Analysis of recurrence of squamous cell carcinoma of the uterine cervix after definitive radiation therapy alone: patterns of recurrence, latent periods, and prognosis

Comparative Analysis of Oncologic Outcomes in Patients with Squamous Cell Carcinoma of the Uterine Cervix with High-Risk Features for Para-Aortic Recurrence: Prophylactic Extended-Field versus Pelvic Chemoradiotherapy

Purpose

To compare the oncologic outcomes of prophylactic extended-field radiation therapy (EFRT) and whole pelvic radiation therapy (WPRT) in cervical patients at high risk of para-aortic lymph node (PALN) recurrence.

Patients and Methods

From July 1999 to May 2022, a total of 115 patients with cervical cancer and high-risk features of PALN recurrence based on tumor markers, positive LNs and extensive parametrial invasion were retrospectively analyzed. All patients had received EFRT or WPRT at a dose of 39.6-45 Gy and concurrent chemotherapy. In EFRT, coverage was extended to include the para-aortic region below the level of the left renal vein or T12.

Results

Twenty-eight and 87 patients underwent EFRT and WPRT, respectively. For patients who survived, the median follow-up time was 60.8 months (range 9.2-131.6 months) in the EFRT group and 115.9 months (range 16.9-212.1 months) in the WPRT group. The 5-year overall survival (OS) and pelvic, extrapelvic and PALN recurrence rates were 87.7% vs 60.8% (p=0.019), 10.9% vs 25.3% (p=0.119), 18.1% vs 45.8% (p=0.011), and 0% vs 30.4% (p=0.005), respectively, between the EFRT and WPRT groups. Multivariate analysis revealed that EFRT and 2018 FIGO stage IV disease status were significant predictors of OS and extrapelvic recurrence.

Conclusion

Compared to WPRT, EFRT significantly improved OS and reduced extrapelvic and PALN recurrence in patients with cervical cancer with high-risk recurrence features.

Clinical analysis of prophylactic para-aortic intensity-modulated radiation in cervical cancer

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.

Unusual finding of bronchopulmonary carcinoma through a pterygoid muscle metastasis. About a case

Bronchopulmonary cancer muscle metastases are uncommon, especially when they are visible. They can impact any muscle in the body, but the psoas, diaphragmatic, and paravertebral muscles have a clear advantage. We present a case of lateral pterygoid muscle metastasis of squamous cell carcinoma of the lung in a 70-year-old habitual smoker (40 packs per year) presents headaches more marked on the right and progressively worsening. A complementary brain MRI revealed a well-limited oval formation with irregular contours in hypo signal T1 hyper signal T2 heterogeneous, with area of central necrosis of the right pterygoid muscle, which was revealed to be a secondary location of bronchopulmonary malignancy after further examination (CT scan of the cervico-thoraco-abdomino-pelvic region, TEP scan, and biopsy). Moreover, muscle metastases are rarely revealing of primary cancer.

PTEN Loss and ARID1A Mutation in an HPV-positive Metastatic Adenocarcinoma Diagnosed Almost 18 yr After an Intact Cone Excision for Endocervical Adenocarcinoma In Situ

There have been previous reports of neoplasms with the morphology of endocervical adenocarcinoma in situ (AIS) that secondarily involve the ovaries, presumably through transtubal spread, with a smaller subset metastasizing to distant sites. These ovarian metastases have been discovered up to 7 yr postexcision of the endocervical lesion, consistent with the known potential for overtly invasive cervical carcinomas to recur late after primary curative management. Herein, we present a case of a premenopausal woman with a pelvic mass classified as metastatic human papillomavirus (HPV)-associated endocervical adenocarcinoma (p16-block immunoreactive, high-risk HPV positive by in situ hybridization with PTEN loss, ARID1A, and PBRM1 mutations detected by qualitative next-generation sequencing), identified 17.7 yr (212 mo) after a fertility-sparing cone excision with negative margins for endocervical AIS [HPV-associated, p16-block immunoreactive; PTEN, and BAF250a (ARID1a) expression retained]. Our case highlights: (1) the potential for a subset of lesions with the morphology of AIS to metastasize, and the extraordinarily long timeframe (almost 18 y, the longest reported to date) during which metastases may still be identified; (2) alterations in PTEN and ARID1A may play a role in the progression of a subset of endocervical carcinomas; and (3) the need for studies to evaluate the utility of incorporating ovarian/pelvic imaging into surveillance protocols following fertility-sparing excisions or ovarian-preserving hysterectomies, during the management of endocervical adenocarcinomas, as well as the need to counsel patients about the small but real risk of delayed discovery of ovarian metastases following fertility-preserving surgeries for AIS.

18F-FDG-PET/CT imaging of uterine cervical cancer recurrence in women with and without HIV infection

BACKGROUND

To compare the rate, time and, pattern of recurrence of cervical cancer between patients with and without HIV infection and to determine factors predicting cervical cancer recurrence in patients evaluated by ¹⁸F-FDG-PET/CT.

METHODS

We reviewed the ¹⁸F-FDG-PET/CT images of patients with histologically proven cervical carcinoma who were presenting with suspected recurrence. We extracted epidemiologic data, previous treatment, histologic subtype, HIV status, viral load and CD4 counts from the electronic laboratory database and the referral form for the ¹⁸F-FDG-PET/CT study.

RESULTS

We studied 303 women including 112 HIV-infected patients. FIGO stage III disease was present in 131 patients. Of 198 patients with recurrence, 74 were HIV-infected while 124 were not (P=0.849). HIV infected patients were younger (41.99±9.30 years) compared to HIV-uninfected (50.19±11.09), P<0.001. Local recurrence was present in 125 patients while 100 patients had a distant recurrence. Recurrence occurred at a single site in 88 patients and two or more sites in 110 patients. No significant difference in the recurrent patterns between HIV-infected and uninfected patients. Median time to recurrence was 10.50 months (range: 6.00-156.00) among HIV-infected versus 12.00 months (IQR:7.00-312.00) among the uninfected, P=0.065. FIGO stage III (P=0.042) and the presence of histological sub-types other than SCC (P=0.005) were significant predictors of recurrence. HIV infection by itself was not significant in predicting recurrence (P=0.843).

