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Wang L, Yi S, Teng Y, Li W, Cai J. Role of the tumor microenvironment in the lymphatic metastasis of cervical cancer (Review). Exp Ther Med 2023; 26:486. [PMID: 37753293 PMCID: PMC10518654 DOI: 10.3892/etm.2023.12185] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/15/2023] [Indexed: 09/28/2023] Open
Abstract
Lymphatic metastasis is the primary type of cervical cancer metastasis and is associated with an extremely poor prognosis in patients. The tumor microenvironment primarily includes cancer-associated fibroblasts, tumor-associated macrophages, myeloid-derived suppressor cells, immune and inflammatory cells, and blood and lymphatic vascular networks, which can promote the establishment of lymphatic metastatic sites within immunosuppressive microenvironments or promote lymphatic metastasis by stimulating lymphangiogenesis and epithelial-mesenchymal transformation. As the most important feature of the tumor microenvironment, hypoxia plays an essential role in lymph node metastasis. In this review, the known mechanisms of hypoxia, and the involvement of stromal components and immune inflammatory cells in the tumor microenvironment of lymphatic metastasis of cervical cancer are discussed. Additionally, a summary of the clinical trials targeting the tumor microenvironment for the treatment of cervical cancer is provided, emphasizing the potential and challenges of immunotherapy.
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Affiliation(s)
- Lufang Wang
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Shuyan Yi
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Yun Teng
- Department of Laboratory Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine; Key Laboratory of Clinical In Vitro Diagnostic Techniques of Zhejiang Province; Institute of Laboratory Medicine, Zhejiang University, Hangzhou, Zhejiang 310000, P.R. China
| | - Wenhan Li
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Jing Cai
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
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Wang W, Meng Q, Zhou Y, Hu K, Zhang F, Qiu J, Hou X, Lian X, Yan J, Liu Z, Sun S, Ma J, Liu X. Prophylactic Extended-Field Irradiation Versus Pelvic Irradiation in Patients With Cervical Cancer With 2018 FIGO Stage IIIC1 Disease. Pract Radiat Oncol 2023; 13:e409-e415. [PMID: 37075837 DOI: 10.1016/j.prro.2023.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/14/2023] [Accepted: 03/14/2023] [Indexed: 04/21/2023]
Abstract
PURPOSE The aim of this study was to compare the survival rates and toxicities of prophylactic extended-field radiation therapy (EFRT) and pelvic radiation therapy (PRT) among patients with cervical cancer with 2018 International Federation of Gynecology and Obstetrics (FIGO) stage IIIC1 disease. METHODS AND MATERIALS We retrospectively analyzed patients with 2018 FIGO stage IIIC1 disease who were treated with definitive concurrent chemoradiotherapy at our institute between 2011 and 2015. A dose of 50.4 Gy in 28 fractions was delivered to the pelvic region (by PRT) or the pelvic plus para-aortic lymph node region (by EFRT) with intensity modulated radiation therapy. The first-line regimen of concurrent chemotherapy was weekly cisplatin. RESULTS A total of 280 patients were included, with 161 patients treated with PRT and 119 patients treated with EFRT. After propensity score matching (1:1), 71 pairs of patients were selected. The respective 5-year rates of the patients treated with PRT and EFRT were 61.9% and 85.0% for overall survival (P = .025) and 53.0% and 77.9% for disease-free survival (DFS) (P = .004), respectively, after matching. In the subgroup analysis, patients were grouped into a high-risk group (122 patients) and a low-risk group (158 patients) based on 3 factors: positive common iliac lymph nodes, ≥3 pelvic lymph nodes, and 2014 FIGO stage IIIB disease. In both the high-risk and low-risk groups, EFRT significantly improved DFS compared with PRT. The rates of grade ≥3 chronic toxicities were 1.2% and 5.9% in the PRT and EFRT groups, respectively (P = .067). CONCLUSIONS In comparison to PRT, prophylactic EFRT was associated with improved overall survival, DFS, and para-aortic lymph node control in patients with cervical cancer with FIGO stage IIIC1 disease. The incidence of grade ≥3 toxicities was higher in the EFRT group than in the PRT group, although the difference was not significant.
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Affiliation(s)
- Weiping Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qingyu Meng
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuncan Zhou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Jie Qiu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaorong Hou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Lian
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Junfang Yan
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhikai Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuai Sun
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiabin Ma
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoliang Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Clinical analysis of prophylactic para-aortic intensity-modulated radiation in cervical cancer. Clin Radiol 2023; 78:e77-e84. [PMID: 36195500 DOI: 10.1016/j.crad.2022.08.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 01/18/2023]
Abstract
AIM This study aimed to compare the survival and toxicity of patients with International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB1-IIIC cervical cancer without common iliac node metastasis treated with extended-field intensity-modulated radiotherapy (EF-IMRT) or pelvic IMRT (P-IMRT). MATERIALS AND METHODS Thirty-one patients treated with EF-IMRT and 37 patients who underwent P-IMRT were analysed retrospectively. Both groups were treated with high-dose-rate 192Ir two-dimensional brachytherapy and concurrent chemotherapy. The chi-square test and Kaplan-Meier method were used to compare toxicity and survival between the two groups. RESULTS The median follow-up time of EF-IMRT group and P-IMRT group was 22 and 30 months, respectively. The 3-year overall survival (OS), progression-free survival (PFS), and para-aortic lymph node metastasis-free survival (PAMFS) in the EF-IMRT group and P-IMRT group were 87% versus 74.6%, 83.6% versus 61.7%, and 96% versus 80.5%, respectively. Treatment regimens, tumour size, and radiation time were independent prognostic factors of OS and PFS. Treatment regimens, tumour size, and total equivalent dose in 2 Gy/f (EQD2) of point A were independent prognostic factors of PAMFS. Five patients in the EF-IMRT group and 14 patients in P-IMET group experienced treatment failure. The cumulative incidence of grade 3 and 4 acute leukopenia in the EF-IMRT group was 51.6%, in comparison with 27.03% in the pelvic group. No difference was found in thrombocytopenia between two groups. CONCLUSIONS Patients with FIGO 2009 stage IB1-IIIC cervical cancer without common iliac node metastases may be benefit from EF-IMRT. Notably, EF-IMRT exhibits increased toxicity incidence; however, this remains within an acceptable range.
