Preoperative adjuvant chemotherapy in the treatment of cervical cancer stage Ib, IIa, and IIb with bulky tumor

Clinical outcome of FIGO 2018 stage IB3/IIA2 cervical cancer treated by neoadjuvant chemotherapy followed by radical surgery due to lack of radiotherapy equipment: A retrospective comparison with concurrent chemoradiotherapy

This study aimed to assess neoadjuvant chemotherapy's clinical outcomes such as efficacy, toxicity, and survival outcomes followed by radical hysterectomy ((NACT-RS) among women with cervical cancer stage IB3 and IIA2, by comparing concurrent chemoradiotherapy (CCRT) and NACT-RS. The study retrospectively reviewed patients with (2018 FIGO) stage IB3 and IIA2 cervical cancer who received preoperative neoadjuvant chemotherapy followed by NACT-RS or concurrent chemoradiotherapy (CCRT). The outcome measures were the 5-year survival and complication rates between the two groups. The median follow-up was 75 months. In total, 218 patients had stage IIA2, 136 patients had stage IB3, 201 patients received CCRT, and 153 patients received preoperative NACT-RS. In the CCRT group, the incidence of early complications (myelosuppression, gastrointestinal and urinary) was higher compared with that in the NACT-RS group (76.1 vs. 26.1%; p < 0.001, respectively). There was no significant difference between the two study groups concerning late complications. Five-year PFS was 79.9% and 85.5% in the NACT-RS and CCRT groups, respectively (p = 0.093). Five-year OS was 86.9% and 85.5% in the NACT-RS and CCRT groups, respectively (p = 0.97). In the multivariate clinicopathologic characteristics analysis for OS, initial tumor size > 4.3 cm (HR 5.11; p < 0.001), AC/ASC (HR 1.89; p = 0.02), histologic grade 2-3 (HR 2.25; p = 0.04), and 2018 FIGO stage IIA2 (HR 8.67; p < 0.001) were independent risk factors. The survival of patients with stage IB3 and IIA2 cervical cancer treated with NACT-RS was similar to that of patients treated with CCRT without increasing side effects.

Feasibility and safety of carboplatin plus paclitaxel as neoadjuvant chemotherapy for locally advanced cervical cancer: a pilot study

The aim of this study is to evaluate the efficacy and safety of the combination of carboplatin and paclitaxel as neoadjuvant chemotherapy (NACT) in patients affected by locally advanced cervical cancer. Between June 2007 and May 2012, all patients with a diagnosis of locally advanced cervical cancer (IB2–IIB) were eligible for this protocol. All patients have received 3 cycles of carboplatin (AUC6) and paclitaxel 175 mg/mq in neoadjuvant setting. The NACT-induced toxicity and the response to treatment were evaluated according to the World Health Organization (WHO) criteria. After NACT, all patients with complete or partial response were submitted to classical radical hysterectomy type III or C2, according to different classifications, and were submitted to four adjuvant cycles of platinum-based chemotherapy. The primary endpoints of the study were to evaluate the efficacy and feasibility of carboplatin regimen. Thirty-five patients with locally advanced cervical cancer were considered. A total of 23 patients completed 3 cycles of NACT. The overall clinical response rate after NACT was 78.3% including 43.5% (n = 10) with complete response, 34.8% (n = 8) with partial response, 17.4% (n = 4) with stable disease and 4.3% (n = 1) of those who suffered disease progression. The most common toxicity was haematologic, nausea/vomiting and neuropathy with grades 1 and 2 and occurred in 56.5, 56.5 and 17.4%, respectively. No renal toxicity was registered. Our results suggest that carboplatin is a well-tolerated drug with a response rate similar to standard cisplatin. Then, it represents, in neoadjuvant setting, a valid alternative in patients affected by locally advanced cervical cancer.

Pulmonary toxicity after a quick course of combinatorial vincristine, bleomycin, and cisplatin neoadjuvant chemotherapy in cervical cancer

Pulmonary toxicity is one of the most serious adverse effects associated with a quick course of vincristine, bleomycin, and cisplatin neoadjuvant chemotherapy (NAC-VBP). The aim of this study was to evaluate pulmonary toxicity related to a quick course NAC-VBP. A total of consecutive 61 patients, who underwent at most 3 cycles of NAC-VBP every 10 days in the International Federation of Gynecology and Obstetrics (FIGO) stage IB-IIB cervical cancer from 1995 to 2007, were retrospectively analyzed. Of the 61 study subjects, 7 (11.5%) were identified to have pulmonary toxicity and 2 (3.3%) died of pulmonary fibrosis progression despite aggressive treatment and the use of a multidisciplinary approach. No factor predisposing pulmonary toxicity was identified. Initial symptoms were non-specific, but bronchiolitis obliterans organizing pneumonia and interstitial pneumonitis were characteristic findings by high-resolution computed tomography of the chest. The benefit of steroid therapy was uncertain and was associated with steroid-induced diabetes mellitus requiring insulin therapy in two patients. Fatal pulmonary toxicity is a major concern of a quick course NAC-VBP. In conclusion, these patients require special monitoring for bleomycin-induced pulmonary toxicity.

Neoadjuvant paclitaxel and cisplatin in uterine cervical cancer: long-term results

OBJECTIVES

To assess the effect of neoadjuvant chemotherapy with paclitaxel and cisplatin on long-term (5-year) survival of patients with stage IB2 to IIB cervical cancer.

MATERIALS AND METHODS

Forty-three consecutive patients with International Federation of Gynecology and Obstetrics stage IB2 to IIB uterine cervical cancer were treated with intravenous paclitaxel (60 mg/m), followed by intravenous cisplatin (60 mg/m) every 10 days. Two weeks after the third cycle of chemotherapy, the patients underwent surgery or radiation therapy, depending on overall condition. They were followed up, and 5-year survival rates and factors affecting prognosis were evaluated.

RESULTS

All of 43 patients underwent surgery. Of the 43 patients, 17 (39.5%) showed a complete response, 22 (51.2%) had a partial response to cisplatin-paclitaxel, making the overall response rate 90.7%; the remaining 4 patients (9.3%) had a stable disease. A down-staging response was seen in 72.1% (31/43) of patients showing a response. After surgery, patients received adjuvant therapy according to their pathological findings. Among the 43 patients, 37 were followed up. Kaplan-Meier analysis showed that the overall 2- and 5-year survival rates were 94.5% and 89.2%, respectively. Initial stage, response to neoadjuvant chemotherapy, differentiation, depth of invasion after chemotherapy, and metastasis were significantly correlated with survival. Differences in TA4, tumor size, and stage before and after chemotherapy were also significantly correlated with survival. In contrast, initial tumor size, carcinoembryonic antigen concentration, cell type, and lymphovascular invasion did not correlate significantly with survival rate.

