Neoadjuvant Chemotherapy: An Alternative Option of Treatment for Locally Advanced Cervical Cancer

Recurrence risk stratification for locally advanced cervical cancer using multi-modality transformer network

Objectives

Recurrence risk evaluation is clinically significant for patients with locally advanced cervical cancer (LACC). We investigated the ability of transformer network in recurrence risk stratification of LACC based on computed tomography (CT) and magnetic resonance (MR) images.

Methods

A total of 104 patients with pathologically diagnosed LACC between July 2017 and December 2021 were enrolled in this study. All patients underwent CT and MR scanning, and their recurrence status was identified by the biopsy. We randomly divided patients into training cohort (48 cases, non-recurrence: recurrence = 37: 11), validation cohort (21 cases, non-recurrence: recurrence = 16: 5), and testing cohort (35 cases, non-recurrence: recurrence = 27: 8), upon which we extracted 1989, 882 and 315 patches for model's development, validation and evaluation, respectively. The transformer network consisted of three modality fusion modules to extract multi-modality and multi-scale information, and a fully-connected module to perform recurrence risk prediction. The model's prediction performance was assessed by six metrics, including the area under the receiver operating characteristic curve (AUC), accuracy, f1-score, sensitivity, specificity and precision. Univariate analysis with F-test and T-test were conducted for statistical analysis.

Results

The proposed transformer network is superior to conventional radiomics methods and other deep learning networks in both training, validation and testing cohorts. Particularly, in testing cohort, the transformer network achieved the highest AUC of 0.819 ± 0.038, while four conventional radiomics methods and two deep learning networks got the AUCs of 0.680 ± 0.050, 0.720 ± 0.068, 0.777 ± 0.048, 0.691 ± 0.103, 0.743 ± 0.022 and 0.733 ± 0.027, respectively.

Conclusions

The multi-modality transformer network showed promising performance in recurrence risk stratification of LACC and may be used as an effective tool to help clinicians make clinical decisions.

Clavien-Dindo classification and risk prediction model of complications after robot-assisted radical hysterectomy for cervical cancer

Although significant progress has been made with surgical methods, the incidence of complications after minimally invasive surgery in patients with cervical cancer remains high. Established as a standardized system, Clavien-Dindo classification (CDC) has been applied in a variety of surgical fields. This study is designed to evaluate the complications after robot-assisted radical hysterectomy (RRH) for cervical cancer using CDC and further establish a prediction model. This is a study on the development of prediction model based on retrospective data. Patients with cervical cancer who received RRH treatment in our hospital from January 2016 to April 2019 were invited to participate in the study. The demographic data, laboratory and imaging examination results and postoperative complications were collected, and the logistic regression model was applied to analyze the risk factors possibly related to complications to establish a prediction model. 753 patients received RRH. The overall incidence of complications was 32.7%, most of which were grade I and grade II (accounting for 30.6%). The results of multivariate analysis showed that the preoperative neoadjuvant chemotherapy (OR = 1.693, 95%CI: 1.210-2.370, P = 0.002), preoperative ALT (OR = 1.028, 95%CI: 1.017-1.039, P < 0.001), preoperative urea nitrogen (OR = 0.868, 95%CI: 0.773-0.974, P = 0.016), preoperative total bilirubin (OR = 0.958, 95%CI: 0.925-0.993, P = 0.0.018), and preoperative albumin (OR = 0.937, 95%CI: 0.898-0.979, P = 0.003) were related to the occurrence of postoperative complications. The area under the curve (AUC) of receiver-operating characteristic (ROC) in the prediction model of RRH postoperative complications established based on these five factors was 0.827 with 95% CI of 0.794-0.860. In patients undergoing robot-assisted radical hysterectomy for cervical cancer, preoperative ALT level, urea nitrogen level, total bilirubin level, albumin level, and neoadjuvant chemotherapy were significantly related to the occurrence of postoperative complications. The regression prediction model established on this basis showed good prediction performance with certain clinical promotion and reference value.

