK3CA in adjacent normal tissue and cervical cancer tissue. Dual luciferase reporter assay was used to verify the targeting relationship between miR-202-5p and PIK3CA gene. Human cervical cancer cell lines HPV-16E6, SiHa, HeLa, and CaSki were purchased for our cell experiments. The expression levels of PIK3CA in the cells were detected by qRT-PCR. The cell line with higher expression levels was selected to complete the follow-up experiment. The cultured cells were transfected and divided into the miR-202-5p mimic NC group, miR-202-5p mimic group, miR-202-5p inhibitor NC group, miR-202-5p inhibitor group, siRNA-PIK3CA NC group, siRNA-PIK3CA group, miR-202-5p inhibitor NC + siRNA-PIK3CA NC group, miR-202-5p inhibitor + siRNA-PIK3CA NC group, and miR-202-5p inhibitor + siRNA-PIK3CA group. QRT-PCR was used to detect the expression of miR-202-5p. Western blot and qRT-PCR were applied to detect the mRNA and protein expression levels of related pathway proteins (PIK3CA, PI3K, PTEN, p-Akt1, and p-mTOR) and epithelial-mesenchymal transition-related factors (N-cadherin, E-cadherin, and vimentin). Cell proliferation was detected by plate colony formation assay. Transwell assay was used to detect the invasion ability of each group. When compared with the adjacent tissues, PIK3CA mRNA expression level was significantly increased and miR-202-5p expression level was significantly decreased in cervical cancer tissues (all P < 0.05). PIK3CA was a target gene of miR-202-5p. The mRNA expression level of PIK3CA in SiHa cervical cancer cells was significantly higher than that in CaSki, HeLa, and HPV-16E6 cells (all P < 0.05), and SiHa cervical cancer cells were selected to complete the follow-up experiments. When compared with the corresponding NC group, the expression of miR-202-5p in miR-202-5p mimic group was increased. In addition, the mRNA and protein expression levels of E-cadherin and PTEN in miR-202-5p mimic and siRNA-PIK3CA groups were increased, and the protein expression of p-Akt1 and p-mTOR was decreased, and also, the mRNA and protein expression levels of PIK3CA, PI3K, N-cadherin, and vimentin were decreased (all P < 0.05); in miR-202-5p inhibitor group, the expression levels of miR-202-5p, E-cadherin, and PTEN decreased, the protein expression of p-Akt1 and p-mTOR increased, and the mRNA and protein expression of PIK3CA, PI3K, N-cadherin, and vimentin increased in miR-202-5p inhibitor group (all P < 0.05); in miR-202-5p inhibitor + siRNA-PIK3CA group, the expression of miR-202-5p decreased (P < 0.05), but the mRNA and protein expression of PIK3CA, PI3K, p-Akt1, p-mTOR, N-cadherin, E-cadherin, and vimentin had no significant changes (all P > 0.05). When compared with the corresponding NC group, the number of cell clones in miR-202-5p mimic group and siRNA-PIK3CA group was decreased, and the invasion ability of miR-202-5p inhibitor group was increased, and the invasion ability was enhanced (all P < 0.05); miR-202-5p inhibitor + siRNA-PIK3CA group showed no significant change in the number of cell clones and the rate of invasion (P > 0.05). In conclusion, the overexpression of miR-202-5p can suppress PIK3CA gene expression and the activation of PI3K/Akt/mTOR signaling pathway to suppress the proliferation, invasion, and EMT of cervical cancer.

Outcomes of locally advanced cervical cancer presenting with obstructive uropathy: An institutional audit

Background

There is paucity of outcome data of patients with cervical cancer presenting with malignant obstructive uropathy. The present retrospective study describes outcomes of patients with cervical cancer who presented with obstructive uropathy at the time of diagnosis and underwent urinary diversion with percutaneous nephrostomy (PCN) before/during treatment.

Methods

Patients who underwent PCN from January 2010 to June 2015 were included. Intent of treatment (radical or palliative) was decided within multidisciplinary team depending on disease stage, Karnofsky performance status (KPS), and degree of renal derangement. Treatment and outcome details were retrieved from electronic records. Time to normalization of creatinine, feasibility of delivering planned treatment, and overall survival (OS) were determined. Impact of various prognostic factors on outcomes was determined using univariate or multivariate analysis.