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Yoon M, Lee HK, Park EY, Kim JH, Lee JH, Kim YS, Kim HJ, Kim H, Yoo CW, Lee S, Hong EK, Kim TH, Kim TS, Seo SS, Kang S, Chang SJ, Shin HJ, Uong TNT, Lee S, Kim JY. Randomized multicenter phase II trial of prophylactic irradiation of para-aortic lymph nodes in advanced cervical cancer according to tumor hypoxia: Korean Radiation Oncology Group (KROG 07-01) study. Int J Cancer 2022; 151:2182-2194. [PMID: 35751421 DOI: 10.1002/ijc.34190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 05/24/2022] [Accepted: 06/13/2022] [Indexed: 11/09/2022]
Abstract
We conducted a prospective phase II study on whether extended-field irradiation (EFI) confers survival benefits depending on hypoxic markers in locally advanced uterine cervical cancer (LAUCC). RNA-seq was performed to identify immune and hypoxic gene signatures. A total of 288 patients were randomized to either EFI or pelvic radiotherapy (PRT). All patients completed chemoradiotherapy. Overall, significantly higher 5-year para-aortic recurrence free survival (PARFS) rate occurred in EFI (97.6%) than in PRT group (87.2%), with marginal tendency to improve disease-free survival (DFS; 78% vs 70%, P = .066). Subgroup analyses were performed based on carbonic anhydrase 9 (CA9)-only positive, CA9/hypoxia-inducible factor (HIF) double positive and CA9 negative. In the CA9-only positive, EFI successfully increased 5-year PARFS (100% vs 76.4%, P = .010), resulting in significantly improved long-term DFS (85.7% vs 54.7%, P = .023) compared to the PRT, while there was no such benefit of EFI in the CA9/HIFs double positive. RNA-seq analysis identified distinct immunehigh subgroup with negative correlation with hypoxia gene signatures (R = -.37, P < .01), which showed a higher 5-year DFS than the immunelow (P = .032). Hypoxia-related genes were upregulated in the CA9/HIFs double positive compared to CA9 negative (P < .05). Only 17.4% of patients in CA9-negative group showed immunelow signatures, while 40.0% of patients in the double-positive group exhibited immunelow signatures. In conclusion, EFI improved PARFS significantly in all patients, but therapeutic efficacy of EFI in terms of improved DFS was solely observed in CA9-only positive LAUCC, and not in CA9/HIFs double-positive subgroup. RNA-seq analysis suggested that hypoxia-induced immunosuppression may be related to treatment resistance in LAUCC.
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Affiliation(s)
- Meesun Yoon
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Hyo Kyung Lee
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology, Ulsan, South Korea
| | - Eun Young Park
- Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Jin Hee Kim
- Department of Radiation Oncology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, South Korea
| | - Jong Hoon Lee
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University, Seoul, South Korea
| | - Young Seok Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, South Korea
| | - Hak Jae Kim
- Department of Radiation Oncology, Seoul National University, College of Medicine, Seoul, South Korea
| | - Hunjung Kim
- Department of Radiation Oncology, Inha University Hospital, Inha University, School of Medicine, Incheon, South Korea
| | - Chong Woo Yoo
- Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Sun Lee
- Department of Pathology, College of Medicine, Kyung Hee University, Seoul, South Korea
| | - Eun Kyung Hong
- Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Tae Hyun Kim
- Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Tae-Sung Kim
- Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Sang-Soo Seo
- Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Sokbom Kang
- Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Suk-Joon Chang
- Gynecologic Cancer Center, Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, South Korea
| | - Hye Jin Shin
- Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Tung Nguyen Thanh Uong
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Semin Lee
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology, Ulsan, South Korea
| | - Joo-Young Kim
- Research Institute and Hospital, National Cancer Center, Goyang, South Korea
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Bukkems LJ, Jürgenliemk-Schulz IM, van der Leij F, Peters M, Gerestein CG, Zweemer RP, van Rossum PS. The impact of para-aortic lymph node irradiation on disease-free survival in patients with cervical cancer: a systematic review and meta-analysis. Clin Transl Radiat Oncol 2022; 35:97-103. [PMID: 35669003 PMCID: PMC9166370 DOI: 10.1016/j.ctro.2022.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/24/2022] [Accepted: 05/27/2022] [Indexed: 11/28/2022] Open
Abstract
Standard of care of locally advanced cervical cancer is based on concurrent chemoradiotherapy. Para-aortic radiotherapy (PAO-RT) has become controversial in the chemotherapy era. Systematic review on impact of PAO-RT on disease-free survival yielded 11 studies. Meta-analysis of 3 studies showed pooled adjusted HR of 0.87 (95% CI: 0.79–0.97). Findings support further investigation in prospective controlled trials.
Background Patients with locally advanced cervical cancer without para-aortic lymph node metastases (PAO-LNM) at diagnosis who undergo concurrent chemoradiotherapy are at 4–11% risk of developing PAO-LNM during follow-up. Some studies suggest a beneficial influence of elective para-aortic radiotherapy (PAO-RT) on disease-free survival (DFS) in these patients. The aim of this study was to systematically review and meta-analyse literature on the impact of PAO-RT on DFS in cervical cancer patients. Methods A systematic search of PubMed/MEDLINE and EMBASE databases was performed. The analysis included intervention studies that reported on DFS in patients with cervical cancer who received chemotherapy and pelvic radiotherapy with or without PAO-RT. From each included study, relevant study characteristics and outcome data including the hazard ratio (HR) adjusted for potential confounders were extracted. An overall pooled adjusted hazard ratio (aHR) for DFS after PAO-RT versus no PAO-RT was calculated using a random-effects model. Results A total of 2,016 articles were evaluated. Eleven articles were included in the systematic review, of which 3 were appropriate for quantitative meta-analysis. Pooling of these 3 cohorts (including 1,113 patients) demonstrated a statistically significant association between PAO-RT and DFS (pooled aHR 0.87, 95% confidence interval: 0.79–0.97). No significant heterogeneity among reported aHRs was observed (I2 = 0.0%). Conclusions This meta-analysis suggests a modest but significant beneficial impact of elective para-aortic radiotherapy on DFS in patients with locally advanced cervical cancer who undergo concurrent chemoradiotherapy. This finding based on non-randomized studies provides an imperative for further investigation in prospective controlled trials.
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Affiliation(s)
- Leslie J.H. Bukkems
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ina M. Jürgenliemk-Schulz
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Corresponding authors at: Department of Radiation Oncology, Q00.3.11, University Medical Center Utrecht, PO Box 85500, 3508GA Utrecht, The Netherlands.
| | - Femke van der Leij
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Max Peters
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Cornelis G. Gerestein
- Department of Gynecologic Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ronald P. Zweemer
- Department of Gynecologic Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Peter S.N. van Rossum
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Corresponding authors at: Department of Radiation Oncology, Q00.3.11, University Medical Center Utrecht, PO Box 85500, 3508GA Utrecht, The Netherlands.
