Combined radiotherapy and chemotherapy for advanced carcinoma of the cervix

Role of induction chemotherapy in invasive cervical cancer

The 386 cases of invasive cervical carcinoma treated with radiotherapy alone were statistically analyzed to delineate the high risk factors (HRFs) associated with a significantly high treatment failure rate; they were (1) stages III-IV, (2) lesion greater than or equal to 4.0 cm, (3) small cell carcinoma or adenocarcinoma, (4) stages I-II with lesion greater than or equal to 4.0 cm, and (5) lymphographic evidence of nodal metastasis. Then, chemoradiotherapy (induction chemotherapy plus subsequent radiotherapy) was instituted to 113 invasive cervical carcinoma patients with at least one such HRF. Each patient received two to three cycles of induction chemotherapy at about 3-week intervals. For squamous cell carcinoma, cisplatin, 100 mg/m2 iv, was followed immediately by 5-fluorouracil, 1000 mg/m2, as a 24-hr iv infusion x 5 days. For adenocarcinoma, cisplatin, 70 mg/m2 iv, on Day 1 was followed by cytoxan, 250 mg/m2, on Day 2, and adriamycin, 45 mg/m2, on Day 3. Five-year survival of these patients according to each HRF, in the above order, was 69.1, 67.2, 68.1, 78.3, and 79.5% after chemoradiotherapy, all significantly higher than 57.4, 53.0, 54.5, 48.0, and 48.8% by radiotherapy alone. Drug toxicities such as leukopenia, hepatotoxicity, nephrotoxicity, and hypomagnesemia were seen in 46.5, 53.2, 47.1, and 55.4% of all cycles, respectively. The toxicities altered drug schedule in 191 (61.2%) ongoing induction chemotherapy cycles. Our cisplatin-based induction chemotherapy is considered an effective preradiotherapy adjunct that can reduce treatment failure in HRF-associated invasive cervical carcinoma.

Concomitant pelvic irradiation, 5-fluorouracil and mitomycin C in the treatment of advanced cervical carcinoma

This was a Phase II study of 24 late (FIGO) Stage IIb and 39 Stage III patients. External beam radiotherapy was given daily, five days a week, using 15 x 15 cm parallel opposed pelvic fields. The first 20 patients had 45.00 Gy mid-plane dose in 20 fractions, Days 1-28, the last 43 patients had 50.40 Gy in 28 fractions, Days 1-43. This was followed by an intracavitary boost of 17.00 Gy to Point A in two fractions over seven days. The first seven patients had concomitant 5-fluorouracil (5FU) 1 g/m2/day (maximum 1.5 g/day) Days 2-5, 30-33 and 57-60, with mitomycin C 10 mg/m2 (maximum 15 mg) Days 2 and 57. Two patients had WHO Grade 4 cytopenia, and only two were able to have full dose intensity. The 5FU dose was reduced to 0.8 g/m2/day, for Days 2-5 and 30-33; mitomycin C was given on Day 2 only. Treatment morbidity with the reduced chemotherapy intensity was comparable with that of radiotherapy alone. Median follow-up was 16 months (range 6-44). Median survival was 35 months. The results were compared with historical controls treated using the same radiation method alone. Two-year survival for late Stage IIb patients was 67% with the combination and 72% with radiotherapy alone; for Stage III, 67% and 49% respectively. Two-year pelvic control for late Stage IIb was 87% (combination) and 84% (radiotherapy alone) and for Stage III, 61% and 55% respectively. In contrast to reports from other centres, these results do not show an overall significant improvement on radiotherapy alone. A Phase III study may not be practicable.

