Chemotherapy in recurrent and advanced cervical cancer

Chemotherapy for recurrent cervical cancer

PURPOSE

Cervical cancer is the second most common cancer of women worldwide and one of the leading cause of death in relative young women. This review gives an outline of chemotherapy of advanced, persistent or recurrent cervical cancer.

METHODS

We performed a literature search in the PubMed of almost all relevant articles concerning chemotherapy of advanced, persistent or recurrent cervical cancer.

RESULTS

The available data from the literature is mainly composed of most recent reviews, phase II and randomized phase III clinical trials.

CONCLUSION

Single-agent cisplatin remains the current standard therapy for advanced, persistent or recurrent cervical cancer. Several single-agents have been tested, but none has been found to be superior compared to cisplatin. Both topotecan and paclitaxel in combination with cisplatin, have yielded superior response rates and progression-free survival without diminishing patient quality of life. However, only the combination of cisplatin and topotecan has improved overall survival. It is important to identify clinical and tumor-related factors predictive of response to cisplatin-based chemotherapy. Future trials are necessary, not only to compare combinations of existing agents, but to incorporate biological agents (monoclonal antibodies or small molecules) to chemotherapy in order to improve the treatment results of advanced, persistent or recurrent cervix cancer.

Chemotherapy for recurrent cervical cancer

OBJECTIVE

To give an overview of chemotherapy schemes used in recurrent cervical cancer.

METHODS

A pubmed search was performed using chemotherapy and recurrent cervical cancer including articles until April 2007.

RESULTS

Most recent articles and articles of interest are discussed.

CONCLUSION

Single agent cisplatin (50 mg/m2) remains the current standard for recurrent cervical cancer. Numerous chemotherapeutic agents have been tested but did not show convincing evidence of improved survival rates, except for the GOG 179 study which showed an improved survival for the combination of cisplatin and topotecan compared with single agent cisplatin. However, nearly 60% of patients in both groups received prior cisplatinum therapy as a radiosensitizer, which could be responsible for the development of platinum resistance, causing lower response and survival rates in the single platinum group. Hence, the apparent benefit in the doublet group is maybe just a reflection from the change in primary therapy and patient population. It is hoped that current trials comparing standard therapy with other single or doublet chemotherapeutic regimens or that the use of molecular-targeted agents will give us promising therapeutic options in the future.

The role of chemotherapy in the management of carcinoma of the cervix

Carcinoma of the cervix remains the most common form of cancer to affect women worldwide despite effective screening techniques. Advances in treatment, particularly systemic therapies, have improved outcomes for cervical cancer. This article examines the role of chemotherapy, particularly in those patients with disseminated disease and those with locally advanced disease in the pelvis.

Role of Ifosfamide in Cervical Cancer: An Overview

Ifosfamide, a cyclophosphamide analogue, has demonstrated a wide spectrum of activity against numerous neoplasms in different oncologic areas, including paediatric, haematological, breast, lung and testicular cancers, soft tissue sarcomas and gynaecological cancer. In gynaecologic cancers in particular, evidence suggests activity in the treatment of epithelial ovarian cancer, cervical carcinoma, germ cell carcinoma of the ovary. Cervical cancer has long been considered a poorly chemosensitive tumour and for several years the role of chemotherapy in the treatment of this tumour was confined to persistent or recurrent disease after failure of surgery and/or radiotherapy. In the management of cervical cancer, chemotherapy has received increasing attention in the last two decades and is currently used in neoadjuvant regimens, as salvage treatment in patients with disseminated or recurrent disease, or as a radiosensitizer. Over the past 30 years, several agents have been tested but cisplatin and ifosfamide are the agents that have attracted the greater attention. Cisplatin represents the cornerstone of chemotherapy for cervical cancer. Ifosfamide has been studied as a single agent or in combination with other drugs in different studies. In this paper we reviewed the approach with systemic therapy and, in particular, the role of ifosfamide in advanced or recurrent, and less advanced cervical cancer.

Phase II clinical study of irinotecan and cisplatin as first-line chemotherapy in metastatic or recurrent cervical cancer

OBJECTIVE

The goal of this study was to evaluate the efficacy and tolerability of irinotecan plus cisplatin as first-line chemotherapy in metastatic or recurrent cervical cancer.

METHODS

Chemotherapy-naive patients with metastatic or recurrent disease and at least one measurable tumor site received irinotecan (60 mg/m(2) IV infusion over 90 min) on Days 1, 8, and 15, followed by cisplatin (60 mg/m(2) IV over 90 min) on Day 1, every 28 days for a maximum of six cycles.