CONCLUSIONS

HIV infection has no significant impact on the rate, time or pattern of recurrence in women with suspected cervical carcinoma recurrence. Advanced disease and histological variant other than SCC are predictive of recurrence.

Efficacy of local salvage therapy for recurrent uterine cervical cancer after definitive radiotherapy

BACKGROUND

The prognosis of patients with recurrence of uterine cervical cancer after definitive radiotherapy and the efficacy of local salvage therapy for recurrence were evaluated.

METHODS

We retrospectively reviewed 110 patients who were treated with definitive radiotherapy/chemoradiotherapy for uterine cervical cancer between 2008 and 2017 at our institution. Local salvage therapy was defined as any surgery or radiotherapy described in the medical record as intended for local control or cure.

RESULTS

We identified 25 patients who developed recurrence after definitive radiotherapy/chemoradiotherapy. The median follow-up time post-recurrence was 18.9 months. Thirteen patients (52%) reported recurrence in the isolated extra-pelvic lymph node (EPLN). The 2-year overall survival after first recurrence (OSr) for patients with isolated EPLN recurrence was 83.1%, compared to that of 31.2% for patients with other patterns of recurrence (p < 0.001). The 2-year OSr for patients who underwent local salvage therapy was 75.2%, whereas that for patients who did not undergo therapy was 41.6% (p = 0.04). Among patients who had recurrence in the isolated EPLN and received local salvage therapy, 20% of the patients reported recurrence in visceral and/or bone metastases after local salvage therapy, and 50% of the patients experienced another EPLN recurrence, which was salvaged with repeating local therapy.

CONCLUSIONS

Patients with uterine cervical cancer with isolated EPLN recurrence had favorable prognoses. The indications of local salvage therapy should be considered, especially for patients with isolated EPLN recurrence.

Definitive chemoradiotherapy for cervical cancer: A 11-year population-based study

PURPOSE

To assess the recurrence pattern and survival in women treated with definitive chemoradiotherapy for cervical cancer.

METHODS

A retrospective cohort study of women FIGO (2012) stage IB2 to IVA from the Grampian region of Scotland between February 2000 and March 2011. These women were followed up until April 2018.

RESULTS

A total of 121 eligible women allocated with mean age at treatment 50.59 years (SD = 13.98, range 22-82). Tumours staged: IB2: n = 24 (19.8%), II: n = 45 (37.2%), III: n = 43 (35.5%) and IVA: n = 7 (5.8%). Two (1.7%) women had no available data. Fifty-five (45.5%) women had recurrence after treatment, and 51 (42.15%) women died from the disease. The sites of recurrence were as follows: central pelvic only (n = 4, 7.27%), pelvic and distant (n = 39, 70.91%) and distant only (n = 12, 21.82%) with median time from end of treatment to first recurrence 44 months (range 2-98), 26 months (range 1-146) and 22 months (range 3-66) respectively. 5-and 8-year overall survival was 76.0% (95% CI: 68.8%-84.0%) and 64.4% (95% CI: 56.4%-73.5%) respectively.

CONCLUSIONS

Though overall survival is better than with radiotherapy alone, recurrence occurs up to 10 years after treatment. This raises the issues of how to reduce late recurrence and the appropriateness of current follow-up protocols.

Para-aortic lymph node recurrence after curative radiotherapy for cervical cancer

Objective

The para-aortic lymph nodes are one of the most common sites in recurrent cervical cancer. However, treatment strategies for para-aortic lymph node recurrence have not yet been established.

This study aimed to evaluate the prognostic factors and treatment outcomes in patients with para-aortic lymph node recurrence after curative radiotherapy for cervical cancer.

Methods

We retrospectively reviewed patients who developed para-aortic lymph node recurrence following curative radiation therapy for cervical cancer from January 2001 and December 2014 at the Samsung Medical Center. Prognostic factors for overall survival after recurrence were analyzed by univariate and multivariate analyses.

Results

A total of 67 patients were included in the analysis. After a median follow-up of 24.0 months (range 4–155), the 3-year overall survival rate was 42.7%. 32 patients had isolated para-aortic lymph node recurrence (group 1), 21 patients had para-aortic lymph node recurrence combined with other lymph node recurrence (group 2), and 14 patients developed para-aortic lymph node recurrence with distant organ metastasis (group 3). The 3-year overall survival rates in groups 1, 2, and 3 were 60.8%, 42.1%, and 7.7%, respectively (p<0.001). In multivariate analysis, histologic type of squamous cell carcinoma (p=0.028), non-symptomatic recurrence (p=0.024), isolated para-aortic lymph node recurrence (p=0.008), and disease-free interval (p=0.008) were significant factors for survival. Among the patients with isolated para-aortic lymph node recurrence, survival rates differed significantly according to disease-free interval; the 3-year overall survival in patients with disease-free interval ≥12 months and disease-free interval <12 months was 69.6% and 37.5%, respectively (p<0.001).

Conclusions

In patients with para-aortic lymph node recurrence from cervical cancer, histologic type, presence of symptoms, extent of disease, and disease-free interval were the prognostic factors for survival. Patients with isolated para-aortic lymph node recurrence with disease-free interval ≥12 months had higher survival outcomes at 3 years.

Extended-field radiotherapy for locally advanced cervical cancer

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.

