Residual pelvic lymph node involvement after concomitant chemoradiation for locally advanced cervical cancer

Primary radical hysterectomy vs chemoradiation for IB2-IIA cervical cancer: A systematic review and meta-analysis

BACKGROUND

To compare the clinical outcomes of radical hysterectomy (RH) with chemoradiotherapy (CRT) in women with stage IB2-IIA cervical cancer.

METHODS

Based on articles published up to December 2017, a literature search of PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and Chinese National Knowledge Infrastructure (CNKI) databases was conducted to identify eligible studies. Overall survival (OS), progression-free survival (PFS) with hazard ratios (HRs), and toxicities with odds ratios (ORs) were analyzed.

RESULTS

In total, 7 studies comprising 687 patients were identified for this meta-analysis. RH showed a significant trend toward improved survival outcomes compared with those of CRT, regardless of OS (HR = 0.49, 95% confidence interval [CI] 0.36-0.67, P < .001); or PFS (1.61, 95% CI 1.15-2.26, P = .005) for IB2-IIA cervical cancer. Subgroup analysis revealed that stage IB2 cervical cancer patients obtained better OS (HR = 0.36, 95% CI 0.23-0.56, P < .001; heterogeneity: P = .32, I = 13%). However, a higher incidence of grade 3/4 genitourinary abnormalities was evident with RH (OR = 2.3, 95% CI 1.42-3.87, P = .021).

CONCLUSION

Our study suggested that RH had distinct advantages over CRT for carcinoma of the uterine cervix with FIGO stage IB2-IIA, especially for IB2 cervical cancer.

Is Routine Curettage a Useful Tool to Evaluate Persistent Tumor in Patients Who Underwent Primary Chemoradiation for Locally Advanced and/or Lymph Node Positive Cervical Cancer?

Objective

Response evaluation after primary chemoradiation (RCTX) in patients with cervical cancer remains difficult. Routine hysterectomy after primary RCTX is associated with considerable surgical morbidity without impact on survival. The purpose of the present study was to evaluate value of routine curettage after RCTX to detect persistent tumor.

Methods

Between 2006 and 2012, patients (n = 217) with cervical cancer in International Federation of Gynecology and Obstetrics stages IB1 N1 (14%), IB2 (9%), IIA (5%), IIB (46%), IIIA (4%), IIIB (15%), IVA (6%), and IVB (1%), respectively, underwent primary RCTX. After RCTX, curettage was recommended to all patients to evaluate response.

Results

In 136 (63%) of patients with cervical cancer, 1 or 2 consecutive curettages were performed at least 6 weeks after primary RCTX without any complications. In 21 (15%) patients, at least 1 curettage was positive for cervical cancer. In 7 patients, secondary hysterectomy was performed after 1 positive finding and persistent tumor was found in all of them. In the remaining 14 patients, there were 2 positive curettages in 5, 1 undetermined result followed by 1 positive in 3, and 1 positive followed by 1 negative in 6 patients, respectively. In the latter group, no tumor was detected in the uterus, whereas in all other patients with 2 curettages except one, residual carcinoma was detected. Five (24%) of 21 patients with positive histology are free of disease during follow-up. Decision for or against secondary hysterectomy was correct due to histological finding of curettage in 99%.

Conclusions

Routine curettage is a useful tool to guide decision for secondary hysterectomy with high accuracy after primary RCTX and avoids overtreatment.

The Effect of Extrafascial Hysterectomy After Completion of External Beam Radiotherapy for Treatment of Locally Advanced Stages (IIB-III) of Cervical Cancer

Background:

Worldwide, cervical cancer is one of the most challenging gynecologic cancers in treatment.

Objectives:

This study was designed with the aim of comparing patients treated with External Beam Radiotherapy (EBRT) and Interactivity Brachytherapy (ICBT) with EBRT and extrafascial hysterectomy in locally advanced stages of cervical cancer (IIB-III).

Patients and Methods:

The present study was designed as a case-control which was performed on the patients with cervical cancer in locally advanced stages (IIB-III) admitted to Namazi and Faghihi hospitals (university hospitals in Shiraz) between 2008-2011. 51 patients were included in two distinct groups: 25 patients were treated with EBRT and Interactivity Brachytherapy (group A). 26 patients were treated with EBRT and extrafascial hysterectomy group B.

