Vascular endothelial growth factor (VEGF) targeting therapy for persistent, recurrent, or metastatic cervical cancer

BACKGROUND

Cervical cancer ranks as the fourth leading cause of death from cancer in women. Historically, women with metastatic or recurrent cervical cancer have had limited treatment options. New anti-angiogenesis therapies, such as vascular endothelial growth factor (VEGF) targeting agents, offer an alternative strategy to conventional chemotherapy; they act by inhibiting the growth of new blood vessels, thereby restricting tumour growth by blocking the blood supply.

OBJECTIVES

To assess the benefits and harms of VEGF targeting agents in the management of persistent, recurrent, or metastatic cervical cancer.

SEARCH METHODS

We performed searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, online registers of clinical trials, and abstracts of scientific meetings up until 27 May 2020.

SELECTION CRITERIA

We examined randomised controlled trials (RCTs) that evaluated the use of VEGF targeting agents alone or in combination with conventional chemotherapy or other VEGF targeting agents.

DATA COLLECTION AND ANALYSIS

Three review authors independently screened the results of search strategies, extracted data, assessed risk of bias, and analysed data according to the standard methods expected by Cochrane. The certainty of evidence was assessed via the GRADE approach.

MAIN RESULTS

A total of 1634 records were identified. From these, we identified four studies with a total of 808 participants for inclusion. We also identified two studies that were awaiting classification and nine ongoing studies. Bevacizumab plus chemotherapy versus chemotherapy Treatment with bevacizumab plus chemotherapy may result in lower risk of death compared to chemotherapy alone (hazard ratio (HR) 0.77, 95% confidence interval (CI) 0.62 to 0.95; 1 study, 452 participants; low-certainty evidence). However, there are probably more specific adverse events when compared to chemotherapy alone, including gastrointestinal perforations or fistulae (risk ratio (RR) 18.00, 95% CI 2.42 to 133.67; 1 study, 440 participants; moderate-certainty evidence); serious thromboembolic events (RR 4.5, 95% CI 1.55 to 13.08; 1 study, 440 participants; moderate-certainty evidence); and hypertension (RR 13.75, 95% CI 5.07 to 37.29; 1 study, 440 participants; moderate-certainty evidence). There may also be a higher incidence of serious haemorrhage (RR 5.00, 95% CI 1.11 to 22.56; 1 study, 440 participants; low-certainty evidence). In addition, the incidence of serious adverse events is probably higher (RR 1.44, 95% CI 1.16 to 1.79; 1 study, 439 participants; moderate-certainty evidence). The incremental cost-effectiveness ratio was USD 295,164 per quality-adjusted life-year (1 study, 452 participants; low-certainty evidence). Cediranib plus chemotherapy versus chemotherapy Treatment with cediranib plus chemotherapy may or may not result in similar risk of death when compared to chemotherapy alone (HR 0.94, 95% CI 0.53 to 1.65; 1 study, 69 participants; low-certainty evidence). We found very uncertain results for the incidences of specific adverse events, including gastrointestinal perforations or fistulae (RR 3.27, 95% CI 0.14 to 77.57; 1 study, 67 participants; very low-certainty evidence); serious haemorrhage (RR 5.45, 95% CI 0.27 to 109.49; 1 study, 67 participants; very low-certainty evidence); serious thromboembolic events (RR 3.41, 95% CI 0.14 to 80.59; 1 study, 60 participants; very low-certainty evidence); and serious hypertension (RR 0.36, 95% CI 0.02 to 8.62; 1 study, 67 participants; very low-certainty evidence). In addition, there may or may not be a similar incidence of serious adverse events compared to chemotherapy alone (RR 1.15, 95% CI 0.75 to 1.78; 1 study, 67 participants; low-certainty evidence). Apatinib plus chemotherapy or chemotherapy/brachytherapy versus chemotherapy or chemotherapy/brachytherapy Treatment with apatinib plus chemotherapy or chemotherapy/brachytherapy may or may not result in similar risk of death compared to chemotherapy alone or chemotherapy/brachytherapy alone (HR 0.90, 95% CI 0.51 to 1.60; 1 study, 52 participants; low-certainty evidence). However, hypertension events may occur at a higher incidence as compared to chemotherapy alone or chemotherapy/brachytherapy alone (RR 5.14, 95% CI 1.28 to 20.73; 1 study, 52 participants; low-certainty evidence). Pazopanib plus lapatinib versus lapatinib Treatment with pazopanib plus lapatinib may result in higher risk of death compared to lapatinib alone (HR 2.71, 95% CI 1.16 to 6.31; 1 study, 117 participants; low-certainty evidence). We found very uncertain results for the incidences of specific adverse events, including gastrointestinal perforations or fistulae (RR 2.00, 95% CI 0.19 to 21.59; 1 study, 152 participants; very low-certainty evidence); haemorrhage (RR 2.00, 95% CI 0.72 to 5.58; 1 study, 152 participants; very low-certainty evidence); and thromboembolic events (RR 3.00, 95% CI 0.12 to 72.50; 1 study, 152 participants; very low-certainty evidence). In addition, the incidence of hypertension events is probably higher (RR 12.00, 95% CI 2.94 to 49.01; 1 study, 152 participants; moderate-certainty evidence). There may or may not be a similar incidence of serious adverse events as compared to lapatinib alone (RR 1.45, 95% CI 0.94 to 2.26; 1 study, 152 participants; low-certainty evidence). Pazopanib versus lapatinib Treatment with pazopanib may or may not result in similar risk of death as compared to lapatinib (HR 0.96, 95% CI 0.67 to 1.38; 1 study, 152 participants; low-certainty evidence). We found very uncertain results for the incidences of specific adverse events, including gastrointestinal perforations or fistulae (RR 1.03, 95% CI 0.07 to 16.12; 1 study, 150 participants; very low-certainty evidence); haemorrhage (RR 1.03, 95% CI 0.31 to 3.40; 1 study, 150 participants; very low-certainty evidence); and thromboembolic events (RR 3.08, 95% CI 0.13 to 74.42; 1 study, 150 participants; very low-certainty evidence). In addition, the incidence of hypertension events is probably higher (RR 11.81, 95% CI 2.89 to 48.33; 1 study, 150 participants; moderate-certainty evidence). The risk of serious adverse events may or may not be similar as compared to lapatinib (RR 1.31, 95% CI 0.83 to 2.07; 1 study, 150 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

