Comparison of no adjuvant treatment and radiotherapy in early-stage cervical carcinoma with intermediate risk factors

Efficacy and safety of chemotherapy as monotherapy in patients with recurrent intermediate/high-risk factors following radical hysterectomy for stage IB-IIA cervical cancer: a single-center retrospective analysis

OBJECTIVE

The aim of this study is to explore the efficacy and safety of chemotherapy (CT) as a monotherapy in patients with recurrent intermediate/high-risk factors following radical hysterectomy for stage IB-IIA cervical cancer.

METHODS

A retrospective analysis was conducted on the medical records of patients diagnosed with stage IB-IIA cervical cancer who underwent radical hysterectomy at the People's Hospital of Suzhou High-tech District between 2010 and 2020. A total of 66 patients with intermediate or high-risk factors for recurrence were treated exclusively with CT. This cohort included 42 patients in the intermediate-risk group and 24 in the high-risk group. Treatment protocols consisted of 4-6 cycles of paclitaxel and cisplatin drugs for the intermediate-risk group, and 6 cycles for the high-risk group. The relapse-free survival (RFS), recurrence rates, and common CT-related adverse reactions, including bone marrow suppression, nausea and vomiting, and diarrhea, were assessed for both groups.

RESULTS

(1) The cumulative 3-year RFS rates for the intermediate-risk and high-risk groups were 97.3% (36/37) and 82.4% (14/17), respectively, with cumulative 5-year RFS rates of 97.1% (34/35) and 82.4% (14/17), respectively. The Log rank test revealed no significant difference between the two groups (P > 0.05), (χ² = 2.718, P = 0.099). The 5-year recurrence rates in the intermediate-risk and high-risk groups were 2.38% (1/42) and 12.50% (3/24), respectively. (2) The incidence of grade III bone marrow suppression in the intermediate-risk and high-risk groups was 21.19% (11/42) and 25.00% (6/24), respectively, while the incidence of grade IV bone marrow suppression was 11.90% (5/42) and 8.33% (2/24), respectively. There was no statistically significant difference in bone marrow suppression grades between the two groups (P > 0.05).

CONCLUSION

CT with paclitaxel and cisplatin, administered as monotherapy post-radical hysterectomy for stage IB-IIA cervical cancer, demonstrates satisfactory survival benefits with an acceptable safety profile. Moreover, no significant differences were observed in prognosis or adverse reactions between the different risk groups treated solely with CT.

Prognostic value of lymph node ratio in patients with non-metastatic cervical cancer treated with radical hysterectomy: A population-based study

BACKGROUND

The lymph node ratio (LNR) is an emerging prognostic biomarker in multiple malignancies. This study aimed to explore the prognostic role of LNR in patients with non-metastatic cervical cancer undergoing radical hysterectomy.

METHODS

Data were extracted from the SEER 17 registry. Univariate and multivariate Cox analyses were performed to identify the prognostic factors associated with cancer-specific survival (CSS). A nomogram was constructed to predict the 5-year and 10-year CSS. Survival analyses stratified by the status of LNR and different adjuvant treatments were performed using the Kaplan-Meier method.

RESULTS

A total of 8128 female patients with non-metastatic cervical cancer who underwent radical hysterectomy and regional node examination (≥8) were enrolled. Of these, 1269 (15.6%) were confirmed as lymph node-positive. Cox regression analyses showed that age, race, tumor size, tumor grade, histology, and LNR were significant factors affecting CSS. A nomogram was developed for predicting the 5-year and 10-year CSS, which showed good discrimination and calibration. Patients without lymph node involvement had inferior CSS with adjuvant treatments compared to those who did not receive further treatment. In patients with LNR ≤10%, only those receiving adjuvant radiotherapy had a trend of better CSS. In patients with an LNR between 10% and 30% and more than 30%, concurrent radiochemotherapy (CCRT) proved to be the best treatment.