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Kumar HS, Daga P, Sharma N, Jakhar S, Harsh K, Dhaka S. Clinical impact of extended field radiation therapy in Stage III carcinoma cervix versus conventional field techniques: A comparative study. J Cancer Res Ther 2022; 18:1083-1087. [DOI: 10.4103/jcrt.jcrt_597_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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Huang X, Fang M, Zhu L, Gu C, Cui H, Yang C, Yang Y. Clinical Observation of Prophylactic Extended-Field Intensity-Modulated Radiation Therapy with Synchronous Chemotherapy in Locally Advanced Cervical Cancer. Med Sci Monit 2021; 27:e930457. [PMID: 34489390 PMCID: PMC8434770 DOI: 10.12659/msm.930457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 05/18/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND We aimed to evaluate the value of prophylactic extended-field intensity-modulated radiation therapy (IMRT) in the treatment of locally advanced cervical cancer with multiple pelvic lymph node metastases (≥2) and negative common iliac and paraaortic lymph nodes. MATERIAL AND METHODS Thirty-four patient with newly diagnosed cervical cancer (IB1-IVA) and multiple pelvic lymph node metastases (≥2) confirmed by computed tomography and magnetic resonance imaging were randomly divided into an extended-field group (17 patients) and a pelvic-field group (17 patients). In the extended-field group, we added the drainage area of paraaortic lymph nodes on the pelvic field. The pelvic field was administered Dt 45.0 to 50.4 Gy, while the drainage area of paraaortic lymph nodes was administered Dt 40.0 to 45.0 Gy. Both groups were given Irl92 intracavitary radiotherapy after 3 weeks of external irradiation. The total dose of point A was 25.0 to 30.0 Gy, fractional 6.0 to 7.0 Gy. All patients had concurrent platinum-based chemotherapy once weekly until the end of radiotherapy. RESULTS No paraaortic lymph node metastasis was found in the extended-field group (P=0.0184), and disease-free survival (DFS) was prolonged (P=0.0286). Adverse effects in patients with III-IV degree myelosuppression were increased in the extended-field group (P=0.0324). However, all patients recovered after symptomatic treatment. CONCLUSIONS Prophylactic extended-field IMRT with chemotherapy reduced the metastasis rate of paraaortic lymph nodes and prolonged the DFS in patients with locally advanced cervical cancer and multiple pelvic lymph node metastases (≥2), while the toxic adverse effects were tolerated.
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Affiliation(s)
- Xue Huang
- Department of Gynecology and Oncology, Changzhou Tumor Hospital Affiliated with Soochow University, Changzhou, Jiangsu, PR China
| | - Mingming Fang
- Department of Radiation Oncology, Changzhou Tumor Hospital Affiliated with Soochow University, Changzhou, Jiangsu, PR China
| | - Lin Zhu
- Department of Gynecology and Oncology, Changzhou Tumor Hospital Affiliated with Soochow University, Changzhou, Jiangsu, PR China
| | - Cheng Gu
- Department of Radiation Oncology, Changzhou Tumor Hospital Affiliated with Soochow University, Changzhou, Jiangsu, PR China
| | - Han Cui
- Department of Gynecology and Oncology, Changxing County People’s Hospital, Huzhou, Zhejiang, PR China
| | - Chun Yang
- Department of Obstetrics and Gynecology, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, Jiangsu, PR China
| | - Yuxing Yang
- Department of Gynecology and Oncology, Changzhou Tumor Hospital Affiliated with Soochow University, Changzhou, Jiangsu, PR China
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Peters M, de Leeuw AAC, Nomden CN, Tanderup K, Kirchheiner K, Lindegaard JC, Kirisits C, Haie-Meder C, Sturdza A, Fokdal L, Mahantshetty U, Hoskin P, Segedin B, Bruheim K, Rai B, Huang F, Cooper R, van der Steen-Banasik E, van Limbergen E, Pieters BR, Tan LT, van Rossum PSN, Nesvacil N, Nout R, Schmid MP, Pötter R, Jürgenliemk-Schulz IM. Risk factors for nodal failure after radiochemotherapy and image guided brachytherapy in locally advanced cervical cancer: An EMBRACE analysis. Radiother Oncol 2021; 163:150-158. [PMID: 34480958 DOI: 10.1016/j.radonc.2021.08.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 07/22/2021] [Accepted: 08/26/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess risk factors for nodal failure (NF) after definitive (chemo)radiotherapy and image-guided brachytherapy for locally advanced cervical cancer (LACC) for patients treated in the EMBRACE I study. MATERIALS AND METHODS Data for pelvic NF and para-aortic (PAO) NF (NFPAO) were analysed. After multiple imputation, univariable and multivariable Cox-regression was performed for clinical and treatment-related variables. For patients with affected pelvic nodes but no PAO nodes at diagnosis, additional analyses were performed for two subgroups: 1. 'small pelvis' nodes in internal and external iliac, obturator, parametrial, presacral and/or common iliac (CI) region and 2. any CI nodes (subgroup of 1). RESULTS 1338 patients with 152 NF and 104 NFPAO events were analysed with a median follow-up of 34.2 months (IQR 16.4-52.7). For the entire group, larger tumour width, nodal risk groups (in particular any CI nodes without PAO nodes), local failure, and lower Hb-nadir increased the risk of NF. Elective PAO-irradiation was independently associated with a decreased risk of NFPAO (HR 0.53, 95%-CI 0.28-1.00, p = 0.05). For subgroup 1, having 'any CI nodes without PAO nodes' and local failure significantly increased NF risk. Additionally, elective PAO-irradiation was associated with less risk of NFPAO (HR 0.38, 95%-CI 0.17-0.86, p = 0.02). For subgroup 2 only local failure was associated with higher risk of NF. CONCLUSION In this patient cohort, nodal disease and tumour width at diagnosis, as well as local failure, are risk factors for NF after definitive treatment. Having either 'any PAO nodes' (with or without pelvic nodes) or 'any CI nodes' (without PAO nodes) are stronger risk factors than involvement of nodes in the small pelvis alone. Elective PAO-irradiation was associated with significantly less NFPAO, particularly in patients with nodal disease in the 'small pelvis' and/or CI region at time of diagnosis.
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Affiliation(s)
- Max Peters
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands.