RESULTS

Thirty patients were included in the response and toxicity analysis. The median age was 45 years (34-65). Nineteen patients had metastatic disease, 6 presented with locally recurrent disease, and 5 presented with locally recurrent plus metastatic disease. Seven patients were stage IVB at diagnosis. There were 2 complete and 18 partial responses and overall response rate was 66.7% (95% confidence interval: 47-85%). Stable disease was observed in 2 patients (6.7%) and progression in 8 (26.7%). Median time to relapse was 13.4 months, with a median survival time of 16.9 months. One-year disease-free survival and overall survival were 26.7 and 65.1%, respectively. Dose-limiting toxicity was observed in 4 patients (13.3%) with grade 3 renal toxicity. Nine patients (30%) developed grade 3 neutropenia, and only grade 1-2 acute and late diarrhea were observed in 20 and 40%, respectively. A patient developed pancolitis after the sixth cycle. There were no chemotherapy-related deaths.

CONCLUSION

The combination of irinotecan and cisplatin is a clinically active regimen for metastatic and/or recurrent cervical cancer with acceptable tolerability.

Randomized phase III trial of bleomycin, vindesine, mitomycin-C, and cisplatin (BEMP) versus cisplatin (P) in disseminated squamous-cell carcinoma of the uterine cervix: an EORTC Gynecological Cancer Cooperative Group study

PURPOSE

Three previous mitomycin-cisplatin-based chemotherapy trials conducted within the EORTC Gynecological Cancer Cooperative Group (GCCG) in patients with disseminated squamous-cell carcinoma of the uterine cervix (SCCUC) suggested that with such regimens a higher overall response rate and a higher complete response rate could be obtained compared to what might have been expected from cisplatin alone. In that respect the combination of bleomycin, vindesine (Eldesine), mitomycin C and cisplatin (BEMP) was the most promising. In the present study BEMP has been compared with the best single agent, cisplatin (P) in the expectation that improved response rates might translate into a better survival.

PATIENTS AND METHODS

Eligible patients were those with SCCUC and disseminated measurable disease outside previously irradiated areas, aged < or = 75 years, with a WHO performance status < or = 2 and adequate bone marrow, renal, hepatic and pulmonary function, who gave consent according to regulations followed in individual institutions. Patients were randomized to BEMP: E 3 mg/m2 day 1, P 50 mg/m2 day 1, B 15 mg (24-hour infusion) day 2-4 and M 8 mg/m2 (at alternate cycles), or P 50 mg/m2. The first four cycles were given every 3 weeks (induction phase). Subsequent cycles were given every four weeks (maintenance phase), during which B was deleted from BEMP (MEP). Patients failing on P could be treated with BEM. Of the 287 patients entered, 235 were eligible and 201 evaluable for response.

RESULTS

BEMP induced a significantly higher response rate than P (42% vs. 25%, P = 0.006). There was no difference in complete response rate (11% vs. 7%). BEMP was significantly more toxic than P (+/- BEM), both with respect to hematologic and nonhematologic toxicities. After a median follow-up of 6.1 years, survival curves were not significantly different. Median progression-free survival and overall survival were 5.3 and 10.1 months with BEMP and 4.5 and 9.3 months with P (+/- BEM), respectively. In a multivariate analysis of prognostic factors for survival, a lower age (P = 0.003), a lower performance status (P = 0.0001) and a short (<1 year) interval since diagnosis (P = 0.0152) were all associated with an increased risk of dying. For progression-free survival, lower age, prior radiotherapy, locoregional involvement and no prior surgery were associated with a high risk. Treatment with BEMP or P had no significant impact on survival, but for progression-free survival there was a trend in favor of BEMP (P = 0.0893). Adjusting for prognostic factors did not change the effect of treatment.

CONCLUSIONS

Combination chemotherapy with BEMP produces more toxicity and more responses compared with cisplatin alone in patients with disseminated SCCUC, but this does not translate into a better survival. Therefore, in the palliative setting single-agent cisplatin should remain the standard therapy for these patients.

Chemotherapy for advanced or recurrent carcinoma of the cervix

The management of early-stage cervical cancer involves primarily surgery and/or chemoradiotherapy. When the disease spreads beyond the cervix but remains confined to the pelvis and draining lymph node basins, the mainstay of management is chemoradiotherapy. The use of primary systemic chemotherapy is related to the management of disease that has recurred or spread beyond the pelvic radiation fields. Although the optimal chemotherapy regimen remains to be determined, current protocols and the associated research to support their use are discussed in this review. Additionally, the rationale for use of chemoradiotherapy in locally advanced disease is presented.