Results:

In group A, the number of patients with FIGO stage IIb and III were 16 and 9, respectively, and 17 and 9 in group B. The median duration of follow-up was 24 months. There were no significant differences between two groups in metastasis and recurrence rate (P > 0.05). 5-years overall survival rate was 54.8% [95% CI: 39-70.9] in group A and in group B was 50.9% [95% CI: 41.5-60] and The LOG-rank test which controls the effect of treatment modalities on overall survival rate, did not show any significant difference between two groups (P = 0.407).

Conclusion:

The results of our study showed that the trend of treatment using EBRT along with intracavity brachytherapy may have the same outcome as the method of using EBRT and extrafascial hysterectomy. Overall, it seems that external beam radiation followed by extrafascial hysterectomy could be a proper substitute for brachytherapy.

Completion Surgery After Intensity-Modulated Arc Therapy in the Treatment of Locally Advanced Cervical Cancer: Feasibility, Surgical Outcome, and Oncologic Results

Introduction

Since the addition of chemotherapy to radiotherapy, the survival rates of locally advanced cervical cancer (LACC) have improved but are still disappointing. Therefore, the idea of surgery after chemoradiation in case of LACC or bulky disease was adopted. One of the concerns regarding surgery following chemoradiotherapy is surgery-related morbidity.

Aim

The objectives of this study were to investigate the feasibility of surgery after advanced radiotherapy techniques such as intensity-modulated arc therapy (IMAT) and to describe the morbidity.

Methods

This was a prospective study of primary inoperable LACC patients primary treated with IMAT, in most cases combined with weekly cisplatin. Then the resectability was reevaluated. If resectable patients were treated with Wertheim type 2 surgery ± pelvic lymphadenectomy (on positron emission tomography–computed tomography indication). If tumor is not resectable, patients were treated with brachytherapy.

Results

Since 2006, 41 consecutive patients were included. After neoadjuvant IMAT, 34 were considered resectable and underwent surgery, whereas 7 proceeded with brachytherapy. The operative mortality rate was nil. There were no major perioperative complications. No ureter, bladder, or bowel injuries occurred. No postoperative urinary/digestive fistulae or stenoses were noted. Eleven patients had postoperatively urinary retention problems. At the time of discharge, 5 patients still needed self-catheterization. All problems resolved within 3 months. In 4 cases, we saw significant lymphoceles. In all patients intended to treat, overall survival and disease-free survival at 3 years were 63% and 74%. In the Wertheim group, overall survival and disease-free survival at 3 years were 81% and 91%.

Conclusions

Completing surgery after chemoradiation therapy (with IMAT) for LACC or bulky disease is feasible, and complication rates are comparable with those of primary surgery for cervical cancer.

Cell Based Autologous Immune Enhancement Therapy (AIET) after Radiotherapy in a Locally Advanced Carcinoma of the Cervix

Radiotherapy is the primary form of treatment in patients with locally advanced cervical carcinoma. However for residual disease in the form of the persistent lymph nodes, surgery or chemotherapy is recommended. As surgery is not acceptable by every patient and chemotherapy has associated side effects, we hereby report the positive outcome of in vitro expanded natural killer cell and activated T lymphocyte based autologous immune enhancement therapy (AIET) for the residual lymphadenopathy in a patient with locally advanced cervical cancer after radiation. After six transfusions of AIET, there was complete resolution of residual lymph nodes and there was no evidence of local lesion. The patient also reported improvement in quality of life. As AIET has been reported as the least toxic among the available therapies for cancer, combining AIET with conventional forms of therapy in similar patients might not only improve the outcome but may also help the patients achieve a good quality of life.

Comparison of outcomes between radical hysterectomy followed by tailored adjuvant therapy versus primary chemoradiation therapy in IB2 and IIA2 cervical cancer

OBJECTIVE

To compare survival outcomes and treatment-related morbidities between radical hysterectomy (RH) and primary chemoradiation therapy (CRT) in patients with bulky early-stage cervical cancer.

METHODS

We selected 215 patients with stage IB2 and IIA2 cervical cancer (tumor diameter > 4 cm on magnetic resonance imaging) who underwent RH followed by tailored adjuvant therapy (n=147) or primary CRT (n=68) at two tertiary referral centers between 2001 and 2010.