Clinical outcome of extended-field irradiation vs. pelvic irradiation using intensity-modulated radiotherapy for cervical cancer

The aim of the present study was to evaluate the distinctions in survival and toxicity between patients with cervical cancer with common iliac node or para-aortic node involvement, who were treated with extended-field intensity-modulated radiotherapy (EF-IMRT) and patients with or without lower involved pelvic nodes, who were treated with pelvic IMRT. A total of 55 patients treated with EF-IMRT and 52 patients treated with pelvic IMRT at the Sun Yat-Sen University Cancer Center (Guangzhou, China) were retrospectively analyzed. Patients treated with EF-IMRT had the highest level of lymph node involvement to the para-aortic or common iliac nodes, while patients treated with pelvic IMRT had no para-aortic or common iliac nodes involved (P<0.001). The median follow-up time was 29.5 months. The 3-year overall survival (OS) rates of EF-IMRT and pelvic IMRT were 79.4 and 82.3% (P=0.45), respectively, and the 3-year disease-free survival (DFS) rates of EF-IMRT and pelvic IMRT were 61.0 and 73.7% (P=0.55), respectively. Cox's regression analysis revealed that EF irradiation was a protective prognostic factor for OS and DFS. A total of 16 patients in the EF-IMRT group and 13 patients in the pelvic IMRT group experienced treatment failure (P=0.67), with the patterns of failure being the same for the two groups (P=0.88). The cumulative incidence of grade 3 and 4 acute toxicities in the EF-IMRT group was 34.5%, in comparison with 19.2% in the pelvic group (P=0.048). The results of the present study suggest that patients with cervical cancer with grossly involved common iliac or para-aortic nodes should be electively subjected to EF irradiation to improve the survival and alter patterns of recurrence. Notably, EF irradiation delivered via IMRT exhibits an increased toxicity incidence, however, this remains within an acceptable range.

Prognostic Importance of the Site of Recurrence in Patients With Metastatic Recurrent Cervical Cancer

PURPOSE

The clinical characteristics and outcomes of patients with metastatic recurrent cervical cancer remain poorly understood. The goals of the present study were to investigate the survival outcomes according to the recurrence site in a large cohort of cervical cancer patients.

METHODS AND MATERIALS

Of 1322 patients with primary cervical cancer from 2000 to 2013, 205 with recurrence after primary or adjuvant postoperative radiation were enrolled retrospectively. Aggressive salvage therapy (AST), which was defined as salvage therapy that aimed not only to relieve symptoms but also to ablate recurrent tumors by the single or combined application of surgical resection of local recurrence, metastasectomy, or metastasis-directed irradiation, followed by chemotherapy, was performed according to our institutional guidelines. The patterns of recurrence, application rate and mode of AST, and survival outcomes were evaluated retrospectively under approval from the institutional review board.

RESULTS

Regarding the pattern of recurrence, distant-only (DO) recurrence was most common (59.5%), followed by combined (21.5%), central (cervix or vaginal stump; 10.7%), and pelvic (pelvic lymph nodes or pelvic side wall; 8.3%) recurrence. Two subgroups (distant lymph nodes and lung parenchyma) of the DO group demonstrated remarkably good prognosis and were categorized as type A DO; the other subgroups were labeled type B DO. Patients with type A DO recurrence constituted 36% of all recurrences and 83.8% of them received AST. The 5-year overall survival rates were significantly greater in the type A DO group than in the other groups (44.8% in the type A DO group, 12.6% in the pelvic group, and 6.8% in the type B DO group).

CONCLUSIONS

We identified a patient subgroup with favorable outcomes after salvage therapy, type A DO, defined as recurrence in the distant lymph nodes only or in the lung parenchyma only. A future prospective trial is needed to investigate whether AST improves survival in this group.

[Muscle metastasis of an epidermoid carcinoma of the cervix: report of a case and review of the literature]

Les métastases musculaires sont rares, leur nombre est probablement sous estimé. Nous rapportons le cas d'une patiente âgée de 65 ans, ayant présenté une métastase musculaire d'un carcinome épidermoïde du col utérin 6 mois après le diagnostic de la tumeur primitive. Le diagnostic a été obtenu à partir de la biopsie et du scanner abdomino-pelvien. Le traitement a consisté en une irradiation palliative à la dose de 30Gy. L’évolution a été marquée par le décès de la patiente. A travers ce cas clinique on a démontré que le muscle peut être touché par les métastases d'un carcinome épidermoïde du col utérin et que leur pronostic reste en général péjoratif.

Distant metastasis in patients with cervical cancer after primary radiotherapy with or without chemotherapy and image guided adaptive brachytherapy

OBJECTIVE

The aim of this study is to investigate patterns of distant relapse after primary radiochemotherapy in cervical cancer patients.

METHODS

All patients with cervical cancer treated in curative intent with external beam radiotherapy +/- chemotherapy and image-guided adaptive brachytherapy between January 1998 and June 2009 at the Medical University of Vienna were included in this retrospective analysis. Patients with locoregional recurrences were excluded from this study. Presence, site of and time to distant metastases were recorded. For identifying prognostic factors, uni- and multivariate analyses using Cox regression analysis were performed. Based on the result from the multivariate analysis, patients were stratified into a high and a low risk group. The Kaplan-Meier method was used to estimate distant-metastasis-free-survival in the overall cohort, in the risk groups and for analysing the impact of chemotherapy within the risk groups.

RESULTS

A total number of 189 patients were included in this study. After a median follow-up of 54 months, 49 patients developed distant metastases. Overall, distant-metastasis-free-survival 5 years after treatment was 73%. FIGO stage, lymph node status and the extent of tumour regression during treatment were significant predictors for distant metastasis. Distant-metastasis-free-survival 5 years after treatment was 91% and 60% in the low and high risk groups, respectively. The number of the cycles of chemotherapy had a significant impact on the occurrence of distant metastasis in high risk patients, but not in low risk patients.

CONCLUSION

Patients with high risk factors have a 40% probability of developing distant metastasis within 5 years. In these patients, decreasing the number of cycles of cisplatin may increase their probability of developing distant metastasis.

Impact of Chemoradiation on Prognosis in Stage IVB Cervical Cancer with Distant Lymphatic Metastasis

PURPOSE

The purpose of this study was to determine whether chemoradiation (CCR) is efficient for improving prognosis, compared with systemic chemotherapy (SC), in patients with stage IVB cervical cancer who have distant lymphatic metastasis.

MATERIALS AND METHODS

Among 2,322 patients with cervical cancer between January 2000 and March 2010, 43 patients (1.9%) had stage IVB disease. After exclusion of 19 patients due to insufficient data and hematogenous metastasis, 24 patients (1%) who received CCR (n=10) or SC (n=14) were enrolled. We compared tumor response, progression-free survival (PFS) and overall survival (OS), and disease recurrence between CCR and SC.

