Lack of benefit of concurrent chemotherapy in patients with cervical cancer and negative lymph nodes by FDG-PET

Definitive chemoradiotherapy for cervical cancer: A 11-year population-based study

PURPOSE

To assess the recurrence pattern and survival in women treated with definitive chemoradiotherapy for cervical cancer.

METHODS

A retrospective cohort study of women FIGO (2012) stage IB2 to IVA from the Grampian region of Scotland between February 2000 and March 2011. These women were followed up until April 2018.

RESULTS

A total of 121 eligible women allocated with mean age at treatment 50.59 years (SD = 13.98, range 22-82). Tumours staged: IB2: n = 24 (19.8%), II: n = 45 (37.2%), III: n = 43 (35.5%) and IVA: n = 7 (5.8%). Two (1.7%) women had no available data. Fifty-five (45.5%) women had recurrence after treatment, and 51 (42.15%) women died from the disease. The sites of recurrence were as follows: central pelvic only (n = 4, 7.27%), pelvic and distant (n = 39, 70.91%) and distant only (n = 12, 21.82%) with median time from end of treatment to first recurrence 44 months (range 2-98), 26 months (range 1-146) and 22 months (range 3-66) respectively. 5-and 8-year overall survival was 76.0% (95% CI: 68.8%-84.0%) and 64.4% (95% CI: 56.4%-73.5%) respectively.

CONCLUSIONS

Though overall survival is better than with radiotherapy alone, recurrence occurs up to 10 years after treatment. This raises the issues of how to reduce late recurrence and the appropriateness of current follow-up protocols.

Positron emission tomography in gynecological malignancies

Positron emission tomography (PET) is a functional diagnostic imaging technique. F-18 fluoro-2-deoxy-d-glucose (FDG) is a commonly used radiopharmaceutical that is an analog of glucose. PET with FDG is now the standard of care in initial staging, monitoring the response to the therapy and management of various cancers. There is not sufficient data to support the use of PET in the initial diagnosis of cervical cancer; however, FDG-PET has a role in initial staging in the detection of distant metastases in patients with cervical cancer. PET has limited value in lesion localization in early stages of ovarian cancer, but plays a significant role in identifying recurrent tumors in patients with rising tumor markers. In this article, the clinical application of PET in gynecological malignancies is reviewed.

Risk Assessment Tool for Distant Recurrence After Platinum-Based Concurrent Chemoradiation in Patients With Locally Advanced Cervical Cancer: A Korean Gynecologic Oncology Group Study

Purpose

Our study aimed to develop a model to predict distant recurrence in locally advanced cervical cancer, which can be used to select high-risk patients in enriched clinical trials.

Patients and Methods

Our study was a retrospective analysis of a multi-institutional cohort of patients treated between 2001 and 2009. According to the order of data submission, data from three institutions were allocated to a model development cohort (n = 434), and data from the remaining two institutions were allocated to an external validation cohort (n = 115). Patient information including [18F]fluorodeoxyglucose positron emission tomography (FDG-PET) data and clinical outcome was modeled using competing risk regression analysis to predict 5-year cumulative incidence of distant recurrence.

Results

The competing risk analysis revealed that the following four parameters were significantly associated with distant recurrence: pelvic and para-aortic nodal positivity on FDG-PET, nonsquamous cell histology, and pretreatment serum squamous cell carcinoma antigen levels. This four-parameter model showed good discrimination and calibration, with a bootstrap-adjusted concordance index of 0.70. Also, the validation set showed good discrimination with a bootstrap-adjusted concordance index of 0.73. A user-friendly Web-based nomogram predicting 5-year probability of distant recurrence was developed.

Conclusion

We have developed a robust model to predict the risk of distant recurrence in patients with locally advanced cervical cancer. Further, we discussed how the selective enrichment of the patient population could facilitate clinical trials of systemic chemotherapy in locally advanced cervical cancer.