RESULTS

About twenty nine percent of patients were cured by RH alone and these patients experienced the best survival outcomes with the lowest morbidity rates. After the median follow-up times of 40 months, 27 RH (18.4%) and 20 CRT (29.4%) patients had recurrence (p=0.068) and 23 (15.6%) and 17 (25%) patients died of disease (p=0.101). The 5-year progression-free survival were 77% and 66% (p=0.047), and the 5-year overall survival were 78% and 67% (p=0.048) after RH and primary CRT, respectively. In multivariate analysis, patients who received primary CRT was at higher risk for tumor recurrence (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.24 to 4.14; p=0.008) and death (OR, 3.02; 95% CI, 1.53 to 5.98; p=0.001) than those who received RH. Grade 3-4, early (17% vs. 30.9%, p=0.021) and late (1.4% vs. 8.8%, p=0.007) complications were significantly less frequent after RH than primary CRT.

CONCLUSION

Thirty percent of patients were cured by RH alone. A treatment outcome was better in this retrospective study in terms of morbidity and survival. Randomized trials are needed to confirm this result.

Contribution of pelvic and para-aortic lymphadenectomy with sentinel node biopsy in patients with IB2-IIB cervical cancer

Objective:

Detection of lymph node involvement in women with IB2–IIB cervical cancer could have a positive effect on survival. We set out to evaluate the incidence of pelvic and/or para-aortic lymph node involvement using the sentinel node (SN) biopsy and its impact on survival.

Methods:

From 2002 to 2010, 66 women with IB2–IIB cervical cancer underwent a pelvic and paraaortic lymphadenectomy with SN biopsy. Survival between groups according to lymph node status was evaluated.

Results:

Mean tumour size was 43.5 mm. At least one SN was detected in 69% of the 45 SN procedures performed. Sixteen of these patients had metastatic SN and the false negative rate was 20%. Metastatic pelvic SNs or non-SNs were detected in 33 patients (50%), including pelvic-positive nodes in 26 (40%), pelvic- and paraaortic-positive lymph nodes in seven (11%), and paraaortic skip metastases in two (6%). Positive paraaortic node was the sole determinant for disease-free survival (DFS) and overall survival (OS; P<0.001). Differences in DFS and OS between groups according to the nodal status were observed (P<0.001).

Conclusion:

SN procedure gave a higher rate of metastasis detection. Further studies are required to evaluate whether pre-therapeutic node staging, including paraaortic and pelvic lymphanedectomy, should be performed.

[((18)F)-fluorodeoxyglucose PET/CT in cervix cancer: lymph node assessment and prognostic/predictive value of primary tumour analysis]

PURPOSE

In cervix carcinoma: (a) to evaluate the ability of ((18)F)-fluorodeoxyglucose (FDG) positron emission tomography (PET) in the lymph node detection; (b) to investigate the prognostic and predictive value of the primary cervical PET parameters.

PATIENTS AND METHODS

Ninety patients treated for cervix carcinoma and evaluated initially by MRI and FGD PET were included. The performances of FDG-PET for lymph node detection (relatively to the lymph node dissection) have been described (sensitivity, specificity, positive predictive value and negative predictive value). PET tumour parameters analyzed were: maximum standard uptake value (SUVmax), the volume and the maximum diameter. The prognostic and predictive values of these parameters were investigated. The tumour response was evaluated on surgical specimens.

RESULTS

PET detected the cervical tumour with a sensitivity of 97% (mean values: SUVmax=15.8, volume=27 mm(3), maximum diameter=47). For the detection of the lymph nodes, the values of sensibility, specificity, positive predictive value and negative predictive value were: 86, 56, 69 and 78% in the pelvic, and 90, 67, 50 and 95% for the para-aortic area, respectively. The SUVmax was correlated with histologic response (P=0.04). The frequency of partial histological response was significantly higher for tumour SUVmax>10.9 (P=0.017). The maximum PET diameter and pathologic response had an impact on disease-free survival and overall survival in multivariate analysis (P<0.05).

CONCLUSION

PET has high sensitivity in detecting pelvic and para-aortic lymph nodes. Some primary cervical tumour PET parameters are useful as prognostic and predictive factors.