CONCLUSIONS

Combination neoadjuvant chemotherapy with paclitaxel and cisplatin may improve long-term survival of patients with uterine cervical cancer.

Comparative study of neoadjuvant chemotherapy before radical hysterectomy and radical surgery alone in stage IB2-IIA bulky cervical cancer

OBJECTIVE

To compare the efficacy of neoadjuvant chemotherapy with paclitaxel plus platinum followed by radical hysterectomy with radical surgery alone in patients with stage IB2-IIA bulky cervical cancer.

METHODS

From November 1999 to September 2007, stage IB2-IIA cervical cancers with tumor diameter >4 cm, as measured by MRI, were managed with two cycles of preoperative paclitaxel and platinum. As a control group, we selected 35 patients treated with radical surgery alone.

RESULTS

There were no significant between group differences in age, tumor size, FIGO stage, level of SCC Ag, histopathologic type and grade. Operating time, estimated blood loss, the number of lymph nodes yielded and the rate of complications were similar in the two groups. In surgical specimens, lymph-vascular space invasion (LVSI), nodal metastasis and parametrial involvement did not differ significantly between the two groups. In the neoadjuvant group, pathologic tumor size was significantly smaller and fewer patients had deep cervical invasion. Radiotherapy, alone and in the form of concurrent chemoradiation, was administered to more patients treated with radical surgery alone (82.9% vs. 52.9%, p=0.006). No recurrence was observed in patients who could avoid adjuvant radiotherapy owing to improved risk factors after neoadjuvant chemotherapy. There were no significant differences in 5-year disease free and overall survival.

CONCLUSION

As neoadjuvant chemotherapy would improve pathologic prognostic factors, adjuvant radiotherapy can be avoided, without worsening the prognosis, in patients with locally advanced bulky cervical cancer. Neoadjuvant chemotherapy would be improving the quality of life after radical hysterectomy in patients with bulky cervical cancer.

Neoadjuvant chemotherapy and radical surgery compared to radical surgery alone in bulky stage IB-IIA cervical cancer

AIM

The aim of this study was evaluation of the efficacy of neoadjuvant chemotherapy (NACT) and radical hysterectomy on long-term survival in stage IB-IIA locally advanced cervical cancer as compared with radical surgery alone.

METHODS

We reviewed all patients with cervical cancer stage IB-IIA who were treated with two treatment modalities, i.e. NACT followed by radical hysterectomy and lymphadenectomy, and radical hysterectomy alone between March 1996 and March 2004. There were 22 patients in the NACT group (group 1) and 160 patients in the immediate radical surgery group (group 2). All patients in group 1 were followed for more than 108months, and long-term survival and factors affecting recurrence were evaluated.

RESULTS

Nineteen patients in the NACT arm underwent radical surgery. Pelvic lymph node metastasis was found in 8 patients in this group and in 36 in the radical surgery group. Eighteen patients in the NACT group and 96 patients in the radical surgery group were scheduled for adjuvant postoperative chemoradiation. During the 9-year follow-up, recurrence rate was 47.1% and 30.2% in NACT and control groups, respectively. In the NACT group lymph node metastasis was a significant independent risk factor for recurrence. Overall survival in the NACT arm was not statistically significantly lower than the control arm (p=0.06).

CONCLUSION

NACT did not improve long-term overall survival of bulky early-stage cervical cancer patients compared to primary radical surgery.

Randomized study of preoperative chemotherapy versus primary surgery for stage IB cervical cancer

AIM

To determine the most effective treatment and long-term outcome of patients with stage IB carcinoma of the cervix.

METHODS

From January 1999 to December 2001, 106 women with cervical cancer stage IB received neoadjuvant chemotherapy (n = 52) or primary surgery (n = 54). These were randomly assigned. Clinical effects and pathological changes were simultaneously recorded.

RESULTS

The overall clinical response rate was 84.6% and included a complete response (CR) in four patients (7.7%), partial response (PR) in 40 patients (76.9%), and stable disease (SD) in the remaining eight patients (15.4%). Surgery revealed positive nodes in 9.6% neoadjuvant chemotherapy group patients and in 29.6% primary surgery group patients (P = 0.014). Similar results occurred with vascular space involvement: 27.8% in the primary surgery group compared to 9.6% in the neoadjuvant chemotherapy group (P = 0.024). However, parametrial infiltration was found in 7.4% of the patients in the primary surgery group, while only 3.8% showed it in the neoadjuvant chemotherapy group (P = 0.679). The overall 5-year survival rate was significantly higher for all patients who received neoadjuvant chemotherapy (84.6%) than for the control group (75.9%) (P = 0.0112). The median survival time in patients with complete response and partial response to chemotherapy (83.3 months) was significantly higher than that of patients with stable disease to chemotherapy (55.2 months) (P = 0.0049). 27.3% of patients developed recurrent disease within 5 years of the primary treatment. The women with recurrence included partial response in six patients (60.0%), and stable disease in four patients (40.0%). For the other patients there was partial response and complete response in 38 patients (90.5%), and stable disease in the remaining four patients (9.5%) (P = 0.035).

CONCLUSION

Neoadjuvant chemotherapy can effectively eliminate the pathological risk factors and improve long-term survival in patients with locally advanced cervical cancer.

Prognostic significance of pathological response after neoadjuvant chemotherapy or chemoradiation for locally advanced cervical carcinoma

BACKGROUND

Cisplatin-based chemoradiation is the standard of care for locally advanced cervical cancer patients; however, neoadjuvant modalities are currently being tested. Neoadjuvant studies in several tumor types have underscored the prognostic significance of pathological response for survival; however there is a paucity of studies in cervical cancer investigating this issue.

METHODS

Four cohorts of patients with locally advanced cervical carcinoma (stages IB2-IIIB); included prospectively in phase II protocols of either neoadjuvant chemotherapy with 1) cisplatin-gemcitabine, 2) oxaliplatin-gemcitabine, 3) carboplatin-paclitaxel or 4) chemoradiation with cisplatin or cisplatin-gemcitabine followed by radical hysterectomy were analyzed for pathological response and survival.