RESULTS

Complete response rates were 60% and 0% after CCR and SC (p<0.01). Grade 3 or 4 leukopenia was more common in patients treated with CCR (24.4% vs. 9.1%, p=0.03), whereas grade 3 or 4 neuropenia was more frequent in those treated with SC (28.4% vs. 11.1%, p=0.03). Development of grade 3 proctitis occurred as a late radiotherapy (RT)-related toxicity in only one patient (10%) treated with CCR. In addition, squamous cell carcinoma and CCR were favorable prognostic factors for improvement of PFS (adjusted hazard ratios [HRs], 0.17 and 0.12; 95% confidence intervals [CIs], 0.04 to 0.80 and 0.03 to 0.61), and only CCR was significant for improvement of OS (adjusted HR, 0.15; 95% CI, 0.02 to 0.90). However, no differences in the rate and pattern of disease recurrence were observed between CCR and SC.

CONCLUSION

CCR may be more effective than SC for improving survival, and can be regarded as a feasible method with some caution regarding late RT-related toxicity for treatment of stage IVB cervical cancer with distant lymphatic metastasis.

Prognostic factors and treatment outcome after radiotherapy in cervical cancer patients with isolated para-aortic lymph node metastases

Objective

The purpose of the present study was to evaluate treatment outcomes and prognostic factors in cervical cancer patients with isolated para-aortic lymph node (PALN) metastases. We especially tried to evaluate PALN factors such as size, site and number.

Methods

From August 1994 to December 2009, 40 cervical cancer patients with isolated PALN node metastases at initial diagnosis were selected for analysis. Patients underwent both extended field external beam and intracavitary brachytherapy. Fourteen patients received 5-fluorouracil and cisplatin (FP) and 16 patients received weekly concurrent cisplatin. Information of PALN, such as size, site, and number, was founded before PALN radiotherapy.

Results

The median follow-up time after primary treatment was 28.5 months (range, 2 to 213 months). The 3-year overall and progression-free survival rate after primary treatment was 44.3% and 31.3%, respectively. In multivariate analysis including tumor stage, performance status, and chemotherapy, FP regimen concurrent chemoradiotherapy was more effective than radiotherapy alone (p=0.030). The 3-year progression-free survival rate was 41.9% and 11.1% in patients with PALN numbers of ≤1 and ≥2, respectively (p=0.008). The 3-year progression-free survival rate was 42.1% and 19.2% in patients with PALN size of <1.5 cm and ≥1.5 cm, respectively (p=0.031).

Conclusion

The radiologic features of PALN, such as number or size, can be used to determine prognosis in PALN metastatic cervical cancer patients. Furthermore, FP regimen concurrent chemoradiotherapy was associated with better patient survival than radiotherapy alone. However, more studies are required to confirm possible different treatment outcomes between FP and weekly cisplatin regimens.

High-dose-rate intra-cavitary brachytherapy combined with external beam radiation therapy for under 40-year-old patients with invasive uterine cervical carcinoma: clinical outcomes in 118 Patients in a Japanese multi-institutional study, JASTRO

BACKGROUND

The current study was designed to evaluate the clinical outcomes of curative intent radiation therapy for young patients with invasive uterine cervical carcinoma in Japan.

METHODS

One hundred and eighteen patients aged ≤40 were registered in the multi-institutional study of the Japanese Society of Therapeutic Radiology and Oncology (JASTRO) from 26 major institutions in Japan. The age range was 24-39 years and the maximum tumor diameter was 2.0-9.2 cm. The International Federation of Gynecology and Obstetrics clinical stages were Ib, IIa, IIb, IIIa, IIIb and IVa in 17, 6, 40, 2, 50 and 3, respectively. Curative intent radiation therapy consisted of the combination of external beam radiation therapy and high-dose rate intra-cavitary brachytherapy. The total dose of external beam radiation therapy ranged between 44 and 68 Gy. Both the median and mode of total high-dose-rate intra-cavitary brachytherapy dose to point A were 24 Gy in four fractions. Ninety-six patients (58%) received chemotherapy.

RESULTS

The 5-year overall survival rate and local control rate of all patients were 61 and 65%, respectively. The 5-year overall survival rates of International Federation of Gynecology and Obstetrics Stage Ib, IIa, IIb, IIIa, IIIb and IVa were 88, 100, 75, 100, 37 and 0%, respectively. The 5-year local control rates of International Federation of Gynecology and Obstetrics Stage Ib, IIa, IIb, IIIa, IIIb and IVa were 82, 75, 75, 100, 51 and 0%, respectively. Sixteen patients experienced grade 3 or greater late radiation morbidity.

CONCLUSIONS

The 5-year overall survival rate of young patients with Stage IIIb was comparatively low at 37%.

Salvage radiotherapy for lymph node recurrence after radical surgery in cervical cancer

OBJECTIVE

This study was to evaluate the treatment outcomes and prognostic factors of patients treated with salvage radiotherapy for the treatment of isolated lymph node recurrence of cervical cancer.

METHODS

Between 1990 and 2009, 22 cervical cancer patients with lymph node recurrence who had previously undergone radical hysterectomy and pelvic lymph node dissection were treated with salvage radiotherapy with (n=18) or without (n=4) chemotherapy. Of the 22 patients, 10 had supraclavicular lymph node recurrence, 9 had para-aortic lymph node, and 3 had inguinal lymph node. The median total radiotherapy dose was 60 Gy (range, 40 to 70 Gy). Initial pathologic findings, latent period to lymph node recurrence and other clinical parameters such as squamous cell carcinoma antigen (SCC-Ag) level and concurrent chemotherapy were identified as prognostic factors for survival.

RESULTS

The median follow-up period after salvage radiotherapy was 31.2 months (range, 12.1 to 148.9 months). The 5-year progression-free and overall survival rates of all patients were 32.7% and 30.7%, respectively. Concurrent chemoradiotherapy (p=0.009) and longer latent period to lymph node recurrence (>18 months vs. ≤18 months, p=0.019) were significant predictors of progression-free survival and SCC-Ag level at the time of recurrence (>8 ng/dL vs. ≤8 ng/dL, p=0.008) and longer latent period to lymph node recurrence (p=0.040) for overall survival. Treatment failure after salvage radiotherapy occurred in 14 (63.6%) for the 22 patients (in field, 2; out of field, 10; both in and out field, 2). Grade 3 acute skin (n=2) and hematologic toxicity (n=1) developed in 3 patients.

