The outcome of advanced or recurrent non-squamous carcinoma of the uterine cervix after platinum-based combination chemotherapy

Initial treatment for FIGO 2018 stage IIIC cervical cancer based on histological type: A 14-year multicenter study

BACKGROUND

To compare the oncological outcomes of radical chemotherapy (R-CT), abdominal radical hysterectomy (ARH), and neoadjuvant chemotherapy and radical surgery (NACT) for International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IIIC cervical cancer, according to histological types: squamous cell carcinoma (SCC) and adenocarcinoma (AC)/adenosquamous cell carcinoma (ASC).

METHODS

A comparison of 5-year overall survival (OS) and disease-free survival (DFS) was performed for the SCC and AC/ASC subgroups for the three initial treatments, assessed using Kaplan-Meier and Cox proportional hazards regression analysis and validated using propensity score matching (PSM).

RESULTS

The study included 4086 patients: R-CT, n = 1913; ARH, n = 1529; and NACT, n = 644. AC/ASC had a lower survival rate (63.7%) than SCC (73.6%) and a higher recurrence and mortality rate (36.3% and 26.4%, respectively). The 5-year OS and DFS rates were different in the SCC group for R-CT, ARH, and NACT (OS: 69.8% vs. 80.8% vs. 73.0%, p < 0.001; DFS: 66.7% vs. 70.7% vs. 56.4%, p < 0.001), also in the AC/ASC group (OS: 46.1% vs. 70.6% vs. 55.6%, p < 0.001; DFS: 42.7% vs. 64.6% vs. 40.8%, p < 0.001). As for initial treatment, survival outcomes were worse for AC/ASC treated with R-CT and ARH than for SCC (both p < 0.05), with no group differences between the two treated with NACT.

CONCLUSION

Initial treatment influences oncological prognosis for patients with FIGO 2018 stage IIIC cervical cancer. ARH is an alternative treatment for stage IIIC cervical SCC and AC/ASC, and NACT needs to be chosen with caution, moreover, R-CT for AC/ASC requires careful selection.

The Updated World Health Organization Classification Better Predicts Survival in Patients With Endocervical Adenocarcinoma (KROG 20-07)

PURPOSE

The 2020 World Health Organization classification divided endocervical adenocarcinoma (ADC) into human papillomavirus-associated (HPVA) and human papillomavirus-independent (HPVI) ADCs. This multi-institutional study aimed to investigate the clinical features and prognosis of patients with endocervical ADC based on the updated World Health Organization classification.

METHODS AND MATERIALS

We retrospectively reviewed the 365 patients with endocervical ADC who underwent radical hysterectomy from 7 institutions. Tumor characteristics, patterns of failure, and survival outcomes were compared between HPVA and HPVI ADCs.

RESULTS

Two hundred seventy-five (75.3%) and 90 (24.7%) patients had HPVA and HPVI ADC diagnoses, respectively. In all cases, the 5-year disease-free survival (DFS) and overall survival (OS) rates were 58.2% and 71.3%, respectively. HPVI ADC showed higher rates of local recurrence (25.6% vs 10.9%) and distant metastasis (33.3% vs 17.5%) than HPVA ADC. Multivariate survival analysis revealed that HPVI ADC showed significantly worse DFS (hazard ratio [HR], 1.919; 95% confidence interval [CI], 1.324-2.781; P < .001), distant metastasis-free survival (HR, 2.100; 95% CI, 1.397-3.156; P < .001), and OS (HR, 2.481; 95% CI, 1.586-3.881; P < .001) than HPVA ADC. Patients with gastric- and serous-type HPVI ADC had significantly worse OS than those with other HPVI ADCs (P = .020). Similarly, invasive stratified mucin-producing-type HPVA ADC showed significantly worse OS than other HPVA ADCs (P < .001).

CONCLUSIONS

We demonstrated that HPVI ADC exhibited inferior DFS and OS and higher rates of local and distant recurrence compared with HPVA ADC. Gastric- and serous-type HPVI ADCs and invasive stratified mucin-producing-type HPVA ADC showed worse OS than other types of HPVI and HPVA ADCs, respectively. Our observation of significant differences in prognoses according to the histologic types needs to be validated in larger cohorts of patients with endocervical ADC.

Clinicopathological characteristics and prognosis of cervical cancer with different histological types: A population-based cohort study

OBJECTIVE

The prognostic impact and treatment responses among cervical cancer patients with different histological types remains inconclusive. To determine the prognostic effects of different histologic types, we identified 39,088 patients with a diagnosis of cervical cancer between 2004 and 2016 from the Surveillance, Epidemiology, and End Results program.

METHODS

Variables related to the prognosis of cervical cancer were evaluated using log-rank method and univariate/multivariate Cox models before and after propensity score matching.