RESULTS

One-hundred and fifty three (86%) of the 178 patients treated within these trials, underwent radical hysterectomy and were analyzed. Overall, the mean age was 44.7 and almost two-thirds were FIGO stage IIB. Pathological response rates were as follows: Complete (pCR) in 60 cases (39.2%), Near-complete (p-Near-CR) in 24 (15.6 %) and partial (pPR) in 69 cases (45.1%). A higher proportion rate of pCR was observed in patients treated with chemoradiotherapy (with cisplatin [19/40, 47.5%]; or with cisplatin-gemcitabine [24/41, 58.5%] compared with patients receiving only chemotherapy, 6/23 (26%), 3/8 (37.5%) and 8/41 (19.5%) for cisplatin-gemcitabine, oxaliplatin-gemcitabine and carboplatin-paclitaxel respectively [p = 0.0001]). A total of 29 relapses (18.9%) were documented. The pathological response was the only factor influencing on relapse, since only 4/60 (6.6%) patients with pCR relapsed, compared with 25/93 (26.8%) patients with viable tumor, either pNear-CR or pPR (p = 0.001). Overall survival was 98.3% in patients with pCR versus 83% for patients with either pNear-CR or pPR (p = 0.009).

CONCLUSION

Complete pathological response but no Near-complete and partial responses is associated with longer survival in cervical cancer patients treated with neoadjuvant chemotherapy or chemoradiotherapy.

Chemotherapy in the primary treatment of cervical carcinoma

Two major treatment modalities in cervical cancer include radiotherapy and surgery. In an attempt to improve the outcome, these modalities have been increasingly supplemented by chemotherapy. Chemotherapy can be combined with local therapies in various sequences. Of the two possible strategies using chemotherapy and radiotherapy (sequential or concomitant), the latter seems to be more effective. Platinum-based regimens applied concurrently with both definitive and post-operative radiation therapy were demonstrated to provide survival benefit in five of the six recently published randomised trials. The positive impact of chemotherapy added to radiotherapy has also been shown in a meta-analysis including 1894 patients in 19 randomised studies. This strategy, however, is accompanied by increased early toxicity. The benefit of chemotherapy applied prior to surgery remains debatable. The role of new cytotoxic and biological substances, as well as agents combating tumour hypoxia, warrants further clinical investigation.

Management strategies for stage IB2 cervical cancer: A cost-effectiveness analysis

OBJECTIVE

To assess the potential effectiveness and medical costs of three common strategies to manage Stage IB2 squamous cell carcinoma of the cervix (CXCA).

METHODS

A decision analysis model compared three strategies to manage Stage IB2 CXCA: (1) radical hysterectomy with pelvic and para-aortic lymphadenectomy followed by tailored chemoradiation therapy for high-risk patients (RHYST); (2) primary chemoradiation therapy for all patients (CTRT); and (3) neoadjuvant chemotherapy followed by radical hysterectomy and tailored chemoradiation therapy for high-risk patients (NAC).

RESULTS

RHYST was the least expensive strategy with a cost of 284 Million (M) per 10,000 women and a 5-year disease free survival (5-DFS) of 69%. Both NAC and CTRT had similar 5-DFS (69.3% and 70%, respectively); however, both NAC and CTRT were more expensive than RHYST at 299 M and 508 M, respectively. This translated into a higher cost-effectiveness ratio for NAC and CTRT ($43,197 and $72,613, respectively) when compared to RHYST ($41,212). NAC yielded 30 additional survivors compared to RHYST but at a cost of $499,783 per survivor. CTRT was more effective than RHYST with 100 additional survivors but at a substantial cost of $2,240,000 per survivor.

CONCLUSIONS

RHYST is the most cost-effective strategy to manage Stage IB2 CXCA and would be favored in settings where resources are limited. Although NAC and CTRT are reasonable treatment strategies, policymakers must be willing to spend approximately $500,000 per additional survivor (NAC) or $2.2 M per additional survivor (CTRT).

Neoadjuvant chemotherapy in cervical cancer: a new trend

PURPOSE OF REVIEW

Although there is effective screening for cervical cancer, it continues to be a healthcare problem in developing countries. To increase survival rates, different strategies with neoadjuvant chemotherapy have been developed. Nearly all trials that analysed neoadjuvant chemotherapy plus surgery demonstrated an improved outcome, but most phase III trials that compared neoadjuvant chemotherapy plus radiotherapy with radiotherapy alone have failed to show further benefit. Recent data on neoadjuvant chemotherapy could change that assumption, so revision is needed.

RECENT FINDINGS

A meta-analysis by the Medical Research Council (UK) based on individual patient data (2074 patients, median follow-up 5.7 years) showed that there was no benefit of survival in patients treated with radiotherapy. Some interesting results were obtained when the trials were grouped together according to cycle length and dose intensity. Trials that gave more intensive chemotherapy in terms of a shorter cycle or a higher dose intensity tended to show an advantage for neoadjuvant chemotherapy. When analysing neoadjuvant chemotherapy followed by surgery, data from meta-analysis showed a reduction in the risk of death of 35% and an absolute gain of 14% in the 5-year survival. The reasons for this could be that short cycle length chemotherapy was used in this subgroup or the surgery may have removed radioresistant cell clones.

SUMMARY

Neoadjuvant chemotherapy may play a role in the treatment of women with cervical cancer. In future, it may be reasonable to compare it with concomitant chemoradiotherapy in terms of efficacy and toxicity.

The role of chemotherapy in locally advanced, metastatic and recurrent cervical cancer

Cervical cancer is among the major health problems world-wide although advances in screening programs. Surgery and radiotherapy are the treatment modalities of choice for early and locally advanced cervical cancer. However, the role of chemotherapy in this setting has been better investigated in the latest years. To improve loco-regional control in locally advanced disease, authors have tested both neo-adjuvant chemotherapy and concurrent chemoradiotherapy. From 1999 NCI clinical announcement, concurrent cisplatin-based chemoradiation is considered the treatment of choice for cervical cancer patients requiring radiation therapy. Neo-adjuvant chemotherapy is reaching encouraging results in IB bulky-IIA cervical cancer, but further investigation are ongoing in locally advanced cervical setting. The optimal treatment for patients with metastatic or recurrent cervical cancer is still undefined and chemotherapy is used with palliation intent. Cisplatin remains the most active cytotoxic agents, although combinations of cisplatin with paclitaxel, topotecan, vinorelbine, have shown encouraging results in phase II and in early phase III studies. This paper reviews the role of chemotherapy in the management of patients with locally advanced, metastatic and recurrent cervical cancer. Studies discussed in this paper were selected trough a search in the med-line database performed in October 2003.

