Adjuvant therapy for high-risk, early stage cervical cancer

The impact of boost radiation therapy after hysterectomy on cervical cancer patients with close or positive resection margins

PURPOSE

We investigated the effect of boost radiation therapy (RT) in addition to whole pelvis RT (WPRT) on treatment outcome and safety of cervical cancer patients following hysterectomy with close/positive resection margins (RM).

METHODS

We retrospectively analyzed 51 patients with cervical cancer who received WPRT with or without boost-RT as adjuvant treatment between July 2006 and June 2022. Twenty patients (39.2%) were treated with WPRT-alone, and 31 (60.8%) received boost-RT after WPRT using brachytherapy or intensity-modulated RT.

RESULTS

The median follow-up period was 41 months. According to RT modality, the 4-year local control (LC) and locoregional control (LRC) rates of patients treated with WPRT-alone were 61% and 61%, respectively, whereas those in LC and LRC rates in patients who underwent WPRT with boost-RT were 93.2% and 75.3%, with p-values equal to 0.005 and 0.090, respectively. Seven patients (35.0%) had local recurrence in the WPRT-treated group compared to only two out of the 31 patients (6.5%) in the WPRT with boost-RT-treated counterparts (p = 0.025). Boost-RT was a significantly good prognostic factor for LC (p = 0.013) and LRC (p = 0.013). Boost-RT did not result in statistically-significant improvements in progression-free survival or overall survival. The acute and late toxicity rates were not significantly different between groups.

CONCLUSION

Boost RT following WPRT is a safe and effective treatment strategy to improve LC without increasing toxicity in patients with cervical cancer with close/positive RM after hysterectomy.

Comparison of treatment outcomes of pelvis external radiotherapy with and without vaginal brachytherapy for cervical cancer patients with positive or close vaginal resected margins

BACKGROUND

We evaluated whether there is a difference in the local recurrence and survival after pelvic external radiotherapy (ERT) with and without boost vaginal brachytherapy (VB) in cervical cancer patients with positive or close vaginal resected margins (RM).

METHODS

We retrospectively reviewed FIGO stage IA-IIB cervical cancer patients treated with postoperative ERT between 1997 and 2018. The sixty patients showing close (safety margin < 5 mm) or positive vaginal RM were included. ERT was delivered with median 50.4 Gy in 28 fractions to the pelvis and VB with median 30 Gy in 6 fractions.

RESULTS

The median follow-up duration was 46 months. Five out of 30 patients treated with ERT alone experienced vaginal recurrence within 2 years after surgery. The 5-year local control (LC) was 100% in patients receiving ERT + VB compared with 81.3% in patients receiving ERT alone (log rank p = 0.022). The 5-year pelvic control (PC) was 95.8% for patients receiving ERT + VB and 76.8% for ERT alone (p = 0.041). The 5-year overall survival and recurrence-free survival (RFS) were not significantly different between treatment groups. In multivariate analysis, perineural invasion was a significant risk factor for PC (p = 0.024). Parametrial involvement (p = 0.044) and vascular invasion (p = 0.032) were unfavorable prognostic factors for RFS. Late toxicity occurrences were not significant in both groups.

CONCLUSION

VB after ERT improved LC and PC in cervical cancer patients with close or positive RM after hysterectomy. The toxicities were not increased after VB was added to ERT.

Adjuvant platinum-based chemotherapy for early stage cervical cancer

BACKGROUND

This is the second updated version of the original Cochrane review published in the Cochrane Library 2009, Issue 3. Most women with early cervical cancer (stages I to IIA) are cured with surgery or radiotherapy, or both. We performed this review originally because it was unclear whether cisplatin-based chemotherapy after surgery, radiotherapy or both, in women with early stage disease with risk factors for recurrence, was associated with additional survival benefits or risks.

OBJECTIVES

To evaluate the effectiveness and safety of adjuvant platinum-based chemotherapy after radical hysterectomy, radiotherapy, or both in the treatment of early stage cervical cancer.

SEARCH METHODS

For the original 2009 review, we searched the Cochrane Gynaecological Cancer Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library 2009, Issue 1), MEDLINE, Embase, LILACS, BIOLOGICAL ABSTRACTS and CancerLit, the National Research Register and Clinical Trials register, with no language restriction. We handsearched abstracts of scientific meetings and other relevant publications. We extended the database searches to November 2011 for the first update and to September 2016 for the second update.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing adjuvant cisplatin-based chemotherapy (after radical surgery, radiotherapy or both) with no adjuvant chemotherapy, in women with early stage cervical cancer (stage IA2-IIA) with at least one risk factor for recurrence.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently. Meta-analysis was performed using a random-effects model, with death and disease progression as outcomes.