Accuracy of 18-fluoro-2-deoxy-D-glucose positron emission tomography in the pretherapeutic detection of occult para-aortic node involvement in patients with a locally advanced cervical carcinoma

PURPOSE

Patients with locally advanced cervical cancer (LACC) are usually treated with concurrent chemoradiotherapy. Extended-field chemoradiotherapy is indicated in case of para-aortic node involvement at initial assessment. 18-Fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (18-FDG PET/CT) is currently considered to be the most accurate method of detection of node or distant metastases. The goal of this study was to evaluate the accuracy of PET at detecting para-aortic lymph node metastases in LACC patients with a negative morphological imaging.

METHODS

Patients from five French institutions with LACC and both negative morphologic (magnetic resonance imaging, CT scan) and functional (PET or PET/CT) findings at the para-aortic level and distantly were submitted to a systematic infrarenal para-aortic node dissection either by laparoscopy or laparotomy. On the basis of pathological results, sensitivity, specificity, and positive and negative predictive values of PET/CT were assessed for para-aortic lymph node involvement.

RESULTS

A total of 125 LACC patients (stage IB2-IVA disease with two local recurrences) fulfilled the inclusion criteria. All had an ilio-infrarenal para-aortic lymphadenectomy, either by laparoscopy (n = 117) or laparotomy (n = 8). Twenty-one patients (16.8%) had pathologically proven para-aortic metastases. Among them, 14 (66.7%) had negative PET/CT. Overall morbidity of surgery was 7.2%. All but one of the complications were mild and did not delay chemoradiotherapy. Sensitivity, specificity, and positive and negative predictive value of the PET/CT were 33.3, 94.2, 53.8, and 87.5%, respectively, for the detection of microscopic lymph node metastases.

CONCLUSIONS

Laparoscopic staging surgery seems warranted in LACC patients with negative PET scan who are candidates for definitive concurrent chemoradiotherapy or exenteration.

Locally advanced cervical cancer: what is the standard of care?

PURPOSE OF REVIEW

Carcinoma of the cervix remains a significant health problem for women worldwide. Locally advanced cervical cancer (LACC) is a common presentation that has been extensively studied in the last three decades. This article reviews the standard of care and discusses current topics of clinical research.

RECENT FINDINGS

A multidisciplinary approach to the treatment of cervical cancer has led to marked improvement in outcome. Main advances are with neoadjuvant chemotherapy, chemoradiation, and preventive vaccination. Concurrent chemoradiation with a platinum-based agent is the recommended treatment for LACC. Palliation with platinum agent remains the standard of care for inoperable patients who have metastatic or recurrent disease.

SUMMARY

This is a review of published and ongoing studies testing multidisciplinary and medical management of LACC, with a focus on newer chemotherapeutic approaches. Optimal multidisciplinary treatment planning improves the outcome of each patient diagnosed with cervical cancer.

Pharmacotherapy of cervical cancer

IMPORTANCE OF THE FIELD

Cervical cancer (CC) remains an important health problem. It is the second most frequent malignancy in women worldwide, with one-third of patients dying from pharmacoresistant disease.

AREAS COVERED IN THIS REVIEW

We reviewed pharmacotherapy approaches in the medical and multidisciplinary management of CC and conducted a systematic search of Pubmed for clinical trials, reviews and meta-analysis published in the last 20 years. Abstracts of the American Society of Clinical Oncology, European Society of Gynecological Oncology and International Gynecologic Cancer Society were also searched, together with the US National Institutes of Health clinical trial database.

WHAT THE READER WILL GAIN

The state-of-the art of cytotoxic and biologically targeted therapies in early, locally advanced and metastatic/recurrent CC is discussed.

TAKE HOME MESSAGE

Until recently, the role of pharmacotherapy in CC was restricted to palliation of advanced/metastatic or recurrent disease. During the past two decades, this reluctant attitude towards chemotherapy has been modified after a series of randomized trials demonstrated its beneficial contribution as an adjunct to radiotherapy or surgery in early and locally advanced CC. Moreover, new combinations of cytotoxics, together with novel molecular target agents, open new perspectives in the treatment of primary and recurrent CC.

[Para-aortic lymphadenectomy in advanced-stage cervical cancer: standard procedure in 2010?]