We found low-certainty evidence in favour of the use of bevacizumab plus chemotherapy. However, bevacizumab probably increases specific adverse events (gastrointestinal perforations or fistulae, thromboembolic events, hypertension) and serious adverse events. We found low-certainty evidence that does not support the use of cediranib plus chemotherapy, apatinib plus chemotherapy, apatinib plus chemotherapy/brachytherapy, or pazopanib monotherapy. We found low-certainty evidence suggesting that pazopanib plus lapatinib worsens outcomes. The VEGF inhibitors apatinib and pazopanib may increase the probability of hypertension events.

[Spontaneous enterocutaneous and rectovaginal fistula: potential complications during therapy with anti-angiogenic drugs in renal cancer]

We present two cases of enterovaginal and enterocutaneous fistulae associated to treatment with pazopanib, which is an angiogenesis inhibitor for the treatment of metastatic renal cancer. The times from drug administration and the first appearance of a fistula were 6 and 16 months, respectively. None of the cases had a history of surgery or radiotherapy in the area where the complication was observed. Enterovaginal and enterocutaneous fistula represent less than 1% of all published complications caused by the use of antiangiogenic drugs. However, they must be taken into account as the reported mortality rate is close to 30%. Given its low incidence, we believe that sharing this data is a great way to help specialists who have to treat these patients to take the necessary precautions and decide on an adequate approach.

Bowel perforation after erlotinib treatment in a patient with non-small cell lung cancer

Erlotinib is accepted as a standard second-line chemotherapeutic agent in patients with non-small cell lung cancer who are refractory or resistant to first-line platinum- based chemotherapy. There has been no previous report of bowel perforation with or without gastrointestinal metastases related to erlotinib in patients with non-small cell lung cancer. The exact mechanism of bowel perforation in patients who received erlotinib remains unclear. In this report, we report the first case of enterocutaneous fistula in a female patient with metastatic non-small cell lung cancer 9 months, following medication with erlotinib as second-line chemotherapy.