CONCLUSION

For isolated lymph node recurrence of cervical cancer, salvage radiotherapy with concurrent chemotherapy should be considered, especially in patients with a long-term progression-free period.

Pretreatment carcinoembryonic antigen level is a risk factor for para-aortic lymph node recurrence in addition to squamous cell carcinoma antigen following definitive concurrent chemoradiotherapy for squamous cell carcinoma of the uterine cervix

Background

To identify pretreatment carcinoembryonic antigen (CEA) levels as a risk factor for para-aortic lymph node (PALN) recurrence following concurrent chemoradiotherapy (CCRT) for cervical cancer.

Methods

From March 1995 to January 2008, 188 patients with squamous cell carcinoma (SCC) of the uterine cervix were analyzed retrospectively. No patient received PALN irradiation as the initial treatment. CEA and squamous cell carcinoma antigen (SCC-Ag) were measured before and after radiotherapy. PALN recurrence was detected by computer tomography (CT) scans. We analyzed the actuarial rates of PALN recurrence by using Kaplan-Meier curves. Multivariate analyses were carried out with Cox regression models. We stratified the risk groups based on the hazard ratios (HR).

Results

Both pretreatment CEA levels ≥ 10 ng/mL and SCC-Ag levels < 10 ng/mL (p < 0.001, HR = 8.838), SCC-Ag levels ≥ 40 ng/mL (p < 0.001, HR = 12.551), and SCC-Ag levels of 10-40 ng/mL (p < 0.001, HR = 4.2464) were significant factors for PALN recurrence. The corresponding 5-year PALN recurrence rates were 51.5%, 84.8%, and 27.5%, respectively. The 5-year PALN recurrence rate for patients with both low (< 10 ng/mL) SCC and CEA was only 9.6%. CEA levels ≥ 10 ng/mL or SCC-Ag levels ≥ 10 ng/mL at PALN recurrence were associated with overall survival after an isolated PALN recurrence. Pretreatment CEA levels ≥ 10 ng/mL were also associated with survival after an isolated PALN recurrence.

Conclusions

Pretreatment CEA ≥ 10 ng/mL is an additional risk factor of PALN relapse following definitive CCRT for SCC of the uterine cervix in patients with pretreatment SCC-Ag levels < 10 ng/mL. More comprehensive examinations before CCRT and intensive follow-up schedules are suggested for early detection and salvage in patients with SCC-Ag or CEA levels ≥ 10 ng/mL.

Identification of prognostic factors in patients with cervical cancer and supraclavicular lymph node recurrence

OBJECTIVE

Patients with cervical cancer and supraclavicular lymph nodes (SLN) recurrence have a poor but heterogeneous prognosis. The aim of this study was to identify potential prognostic factors - including FDG-PET results - that may affect survival and treatment outcomes in patients with this group of patients.

METHODS

Between January 2001 and December 2008, we identified a total of 31 consecutive patients with cervical cancer who had evidence of SLN recurrence. All participants underwent FDG-PET. Survival was measured from the date of documented SLN recurrence. The latency period was defined as the length of time from the date of first diagnosis to the date of SLN recurrence.

RESULTS

The median follow-up time was 22.8 months (range: 4.7-105.1). The 3- and 5-year survival rates were 41% and 27.3%, respectively. Patients with intermediate SUV values (between 4.3 and 8) had a significantly better prognosis than subjects with both high (>8) or low (<4.3) SUV values (p=0.004). Latency period <2 years, SCC-Ag levels ≥ 4ng/mL, recurrence extend beyond SLN, and SUV of <4.3 >8 were significant adverse prognostic factors by multivariate analysis. The 3-year overall survival (OS) rate of patients carrying 0-1 adverse prognostic factors was 90% (low-risk group), while 3-year OS rates for intermediate-risk group (2 factors) and high-risk group (3-4 factors) were 30% and 0%, respectively (p=0.001).

CONCLUSION

Our results justify the use of PET (accurate extent of relapse and SUV) as a prognostic tool in patients with cervical cancer and SLN recurrence.

Detection of hematogenous bone metastasis in cervical cancer: 18F-fluorodeoxyglucose-positron emission tomography versus computed tomography and magnetic resonance imaging

BACKGROUND

In this large-scale, retrospective study, the authors evaluated the diagnostic performances of computed tomography (CT), magnetic resonance (MR) imaging, and (18)F-fluorodeoxyglucose-positron emission tomography ((18)F-FDG-PET) in detecting hematogenous bone metastasis in patients with cervical cancer. The associated risk factors also were analyzed.

METHODS

Patients with invasive cervical cancer who had both (18)F-FDG-PET studies and CT or MR imaging studies were selected. Patients who had either International Federation of Gynecology and Obstetrics (FIGO) stage III/IV disease or positive lymph node metastasis at the time of primary staging and patients who had suspected recurrent disease were included in the analyses. The diagnostic performances of PET was compared with the performance of CT and MR imaging by using the area under the receiver-operating-characteristic curve (AUC). Both univariate and multivariate analyses were applied to assess the risk factors for hematogenous bone metastasis at primary staging.

RESULTS

PET was more sensitive than CT (P = .004) and was more specific than MR imaging (P = .04). The diagnostic performance of PET was significantly superior to the performance CT (AUC, 0.964 vs 0.662; P < .001) and MR (AUC, 0.966 vs 0.833; P = .033). Both FIGO stage and the extent of lymph node metastases were associated with hematogenous bone metastasis in univariate analysis. However, the extent of lymph node metastases was the only significant risk factor in multivariate analysis (P = .025).

CONCLUSIONS

The current study demonstrated the superiority of (18)F-FDG-PET over CT and MR imaging for detecting hematogenous bone metastasis in patients with advanced cervical cancer. Hematogenous bone metastasis in cervical cancer was associated with the extent of lymph node metastases rather than with FIGO stage.