Results

After PCN and double-J stenting, 50% were eligible for (chemo) radiation. All radically treated patients (26/52) received brachytherapy. The median EQD2 to point A was 78 Gy (72-84 Gy). The median OS was 10 (0.5-60) months. Patients who completed chemoradiation had median OS of 31 months. Those receiving radical radiation and palliative radiation had median OS of 11 and 6 months, respectively. On univariate analysis, smaller tumor size (p = 0.03), high KPS (P = 0.04), and radical intent of treatment (P = 0.05) predicted for OS.

Conclusion

Patients presenting with obstructive uropathy have median OS less than a year despite urinary diversion. Select cohort with good performance status, small tumor size, and serum creatinine of ≤3 mg/dL may be selected for diversion procedures and potential radical treatment.

Development and clinical validation of Knowledge-based planning for Volumetric Modulated Arc Therapy of cervical cancer including pelvic and para aortic fields

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A knowledge-based planning model was configured for VMAT of cervical cancer.

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Knowledge-based plans were comparable, and for some OARs, outperformed clinical plans.

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Improved organ sparing was observed, when individual patient geometry was considered.

Background and Purpose

Knowledge-based planning (KBP) is based on a model to estimate dose-volume histograms, configured using a library of historical treatment plans to efficiently create high quality plans. The aim was to report configuration and validation of KBP for Volumetric Modulated Arc Therapy of cervical cancer.

Materials and methods

A KBP model was configured from the institutional database (n = 125), including lymph node positive (n = 60) and negative (n = 65) patients. KBP Predicted plans were compared with Clinical Plans (CP) and Re-plans (Predicted plan as a base-plan) to validate the model. Model quality was quantified using coefficient of determination R2, mean square error (MSE), standard two-tailed paired t-test and Wilcoxon signed rank test.

Results

Estimation capability of the model was good for the bowel bag (MSE = 0.001, R2 = 0.84), modest for the bladder (MSE = 0.008) and poor for the rectum (MSE = 0.02 R2 = 0.78). KBP resulted in comparable target coverage, superior organ sparing as compared to CP. Re-plans outperformed CP for the bladder, V30 (66 ± 11% vs 74 ± 11%, p < .001), V40 (48 ± 14% vs 52 ± 14%, p < .001), however sparing was modest for the bowel bag V30 (413 ± 191cm³ vs 445 ± 208cm³, p = .037) V40 (199 ± 105cm³ vs 218 ± 127cm³, p = .031). All plans were comparable for rectum, while KBP resulted in significant sparing for spinal cord, kidneys and femoral heads.

Conclusion

KBP yielded comparable and for some organs superior performance compared to CP resulting in conformal and homogeneous target coverage. Improved organ sparing was observed when individual patient geometry was considered.

Multi-Omics Data Analyses Construct a Six Immune-Related Genes Prognostic Model for Cervical Cancer in Tumor Microenvironment

The cross-talk between tumor cells and the tumor microenvironment (TME) is an important factor in determining the tumorigenesis and progression of cervical cancer (CC). However, clarifying the potential mechanisms which trigger the above biological processes remains a challenge. The present study focused on immune-relevant differences at the transcriptome and somatic mutation levels through an integrative multi-omics analysis based on The Cancer Genome Atlas database. The objective of the study was to recognize the specific immune-related prognostic factors predicting the survival and response to immunotherapy of patients with CC. Firstly, eight hub immune-related prognostic genes were ultimately identified through construction of a protein–protein interaction network and Cox regression analysis. Secondly, 32 differentially mutated genes were simultaneously identified based on the different levels of immune infiltration. As a result, an immune gene-related prognostic model (IGRPM), including six factors (chemokine receptor 7 [CCR7], CD3d molecule [CD3D], CD3e molecule [CD3E], and integrin subunit beta 2 [ITGB2], family with sequence similarity 133 member A [FAM133A], and tumor protein p53 [TP53]), was finally constructed to forecast clinical outcomes of CC. Its predictive capability was further assessed and validated using the Gene Expression Omnibus validation set. In conclusion, IGRPM may be a promising prognostic signature to predict the prognoses and responses to immunotherapy of patients with CC. Moreover, the multi-omics study showed that IGRPM could be a novel therapeutic target for CC, which is a promising biomarker for indicating the immune-dominant status of the TME and revealing the potential mechanisms responsible for the tumorigenesis and progression of CC.