RESULT

Of the 36,310 patients, Squamous cell carcinoma (SCC) was the most common histological type (n = 27,043, 74.5%), followed by adenocarcinoma (AC, n = 7755, 21.4%) and adenosquamous carcinoma (ASC, n = 1512, 4.1%). Compared to SCC patients, patients with AC (HR = 1.14, 95%CI = 1.09-1.20, P < 0.01) and ASC (HR = 1.28, 95%CI = 1.18-1.40, P < 0.01) showed significantly poorer prognosis. Subgroup analyses indicated that the differences in prognosis between AC and SCC were only observed in stage II and III patients (P < 0.01). In patients with concurrent chemoradiotherapy, survival rates of patients with AC were significantly worse compared with similar patients with SCC (HR = 1.14, 95%CI = 1.03-1.27; P < 0.01).

CONCLUSION

The prognostic impact of histologic types among patients with cervical cancer depends on tumor stages and therapeutic approaches. Tailored treatment and follow-up planning need to be developed across patients with different histological types and stages.

Changing the Prognosis of Metastatic Cervix Uteri Adenosquamous Carcinoma through a Multimodal Approach: A Case Report

Adenocarcinoma and adenosquamous carcinoma (AS) are 2 rare histological types of cervix uteri cancer constituting almost 20% of all cervix cancers, leading to a lack in patient management guidelines. We report the case of a 32-year-old woman with an oligometastatic cervix AS for which a multimodal treatment approach was used. Despite the patient's bad prognosis, a complete response was achieved, which further resulted in excellent local control and prolonged survival. This case report serves the purpose of encouraging multidisciplinary team work and out-of-the-box thinking that should result in an individualized treatment for rare cancer subtypes.

Multi-Habitat Based Radiomics for the Prediction of Treatment Response to Concurrent Chemotherapy and Radiation Therapy in Locally Advanced Cervical Cancer

Objectives: To develop a radiomic model based on multiparametric magnetic resonance imaging (MRI) for predicting treatment response prior to commencing concurrent chemotherapy and radiation therapy (CCRT) for locally advanced cervical cancer.

Materials and methods: The retrospective study enrolled 120 patients (allocated to a training or a test set) with locally advanced cervical cancer who underwent CCRT between December 2014 and June 2017. All patients enrolled underwent MRI with nine sequences before treatment and again at the end of the fourth week of treatment. Responses were evaluated by MRI according to RECIST standards, and patients were divided into a responder group or non-responder group. For every MRI sequence, a total of 114 radiomic features were extracted from the outlined tumor habitat. On the training set, the least absolute shrinkage and selection operator method was used to select key features and to construct nine habitat signatures. Then, three kinds of machine learning models were compared and applied to integrate these predictive signatures and the clinical characteristics into a radiomic model. The discrimination ability, reliability, and calibration of our radiomic model were evaluated.

Results: The radiomic model, which consisted of three habitat signatures from sagittal T2 image, axial T1 enhanced-MRI image, and ADC image, respectively, has shown good predictive performance, with area under the curve of 0.820 (95% CI: 0.713–0.927) in the training set and 0.798 (95% CI: 0.678–0.917) in the test set. Meanwhile, the model proved to perform better than each single signature or clinical characteristic.

Conclusions: A radiomic model employing features from multiple tumor habitats held the ability for predicting treatment response in patients with locally advanced cervical cancer before commencing CCRT. These results illustrated a potential new tool for improving medical decision-making and therapeutic strategies.

Neoadjuvant Chemotherapy with Taxane and Platinum Followed by Radical Hysterectomy for Stage IB2-IIB Cervical Cancer: Impact of Histology Type on Survival

The current study examined the histology-specific impact of neoadjuvant chemotherapy (NACT) with a taxane/platinum regimen on survival in women with locally-advanced cervical cancer who underwent radical hysterectomy. This nation-wide retrospective cohort study examined women with clinical stage IB2-IIB cervical cancer who received NACT prior to radical hysterectomy from 2004–2008 (n = 684). NACT type (taxane/platinum versus others) was correlated with survival based on histology: 511 squamous versus 173 non-squamous. Taxane/platinum chemotherapy use was more common in non-squamous compared to squamous tumors (53.8% versus 20.7%, P < 0.001). In both histology types, the taxane/platinum regimen was more frequently utilized over time (both, P < 0.01). Among squamous tumors, women who received taxane/platinum chemotherapy had survival comparable to those who received other regimens: 5-year rates for disease-free survival, 69.0% versus 70.1%, P = 0.98; and cause-specific survival, 80.0% versus 81.0%, P = 0.93. Similarly, in non-squamous tumors, disease-free survival (5-year rates: 60.4% versus 59.0%, P = 0.86) and cause-specific survival (74.7% versus 76.3%, P = 0.70) were similar. In conclusion, use of taxane/platinum regimens for NACT significantly increased during the study period. Irrespective of histology type, in women with clinical stage IB2-IIB cervical cancer who underwent NACT prior to radical hysterectomy, taxane/platinum regimens had a similar effect on survival compared to non-taxane/platinum regimens.