Stage Ia-IIa Cancer of the Cervix

Early-stage cervical cancer is unique among malignancies in that two radically different yet equally efficacious treatments can be offered to most patients with the disease. The choice between surgery and radiation therapy depends on the patient's age and comorbidities, tumor factors, physician bias, and discussion of the risks and benefits of each modality. A thorough discussion between the physician and patient is necessary to determine the optimal management for each individual. This review discusses the major factors that influence physician and patient management choices.

Cisplatin and vinorelbine as neoadjuvant chemotherapy in locally advanced cervical cancer: a phase II study

Fifty eight consecutive untreated patients with locally advanced cervical carcinoma (LACC) received neoadjuvant chemotherapy (NACT) with cisplatin (CDDP) 80 mg/sqm (day 1) + vinorelbine (VRL) 25 mg/sqm (day 1 and 8). Three cycles of chemotherapy were planned every 21 days. Within 28 days from the completion of chemotherapy patients in complete or partial response were submitted to radical hysterectomy with pelvic lymphadenectomy. On 155 cycles, hematologic toxicity was mild (G3-4 neutropenia and anemia occurred in 16% and 5%, respectively). Forty-seven patients (81%) were submitted to radical surgery; eight (14%) patients were deemed ineligible for surgery because of poor response to treatment, two (3%) for anesthesia contraindications and one (2%) refused surgery. At pathologic examination 12 patients (25%) had a complete response, one (2%) in-situ carcinoma, six (13%) residual microinvasive disease, and 28 (60%) a partial response. None had extracervical disease. Eight patients (14%) had microscopic lymph node metastases. The number of cycles administered was significantly associated with a good pathologic response. Association of CDDP and VRL as NACT in LACC appears safe and effective. Low cost and modest toxicity would support the initiation of a multicenter randomized phase III trial to compare this association with cisplatin alone.

Ten-year survival of patients with locally advanced, stage ib-iib cervical cancer after neoadjuvant chemotherapy and radical hysterectomy

OBJECTIVE(S)

The aim of this study was to evaluate the effects of neoadjuvant chemotherapy and radical hysterectomy on long-term survival in stage IB-IIB locally advanced cervical cancer by conducting a 10-year follow-up.

METHODS

Between August 1983 and May 1990, 80 locally advanced, stage IB-IIB cervical cancer patients with tumor diameter greater than or equal to 4 cm were treated with neoadjuvant VBP chemotherapy (cisplatin, vinblastine, and bleomycin) followed by radical hysterectomy with pelvic lymphadenectomy. After this therapeutic modality, patients were followed for more than 10 years. Ten-year survival rates and factors affecting recurrence after this therapy were evaluated.

RESULTS

Of 80 patients, 75 (93.7%) showed a reduction in tumor size after neoadjuvant chemotherapy. At pathologic examination, stage reduction was noted in 53 (66.2%) patients and 20 patients (25%) showed no residual or microinvasive cervical tumor. Pelvic lymph node metastases were found in 17 patients (21.3%). During the 10-year follow up, 2 patients were lost and 16 patients recurred. Overall 5-year and 10-year disease-free actual survival rates were 82.0 (64/78) and 79.4% (62/78), respectively. Clinical stage, initial tumor size, clinical response, and residual tumor size were not risk factors for recurrence after this therapy. However, pelvic lymph node metastasis was a significant risk factor for recurrence.

CONCLUSION(S)

Neoadjuvant VBP chemotherapy followed by radical hysterectomy in locally advanced, stage IB-IIB cervical cancer patients seemed to improve the long-term survival rate for these patients compared to that of conventional therapy. However, randomized controlled trials are needed to confirm this result.

Cisplatin, radiation, and amifostine in carcinoma of the uterine cervix

A pilot, open, comparative study was performed on patients with locally advanced cervical cancer to investigate the efficacy and safety of amifostine. Twenty patients with a histologic diagnosis of squamous cervical cancer were treated with radiotherapy and randomized in two groups. Group A received cisplatin at 20 mg/m2 for five days in two cycles during intracavitary radiotherapy and 100 mg/m2 x 2 cycles during external radiotherapy, and amifostine 825 mg/m2 15 min before the cisplatin infusion. Patients in group B received cisplatin in the same doses without amifostine. All patients had complete responses during a median follow-up of 20 months. Grade three neutropenia was present in two patients in group A and in four of the control group, P = 0.31; grade 2 neurologic toxicity was seen in four patients in group B and in one of the patients in group A, P = 0.15. One patient needed temporary interruption of amifostine due to hypotension. Eight of 10 patients in group A developed hypocalcemia during the treatment with amifostine. Our findings indicate that amifostine was well tolerated. In this series a mild neurologic and hematologic protection was found in patients that received amifostine, although this was not statistically significant. No differences in disease-free survival response and overall survival was seen between the two groups.

Current developments in the treatment of newly diagnosed cervical cancer

The International Federation of Gynecology and Obstetrics (FIGO) staging of cervical cancer relies on physical examination. However, surgical staging, which helps determine the extent of invasion of lymph nodes by cancer, is currently used more widely to define the need for additional therapies. Examples of these additional treatments include high-dose-rate brachytherapy techniques, extension of radiotherapy fields, surgery, concurrent chemotherapy and radiotherapy, and neoadjuvant chemotherapy prior to surgery. Currently there are many ongoing randomized studies that strive to define the risk-to-benefit ratio of these additional therapies.

Randomised study of radical surgery versus radiotherapy for stage Ib-IIa cervical cancer

BACKGROUND

Stage Ib and IIa cervical carcinoma can be cured by radical surgery or radiotherapy. These two procedures are equally effective, but differ in associated morbidity and type of complications. In this prospective randomised trial of radiotherapy versus surgery, our aim was to assess the 5-year survival and the rate and pattern of complications and recurrences associated with each treatment.