HPV-Negative Cervical Cancer: A Narrative Review

Cervical cancer (CC) is the fourth most frequent cancer in women worldwide. HPV infection is associated with the majority of CC cases, but a small proportion of CCs actually test negative for HPV. The prevalence of HPV among CC histotypes is very different. It has been suggested that HPV-negative CC may represent a biologically distinct subset of tumors, relying on a distinct pathogenetic pathway and carrying a poorer prognosis, than HPV-positive CCs. Although, the discordance in terms of sensitivity and specificity between different HPV tests as well as the potential errors in sampling and storing tissues may be considered as causes of false-negative results. The identification of HPV-negative CCs is essential for their correct management. The aim of this narrative review is to summarize the clinical and pathological features of this variant. We also discuss the pitfalls of different HPV tests possibly leading to classification errors.

A Fifteen-Gene Classifier to Predict Neoadjuvant Chemotherapy Responses in Patients with Stage IB to IIB Squamous Cervical Cancer

Neoadjuvant chemotherapy (NACT) remains an attractive alternative for controlling locally advanced cervical cancer. However, approximately 15-34% of women do not respond to induction therapy. To develop a risk stratification tool, 56 patients with stage IB-IIB cervical cancer are included in 2 research centers from the discovery cohort. Patient-specific somatic mutations led to NACT non-responsiveness are identified by whole-exome sequencing. Next, CRISPR/Cas9-based library screenings are performed based on these genes to confirm their biological contribution to drug resistance. A 15-gene classifier is developed by generalized linear regression analysis combined with the logistic regression model. In an independent validation cohort of 102 patients, the classifier showed good predictive ability with an area under the curve of 0.80 (95% confidence interval (CI), 0.69-0.91). Furthermore, the 15-gene classifier is significantly associated with patient responsiveness to NACT in both univariate (odds ratio, 10.8; 95% CI, 3.55-32.86; p = 2.8 × 10-5) and multivariate analysis (odds ratio, 17.34; 95% CI, 4.04-74.40; p = 1.23 × 10-4) in the validation set. In conclusion, the 15-gene classifier can accurately predict the clinical response to NACT before treatment, representing a promising approach for guiding the selection of appropriate treatment strategies for locally advanced cervical cancer.

A Machine Learning Tool to Predict the Response to Neoadjuvant Chemotherapy in Patients with Locally Advanced Cervical Cancer

Despite several studies having identified factors associated with successful treatment outcomes in locally advanced cervical cancer, there is the lack of accurate predictive modeling for progression-free survival (PFS) in patients who undergo radical hysterectomy after neoadjuvant chemotherapy (NACT). Here we investigated whether machine learning (ML) may have the potential to provide a tool to predict neoadjuvant treatment response as PFS. In this retrospective observational study, we analyzed patients with locally advanced cervical cancer (FIGO stages IB2, IB3, IIA1, IIA2, IIB, and IIIC1) who were followed in a tertiary center from 2010 to 2018. Demographic and clinical characteristics were collected at either treatment baseline or at 24-month follow-up. Furthermore, we recorded data about magnetic resonance imaging (MRI) examinations and post-surgery histopathology. Proper feature selection was used to determine an attribute core set. Three different machine learning algorithms, namely Logistic Regression (LR), Random Forest (RFF), and K-nearest neighbors (KNN), were then trained and validated with 10-fold cross-validation to predict 24-month PFS. Our analysis included n. 92 patients. The attribute core set used to train machine learning algorithms included the presence/absence of fornix infiltration at pre-treatment MRI as well as of either parametrium invasion and lymph nodes involvement at post-surgery histopathology. RFF showed the best performance (accuracy 82.4%, precision 83.4%, recall 96.2%, area under receiver operating characteristic curve (AUROC) 0.82). We developed an accurate ML model to predict 24-month PFS.