MAIN RESULTS

For this second updated version we identified only one small trial reporting grade 4 toxicity results, without disease-free or overall survival data with a median follow-up of 16 months.From the first updated version, we identified three trials that were ongoing, and remain so in 2016.Four trials including 401 women with evaluable results with early cervical cancer were included in the meta-analyses. The median follow-up period in these trials ranged from 29 to 42 months. All women had undergone surgery first. Three trials compared chemotherapy combined with radiotherapy versus radiotherapy alone; and one trial compared chemotherapy followed by radiotherapy versus radiotherapy alone. It was not possible to perform subgroup analyses by stage or tumour size.Compared with adjuvant radiotherapy, chemotherapy combined with radiotherapy significantly reduced the risk of death (two trials, 297 women; hazard ratio (HR) = 0.56, 95% confidence interval (CI): 0.36 to 0.87) and disease progression (two trials, 297 women; HR = 0.47, 95% CI 0.30 to 0.74), with no heterogeneity between trials (I² = 0% for both meta-analyses). Acute grade 4 toxicity occurred significantly more frequently in the chemotherapy plus radiotherapy group than in the radiotherapy group (three trials, 321 women; risk ratio (RR) 6.26, 95% CI 2.50 to 15.67). We considered the evidence for all three outcomes to be of a moderate quality, using the GRADE approach due to small numbers and limited follow-up in the included studies. In addition, it was not possible to separate data for bulky early stage disease.In the one small trial that compared adjuvant chemotherapy followed by radiotherapy with adjuvant radiotherapy alone there was no difference in disease recurrence between the groups (one trial, 71 women; HR = 1.34; 95% CI 0.24 to 7.66) and overall survival was not reported. We considered this evidence to be of a low quality.No trials compared adjuvant platinum-based chemotherapy with no adjuvant chemotherapy after surgery for early cervical cancer with risk factors for recurrence.

AUTHORS' CONCLUSIONS

The addition of platinum-based chemotherapy to adjuvant radiotherapy (chemoradiation) may improve survival in women with early stage cervical cancer (IA2-IIA) and risk factors for recurrence. Adjuvant chemoradiation is associated with an increased risk of severe acute toxicity, although it is not clear whether this toxicity is significant in the long term due to a lack of long-term data. This evidence is limited by the small numbers and low to moderate methodological quality of the included studies. We await the results of three ongoing trials, which are likely to have an important impact on our confidence in this evidence.

Clinicopathology significance of p53 and p63 expression in Indonesian cervical squamous cell carcinomas

BACKGROUND

Human papilloma virus infection is associated with genesis and malignant potential of cervical cancer. E6 and E7 oncogens are known to bind to p53 and retinoblastoma gene products, abrogating their functions as tumor suppressors, leading to an abnormal cell cycle machinery. Roles of the p53 homolog p63 have also been postulated, E6 expression leading to TAp63b degradation allowing anchorage independent growth. Molecular studies correlated with clinicopathological factors are important to determine prognosis and treatment strategies, but results have been controversial and need to be clarified.

AIM

To investigate expression of p53 and p63 in cervical squamous cell carcinomas in correlation with age, FIGO staging, morphology, and cancer cell proliferation.

MATERIALS AND METHODS

Expression of p53 and p63 immunohistochemical staining in a total of 56 paraffin-embedded tissues of cervical squamous cell carcinomas from Dr. Sardjito General Hospital Indonesia, was evaluated for correlation with clinicopathological parameters. The Mann-Whitney test was used to compare the percentage of p53 and p63 expression with patient age, FIGO staging and morphology and to compare mean p53 and p63 expression. The Spearman correlation test was applied to correlate p53 and p63 expression with that of Ki-67. A p-value of <0.05 was considered statistically significant.

RESULTS

There were significant associations between p53 expression with age (p=0.019) and FIGO staging (p=0.026), but not with with morphology or Ki-67 expression. There were no links between p63 expression and age, morphology, FIGO staging or Ki-67.