METHODS

Between September, 1986, and December, 1991, 469 women with newly diagnosed stage Ib and IIa cervical carcinoma were referred to our institute. 343 eligible patients were randomised: 172 to surgery and 171 to radical radiotherapy. Adjuvant radiotherapy was delivered after surgery for women with surgical stage pT2b or greater, less than 3 mm of safe cervical stroma, cut-through, or positive nodes. The primary outcome measures were 5-year survival and the rate of complications. The analysis of survival and recurrence was by intention to treat and analysis of complications was by treatment delivered.

FINDINGS

170 patients in the surgery group and 167 in the radiotherapy group were included in the intention-to-treat analysis; scheduled treatment was delivered to 169 and 158 women, respectively, 62 of 114 women with cervical diameters of 4 cm or smaller and 46 of 55 with diameters larger than 4 cm received adjuvant therapy. After a median follow-up of 87 (range 57-120) months, 5-year overall and disease-free survival were identical in the surgery and radiotherapy groups (83% and 74%, respectively, for both groups), 86 women developed recurrent disease: 42 (25%) in the surgery group and 44 (26%) in the radiotherapy group. Significant factors for survival in univariate and multivariate analyses were: cervical diameter, positive lymphangiography, and adeno-carcinomatous histotype. 48 (28%) surgery-group patients had severe morbidity compared with 19 (12%) radiotherapy-group patients (p = 0.0004).

INTERPRETATION

There is no treatment of choice for early-stage cervical carcinoma in terms of overall or disease-free survival. The combination of surgery and radiotherapy has the worst morbidity, especially urological complications. The optimum therapy for each patient should take account of clinical factors such as menopausal status, age, medical illness, histological type, and cervical diameter to yield the best cure with minimum complications.

Neoadjuvant chemotherapy in stage IB2 squamous cell carcinoma of the cervix

To determine the effects of neoadjuvant chemotherapy (NAC) in the management of cervical carcinoma Stage IB2 (tumor diameter > 4 cm), we reviewed 52 surgically treated patients diagnosed between January 1987 and December 1993. There were 20 patients treated with preoperative neoadjuvant chemotherapy and 32 treated by primary radical hysterectomy. Mean tumor diameter was significantly larger in the neoadjuvant, compared with the primary surgery group (6.5 +/- 1.8 vs 5.4 +/- 0.7, P = 0.003). In the NAC group, 5 of 20 patients were treated with three courses of cisplatin, methotrexate, and bleomycin every 21 days, whereas 15 of 20 patients received three courses of cisplatin, vincristine, and bleomycin every 10 days. Postoperative adjuvant therapy consisting of either radiation or chemotherapy was employed in 13/20 patients (65%) in the NAC group and 20/32 patients (63%) in the primary surgical group. At a median follow-up of 52.5 months, 4/20 patients (20%) in the NAC group recurred vs 11/32 (34%) in the primary surgery group. The overall response rate to NAC was 90%, with 2/20 complete clinical responders and 16/20 partial responders. High-risk pathologic factors were less commonly observed in the NAC group when compared with the primary surgical group with the incidence of nodal metastases, positive vascular space involvement, undiagnosed parametrial disease, and > or = 75% depth of invasion observed in 10.0% vs 37.5%, 20.0% vs 46.9%, 0.0% vs 15.6%, and 30.0% vs 68.8%, respectively. No differences were noted in operative time or blood loss. Cox proportional-hazards analysis indicated that the most significant prognostic factor was depth of invasion. Although the patients who received neoadjuvant chemotherapy had significantly larger tumors at baseline, their 5-year survival rate was slightly higher than that of the primary surgery group (80.0% vs 68.7%, P = 0.162). Patients receiving neoadjuvant chemotherapy, despite having significantly larger pretreatment tumors, had fewer high-risk pathologic factors, postoperatively. Although this was a small, nonrandomized study, the relative improvement in pathologic response and long-term outcome associated with neoadjuvant chemotherapy was encouraging. This highlights the need for a prospective randomized clinical trial to establish whether neoadjuvant chemotherapy can significantly improve the long-term outcome of women with Stage IB2 squamous cell carcinoma of the cervix.

Intense neoadjuvant chemotherapy with cisplatin and epirubicin for advanced or bulky cervical and vaginal adenocarcinoma

Twenty-two consecutive patients with bulky or locally advanced cervical or vaginal adenocarcinoma were treated with a neoadjuvant chemotherapy regimen consisting of nine weekly courses of cisplatin (50 mg/m2) and three courses of epirubicin (70 mg/m2) at Weeks 1, 4, and 7, followed by radical hysterectomy. Salvage radiotherapy was administered to inoperable patients, whereas postoperative treatment with irradiation or further chemotherapy was given to those with detection of risk factors at surgery. Three patients (14%) did not complete the planned courses of chemotherapy (one refused after the first administration, one had severe myelotoxicity, and one had severe nephrotoxicity). Twenty-one subjects received at least four courses of treatment and were therefore evaluable for response. We observed 4 clinically complete and 10 partial responses, accounting for an objective response rate of 67%. Eighteen subjects (82%) underwent surgery without serious complications. No histopathologic complete response was observed. The response rate is in the lower range observed with other regimens for squamous cell carcinoma. Although feasible, this regimen implies a significant risk of myelotoxicity. This enhanced toxicity may be justified only if balanced by long-term survival.

Prognostic factors in patients with bulky stage IB or IIA cervical carcinoma undergoing neoadjuvant chemotherapy and radical hysterectomy

All patients with bulky (> or =4 cm) Stage Ib or IIa cervical carcinoma treated at Chang Gung Memorial Hospital between August 1988 and December 1991 using a strategy of neoadjuvant chemotherapy with cisplatin, vincristine, and bleomycin and radical hysterectomy were reviewed. Fifty-nine evaluable patients received 1 to 3 courses of chemotherapy, and 51 underwent subsequent hysterectomy. The remaining 8 patients, not completing planned surgery, were treated with definitive radiotherapy. The overall clinical response rate was 81.4% (48/59) with 18.6% complete response. Clinical response to chemotherapy was not different by stage, histologic type, tumor size, level of squamous cell carcinoma antigen, or DNA ploidy. However, tumors with DNA indices (DI) greater than 1.3 were associated with higher clinical response rates than tumors with DI < or = 1.3 (P = 0.043). Histologically proven pelvic node metastases was noted in 18.5% (10/54) who had laparotomy. Concomitant pregnancy and more than one node metastases had significant adverse influence on recurrence and death. The 5-year survival rate of those patients who received hysterectomy was 80.3%, while only 1 of the 8 patients without hysterectomy survived. Of the 7 patients received hysterectomy despite clinical poor response, only 2 had node metastases and 3 died, whereas all the 4 patients deterred hysterectomy for poor response died. This study demonstrates the value of DNA flow cytometry in predicting chemosensitivity. However, with a DI cutoff at 1.3, only 29.2% patients could be selected. Further studies are necessary to find additional indicators that predict histological response to select better candidates for this approach and to determine optimal adjunctive treatment in case that poor prognostic features are found.