Comparison of adjuvant therapy for node-positive clinical stage IB-IIB cervical cancer: Systemic chemotherapy versus pelvic irradiation

This was a nation-wide retrospective study in Japan examining women who underwent radical hysterectomy for clinical stage IB-IIB cervical cancer with pelvic and/or para-aortic lymph node metastasis between 2004 and 2008. Time to recurrence or death and patterns of disease recurrence were compared based upon the adjuvant treatment pattern: whole pelvic radiotherapy alone (n = 253), concurrent chemoradiotherapy (CCRT, n = 502) and chemotherapy alone (n = 319). Women who received chemotherapy alone had similar recurrence (5-year rates, 36.6% vs. 34.1%, adjusted-hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.70-1.28, P = 0.72) and cervical cancer mortality (24.7% vs. 21.8%, adjusted-HR 0.96, 95% CI 0.67-1.38, P = 0.83) rates compared to those who received CCRT on multivariate analysis. However, when recurrence patterns were stratified, chemotherapy treatment was independently associated with decreased risk of distant recurrence (5-year cumulative rates, 19.2% vs. 24.6%, adjusted-HR 0.47, 95% CI 0.31-0.71, P < 0.001) but increased risk of local recurrence (23.9% vs. 14.3%, adjusted-HR 2.03, 95% CI 1.34-3.08, P = 0.001) compared to CCRT. Non-squamous histology, parametrial involvement and high lymph node ratio were independent predictors for local recurrence, and presence of multiple risk factors was associated with high 5-year cumulative local recurrence rate in the chemotherapy group: no risk factor 3.9%, single factor 14.2-22.1%, and multiple risk factors 27.8-71.9% (P < 0.001). In conclusion, while exhibiting different recurrence patterns, systemic chemotherapy may be as effective a postoperative treatment as radiation-based therapy in node-positive high-risk stage IB-IIB cervical cancer. When tumor exhibits certain risk factors, chemotherapy alone is likely insufficient for local control and adding pelvic irradiation to systemic chemotherapy is recommended in this subgroup.

The prognostic value of histologic subtype in node-positive early-stage cervical cancer after hysterectomy and adjuvant radiotherapy

BACKGROUND

To assess the survival outcomes in patients with International Federation of Gynecology and Obstetrics (FIGO) stage I-IIA adenocarcinoma (AC) or squamous cell carcinoma (SCC) of the uterine cervix after hysterectomy and adjuvant radiotherapy (RT).

METHODS

Patients with a primary diagnosis of FIGO stage I-IIA AC or SCC of the uterine cervix after hysterectomy and adjuvant RT between 1988 and 2012 were included using data from the Surveillance, Epidemiology, and End Results database. Univariate and multivariate Cox regression analyses were used to analyze the effect of histologic subtype on cause-specific survival (CSS) and overall survival (OS).

RESULTS

We included 1171 patients: 919 with cervical SCC and 252 with cervical AC. In multivariate analysis, cervical AC was an independent adverse prognostic factor for survival. Patients with cervical AC had worse CSS (p = 0.001) and OS (p = 0.001) compared to patients with cervical SCC. In the subgroup analysis, patients with cervical SCC in the era of concurrent chemoradiotherapy (CCRT) (2000-2012) had better CSS (p = 0.006) and OS (p = 0.004) compared with the era of RT. However, there was no significant difference in CSS (p = 0.079) and OS (p = 0.053) between the eras of RT (1988-1999) and CCRT for patients with cervical AC.

CONCLUSIONS

Survival of cervical AC is significantly worse than that of cervical SCC. As CCRT usage increases, the survival benefit is derived only in cervical SCC, but not in cervical AC.

Predicting tumor recurrence in patients with cervical carcinoma treated with definitive chemoradiotherapy: value of quantitative histogram analysis on diffusion-weighted MR images