Promising anti- cervical carcinoma and inflammatory agent, Resveratrol targets poly (ADP-ribose) polymerase 1 (PARP-1) induced premature ovarian failure with a potent enzymatic modulatory activity

Radioprotective effects of Resveratrol is well known in normal cells exposed to the damaging effects of ionizing radiation however, its potential radioprotective effect on ovarian follicle formation and development is still uncertain. Astonishingly, it has been reported that PARP contributed to the pathogenesis of immune-mediated ovarian injury. In this paper, Resveratrol was tested for its inflammatory, anti-cervical carcinoma activity, and checked its targets poly (ADP-ribose) polymerase 1 (PARP-1) induced premature ovarian failure with a potent enzymatic modulatory activity. Through high-throughput virtual screening method, Resveratrol was screened to find its target. That the compound strongly inhibited cervical carcinoma HT-3 cell. The cell proliferation was evaluated by an CCK-8 assay, and the cell apoptosis was assessed by a flow cytometry. Rat model of premature ovarian failure was used to introduce resveratrol preparation and rtPCR was done to measure expression of apoptosis related markers. We report resveratrol as a potential target for PARP-1 and its modulator from a high-throughput virtual screening method. Resveratrol was measured its anti-cervical carcinoma activity by using an CCK-8 assay, which suggested that the compound strongly inhibited HT-3 cell proliferation, the IC₅₀ value is 0.65 μM. In addition, the compound induced HT-3 cell apoptosis in a dose-response manner. Resveratrol preserves the entire ovarian follicle pool manifested by increasing serum anti-Müllerian hormone (AMH) levels. Study suggest that resveratrol restored ovarian function through increasing AMH levels, and diminishing ovarian inflammation, predominantly modulation of PPAR-1 and inhibition of inflammatory cytokines. Resveratrol was identified targets for PARP-1 from a high-throughput virtual screening method, strongly inhibited PARP-1 protein and HT-3 cell proliferation. Resveratrol is a promising PARP-1 modulator with anti-cervical carcinoma activity, which deserves further investigation.

Perioperative Complications and Safety Evaluation of Robot-Assisted Radical Hysterectomy of Cervical Cancer After Neoadjuvant Chemotherapy

Purpose

To evaluate the perioperative complications of patients with cervical cancer who are treated with robot-assisted radical hysterectomy (RRH) and to further evaluate the safety of patients undergoing NACT.

Methods

A total of 805 consecutive cervical cancer patients undergoing RRH were involved in this report. Their clinical characteristics were retrieved from hospital medical records. Perioperative complications were subdivided into intraoperative and postoperative complications, which were graded according to the Clavien-Dindo classification (CDC), and the complications of grade III and above were defined as severe complications. Furthermore, the two-level logistic regression model was used to estimate the risk factors of perioperative and severe complications and to further confirm the relationship between NACT and perioperative and severe complications.

Results

The perioperative complication rate and severe complications were 45.09% and 7.83%, respectively. Poorly differentiated tumor and NACT were identified as independent risk factors for perioperative complications by multifactor analysis. Furthermore, we concentrated on the relations between NACT and complications. The risk of perioperative complications of the group with NACT (OR = 11.08, 95% CI: 5.70-21.54) was significantly higher than the group without NACT, especially in postoperative complications (OR=17.65, 95% CI: 8.63-36.08), even after adjusting confounding factors. However, there was no statistically significant difference in terms of severe complications (OR=1.68, 95% CI: 0.64-4.41) and intraoperative complications (OR=0.51, 95% CI: 0.18-1.41). Moreover, as the times of NACT increase, the impact on perioperative complications is more pronounced. A similar trend was observed in postoperative complications, while this statistical difference was still not observed in intraoperative and severe complications.

Conclusion

This result demonstrates the feasibility and safety of RRH of cervical carcinoma after NACT in generally, since it only causes mild complications, not severe complications.

A phase II study: dose-dense carboplatin and paclitaxel as neoadjuvant chemotherapy in locally advanced cervical cancer

This study evaluates the efficacy and toxicity of dose-dense weekly paclitaxel and carboplatin as neoadjuvant chemotherapy in locally advanced cervical cancer (LACC). We collected 23 cases of LACC treated with weekly paclitaxel and carboplatin for nine cycles: 20 patients had complete or partial response to chemotherapy and were submitted to surgery, 3 with poor response received chemoradiation therapy. Pathologic examination showed complete response in four patients, myometrial invasion <50% in nine and >50% in seven patients, parametrial involvement in two, vaginal metastasis in one and lymphovascular space invasion, with positive margins, in another case. Despite seven patients had radiological evidence of lymph nodes involvement at diagnosis, only one had nodal metastases. Five patients showed grade 3-4 of hematologic toxicity.