Clinical evidence on PET-CT for radiation therapy planning in cervix and endometrial cancers

PET-CT plays an increasing role in the diagnosis and treatment of gynaecological cancers. In cervix cancer, whilst MRI remains the best imaging technique for initial primary tumor staging, PET-CT has been showed to be a highly sensitive method to determine lymph node status, except in patients with early-stage cervical cancer where PET-CT cannot replace surgical exploration of pelvic lymph nodes. In patients with advanced cervical cancer, PET-CT has the potential of showing lymph node metastasis not only within the pelvis, but also outside the pelvis, more particularly in the para-aortic area. PET-CT has also been described as a useful tool in 3-D-based adaptative brachytherapy. In endometrial cancer, the issues are different, as the recent decade has seen a therapeutic decrease in early-stage disease, especially in postoperative radiation therapy, whilst more advanced disease have been approached with more aggressive treatments, integrating chemotherapy and external beam radiotherapy. Lymph node status is also an important issue and PET-Scan may replace lymph node surgical procedure particularly in obese patients.

Predicting the response of advanced cervical and ovarian tumors to therapy

The management of advanced cervical and ovarian cancers remains a significant challenge as many women fail to respond to recommended therapy, resulting in disease progression and ultimately patient death. Because of tumor heterogeneity, it is rare for all cancers of a particular type to respond to a specific therapy; and, as a result, many patients receive treatment from which they derive little or no benefit, leading to increased morbidity and undue costs. A marker that could rapidly predict or forecast disease outcome would clearly be beneficial in allowing the administration of a tailored regime for each patient while reducing toxicity and cost. Traditional prognostic factors of tumor size, grade, and stage are not ideal for predicting patient outcome, whereas the use of in vitro assays to detect chemosensitivity or resistance has not yet translated into routine clinical practice. Similarly, biomarkers and tumor markers vary in their predictive ability. DNA array technology offers great promise in predicting the response to therapy based on gene expression profiles, and can allow for targeted therapies against specific molecular alterations that cause disease. Imaging techniques, particularly those with the ability to characterize biological tissues and provide functional, structural, and molecular information, have the potential to noninvasively integrate physical and metabolic information. These include F-18-fluorodeoxyglucose positron emission tomography, dynamic contrast-enhanced magnetic resonance imaging, and diffusion weighted magnetic resonance imaging, all techniques that attempt to evaluate and predict therapy response and so influence clinical outcome. This review examines different methods of predicting the response to treatment in advanced cervical and ovarian tumors.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to describe why prediction of response to therapy for cervical and ovarian cancers is important, describe obstacles to use of in vitro assays to predict outcomes for therapy for ovarian and cervical cancers, and explain potentially new predictive markers.

Clinical outcome for chemoradiotherapy in carcinoma of the cervix

AIMS

Two recent meta-analyses have shown a survival advantage for the addition of concurrent chemotherapy to radiotherapy in the treatment of cervical cancer. However, there is insufficient information available on late toxicity and few data from UK practice. The aims of this study were to examine treatment outcomes (survival and toxicity) in patients with cervical cancer treated with chemoradiation and to compare these with outcomes in patients treated with radiation alone.

MATERIALS AND METHODS

Between July 2000 and December 2003, 75 patients with cervical cancer were treated with chemoradiation. Case notes were reviewed retrospectively. Acute and late toxicity were recorded, with late toxicity graded using the Franco-Italian glossary. The median age was 47 years. All patients were staged with examination under anaesthesia and magnetic resonance imaging scans. Forty-two patients were treated with concurrent chemoradiation alone and 33 patients were treated with a combination of neoadjuvant and concurrent chemoradiation. This was due to waiting list problems. The chemotherapy used was cisplatin 40 mg/m(2) weekly with radiotherapy, (the neoadjuvant dose was 60 mg/m(2) 3 weekly). External beam radiotherapy was given to the pelvis (40-45 Gy/20 fractions/4 weeks) followed by low dose rate brachytherapy (22.5-32.5 Gy to point A). Patients who were unable to have brachytherapy were given an external beam boost (15-20 Gy/8-10 fractions).

RESULTS

The 3-year overall survival rate was 70%, with an estimated 5-year overall survival rate of 60%. The 3-year disease-free survival was 63.6%, with an estimated 5-year disease-free survival rate of 55%. Compared with the cohort of 183 patients from the Christie Hospital in a 1993 audit, there was a trend towards improved overall survival from 49 to 60% (P=0.06), which may become significant with longer follow-up. There were seven patients (9.3%) with grade 3 toxicity and no cases of grade 4 toxicity. In comparison with patients treated in the 1993 audit, the late toxicity rate has increased from 3.4 to 9.3%, but this was not statistically significant (P=0.14).