CONCLUSIONS

This study indicated that p53 has a prognostic value in cervical squamous cell carcinomas given the relation with FIGO staging.

Glassy cell carcinoma of the cervix: a literature review

Glassy cell carcinoma (GCC) is a histologically aggressive subtype of cervical cancer with rapid growth and early metastases. The prognosis for patients with GCC is poor. This article reviews the literature pertinent to the epidemiology, cytology, pathology, immunohistochemistry, treatment and prognosis of GCC. MEDLINE (PubMed) was searched for all articles or abstracts on patients diagnosed with GCC published (in English) since the original definition by Glucksmann and Cherry, Cancer 1956;9:971. Accurate diagnosis of GCC enables implementation of the correct treatment strategy. Early-stage GCC should be treated with hysterectomy and pelvic lymph node dissection, with adjuvant radiochemotherapy if at least one intermediate or high risk factor for cervical cancer is present. Advanced GCC should be treated with neoadjuvant radiochemotherapy or chemotherapy with the aim of making the disease operable. There is a need for retrospective evaluation of GCC treatment from several centres to explore knowledge about this rare entity. Future studies should explore the role of targeted therapies and the most efficient chemotherapy regimen for the management of GCC.

Surgical treatment of stage IB cervical cancer

INTRODUCTION

Recurrence originating from the pelvic lymph node containing fibro-fatty tissue has consistently been identified as the most frequent pattern of treatment failure in early-stage cervical cancer. A surgical technique for the complete removal of the connective tissue content of the pelvis was introduced at St. Stephen Hospital in 1993 to improve oncological outcome by reducing the risk of recurrence from the pelvis. Efficacy and toxicity of the procedure were studied in 563 patients with stage IB cervical cancer with a completed 5-year follow-up.

METHODS

Final pathology in 492 (87.4%) of 563 consecutive completed radical hysterectomies suggested that all tissue, which could contain tumor dissemination, was removed from the pelvis; thus, no adjuvant treatment was applied. Adjuvant chemoradiotherapy was advised in 71 cases (12.6%), where pathologic finding alluded tumor spread beyond the study criteria.

FINDING

At completed 5-year follow-up, the overall survival of 492 patients who had surgery without adjuvant therapy was 94.0%. Pathologic stage, lymphovascular space involvement, pelvic lymph node metastases, histology classification, and grade had no significant influence on prognosis. The only factor that influenced the overall survival was International Federation of Gynecology and Obstetrics stage (IB1 or IB2). Five-year overall survival of 71 patients to whom adjuvant therapy was recommended was 56.3%. Five-year overall survival of the whole cohort (n = 563) was 88.8%. The complication rate did not seem to be different from the published data on traditional radical surgery in cervical cancer.

CONCLUSIONS

Our results (in accordance with other recent publications) suggest that complete excision of the connective tissue content of the pelvis provides equal or better survival chances without any adjuvant treatment for almost 90% of operable patients with stage IB cervical cancer than less radical surgery with or without adjuvant treatment. We suggest this strategy to be mentioned as one alternative in future treatment protocols.

Adjuvant platinum-based chemotherapy for early stage cervical cancer

BACKGROUND

This is an updated version of the original Cochrane review published in The Cochrane Library 2009, Issue 3. Most women with early cervical cancer (stages I to IIA) are cured with surgery or radiotherapy, or both. We performed this review originally because it was unclear whether cisplatin-based chemotherapy after surgery, radiotherapy or both, in women with early stage disease with risk factors for recurrence, was associated with additional survival benefits or risks.

OBJECTIVES

To evaluate the effectiveness and safety of platinum-based chemotherapy after radical hysterectomy, radiotherapy, or both in the treatment of early stage cervical cancer.

SEARCH METHODS

For the original 2009 review, we searched the Cochrane Gynaecological Cancer Group Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2009, Issue 1), MEDLINE, EMBASE, LILACS, BIOLOGICAL ABSTRACTS and CancerLit, the National Research Register and Clinical Trials register, with no language restriction. We handsearched abstracts of scientific meetings and other relevant publications. We extended the database searches to November 2011 for this update.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing adjuvant cisplatin-based chemotherapy (after radical surgery, radiotherapy or both) with no adjuvant chemotherapy, in women with early stage cervical cancer (stage IA2-IIA) with at least one risk factor for recurrence.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently. Meta-analysis was performed using a random-effects model, with death and disease progression as outcomes.