Prevalence of late-stage presentation and associated factors of cervical cancer patients in Tikur Anbesa Specialized Hospital, Ethiopia: institutional based cross-sectional study

Background

Cancer of the uterine cervix remains a main public health problem in Sub-Saharan Africa. About two-thirds of patients with cervical cancer were diagnosed at late stage with contributing factors of out-of-pocket medical bill, looking for care out of conventional health settings and multiple visits to healthcare facilities before diagnostic confirmations in Addis Ababa. Therefore, the aim of this study was to identify prevalence of late-stage presentation and associated factors among cervical cancer patients in Tikur Anbesa Specialized Hospital (TASH).

Methods

Institutional based cross-sectional study was conducted from March to April 2019 in TASH oncology center. Data were extracted from patient’s chart using structured checklist prepared in English and analyzed using STATA14.2. Binary logistic regression model was used to identify variables that affect the outcome variable.

Results

A total of 1057 cervical cancer patients were included in this five-years retrospective study. The prevalence of late-stage presentation among cervical cancer patients was 56.8%. It was affected by being anemic [AOR = 1.55,95%CI (1.17–2.10)], came from Oromia region (AOR = 0.65,95%CI (0.46–0.91) and Addis Ababa city [AOR:0.5;95%CI (0.34–0.73)], rural residency [AOR:1.88;95% (1.38–2.56)] and age ≥ 60 years [AOR:1.89;95%CI (1.12–3.20)].

Conclusion

The study revealed that the prevalence of late-stage presentation among cervical cancer patients is high. Being anemic, regions where patients came from, rural residency and age group ≥ 60 years were statically significant. It is better to expand cervical cancer education for rural dwellers, expand cancer treatment centers and prioritize to patients with anemia and advanced age.

Identification of an immune signature to predict poor clinical outcome in cervical cancer

Aim: To explore tumor immune microenvironment and identify immune prognostic-related circRNAs in cervical cancer. Materials & methods: RNA-seq in combination with bioinformatics were performed to establish a prognostic risk model and a circRNAs-miRNAs-CXCL8 network. Results: High-risk group correlated with poor survival outcome, and had lower PD-1 immunogenicity. Additionally, CXCL8 could distinguish normal tissue, low- and high-risk tumor tissues, the expression of which showed an increasing trend among the three groups. RNA-seq and bioinformatics indicated that circRNAs like hsa_circ_0025721 might upregulate CXCL8 through sponging miRNAs including hsa-miR-4428. Conclusion: We constructed an immune risk model related with CD8 T cells to predict the cervical cancer patients' prognosis and explored the abnormal expression mechanism of CXCL8 through the ceRNA mechanism.

Integrated Bioinformatical Analysis Identifies GIMAP4 as an Immune-Related Prognostic Biomarker Associated With Remodeling in Cervical Cancer Tumor Microenvironment

Tumor microenvironment (TME) is emerging as an essential part of cervical cancer (CC) tumorigenesis and development, becoming a hotspot of research these years. However, comprehending the specific composition of TME is still facing enormous challenges, especially the immune and stromal components. In this study, we downloaded the RNA-seq profiles and somatic mutation data of 309 CC cases from The Cancer Genome Atlas (TCGA) database, which were analyzed by integrative bioinformatical methods. Initially, ESTIMATE computational method was employed to calculate the amount of immune and stromal components. Then, based on the high- and low-immunity cohorts, we recognized the differentially expressed genes (DEGs) as well as the differentially mutated genes (DMGs). Additionally, we conducted an intersection analysis of DEGs and DMGs, ultimately determining an immune-related prognostic signature, GTPase, IMAP Family Member 4 (GIMAP4). Moreover, sequential analyses demonstrated that GIMAP4 was a protective factor in CC, positively correlated with the overall survival (OS) and negatively with distant metastasis. Besides, we utilized the Gene Set Enrichment Analysis (GSEA) to explore the enrichment-pathways in high and low-expression cohorts of GIMAP4. The results indicated that the genes of the high-expression cohort had a high enrichment in immune-related biological processes and metabolic activities in the low one. Furthermore, CIBERSORT analysis was applied to evaluate the proportion of tumor-infiltrating immune cells (TICs), illustrating that several activated TICs were strongly associated with GIMAP4 expression, which suggested that GIMAP4 had the potential to be an indicator for the immune state in TME of CC. Hence, GIMAP4 contributed to predicting the CC patients’ clinical outcomes, such as survival rate, distant metastasis and immunotherapy response. Moreover, GIMAP4 could serve as a promising biomarker for TME remodeling, suggesting the possible underlying mechanisms of tumorigenesis and CC progression, which may provide different therapeutic perceptions of CC, and therefore improve treatment.