Vesicoenteric, vesicovaginal, vesicocutaneous fistula -an unusual complication with intravesical mitomycin

Intravesical instillation of mitomycin C is a routine practice for treatment of superficial transitional cell carcinoma of bladder. Despite usual precautions serious side effects like fistulation can occur with diverse presentation as illustrated by this report. The pathology demonstrates a dense necrotic and massive inflammatory reaction in the peri vesical tissue following the extravasation of an intravesically administered chemotherapeutic agent. The severe inflammatory tissue response and the necrotic effect associated with the extravasated chemotherapeutic agent could potentially lead to local sepsis with a subsequent fistula formation.

Gastrocolic fistula secondary to nonsteroidal anti-inflammatory drugs abuse in a cirrhotic patient

Gastrocolic fistula is rarely described in the literature. It has been associated with a variety of diseases and recently with benign gastric ulcers related to the use of nonsteroidal anti-inflammatory drugs (NSAIDs'). The present case represents the first report of gastrocolic fistula due to NSAIDs in a cirrhotic patient. This is in keeping with the established knowledge that cirrhotic patients constitute a high-risk group of patients when treated with NSAIDs'. Review of the literature shows that this condition warrants a complete diagnostic work-up to exclude more ominous underlined diseases.

Colovesical fistula an unusual complication of cytotoxic therapy in a case of non-Hodgkin's lymphoma

A 65-year old man, a known case of non-Hodgkin's lymphoma of base of the tongue and epiglottis presented with complaints of pneumaturia and faecaluria. He had received the first cycle of cytotoxic therapy (CHOP-regimen). At the end of the cycle he developed febrile neutropenia (circulating granulocyte count <1500/mm3). Cystogram showed air in the bladder area and a fistulous communication to a cavity behind the bladder. CT-scan showed air in the bladder, a fistulous communication between the sigmoid colon and bladder along with an intervening small abscess cavity. On exploration a fistulous communication between the sigmoid and bladder along with an intervening small abscess cavity was found. Resection of involved portion of sigmoid and end to end anastomosis along with a diverting colostomy was done. The bladder was closed in two layers with an omental interposition between it and the sigmoid along with a suprapubic cystostomy. The histopathology demonstrated only inflammatory response without any evidence of malignancy or diverticular disease.

The split notochord syndrome with dorsal enteric fistula, meningomyelocele and imperforate anus

A male infant was referred to our department because of lumbosacral meningomyelocele, dorsal enteric fistula and imperforate anus. The mother had received a parenteral drug containing estradiol benzoate and progesterone for inducing abortion in the first trimester. She also used an anal pomade containing triamcinolone and lidocaine-HCl during the pregnancy for hemorrhoids. Sigmoid end colostomy was performed after meningomyelocele repair. On abdominal exploration a wandering spleen was detected but no other anomalies. Two months later, an abdominoperineal pullthrough was performed, and the patient was discharged well after three weeks. Our case is the sixth that had split notochord syndrome associated with dorsal enteric fistula and imperforate anus. Additionally, penoscrotal transposition and wandering spleen were present in this case. To our knowledge, these associated anomalies have been extremely rare.

[Complications of colonic diverticular disease during rheumatoid polyarthritis: 7 cases]

INTRODUCTION

Among the gastrointestinal adverse effects of nonsteroidal anti-inflammatory drugs (NSAID) and corticoids are mentioned complications of colonic diverticular disease. However, very few studies have described their consequences in rheumatoid arthritis.

EXEGESIS

We report on seven patients who were admitted in our department between 1984 and 1997. All patients received corticoids and another antirheumatic drug (gold salts, hydroxychloroquine, immunosuppressive drugs); treatment also included NSAID in four cases. Two patients had a necrotizing vasculitis accompanying rheumatoid arthritis. Intestinal accompanying diseases were the following: one diverticulitis, three colonic perforations with pelviperitonitis, one colovesical fistula, one pelvic abscess, and one diverticular hemorrhage. All patients underwent surgery with positive results.

CONCLUSION

Combination of the four following symptoms: fever, abdominal pain, diarrhea, and hemorrhage, can uncover a complication of colónic diverticular disease occurring in the course of rheumatoid arthritis. It should be investigated, even if no history of diverculosis may be evidenced.