MAIN RESULTS

For this updated version, we identified three additional ongoing trials but no new studies for inclusion. Three trials including 368 evaluable women with early cervical cancer were included in the meta-analyses. The median follow-up period in these trials ranged from 29 to 42 months. All women had undergone surgery first. Two trials compared chemotherapy combined with radiotherapy to radiotherapy alone; and one trial compared chemotherapy followed by radiotherapy to radiotherapy alone. It was not possible to perform subgroup analyses by stage or tumour size.Compared with adjuvant radiotherapy, chemotherapy combined with radiotherapy significantly reduced the risk of death (two trials, 297 women; hazard ratio (HR) = 0.56, 95% confidence interval (CI): 0.36 to 0.87) and disease progression (two trials, 297 women; HR = 0.47, 95% CI 0.30 to 0.74), with no heterogeneity between trials (I² = 0% for both meta-analyses). Acute grade 4 toxicity occurred significantly more frequently in the chemotherapy plus radiotherapy group than in the radiotherapy group (risk ratio (RR) 5.66, 95% CI 2.14 to 14.98). We considered this evidence to be of a moderate quality due to small numbers and limited follow-up in the included studies. In addition, it was not possible to separate data for bulky early stage disease.In the one small trial that compared adjuvant chemotherapy followed by radiotherapy with adjuvant radiotherapy alone there was no significant difference in disease recurrence between the groups (HR = 1.34; 95% CI 0.24 to 7.66) and OS was not reported. We considered this evidence to be of a low quality.No trials compared adjuvant platinum-based chemotherapy with no adjuvant chemotherapy after surgery for early cervical cancer with risk factors for recurrence.

AUTHORS' CONCLUSIONS

The addition of platinum-based chemotherapy to adjuvant radiotherapy (chemoradiation) may improve survival in women with early stage cervical cancer (IA2-IIA) and risk factors for recurrence. Adjuvant chemoradiation is associated with an increased risk of severe acute toxicity, although it is not clear whether this toxicity is significant in the long-term due to a lack of long-term data. This evidence is limited by the small numbers and poor methodological quality of included studies. We await the results of three ongoing trials, that are likely to have an important impact on our confidence in this evidence.

Adjuvant platinum-based chemotherapy for early stage cervical cancer

BACKGROUND

Patients with early stage cervical cancer (stages IA2, IB1 or IIA) with risk factors such as lymph node metastasis, lympho vascular space invasion, depth invasion of more than 10mm, microscopic parametrial invasion, non-squamous histology and positive surgical margins have a high risk of recurrence when compared to patients with early stage cervical cancer with no risk factors for recurrence.

OBJECTIVES

To evaluate the effectiveness and safety of platinum-based adjuvant chemotherapy after radical hysterectomy, radiotherapy, or both in the treatment of early stage cervical cancer (stages IA2, IB1 or IIA).

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library Issue 1, 2009), MEDLINE, EMBASE, LILACS, BIOLOGICAL ABSTRACTS and Cancerlit, the National Research Register and Clinical Trials register, with no language restriction. Abstracts of scientific meetings and the citation lists of included studies and other relevant publications were checked through hand searching and experts in the field were contacted to identify further reports of trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing adjuvant radiotherapy with adjuvant radiotherapy and cisplatin-chemotherapy after radical surgery for early stage cervix cancer were included.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently to assess whether the studies met the specified inclusion criteria. Any discrepancies were solved by a third and a forth review author. Meta-analysis was performed using a random effects model, with death and disease progression as outcomes.

MAIN RESULTS

Three trials were included. Two trials enrolling 325 participants, of whom 297 (91%) were assessed and compared radiotherapy and chemotherapy with radiotherapy alone found that adjuvant chemotherapy significantly reduced the risk of death (hazard ratio (HR) = 0.56, 95% confidence interval (CI): 0.36 to 0.87) and disease progression (HR = 0.47, 95%CI: 0.30 to 0.74), with no heterogeneity between trials (I(2) = 0% for both meta-analyses). One trial assessing 71 participants compared chemotherapy followed by radiotherapy with radiotherapy alone and found no significant difference between the two groups (HR = 1.34; 95%CI: 0.24 to 7.66). The median follow up of patients varied from 29 to 42 months.

