The Effect of Neoadjuvant Chemotherapy on Lymph Node Metastasis of FIGO Stage IB1-IIB Cervical Cancer: A Systematic Review and Meta-Analysis

The prognostic value of radiological and pathological lymph node status in patients with cervical cancer who underwent neoadjuvant chemotherapy and followed hysterectomy

To investigate the prognostic value of lymph node status in patients with cervical cancer (CC) patients who underwent neoadjuvant chemotherapy (NACT) and followed hysterectomy. Patients in two referral centers were retrospectively analyzed. The baseline tumor size and radiological lymph node status (LNr) were evaluated on pre-NACT MRI. Tumor histology, differentiation and pathological lymph node status (LNp) were obtained from post-operative specimen. The log-rank test was used to compare survival between patient groups. Cox proportional hazards regression models were employed to estimate the hazard ratio (HR) of various factors with progression-free survival (PFS) and overall survival (OS). A total of 266 patients were included. Patients with 2018 FIGO IIIC showed worse PFS compared to those with FIGO IB-IIB (p < 0.001). The response rate in patients with LNp(-) was 64.1% (134/209), significantly higher than that of 45.6% (26/57) in patients with LNp( +) (p = 0.011). Multivariate Cox analysis identified the main independent predictors of PFS as LNp( +) (HR = 3.777; 95% CI 1.715-8.319), non-SCC (HR = 2.956; 95% CI 1.297-6.736), poor differentiation (HR = 2.370; 95% CI 1.130-4.970) and adjuvant radiation (HR = 3.266; 95% CI 1.183-9.019). The interaction between LNr and LNp regarding PFS were significant both for univariate and multivariate (P = 0.000171 and 1.5357e-7 respectively). In patients with LNr( +), a significant difference in PFS was observed between patients with LNp(-) and LNp( +) (p = 0.0027). CC patients with FIGO 2018 stage IIIC who underwent NACT and followed hysterectomy had worse PFS compared to those with IB-IIB. LNp( +), non-SCC, poor differentiation and adjuvant radiation were independent risk factors for PFS. The adverse prognostic value of LNp( +) was more significant in patients with LNr( +).

A nomogram-based optimized Radscore for preoperative prediction of lymph node metastasis in patients with cervical cancer after neoadjuvant chemotherapy

Purpose

To construct a superior single-sequence radiomics signature to assess lymphatic metastasis in patients with cervical cancer after neoadjuvant chemotherapy (NACT).

Methods

The first half of the study was retrospectively conducted in our hospital between October 2012 and December 2021. Based on the history of NACT before surgery, all pathologies were divided into the NACT and surgery groups. The incidence rate of lymphatic metastasis in the two groups was determined based on the results of pathological examination following lymphadenectomy. Patients from the primary and secondary centers who received NACT were enrolled for radiomics analysis in the second half of the study. The patient cohorts from the primary center were randomly divided into training and test cohorts at a ratio of 7:3. All patients underwent magnetic resonance imaging after NACT. Segmentation was performed on T1-weighted imaging (T1WI), T2-weighted imaging, contrast-enhanced T1WI (CET1WI), and diffusion-weighted imaging.

Results

The rate of lymphatic metastasis in the NACT group (33.2%) was significantly lower than that in the surgery group (58.7%, P=0.007). The area under the receiver operating characteristic curve values of Radscore_CET1WI for predicting lymph node metastasis and non-lymphatic metastasis were 0.800 and 0.797 in the training and test cohorts, respectively, exhibiting superior diagnostic performance. After combining the clinical variables, the tumor diameter on magnetic resonance imaging was incorporated into the Rad_clin model constructed using Radscore_CET1WI. The Hosmer-Lemeshow test of the Rad_clin model revealed no significant differences in the goodness of fit in the training (P=0.594) or test cohort (P=0.748).

Conclusions

The Radscore provided by CET1WI may achieve a higher diagnostic performance in predicting lymph node metastasis. Superior performance was observed with the Rad_clin model.

Neoadjuvant chemotherapy followed by radical trachelectomy versus upfront abdominal radical trachelectomy for patients with FIGO 2018 stage IB2 cervical cancer

OBJECTIVE

To explore the optimal fertility-sparing treatment for stage IB2 cervical cancer. We compared the outcomes of neoadjuvant chemotherapy (NACT) followed by radical trachelectomy (RT) with those of upfront abdominal RT (ART).

METHODS

This is a retrospective study with prospectively collected data between August 2015 and July 2019. Patients with IB2 cervical cancer who desired fertility preservation underwent NACT followed by RT, or upfront ART, per their choice.

RESULTS

This study included 51 patients, of which, 16 patients underwent NACT followed by RT and 35 patients chose upfront ART. Fertility was preserved in 12 (75.0%) and 27 (77.1%) patients from the NACT and upfront ART groups, respectively. Incidence rates of intraoperative (0% versus 3.7%) and postoperative complications (25.0% versus 48.1%) of the NACT group were lower compared to the upfront ART group (P=NS). Eleven (91.7%) patients in NACT group and 17 (63.0%) patients in upfront ART groups received adjuvant chemotherapy after surgery. The median follow-up, and 5-year recurrence-free survival rates of the NACT-RT and upfront ART groups were 56 and 61 months, and 83.3% and 96.3%, respectively (P=NS). The recurrence rate was higher in patients with tumor reduction <50% after NACT than that in patients with tumor reduction >50% (66.7% versus 0%, P < 0.05). Tumor reduction <50% was the only independent predictor of recurrence in patients who underwent NACT before RT.