Phase I study of concurrent chemoradiotherapy with weekly cisplatin and paclitaxel chemotherapy for locally advanced cervical carcinoma in Japanese women

The purpose of this study was to evaluate the use of concurrent chemoradiotherapy involving weekly administration of cisplatin and paclitaxel for the treatment of locally advanced cervical carcinoma in Japanese women. Twenty Japanese patients were registered for this phase I study. Radiation therapy was performed using external irradiation and high-dose rate intracavitary irradiation of the pelvis. Chemotherapy was performed once a week until termination of the radiation therapy. The dose of cisplatin was decided as 30 mg/m2, and the initial dose of paclitaxel was set as 30 mg/m2, with a planned incremental increase of 10 mg/m2 up to 70 mg/m2. When 3 to 6 patients were registered at each dose level and dose-limiting toxicity (DLT) was noted in more than 3 patients, the dose level was assumed to be the maximum tolerated dose. Among the 20 patients, 1 patient experienced DLT during 2 courses because of dehydration and arrhythmia. In another patient, chemotherapy was discontinued after 4 courses because of a hypersensitivity reaction to paclitaxel at dose level 3. No patient experienced DLT resulting from hematologic toxicities. All patients underwent radiation therapy according to schedule without any discontinuations. A complete response was obtained in 16 patients. Based on the results obtained from this study, weekly administration of 30 mg/m2 cisplatin and 50 mg/m2 paclitaxel with concurrent chemoradiotherapy can be considered a tolerable and safe dose for the treatment of locally advanced cervical carcinoma in Japanese women.

Multivariate analysis of para-aortic lymph node recurrence after definitive radiotherapy for stage IB-IVA squamous cell carcinoma of uterine cervix

PURPOSE

To evaluate the pretreatment risk factors of para-aortic lymph node (PALN) recurrence after primary radiotherapy for cervical cancer.

METHODS AND MATERIALS

Between May 1992 and January 2006, the data from 758 patients with squamous cell carcinoma of the uterine cervix were retrospectively analyzed. No patient had undergone PALN radiotherapy as their initial treatment. PALN recurrence was diagnosed by computed tomography. PALN relapse-free status was determined clinically or radiographically. We analyzed the actuarial rates of PALN recurrence using Kaplan-Meier curves. Multivariate analyses were performed with Cox regression models.

RESULTS

Of the 758 patients, 38 (5%) and 42 (6%) had isolated and nonisolated PALN recurrences after a median follow-up of 50 months (range, 2-159 months), respectively. The 3-year and 5-year overall survival rate after PALN recurrence was 35% and 28%, respectively. A squamous cell carcinoma antigen (SCC-Ag) level >40 ng/mL (p <0.001), advanced parametrial involvement (score 4-6; p = 0.002), and the presence of pelvic lymphadenopathy (p = 0.007) were independent factors associated with PALN relapse on multivariate analysis. The 5-year PALN recurrence rate in patients with a SCC-Ag level >40 ng/mL, SCC-Ag level of 20-40 ng/mL, parametrial score of 4-6, pelvic lymphadenopathy, and no risk factors was 57%, 22%, 34%, 37%, and 9%, respectively.

CONCLUSIONS

Patients with squamous cell carcinoma of the uterine cervix and a high SCC-Ag level, pelvic lymphadenopathy, or advanced PM involvement were predisposed to PALN recurrence after definitive radiotherapy. More intensive follow-up schedules are suggested for early detection and salvage in high-risk patients.

Cyclooxygenase-2 impairs treatment effects of radiotherapy for cervical cancer by inhibition of radiation-induced apoptosis

PURPOSE

Cyclooxygenase-2 (COX-2) plays a pivotal role in regulation of radiation-induced apoptosis. The aim of this study was to analyze the relationship between COX-2 expression and postradiotherapy outcomes of patients with cervical cancer.

METHODS AND MATERIALS

Biopsy specimens from 47 consecutive patients who had undergone definitive radiotherapy alone or radiotherapy combined with chemotherapy between October 2002 and November 2004 were investigated.

RESULTS

The COX-2 expression rate of the pretreatment samples was 46.1% +/- 21.0%, and the apoptotic index (AI) 1 week after start of radiotherapy was 2.1% +/- 0.9%. There was a significant negative correlation between the pretreatment COX-2 expression and the AI during radiotherapy (r = -0.52, p = 0.0002). Complete response rates were 59% for COX-2-positive patients compared with 80% for COX-2-negative patients (p = 0.12). The 2-year local control rate for COX-2-positive patients was 71.3%, whereas the corresponding rate for COX-2-negative patients was 96.0% (p = 0.06).

CONCLUSIONS

To the best of our knowledge, this is the first report to prove clinically that COX-2 can make cervical squamous cell carcinomas more refractory to radiotherapy by inhibition of radiation-induced apoptosis. Furthermore, expression of COX-2 may be a good indicator to predict local tumor control after radiotherapy. Although long-term results are ultimately needed, the combination therapy of radiotherapy with use of a COX-2 inhibitor could yield improved outcomes for patients with COX-2 expressing cervical cancer.

Human papillomavirus prevalence in postradiotherapy uterine cervical carcinoma patients: correlation with recurrence of the disease

To understand the role of human papillomavirus (HPV) in recurrence of uterine cervical cancer (CA-CX) after radiotherapy, we have analyzed the HPV prevalence in the exfoliated cells of 56 patients and their corresponding plasma. HPV DNA was detected in exfoliated cells of 78% (44/56) patients (HPV-16, 68%; HPV-18, 14%; HPV-X [other than 16, 18], 11%; and mixed infection of HPV-16 and HPV-18 in three cases). HPV DNA in plasma was present in only 25% (11/44) of the HPV-positive exfoliated cells (positive predictive value, 100%; negative predictive value, 27%) with concordance in HPV types. The recurrence of the disease was significantly associated with the presence of HPV in the exfoliated cell (P= 0.01) and plasma (P= 0.007) as well as high viral load in the exfoliated cell (P= 0.0002). Kaplan-Meier disease-free estimates have also shown the significant association between HPV prevalence in plasma and recurrence of the disease (P= 0.045). Thus, it indicates that in postradiotherapy CA-CX patients, the high viral load in the exfoliated cell as well as HPV presence in the plasma samples could be used in early detection of the patients at increased risk for disease recurrence and progression.