CONCLUSIONS

LNR is an independent prognostic factor in patients with non-metastatic cervical cancer undergoing radical hysterectomy. For patients with negative lymph nodes, no further treatment is recommended. Patients with positive lymph nodes could benefit more from CCRT.

Role of Adjuvant Radiotherapy in Patients with Cervical Cancer Undergoing Radical Hysterectomy

The benefit of adjuvant radiotherapy (RT) after radical hysterectomy in patients with cervical cancer remains controversial. The aim of this study was to determine adjuvant RT's impact on survival in accordance with Sedlis criteria. Patients with early-stage cervical cancer undergoing radical hysterectomy between 2005 and 2022 at a single tertiary care institution were included. A multivariate analysis was performed to determinate if RT was an independent prognostic factor for recurrence or death. We also analysed whether there was a statistically significant difference in overall survival (OS) between patients who met only one or two Sedlis criteria, depending on whether they received adjuvant RT or not. 121 patients were included in this retrospective study, of whom 48 (39.7%) received adjuvant RT due to the presence of unfavourable pathological findings. In multivariate analysis, RT was not found to be a statistically significant prognostic factor for OS (p = 0.584) or disease-free survival (DFS) (p = 0.559). When comparing patients who met one or two Sedlis criteria, there were no statistically significant differences in OS between RT and no adjuvant treatment in either group. Since the selection of patients with cervical cancer eligible for surgery is becoming more accurate, adjuvant RT might not be necessary for patients with intermediate risk factors.

Impact of different postoperative adjuvant therapies on the survival of early-stage cervical cancer patients with one intermediate-risk factor: A multicenter study of 14 years

OBJECTIVE

To compare survival outcomes of different postoperative adjuvant therapies (PATs) for early-stage cervical cancer (ECC) patients with one intermediate-risk pathological factor (IPF).

METHODS

A total of 2889 patients with stage IA1 to IIA2 cervical cancer were included in this study. Three PAT groups were identified, namely a no adjuvant therapy (NAT) group (n = 773), an adjuvant radiotherapy/chemoradiotherapy (ART) group (n = 1648) and an adjuvant chemotherapy (ACT) group (n = 468). Kaplan-Meier analysis and COX regression analysis were used to compare the overall survival (OS) and disease-free survival (DFS) among the three groups, before and after propensity score matching (PSM).

RESULTS

The recurrence and mortality rate rates in the NAT, ART and ACT groups were 9.2%, 8.6%, and 7.9%, respectively (p = 0.737). Kaplan-Meier analysis demonstrated no significant differences in the NAT, ART, and ACT groups in 5-year OS rates (92.8% vs. 93.6% vs. 94.7%, p = 0.594) and DFS rates (88.7% vs. 89.6% vs. 90.5%, p = 0.772). Post-hoc tests yielded similar results, with no differences in 5-year OS and DFS (NAT vs. ART, before and after matching, p > 0.05); (NAT vs. ACT, before and after matching, p > 0.05); and (ACT vs. ART, before and after matching, p > 0.05).

CONCLUSION

Postoperative adjuvant radiotherapy, chemoradiotherapy, and chemotherapy are not associated with survival outcomes of ECC patients with one IPF. Considering the side effects and impact on patients' quality of life, the PATs should be carefully considered.

Role of adjuvant therapy in intermediate-risk cervical cancer patients - Subanalyses of the SCCAN study

OBJECTIVE

The "intermediate-risk" (IR) group of early-stage cervical cancer patients is characterized by negative pelvic lymph nodes and a combination of tumor-related prognostic risk factors such as tumor size ≥2 cm, lymphovascular space invasion (LVSI), and deep stromal invasion. However, the role of adjuvant treatment in these patients remains controversial. We investigated whether adjuvant (chemo)radiation is associated with a survival benefit after radical surgery in patients with IR cervical cancer.