With tumour size, node involvement is the most important prognosis factor in advanced stage cervical cancer. Para-aortic (PA) disease is observed in 15 to 30% of these patients. CT scan and magnetic resonance imaging (MRI) are not efficient enough to detect these lesions and PET CT have false negatives. Surgical staging is useful to detect carcinosis associated and to adapt therapy (radiotherapy fields are extended if PA nodes are involved). Laparoscopy was crucial to develop this staging because its morbidity associated to chemoradiotherapy is limited. If prognosis impact of PA lymphadenectomy is well established, therapeutic impact is still discussed. The systematic extension of this staging to pelvic nodes that are included in the basic radiotherapy fields is debated because it does not modify therapeutic management and is morbid. Radiotherapy progress, especially with boost and combination to MRI (MRIT), will impact on future therapeutic management.

Prognostic factors and morbidities after completion surgery in patients undergoing initial chemoradiation therapy for locally advanced cervical cancer

PURPOSE

The aim of this study was to evaluate the prognostic factors and morbidities of patients undergoing completion surgery for locally advanced-stage cervical cancer after initial chemoradiation therapy (CRT).

PATIENTS AND METHODS

Patients fulfilling the following inclusion criteria were studied: stage IB2-IVA cervical carcinoma, tumor initially confined to the pelvic cavity on conventional imaging, pelvic external radiation therapy with delivery of 45 Gy to the pelvic cavity and concomitant chemotherapy (cisplatin, 40 mg/m(2) per week) followed by uterovaginal brachytherapy, and completion surgery after the end of radiation therapy including at least a hysterectomy.

RESULTS

One-hundred fifty patients treated in 1998-2007 fulfilled the inclusion criteria. Prognostic factors for overall survival in the multivariate analysis were the presence and level of nodal spread (positive pelvic nodes alone: hazard ratio [HR], 2.03; positive para-aortic nodes: HR, 5.46; p < .001) and the presence and size of residual disease (RD) in the cervix (p = .02). Thirty-seven (25%) patients had 55 postoperative complications. The risk for complications was higher with a radical hysterectomy (p = .04) and the presence of cervical RD (p = .01).

CONCLUSION

In this series, the presence and size of RD and histologic nodal involvement were the strongest prognostic factors. Such results suggest that the survival of patients treated using CRT for locally advanced cervical cancer could potentially be enhanced by improving the rate of complete response in the irradiated area (cervix or pelvic nodes) and by initially detecting patients with para-aortic spread so that treatment could be adapted in such patients. The morbidity of completion surgery is high in this context.

Differing prognosis of cervical cancer patients with high risk of treatment failure after radical hysterectomy warrants trial treatment modification

OBJECTIVE

The aim of this study was to ascertain whether all cervical cancer patients who received adjuvant concurrent chemoradiation (CCRT) for high risk of treatment failure after radical hysterectomy are at the same risk of treatment failure, and if not, to propose trial treatment modification.

METHODS

Between January 1999 and December 2007, 58 patients with FIGO stage Ib-IIa cervical cancer received adjuvant CCRT due to high risk factors such as positive lymph nodes or positive parametrium, or positive vaginal resection margins. Patients were divided into two Groups. Group A were patients with negative parametrium, negative vaginal resection margins, and only unilateral lymph node metastasis (involved L/N</=2). Group B were those with either bilateral pelvic lymph node involvement, or more than 2 lymph node involvement, or positive parametrium with lymph node involvement.

RESULTS

During a median follow-up period of 34 months (range, 6 to 102 months), 9 patients (15.5%) experienced recurrence; among whom 2 patients (2/28, 7.1%) were Group A, and 7 patients (7/30, 23.3%) were Group B. At 3 years, the estimated progression-free survival rate of all 58 patients was 78.3%, and the overall survival rate was 89.7%. Patients in Group A had significantly better progression-free survival (88.2% vs. 68.2%, p=0.042) and overall survival rate (100% vs. 78.8%, p=0.034) than Group B.

CONCLUSION

Treatment modifications such as consolidation chemotherapy after CCRT may be considered based on the poor prognosis of very high risk patients such as those patients in Group B.