A randomised, prospective, phase III clinical trial of primary bleomycin, ifosfamide and cisplatin (BIP) chemotherapy followed by radiotherapy versus radiotherapy alone in inoperable cancer of the cervix

BACKGROUND

Phase II studies have shown primary (neo-adjuvant) chemotherapy with bleomycin, ifosfamide and cisplatin (BIP) is active against inoperable cervical cancer. We present here results of a randomised phase III multicentre trial comparing radical radiotherapy with neo-adjuvant BIP chemotherapy followed by radical radiotherapy in patients with inoperable cervical cancer, designed to discover whether this combination might improve survival.

PATIENTS AND METHODS

Patients with inoperable cervical carcinoma were randomised to pelvic radiotherapy alone [RT] or two to three cycles of bleomycin 30 units/24-hour infusion, ifosfamide 5 g/m2/24 hours, and cisplatin 50 mg/m2) chemotherapy followed by pelvic radiotherapy (BIP + RT). Randomisation was stratified by stage and radiotherapy centre.

RESULTS

One hundred seventy-two eligible women were randomised into this trial; eighty-six to RT and eighty-six to BIP + RT. A total of 190 cycles of chemotherapy were given. Median follow-up for the 47 patients still alive is 9 years with a minimum follow-up of 3 years. Complete or partial response occurred in 51 of 86 (59%) of those randomised to RT and 60 of 86 (69%) of those randomised to BIP + RT. The difference between response rates does not reach statistical significance (chi2 = 2.06, P = 0.15). Median survival is two years with an actuarial survival at five years of 32% (95% confidence interval (95% CI): 25%-39%). There is no significant difference between the treatment groups (chi2log-rank = 0.11, P = 0.74).

CONCLUSIONS

This study does not show any survival benefit from the use of neo-adjuvant BIP chemotherapy in advanced cervical cancer.

A phase II trial of mitomycin, ifosfamide and cisplatin in recurrent carcinoma of the cervix

The purpose of this study was to evaluate the efficacy and the toxicity of mitomycin, ifosfamide, and cisplatin in patients with recurrent carcinoma of the cervix. Between July 1992 and March 1995, 20 patients with recurrent cervical cancer were enrolled in this study. No patients had received prior chemotherapy for metastatic disease, except some were exposed to cisplatin as a radiosensitizer at the time of their diagnosis. Mitomycin-C 6 mg/m2, ifosfamide 3 g/m2, and cisplatin 50 mg/m2 were given intravenously every 3 weeks. All patients were assessible for response and toxicity, and none was lost to follow-up. All patients except one had squamous cell carcinoma. The overall response rate was 45% (2 complete remissions and 7 partial remissions). The mean response duration was 35 months, and the median survival from treatment for the whole group was 14 months. Fifteen percent of all cycles produced grade 3 or 4 myelosuppression, and the main nonhematologic toxicity was nausea and vomiting, which was reported in 11.5% of all cycles. One death occurred secondary to chemotherapy-induced septicemia. Three patients are still alive, two with a complete response and one with a partial response. In conclusion, mitomycin, ifosfamide, and cisplatin have a good activity in recurrent carcinoma of the cervix and are comparable to other combination chemotherapy.

A clinicopathological study of postoperative pulmonary metastasis of uterine cervical carcinomas

OBJECTIVE

To investigate the clinicopathological backgrounds and prognostic factors of uterine cervical carcinomas metastatic to the lung.

METHODS

A total of 519 patients with invasive cervical carcinoma (Stage pTIb-IIb) treated by abdominal radical hysterectomy at the Saitama Cancer Center from January 1, 1976 to December 31, 1989 were analyzed clinicopathologically.

RESULTS

The frequencies of pulmonary metastasis were 6.4% (24/377) and 11.3% (16/142) in patients with negative and positive pelvic lymph nodes, respectively. Among 24 negative lymph node patients, 15 had pulmonary metastasis only. The overall 5-year survival rate of these 15 patients was 36% after relapse. Of the 15, the prognosis of 12 patients with 1-3 pulmonary metastases only was better, that is, 46% after surgical resection (mean size of resectable tumor = 2.8 cm) and/or chemotherapy. But the other patients died within 3.3 years after relapse.