METHODS

We analyzed data from patients with IR cervical cancer (tumor size 2-4 cm plus LVSI OR tumor size >4 cm; N0; no parametrial invasion; clear surgical margins) who underwent primary curative-intent surgery between 2007 and 2016 and were retrospectively registered in the international multicenter Surveillance in Cervical CANcer (SCCAN) study.

RESULTS

Of 692 analyzed patients, 274 (39.6%) received no adjuvant treatment (AT-) and 418 (60.4%) received radiotherapy or chemoradiotherapy (AT+). The 5-year disease-free survival (83.2% and 80.3%; PDFS = 0.365) and overall survival (88.7% and 89.0%; POS = 0.281) were not significantly different between the AT- and AT+ groups, respectively. Adjuvant (chemo)radiotherapy was not associated with a survival benefit after adjusting for confounding factors by case-control propensity score matching or in subgroup analyses of patients with tumor size ≥4 cm and <4 cm. In univariable analysis, adjuvant (chemo)radiotherapy was not identified as a prognostic factor in any of the subgroups (full cohort: PDFS = 0.365; POS = 0.282).

CONCLUSION

Among patients with IR early-stage cervical cancer, radical surgery alone achieved equal disease-free and overall survival rates to those achieved by combining radical surgery with adjuvant (chemo)radiotherapy.

Adjuvant pelvic radiation versus observation in intermediate-risk early-stage cervical cancer patients following primary radical surgery: a propensity score-adjusted analysis

OBJECTIVE

To compare survival outcomes, posttreatment complications, and quality of life (QoL) of early-stage cervical cancer patients with intermediate-risk factors between those who received adjuvant pelvic radiation and those without adjuvant treatment.

METHODS

Stages IB-IIA cervical cancer patients classified as having intermediate-risk following primary radical surgery were included. After propensity score weighted adjustment, all baseline demographic and pathological characteristics of 108 women who received adjuvant radiation and 111 women who had no adjuvant treatment were compared. The primary outcomes were progression-free survival (PFS) and overall survival (OS). The secondary outcomes included treatment-related complications and QoL.

RESULTS

Median follow-up time was 76.1 months in the adjuvant radiation group and 95.4 months in the observation group. The 5-year PFS (91.6% in the adjuvant radiation group and 88.4% in the observation group, p=0.42) and OS (90.1% in the adjuvant radiation group and 93.5% in the observation group, p=0.36) were not significantly different between the groups. There was no significant association between adjuvant treatment and overall recurrence/death in the Cox proportional hazard model. However, a substantial reduction in pelvic recurrence was observed in participants with adjuvant radiation (hazard ratio=0.15; 95% confidence interval=0.03-0.71). Grade 3/4 treatment-related morbidities and QoL scores were not significantly different between the groups.

CONCLUSION

Adjuvant radiation was associated with a lower risk of pelvic recurrence. However, its significant benefit in reducing overall recurrence and improving survival in early-stage cervical cancer patients with intermediate-risk factors could not be demonstrated.

Adjuvant treatment after radical surgery for cervical cancer with intermediate risk factors: is it time for an update?

Cervical cancer is the fourth most common cancer in women worldwide. The preferred treatment for early stage cervical cancer is radical hysterectomy with pelvic lymph node assessment, and adjuvant therapy is suggested according to histopathological risk factors. A landmark study was published in 1999 that established 'intermediate risk' criteria for relapse, showing a benefit in recurrence free rate in patients that received pelvic radiotherapy. Furthermore, in the presence of parametrial, nodal, or vaginal margin involvement, another key study found that the addition of concurrent cisplatin based chemotherapy to radiation therapy improved progression free and overall survival for 'high risk' early cervical cancer. With the advancement in treatment modalities in surgery and radiotherapy, and the improved identification of prognostic histopathological factors, several authors have reconsidered the role of adjuvant therapy after radical hysterectomy in the presence of intermediate risk criteria. Here we review the literature on the evolution of adjuvant therapy for intermediate risk factors.