Brachytherapy versus radical hysterectomy after external beam chemoradiation: a non-randomized matched comparison in IB2-IIB cervical cancer patients

Background

A current paradigm in the treatment of cervical cancer with radiation therapy is that intracavitary brachytherapy is an essential component of radical treatment. This is a matched retrospective comparison of the results of treatment in patients treated with external beam chemoradiation (EBRT-CT) and radical hysterectomy versus those treated with identical chemoradiation followed by brachytherapy.

Methods

In this non-randomized comparison EBRT-CT protocol was the same in both groups of 40 patients. In the standard treated patients, EBRT-CT was followed by one or two intracavitary Cesium (low-dose rate) applications within 2 weeks of finishing external radiation to reach a point A dose of at least 85 Gy. In the surgically treated patients, radical hysterectomy with bilateral pelvic lymph node dissection and para-aortic lymph node sampling were performed within 7 weeks after EBRT-CT. Response, toxicity and survival were evaluated.

Results

A total of 80 patients were analyzed. The patients receiving EBRT-CT and surgery were matched with the standard treated cases. There were no differences in the clinicopathological characteristics between groups or in the delivery of EBRT-CT. The pattern of acute and late toxicity differed. Standard treated patients had more chronic proctitis while the surgically treated had acute complications of surgery and hydronephrosis. At a maximum follow-up of 60 months, median follow-up 26 (2–31) and 22 (3–27) months for the surgery and standard therapy respectively, eight patients per group have recurred and died. The progression free and overall survival are the same in both groups.

Conclusion

The results of this study suggest that radical hysterectomy can be used after EBRT-CT without compromising survival in FIGO stage IB2-IIB cervical cancer patients in settings were brachytherapy is not available. A randomized study is needed to uncover the value of surgery after EBRT-CT.

Matched-case comparison for the role of surgery in FIGO stage Ib1-IIa squamous cell carcinoma of cervix and suspicious para-aortic lymph node metastasis

We sought to compare the efficacy and toxicity between surgery followed by concurrent chemoradiation and primary concurrent chemoradiation in patients with International Federation of Gynecology and Obstetrics (FIGO) stage Ib1-IIa squamous cell carcinoma of cervix and suspicious para-aortic lymph node metastasis by preoperative computed tomographic and magnetic resonance imaging. From January 2000 to December 2007, 48 patients treated with radical hysterectomy with pelvic and para-aortic lymphadenectomy followed by concurrent chemoradiation (group 1) were matched to 16 patients treated with primary concurrent chemoradiation (group 2) from medical records. Primary end points were progression-free survival (PFS) and overall survival, and secondary end points were late complications by concurrent chemoradiation and pattern of disease recurrence. Among 48 patients in group 1, 39 (81.3%) and 35 (72.9%) had histologic pelvic and para-aortic lymph node metastases, respectively. Distant metastasis was more frequent in group 2 than in group 1 (37.6% vs. 12.5%, p = 0.027), although there was no difference in locoregional recurrence between the two groups. Surgery followed by concurrent chemoradiation and FIGO stage Ib1 were only statistically significant factors for improved PFS (adjusted hazard ratio, 0.231 and 0.244; 95% confidence interval, 0.072-0.821 and 0.086-0.697), although there was no prognostic factor for overall survival. Furthermore, there was no difference in grade 3 or 4 late complications between groups 1 and 2 (25.0% vs. 31.3%, p = 0.745). Surgery followed by concurrent chemoradiation may improve PFS and reduce distant metastasis without difference in late complications compared with primary concurrent chemoradiation in patients with FIGO stage Ib1-IIa squamous cell carcinoma of cervix and suspicious para-aortic lymph node metastasis.

The role of surgery after chemoradiation therapy and brachytherapy for stage IB2/II cervical cancer

OBJECTIVE

The aim of this study was to review the results of completion surgery after chemoradiation therapy in stage IB2/II cervical carcinoma.

METHODS

Analysis of series published in the literature about completion surgery in this context.

RESULTS

Stages of the disease included in those series were stage IB2-IVA disease. The rate of residual disease was correlated with initial stage of the disease and the use of preoperative brachytherapy. Morbidity of such management varied between 15% and 47% and was correlated with the radicality of the surgical procedure and the size of the residual disease. The rate of complete pathological response varied between 52% and 76%. The survival of patients was correlated with the presence and the size of the residual disease and the presence of a nodal involvement.