Robotic single site radical hysterectomy plus pelvic lymphadenectomy in gynecological cancers

Objective

To evaluate the feasibility and the safety of robotic single-site radical hysterectomy (RSSRH) plus pelvic lymphadenectomy (PL) in endometrial or cervical cancer.

Methods

Patients with endometrial cancer (EC) International Federation of Gynecology and Obstetrics (FIGO) stage II, early cervical cancer (ECC) FIGO stage IB1 or locally advanced cervical cancer (LACC) FIGO stage IB2–IIB with clinical response ≥50% after neo-adjuvant chemotherapy (NACT) were enrolled in a prospective cohort trial. All cases were performed using the da Vinci Si Surgical Single Site System^®.

Results

Between April 2014 and November 2016, twenty patients were included in our pilot study. Three and 17 patients underwent type B1 or C1 RSSRH plus PL, respectively. The median age of patients was 46 years (range, 36–68 years) and the median body mass index was 23.5 kg/m² (range, 19.1–36.3 kg/m²). The median total operative time was 190 minutes (range, 90–310 minutes). The median blood loss was 75 mL (range, 20–700 mL) and the median number of pelvic lymph nodes removed was 16 (range, 5–27). No laparoscopic/laparotomic conversions were reported and the median time to discharge was 6 days (range, 4–16 days). No intra-operative complications occurred while 4 (20%) post-operative complications were reported: one pelvic abscess, one lymphorrea, one bowel perforation, and one vaginal dehiscence.

Conclusion

RSSRH plus PL is technically feasible in patients affected by gynecological cancer.

Impact of the care provided by gynecologic oncologists on outcomes of cervical cancer patients treated with radical hysterectomy

For many malignant diseases, specialized care has been reported to be associated with better outcomes. The purpose of this study is to investigate the influence of gynecologic oncologists on treatment outcomes for cervical cancer patients treated by radical hysterectomy. Records of patients who received radical hysterectomy between January 2005 and June 2010 were reviewed. Perioperative morbidity, recurrence-free survival, and cancer-specific survival were assessed. Cox regression model was used to evaluate gynecologic oncologists as an independent predictor of survival. A total of 839 patients were included. Of these patients, 553 were treated by gynecologic oncologists, while 286 were treated by other subspecialties. With regard to operative outcomes, significant differences in favor of operation by gynecologic oncologists were found in number of patients receiving para-aortic node sampling and dissection (P=0.038), compliance with surgical guidelines (P=0.003), operative time (P<0.0001), estimated blood loss (P<0.0001), transfusion rate (P=0.046), number of removed nodes (P=0.033), and incidences of ureteric injury (P=0.027), cystotomy (P=0.038), and fistula formation (P=0.002). Patients who were operated on by gynecologic oncologists had longer recurrence-free survival (P=0.001; hazard ratio [HR] =0.64; 95% confidence interval [CI] [0.48, 0.84]) and cancer-specific survival (P=0.005; HR=0.64; 95% CI [0.47, 0.87]), and this association remained significant in patients with locally advanced disease. Care by gynecologic oncologists was an independent predictor for improved recurrence-free survival (P<0.0001; HR=0.57; 95% CI [0.42, 0.76]) and cancer-specific survival (P=0.001; HR=0.58; 95% CI [0.42, 0.81]), which was still significant among patients with locally advanced cancer. Given the results, we believe for cervical cancer patients receiving radical hysterectomy, operation by gynecologic oncologists results in significantly improved surgical and survival outcomes. The importance of the subspecialty of a gynecologist for cervical cancer patients should be addressed in clinical practice, especially for those in developing countries.