CONCLUSIONS

The occurrence of pulmonary metastasis only, its number (1-3) and size (mean size = 2.8 cm), and no lymph node metastasis are important prognostic factors. For these patients, active surgical resection of the pulmonary lesion(s) and further chemotherapy are recommended in order to improve their prognosis.

Palliative chemotherapy in recurrent carcinoma of the cervix: an audit of the use of ifosfamide and review of the literature

A review was conducted on 34 patients treated with intravenous ifosfamide for relapsed, inoperable carcinoma of the cervix between 1988 and 1996. The median age of patients was 44 years. Thirty-two patients had squamous cell carcinoma and 2 had adenocarcinoma. Radiotherapy had been used in primary management in 33, neo-adjuvant platinum chemotherapy in 7, and previous palliative chemotherapy in 11. Symptomatic response was assessed with respect to the symptom requiring palliaton. 25 patients failed to complete 6 cycles of chemotherapy: due to progressive disease in 14, lack of symptom response in 2, and toxicity in 11 of whom 7 had encephalopathy sufficient to abandon treatment. 32 patients were evaluable for objective response. Pathologic complete response (CR) was achieved in 1 patient, and partial response (PR) was achieved in 3 patients. The objective response rate was 11.8%. Symptomatic response throughout treatment occurred in 8 patients (24%); objective response was seen in only 3 (1 CR, 2 PR) of them and progressive disease in the remaining 5. Response duration in the 4 objective responders was 25 months in the patient with CR and 4, 6 and 8 weeks in the 3 patients with PR. In conclusion, ifosfamide, as given, is associated with unacceptable toxicity and insufficient symptomatic efficacy for use as a palliative treatment in patients with relapsed carcinoma of the cervix.

Single agent versus combination chemotherapy in recurrent cervical cancer

OBJECTIVE

Cisplatin and ifosfamide are two most active agents in patients with recurrent and metastatic cervical cancer. Combination of bleomycin, ifosfamide and cisplatinum (BIP) was compared with cisplatinum alone.

PATIENTS AND METHODS

One hundred and six patients with recurrent/persistent and metastatic cervical cancer received either a combination of bleomycin, ifosfamide and cisplatinum, (Group A, n = 50) or cisplatinum alone (Group B, n = 56) every 3 weeks for up to 6 courses. Ninety-seven patients were evaluable and were analysed for response and survival.

RESULTS

Patients receiving BIP (Group A) had a higher response rate (complete and partial responses), 52.2% vs 29.4%, p < 0.01 with overall median survival, 8 months (1 to 92+ months) vs 6 months (1 to 40+ months), p = 0.18. Chemotherapy responders had a significantly higher survival in both groups compared to the non-responders (Group A: 17 vs 6 months, p < 0.001, Group B: 20.5 months vs 5 months, p < 0.001). Patients in good performance status (ECOG, 0-2) had a significantly higher response rate to chemotherapy (Group A: 70.3% vs 26.3%, p < 0.01, Group B: 38.2% vs 11.7%, p < 0.05). In Group A, patients with extrapelvic disease responded better compared to pelvic disease (83.3% vs 34.5%, p < 0.01). Chemotherapy side effects were mainly nausea/vomiting, alopecia, myelosuppression, reversible encephalopathy (in Group A), and impaired renal functions. Chemotherapy toxicity was higher for patients receiving BIP, 2 patients died of BIP toxicity. Currently, in 'Group A' 8 patients are alive, 7 disease-free and one with disease at a median interval of 51 months after chemotherapy treatment. While in Group B, 3 patients are alive, 2 disease-free and one with disease.

CONCLUSIONS

Bleomycin, ifosfamide and cisplatin improved the response rate in recurrent and metastatic cervical cancer compared with cisplatinum alone. However, the toxicity was moderate and survival was not significantly improved. These results need to be confirmed in a phase III, randomized study in larger number of patients.

Treatment of late recurrent vaginal malignancy after initial radiotherapy for carcinoma of the cervix: an analysis of 73 cases

PURPOSE

To evaluate the reirradiation therapy in late recurrent vaginal malignancy after initial radiotherapy for carcinoma of the cervix.