CONCLUSION

Completion surgery after chemoradiation therapy has a place in the multimodality management of stage IB2 or II cervical cancer, particularly in cases of bulky residual disease. Nevertheless further investigations are needed, particularly with collaborative studies, to analyze the real impact of such surgery on the survival of patients.

Preoperative concomitant chemoradiotherapy in locally advanced cervical cancer: safety, outcome, and prognostic measures

OBJECTIVES

To evaluate the morbidity, and the therapeutic value of surgery after chemoradiation in a large series of locally advanced cervical cancers (LACC). The prognostic role of different clinico-pathological factors has been also evaluated.

METHODS

Between October 1997 and October 2006, 161 LACC patients were treated at both the Gynecologic Oncology Units of the Catholic University of Rome and Campobasso. Radiotherapy was administered to the whole pelvic region in combination with cisplatin and 5-fluorouracil. Radical surgery was performed 5-6 weeks after the end of the treatment.

RESULTS

A clinical complete/partial response was observed in 153 patients and radical surgery was performed in 152 cases. The overall rate of surgical complications was 33% with 15 (10%) patients experiencing severe toxicities. At pathological examination 111 of 152 patients (73%) showed absent/microscopic residual disease. With a median follow-up of 28 months, the 5-year disease free-survival (DFS) was 83% and the 5-year overall survival (OS) 90%. Advanced FIGO (Federation Internationale de Gynecolgie et d'Obstetrique) stage, pathological response and lymph node involvement were found significantly associated with clinical outcome.

CONCLUSIONS

We confirmed in a larger series the safety and efficacy of this multimodal approach in the treatment of LACC. The pathological assessment of response can allow not only a tailored surgery in selected patients, but also the identification of patients with higher risk of recurrence to be submitted to adjuvant therapies.

Para-Aortic Involvement and Interest of Para-Aortic Lymphadenectomy after Chemoradiation Therapy in Patients with Stage IB2 and II Cervical Carcinoma Radiologically Confined to the Pelvic Cavity

BACKGROUND

Pelvic radiation therapy with concomitant chemotherapy (PCRT) is the standard treatment of stage IB2/II cervical carcinoma. The impact of concomitant chemotherapy on positive para-aortic nodes (PA+), however, remains unknown. The aim of this study was twofold: to evaluate the rate of histological PA+ after PCRT and to determine the survival of patients with PA+.

METHODS

Patients fulfilling the following inclusion criteria were studied: (1) stage IB2/II cervical carcinoma, (2) histological subtype: squamous cell, adenocarcinoma or an adenosquamous tumor, (3) exclusion of patients with radiological PA+ (CT scan/MRI), (4) pelvic external radiation therapy of 45 Gy with concomitant chemotherapy (cisplatin 40 mg/m2/week) + utero-vaginal brachytherapy, and (5) completion surgery after the end of PCRT including at least a para-aortic lymphadenectomy.

RESULTS

Seventy-three patients (16 stage IB2, 57 stage II) treated between 1998 and 2004 fulfilled all the inclusion criteria. PA+ after PCRT were observed in 13 patients (18%) with a median of five (range, 2-22) positive nodes. Overall and disease-free survival at 24 months in patients with PA+ was 40% and 17%. Only two patients with PA+ are currently alive and in remission.

CONCLUSIONS

The rate of PA+ remains high after PCRT in patients treated for stage IB2/II cervical carcinoma. Furthermore, the survival rate of patients with PA+ is very low. These important results suggest that detection of PA + at the time of completion surgery (after PCRT) is not beneficial for improving survival.

Sentinel lymph node procedure followed by laparoscopic pelvic and paraaortic lymphadenectomy in women with IB2-II cervical cancer

OBJECTIVE

To evaluate the contribution of the sentinel node (SN) procedure followed by pelvic and paraaortic lymphadenectomy to determine lymph node status in women with locally advanced cervical cancer.

PATIENTS AND METHODS

A total of 21 women with locally advanced cervical cancer underwent a first laparoscopic SN procedure and pelvic and paraaortic lymphadenectomy followed by concurrent chemoradiotherapy (CCR). Laparoscopic radical hysterectomy was performed after CCR when the pelvic and paraaortic nodes were not involved.