| | - Astrid A C de Leeuw
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Christel N Nomden
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Kari Tanderup
- Aarhus University Hospital, Department of Oncology, Aarhus, Denmark
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | | | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | | | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | - Lars Fokdal
- Aarhus University Hospital, Department of Oncology, Aarhus, Denmark
| | | | - Peter Hoskin
- Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - Barbara Segedin
- Institute of Oncology Ljubljana, Department of Radiotherapy, Ljubljana, Slovenia
| | - Kjersti Bruheim
- The Norwegian Radium Hospital-Oslo University Hospital, Department of Oncology, Oslo, Norway
| | - Bhavana Rai
- Postgraduate Institute of Medical Education and Research, Department of Radiotherapy and Oncology, Chandigarh, India
| | - Fleur Huang
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | - Rachel Cooper
- St James's University Hospital, Leeds Cancer Centre, Leeds, United Kingdom
| | | | | | - Bradley R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands
| | - Li Tee Tan
- Department of Oncology, Addenbrooke's Hospital, Cambridge University Hospitals, United Kingdom
| | - Peter S N van Rossum
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Nicole Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | - Remi Nout
- Leiden University Medical Center, Department of Radiation Oncology, Leiden, the Netherlands
| | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
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Wang D, Yang B, Wang W, Liu X, Liang Y, Sun S, Ma J, Zhou B, Hu K, Zhang F. Higher Dose to Organs at Risk: The Unintended Consequences of Intravenous Contrast Use in Computed Tomography Simulation for Cervical Cancer. Pract Radiat Oncol 2021; 11:534-543. [PMID: 34419624 DOI: 10.1016/j.prro.2021.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE To compare the volumes of interest and doses to the organs at risk on contrast and noncontrast scans in patients with cervical cancer who underwent prophylactic extended-field radiation therapy (EFRT). METHODS AND MATERIALS We reviewed twenty cervical cancer patients treated with prophylactic EFRT at Peking Union Medical College Hospital between March 2021 and April 2021. Each patient underwent noncontrast and contrast scans during simulation. All structures were contoured, and radiation therapy plans were created based on both scans. Student t test and Pearson correlation coefficient test were performed. RESULTS Compared with the noncontrast scan, on the contrast scan, the mean volume of the inferior vena cava expanded by 44% (P ≤ .001), and the mean volume of the para-aortic nodal clinical target volume increased by 17% (P ≤ .001). For the second portion of the duodenum, the V30 (38.2% vs 43.8%, P = .038), V35 (27.6% vs 35.1%, P = .002), V40 (18.3% vs 26.3%, P = .014), V45 (11.2% vs 18.5%, P = .008), and V50 (4.2% vs 9.1%, P = .005) were significantly lower on the noncontrast scan than on the contrast scan. For the third portion of the duodenum, the V45 (78.4% vs 81.6%, P = .03) and V50 (59.7% vs 67%, P ≤ .001) were significantly lower on the noncontrast scan than on the contrast scan. For the right kidney, the V5, V10, V15, V20, and V25 on the contrast and noncontrast scans were 85.4% versus 79.8% (P = .013), 52.5% versus 45.6% (P = .021), 25.6% versus 20.1% (P = .003), 11.1% versus 7.5% (P = .001), and 3.8% versus 2.3% (P = .027), respectively. CONCLUSIONS Compared with the noncontrast scan, expansion of the inferior vena cava on the contrast scan can lead to excessive contouring and an overdose to the duodenum and right kidney in cervical cancer patients treated with prophylactic EFRT.
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Affiliation(s)
- Dunhuang Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Bo Yang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Weiping Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaoliang Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yongguang Liang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Shuai Sun
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jiabin Ma
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Bing Zhou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
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Definitive Chemoradiotherapy versus Radical Hysterectomy Followed by Tailored Adjuvant Therapy in Women with Early-Stage Cervical Cancer Presenting with Pelvic Lymph Node Metastasis on Pretreatment Evaluation: A Propensity Score Matching Analysis. Cancers (Basel) 2021; 13:cancers13153703. [PMID: 34359603 PMCID: PMC8345149 DOI: 10.3390/cancers13153703] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/16/2021] [Accepted: 07/19/2021] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Pelvic nodal involvement is frequently present in early-stage cervical cancer patients on pretreatment imaging studies. However, it is unclear whether radical chemoradiotherapy (CRT) or radical hysterectomy RH followed by tailored adjuvant radiotherapy is more appropriate in these patients. We compared oncological outcomes of up-front surgery followed by tailored adjuvant radiotherapy and definitive CRT in these patients. We found no differences in outcomes existed between definitive CRT and hysterectomy with tailored adjuvant radiotherapy. However, after surgery, 88.7% of patients required adjuvant radiotherapy. These findings suggest that definitive CRT can avoid unplanned tri-modality therapy without compromising oncologic outcomes. Abstract To compare the oncologic outcomes between chemoradiotherapy (CRT) and radical hysterectomy followed by tailored adjuvant therapy in patients with early cervical cancer presenting with pelvic lymph node metastasis. We retrospectively analyzed the medical records of women with early cervical cancer presenting with positive pelvic nodes identified on pretreatment imaging assessment. Propensity score matching was employed to control for the heterogeneity between two groups according to confounding factors. Overall survival, disease-free survival, and pattern of failure were compared between the two groups. A total of 262 patients were identified; among them, 67 received definitive CRT (group A), and 195 received hysterectomy (group B). Adjuvant therapy was administered to 88.7% of group B. There were no significant differences between group A and group B regarding the 5-year overall survival rates (89.2% vs. 89.0%) as well as disease-free survival rates (80.6% vs. 82.7%), and patterns of failure. Distant metastasis was the major failure pattern identified in both groups. In multivariate analysis, non-squamous histology was significantly associated with poorer overall survival. As there are no significant differences in 5-year OS, DFS, and patterns of failure, definitive CRT could avoid the combined modality therapy without compromising oncologic outcomes.
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Li Y, Lu S, Wang S, Peng X, Lang J. Identification of immune subtypes of cervical squamous cell carcinoma predicting prognosis and immunotherapy responses. J Transl Med 2021; 19:222. [PMID: 34030694 PMCID: PMC8142504 DOI: 10.1186/s12967-021-02894-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 05/17/2021] [Indexed: 12/22/2022] Open
Abstract
Background The main limitation of current immune checkpoint inhibitors (ICIs) in the treatment of cervical cancer comes from the fact that it benefits only a minority of patients. The study aims to develop a classification system to identify immune subtypes of cervical squamous cell carcinoma (SCC), thereby helping to screen candidates who may respond to ICIs. Methods A real-world cervical SCC cohort of 36 samples were analyzed. We used a nonnegative matrix factorization (NMF) algorithm to separate different expression patterns of immune-related genes (IRGs). The immune characteristics, potential immune biomarkers, and somatic mutations were compared. Two independent data sets containing 555 samples were used for validation. Results Two subtypes with different immunophenotypes were identified. Patients in sub1 showed favorable progression-free survival (PFS) and overall survival (OS) in the training and validation cohorts. The sub1 was remarkably related to increased immune cell abundance, more enriched immune activation pathways, and higher somatic mutation burden. Also, the sub1 group was more sensitive to ICIs, while patients in the sub2 group were more likely to fail to respond to ICIs but exhibited GPCR pathway activity. Finally, an 83-gene classifier was constructed for cervical SCC classification. Conclusion This study establishes a new classification to further understand the immunological diversity of cervical SCC, to assist in the selection of candidates for immunotherapy. Supplementary Information The online version contains supplementary material available at 10.1186/s12967-021-02894-3.
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Affiliation(s)
- Yimin Li
- School of Medicine, University of Electronic Science and Technology of China, No.2006, Xiyuan Avenue, High-Tech Zone (West District), Chengdu City, 611731, Sichuan Province, People's Republic of China
| | - Shun Lu
- Department of Radiation Oncology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, No.55, South Renmin Avenue Fourth Section, Chengdu City, 610041, Sichuan Province, People's Republic of China.,Radiation Oncology Key Laboratory of Sichuan Province, No.55, South Renmin Avenue Fourth Section, Chengdu City, 610041, Sichuan Province, People's Republic of China
| | - Shubin Wang
- School of Medicine, University of Electronic Science and Technology of China, No.2006, Xiyuan Avenue, High-Tech Zone (West District), Chengdu City, 611731, Sichuan Province, People's Republic of China
| | - Xinhao Peng
- School of Medicine, University of Electronic Science and Technology of China, No.2006, Xiyuan Avenue, High-Tech Zone (West District), Chengdu City, 611731, Sichuan Province, People's Republic of China
| | - Jinyi Lang
- Department of Radiation Oncology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, No.55, South Renmin Avenue Fourth Section, Chengdu City, 610041, Sichuan Province, People's Republic of China. .,Radiation Oncology Key Laboratory of Sichuan Province, No.55, South Renmin Avenue Fourth Section, Chengdu City, 610041, Sichuan Province, People's Republic of China.