Background Further research is required for evaluating the use of ADC histogram analysis in more advanced stages of cervical cancer treated with definitive chemoradiotherapy (CRT). Purpose To investigate the utility of apparent diffusion coefficient (ADC) histogram derived from diffusion-weighted magnetic resonance images in cervical cancer patients treated with definitive CRT. Material and Methods The clinical and radiological data of 50 patients with histologically proven cervical squamous cell carcinoma treated with definitive CRT were retrospectively analyzed. The impact of clinicopathological factors and ADC histogram parameters on prognostic factors and treatment outcomes was assessed. Results The mean and median ADC values for the cohort were 1.043 ± 0.135 × 10^-3 mm²/s and 1.018 × 10^-3 mm²/s (range, 0.787-1.443 × 10^-3 mm²/s). The mean ADC was significantly lower for patients with advanced stage (≥IIB) or lymph node metastasis compared with patients with stage <IIB or no lymph node metastasis. The mean ADC, 75th percentile ADC (ADC75), 90th percentile ADC (ADC90), and 95th percentile ADC (ADC95) were significantly lower in patients with tumor recurrence compared with patients without recurrence. In multivariate analysis, tumor size, ADC75 and ADC95 were independent prognostic factors for both overall survival and disease-free survival. Conclusion ADC histogram parameters could be markers for disease recurrence and for predicting survival outcomes. ADC75, ADC90, and ADC95 of the primary tumor were significant predictors of disease recurrence in cervical cancer patients treated with definitive CRT.

Safety and Efficacy of Neoadjuvant Chemotherapy Followed by Radical Surgery Versus Radical Surgery Alone in Locally Advanced Cervical Cancer Patients

Objectives

This study aimed to evaluate the safety and efficacy of neoadjuvant chemotherapy (NACT) followed by radical surgery (RS) among patients with locally advanced cervical cancer (LACC).

Methods

Eight hundred patients with LACC received either NACT followed by RS (NACT–RS) or RS alone. The primary outcome measures assessed the efficacy and adverse effects of NACT. Secondary outcome measures compared the preoperative clinical stage to the postoperative pathologic stage in NACT–RS and RS patients, assessed intraoperative and postoperative complications, including the adverse effects of postoperative radiotherapy and radiochemotherapy, and estimated the 5-year progression-free survival and 5-year overall survival.

Results

The clinical response to NACT was 89.54%. Patients in the NACT–RS group had lower preoperative hemoglobin levels (115.20 vs 122.04 g/L, P < 0.001), a longer operative time (mean, 233.66 vs 224.37 minutes, P = 0.008), more intraoperative bleeding (750.34 vs 684.41 mL, P = 0.011), a shorter duration of catheter use (mean, 29.84 vs 32.14 days, P = 0.036), and a lower incidence of postoperative complications (7.30% vs 13.62%, P = 0.002) and postoperative radiotherapeutic and radiochemotherapeutic adverse effects (3.16% vs 4.63%, P < 0.001) compared to patients in the RS group. The 5-year progression-free survival and 5-year overall survival were 80.30% and 81.10% in the NACT–RS group and 81.00% and 78.50% in the RS group (P > 0.05). Pathological poor differentiation, nonsquamous cell carcinoma, parametrial invasion, positive pelvic lymph node, and lymphovascular invasion (P < 0.05) were independent risk factors for recurrence.

Conclusions

Neoadjuvant chemotherapy may reduce RS-associated complications and postoperative radiotherapeutic and radiochemotherapeutic adverse effects in Chinese patients with LACC.

Gynecologic Cancer InterGroup (GCIG) consensus review for cervical adenocarcinoma

Cervical adenocarcinoma is known to be less common than squamous cell carcinoma of the cervix comprising approximately 25% of all cervical carcinomas. Differences in associated human papillomavirus types, patterns of spread, and prognosis call for treatments that are not always like those for squamous cancers. In this review, we report a consensus developed by the Gynecologic Cancer InterGroup surrounding cervical adenocarcinoma for epidemiology, pathology, treatment, and unanswered questions. Prospective clinical trials are needed to help develop treatment guidelines.

Phase 2 trial of paclitaxel, 13-cis retinoic acid, and interferon alfa-2b in the treatment of advanced stage or recurrent cervical cancer

OBJECTIVE

Overexpression of bcl-2 is a mechanism of drug resistance in cervical cancer. Agents that down-regulate bcl-2 may decrease tumor cell threshold and sensitize tumor cells to chemotherapy. The objective of this multi-institutional phase 2 trial was to evaluate the efficacy and toxicity of paclitaxel and bcl-2 modulators (13-cis retinoic acid and interferon alfa-2b) in patients with advanced-stage or recurrent cervical cancer.

MATERIALS AND METHODS

Patients had biopsy-proven metastatic, first relapse, or persistent cervical cancer with no prior chemotherapy except for chemosensitizing agents. The treatment consisted of oral 13-cis retinoic acid, 1 mg/kg, and subcutaneous interferon alfa-2b, 6 mU/m, days 1 to 4, and intravenous paclitaxel, 175 mg/m, day 4 until disease progression or adverse events prohibited treatment. The primary endpoint was overall response rate.