AUTHORS' CONCLUSIONS

The addition of platinum-based chemotherapy to radiotherapy may offer clinical benefit in the adjuvant treatment of early stage cervical cancer with risk factors for recurrence. However, the evidence is limited because the selected studies were quantitatively and qualitatively limited, with small number of patients and limited period of follow-up.

Treatment options in bulky stage IB cervical carcinoma

Cervical cancer is the most common female cancer in the developing countries. Treatments of bulky stage IB cervical cancer have been challenged as the local control is relatively poor compared to smaller stage I disease, whether treated by radical surgery or irradiation. The treatment options are definitive concurrent chemoradiation therapy or radical surgery with or without neoadjuvant or adjuvant therapy. The treatment decision is based on the patients' status and preferences, tumor characteristics, and experiences of clinician. This study will review and compare the treatment modalities and rationales of a combination of treatment including surgery, radiation therapy, and chemotherapy for bulky stage IB cervical carcinoma.

Influence of margin status and radiation on recurrence after radical hysterectomy in Stage IB cervical cancer

PURPOSE

To examine the relationship between margin status and local recurrence (LR) or any recurrence after radical hysterectomy (RH) in women treated with or without radiotherapy (RT) for Stage IB cervical carcinoma.

METHODS AND MATERIALS

This study included 284 patients after RH with assessable margins between 1980 and 2000. Each margin was scored as negative (> or =1 cm), close (>0 and <1 cm), or positive. The outcomes measured were any recurrence, LR, and relapse-free survival.

RESULTS

The crude rate for any recurrence was 11%, 20%, and 38% for patients with negative, close, and positive margins, respectively. The crude rate for LR was 10%, 11%, and 38%, respectively. Postoperative RT decreased the rate of LR from 10% to 0% for negative, 17% to 0% for close, and 50% to 25% for positive margins. The significant predictors of decreased relapse-free survival on univariate analysis were the depth of tumor invasion (hazard ratio [HR] 2.14/cm increase, p = 0.007), positive margins (HR 3.92, p = 0.02), tumor size (HR 1.3/cm increase, p = 0.02), lymphovascular invasion (HR 2.19, p = 0.03), and margin status (HR 0.002/increasing millimeter from cancer for those with close margins, p = 0.03). Long-term side effects occurred in 8% after RH and 19% after RH and RT.

CONCLUSION

The use of postoperative RT may decrease the risk of LR in patients with close paracervical margins. Patients with other adverse prognostic factors and close margins may also benefit from the use of postoperative RT. However, RT after RH may increase the risk of long-term side effects.

Management of cervical cancer

AIMS

The aim of the article was to review the current approach to management of cervical cancer.

METHODS

The relevant literature has served as a source for review of different options applied in the management of cervical cancer.

RESULTS

Treatment of invasive cervical cancer is affected by the stage of the disease, which is based on clinical evaluation. Microinvasive carcinoma of the cervix has limited metastatic potential and therefore is most likely curable by non-radical treatment. There is no standard management of stage Ib-IIa cervical carcinoma. Both radical surgery and radical radiotherapy have proven to be equally effective, but differ in associated morbidity and complications. Most often, stage Ib1 cervical cancer is treated by radical hysterectomy with pelvic lymphadenectomy. Laparoscopically assisted radical vaginal hysterectomy has shown similar efficacy and recurrence rates. Radical vaginal trachelectomy with laparoscopic pelvic lymphadenectomy may be an option in small cervical cancer where preservation of fertility is desired. There is lot of conflicting published work regarding the treatment of bulky stage Ib-IIa cervical cancer. While some centers are performing primary surgery as for Ib1 disease followed by tailored postoperative radiation with or without chemotherapy, the others are in favor of primary chemo-radiation therapy. Neoadjuvant chemotherapy followed by radical surgery has emerged as a possible alternative, which may improve a survival in patients with stage Ib2 disease. Concomitant chemoradiation is becoming a new standard in treatment of advanced disease, because it has been clearly shown to improve disease-free, progression-free and overall survival. Management of recurrent disease depends on previous treatment, site and extent of recurrence, disease-free interval and patient's performance status.

CONCLUSIONS

Treatment decisions should be individualized and based on multiple factors including the stage of the disease, age, medical condition of the patient, tumor-related factors and treatment preferences, to yield the best cure with minimum complications.