Neoadjuvant chemotherapy for locally advanced cervical cancer--where does it stand?: a review

Platinum-based combination chemotherapy has been utilized in the neoadjuvant setting in locally advanced inoperable cervical cancer with the aim of improving response and survival. Neoadjuvant chemotherapy can be followed by either radiation therapy (RT) or by surgery in cases in which it seems to be appropriate. Available data indicate that preradiation chemotherapy yields no survival advantage over RT alone. However, presurgery chemotherapy may increase resectability in women with locally advanced cervical cancer to around 70 percent. Nonrandomized trials of neoadjuvant chemotherapy followed by surgery have shown some improvement in the outcome. Prospective randomized trials are needed to evaluate this approach as compared with RT alone and to define its precise role in locally advanced cervical cancer.

Phase I/II study of neoadjuvant intraarterial chemotherapy with mitomycin-C, vincristine, and cisplatin in patients with stage IIb bulky cervical carcinoma

BACKGROUND

Stage IIb bulky cervical carcinomas have been considered difficult to treat successfully by radiation and/or surgery, compared with smaller lesions. This study was designed to evaluate the efficacy of neoadjuvant pelvic intraarterial chemotherapy (IAC) and to determine the optimal dosage of cisplatin for reducing tumor volume in these patients.

METHODS

Twenty-one previously untreated patients with primary cervical carcinoma of more than 4 cm in greatest dimension and parametrial invasion were included in this study. Pelvic IAC was administered using a combination of mitomycin-C, 10 mg/m2; vincristine, 1 mg/m2; and cisplatin, 50 mg/m2 (MVC; group 1, 8 patients) or 75 mg/m2 (group 2, 13 patients). Tumor volumes were measured three-dimensionally by magnetic resonance imaging (MRI) before and after three courses of IAC. Clinical responses were evaluated with gynecologic examination and MRI; pathologic responses were evaluated with histologic examinations of surgical specimens.

RESULTS

The mean volume reduction rate (74.2% vs. 97.2% in groups 1 and 2, respectively, P = 0.0022), the clinical complete response rate (0% vs. 69.2%, P = 0.0033), and the pathologic complete response rate (0% vs. 46.2%, P = 0.0445) were significantly higher in group 2. Type III radical hysterectomy was possible in 19 patients (90.5%). Toxicities of grades 2-3 (World Health Organization criteria) were nausea and/or vomiting (38.1%), leukopenia (33.3%), and fever (14.2%).

CONCLUSIONS

These preliminary results suggest that neoadjuvant pelvic IAC with MVC (especially with cisplatin at a dose of 75 mg/m2) is effective in reducing tumor volume, increasing the clinical and pathologic complete response rate, and improving the operability in most patients with Stage IIb bulky cervical carcinoma, generally considered inoperable.

Lymph node metastases, cell type, age, HPV status and type, neoadjuvant chemotherapy and treatment failures in cervical cancer

Conflicting evidence on the prognostic influence of some of the clinical and histopathological variables in cervical cancer of the HPV status and type and chemotherapeutic response prompted a number of reviews from nearly 40 years experience in a tertiary referral centre. The collation and analyses of these data with those from recent literature allow some proposals to be made. The disease is more prevalent in the young women in whom, in many centers, the mortality is also higher; the latter may be related to the reported increase in both small cell types and adeno and adenosquamous carcinoma--a finding more marked in the young. Lymph node metastases, related to increasing grade, size, stage and lymph space invasion, are unequivocally associated with a worse prognosis. Resolution of the exact nature of the intimate association of this disease with the human papilloma virus remains to be resolved as does the influence on prognosis of the tumor HPV status and that of the different oncogenic types. Reports on the efficiency of neoadjuvant platinum based combination chemotherapy are generally promising but vary considerably depending on the regimen used. Its value will not be determined without properly conducted large randomized studies.

Multimodal treatment for the locally advanced stage IB, IIA, IIB patients of cervical cancer

By employing neoadjuvent chemotherapy (NCT) before radical hysterectomy (RS) and pelvic radiotherapy (RT) in bulky locally advanced cervical cancer (IB, IIA, IIB), the study was focused to update the results of the author's therapeutic experience with multimodal treatment by observing tumor free survivals along with related prognostic factors in different treatment modalities with NCT. The chemotherapy regimen for induction is composed of Vinblastin, Bleomycin and cis-Platin regimen (VBP). The effect of neoadjuvent chemotherapy was evaluated by the WHO definition of clinical response (CR, PR, ST, PG). As a result of NCT study in the stage IA, IIA, and IIB cervical cancer patients recurrence occurred in 50 out of 138 patients (35.5%) treated with radical hysterectomy only (RS) compared with 17 out of 92 patients (18.5%) treated with NCT followed by radical surgery. In conjunction with the NCT study in the cervical cancer, another two groups of patients who were treated by neoadjuvent chemotherapy followed by radical hysterectomy (NCST) and adjuvent radiation (NCSRT) were evaluated in the high-risk patients of cervical cancer with stage IB, IIA, and IIB. Primary responses in the NCST group (n = 61) were CR (68.9%), PR (22.9%), ST (4.9%) and PG (3.3%) respectively, while the chemoresponse of the NCSRT group (n = 101) were CR (65.3%), PR (18.9%), ST (4.9%) and PG (10.9%), respectively. The survival rates of the NCSRT group (n = 101) were 100% in all 1-5 years in CR group, while the rate of the NCST group was 100% at 1 year and 98.5% at 5 years in the CR group of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of chemotherapy in squamous cell carcinoma of the uterine cervix: a review

A critical review of the potential role of chemotherapy in the management of patients with squamous cell carcinoma of the uterine cervix is presented. Both its role in the management of recurrent and/or metastatic cervical cancer and its usefulness as part of the primary treatment of high-risk patients are discussed. It is emphasized that high-risk patients with cervical cancer should preferably be treated in specialized centers and entered into research protocols.