The effect of 3-aminobenzamide in the radiation response of three human cervix carcinoma xenografts

By means of growth delay measurements, the in vivo radiation response of three recently established human cervix carcinoma xenograft lines has been determined at both high (70 cGy/min) and low dose rate (5 cGy/min). In addition, we have investigated the role of the polyADP-ribosylation inhibitor, 3-aminobenzamide, (3-AB, administered at 450 mg/kg) in modifying the xenograft response to continuous low dose rate irradiation (5 cGy/min). For all three lines, less growth delay was observed for 9 Gy administered at 5 cGy/min compared to 70 cGy/min; in terms of the times for tumours to reach twice their original weight (T2 values), low dose rate effect sparing ratios of 2.1 for HX 155, 1.5 for HX 156 and 2.4 for HX 160 were observed. 3-AB exerted no significant effect on the growth of unirradiated tumours. When 3-AB was given during irradiation at 5 cGy/min to 9 Gy, an enhancement in growth delay was observed for each line. However, the degree of radioenhancement by 3-AB varied among the lines; significant enhancement (p less than 0.01) at all time points tested was observed for HX 156, while for the other two lines, the degree of enhancement was not significant. Enhancement effect ratios (in terms of T2 values) were 1.37 for HX 155, 1.55 for HX 156 and 1.02 for HX 160. Similar differential radiosensitizing effects with 3-AB have been observed previously in vitro. More potent poly(ADP-ribosylation) inhibitors are probably required along with additional normal tissue studies before such an approach may be proposed at the clinical level.

Concomitant radiation therapy and chemotherapy in the treatment of advanced squamous carcinoma of the lower female genital tract

Twenty-three consecutive patients with advanced squamous carcinoma of the lower female genital tract were entered into a pilot study to determine the response rate and toxicity of a combination of intravenous cisplatin and 5-fluorouracil given concomitantly with radiation therapy. Twenty (87%) of the patients had a complete clinical response. Two patients (9%) had a partial response and one (4%) had stable disease. Nine (45%) of the complete responders have recurred with a median time to recurrence of 4 months. Seven (35%) had some component of local recurrence. The complete responders who have not recurred have been followed a median of 17 months. The acute toxicity was generally mild and there was no life-threatening acute complications. Three patients developed significant late complications. The response rate in this study was very high. The responses were usually prompt and dramatic, but often not sustained.

Chemotherapy-radiation interactions in human cervix carcinoma xenografts

The combination of irradiation and four agents of clinical interest in the treatment of cervix carcinoma (bleomycin, etoposide, cisplatin and ifosfamide) have been investigated using two human cervix carcinoma xenografts in nude mice. As a model of clinical brachytherapy regimes, radiation was administered at a continuous low dose rate of 5 cGy min-1 to a total dose of 9 or 12 Gy. No substantial enhancement in tumour growth delay over that observed for radiation alone was observed with bleomycin, etoposide or cisplatin. Ifosfamide, however, led to substantial additional growth delay, an effect which was lost when irradiation was administered at a higher dose rate of 70 cGy min-1. As dose-rates of around 5 cGy min-1 allow greater repair of radiation damage than at the higher dose-rate without significant cell cycling or repopulation, it is possible that ifosfamide may act as an inhibitor of repair processes in this model. It would be of interest to evaluate the role of ifosfamide and brachytherapy regimes in the clinical treatment of carcinoma of the cervix.

Feasibility study of an alternating schedule of radiotherapy and chemotherapy in advanced uterine cervical carcinoma

From July 1981 to April 1982, 36 patients with advanced cervical carcinoma stage III (24 patients) and stage IV (12 patients) entered a feasibility study of a radiotherapy and chemotherapy combination. The first three chemotherapy courses consisted of cis-platinum alone (50 mg/m2) and were interdigitated with radiotherapy. Six more courses composed of an association of cis-platinum (50 mg/m2) and cyclophosphamide (400 mg/m2) were given after the completion of radiotherapy. Radiotherapy was delivered in two courses of 25 Gy separated by a gap of 2 weeks. The overall 4-year survival rate was 35% (95% CI: 22%). The 4-year survival rate, cumulative loco-regional failure rate, and cumulative metastasis rate were respectively 44% (95% CI: 20%), 56% (95% CI: 21%), and 30% (95% CI: 21%) in stage III and 28% (95% CI: 27%), 83% (95% CI: 21%) and 74% (95% CI: 30%) in stage IV. The incidence of immediate and late complications was low: no patient had her radiotherapy stopped because of an intolerance and two patients had their chemotherapy stopped because of an haematological intolerance. Only one patient presented a severe late clinical complication (small bowel injury).