RESULTS

Thirty-three patients were enrolled between March 2001 and June 2009. Thirty-one patients were eligible for evaluation of treatment response. Twenty-seven patients (82%) received prior concurrent chemoradiation or radiotherapy alone before study enrollment. The overall response rate was 30% (6 complete responses and 4 partial responses). Furthermore, 7 patients (21%) had stable disease. Grade 3 or 4 adverse events included neutropenia (n =16 [48%]), febrile neutropenia (n = 1 [3%]), and anemia (n = 1 [3%]). There were no treatment-related deaths. The median progression-free survival was 3.4 months (95% confidence interval, 2.0-7.4 months), and overall survival was 11.2 months (95% confidence interval, 7.5-26.2 months). Of 6 patients with complete responses, 5 patients survived more than 2 years.

CONCLUSIONS

Combination therapy with paclitaxel, 13-cis retinoic acid, and interferon alfa-2b is feasible and safe in treating patients with advanced and recurrent cervical cancer.

Validation of optimal DCE-MRI perfusion threshold to classify at-risk tumor imaging voxels in heterogeneous cervical cancer for outcome prediction

PURPOSE

To classify tumor imaging voxels at-risk for treatment failure within the heterogeneous cervical cancer using DCE MRI and determine optimal voxel's DCE threshold values at different treatment time points for early prediction of treatment failure.

MATERIAL AND METHOD

DCE-MRI from 102 patients with stage IB2-IVB cervical cancer was obtained at 3 different treatment time points: before (MRI 1) and during treatment (MRI 2 at 2-2.5 weeks and MRI 3 at 4-5 weeks). For each tumor voxel, the plateau signal intensity (SI) was derived from its time-SI curve from the DCE MRI. The optimal SI thresholds to classify the at-risk tumor voxels was determined by the maximal area under the curve using ROC analysis when varies SI value from 1.0 to 3.0 and correlates with treatment outcome.

RESULTS

The optimal SI thresholds for MRI 1, 2 and 3 were 2.2, 2.2 and 2.1 for significant differentiation between local recurrence/control, respectively, and 1.8, 2.1 and 2.2 for death/survival, respectively.

CONCLUSION

Optimal SI thresholds are clinically validated to quantify at-risk tumor voxels which vary with time. A single universal threshold (SI=1.9) was identified for all 3 treatment time points and remained significant for the early prediction of treatment failure.

Comparison of clinical outcomes of adenocarcinoma and adenosquamous carcinoma in uterine cervical cancer patients receiving surgical resection followed by radiotherapy: a multicenter retrospective study (KROG 13-10)

OBJECTIVE

To evaluate the prognostic influence of adenocarcinoma (AC) and adenosquamous carcinoma (ASC) in patients with FIGO stage IB-IIA cervical cancer who received radical hysterectomy followed by adjuvant radiotherapy (RT) or concurrent chemoradiotherapy (CCRT).

METHODS

We analyzed 1323 patients who satisfied the following criteria: histologically proven squamous cell carcinoma (SCC), AC, or ASC of the uterine cervix; FIGO stage IB-IIA disease; no history of neoadjuvant chemotherapy; and a history of radical hysterectomy with pelvic lymph node (PLN) dissection, followed by postoperative pelvic RT at a dose ≥ 45 Gy. The median age was 50 years. Median RT dose delivered to the whole pelvis was 50.4 Gy, and 219 (16.6%) patients received brachytherapy at a median dose of 24 Gy. Concurrent chemotherapy was delivered to 492 (37.2%) patients.

RESULTS

Pathologic risk factors were not different according to pathologic subtype. The median follow-up duration was 75.7 months. Locoregional recurrence-free survival, relapse-free survival (RFS), and overall survival were significantly affected by histology, tumor size, PLN metastasis, parametrial invasion, lymphovascular invasion, and deep stromal invasion. The 5-year RFS rates were 83.7%, 66.5%, and 79.6% in patients with SCC, AC, and ASC histology, respectively (P<0.0001). By multivariate analysis, AC histology was the only significant prognostic factor affecting all survival outcomes.

CONCLUSIONS

AC histology was associated with poor survival outcomes in patients with FIGO stage IB-IIA cervical cancer who received adjuvant RT or CCRT. Prognosis of ASC histology was closer to that of SCC histology than that of AC histology.

Bone Metastasis in Primary Endometrial Carcinoma: Features, Outcomes, and Predictors

Objectives

This study aimed to describe the clinicopathologic characteristics and outcomes and to assess the predictors associated with prognosis in endometrial carcinoma that developed bone metastasis.

Methods

A retrospective review of medical records was performed to identify the patients with endometrial carcinoma who developed bone metastasis between October 1994 and May 2012.