CONCLUSIONS

NACT followed by RT could be a feasible fertility-sparing option for selected patients with 1B2 cervical cancer. The NACT group had a relatively higher recurrence rate and fewer complications compared to the upfront ART group, albeit without statistical significance. Patients with tumor regression >50% after NACT could be ideal candidates for RT after NACT.

Pretreatment Radiologically Enlarged Lymph Nodes as a Significant Prognostic Factor in Clinical Stage IIB Cervical Cancer: Evidence from a Taiwanese Tertiary Care Center in Reaching Consensus

The incidence of lymph node (LN) involvement and its prognostic value based on radiological imaging in stage IIB cervical cancer (CC) remains unclear, and evidence regarding oncological outcomes of patients with stage IIB CC with LN metastases is limited. In this study we retrospectively reviewed the incidence and prognostic significance of pretreatment radiologic LN status in 72 patients with clinical stage IIB CC (FIGO 2009), with or without radiologic evidence of LN enlargement. An enlarged LN was defined as a diameter > 10 mm on CT/MRI. Progression-free survival (PFS) and overall survival (OS) were assessed. Radiologic LN enlargement of >10 mm was observed in 45.8% of patients with stage IIB CC. PFS (p = 0.0088) and OS rates (p = 0.0032) were significantly poorer in the LN group (n = 33) than in the non-LN group (n = 39). Univariate Cox analysis revealed that LN > 10 mm contributed to a higher rate of recurrence and mortality. In conclusion, nearly half of the patients with clinical stage IIB CC had enlarged LNs (>10 mm) identified during pretreatment radiologic evaluation, which negatively impacted prognosis. Our findings highlight the need to incorporate CT- or MRI-based LN assessment before treatment for stage IIB CC.

Treatment Strategies and Prognostic Factors of 2018 FIGO Stage IIIC Cervical Cancer: A Review

Cervical cancer is the fourth most common malignant tumor globally in terms of morbidity and mortality. The presence of lymph node metastasis (LNM) is an independent prognostic factor for progression-free survival (PFS) and overall survival (OS) in cervical cancer patients. The International Federation of Gynecology and Obstetrics (FIGO) staging system was revised in 2018. An important revision designates patients with regional LNM as stage IIIC, pelvic LNM only as stage IIIC1, and para-aortic LNM as stage IIIC2. However, the current staging system is only based on the anatomical location of metastatic lymph nodes (LNs). It does not consider other LN status parameters, which may limit its prognostic significance to a certain extent and needs further exploration and confirmation in the future. The purpose of this review is to summarize the choice of treatment for stage IIIC cervical cancer and the effect of different LN status parameters on prognosis.

T-box 2 expression is a useful indicator of the response to neoadjuvant chemotherapy for patients with locally advanced uterine cervical squamous cell carcinoma

Platinum-based concurrent chemoradiotherapy is the standard treatment for patients with locally advanced uterine cervical squamous cell carcinoma. Reducing the tumor size by administering neoadjuvant chemotherapy (NAC) is beneficial for successful hysterectomy, resulting in a more favorable prognosis. Therefore, identifying biomarkers that predict the effectiveness of NAC in patients with cervical squamous cell carcinoma remains a priority. Cancer cells widely express T-box 2 (TBX2), which contributes to the resistance to DNA-damaging chemotherapeutic agents. The present study aimed to determine the association between TBX2 protein expression in tumor tissues and the efficacy of NAC in locally advanced uterine cervical squamous cell carcinoma using immunohistochemistry. Data from 46 patients with locally advanced uterine cervical squamous cell carcinoma were classified into two groups based on their effective or ineffective response to NAC treatment. In addition, the effect of small interfering RNA-mediated knockdown of TBX2 on the sensitivity of cervical cancer cells to cisplatin was investigated in vitro. The results revealed that there were no significant differences in patient clinicopathological features between the NAC effective and NAC ineffective groups. The overall survival of the NAC effective group was significantly improved compared with the NAC ineffective group (P=0.007). Tumors from the NAC effective group also had significantly downregulated TBX2 expression levels compared with those from the NAC ineffective group (P=0.0138). Of note, decreased TBX2 expression was indicated to be significantly associated with higher sensitivity to NAC (P=0.009). The low TBX2 expression group had a more favorable overall survival compared with the high TBX2 expression group (P=0.049). Furthermore, knockdown of TBX2 expression significantly increased cancer cell sensitivity to cisplatin in vitro. In conclusion, the results of the present study suggested that TBX2 expression may be a useful predictor of the response to NAC in patients with locally advanced uterine cervical squamous cell carcinoma.