Outcome of international Federation of gynecology and obstetrics stage IIb cervical cancer from 2003 to 2012: an evaluation of treatments and prognosis: a retrospective study

OBJECTIVE

To compare the clinical outcomes of patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIB cervical carcinoma receiving neoadjuvant chemotherapy followed by radical hysterectomy (RH) with those of patients receiving chemoradiation therapy (CRT) alone.

METHODS

We retrospectively reviewed the medical records of patients with FIGO stage IIB cervical carcinoma. A total of 621 patients were eligible for the study according to the surgery-based or radiotherapy-based treatment; 285 patients received cisplatin-based neoadjuvant chemotherapy (NACT) followed by RH, and 336 patients underwent sequential or concurrent chemoradiation. The disease-free survival, overall survival, recurrence rates, and late complications were compared. Cox regression analysis was used to identify potential prognostic factors.

RESULTS

Complete or partial response was seen in 77.6% (221/285) of the NACT-treated patients. Disease-free survival and overall survival rates of the patients who had NACT-sensitive responses were significantly higher than those who did not response (P = 0.021 and P = 0.008). Overall survival rates in the NACT + RH group were comparable with the concurrent chemoradiotherapy or chemoradiation groups (P > 0.05). Neoadjuvant chemotherapy followed by RH significantly decreased the recurrence rate (22.6% vs 35.5%), resulted in fewer treatment-related complications, and ultimately improved survival when compared with concurrent CRT. A survival benefit was observed for 63.9% of the patients in the NACT + RH group without adjuvant radiotherapy or CRT.

CONCLUSIONS

Compared with concurrent chemoradiotherapy, NACT followed by RH achieved comparable survival outcomes for patients with FIGO stage IIB cervical cancer. This treatment method was significantly effective at reducing radiotherapy rates and complications, and it is worthy of recommending for younger patients.

Early cervical cancer impact of peritoneal vaginoplasty combined with laparoscopic radical hysterectomy improved sexual function

OBJECTIVE

We investigated the impact of laparoscopic radical hysterectomy (LRH) in combination with peritoneal vaginoplasty (PV) in improving sexual function after radical hysterectomy (RH) in patients with early cervical cancer.

METHODS

A total of 79 patients with early-stage cervical cancer younger than 45 years were assigned to receive LRH in combination with PV (the LRH-PV group; n = 31) or LRH alone (the LRH group; n = 48). Other 40 healthy females were selected as controls (the control group). The sexual function was assessed with Female Sexual Functioning Index (FSFI). The FSFI scores and sexual function in the postoperative 1 year were compared between the LRH-PV and LRH groups, LRH-PV and control groups, and LRH and control groups, respectively.

RESULTS

Patients with LRH-PV showed significantly higher scores in sexual satisfaction, lubrication, pain, and total score than those with LRH alone (P < 0.05) but were not statistically different in scores regarding sexual desire, arousal, and orgasm (P > 0.05). Healthy controls showed the highest in total scores and 6 domains among all subjects. In addition, the FSFI total scores in the LRH-PV group, LRH group, and LRH-PV + LRH group were significantly decreased compared with the control (P < 0.05).

CONCLUSIONS

Peritoneal vaginoplasty to lengthen the vagina improves sexual function of patients with early cervical cancer receiving LRH in sexual satisfaction, lubrication, and pain.

A multicenter study of the importance of systemic chemotherapy for patients with small-cell neuroendocrine carcinoma of the uterine cervix

AIMS

We investigated the prognosis of patients with small-cell neuroendocrine carcinoma of the uterine cervix (SCNEC) in relation to treatment modalities.

METHODS

We retrospectively reviewed the medical records and pathological reports of 102 patients who were histologically diagnosed with SCNEC at 5 different institutes. Time to progression (TTP) and overall survival (OS) were analyzed for each treatment modality.

RESULTS

Of the patients with early-stage [International Federation of Obstetrics and Gynecology (FIGO) stage IB2 or below] SCNEC, 57.8 and 79.3% underwent radical hysterectomy followed by adjuvant therapy. In advanced-stage SCNEC, concurrent chemoradiation therapy was given to 51.4% of the patients. The overall recurrence rate was 51.6%. In early- and advanced-stage SCNEC, the TTP was not different (22.3 vs. 13.3 months, p = 0.104), but the OS was different (40.7 vs. 21.4 months, p = 0.029). Parametrial involvement and lymph vascular space invasion were found to be associated with an unfavorable prognosis. Interestingly, survival was the most unfavorable in patients with early-stage SCNEC who had never received chemotherapy. FIGO stage and use of chemotherapy were identified as independent prognostic factors in SCNEC patients.