A randomized trial comparing platinum-based chemotherapy followed by radiotherapy vs. radiotherapy alone in patients with locally advanced cervical cancer

Seventy-one patients with stage IIb-IVa cervical cancer were entered on a randomized trial comparing standard pelvic radiotherapy vs. 3 cycles of combination chemotherapy with cisplatin, vinblastine and bleomycin followed by pelvic radiotherapy. Four out of 34 patients randomized to PVB followed by radiotherapy received no PVB and a further 3 patients had only one or 2 cycles of chemotherapy prior to radiotherapy due to drug-related toxicity or progressive disease. After a median follow-up of 3.1 years, no significant difference in survival has emerged between the two randomized groups. However, a difference in the pattern of relapse is emerging with a relatively reduced frequency of systemic relapse in patients receiving chemotherapy prior to local radiotherapy compared to radiotherapy alone. Tumor response was seen following PVB treatment and prior to radiotherapy in 47% of patients. Overall the tumor response rate following completion of radiotherapy was 89% in those treated by radiotherapy and 94% after PVB+radiotherapy. Thirty-three percent of patients randomized to radiotherapy alone relapsed first at a distant (extra pelvic site), and only 18% of patients randomized to initial PVB followed by radiotherapy relapsed systemically initially. When results are presented according to treatment actually given, these trends in patterns of treatment failure are magnified. No treatment-related deaths were reported, and there was no excess of complications with pelvic radiotherapy in the group who had received prior PVB chemotherapy.

Preoperative radiation therapy and surgery in the treatment of "bulky" squamous cell carcinoma of the uterine cervix (stage Ib, IIa, and IIb operable tumors)

Forty-two women with "bulky" squamous cell carcinoma of the uterine cervix, larger than 5 cm, were treated between 1982 and 1988. The median follow-up was 5 years (from 37 to 106 months). The age range was from 25 to 77 years (mean: 49). There were 14 stage Ib, 5 stage IIa, and 23 stage IIb operable patients. Forty grays were delivered at mid-plane of the pelvis (23 fractions in 31 days) using the four-field technique (6-18 MV). External beam radiation therapy was followed by 20 Gy of intracavitary radiation therapy. Forty-eight days later total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO) and bilateral pelvic lymphadenectomy were performed. The 3- and 5-year disease-free survival was 83 and 81%, respectively. The 5-year locoregional control rate was 83%. Thirteen patients suffered from mild to severe complications (31%) but there were only two long-term (5%) complications.

Neoadjuvant chemotherapy with cisplatin, vincristine, and bleomycin and radical surgery in early-stage bulky cervical carcinoma

Neoadjuvant chemotherapy consisting of 2-3 courses of cisplatin, vincristine, and bleomycin was used in the primary treatment of 36 consecutive patients with locally advanced early-stage cervical carcinoma [International Federation of Gynecology and Obstetrics (FIGO) stages Ib or IIa; tumor size, greater than or equal to 4 cm]. The effectiveness of the preoperative chemotherapy was evaluated in the surgical specimens. Among the 33 evaluable patients, the overall clinical response rate was 84.8%, which included a complete response in 8 patients (24.2%) and a partial response in 20 subjects (60.6%). No residual tumor was found in the surgical specimens obtained from 2 complete responders. This therapy induced varying degrees of tumor shrinkage and rendered radical surgery feasible in all evaluable cases despite the initial bulky size of the lesions. No significant difference was observed in the response rate according to age and disease stage. Lymph-node metastases were found after chemotherapy in 18.2% (6/33) of the patients. Grade II and III hematological toxicities occurred in 23.3% of the 90 chemotherapy cycles completed. Nausea and vomiting occurred to a mild to moderate degree in 75 (83.3%) cycles. These preliminary results suggest that the administration of induction chemotherapy involving two to three courses of cisplatin, vincristine, and bleomycin prior to surgery is effective in reducing the tumor volume and in providing better circumstances for surgical removal of the early yet bulky cervical tumors and results in tolerable toxicity. This protocol is now undergoing prospective randomized trials to test its impact on long-term survival.

A preliminary report of combination chemotherapy with cisplatin and mitomycin-C followed by radical hysterectomy or radiation therapy in patients with locally advanced cervical cancer

Neoadjuvant chemotherapy with cisplatin and mitomycin-C was used in the primary treatment of 17 patients with locally advanced cervical cancer (stages Ib-IIIb; tumor diameter greater than 5 cm) prior to definitive local treatment with radical hysterectomy or radiotherapy. Thirteen of the seventeen patients (76.5%) responded to initial chemotherapy, permitting a radical hysterectomy in ten patients. At histologic examination of the surgically resected primary tumor and lymph nodes, complete pathologic responses were found in 2 patients and partial pathologic responses in 8 patients. The median follow-up time is 14.5 months with a median survival for all patients of 52 weeks. All responders are alive. No therapy-related deaths, major complications, or delay in treatment occurred. Neoadjuvant chemotherapy with mitomycin-C and cisplatin is feasible and may be of benefit for patients with locally advanced cervical cancer.

Induction chemotherapy followed by radical surgery in cervical cancer

To evaluate the therapeutic potential of cytotoxic therapy in patients with squamous cell carcinoma of the cervix, 28 patients with disease clinically localized to the pelvis were treated with chemotherapy followed by radical pelvic surgery. Treatment consisted of cis-platinum 50 mg/m2, mitomycin C 10 mg/m2, vincristine 1.0 mg/m2, and bleomycin 10 U IM given as a course (over 21 days) of induction chemotherapy followed by radical hysterectomy and pelvic and aortic lymphadenectomy in 26 patients and total pelvic exenteration in 2 patients. The stage distribution of the patients in the study was 4 stage IB, 6 stage IIA, 7 stage IIB, 1 stage IIIA, 11 stage IIIB, and 1 stage IVA. Two patients with stage IIIB cancer were found, at the time of laparotomy, to have carcinomatosis and were excluded from the final evaluation in this study. All patients achieved a clinical and histologic response to chemotherapy. There were 35% complete and 65% partial responses. After chemotherapy, at the time of surgery, 4 patients were found to be histologically free of disease, and the incidence of surgically documented nodal disease after chemotherapy was found to be 32%. There was no significant hematologic or pulmonary toxicity. Induction chemotherapy is well tolerated and may be beneficial in the management of some patients with cervical cancer who are at high risk for failure with conventional treatment.