FDG-PET in the detection of recurrence of uterine cervical carcinoma following radiation therapy—tumor volume and FDG uptake value

PURPOSE

We evaluated the use of positron emission tomography (PET) with fluorine-18-labeled fluoro-2-deoxy-d-glucose (FDG) in follow-up study after radiation therapy in patients with uterine cervical carcinoma.

MATERIALS AND METHODS

Thirty-two studies in 25 patients were reviewed. Twenty patients were treated with external beam irradiation and intracavitary brachytherapy, and five with irradiation following initial surgery. Time from initial treatment to FDG-PET was 23.3 (5.2-88.0) months. Rationale for FDG-PET was the presence of symptoms in 6 patients, abnormal serum tumor marker values in 13, abnormal lesions on other diagnostic imaging modalities in 19, and patient request in 2. On visualization of a lesion, the maximum standardized uptake value (maxSUV) of the lesion was calculated, and values over 2.0 were classified as FDG-positive. Maximum tumor diameter and tumor volume in the corresponding disease were estimated by computed tomography (CT) or magnetic resonance imaging (MRI).

RESULTS

Sensitivity and specificity of FDG-PET in the detection of recurrent disease were 91.5% (43/47) and 57.1% (4/7), respectively. Four false-negative findings were seen for small lung metastases having a volume less than 1 cm3. Three false-positive cases were a localized pneumonitis, a benign pubic bone fracture, and a fibrosis after interstitial brachytherapy. Sensitivity for extrapelvic lymph node metastases was extremely high (100%); in contrast, sensitivity and specificity for lung and bone lesions were 75.0% (12/16) and 33.3% (1/3), respectively. Regarding tumor volume measurement, good correlation between maxSUV on FDG-PET and tumor volume was obtained (lung metastases, P = 0.03; extrapelvic nodes, P < 0.0001). Within this study, all corresponding lesions over 1 cm3 showed a maxSUV value greater than 2.0.

CONCLUSION

FDG-PET is a useful tool for the detection of extrapelvic lesions during the follow-up period after radiation therapy for cervical cancer. This study suggests that FDG uptake is associated with tumor volume, and FDG-PET has limitations in the detection of lesions less than 1 cm3 or microscopic disease. Careful diagnostic agreement between PET and CT/MRI for positive but benign lesions, such as inflammation and bone fracture, remains important.

Positron emission tomography in gynecologic cancer

Most positron emission tomography (PET) imaging studies in gynecologic cancer are performed using (18)F-fluorodeoxyglucose (FDG). It contributes valuable information in primary staging of untreated advanced cervical cancer, in the post-treatment surveillance with unexplained tumor marker (such as squamous cell carcinoma antigen [SCC-Ag]) elevation or suspicious of recurrence, and restaging of potentially curable recurrent cervical cancer. Its value in early-stage resectable cervical cancer is questionable. In ovarian cancer, FDG-PET provides benefits for those with plateaued or increasing abnormal serum CA 125 (>35 U/mL), computed tomography and/or magnetic resonance imaging (CT-MRI) defined localized recurrence feasible for local destructive procedures (such as surgery, radiotherapy, or radiofrequency ablation), and clinically suspected recurrent or persistent cancer for which CT-guide biopsy cannot be performed. The role of FDG-PET in endometrial cancer is relatively less defined because of the lack of data in the literature. In our prospective study, FDG-PET coupled with MRI-CT may facilitate optimal management of endometrial cancer in well-selected cases. The clinical impact was positive in 29 (48.3%) of the 60 scans, 22.2% for primary staging, 73.1% for post-therapy surveillance, and 57.1% after salvage therapy, respectively. Scant studies have been reported in the management of vulvar cancer using FDG-PET. More data are needed. Gestational trophoblastic neoplasia is quite unique in biological behavior and clinical management. Our preliminary results suggest that FDG-PET is potentially useful in selected gestational trophoblastic neoplasia by providing a precise metastatic mapping of tumor extent up front, monitoring response, and localizing viable tumors after chemotherapy. The evaluation of a diagnostic tool, such as PET, is usually via comparing the diagnostic efficacy (sensitivity, specificity, etc), by using a more sophisticated receiver operating curve method, or the proportion of treatment been modified. Evaluating PET by clinical benefit is specific to the individual tumor and an attractive new endpoint.

Late recurrence of invasive cervical cancer: twenty years' experience in a single cancer institute

AIM

To estimate the characteristics of, and prognosis for, late recurrence of cervical cancer.

METHOD

Between 1977 and 1996, of 1721 patients with invasive cervical cancer, 1157 survived more than 5 years. Twenty-eight patients whose cancer recurred after a disease-free interval of 5 years were retrospectively investigated. For 22 patients the cancer recurred after less than 10 years, for five patients it recurred between 10 and 20 years after the original occurrence, and in one patient the cancer recurred after more than 20 years.

RESULTS

The histologic subtypes included 20 squamous cell carcinomas and eight adenocarcinomas. The initial therapies were surgery alone (on one patient), surgery and adjuvant radiotherapy (on 20 of the patients) and radiotherapy alone (on seven of the patients). Recurrence was initially diagnosed by internal or external examination (11 patients), chest X-ray (six patients) and computed tomography (11 patients). Rates of lymphogenous metastases were 19% of patients with primary surgery and 57% of patients without primary surgery, while those of hematogenous metastases were 48% of patients with primary surgery and none of patients without primary surgery (P = 0.023). The overall survival rate after recurrence was 50.5% after 2 years and 22.3% after 5 years, respectively. Four of the patients survived for more than 3 years without evidence of disease; these patients all had recurrence outside the irradiated field and achieved complete remission with radiotherapy.

CONCLUSIONS

Late recurrence of cervical cancer was frequently observed in patients with initial treatment, including radiotherapy. Some had very long disease-free intervals, but many were diagnosed by ordinary internal or external examination or chest X-ray. Patients with primary surgery experienced recurrence less frequently in the case of lymph node metastasis than was the case for hematogenous metastasis. Radiotherapy was effective and improved prognosis, especially for recurrence of cancer outside the irradiated field.