CONCLUSIONS

SCNEC requires systemic chemotherapy as part of the initial treatment, along with surgery or radiation, even in patients with early-stage disease.

Neoadjuvant chemotherapy in locally advanced cervical carcinoma: which is better, intravenous or intra-arterial?

Purpose

The aim of our study is to investigate the differences in therapeutic effects and clinical significance between intravenous systematic chemotherapy and intra-arterial interventional chemotherapy in stage Ib2–IIb cervical carcinomas.

Methods

A retrospective analysis was performed on 93 cases of intravenous and 118 cases of intra-arterial neoadjuvant chemotherapy for stage Ib2–IIb cervical carcinomas treated in Peking Union Medical College Hospital from the year 2001 to 2010.

Results

After neoadjuvant chemotherapy, the overall response rate was 84.9% versus (vs) 88.2% and the operability rate was 77.4% vs 81.4%, for intravenous vs intra-arterial (P>0.05). There were no significant differences in toxicities, surgical duration, perioperative blood loss, and operative complications between these two groups. Postoperative pathological examination revealed a significantly lower parametrial infiltration in the intra-arterial group (12.5% vs 38.1%, P<0.05), while the positive vaginal margin, lymph node metastasis, and intravascular tumor embolus showed no significant differences. The intravenous group and the intra-arterial group had similar recurrence rate (16.0% vs 12.3%), distant metastasis rate (9.1% vs 8.5%), and 5 year survival rate (79.5% vs 84.9%), without significant differences.

Conclusion

Neoadjuvant chemotherapy with cisplatin and 5-fluorouracil are safe and effective for patients with locally advanced cervical carcinomas. The intravenous and the intra-arterial approaches present with similar chemotherapy efficacy and clinical outcome. Since it is more simple and economical, the intravenous systematic approach shows greater value in clinical application.

Bowel dysfunction following nerve-sparing radical hysterectomy for cervical cancer: a prospective study

OBJECTIVE

To objectively assess anorectal dysfunction following nerve-sparing radical hysterectomy in stage I-II cervical carcinoma patients.

MATERIAL AND METHODS

Between 2008 and 2012, 21 patients with primary cervical cancer stage FIGO I-II were enrolled in this prospective study. All women underwent nerve-sparing radical hysterectomy. Anorectal manometry was performed preoperatively and 6 months after surgery. A paired Student t test was used to assess the statistical difference between the manometric evaluations. A p value <0.05 was considered statistically significant.

RESULTS

Twenty-one patients were available for follow-up. Maximal and mean anal resting and squeezing pressures were unaffected by the surgical procedure, rectoanal inhibitory reflex and length of the high anal pressure zone did not change after the operation. The minimal volume to elicit rectal sensation, urge to defecate and maximal tolerable volume did not change significantly in the postoperative period, although they decreased in 2 and increased in 3 patients. In addition, rectal compliance did not change after surgery. Furthermore, no significant differences were found between patients who were or were not treated with adjuvant radiotherapy.

CONCLUSIONS

Our findings suggest that nerve-sparing radical hysterectomy for cervical cancer does not seem to be associated with long-term anorectal dysfunction. © 2014 S. Karger AG, Basel.

Neoadjuvant chemotherapy followed by radiotherapy and concurrent hyperthermia in patients with advanced-stage cervical cancer: a retrospective study

OBJECTIVE

To evaluate the efficacy of neoadjuvant chemotherapy, followed by radiotherapy and concurrent hyperthermia (triple therapy) in patients with advanced-stage cervical cancer.

