High ALDH-1 Expression Predicts Non-Complete Response of Radiotherapy in Stage III Squamous Cell Cervical Carcinoma Patients

BACKGROUND

ALDH1 is a cervical cancer stem cell marker that has radioresistance profile. Recurrence and metastasis following radiotherapy are still being problems of most patients. This study aimed to determine the correlation between ALDH1 and radiotherapy response in stage III squamous cell cervical carcinoma (SCCC) of the cervix.

METHODS

A total 58 of 360 patients of stage III SCCC who received external beem radiation and brachytherapy (2016-2021) at Cipto Mangunkusumo Hospital met the eligibility criteria of this study. Pre- and post-irradiation MRI examinations and ALDH expression with immunohistochemistry (Santa Cruz®) were performed on formalin-fixed paraffin-embedded of pre-treatment cervical tissue biopsy taken from RSCM pathological anatomy laboratory. Patients were divided into two groups, complete responders vs non-complete responders. ALDH-1 scores were compared between two groups to assess ALDH-1 expression. The statistical analyses were carried out by SPSS 24.

RESULTS

The optimal ALDH-1 score cut-off point on the radiation response was 166.05 pg/mL which was obtained from the analysis of the ROC curve. The AUC value was 0.682 with sensitivity and specificity, 63,6% and 64%, respectively. ALDH score ≥166.05 increased the risk by 3.127 times for not achieving complete response (adj OR 3.127, 95% CI 1.034 - 9.456, p = 0.043). Pre-radiation tumor size (p = 0.593), degree of differentiation (p = 0.161), renal abnormalities (p = 0.114), and keratinization (p = 0.477) were not associated with radiation response.

CONCLUSIONS

High ALDH expression was associated with non-complete radiation response in stage III squamous cell cervical carcinoma. 
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Treatment delay of cancer patients in Indonesia: a reflection from a national referral hospital

BACKGROUND Cancer is a complex disease requiring a multidisciplinary approach in establishing prompt diagnosis and treatment. Treatment in a timely manner is crucial for the outcomes. Hence, this study aimed to provide information on treatment delay including patient and provider delays and its associated factors. METHODS Cancer patients were recruited conveniently in the outpatient clinic of Department of Radiation Oncology, Cipto Mangunkusumo Hospital, Indonesia between May and August 2015. All patients were asked to fill a questionnaire and interviewed in this cross-sectional study. Treatment delay was explored and categorized into patient delay and provider delay. Patient delay could be happened before (patient-delay-1) or after (patient-delay-2) the patient was diagnosed with cancer. Provider delay could be due to physician, system-diagnosis, and system-treatment delays. RESULTS Among 294 patients, 86% patient had treatment delay. Patient delay was observed in 153 patients, and 43% of them had a history of alternative treatment. An older age (p = 0.047), lower educational level (p = 0.047), and history of alternative treatment (p<0.001) were associated with patient delay. Meanwhile, 214 patients had provider delay, and 9%, 36%, and 80% of them experienced physician, system-diagnosis, and system-treatment delays, respectively. All types of provider delay were associated with patient delay (p<0.001). CONCLUSIONS Most of the patient had treatment delay caused by either patient or provider.

Rapid advancement in cancer genomic big data in the pursuit of precision oncology

In the current big data era, massive genomic cancer data are available for open access from anywhere in the world. They are obtained from popular platforms, such as The Cancer Genome Atlas, which provides genetic information from clinical samples, and Cancer Cell Line Encyclopedia, which offers genomic data of cancer cell lines. For convenient analysis, user-friendly tools, such as the Tumor Immune Estimation Resource (TIMER), which can be used to analyze tumor-infiltrating immune cells comprehensively, are also emerging. In clinical practice, clinical sequencing has been recommended for patients with cancer in many countries. Despite its many challenges, it enables the application of precision medicine, especially in medical oncology. In this review, several efforts devoted to accomplishing precision oncology and applying big data for use in Indonesia are discussed. Utilizing open access genomic data in writing research articles is also described.