Survival rate of cervical cancer from a study conducted in India

Objectives:

The incidence and mortality rates of cervical cancer in the world are 13.1/105 and 6.9/105, respectively. In India, it is estimated that there are 96,922 new cervical cancer cases and 60,078 deaths and ranked second among women cancers. The incidence and mortality rates are 14.7/105 and 9.2/105, respectively, although the incidence varies within Indian population. The majority of these cervical patients report at a late-stage of disease in health-care facility due to lack of awareness. A premier tertiary cancer hospital in Mumbai conducted the present survival-study. The aim of the study was to assess the various factors that determine the survival outcomes by age at diagnosis, role of comorbidities, stage of disease, and treatment.

Material and Methods:

The main source of information was patients’ medical records from which the data were abstracted, and active follow-up was undertaken. 1678 cases diagnosed between the years 2006 and 2008 at Tata Memorial Hospital are analyzed using actuarial method for obtaining survival rates and log-rank tests for comparison of survival groups.

Results:

The 5-year survival rate was 76.0% for those aged ≤50 years, 73.3% for non-residents, 74.4% for literates, and 81.8% for Christians and 72.5% for those with squamous cell carcinoma histology; those with no comorbidities had marginally better survival than their counter-parts. The survival rates were 83.5%, 80.6%, 66.0%, and 37.1% for Stage I, Stage II, Stage III, and Stage IV, respectively. The best survival outcomes were for those treated with only surgery (95.6%), or in combination with either radiotherapy (90.6%) or with radiotherapy and chemotherapy (85.5%). Involvement of either nodes/sites had poorer survival than those with no-involvement. In the multivariate analysis, only stage of the disease emerged as a significant prognosis factor.

Conclusion:

The study concluded that younger patients, early stage of disease, non-involvement of any sites/ nodes, and radiotherapy either alone or in combination with other treatment type provided better outcomes. Early detection and prevention strategies are keys to obtain better outcomes.

Evaluation of outcomes in patients of cervical Cancer with lower one third vaginal involvement: A single institutional experience

OBJECTIVE(S)

The objective of this study was to evaluate the clinical outcomes and prognostic factors affecting survival of cervical cancer patients presenting with lower third vaginal involvement.

MATERIALS/METHODS

The patients with histologically proven invasive cervical cancer with clinical FIGO-2009 stage IIIA and IIIB with lower one-third vaginal involvement, treated with radio (chemo) therapy between 2010 and 2016 at our institution were retrospectively analyzed.

RESULTS

There were 118 cervical cancer patients with lower third vaginal involvement with median age of 56.5 years (Range: 33-77 years). Forty-five patients were of FIGO stage IIIA, 73 patients staged as stage IIIB at diagnosis with predominant squamous histology. At a median follow up of 30 months, 12 patients (10.1%) developed local vaginal recurrences and 4 patients (3.3%) had developed loco regional recurrences, 27 patients (23%) developed distant and 2 patients developed loco-regional and distant relapses. The 3- year DFS and OS rates were 61.5% and 69.8% respectively. The 3-year DFS and OS of patients with IIIA was significantly better than IIIB patients (71% vs 56%, p: 0.02 and 76% vs 66%, p: 0.01 respectively) on univariate analysis. Concurrent chemotherapy and absence of persistent disease emerged as independent predictors of survival on multi-variate analysis.