Results

Of the 1185 patients with endometrial carcinoma, 22 (1.8%) were identified with bone metastasis, and 21 patients were analyzed in the study. Seventeen (80.9%) patients had advanced-stage disease (2009 International Federation of Gynecologists and Obstetricians stages III-IV). Four (19.0%) patients had a bone lesion at the diagnosis of endometrial cancer. The median time of recurrence to the bone in 17 patients was 9 months (range, 2–43 months). The median overall survival (OS) and survival after bone metastasis of the entire cohort were 33 months (range, 9–57 months) and 15 months (range, 12–17 months), respectively. The patients with bone metastasis at recurrence had significantly longer OS than those patients with bone metastasis at diagnosis of endometrial cancer (36 vs 13 months; P = 0.042). Metastasis to extrapelvic bone was significantly associated with longer OS (46 vs 19 months; P = 0.001) and longer survival after bone metastasis (25 vs 12 months; P = 0.002). Isolated bone recurrence without extraosseous metastases and extrapelvic bone metastasis revealed independent predictors for survival after bone metastasis (hazard ratio, 0.09; 95% confidence interval, 0.01–0.67; P = 0.019 and hazard ratio, 0.07; 95% confidence interval, 0.01–0.53; P = 0.01).

Conclusions

In endometrial carcinoma that develops bone metastasis, isolated bone recurrence and extrapelvic bone metastasis are significant predictors of prolonged survival after the diagnosis of bone metastasis. Further researches on the optimal treatment modality and factors that have the clinical implications are warranted.

Pre-treatment diffusion-weighted MR imaging for predicting tumor recurrence in uterine cervical cancer treated with concurrent chemoradiation: value of histogram analysis of apparent diffusion coefficients

OBJECTIVE

To evaluate the value of apparent diffusion coefficient (ADC) histogram analysis for predicting tumor recurrence in patients with uterine cervical cancer treated with chemoradiation therapy (CRT).

MATERIALS AND METHODS

Our institutional review board approved this retrospective study and waived informed consent from each patient. Forty-two patients (mean age, 56 ± 14 years) with biopsy-proven uterine cervical squamous cell carcinoma who underwent both pre-treatment pelvic magnetic resonance imaging with a 3.0 T magnetic resonance scanner and concurrent CRT were included. All patients were followed-up for more than 6 months (mean, 36.4 ± 11.9 months; range 9.0-52.8 months) after completion of CRT. Baseline ADC parameters (mean ADC, 25th percentile, 50th percentile, and 75th percentile ADC values) of tumors were calculated and compared between the recurrence and no recurrence groups.

RESULTS

In the recurrence group, the mean ADC and 75th percentile ADC values of tumors were significantly higher than those of the no recurrence group (p = 0.043 and p = 0.008, respectively). In multivariate analysis, the 75th percentile ADC value of tumors was a significant predictor for tumor recurrence (p = 0.009; hazard ratio, 1.319). When the cut-off value of the 75th percentile ADC (0.936 × 10(-3) mm(2)/sec) was used, the overall recurrence free survival rate above the cut-off value was significantly lower than that below the cut-off value (51.9% vs. 91.7%, p = 0.003, log-rank test).

CONCLUSION

Pre-CRT ADC histogram analysis may serve as a biomarker for predicting tumor recurrence in patients with uterine cervical cancer treated with CRT.

Characterizing tumor heterogeneity with functional imaging and quantifying high-risk tumor volume for early prediction of treatment outcome: cervical cancer as a model

PURPOSE

Treatment response in cancer has been monitored by measuring anatomic tumor volume (ATV) at various times without considering the inherent functional tumor heterogeneity known to critically influence ultimate treatment outcome: primary tumor control and survival. This study applied dynamic contrast-enhanced (DCE) functional MRI to characterize tumors' heterogeneous subregions with low DCE values, at risk for treatment failure, and to quantify the functional risk volume (FRV) for personalized early prediction of treatment outcome.

METHODS AND MATERIALS

DCE-MRI was performed in 102 stage IB(2)-IVA cervical cancer patients to assess tumor perfusion heterogeneity before and during radiation/chemotherapy. FRV represents the total volume of tumor voxels with critically low DCE signal intensity (<2.1 compared with precontrast image, determined by previous receiver operator characteristic analysis). FRVs were correlated with treatment outcome (follow-up: 0.2-9.4, mean 6.8 years) and compared with ATVs (Mann-Whitney, Kaplan-Meier, and multivariate analyses).

RESULTS

Before and during therapy at 2-2.5 and 4-5 weeks of RT, FRVs >20, >13, and >5 cm(3), respectively, significantly predicted unfavorable 6-year primary tumor control (p = 0.003, 7.3 × 10(-8), 2.0 × 10(-8)) and disease-specific survival (p = 1.9 × 10(-4), 2.1 × 10(-6), 2.5 × 10(-7), respectively). The FRVs were superior to the ATVs as early predictors of outcome, and the differentiating power of FRVs increased during treatment.

DISCUSSION

Our preliminary results suggest that functional tumor heterogeneity can be characterized by DCE-MRI to quantify FRV for predicting ultimate long-term treatment outcome. FRV is a novel functional imaging heterogeneity parameter, superior to ATV, and can be clinically translated for personalized early outcome prediction before or as early as 2-5 weeks into treatment.