CERVANTES: an international randomized trial of radical surgery followed by adjuvant (chemo) radiation versus no further treatment in patients with early-stage, intermediate-risk cervical cancer (CEEGOG-CX-05; ENGOT-CX16)

BACKGROUND

The role of adjuvant treatment in the intermediate-risk group of patients with early-stage cervical cancer is controversial and is supported by a single randomized Gynecologic Oncology Group (GOG) 92 study performed more than 20 years ago. Recent retrospective studies have shown excellent local control in this group of patients after radical surgery with no additional adjuvant treatment.

PRIMARY OBJECTIVE

To evaluate if adjuvant (chemo)radiation is associated with a survival benefit after radical surgery in patients with intermediate-risk cervical cancer.

STUDY HYPOTHESIS

Radical surgery alone is non-inferior to the combined treatment of radical surgery followed by adjuvant (chemo)radiation in disease-free survival in patients with intermediate-risk cervical cancer.

TRIAL DESIGN

This is a phase III, international, multicenter, randomized, non-inferiority trial in which patients with intermediate-risk cervical cancer will be randomized 1:1 into arm A, with no additional treatment after radical surgery, and arm B, receiving adjuvant external beam radiotherapy±brachytherapy ± concomitant chemotherapy. Patient data will be collected over 3 years post-randomization of the last enrolled patient for primary endpoint analysis or for 6 years for the overall survival analysis.

MAJOR INCLUSION/EXCLUSION CRITERIA

Patients with intermediate-risk early-stage cervical cancer (IB1-IIA), defined as lymph node-negative patients with a combination of negative prognostic factors (tumor size >4 cm; tumor size >2 cm and lymphovascular space invasion; deep stromal invasion >2/3; or tumor-free distance <3 mm) with squamous cell carcinoma or human papillomavirus (HPV)-related adenocarcinoma, are eligible for the trial.

PRIMARY ENDPOINT

Disease-free survival defined as time from randomization to recurrence diagnosis.

SAMPLE SIZE

514 patients from up to 90 sites will be randomized.

ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS

It is estimated that the accrual will be completed by 2027 (with 3 additional years of follow-up) and primary endpoint results will be published by 2031. Estimated trial completion is by 2034.

TRIAL REGISTRATION

NCT04989647.

Clinical Implication of Simultaneous Intensity-modulated Radiotherapy Boost to Tumor Bed for Cervical Cancer with Full-thickness Stromal Invasion

OBJECTIVE

The objective of this study was to retrospectively explore the clinical implications of simultaneous intensity-modulated radiotherapy (IMRT) boost to the tumor bed in cervical cancer with full-thickness stromal invasion (FTSI).

PATIENTS AND METHODS

Patients diagnosed with the International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB and IIA cervical cancer with confirmed FTSI were included. Patients received pelvic IMRT from a dose of 50.4 Gy in 28 fractions with (or without) a simultaneous integrated boost (SIB) to 58.8 Gy in 28 fractions for the tumor bed. The progression-free survival (PFS), overall survival (OS), and pelvic-PFS (p-PFS) were analyzed using the Kaplan-Meier method, and independent prognostic factors were explored by Cox regression analyses.

RESULTS

Patients without a tumor bed boost had a poor prognosis. The 5-year OS was 81.3% versus 58.3% and the 5-year PFS rates were 75.0% versus 57.6% (boost vs non-boost). The FIGO stage, pathology, adjuvant chemotherapy, and tumor bed boost were independent factors affecting both the 5-year OS and PFS. Subgroup analysis showed that the SIB group had a higher 5-year OS, PFS, and p-PFS for different stages, lymph node status, and risk groups than the non-SIB group. Recurrence occurred in 268 of 910 (29.5%) patients without SIB and 49 of 293 (16.7%) with SIB. Among patients with recurrence, 113 of 282 (40.1%) in the non-boost group compared with 14 of 51 (23.0%) patients in the boost group had a pelvic recurrence. Tumor bed boost resulted in an increase in the mean radiation dose to the intestine, rectum, and bladder, although there were no differences in the rates of acute and late toxicities between the 2 groups.