METHODS

We selected 43 patients from our hyperthermia database, who were treated from 1996 to 2010 with triple therapy for large primary tumours (>6 cm) or para-aortic lymph node metastases. All patients received platinum-based chemotherapy followed by full-dose radiotherapy, brachytherapy and five hyperthermia treatments. The response was evaluated by gynaecological examination and a CT-scan. Time-to-event variables were estimated using the Kaplan Meier method and the Cox regression method.

RESULTS

The mean age of the patients was 50.4 years (range 29-80). The median tumour size was 5.6 cm at diagnosis (range 2.6-8.2), positive lymph nodes were present in 90.7%. A total of 67% of the patients completed all six planned courses of chemotherapy. After completion of neoadjuvant chemotherapy, 83.7% of patients achieved a complete or partial response. At the end of treatment, the complete response rate was 81.4% (95%CI 69.2-93.5). Grade 2, 3 and 4 acute vascular toxicity occurred in 17 patients. The incidence of grade 3-4 haematological toxicity did not exceed 10% and no neutropenic fever occurred. For grade 1-2 renal toxicity, a switch to carboplatin was made (n = 6). No acute grade 3-4 renal toxicity was observed. No treatment-related deaths were recorded. The median follow-up time was 29.8 months (range 4.1-124.8). Overall survival rate at 12 months was 79% (95%CI 57.4-92.3).

CONCLUSION

The triple therapy seems feasible and effective in the treatment of advanced-stage, high-risk cervical cancer. However, chemotherapy-induced vascular toxicity occurred frequently, which may warrant the use of prophylactic anticoagulants. We recommend a phase II trial for prospective confirmation for comparison with standard chemoradiation and the use of anticoagulants.

Value of three-dimensional power Doppler to predict clinical and histological response to neoadjuvant chemotherapy in locally advanced cervical carcinoma

OBJECTIVE

Platinum-based neoadjuvant chemotherapy followed by radical hysterectomy is an alternative therapeutic strategy for locally advanced cervical carcinoma but variables used to predict chemotherapy response are not well defined. We investigated the potential of three-dimensional (3D) power Doppler in predicting response to neoadjuvant chemotherapy.

METHODS

We enrolled 61 eligible patients with locally advanced cervical carcinoma who underwent neoadjuvant chemotherapy followed by surgery or radiation. Before the initial chemotherapy, we measured 3D power Doppler vascular indices, including vascularization index (VI), flow index (FI) and vascularization flow index (VFI), of the whole cervical carcinoma. We also measured two-dimensional (2D) hemodynamic parameters, such as resistance index and pulsatility index, at three random spots inside the tumor. The associations of all parameters with clinical and histological responses to chemotherapy were evaluated through univariable and multiple logistic regression analysis.

RESULTS

The clinical and histological response rates to chemotherapy were 70.5% and 70.7%, respectively. Univariable logistic regression analysis showed that VI, FI and VFI were significantly higher in clinical responders than in non-responders (P < 0.05), and that FI was significantly higher in histological responders (P = 0.012). Multiple logistic regression analysis showed that FI was the only significant factor associated with both clinical and histological responses. The best FI cut-off values were 35.3 and 37.3 for clinical response and histological response, respectively (with sensitivity 86.0% and 73.2%, and specificity 72.2% and 64.7%). Interestingly, none of the 2D hemodynamic parameters was significantly correlated with either response.

CONCLUSION

FI is a potential marker for predicting both clinical and histological responses to chemotherapy in patients with locally advanced cervical carcinoma.

A Modified Shortened Administration Schedule for Neoadjuvant Chemotherapy With Irinotecan and Cisplatin in Locally Advanced Cervical Cancer

Introduction:

The commonly used administration schedule of irinotecan in combination therapy with cisplatin in cervical cancer was once weekly for 3 weeks. To some extent, this administration schedule may be inconvenient for patients who were far from hospital. The aim of the current study is to investigate the efficacy and toxicities of a modified shortened administration schedule for neoadjuvant chemotherapy with irinotecan and cisplatin in locally advanced cervical cancer.