Association between Bcl-2 expression and tumor recurrence in cervical cancer: a matched case-control study

OBJECTIVES

To evaluate the association between bcl-2 expression, some pathological factors (lymph-vascular space invasion (LVSI), tumor grade, depth of stromal invasion), and tumor recurrence in cervical cancer.

METHODS

A matched case-control study was performed in cervical cancer patients who underwent radical hysterectomy and were found to have negative lymph node between January 1992 and June 1998 in Bangkok Metropolitan Administration Medical College and Vajira Hospital and Maharaj Nakorn Chiangmai Hospital, Thailand. Cases were 32 patients who had tumor recurrence within 5 years after surgery. Controls were 63 patients who were disease free for at least 5 years after surgery. Cases and controls were matched for age, stage, histology, and tumor size. All except one case, who had only one matching control, had two controls. Paraffin-embedded cervical cancer tissues of cases and controls were immunohistochemical stained for bcl-2.

RESULTS

Bcl-2 positive was demonstrated in 43.7% of tumor from recurrent cases, which was not different from 50.8% from non-recurrent controls (P = 0.378). Tumor grade and LVSI had significant association with tumor recurrence. From multivariable analysis, the patients with grade 2-3 tumors had the odds ratio of 6.9 for recurrence compared to patients with grade 1 tumors. The patients whose tumors had LVSI had the recurrent odds ratio of 5.4 compared to those without LVSI.

CONCLUSIONS

There was no association between bcl-2 expression and tumor recurrence in cervical cancer, while tumor grade and LVSI had significant association with tumor recurrence.

Postoperative radiation therapy for carcinoma of the uterine cervix

Postoperative radiation therapy (PORT) for cervical cancer has been empirically performed for patients with pathologic risk factors for recurrence after surgery. The efficacy of PORT is mainly supported by retrospective studies. Despite convincing evidence demonstrating a reduction in pelvic recurrence rates when PORT is employed, there is no evidence that it eventually improves patient survival. Local recurrence, such as vaginal stump recurrence, is not always fatal if diagnosed earlier. Some patients, unfortunately, may develop distant metastases even after PORT. The positive effects of PORT also may be counterbalanced by increased toxicities that result from combining local therapies. These factors obscure the efficacy of PORT for cervical cancer patients. There has been no consensus on the predictive value of risk factors for recurrence, which renders indication of PORT for early-stage cervical cancer quite variable among institutions. Today, efforts have been made to divide patients into three risk groups based on the combination of risk factors present after radical hysterectomy. In Europe/USA and Japan, however, a fundamental difference exists in the indications for radical surgery, highlighting differences in the concept of PORT; "adjuvant pelvic irradiation for stage IB-IIA patients after complete resection" in Europe/USA and "pelvic irradiation after surgery irrespective of initial clinical stage and surgical margin status" in Japan. Thus, it is questionable whether scientific evidence established in Europe/USA is applicable to Japanese clinical practice. The purpose of this article is to review the role of PORT by interpreting the results of clinical studies.

Treatment with a belly-board device significantly reduces the volume of small bowel irradiated and results in low acute toxicity in adjuvant radiotherapy for gynecologic cancer: results of a prospective study

BACKGROUND AND PURPOSE

To determine whether treatment prone on a belly-board significantly reduces the volume of small bowel irradiated in women receiving adjuvant radiotherapy for gynecologic cancer, and to prospectively study acute small bowel toxicity using an accepted recording instrument.

MATERIAL AND METHODS

Thirty-two gynecologic patients underwent simulation with CT scanning supine and prone. Small bowel was delineated on every CT slice, and treatment was prone on the belly-board using 3-5 fields-typically Anterior, Right and Left Lateral, plus or minus Lateral Boosts. Median prescribed dose was 50.4 Gy and all treatments were delivered in 1.8 Gy fractions. Concomitant Cisplatin was administered in 13 patients with cervical carcinoma. Comparison of small bowel dose-volumes was made between supine and prone, with each subject acting as their own matched pair. Acute small bowel toxicity was prospectively measured using the Common Toxicity Criteria: Version 2.0.

RESULTS

Treatment prone on the belly-board significantly reduced the volume of small bowel receiving > or = 100; > or = 95; > or = 90; and > or = 80% of the prescribed dose, but not > or = 50%. This was found whether volume was defined in cubic centimeters or % of total small bowel volume. Of 29 evaluable subjects, 2 (7%) experienced 1 episode each of grade 3 diarrhoea. All other toxicity events were grade 2 or less and comprised diarrhoea (59%), abdominal pain or cramping (48%), nausea (38%), anorexia (17%), vomiting (10%). There were no Grade 4 events and no treatment days were lost due to toxicity.