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12
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Ballari N, Rai B, Bahl A, Mittal BR, Ghoshal S. Prospective observational study evaluating acute and delayed treatment related toxicities of prophylactic extended field volumetric modulated arc therapy with concurrent cisplatin in cervical cancer patients with pelvic lymph node metastasis. Tech Innov Patient Support Radiat Oncol 2021; 17:48-56. [PMID: 33748442 PMCID: PMC7970137 DOI: 10.1016/j.tipsro.2021.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 02/10/2021] [Accepted: 02/15/2021] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To evaluate the treatment related acute and delayed toxicities of extended field Volumetric modulated arc therapy (VMAT) with concurrent chemotherapy in patients of locally advanced cervical cancer with pelvic lymph nodes. MATERIAL AND METHODS From 2014 to 2016, 15 patients of locally advanced cervical cancer with Fluoro-deoxyglucose positron emission tomography (FDG-PET) positive pelvic lymph nodes were treated with extended field Simultaneous integrated boost (SIB)-VMAT 45 Gy/55 Gy/25#/5weeks and concurrent cisplatin. Acute toxicities were documented according to common terminology criteria for adverse events version 4 (CTCAE v.4). Dose volume parameters and patient characteristics were analyzed for association with toxicities. RESULTS Median age of patients at diagnosis was 48 years. 40% (6 patients) were stage IIB & 60% (9 patients) were stage IIIB. Median number of involved pelvic lymph nodes was 2 (range, 1-4), commonest location was external iliac lymph node region (86%). Median number of concurrent chemotherapy cycles received was five. Treatment was well tolerated and there were no grade ≥ 3 acute toxicities. Commonest acute toxicities observed were vomiting (≥grade2 -13.3%) followed by & nausea (grade ≥ 2 in 6%) and were associated with volume of bowel bag receiving 45 Gy. Constitutional symptoms (≥grade 2) were observed in 6% patients and had no dosimetric associations. At a median follow up of 43 months, delayed ≥ grade1, 2, 3 toxicity were observed in 80%, 0%, and 0% respectively with diarrhea being the commonest. CONCLUSION Prophylactic para aortic extended field VMAT with concurrent chemotherapy for locally advanced cervical cancer is well tolerated with acceptable acute toxicity profile. Significant grade 3 acute/delayed toxicities were not observed in this cohort of patients.
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Affiliation(s)
- N Ballari
- Departments of Radiotherapy, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - B Rai
- Departments of Radiotherapy, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - A Bahl
- Departments of Radiotherapy, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - B R Mittal
- Nuclear Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - S Ghoshal
- Departments of Radiotherapy, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Wang W, Zhou Y, Wang D, Hu K, Zhang F. Prophylactic Extended-Field Irradiation in Patients With Cervical Cancer: A Literature Review. Front Oncol 2020; 10:579410. [PMID: 33123482 PMCID: PMC7567016 DOI: 10.3389/fonc.2020.579410] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/14/2020] [Indexed: 11/13/2022] Open
Abstract
Currently, the standard radiation field for locally advanced cervical cancer patients without evidence of para-aortic lymph node (PALN) metastasis is the pelvis. Due to the low accuracy of imaging in the diagnosis of PALN metastasis and the high incidence of PALN failure after pelvic radiotherapy, prophylactic pelvic and para-aortic irradiation, also called extended-field irradiation (EFI), is performed for patients with cervical cancer. In the era of concurrent chemoradiotherapy, randomized controlled trials are limited, and whether patients with cervical cancer can benefit from prophylactic EFI is still controversial. With conformal or intensity-modulated radiation therapy, patients tolerate prophylactic EFI very well. The severe toxicities of prophylactic EFI are not significantly higher than those of pelvic radiotherapy. We recommend delivering prophylactic EFI to cervical cancer patients with common iliac lymph nodes metastasis. Clinical trials are needed to investigate whether patients with ≥3 positive pelvic lymph nodes and FIGO stage IIIB disease can benefit from prophylactic EFI. According to the distribution of PALNs, it is reasonable to use the renal vein as the upper border of the radiation therapy field for patients treated with prophylactic EFI. The clinical target volume expansion of the node from the vessel should be smaller in the right para-caval region than in the left lateral para-aortic region. The right para-caval region above L2 or L3 may be omitted from the PALN target volume to reduce the dose to the duodenum. More clinical trials on prophylactic EFI in cervical cancer are needed.
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Affiliation(s)
- Weiping Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuncan Zhou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dunhuang Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Wang W, Wang D, Liu X, Zhou Y, Ma J, Hou X, Hu K, Zhang F. Risk factors associated with Para-Aortic Lymph Node Failure after pelvic irradiation in patients with Cervical Cancer. J Cancer 2020; 11:5099-5105. [PMID: 32742457 PMCID: PMC7378915 DOI: 10.7150/jca.45520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 06/14/2020] [Indexed: 12/24/2022] Open
Abstract
Objective: Previous studies have shown that prophylactic extended-field irradiation can reduce para-aortic lymph node failure (PALNF) rates in patients with cervical cancer. As such, this type of irradiation may particularly benefit patients with a high risk of PALNF. In the present study, we analyzed the risk factors for PALNF in patients with cervical cancer treated with pelvic irradiation in order to identify potential indications of prophylactic extended-field irradiation. Methods: We evaluated patients with 2018 FIGO stage IB3-IIIC1 cervical cancer who were treated with definitive pelvic radiotherapy or concurrent chemoradiotherapy at our institution between 2011 and 2014. Univariate and multivariate analyses were performed to identify risk factors for PALNF. Results: We included 572 patients in the study. The median follow-up period was 37.9 months. Eighteen patients (3.1%) first site of tumor relapse was the para-aortic lymph nodes, and thus showed PALNF. Using multivariate Cox regression analysis, we identified two significant risk factors for PALNF: tumor extension to the pelvic wall (hazard ratio, HR 3.60, p=0.026) and ≥ 2 pelvic MLNs (HR 5.30, p=0.005). For patients with and without risk factors, the 3-year overall survival, disease-free survival, and PALNF rates were 77.3% and 90.1% (p<0.001), 56.4% and 83.1% (p<0.001), and 12.0% and 2.3% (p<0.001), respectively. Conclusion: Tumor extension to the pelvic wall and ≥ 2 pelvic MLNs are positively associated with PALNF after pelvic irradiation in patients with cervical cancer. Further trials will be required to validate whether patients with these two risk factors may benefit from prophylactic extended-field irradiation.