METHODS

From July 1972 to July 1992, 73 cases of late recurrent (over 5 years) vaginal malignancy after initial radiotherapy for cervical cancer were treated in our hospital. Both the original and recurrent cancers were biopsy-proven squamous cell carcinoma. All of these patients received reirradiation therapy; chemotherapy or operation was combined when necessary. The reirradiation was planned according to the site and volume of the recurrent tumor, previous radiation dose, and radiation side effects. Brachytherapy was mainly used. Before 1981, radium therapy was delivered at 30-40 Gy in 3-5 fractions to tumor base within 3-4 weeks. High-dose-rate (100 cGy/min) cobalt-60 afterloading therapy (Ralstron therapy) has been used instead of radium since 1981; the dose to the tumor base was 20-35 Gy/3-5 fractions/3-4 weeks. Then, vaginal mold was supplemented with a dose to a point 0.5 cm below the surface of the vaginal mucosa at 20-30 Gy/4-6 fractions/2-3 weeks. When the vulva or groin was involved, cobalt-60 or high-energy electron beam radiation was added with a dose at 30-40 Gy. Among these, 61 patients received irradiation therapy alone. Eleven patients received irradiation combined with chemotherapy. One patient received hysterectomy after reirradiation.

RESULTS

The 2-, 3-, and 5-year survival rates in this series were 54.7% (40/73), 46. 6% (28/60), and 40.3% (21/52), respectively. The 5-year survival rates for upper, upper-middle, and upper-lower vaginal tumor were 81. 8% (9/11), 33.3% (5/15), and 25.0% (3/12), respectively. The effect for upper vaginal recurrent malignancy was remarkably better than that for the upper-lower rate (P < 0.05). The local control rates for tumor >4 and <4 cm were 26.6% (4/15) and 86.5% (32/37), respectively (P < 0.01). The side effects of reirradiation in this series were serious: both moderate and severe radiation reactions were rectum 13.6% (10/73), hematuria 12.3% (9/73), vesicovaginal fistula 1.4% (1/73), and rectum-vaginal fistula 11.0% (8/73).

CONCLUSIONS

We conclude that reirradiation for late recurrence in the vagina after previous radiotherapy for cervical cancer is valuable. Early detection and treatment could achieve better results. The smaller the recurrent tumor volume, the better the treatment effects. Reirradiation therapy should be carefully managed in order to reduce the complications as much as possible.

The addition of bleomycin and dose-escalated ifosfamide to the combination of cisplatin plus ifosfamide does not improve survival in advanced or recurrent cervical carcinoma

Twenty patients with advanced or recurrent cervical cancer were treated with bleomycin 30 U, ifosfamide 5 g/m2, and cisplatin 50 mg/m2 (BIP) every 28 days in a phase II trial. The primary purpose of this study was to compare response rate, survival, and toxicity of this regimen with results obtained in a similar group of patients treated with cisplatin 1 mg/kg per week for six courses followed by cisplatin, 20 mg/m2, plus ifosfamide 1.2 g/m2 daily for 3 days every 28 days. Four of 17 evaluable patients (23.5%) treated with BIP demonstrated a response to therapy (complete response 11.7%; partial response 11.7%). The median duration of response was 8.5+ months (range, 6+ to 24 months). These data do not differ significantly (P = 0.76) from a response rate of 27.5% among patients treated with cisplatin plus ifosfamide (PI). A significant (P = 0.003) increase in myelotoxicity was observed among patients treated with BIP versus those treated with PI. The median survival of patients treated with BIP of 13.5+ months (range, 8+ to 24 months) does not differ significantly from the median survival of 9+ months (3 to 26+ months) among patients treated with PI. The addition of bleomycin and dose-escalated ifosfamide did not significantly improve response rate or survival among patients with advanced or recurrent cervical cancer and resulted in a significant increase in myelotoxicity.

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.

Neoadjuvant chemotherapy using a platinum, vincristine and peplomycin (CVP) combination in patients with carcinoma of the uterine cervix

Neoadjuvant chemotherapy consisting of a cis-platinum, vincristine and peplomycin (CVP) combination has been used to treat patients with carcinoma of the uterine cervix at our departments since 1983. Twenty-one patients are reviewed in this study. A high response rate (71.4%) was obtained with 19.0% complete and 52.4% partial responses prior to radical therapy. Survival times and the progression free interval for stage I and III disease treated with CVP show improvement compared to patients not treated with CVP. No life-threatening toxicity related to chemotherapy was noted. This combination chemotherapy used in neoadjuvant setting warrants further study.

A phase II study of weekly cisplatin followed by cisplatin and ifosfamide in advanced or recurrent cervical carcinoma

BACKGROUND

Ifosfamide is an active agent in cisplatin-resistant cervical cancer. To determine the response rate of the combination of cisplatin and ifosfamide, a Phase II study was conducted of the administration of the combination after weekly cisplatin induction therapy.