Hemolytic-uremic syndrome associated with neoadjuvant chemotherapy in the treatment of advanced cervical cancer

Hemolytic-uremic syndrome (HUS) is a rare but severe complication of neoplastic disease as well as some of its treatments. The pathophysiology of HUS is poorly understood, but it affects multiple organ systems and carries a high mortality rate. The diagnosis of HUS is based on a clinical triad of microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and renal failure, for which no proven therapies exist. This report describes a case of HUS developing in a patient with stage IVA squamous cell carcinoma of the uterine cervix following treatment with cisplatin/bleomycin/vincristine neoadjuvant chemotherapy prior to radiation therapy.

Lymph node metastases in carcinoma of the cervix uteri: response to neoadjuvant chemotherapy and its impact on survival

One hundred and sixty-nine patients with squamous cancer of the cervix uteri treated with three courses of neoadjuvant chemotherapy with the modified VBP scheme are presented. All were subjected to a Wertheim-Meigs operation with paraaortic lymph-adenectomy. The incidence of lymph node metastases is analyzed according to clinical stage, tumor volume, residual tumor in the surgical specimen, and clinical response to neoadjuvant chemotherapy. A significant decrease in the incidence of lymph node involvement was observed in good responders. Survival rates, after 2 years of follow-up, improved in those cases with small residual tumor, negative parametria, and negative nodes.

Neoadjuvant chemotherapy in locally advanced carcinoma of the cervix uteri

One hundred fifty-one patients (107 stage IIB and 44 stage IIIB) who had completed 2 years of follow-up after treatment with neoadjuvant chemotherapy ("Quick" VBP scheme), prior to standard therapy, are presented. Four groups of patients with different prognosis and operability status, according to tumor response, were identified. In the first group (excellent responders) 96% of the patients had no evidence of disease (NED), whereas in the fourth group (no response), only 33% had NED after 2 years of follow-up. In the first group, no pelvic failure was observed. On the other hand, of 21 patients in group 4, 11 (52%) had pelvic recurrences. The response to neoadjuvant therapy is strongly associated with the initial tumor volume ecographically evaluated. The critical pretreatment volume for response was 84 cm3 (4.85 cm in diameter). Surgery and radiotherapy were equally effective in those patients with initial tumor volume of 84 cm3 or less. But surgery appears to have a better outcome in those patients with tumors larger than the critical pretreatment tumor volume. Radiotherapy in this controversial group was ineffective in avoiding pelvic recurrences, especially when the tumor volume was not sufficiently reduced. The advantage of neoadjuvant chemotherapy is evident in stage IIB, with 79% (85/107) of patients showing no evidence of disease as compared with 47% (24/51) in a nonrandomized control group (P less than 0.01). Statistically significant differences were also obtained in stage IIIB (50% vs 26% in the control group).

Histologic disappearance of locally advanced vaginal cancer after combination chemotherapy

Clinically and histologically complete disappearance of local tumor and pelvic sidewall involvement was achieved in a patient with primary advanced squamous cell carcinoma of the vagina administered combination chemotherapy prior to operation. Radical hysterectomy, total vaginectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymphadenectomy, and paraaortic lymph node biopsy were performed after seven courses of combination chemotherapy with vinblastine, bleomycin, and cis-platinum. This encouraging result warrants further investigation of combination chemotherapy in other patients.

Two-year survival: preoperative adjuvant chemotherapy in the treatment of cervical cancer stages Ib and II with bulky tumor

The effect of preoperative adjuvant chemotherapy on the 2-year survival rate of patients with locally advanced cervical cancer (stages Ib and II with bulky tumour) was evaluated. The 54 patients first received initial chemotherapy of vinblastine, bleomycin, and cis-platinum in a combined regimen (VBP) and then radical hysterectomy. The overall histologic response rate to chemotherapy of the primary tumor confirmed in the surgical specimen was 81% including microscopic or no evidence of disease (41%, Grade III or IV). A lower than expected incidence of lymph node metastasis (20%) was found. All nodal metastasis was noted in patients with Grades I or II (P = 0.0034). Median follow-up was 36 months (range 26-60 months). Three recurrences (6%) appeared and those patients died of the disease within 24 months. Thus the 2-year tumour-free survival rate was 94%. The patients who had positive nodes more often experienced recurrence (27 vs 0%) and a lower 2-year survival rate (72 vs 100%) (P = 0.0067). All of these recurrences were found in patients with three or more positive nodes. This preliminary study suggest that preoperative adjuvant chemotherapy (VBP) is effective (1) in reducing tumour volume or the stage of the disease, (2) in curing the lymph node involvement, and (3) in improving the 2-year tumour-free survival rate. A prospective randomized study comparing radical surgery alone with preoperative adjuvant chemotherapy followed by radical surgery is in progress.

Prognostic factors for risk of recurrence in stages Ib and IIa cervical cancer

The following factors can be clearly identified as independent risk factors for an increased incidence of recurrence and decreased survival in patients with early (Stages Ib and IIa) cervical cancer: 1. Nodal metastases (a) multiple nodes or node groups (b) bilateral nodes or node groups 2. Size of tumour equal to, or greater than, 4 cm 3. Depth of invasion into the cervix equal to, or greater than, 10 mm, or invasion into the outer one-third of the cervix Risk factors which may be important but which are not clearly established as being independent of other factors are: 1. Histological cell type 2. Histological grade 3. Lymphovascular invasion 4. Extension to the corpus uteri 5. Age of the patient at diagnosis 6. Stage IIa It is thus clear that patients with nodal metastases, patients who have large primary tumours, and patients with deep invasion into the cervix should be identified for prospective randomized trials of adjunctive therapy. On the basis of non-randomized historical data, one could legitimately question the value of pelvic irradiation alone in these patients. Recent reports of the use of adjunctive chemotherapy administered preoperatively (Kim et al, 1988) or of adjunctive chemotherapy and radiotherapy administered postoperatively (Wertheim et al, 1985) indicate possible avenues for further investigation.