Sequential magnetic resonance imaging of cervical cancer: the predictive value of absolute tumor volume and regression ratio measured before, during, and after radiation therapy

BACKGROUND

The objectives of this study were to investigate outcome prediction by measuring absolute tumor volume and regression ratios using serial magnetic resonance imaging (MRI) during radiation therapy (RT) for cervical cancer and to develop algorithms capable of identifying patients at risk of a poor therapeutic outcome.

METHODS

Eighty patients with stage IB2 through IVA cervical cancer underwent 4 MRI scans: before RT (MRI1), during RT at 2 to 2.5 weeks (MRI2) at 4 to 5 weeks (MRI3), and 1 to 2 months after RT (MRI4). The median follow-up was 6.2 years (range, 0.2-9.4 years). Tumor volumes at MRI1, MRI2, MRI3, and MRI4 (V1, V2, V3, and V4, respectively) and tumor regression ratios (V2/V1, V3/V1, and V4/V1) were measured by 3-dimensional volumetry. Predictive metrics based on tumor volume/regression parameters were correlated with ultimate clinical outcomes, including tumor local recurrence (LR) and dying of disease (DOD). Predictive power was evaluated using the Mann-Whitney test, sensitivity/specificity analyses, and Kaplan-Meier analyses.

RESULTS

Both tumor volume and regression ratio were strongly correlated with LR (P=.06, P = 5×10(-4), P=1×10(-6), and P=2×10(-8) for V1, V2, V3, and V4, respectively; and P=7×10(-5), P=1×10(-6), and P=1×10(-8) for V2/V1, V3/V1, and V4/V1, respectively) and DOD (P=.015, P=.004, P=.001, and P=3×10(-4) for V1, V2, V3, and V4, respectively; and P=.03, P=.009, and P=3×10(-4) for V2/V1, V3/V1, and V4/V1, respectively). Algorithms that combined tumor volumes and regression ratios improved predictive power (sensitivity, 61%-89%; specificity, 79%-100%). The strongest predictor, pre-RT volume and regression ratio at MRI3 (V1>40 cm3 and V3/V1>20%, respectively), achieved 89% sensitivity, 87% specificity, and 88% accuracy for LR and achieved 54% sensitivity, 83% specificity, and 73% accuracy for DOD.

CONCLUSIONS

The current results suggested that tumor volume/regression parameters obtained during primary therapy are useful in predicting LR and DOD. Both tumor volume and regression ratio provided important information as early outcome predictors that may guide early intervention for patients with cervical cancer who are at high risk of treatment failure.

A comparison of pure adenocarcinoma and squamous cell carcinoma of the cervix after radical hysterectomy in stage IB-IIA

OBJECTIVE

This study was designed to investigate the survival difference between pure adenocarcinoma (AC) and squamous cell carcinoma (SCC) in early cervical cancer (FIGO stage IB-IIA) after radical hysterectomy with or without adjuvant therapy performed at a single institution.

METHODS

Patients with AC or SCC between November 1994 and September 2007 at the Samsung Medical Center, Sungkyunkwan University School of Medicine in Seoul, Korea were evaluated.

RESULTS

Among the 775 patients, 636 patients had SCC, and 139 patients had pure AC. In basal characteristics, preoperative FIGO stage, adjuvant therapy after surgery, as well as chemotherapeutic regimens, were not different between the two groups. However, the median age was about 5 years younger in pure AC patients than in SCC patients (44 years vs. 49 years, P=.001). In the comparison of pathological findings after surgery between the two groups, there were no differences between the two groups, except for LVSI status. The recurrence rate was higher in the pure AC group than in the SCC group (SCC; 36/636; 5.7%, AC; 20/139; 14.4%, P=<0.001, respectively). The pure AC group had a higher recurrence rate in hematogenous/distant areas than the SCC group (SCC: 8/36; 22.2%, AC; 9/20; 45.0%, P=.076, respectively). In multivariable analysis, positive for pelvic LN and the pure AC cell type were independent factors in both DFS and OS.

CONCLUSION

We observed that pure AC of the cervix might entail a worse survival outcome than SCC in patients with early cervical cancer (IB-IIA).

Ultra-early predictive assay for treatment failure using functional magnetic resonance imaging and clinical prognostic parameters in cervical cancer

BACKGROUND

The authors prospectively evaluated magnetic resonance imaging (MRI) parameters quantifying heterogeneous perfusion pattern and residual tumor volume early during treatment in cervical cancer, and compared their predictive power for primary tumor recurrence and cancer death with the standard clinical prognostic factors. A novel approach of augmenting the predictive power of clinical prognostic factors with MRI parameters was assessed.