CONCLUSIONS

Treatment prone on a belly-board device results in significant small bowel sparing, during adjuvant radiotherapy for gynecologic cancer. The absence of Grade 4 events or Treatment Days Lost compares favorably with the published literature.

Use of the small pelvic field instead of the classic whole pelvic field in postoperative radiotherapy for cervical cancer: Reduction of adverse events

PURPOSE

We examined whether use of small pelvic (SP) field encompassing only the pericervical regions and upper stream lymphatic will reduce the adverse events that occur with classic whole pelvic (WP) field, in postoperative radiotherapy (RT) for cervical cancer.

METHODS AND MATERIAL

This retrospective study included 72 patients treated with SP field (SP group) used specifically for node-negative status and 46 patients treated with WP field (WP group) used conventionally for node-positive status. Total dose was 50.0 or 50.4 Gy at 2.0 or 1.8 Gy per fraction. Acute adverse events (nausea, diarrhea, cystitis, and leukopenia) and late adverse events (lymphedema, cystitis, ileus, and diarrhea) were graded according to the Common Toxicity Criteria and compared between groups.

RESULTS

Diarrhea (Grades 2-3) and leukopenia (Grades 1-3) occurred significantly more often in WP group (32.4% and 80.5%, respectively) than in SP group (9.2% and 52.2%, respectively). Among the late events, lymphedema occurred most often overall (5-year rate: SP, 47.0%; WP, 49.1%). Only ileus occurred at a significantly higher rate in The WP group than in SP group (5-year rate: 16.2% vs. 3.2%).

CONCLUSIONS

Use of the SP field tailored for node-negative status was suggested to reduce adverse events involving the intestine and hemopoietic system.

Surgical treatment of lymph node metastases in stage IB cervical cancer: the laterally extended parametrectomy (LEP) procedure

A surgical method has been introduced for the treatment of early stage cervical cancer patients with pelvic lymph node metastases. The procedure was used without any adjuvant treatment in 31 stage IB cervical cancer patients, where pelvic lymph node metastases were proven by intraoperative histology. Two patients were lost for follow-up. Twenty-nine patients were followed up for 24-105 months (mean 60 months). Twenty-five of 29 patients were alive and disease-free at the end of the study period. Kaplan-Meier 5 years cumulative proportion survival was 85% (SE 7%). Complications in four cases (16%) necessitated a second operation. One patient developed treatment-refractory grade II incontinence. All but the one incontinent patient are alive without significant treatment related symptoms. The results suggest that pelvic lymph node metastases can be cured by surgery alone. The LEP procedure seems to be a treatment alternative to chemoradiotherapy for early stage cervical cancer patients with pelvic lymph node metastases.

Glassy cell carcinoma of the cervix revisited

OBJECTIVE

Glassy cell carcinoma (GCC) of the cervix has traditionally been characterized as an aggressive histologic subtype with poor outcomes. An earlier series from our institution supported a grim prognostic outlook, demonstrating a survival rate of only 55% in women with stage I disease. We present a comparison of a contemporary series of patients with GCC.

METHODS

All cases of GCC treated from 1993 to 1999 identified by our tumor registry were reviewed for a variety of clinicopathologic features, treatment strategies, and outcome.

RESULTS

A total of 403 cases of invasive cancer of the cervix were identified. There were 22 patients with histologically confirmed GCC, representing only 5.4% of all cervical cancer diagnoses. Patients with GCC had an overall survival of 73% (16/22) and a disease-free survival of 64% (14/22). The incidence of stage I lesions was 64% (14/22). Overall survival of patients with stage I disease was 86% (12/14), with a disease-free survival of 71% (10/14) at a median follow-up of 28.5 months. Seven stage IB lesions were treated with surgery alone, whereas six received adjuvant radiation or chemoradiation following surgery. Two patients in each treatment group recurred, yielding an overall recurrence rate of 29% (4/14). However, of those who recurred with stage I disease, all 4 patients had two or more intermediate risk factors (lymph-vascular space invasion [LVSI], deep tumor invasion, or tumor size greater than 3 cm).