CONCLUSION

The outcome of patients with FIGO IIIA is better than IIIB with lower vaginal involvement. Elderly patients, patients not receiving concomitant chemotherapy and presence of residual disease at BT are associated with poorer outcomes.

Minimal residual disease in advanced or metastatic solid cancers: The G0-G1 state and immunotherapy are key to unwinding cancer complexity

In the last decade, a large amount of research has focused on elucidating the mechanisms that account for homing disseminated cancer cells (DCCs) from solid tumours to distant organs, which successively progress to overt metastatic disease; this is currently incurable. A better understanding of DCC behaviour is expected to allow detectable metastasis prevention by more effectively targeting 'metastatic seeds before they sprout'. As DCC biology co-evolved with that of the primary tumour, and due to the many similarities between them, the term 'niche' has been borrowed from normal adult stem cells (ASCs) to define the site of DCC metastatic colonisation. Moreover, heterogeneity, survival, protection, stemness and plasticity as well as the prolonged G0-G1 dormant state in the metastatic niche have been the main aspects of intense investigation. Consistent with these findings, in solid cancers with minimal residual disease (MRD), it has been proposed to prolong adjuvant therapy by targeting specific molecular pathway(s) involving DCC dormancy. However, so far, few disappointing clinical data have been reported. As an alternative strategy, because immune-surveillance contributes to the steady state of the DCC population and likely to the G0-G1 state of cancer cells, we have used prolonged immune-modulatory cytostatic chemotherapy, active immune stimulation with an INF-β/IL-2 sequence or drugs inhibiting myeloid-derived suppressor cell (MDSC)/Treg-mediated immune suppression. This strategy, mainly aimed at boosting the immune response, is based on recent findings suggesting the downregulation of immune escape mechanisms as well as other principal hallmarks during the G0-G1 state and/or in MRD. Preliminary clinical and/or laboratory data suggest the efficacy of this strategy in gastrointestinal and some endocrine-dependent cancers. Following this, we propose therapeutic schedules to prevent DCC activation and proliferation in solid cancers at a high risk of relapse or as maintenance therapy in metastatic patients after complete response (CR) to conventional treatment.

Identification of Core Prognosis-Related Candidate Genes in Cervical Cancer via Integrated Bioinformatical Analysis

Purposes

Cervical cancer (CC) is one of the highest frequently occurred malignant gynecological tumors with high rates of morbidity and mortality. Here, we aimed to identify significant genes associated with poor outcome. Materials and methods. Differentially expressed genes (DEGs) between CC tissues and normal cervical tissues were picked out by GEO2R tool and Venn diagram software. Database for Annotation, Visualization and Integrated Discovery (DAVID) was performed to analyze gene ontology (GO) and Kyoto Encyclopedia of Gene and Genome (KEGG) pathway. The protein-protein interactions (PPIs) of these DEGs were visualized by Cytoscape with Search Tool for the Retrieval of Interacting Genes (STRING). Afterwards, Kaplan-Meier analysis was applied to analyze the overall survival among these genes. The Gene Expression Profiling Interactive Analysis (GEPIA) was applied for further validation of the expression level of these genes.

Results

The mRNA expression profile datasets of GSE63514, GSE27678, and GSE6791 were downloaded from the Gene Expression Omnibus database (GEO). In total, 76 CC tissues and 35 normal tissues were collected in the three profile datasets. There were totally 73 consistently expressed genes in the three datasets, including 65 up-regulated genes and 8 down-regulated genes. Of PPI network analyzed by Molecular Complex Detection (MCODE) plug-in, all 65 up-regulated genes and 4 down-regulated genes were selected. The results of the Kaplan-Meier survival analysis showed that 3 of the 65 up-regulated genes had a significantly worse prognosis, while 3 of the 4 down-regulated genes had a significantly better outcome. For validation in GEPIA, 4 of 6 genes (PLOD2, ANLN, AURKA, and AR) were confirmed to be significantly deregulated in CC tissues compared to normal tissues.

Conclusion

We have identified three up-regulated (PLOD2, ANLN, and AURKA) and a down-regulated DEGs (AR) with poor prognosis in CC on the basis of integrated bioinformatical methods, which could be regarded as potential therapeutic targets for CC patients.