METHODS

Sixty-two cervical cancer patients underwent dynamic contrast-enhanced (DCE) MRI before and during early radiation/chemotherapy (2-2.5 weeks into treatment). Heterogeneous tumor perfusion was analyzed by signal intensity (SI) of each tumor voxel. Poorly perfused tumor regions were quantified as lower 10th percentile of SI (SI[10%]). DCE-MRI and 3-dimensional (3D) tumor volumetry MRI parameters were assessed as predictors of recurrence and cancer death (median follow-up, 4.1 years). Their discriminating capacity was compared with clinical prognostic factors (stage, lymph node status, histology) using sensitivity/specificity and Cox regression analysis.

RESULTS

SI(10%) and 3D volume 2-2.5 weeks into therapy independently predicted disease recurrence (hazard ratio [HR], 2.6; 95% confidence interval [95% CI], 1.0-6.5 [P = .04] and HR, 1.9; 95% CI, 1.1-3.5 [P = .03], respectively) and death (HR, 1.9; 95% CI, 1.0-3.5 [P = .03] and HR, 1.9; 95% CI, 1.2-2.9 [P = .01], respectively), and were superior to clinical prognostic factors. The addition of MRI parameters to clinical prognostic factors increased sensitivity and specificity of clinical prognostic factors from 71% and 51%, respectively, to 100% and 71%, respectively, for predicting recurrence, and from 79% and 54%, respectively, to 93% and 60%, respectively, for predicting death.

CONCLUSIONS

MRI parameters reflecting heterogeneous tumor perfusion and subtle tumor volume change early during radiation/chemotherapy are independent and better predictors of tumor recurrence and death than clinical prognostic factors. The combination of clinical prognostic factors and MRI parameters further improves early prediction of treatment failure and may enable a window of opportunity to alter treatment strategy.

Adenocarcinoma: a unique cervical cancer

Adenocarcinoma of the cervix constitutes only approximately 20% of all cervical carcinomas; therefore, specific Level 1 evidence to guide patient management is lacking. Most trials have included this histologic subtype but in insufficient numbers to do more than generate hypotheses from subset analyses. As a consequence, our understanding of the natural history and optimal management of adenocarcinoma of the cervix is limited. The optimal management of adenocarcinoma of the cervix continues to be a subject of debate among practitioners as to whether or not it should be different from squamous cell carcinoma and what would constitute this management. The purpose of this review was to give an overview of the current knowledge on adenocarcinoma of the cervix and its differences from squamous cell carcinoma with regard to risk factors, prognosis, survival rates, patterns of recurrence, and response to treatment. This article will focus on possible specific therapeutic directions to explore in the management of locally advanced adenocarcinomas.

Translating response during therapy into ultimate treatment outcome: a personalized 4-dimensional MRI tumor volumetric regression approach in cervical cancer

PURPOSE

To assess individual volumetric tumor regression pattern in cervical cancer during therapy using serial four-dimensional MRI and to define the regression parameters' prognostic value validated with local control and survival correlation.

METHODS AND MATERIALS

One hundred and fifteen patients with Stage IB(2)-IVA cervical cancer treated with radiation therapy (RT) underwent serial MRI before (MRI 1) and during RT, at 2-2.5 weeks (MRI 2, at 20-25 Gy), and at 4-5 weeks (MRI 3, at 40-50 Gy). Eighty patients had a fourth MRI 1-2 months post-RT. Mean follow-up was 5.3 years. Tumor volume was measured by MRI-based three-dimensional volumetry, and plotted as dose(time)/volume regression curves. Volume regression parameters were correlated with local control, disease-specific, and overall survival.

RESULTS

Residual tumor volume, slope, and area under the regression curve correlated significantly with local control and survival. Residual volumes >or=20% at 40-50 Gy were independently associated with inferior 5-year local control (53% vs. 97%, p <0.001) and disease-specific survival rates (50% vs. 72%, p = 0.009) than smaller volumes. Patients with post-RT residual volumes >or=10% had 0% local control and 17% disease-specific survival, compared with 91% and 72% for <10% volume (p <0.001).

CONCLUSION

Using more accurate four-dimensional volumetric regression analysis, tumor response can now be directly translated into individual patients' outcome for clinical application. Our results define two temporal thresholds critically influencing local control and survival. In patients with >or=20% residual volume at 40-50 Gy and >or=10% post-RT, the risk for local failure and death are so high that aggressive intervention may be warranted.

A rare case of minimal deviation adenocarcinoma of the uterine cervix in a renal transplant recipient

INTRODUCTION

We report the first described case of minimal deviation adenocarcinoma of the uterine cervix in the setting of a female renal cadaveric transplant recipient.

MATERIALS AND METHODS

A retrospective review of this clinical case was performed.

CONCLUSION

This rare cancer represents only about 1% of all cervical adenocarcinoma.