CONCLUSION

Tumor bed boost by external beam radiotherapy (EBRT) is an effective and safe method for patients with FTSI and risk factors. Compared with the standard prophylactic radiation, tumor bed boost by EBRT was not associated with increased acute and late toxicities.

Significance of the Number of Intermediate-Risk Factors in Cervical Cancer Patients Treated with Radical Hysterectomy: A Retrospective Study of 976 Patients

BACKGROUND AND OBJECTIVES

This study aimed to investigate the impact of intermediate-risk factors (IRFs) on the prognosis of stage I-II cervical cancer (CC) patients, and evaluate the necessity of adjuvant treatment based on investigation.

METHODS

Medical records of 976 negative high-risk factors' CC patients were retrospectively reviewed. Clinicopathologic characteristics and adjuctive therapy were analyzed using Kaplan-Meier analysis and log-rank tests to identify significant factors. The multivariate Cox proportional hazards regression analysis was performed to identify the independent prognostic factors.

RESULTS

For patients with none, single and multiple IRFs, the 3-year recurrence-free survival rates were 97.8%, 86.3%, and 68.0% respectively (p < 0.001), and 3-year overall survival rates were 99.3%, 93.6% and 79.0% respectively (p < 0.001). Multivariate analysis showed histological type, differentiation grade, the number of IRFs and adjuvant therapy were independent prognostic factors.

CONCLUSIONS

The number of IRFs was demonstrated with higher predictive efficacy on survival of CC than individual IRF. Patients with multiple IRFs had significantly worse survival outcomes than patients with none or one. Different adjuvant treatment plans should be formulated based on the number of present IRFs. The prognostic management of patients with multiple IRFs should be pay more attention.

Adenosquamous Carcinoma of the Cervix: A Population-Based Analysis

Background

Due to the rarity of adenosquamous carcinoma of the cervix (ASCC), studies on the incidence, prognostic factors, and treatment outcomes of ASCC remain scarce. Therefore, we performed a retrospective population-based study to systematically investigate the characteristics of ASCC patients.

Methods

Patients with a histopathologically confirmed diagnosis of ASCC were enrolled from the Surveillance, Epidemiology, and End Results database between 1975 and 2016. Univariate and multivariate Cox regression analyses were performed to identify the potential predictors of cancer-specific survival (CSS) in patients with ASCC. Selected variables were integrated to establish a predictive nomogram and the predictive performance of the nomogram was estimated using Harrell’s concordance index (C-index), calibration curve, and decision curve analysis (DCA).

Results

A total of 1142 ASCC patients were identified and included in this study and were further randomized into the training and validation cohorts in a 7:3 ratio. The age-adjusted incidence of ASCC declined from 0.19 to 0.09 cases per 100,000 person-years between 2000 and 2017, with an annual percentage change of -4.05% (P<0.05). We identified age, tumor grade, FIGO stage, tumor size, and surgical procedure as independent predictors for CSS in ASCC patients and constructed a nomogram to predict the 3- and 5-year CSS using these prognostic factors. The calibration curve indicated an outstanding consistency between the nomogram prediction and actual observation in both the training and testing cohorts. The C-index was 0.7916 (95% CI: 0.7990-0.8042) and 0.8148 (95% CI: 0.7954-0.8342) for the training and testing cohorts, respectively, indicating an excellent discrimination ability of the nomogram. The DCA showed that the nomogram exhibited more clinical benefits than the FIGO staging system.

Conclusions

We established and validated an accurate predictive nomogram for ASCC patients based on several clinical characteristics. This model might serve as a useful tool for clinicians to estimate the prognosis of ASCC patients.