Evaluation of adjuvant vaginal vault brachytherapy in early stage cervical cancer patients

Brachytherapy and surgery versus surgery alone for IB2 (FIGO 2018) cervical cancers: A FRANCOGYN study

OBJECTIVE

Evaluation of the management by first brachytherapy followed by radical hysterectomy (Wertheim type) compared to radical hysterectomy alone (Wertheim type) for the treatment of IB2 cervical cancer.

METHODS

Data from women with histologically proven FIGO stage IB2 cervical cancer treated between April 1996 and December 2016 were retrospectively abstracted from twelve French institutions with prospectively maintained databases.

RESULTS

Of the 211 patients with FIGO stage IB2 cervical cancer without lymph node involvement included, 136 had surgical treatment only and 75 had pelvic lymph node staging and brachytherapy followed by surgery. The surgery-only group had significantly more adjuvant treatment (29 vs. 3; p = 0.0002). A complete response was identified in 61 patients (81%) in the brachytherapy group. Postoperative complications were comparable (63,2% vs. 72%, p = 0,19) and consisted mainly of urinary (36vs. 27) and digestive (31 vs 22) complications and lymphoceles (4 vs. 1). Brachytherapy had no benefit in terms of progression-free survival (p = 0.14) or overall survival (p = 0.59). However, for tumors of between 20 and 30 mm, preoperative brachytherapy improved recurrence-free survival (p = 0.0095) but not overall survival (p = 0.41). This difference was not observed for larger tumors in terms of either recurrence-free survival (p = 0.55) or overall survival (p = 0.95).

CONCLUSION

Our study found that preoperative brachytherapy had no benefit for stage IB2 cervical cancers in terms of recurrence-free survival or overall survival. For tumor sizes between 2 and 3 cm, brachytherapy improves progression-free survival mainly by reducing pelvic recurrences without improving overall survival.

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.

Current Standards in the Management of Early and Locally Advanced Cervical Cancer: Update on the Benefit of Neoadjuvant/Adjuvant Strategies

Simple Summary

Cervical cancers is a human papillomavirus infection-induced gynecologic cancer. Due to the uneven access to prevention measures in the world, it is still a leading cause of cancer death in women in low- and middle-income countries. The mainstay of treatment for early-stage cervical cancers is upfront surgery. Clinical trials confirmed the place of adjuvant radiotherapy to improve disease control, but also highlighted the need for a careful selection of patients prior to surgery, in order to avoid the cumulative morbidities of each treatment. In locally advanced cervical cancers, the standard of care remains concurrent pelvic chemoradiotherapy followed by an image-guided adaptive brachytherapy boost allowing for dose escalation and leading to a very high probability of local control. Systemic failures remain a major concern, and neoadjuvant or adjuvant approaches in this context are discussed in the light of recent literature.

Abstract

Globally, cervical cancers continue to be one of the leading causes of cancer-related deaths. The primary treatment of patients with early-stage disease includes surgery or radiation therapy with or without chemotherapy. The main challenge in treating these patients is to maintain a curative approach and limit treatment-related morbidity. Traditionally, inoperable patients are treated with radiation therapy solely and operable patients undergo upfront surgery followed by adjuvant (chemo) radiotherapy in cases with poor histopathological prognostic features. Patients with locally advanced cervical cancers are treated with concurrent chemoradiotherapy followed by an image-guided brachytherapy boost. In these patients, the main pattern of failure is distant relapse, encouraging intensification of systemic treatments to improve disease control. Ongoing trials are evaluating immunotherapy in locally advanced tumours following its encouraging efficacy reported in the recurrent and metastatic settings. In this article, clinical evidence of neoadjuvant and adjuvant treatments in cervical cancer patients is reviewed, with a focus on potential strategies to improve patients’ outcome and minimize treatment-related morbidity.

Radiotherapy of cervical cancer

External beam radiotherapy and brachytherapy are major treatments in the management of cervical cancer. For early-stage tumours with local risk factors, brachytherapy is a preoperative option. Postoperative radiotherapy is indicated according to histopathological criteria. For advanced local tumours, chemoradiation is the standard treatment, followed by brachytherapy boost, which is not optional. We present the update of the recommendations of the French Society of Oncological Radiotherapy on the indications and techniques for external beam radiotherapy and brachytherapy for cervical cancer.

Incorporation of vaginal brachytherapy to external beam radiotherapy in adjuvant therapy for high-risk early-stage cervical cancer: A comparative study

PURPOSE

To examine trends, characteristics, and outcomes related to addition of vaginal brachytherapy (VBT) to external beam radiotherapy (EBRT) for adjuvant radiotherapy in high-risk early-stage cervical cancer.

METHODS AND MATERIALS

This comparative study is a retrospective observational analysis of the National Cancer Institutes' Surveillance, Epidemiology, and End Results Program. Surgically treated women with stage T1-2 cervical cancer who had high-risk factors (nodal metastasis and/or parametrial invasion) and received adjuvant radiotherapy from 2000 to 2018 were examined. Propensity score inverse probability of treatment weighting was used to assess the survival estimates for addition of VBT use.

RESULTS

Among 2470 women with high-risk factors receiving EBRT, 760 (30.8%) had additional VBT. During the study period, there was an increasing trend of VBT use from 27.4% to 36.1% (p< 0.001). In a multivariable analysis, year of diagnosis and high-risk tumor factors: parametrial involvement, large tumor size, and use of chemotherapy remained independent characteristics associated with VBT use (all, p< 0.05). In propensity score-weighted models, VBT use with EBRT and EBRT alone had comparable overall survival (5-year rates 73.8% vs. 77.4%, hazard ratio [HR] 1.07, 95% confidence interval [CI] 0.92-1.25). Nonsignificant association was also observed in squamous or nonsquamous tumors, young or old age, low or high nodal ratio, chemotherapy use, and simple or radical hysterectomy (all, p> 0.05). Lastly, the addition of VBT was not associated with cervical cancer-specific survival (subdistribution-HR 1.15, 95% CI 0.94-1.41).

CONCLUSIONS

Utilization of VBT with EBRT for adjuvant radiotherapy in high-risk early-stage cervical cancer is increasing in the United States. Addition of VBT was associated with neither overall survival nor cancer-specific survival.