Expression of hypoxic-inducible factor 1α predicts metastasis-free survival after radiation therapy alone in stage IIIB cervical squamous cell carcinoma

PURPOSE

Hypoxia-inducible factor-1alpha (HIF-1alpha) is an intrinsic marker of tumor hypoxia. It has been considered that the hypoxic status reduces radiosensitivity, but the role of HIF-1alpha in advanced cervical carcinoma is still unclear. The objective of this study was to clarify the impact of HIF-1alpha, human papillomavirus (HPV), and other molecular factors, such as p53, bax, bcl-2, and their correlations on the outcome of patients with Stage IIIB cervical carcinoma in radiation therapy.

METHODS AND MATERIALS

We analyzed 38 patients with FIGO Stage IIIB squamous cell carcinoma of the cervix treated with radiation therapy alone. All patients received the combination therapy of external beam irradiation and low-dose-rate intracavity brachytherapy. The tumor expressions of HIF-1alpha, p53, bax, and bcl-2 were examined by immunohistochemical staining of the pretreatment paraffin embedded specimens. HPV infection was also detected by polymerase chain reaction. The effects of these parameters on clinical outcomes were analyzed by univariate analysis.

RESULTS

Of 38 patients, high expression of HIF-1alpha, p53, bax, and bcl-2 were seen in 17 (45%), 22 (58%), 15 (39%), and 15 (39%) patients, respectively, and 28 patients (74%) showed positive infection with HPV. There was a significant positive correlation between high HIF-1alpha expression and disease recurrence (p < 0.05). Furthermore, HIF-1alpha had a significant correlation with the recurrence-free survival rate (p = 0.04). No statistical correlation was noted between high HIF-1alpha expression and the local control rate (p = 0.17), whereas the HIF-1alpha status predicted distant metastasis with strong significance (p = 0.03). Conversely, other factors demonstrated no impact on the clinical outcome.

CONCLUSIONS

The present results suggest that HIF-1alpha is an important prognostic factor, especially for predicting future metastasis after radiation therapy for patients with Stage IIIB squamous cell carcinoma of the cervix.

Clinical effects in a cohort of cancer patients overexposed during external beam pelvic radiotherapy

PURPOSE

To evaluate the clinical outcome of 28 overexposed cancer patients in a cohort of 153 treated with pelvic irradiation and to correlate the outcome with the doses received.

METHODS AND MATERIALS

Between August 2000 and March 2001, 153 patients were treated at the Instituto Oncológico Nacional of Panama with radiotherapy for cancers of the cervix, uterus, endometrium, prostate, and rectum using conventional techniques. In 56 patients, irradiated with partially blocked teletherapy fields, the treatment times were determined using a treatment planning system that generated isodose distributions. The absorbed doses received by the patients were calculated and the biologically effective doses (BEDs) and 2-Gy equivalent doses derived. The clinical outcome was evaluated using the Radiation Therapy Oncology Group (RTOG) and late effects on normal tissues-subjective, objective, management, analytic scales (LENT/SOMA). The relationships between clinical outcome and dose were investigated and compared with published data.

RESULTS

Of the 56 patients for whom treatment times were generated with the treatment planning system, 28 received some doses per fraction approximately double those prescribed. Using an alpha/beta = 10 Gy, the tumor BED(10) values ranged from 77 to 225 Gy. The rest of the patients received doses within 10% of the prescribed values. Seventeen of the 28 overexposed patients died 35 days to 21 months after treatment; 13 of the fatalities were caused by rectal complications. Survival was longer in those patients who had undergone colostomy. Bladder complications were less enhanced. The nonoverexposed patients with cervical cancer exhibited a greater incidence of treatment failures than generally reported in other centers.

CONCLUSION

This study provides the clinical outcome after high doses of pelvic radiotherapy in a range not previously well documented. For cervical cancer patients receiving both tele- and brachytherapy, some deaths in this overexposure cohort occurred from assumed consequential rectal injury within 2 years, when the BED(10) values exceeded 70-80 Gy. The incidence was asymptotic to 100% fatalities at >150 Gy. This confirmed and extended other data in the literature.

Positron emission tomography for unexplained elevation of serum squamous cell carcinoma antigen levels during follow-up for patients with cervical malignancies

BACKGROUND

During follow-up for patients with cervical carcinoma, elevation of serum squamous cell carcinoma antigen (SCC-Ag) levels in the absence of detectable recurrent lesions presents a diagnostic and therapeutic challenge. In the current prospective study, the authors evaluated the use of fluorine-18-labeled fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) to detect disease recurrence in this setting.

METHODS

Women with cervical carcinoma who experienced complete responses to primary treatment or salvage therapy and who had no evidence of recurrent disease as detected by conventional methods but had serum SCC-Ag levels > or = 2.0 ng/mL on 2 consecutive occasions were eligible for the study. PET was performed within 2 weeks after the completion of conventional studies for the assessment of recurrence.

RESULTS

Twenty-seven consecutive patients were registered for the current study. PET findings were positive for 19 patients: 14 who had a distant lesion or lesions, 2 who had a local lesion or lesions, and 3 who had both local and distant lesions. Of these 19 patients, 17 were confirmed to have recurrent disease; the remaining two were found to be free of disease but had severe anthracosis in the PET-positive mediastinal lymph nodes. Seven of the eight patients with negative PET findings were not found to have recurrent disease on follow-up. Overall, PET detected FDG-avid lesions in 17 (94%; P < 0.001) of the 18 patients with recurrent disease. Seven of these 18 patients received therapy with curative intent; complete control was achieved in 6, four of whom currently are alive and free of disease. The addition of PET in the current setting curbed the use of futile curative therapy and significantly increased overall survival for patients in the current cohort compared with a historical group of 30 consecutive patients who had elevated SCC-Ag levels as a first sign of recurrence.

CONCLUSIONS

PET expedited the detection of recurrent cervical carcinoma in patients with unexplained elevation of SCC-Ag levels. Such expedited detection may have positive effects on patient survival.