CONCLUSIONS

Glassy cell carcinoma of the cervix appears to have a better prognosis than previously reported. We observed that intermediate risk histopathologic features identified in squamous cell cohorts are also predictive of a poorer outcome in patients with GCC. Thus, patients with LVSI, deep stromal invasion, and large tumor size are at the highest risk for pelvic relapse and should be candidates for adjuvant treatment.

[Adenocarcinoma of the cervix uteri: a retrospective study of 83 cases]

The frequency of the adenocarcinoma of cervix uteri is increasing.

AIM OF THE STUDY

To define the characteristics of the entity.

PATIENTS AND METHODS

Between 1986 and 1992, 83 adenocarcinoma of cervix uteri, were treated at the Ibn Rochd Oncology Centre in Casablanca. It's a retrospective study with univariate analysis of the prognostic factors. This analysis was done for patients who were followed until the death or have 5 years or more follow up and the survival was calculated according the Kaplan & Meier method at 5 years. The local and regional recurrence factors were evaluated statically according the chi 2 and those for survival rate according the Logrank test.

RESULTS

The frequency increased during the period with 2.1% in 1986 and 8.2% in 1992. The median of aged was 49 years. Fifty one patients have localised stage. Combined radiotherapy and surgery was performed in 66 cases and 17 received radiation alone. The loco-regional control was obtained in 83% among 73 available patients for results. The univariate analysis showed that the histological type was not a significant factor. However, age, tumor size, stage, histological grade and lymph node involvement were significant factors. These factors, the degree of differentiation and the lymph node involvement were significant for the 5-years survival.

CONCLUSION

The prognosis factors of the cervix uteri adenocarcinoma are, size tumor more than 4 cm, lymph node involvement, microscopic involvement to the parameters and positives excision merges.

[Radiotherapy for tumors of the uterine cervix. Gross tumor volume and clinical target volume]

Treatment of carcinoma of the uterine cervix needs a multidisciplinary approach. External irradiation and brachytherapy are highly curative because of the tumor radiosensitivity. The main prognostic factors are tumoral volume and nodal involvement. Tumoral extent is evaluated by diagnostic MR imaging, and gynecological exam. Nodal involvement can be assessed, accurately by coelioscopic pelvic node sampling and by imaging modalities such as CT scan. The knowledge of these two factors helps to choose the treatment strategy. The use of imaging (MRI and CT) added to clinical findings allows to design external irradiation fields. 3D treatment planning in external irradiation and brachytherapy is based upon the use of imaging (CT and MRI). It leads to a better knowledge of dose distribution to the target and critical organs and allows more individualized and conformal treatment.

Prognostic factors in surgically treated stage ib-iib cervical carcinomas with special emphasis on the importance of tumor volume

OBJECTIVE

The aim of the study was to analyze the importance of tumor volume as a prognostic factor for overall survival (OS) in surgically treated stage Ib-IIb cervical carcinoma.

METHODS

One hundred thirteen of one hundred sixty-five patients with histopathological stage Ib-IIb cervical carcinoma (44 Ib1, 24 Ib2, 10 IIa, 35 IIb) treated by radical abdominal hysterectomy between 1989 and 1999, for whom tumor volume could be assessed, were included in this study. Of the 113 patients, 90 (79.6%) received postoperative radiotherapy. Measurement of tumor volume was performed on giant histological sections using a semiautomatic image analyzer. The prognostic significance of tumor volume was analyzed and compared with that of various clinicopathological parameters using uni- and multivariate statistics.

RESULTS

The 5-year disease-free survival was 71.4%. Increasing tumor volume was associated with more frequent lymph node metastases and a significant decrease in OS (P = 0.0112). The Median tumor volume was smaller in stage IIa tumors than in stage Ib2 tumors, and histopathological stage did not correlate linearly with lymph node metastases as well as OS. Stage Ib2 tumors were associated with worse overall survival than stage IIa tumors. In univariate analysis, lymph node metastases, histopathological stage, lymph vascular space involvement, tumor volume, parametrial spread, and tumor involvement of resection margins were significant parameters for OS. In multivariate statistical analysis, only lymph node metastases and histopathological staging remained independent prognostic factors for OS.

CONCLUSIONS

Tumor volume does not seem to confer additional prognostic information if histopathological stage and lymph node status are known. However, it may provide important prognostic information if lymph node status is not known or histopathological stage cannot be assessed.