RESULTS

SNs were detected by means of lymphoscintigraphy in 10 women (47.6%) and intra-operatively in 14 women (66.6%). Of the latter 14 patients, 9 (64%) had an involved SN and 1 of the remaining 5 had pelvic non-SN metastases. The SN false-negative rate was 10%. At final histology, 13 of the 21 women (62%) had lymph node metastases. The total number of recovered pelvic non-SNs was 262, and 10 nodes in 8 women were involved. The total number of paraaortic non-SNs was 255, and 2 nodes in 2 women were involved.

CONCLUSION

This study shows the poor correlation between pre-operative lymphoscintigraphy and surgical SN mapping in women with locally advanced cervical cancer. A high proportion of women had SN metastases, underlining the importance of multiple sectioning and immunohistochemical staining of SNs.

Lymph node involvement in locally advanced cervical cancer patients administered preoperative chemoradiation versus chemotherapy

BACKGROUND

A retrospective study was planned in 127 locally advanced cervical cancer (LACC) to investigate: (1) the rate and pattern of metastatic lymph node involvement in patients administered preoperative chemoradiation (CT/RT) versus neoadjuvant chemotherapy (NACT), and (2) the profile of clinico-pathological parameters predictive of metastatic lymph node involvement in these two clinical settings. Finally, we investigated whether the pathologically assessed status of lower pelvic nodes (LPN) was able to predict the pathologically assessed status of upper pelvic nodes (UPN) and parametrium in cases administered CT/RT.

METHODS

Patients were selected including LACC patients who were administered concomitant CT/RT (n = 87) or NACT (n = 40), before radical surgery.

RESULTS

Metastatic pelvic lymph node involvement was significantly lower in cases administered CT/RT (11.5%) compared to cases administered NACT (30.0%) (P value = 0.009). In the CT/RT group, only MRI-assessed pelvic node status (both at staging and post-treatment evaluation) was associated with pathologic pelvic node status. In patients administered CT/RT, the status of LPN appeared associated with the status of UPN.

CONCLUSIONS

(1) Preoperative CT/RT treatment is associated with a lower rate of pelvic node disease in LACC patients compared to NACT; (2) there is no association between the preoperative extent of residual cervical disease after CT/RT and pathologically assessed pelvic node status; (3) the pathological status of LPN is predictive of the pathological status of UPN and parametrium.

Radiation-sparing managements for cervical cancer: a developing countries perspective

Cervical cancer is the seventh most frequent cancer worldwide but more than 80% of cases occur in developing countries. Till date, radiation therapy with external beam and brachytherapy remains as the core treatment for most stages of cervical cancer. However, radiation treatment protocols and equipment modelled on the best developed countries can be seldom applied directly to developing countries owing to financial constraints and lack of qualified personnel, thus, a substantial proportion of patients do not have access to even palliative radiation therapy. Treatment options when the standard therapy is either not available or difficult to reproduce in particular settings is highly desirable with the potential to save lives that otherwise could be lost by the lack of adequate treatment. These options of treatment ideally had to have show, 1) that these are not inferior to the "standard" in terms of either survival or quality of life; 2) that these can be delivered in settings were the "standard" is not available or if available its quality is poor; and 3) that the treatment option be accepted by the population to be treated.

Based on these considerations, it is obvious that cervical cancer patients, particularly those who live in countries with limited resources and therefore may not have sufficient radiation therapy resources are in need of newer therapeutical options. There is now a considerable amount of information emanating from clinical studies where surgery has a major role in treating this disease. These forms of "radiation-sparing" treatments include total mesometrial resection that could make unnecessary the use of adjuvant radiation; neoadjuvant chemotherapy that could avoid the use of adjuvant radiation in around 85% of patients and preoperative chemoradiation that could make brachytherapy dispensable. The feasibility and therapeutical value of these potential forms of management need to be prospectively evaluated.

Place de la chirurgie après chimioradiothérapie des cancers du col localement évolués

Standard treatment of locally advanced cervical carcinoma is actually represented by concomitant chemoradiotherapy followed by brachytherapy since several randomised study results in 1999. Surgical resection after concomitant chemoradiotherapy for locally advanced cervical carcinoma is discussed without evidence of benefice on survival and because morbidity. The aim of this study is to discuss surgery after chemoradiotherapy in terms of rate of morbidity and residual tumor, rate of pelvic disease control, overall survival and disease-free survival.