Methods:

We retrospectively reviewed the clinical records of patients with cervical cancer who received neoadjuvant chemotherapy with irinotecan and cisplatin delivered by the modified administration schedule at Sun Yat-sen University Cancer Center from November 2005 to May 2010. Irinotecan was administrated by intravenous infusion for 1 hour at a dose of 80 mg/m2on days 1 and 8. Cisplatin was administrated intravenously at a total dose of 60 to 70 mg/m2, which was infused on day 1 or was divided into 2 or 3 doses and given on days 1 to 2 or 3. The treatment was repeated every 3 weeks.

Results:

The total response rate was 78.8% (42/52), including a complete response and partial response rate of 11.5% (6/52) and 67.3% (35/52), respectively. Pathologically confirmed complete response was noted in 7.7% (4/52) of patients. Stable disease was observed in 17.3% (9/52) of patients and progression disease in 3.8% (2/52) of patients. Diarrhea and hematological toxicity were the major dose-limiting toxicities. Diarrhea occurred in 23.1% of patients with grades 1, 2, and 3 in 11.5%, 7.7%, and 3.8% of patients, respectively. No grade 4 diarrhea was noted. Grade 3/4 neutropenia developed in 7.7% (4/52) of patients. Grade 3/4 anemia occurred in 19.2% (10/52) of patients.

Conclusions:

The modified shortened administration schedule of combined therapy with irinotecan and cisplatin may be active against cervical cancer as neoadjuvant chemotherapy. The adverse effects could be controllable.

Locally advanced cervical cancer: what is the standard of care?

PURPOSE OF REVIEW

Carcinoma of the cervix remains a significant health problem for women worldwide. Locally advanced cervical cancer (LACC) is a common presentation that has been extensively studied in the last three decades. This article reviews the standard of care and discusses current topics of clinical research.

RECENT FINDINGS

A multidisciplinary approach to the treatment of cervical cancer has led to marked improvement in outcome. Main advances are with neoadjuvant chemotherapy, chemoradiation, and preventive vaccination. Concurrent chemoradiation with a platinum-based agent is the recommended treatment for LACC. Palliation with platinum agent remains the standard of care for inoperable patients who have metastatic or recurrent disease.

SUMMARY

This is a review of published and ongoing studies testing multidisciplinary and medical management of LACC, with a focus on newer chemotherapeutic approaches. Optimal multidisciplinary treatment planning improves the outcome of each patient diagnosed with cervical cancer.

Treatment of cervical cancer in Italy: strategies and their impact on the women

Treatment of cervical cancer greatly varies according to the stage of the disease. Laparoscopic surgical staging is emerging as a valid approach, compared to clinical and imaging staging, to better identify the treatment plan. Minimally invasive surgery plays the greatest role in the treatment of early cervical carcinoma (ECC). Laparoscopically assisted radical vaginal hysterectomy (LARVH) is an alternative surgical strategy in this subset of patients. Interest has been increasing in using conservative fertility-sparing surgery such as laparoscopic vaginal radical trachelectomy (LVRT) or chemo-conization, options to be preferred in selected patients, with early-stage disease and asking for future fertility. Chemoradiotherapy currently represents the gold standard in the treatment of patient with locally advanced cervical cancer (LACC). In Italy, neoadjuvant chemotherapy (NACT) followed by radical surgery is today emerging as a valid alternative to the standard chemoradiation and the paclitaxel, ifosfamide and cisplatin (TIP) regimen is one of the most active neoadjuvant chemotherapeutic treatments. Moreover, the combination of different strategies to maximize local control should be considered. Among different approaches to this issue the use of a three-modality treatment, including radiotherapy, chemotherapy and surgery has been investigated. Our data on a large single-institutional series of LACC patients treated with chemoradiation followed by radical surgery confirm that this three-modality treatment can achieve overall survival (OS) and Disease Free Survival (DFS) rates at least comparable to chemoradiation alone, with an acceptable rate of complications. Tailoring of radical surgery, on the basis of intraoperative findings, such as lympho-nodes status, might play an important role in diminishing the overall rate of complications and eventually improve quality of life (QoL) of these patients. Cervical cancer generally has an aggressive impact on relatively young women and, as we experienced, the relevance of psychosocial aspects in gynaecologic oncology has become a main issue.