Survival of nasopharyngeal cancer in national referral hospital of Indonesia: A study on radiotherapy patients

INTRODUCTION

Nasopharyngeal cancer in Indonesia has a poor survival rate and there is only few studies regarding nasopharyngeal cancer in Indonesia. Therefore, this study was made to present Indonesian nasopharyngeal cancer data with special focus on survival of nasopharyngeal cancer profile that receives radiation therapy.

METHODS

This was a retrospective study conducted in the Department of Radiation Oncology, Dr. Cipto Mangunkusumo Hospital (RSCM). Moreover, survival analysis was done using Kaplan Meier, log rank and cox regression test.

RESULTS

A total of 398 patients were included with the median follow-up time of 16 (0-65) months. The 3-year survival in patients with stage I-III was >50% while the survival of 5 years was >50% only in early stage patients. The median survival for men was 46 months and for women 42 months. For OTT ≤ 49 days survival of 3 years and 5 years is 67.1%. Stage III-IVB, size N2-N3, and overall treatment time >49 days were the prognostic factors for nasopharyngeal cancer patients. After multivariate analysis, only stage III-IVB was statistically significant as a prognostic factor independent of survival.

CONCLUSION

Most of nasopharyngeal cancer patient came in advanced stage. The median time needed for patients to get radiation therapy and median OTT were good. Only stage III-IVB was statistically significant as a prognostic factor independent of survival.

The future of radiotherapy and immunotherapy concomitantly in cancer management

Immunotherapy is a developing field in cancer treatment. Immunotherapy using immune checkpoint inhibitors has been successful in treating patients with metastatic disease, as well as patients who are refractory to standard treatments. Although immunotherapy has yielded considerably positive outcomes, its clinical benefits are limited to a small subset of patients. A combination of radiotherapy and immunotherapy has been shown to provide greater clinical benefits to more patients. Radiation, particularly hypofractionated radiation with stereotactic radiosurgery or stereotactic body radiotherapy, works by priming T cells, upregulating proinflammatory chemokines, and increasing the immunogenicity of tumor cells. Tumor cells develop immunosuppressive mechanisms that protect them from attack by the immune system. Immunotherapy works by disrupting the ability of tumor cells to setup these defenses. When combined with radiotherapy, it can synergistically enhance tumor cell death via cytotoxic T cells, thus causing systemic tumor regression and generating better clinical response.

Role of Cancer Stem Cell, Apoptotic Factor, DNA Repair, and Telomerase Toward Radiation Therapy Response in Stage IIIB Cervical Cancer

Objectives

Cancer stem cells are involved in radioresistant cancers. Transcription factors Sry-related HMG box (SOX2) and octamer binding transcription factor 4 (OCT4) can confer pluripotent cell characteristics and self-renewal ability and are involved in carcinogenesis, metastasis, tumor recurrence, and resistance to therapy. Apoptosis, DNA repair, and telomerase factors also contribute to radioresistance. We sought to identify the role of SOX2 and OCT4 as cancer stem cell markers and their effects on apoptosis (via caspase 3), DNA repair (Chk1) and telomerase (hTERT) in conferring resistance to radiotherapy.

Methods

We conducted a case-control study of 40 patients with stage IIIB cervical squamous cell carcinoma who completed radiation therapy at Cipto Mangunkusumo Hospital, Jakarta, Indonesia. The patients were classified according to their treatment response as having exhibited a complete or incomplete response. Clinical follow-up and Pap smears were performed between six and 12 months after therapy for those with a good initial response to determine the final response to therapy. Immunohistochemistry was used to analyze SOX2, OCT4, caspase-3, Chk1, and hTERT expression in paraffin sections of the initial biopsy.

Results

Strong expression of SOX2 (p = 0.011, p = 0.001) and OCT4 (p < 0.001, p < 0.001) was significantly associated with both an incomplete initial and final therapy response, respectively. Multivariate analysis showed that SOX2 and OCT4 expression levels were the strongest markers of an incomplete response to radiotherapy (odds ratio (OR) = 5.12, p = 0.034, and OR = 17.03, p = 0.004, respectively).

Conclusions

Strong expression of SOX2 and OCT4 may be a good indicator of incomplete radiotherapy outcome in patients with stage IIIB cervical cancer.