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Affiliation(s)
- Weiping Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Dunhuang Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaoliang Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yuncan Zhou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jiabin Ma
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaorong Hou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Tumor microenvironment, immune response and post-radiotherapy tumor clearance. Clin Transl Oncol 2020; 22:2196-2205. [PMID: 32445035 DOI: 10.1007/s12094-020-02378-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/07/2020] [Indexed: 02/06/2023]
Abstract
Radiotherapy is the treatment of choice for many cancer patients. Residual tumor leads to local recurrence after a period of an equilibrium created between proliferating, quiescent and dying cancer cells. The tumor microenvironment is a main obstacle for the efficacy of radiotherapy, as impaired blood flow leads to hypoxia, acidity and reduced accessibility of radiosensitizers. Eradication of remnant disease is an intractable clinical quest. After more than a century of research, anti-tumor immunity has gained a dominant position in oncology research and therapy. Immune cells play a significant role in the eradication of tumors during and after the completion of radiotherapy. The tumor equilibrium reached in the irradiated tumor may shift towards cancer cell eradication if the immune response is appropriately modulated. In the modern immunotherapy era, clinical trials are urged to standardize immunotherapy schemes that could be safely applied to improve clearance of the post-radiotherapy remnant disease.
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Tan LT, Pötter R, Sturdza A, Fokdal L, Haie-Meder C, Schmid M, Gregory D, Petric P, Jürgenliemk-Schulz I, Gillham C, Van Limbergen E, Hoskin P, Tharavichitkul E, Villafranca E, Mahantshetty U, Kirisits C, Lindegaard J, Kirchheiner K, Tanderup K. Change in Patterns of Failure After Image-Guided Brachytherapy for Cervical Cancer: Analysis From the RetroEMBRACE Study. Int J Radiat Oncol Biol Phys 2019; 104:895-902. [DOI: 10.1016/j.ijrobp.2019.03.038] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/13/2019] [Accepted: 03/19/2019] [Indexed: 12/14/2022]
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Nomograms predicting survival and patterns of failure in patients with cervical cancer treated with concurrent chemoradiotherapy: A special focus on lymph nodes metastases. PLoS One 2019; 14:e0214498. [PMID: 30986236 PMCID: PMC6464190 DOI: 10.1371/journal.pone.0214498] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 12/08/2018] [Indexed: 01/21/2023] Open
Abstract
Objective To construct nomograms predicting survival and patterns of failure in patients with cervical cancer treated with concurrent chemoradiotherapy (CCRT). Methods A total of 833 patients with cervical cancer treated with definitive radiotherapy or CCRT in our institute from January 2011 to December 2014 were included. Cox proportional hazard regression models were used in univariate and multivariate analysis. The following variables were included in the univariate analysis: histology, FIGO stage, lymph node metastases (para-aortic, pelvic, common iliac, binary pelvic, and binary common iliac LNMs), the number of pelvic metastatic lymph nodes (MLNs), and the diameter of pelvic MLNs. Nomograms predicting the 3- and 5-year overall survival (OS), disease-free survival (DFS), local control (LC) and distant metastasis-free (DMF) were constructed. The nomograms were internally validated with respect to discrimination and calibration. Results The median follow-up period was 36.4 months (range,1.0 to 76.2 months). After univariate and multivariate analysis, histology, FIGO stage, para-aortic LNM, pelvic LNM, number of MLNs and diameter of pelvic MLNs significantly predicted OS, DFS, LC or DMF. Nomograms predicting the 3- and 5-year OS, DFS, LC and DMF were constructed incorporating these significant variables. These nomograms showed good discrimination and calibration, with a concordance index of 0.73 for predicting OS, 0.71 for DFS, 0.73 for LC and 0.67 for DMF. Conclusion We constructed nomograms predicting survival and patterns of failure with a special focus on regional LNM in patients with cervical cancer treated with concurrent chemoradiotherapy.
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Yoshida K, Kajiyama H, Yoshihara M, Ikeda Y, Yoshikawa N, Nishino K, Utsumi F, Niimi K, Suzuki S, Kikkawa F. Does postoperative prophylactic irradiation of para-aortic lymph nodes reduce the risk of recurrence in uterine cervical cancer with positive pelvic lymph nodes? Int J Clin Oncol 2019; 24:567-574. [PMID: 30612268 DOI: 10.1007/s10147-018-1376-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 12/02/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND In cervical cancer, para-aortic lymph nodes are common sites of metastasis. The purpose of the study was to evaluate the clinical benefits of prophylactic irradiation as postoperative therapy. METHODS A retrospective cohort study was conducted during 2001-2015 at a single institution. Patients with a high risk of para-aortic lymph nodes recurrence were eligible for this study, and we identified patients who had pelvic lymph node metastasis and underwent radical surgery and concurrent chemo-radiotherapy. As a result, 33 and 46 patients were included in the treatment (prophylactic irradiation) and non-treatment groups, respectively. Baseline differences between the two groups were adjusted with the inverse probability of treatment weighting using propensity scores composed of the independent variables including age, stage, tumor size, pathological findings, lymph node status, and pathological subtypes. RESULTS In the 68-month median follow-up period (range 6-178 months), 25 patients experienced recurrence, and 17 patients were dead. After adjustment with the inverse probability of treatment weighting, the recurrence rates tended to decrease in the treatment group, but there was no significant difference between the two groups [treatment vs. non-treatment, 29.4% and 44.3%, respectively; hazard ratio, 0.593 (95% CI 0.320-1.099); P = 0.097]. However, adjusted para-aortic lymph nodes recurrence rates were not significantly different [treatment vs. non-treatment, 7.8% and 11.4%, respectively; odds ratio, 0.660 (95% CI 0.187-2.322); P = 0.558]. Moreover, Kaplan-Meier curves showing post-recurrence survival revealed no significant difference between the two groups (P = 0.141). CONCLUSIONS Prophylactic para-aortic lymph nodes irradiation did not reduce the risk of recurrence.
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Affiliation(s)
- Kosuke Yoshida
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Tsuruma-cho 65, Showa-ku, Nagoya, 466-8550, Japan
| | - Hiroaki Kajiyama
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Tsuruma-cho 65, Showa-ku, Nagoya, 466-8550, Japan.