METHODS

Forty-seven patients with advanced or recurrent cervical carcinoma were treated with 1 mg/kg of cisplatin weekly for six courses, followed by 20 mg/m2 of cisplatin and 1.2 g/m2 of ifosfamide daily for 3 days every 28 days.

RESULTS

Objective responses were seen in 11 of 40 (27.5%) assessable patients (complete response, 20%; partial response, 7.5%). The duration of response ranged from 3 months to 26+ months (median, 9+ months). All of the patients who responded to the cisplatin-ifosfamide combination initially responded to weekly cisplatin induction therapy. None of the four patients who had previously received chemotherapy responded. Grade 3 or 4 hematologic toxic effects occurred in 17 of 43 patients (39%). Neurologic and urologic toxic effects were infrequent. The current response rates are not better than the prior experience of the authors with other cisplatin combinations.

CONCLUSIONS

These results do not confirm the favorable reports of other authors with cisplatin-ifosfamide regimens in cervical carcinoma. The results of ongoing Phase III studies comparing cisplatin-ifosfamide with cisplatin alone in cervical carcinoma are awaited.

Proposal of a modified (FIGO 1985) classification of stages I and II cancer of the uterine cervix

A modified FIGO (1985) classification of cancer of the uterine cervix has been suggested. The changes refer to stages I and II of the disease. The already accepted system of cervical cancer staging has been used. Stages Ib, IIa, and IIb have been subdivided, similar to stage Ia. The criterion used in staging is the size of the tumor up to, or more than 2 cm (Ib 1 and Ib 2) and, for stage II, the extent of penetration into adjacent tissue. The condition of lymph nodes should be noted by LN(+) or LN(-) along with the stage of the disease. Such staging should demonstrate an objective evaluation of treatment results obtained by different methods and their combinations.

Intracranial metastases from carcinoma cervix and review of literature

Brain metastases from primary cervical carcinoma are uncommon. Only 41 cases have been reported so far in the English literature. We have seen 2 cases over the last 2 years among 481 patients with cervical cancer. Brain metastases developed 7 and 35 months after the primary diagnosis. One patient with solitary metastasis had no evidence of disease elsewhere and is free of disease after surgery and radiation therapy 7 months after the brain metastasis. Another patient with multiple brain metastases and cervical disease is alive 2 months after palliative radiation therapy.

Combined chemotherapy using cisplatin, ifosfamide and bleomycin (PIB) in the treatment of advanced and recurrent cervical carcinoma

Combined cisplatin, ifosfamide and bleomycin (PIB) chemotherapy was given to 14 (11 recurrent and 3 advanced and metastatic) cervical carcinoma patients. At least 2 cycles of chemotherapy were given before assessment of tumour response. The overall response rate was 28.6%; the complete response rate was 14.3%. Sites of response included cervical lymph nodes and the lung. Toxicity was common. Alopecia was universal. Other toxicity included suppression of haematopoiesis (73%), leucopenia (71%) and nausea and vomiting. Two patients died from sepsis during the myelosuppressive phase. The role of PIB in the management of advanced and recurrent carcinoma of the cervix should be evaluated in a randomized-controlled trial.

A preoperative single course of high-dose cisplatin and bleomycin with glutathione protection in bulky stage IB/II carcinoma of the cervix

One course of preoperative chemotherapy including high-dose cisplatin (40 mg/m2 daily for 5 consecutive days) with glutathione protection and bleomycin (15 mg on days 2, 8 and 9) was administered to 27 patients with bulky operable cervical carcinoma (stage IB/II) in a pilot study. In all patients the tumor diameter was greater than 4 cm. Surgery (radical hysterectomy with pelvic and para-aortic lymphadenectomy) was planned within one month of chemotherapy. In 27 evaluable patients, nausea/vomiting was the most pronounced side effect. Significant (but transient) increases in serum transaminases were detected in 19 patients. Electrolyte imbalance (hypokalemia) was detected in 6 patients (one with hypocalcemia). These reversible effects were not associated with other signs of renal toxicity. Objective clinical responses were observed in 21 patients, 18 of them partial and 3 complete responders (pathologically confirmed in 2). Radical hysterectomy with pelvic and para-aortic lymphadenectomy was performed with no particular complications. The shrinking of bulky tumor made the operation easier, especially in parametrial resections. High-dose cisplatin chemotherapy prior to surgery is feasible with acceptable toxicity. The encouraging results of this study warrant further investigations to define the role of neoadjuvant therapy.