New advances in radiation oncology for gynecologic cancer

Neoadjuvant Chemotherapy to Radiation and Concurrent Chemoradiation for Locally Advanced Squamous Cell Carcinoma of the Cervix: A Review of the Recent Literature

Radiotherapy is the standard treatment for locally advanced cervical cancer; nevertheless it fails to control disease progression within the irradiation fields in more than 40% of cases, particularly in patients with bulky tumor. Distant metastases are not infrequent in more advanced cases. Chemotherapy has been integrated with radiotherapy to improve local control and treat distant subclinical metastases. Schedules of combined treatment more frequently represented by neoadjuvant chemotherapy followed by radiation (NACT) and by concomitant chemotherapy and radiation (CT-RT). A review of the recent literature is presented. The role of NACT is controversial: high response rates are reported but doubtful advantages in terms of survival or local control have been shown. In randomized trials, hydroxyurea concomitant to radiation improves local control and survival, particularly in stage IIIB and IVA. Several randomized trials of concurrent chemoradiation with 5FU, cisplatin and mitomycin C are underway, but few have been published: no significative differences are reported in term of local control or survival. Acute toxicity is higher than in radiation alone, but usually manageable. For the analysis of late morbidity a longer follow-up is required. Large randomized trials of adequate radiotherapy versus concomitant chemoradiation are necessary to refine our understanding of the benefits of this integrated treatment.

Concurrent Carboplatin/5Fu and Radiotherapy Compared to Radiotherapy Alone in Locally Advanced Cervical Carcinoma: A Case-Control Study

Aims and background

Despite the introduction of innovative techniques in radiotherapy (RT) delivery, no significant improvement in survival has been achieved in the last decades. Concurrent chemoradiation therapy (CRT) is one of the several avenues being explored to improve the results.

Methods and study design

Twenty-eight women with locally advanced squamous cell carcinoma of the uterine cervix were treated with CRT comprising a combination of external and intracavitary RT, along with 3 cycles of 5-fluorouracil (5-FU) and carboplatin. Toxicity, pelvic control rate and disease-free survival achieved in this group of patients were compared in a case-control study with those of a group of 28 patients with similar clinicopathologic characteristics treated with radical RT alone at our institution.

Results

CRT was well tolerated, with 97% of the patients completing the protocol as planned. Acute toxicity, primarily hematologic, was significantly (P=0.05) higher in the cases than in the controls (25% vs 3%). One treatment-related death occurred in a stage III patient in the CRT group. The median follow-up was 55 months (range, 20–156) in the RT group and 20 months (range, 14–46) in the CRT group. Pelvic control rate, disease-free survival and overall survival were not significantly different in the two groups. Estimated 5-year survival rate was 70% and 66% respectively for the RT and CRT group.

Conclusions

Concomitant carboplatin/5-FU and radiotherapy is a safe and tolerable means of treatment for locally advanced cervical cancer. In our study, however, concurrent CRT did not result in a significant improvement in pelvic control rate or survival compared to standard conventional radiotherapy.

Cervical carcinoma metastatic to para-aortic nodes: extended field radiation therapy with concomitant 5-fluorouracil and cisplatin chemotherapy: a Gynecologic Oncology Group study

PURPOSE

A multicenter trial of chemoradiation therapy to evaluate the feasibility of extended field radiation therapy (ERT) with 5-fluorouracil (5-FU) and cisplatin, and to determine the progression-free interval (PFI), overall survival (OS), and recurrence sites in patients with biopsy-confirmed para-aortic node metastases (PAN) from cervical carcinoma.

METHODS AND MATERIALS

Ninety-five patients with cervical carcinoma and PAN metastases were entered and 86 were evaluable: Stage I--14, Stage II--40, Stage III--27, Stage IVA--5. Seventy-nine percent of the patients were followed for 5 or more years or died. ERT doses were 4500 cGy (PAN), 3960 cGy to the pelvis (Stages IB/IIB), and 4860 cGy to the pelvis (Stages IIIB/IVA). Point A intracavitary (IC) doses were 4000 cGy (Stages IB/IIB), and 3000 cGy (Stages IIIB/IVA). Point B doses were raised to 6000 cGy (ERT + IC) with parametrial boost. Concomitant chemotherapy consisted of 5-FU 1000 mg/m2/day for 96 hours and cisplatin 50 mg/m2 in weeks 1 and 5.

RESULTS

Eighty-five of 86 patients completed radiation therapy and 90% of patients completed both courses of chemotherapy. Gynecologic Oncology Group (GOG) grade 3-4 acute toxicity were gastrointestinal (18.6%) and hematologic (15.1%). Late morbidity actuarial risk of 14% at 4 years primarily involved the rectum. Initial sites of recurrence were pelvis alone, 20.9%; distant metastases only, 31.4%; and pelvic plus distant metastases, 10.5%. The 3-year OS and PFI rate were 39% and 34%, respectively, for the entire group. OS was Stage I--50%, Stage II--39%, and Stage III/IVA--38%.

CONCLUSIONS

Extended field radiation therapy with 5-FU and cisplatin chemotherapy was feasible in a multicenter clinical trial. PFI of 33% at 3 years suggests that a proportion of patients achieve control of advanced pelvic disease and that not all patients with PAN metastases have systemic disease. This points to the importance of assessment and treatment of PAN metastases.

Interstitial brachytherapy in the management of primary carcinoma of the cervix and vagina

PURPOSE

The purpose of this study was to determine the role of interstitial brachytherapy in the management of selected primary cancers of the cervix and the vagina.

METHODS

Thirty-nine previously untreated patients with histologically confirmed carcinoma of the cervix (31 patients) and of the vagina (8 patients) were treated by a combination of external beam radiotherapy and fluoroscopic-guided interstitial brachytherapy between November 1989 and May 1995 at the Ohio State University Medical Center because they were not suitable for standard intracavitary brachytherapy. Clinical indications for interstitial brachytherapy were extensive parametrial involvement in 22 patients, extensive vaginal involvement in 10, and poor vaginal anatomy in 7.

RESULTS

With a median follow-up of 36 months (range 12-66 months), 16 patients (51%) with cervical carcinomas and 5 patients (62.5%) with vaginal carcinomas have experienced local control of their tumor. The local control was better for tumors < 4 cm in largest diameter compared to tumors > 6 cm in largest diameter. The 5-year actuarial survival was 34 and 38% for cervical and vaginal cancers, respectively. Only 1 patient experienced grade 3 complications (2.5%).

CONCLUSIONS

Interstitial brachytherapy can be safely used to treat patients unsuitable for standard intracavitary brachytherapy. When intracavitary dose distribution is expected to be suboptimal, interstitial brachytherapy is a good alternative.

Therapeutic advances in radiologic treatment of cancer

In 1993, roughly 1,170,000 new cases of invasive cancer will be diagnosed in the United States. A considerable portion of these patients who die will do so because of uncontrolled local and/or regional disease. Numerous advances in the radiologic treatment of cancer have led to improved local and regional control, as well as survival. These advances include improved radiologic imaging techniques, improved techniques of radiation therapy, innovative brachytherapeutic techniques, intraoperative electron beam therapy techniques, and stereotaxic radiosurgical techniques. In this paper, the authors discuss these techniques with specific attention to how they have lead to improved local and regional control, as well as cancer cure with organ preservation.