CONCLUSION

There was a trend towards improved survival with concurrent chemoradiation in this cohort of patients that may become significant with longer follow-up.

Primary surgery versus chemoradiation in the treatment of IB2 cervical carcinoma: A cost effectiveness analysis

OBJECTIVES

To estimate the relative cost-effectiveness of treatments for patients with FIGO stage IB2 cervical cancer and no evidence of metastasis as determined by combination of positron emission tomography/computed tomography (PET/CT).

METHODS

A Markov state transition model was constructed to compare two strategies: (1) radical hysterectomy and pelvic lymphadenectomy with tailored adjuvant therapy (RH+TA); (2) primary chemoradiation (CR). Five-year survival estimates for FIGO stage IB2 cervical cancer were obtained from literature. Medicare reimbursement rates and Agency for Healthcare Research and Quality database were used to obtain costs of treatment regimens and grades 3-5 adverse events. Strategies were compared using incremental cost per year of life saved (YLS). Extensive sensitivity analyses were performed.

RESULTS

Overall survival estimates were 78.9% for CR; 79.6% for RH+TA. Mean cost for CR at 5 years was $21,403 compared to $27,840 for RH+TA. RH+TA cost $63,689 per additional year of life saved (YLS) compared to CR. Results were most sensitive to survival estimates and the costs associated with high dose rate (HDR) versus low dose rate (LDR) brachytherapy. If 90% of patients with intermediate pathologic risk factors at surgery were assumed to receive adjuvant CR, the ICER of RH+TA rose to $100,000 per YLS compared to CR.

CONCLUSIONS

RH+TA is potentially cost effective when compared to CR for patients with stage IB2 cervical cancer without metastatic disease by PET/CT imaging. Key factors in the cost-effectiveness of treatments include physician's expected recommendation of adjuvant therapy, brachytherapy modality employed for primary CR and quality of life related to both treatment and its complications.

Positron emission tomography: clinical applications in oncology. Part 2

This review continues from a previous review on this topic, which was published in the December issue. In that review, the role of positron emission tomography in lung cancer, lymphoma, breast cancer, head and neck cancer, gastroesophageal cancer, colorectal cancer, malignant melanoma, bone tumors and ovarian cancer was discussed. In this review, the role of positron emission tomography in other malignancies, such as gynecological malignancies other than ovary, pancreatic cancer, hepatocellular cancer, gastrointestinal tumors, urological malignancies, neuroendocrine tumors, adrenocortical tumors, soft-tissue sarcomas, pituitary and brain tumors, is discussed.

Advances in image-guided radiation therapy—the role of PET-CT

In the era of image-guided radiation therapy (IGRT), the greatest challenge remains target delineation, as the opportunity to maximize cures while simultaneously decreasing radiation dose to the surrounding normal tissues is to be realized. Over the last 2 decades, technological advances in radiographic imaging, biochemistry, and molecular biology have played an increasing role in radiation treatment planning, delivery, and evaluation of response. Previously, fluoroscopy formed the basis of radiation treatment planning. Beginning in the late 1980s, computed tomography (CT) has become the basis for modern radiation treatment planning and delivery, coincident with the rise of 3-dimensional conformal radiation therapy (3DCRT). Additionally, multi-modality anatomic imaging registration was the solution pursued to augment delineation of tumors and surrounding structures on CT-based treatment planning. Although these imaging modalities provide the customary anatomic details necessary for radiation treatment planning, they have limitations, including difficulty with identification of small tumor deposits, tumor extension, and distinction from scar tissues. To overcome these limitations, PET and, more recently, PET-CT have been innovative regarding the extent of disease appraisal, target delineation in the treatment planning, and assessment of therapy response. We review the role of functional imaging in IGRT as it reassures transformations on the field of radiation oncology. As we move toward the era of IGRT, the use of multi-modality imaging fusion, and the introduction of more sensitive and specific PET-CT tracers may further assist target definition. Furthermore, the potential to predict early outcome or even detect early recurrence of tumor, may allow for the tailoring of intervention in cancer patients. The convergence of a biological target volume, and perhaps multi-tracer tumor, molecular, and genetic profile tumors will probably be vital in cancer treatment selection. Nevertheless, prospective clinical experience with outcome is encouraged and needs to be expanded to entirely exploit the benefits of the IGRT.