Global Collaborations for Cervical Cancer: Can the East-West Alliance Facilitate Treatment for all?

Despite the advances in the primary prevention of cervical cancer, there is an absolute increase in the incidence of cervical cancer as a result of an increase in world population. A vast majority of patients in low and low-middle income countries continue to present at a locally advanced stage, necessitating treatment with chemoradiation and brachytherapy. There is a dearth of equipment and trained professionals for the treatment of cervical cancer, especially in low and low-middle income countries. There is an urgent need to improve treatment availability and develop better treatments. Worldwide trends, however, reveal a low number of therapeutic and innovative research trials in cervical cancer. The present article elucidates the existing challenges and provides solutions to improve outcomes. The proposed strategies hinge on strengthening collaborations for global advocacy.

Identification of candidate biomarkers correlated with the diagnosis and prognosis of cervical cancer via integrated bioinformatics analysis

Background: Cervical carcinoma is one of the most common malignant gynecological tumors and is associated with high rates of morbidity and mortality. Early diagnosis and early treatment can reduce the mortality rate of cervical cancer. However, there is still no specific biomarkers for the diagnosis and detection of cervical cancer prognosis. Therefore, it is greatly urgent in searching biomarkers correlated with the diagnosis and prognosis of cervical cancer.

Results: The mRNA and microRNA expression profile datasets (GSE7803, GSE9750, GSE63514, and GSE30656) were downloaded from the Gene Expression Omnibus database (GEO). The three microarray datasets were integrated to one via integrated bioinformatics. Differentially expressed genes (DEGs) and microRNAs (DEMs) were obtained by R software. The protein–protein interaction (PPI) networks of the DEGs were performed from the STRING database and further visualized by Cytoscape software. A total of 83 DEGs and 14 DEMs were screened from the microarray expression profile datasets. The miRNAs validated to be associated with cervical cancer were obtained using HMDD online website and the target genes of DEMs were identified using the miRWalk2.0 online database. ESR1, PPP1R3C, NSG1, and TMPRSS11D were the gene targets of hsa-miR-21; the targets of hsa-miR-16 were GYS2, ENDOU, and KLF4. These targets were all downregulated in cervical cancer. Finally, we verified the expression of those targets in cervical tissues from TCGA and GTEx databases and analyzed their relationship with survival of cervical cancer patients. In the end, the expression of key genes in cervical cancer tissues was verified via experiment method, we found KLF4 and ESR1 were downregulated in tumor tissues.

Conclusion: This study indicates that KLF4 and ESR1 are downregulated by the upregulated miR21 and miRNA16 in cervical cancer, respectively, using bioinformatics analysis, and the lower expression of KLF4 and ESR1 is closely related to the poor prognosis. They might be of clinical significance for the diagnosis and prognosis of cervical cancer, and provide effective targets for the treatment of cervical cancer.

The analysis of the long-term outcomes in elderly women treated for locally advanced cervical cancer

Purpose

Locally advanced cervical cancer (LACC) should be treated with a combination of external irradiation and brachytherapy with concurrent chemotherapy. However, as cervical carcinoma cells can disperse by way of the lymphatic system to either pelvic or para-aortic nodes, planning the extent of radiation requires precise information about the spread of the disease to the lymph nodes, especially to the para-aortic area.

Material and methods

All of the 75 women included in our study underwent chemoradiotherapy, which started with brachytherapy. Out of them, 54 have undergone radical hysterectomy with lymphadenectomy followed by chemoradiation. We have retrospectively analyzed the 5-year overall survival (OS) rates relative to the lymph node involvement, the type of lymphadenectomy performed (pelvic, para-aortic, or both), the size of the tumor (> or < 4 cm), the histological type, grading, and the age of patients.

Results

We observed significant differences in the OS rates relative to the age of the patients with LACC. We noted significant differences in the OS rates related to para-aortic lymphadenectomy and presence of lymph node metastases.

Conclusions

Para-aortic lymphadenectomy seems to have a positive influence on long-term outcomes in the LACC patients, and elderly patients may benefit more from applied therapy.