| | - Masato Yoshihara
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Tsuruma-cho 65, Showa-ku, Nagoya, 466-8550, Japan
| | - Yoshiki Ikeda
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Tsuruma-cho 65, Showa-ku, Nagoya, 466-8550, Japan
| | - Nobuhisa Yoshikawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Tsuruma-cho 65, Showa-ku, Nagoya, 466-8550, Japan
| | - Kimihiro Nishino
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Tsuruma-cho 65, Showa-ku, Nagoya, 466-8550, Japan
| | - Fumi Utsumi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Tsuruma-cho 65, Showa-ku, Nagoya, 466-8550, Japan
| | - Kaoru Niimi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Tsuruma-cho 65, Showa-ku, Nagoya, 466-8550, Japan
| | - Shiro Suzuki
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Tsuruma-cho 65, Showa-ku, Nagoya, 466-8550, Japan
| | - Fumitaka Kikkawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Tsuruma-cho 65, Showa-ku, Nagoya, 466-8550, Japan
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Meng Q, Wang W, Liu X, Hou X, Lian X, Sun S, Yan J, Liu Z, Miao Z, Hu K, Zhang F. Escalated radiation and prophylactic extended field nodal irradiation are beneficial for FIGO IIIB cervical cancer patients' prognosis. Radiat Oncol 2018; 13:223. [PMID: 30453993 PMCID: PMC6245932 DOI: 10.1186/s13014-018-1172-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 11/06/2018] [Indexed: 12/03/2022] Open
Abstract
Background Currently, the standard treatment for locally advanced cervical cancer patients is concurrent chemoradiotherapy. Here we aim to evaluate therapeutic efficacy, treatment failure, toxicity and prognostic factors for FIGO IIIB cervical cancer patients. Methods A comprehensive retrospective analysis was performed to understand various factors which contribute to IIIB cervical cancer prognosis. In total 223 well defined patients were assigned according to their pathological subtype, age, pre-treatment HGB level, tumor size, pelvic lymph node (LN) metastasis, para-aortic LN metastasis as well as external irradiation technologies, treatment duration, point A EQD2 dose and concurrent chemotherapy cycles. We then performed correlation studies of these factors and OS, DFS, LCR, DMFS using univariate and multivariate analysis respectively. Results We managed to achieve 207 (92.8%) complete response (CR) and 16 (7.2%) partial response (PR) with acceptable adverse effects. Notably, the 5 years OS, DFS, LCR, DMFS for these patients were 61.1, 55.2, 83.6 and 66.4% respectively. Importantly, our studies suggest that escalated point A EQD2 can significantly improve OS, DFS and LCR for FIGO IIIB cervical cancer patients, furthermore, patients without para-aortic LN metastasis who received prophylactic extended field irradiation have significant survival advantage for DFS and a tendency to improve OS and DMFS. Conclusions Our results suggest that FIGO IIIB cervical cancer patients should receive higher EQD2 (≥98Gy10) radiotherapy, moreover, patients without para-aortic LN metastasis should receive prophylactic extended field nodal irradiation to improve prognosis. Electronic supplementary material The online version of this article (10.1186/s13014-018-1172-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Qingyu Meng
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Weiping Wang
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xiaoliang Liu
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xiaorong Hou
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xin Lian
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Shuai Sun
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Junfang Yan
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhikai Liu
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zheng Miao
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Ke Hu
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
| | - Fuquan Zhang
- Department of radiation oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
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Thamronganantasakul K, Supakalin N, Kietpeerakool C, Pattanittum P, Lumbiganon P. Extended-field radiotherapy for locally advanced cervical cancer. Cochrane Database Syst Rev 2018; 10:CD012301. [PMID: 30362204 PMCID: PMC6516992 DOI: 10.1002/14651858.cd012301.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The para-aortic lymph nodes (located along the major vessels in the mid and upper abdomen) are a common place for disease recurrence after treatment for locally advanced cervical cancer. The para-aortic area is not covered by standard pelvic radiotherapy fields and so treatment to the pelvis alone is inadequate for women at a high risk of occult cancer within para-aortic lymph nodes. Extended-field radiotherapy (RT) widens the pelvic RT field to include the para-aortic lymph node area. Extended-field RT may improve outcomes in women with locally advanced cervical cancer by treating occult disease in para-aortic nodes not identified at pretreatment imaging. However, RT treatment of the para-aortic area can cause severe adverse effects, so may increase harms.Studies of pelvic chemoradiotherapy (CRT) demonstrated improved survival rates compared to pelvic RT alone. CRT is now the standard of care in the treatment of locally advanced cervical cancer. Studies comparing pelvic RT alone (without concurrent chemotherapy) with extended-field RT should therefore be viewed with caution, since they compare treatments against what is now substandard treatment (pelvic RT alone). This review should therefore be read with this in mind and comparisons with pelvic RT cannot be extrapolated to pelvic CRT. OBJECTIVES To evaluate the effectiveness and toxicity of extended-field radiotherapy in women undergoing first-line treatment for locally advanced cervical cancer. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 7), MEDLINE via Ovid (1946 to August week 4, 2018), and Embase via Ovid (1980 to 2018, week 35). We checked registers of clinical trials, grey literature, conference reports, and citation lists of included studies to August 2018. SELECTION CRITERIA We included randomised controlled trials (RCTs) evaluating the effectiveness and toxicity of extended-field RT for locally advanced cervical cancer. DATA COLLECTION AND ANALYSIS Two review authors independently selected potentially relevant RCTs, extracted data, assessed risk of bias, compared results, and made judgements on the quality and certainty of the evidence for each outcome. Any disagreements were resolved by discussion or consultation with a third review author. MAIN RESULTS Five studies met the inclusion criteria. Three included studies compared extended-field RT versus pelvic RT, one included study compared extended-field RT with pelvic CRT, and one study compared extended-field CRT versus pelvic CRT.Extended-field radiotherapy versus pelvic radiotherapy aloneCompared to pelvic RT, extended-field RT probably reduces the risk of death (hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.48 to 0.94; 1 study; 337 participants; moderate-certainty evidence) and para-aortic lymph node recurrence (risk ratio (RR) 0.36, 95% CI 0.18 to 0.70; 2 studies; 477 participants; moderate-certainty evidence), although there may or may not have been improvement in the risk of disease progression (HR 0.92, 95% CI 0.69 to 1.22; 1 study; 337 participants; moderate-certainty evidence) and severe adverse events (RR 1.05, 95% CI 0.79 to 1.41; 2 studies; 776 participants; moderate-certainty evidence).Extended-field radiotherapy versus pelvic chemoradiotherapyIn a comparison of extended-field RT versus pelvic CRT, women given pelvic CRT probably had a lower risk of death (HR 0.50, 95% CI 0.39 to 0.64; 1 study; 389 participants; moderate-certainty evidence) and disease progression (HR 0.52, 95% CI 0.37 to 0.72; 1 study; 389 participants; moderate-certainty evidence). Participants given extended-field RT may or may not have had a lower risk of para-aortic lymph node recurrence (HR 0.44, 95% CI 0.20 to 0.99; 1 study; 389 participants; low-certainty evidence) and acute severe adverse events (RR 0.05, 95% CI 0.02 to 0.11; 1 study; 388 participants; moderate-certainty evidence). There were no clear differences in terms of late severe adverse events among the comparison groups (RR 1.06, 95% CI 0.69 to 1.62; 1 study; 386 participants; moderate-certainty evidence).Extended-field chemoradiotherapy versus pelvic chemoradiotherapyVery low-certainty evidence obtained from one small study (74 participants) showed that, compared to pelvic CRT, extended-field CRT may or may not have reduced risk of death (HR 0.37, 95% CI 0.14 to 0.96) and disease progression (HR 0.25, 95% CI 0.07 to 0.87). There were no clear differences between the groups in the risks of para-aortic lymph node recurrence (RR 0.19, 95% CI 0.02 to 1.54; very low-certainty evidence) and severe adverse events (acute: RR 0.95, 95% CI 0.20 to 4.39; late: RR 0.95, 95% CI 0.06 to 14.59; very low-certainty evidence). AUTHORS' CONCLUSIONS Moderate-certainty evidence shows that, compared with pelvic RT alone, extended-field RT probably improves overall survival and reduces risk of para-aortic lymph node recurrence. However, pelvic RT alone would now be considered substandard treatment, so this result cannot be extrapolated to modern standards of care. Low- to moderate-certainty evidence suggests that pelvic CRT may increase overall and progression-free survival compared to extended-field RT, although there may or may not be a higher rate of para-aortic recurrence and acute adverse events. Extended-field CRT versus pelvic CRT may improve overall or progression-free survival, but these findings should be interpreted with caution due to very low-certainty evidence.High-quality RCTs, comparing modern treatment techniques in CRT, are needed to more fully inform treatment for locally advanced cervical cancer without obvious para-aortic node involvement.