Colosplenic fistula in a patient treated with interleukin-2 for malignant melanoma

Interleukin-2 (IL-2) therapy often causes gastrointestinal side effects and at least 8 cases of bowel perforation have been reported. The patient reported here developed a colosplenic fistula, diagnosed by CT, with no neoplastic involvement of these organs. Awareness of these complications of IL-2 can help lead to earlier diagnosis.

Gastrocolic fistula-secondary to aspirin abuse

Gastrocolic fistula is a rare complication of benign gastric ulcer disease. It has been associated more commonly, in the past, with marginal ulceration following gastrojejunostomy for peptic ulcer disease. We will describe a classic case of gastrocolic fistula as a complication of acetylsalicylic acid abuse in a middle aged female with a remote history of aspirin induced ulcer. Her presentation was classic and required a surgical approach with excellent recovery. We will describe the clinical, radiographic, endoscopic and surgical aspects of this interesting and unusual disorder.

Gastrocolic fistulas: the increasing role of aspirin

Eight patients had gastrocolic fistulas depicted on barium studies at the authors' hospital during a 10-year period between 1982 and 1992. Seven of those patients (88%) had benign disease, including aspirin-induced gastric ulcers of the greater curvature (n = 4), granulomatous colitis (n = 1), tuberculosis (n = 1), and a penetrating anastomotic ulcer after partial gastrectomy (n = 1). The remaining patient had a malignant gastrocolic fistula caused by carcinoma of the transverse colon. Two patients (25%) experienced classic symptoms of gastrocolic fistulas (ie, feculent vomiting or foul-smelling eructations), but the other six (75%) experienced abdominal pain or other nonspecific clinical findings. In the four patients who were taking aspirin, upper gastrointestinal examinations revealed giant penetrating ulcers of the greater curvature that communicated with the superior border of the transverse colon via a fistula. Three of these patients exhibited marked clinical improvement after conservative medical treatment and did not need surgery. This experience suggests that aspirin-induced gastric ulcers of the greater curvature have become a more common cause of gastrocolic fistulas than is carcinoma of the stomach or transverse colon.

Non-steroidal anti-inflammatory drugs and complicated diverticular disease: a case-control study

Fifty patients with severe complications of diverticular disease were compared with two groups of 50 controls, matched for age and sex. The first control group (A) was randomly selected from all emergency hospital admissions, and the second group (B) from patients with uncomplicated diverticular disease. Of the 50 study patients, 24 (48 per cent) were taking non-steroidal anti-inflammatory drugs (NSAIDs) at the time of admission compared with nine (18 per cent) of control group A and ten (20 per cent) of control group B. Both of these differences were statistically significant, indicating a strong association between the ingestion of NSAIDs and the development of severe complications of diverticular disease.

Iatrogenic gastrocolic fistula associated with non-steroidal anti-inflammatory drug administration

An unusual case is presented of a benign gastrocolic fistula occurring in a 70-year-old man treated with piroxicam for arthritis for a period of only two months. This report illustrates that significant upper gastrointestinal complications can occur, even with short-term treatment, with non-steroidal anti-inflammatory drugs (NSAIDs).

Gastro-colic fistula complicating benign gastric ulcer in analgesic abusers

Two cases of gastro-colic fistula occurring in analgesic abusers are described. In both patients, the fistulous communication was diagnosed at endoscopy and subsequently verified by upper gastrointestinal tract barium studies. Gastro-colic fistula is a rare complication of benign peptic ulcer disease. Whilst salcylates and cortico-steroids have been implicated as aetiological agents, abuse of compound analgesics has not previously been reported. Since the first description of gastro-colic fistula in 1755, thirty documented cases associated with benign gastric ulcer have been reported. Most often, gastro-colic fistula occurs secondary to gastric or colonic malignancy. Barium enema examination is the most accurate diagnostic study. Endoscopy has been confined to the visual inspection of the ulcer and establishing the benign nature of these lesions.

[Gastroduodenal complications after the ingestion of hydrochloric acid. One case (author's transl)]

The ingestion of a caustic acid resulted in retractile fibrosis of 2/3 of the stomach with a secondary duodenal fistula. The antro-pyloro-duodenal circuit was re-established at around the 3rd after ingestion. However, the duodenal fistula caused the formation of encysted pelvic abscesses which were difficult to drain and satisfactorily treat. The clinical course stretched over a period of 4 years.