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Affiliation(s)
- Komsan Thamronganantasakul
- Khon Kaen UniversityDepartment of RadiologyFaculty of MedicineMittraphap RoadMuangKhon KaenThailand40002
| | - Narudom Supakalin
- Khon Kaen UniversityDepartment of RadiologyFaculty of MedicineMittraphap RoadMuangKhon KaenThailand40002
| | - Chumnan Kietpeerakool
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | - Porjai Pattanittum
- Khon Kaen UniversityDepartment of Epidemiology and Biostatistics, Public Health FacultyMitraparp RoadMueng DistrictKhon KaenKhon KaenThailand40002
| | - Pisake Lumbiganon
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
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Chopra S, Deodhar K, Pai V, Pant S, Rathod N, Goda JS, Sudhalkar N, Pandey P, Waghmare S, Engineer R, Mahantshetty U, Ghosh J, Gupta S, Shrivastava S. Cancer Stem Cells, CD44, and Outcomes Following Chemoradiation in Locally Advanced Cervical Cancer: Results From a Prospective Study. Int J Radiat Oncol Biol Phys 2018; 103:161-168. [PMID: 30213750 DOI: 10.1016/j.ijrobp.2018.09.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 08/20/2018] [Accepted: 09/03/2018] [Indexed: 12/12/2022]
Abstract
PURPOSE Although cancer stem cells (CSCs) have been reported across solid tumors, there is a dearth of data regarding CSC and its impact on outcomes of cervical cancer. METHODS AND MATERIALS From October 2013 to December 2015, patients with squamous cancer of the cervix (stage IB2-IVA) were included. Pretreatment and posttreatment biopsy was obtained and immunohistochemistry was performed for SOX-2, OCT-4, Nanog, CD44, and Podoplanin. All patients received concurrent radiation and brachytherapy to an equivalent dose of 80 to 84 Gy to point A with concurrent weekly cisplatin. Correlation of CSC expression was performed with known prognostic factors. The effect of stem cell expression on disease outcomes was tested within multivariate analysis. RESULTS One hundred fifty patients were included. The median dose to point A was 83 Gy (46-89 Gy) and a median of 4 cycles (range, 0-6 cycles) of chemotherapy was administered. At baseline, moderate to strong immunohistochemical expression of SOX-2, OCT-4, Nanog, CD44, and Podoplanin was observed in 12.8%, 4.8%, 24.4%, 15.5%, and 1.3% of patients, respectively. At median follow-up of 30 months (range, 3-51 months), locoregional and distant relapse was observed in 12.2% and 23.1% of patients, of whom 4.7% had both local and distant relapse. The 3-year disease-free survival rate was 87%. On multivariate analysis, moderate to high CSC expression and CD44 low status (hazard ratio [HR] = 8.8; 95% confidence interval [CI], 1.0-77.2; P < .04) independently predicted for locoregional relapse-free survival. International Federation of Gynecology and Obstetrics stage (HR = 2.6; 95% CI, 1.3-5.4; P = .004) and presence of residual tumor after external radiation (HR = 3.5; 95% CI, 1.8-6.5; P = .0001) predicted for a detriment in disease-free survival. CONCLUSIONS The presence of stem cell proteins and loss of CD44 independently predicts for reduced locoregional control in locally advanced cervical cancer. Further investigation into the interaction of stem cell and CD44 biology is warranted.
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Affiliation(s)
- Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment, Education and Research in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Kedar Deodhar
- Department of Pathology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Venkatesh Pai
- Clinical Biology Laboratory, Department of Radiation Oncology, Advanced Centre for Treatment, Education and Research in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sidharth Pant
- Department of Radiation Oncology, Advanced Centre for Treatment, Education and Research in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Nidul Rathod
- Clinical Biology Laboratory, Department of Radiation Oncology, Advanced Centre for Treatment, Education and Research in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Jayant S Goda
- Department of Radiation Oncology, Advanced Centre for Treatment, Education and Research in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Niyati Sudhalkar
- Clinical Biology Laboratory, Department of Radiation Oncology, Advanced Centre for Treatment, Education and Research in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Puloma Pandey
- Clinical Biology Laboratory, Department of Radiation Oncology, Advanced Centre for Treatment, Education and Research in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sanjeev Waghmare
- Stem Cell Biology, Advanced Centre for Treatment, Education and Research in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Umesh Mahantshetty
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Jaya Ghosh
- Medical Oncology, Advanced Centre for Treatment, Education and Research in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sudeep Gupta
- Medical Oncology, Advanced Centre for Treatment, Education and Research in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Shyam Shrivastava
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Tanderup K, Lindegaard JC, Kirisits C, Haie-Meder C, Kirchheiner K, de Leeuw A, Jürgenliemk-Schulz I, Van Limbergen E, Pötter R. Image Guided Adaptive Brachytherapy in cervix cancer: A new paradigm changing clinical practice and outcome. Radiother Oncol 2016; 120:365-369. [PMID: 27555228 DOI: 10.1016/j.radonc.2016.08.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 08/03/2016] [Accepted: 08/03/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Kari Tanderup
- Aarhus University Hospital, Department of Oncology, Denmark
| | | | - Christian Kirisits
- Medical University of Vienna, Comprehensive Cancer Center, Department of Radiation Oncology, Austria
| | - Christine Haie-Meder
- Gustave Roussy Cancer Campus Grand Paris, Department of Radiation Oncology, Villejuif, France
| | - Kathrin Kirchheiner
- Medical University of Vienna, Comprehensive Cancer Center, Department of Radiation Oncology, Austria
| | - Astrid de Leeuw
- University Medical Center Utrecht, Department of Radiotherapy, The Netherlands
| | | | - Erik Van Limbergen
- Department of Radiation Oncology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Richard Pötter
- Medical University of Vienna, Comprehensive Cancer Center, Department of Radiation Oncology, Austria.
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