Concomitant chemoradiation versus neoadjuvant chemotherapy in locally advanced cervical carcinoma: results from two consecutive phase II studies

Treatment of FIGO 2018 stage IIIC cervical cancer with different local tumor factors

BACKGROUND

To compare the oncological outcomes of patients with FIGO 2018 stage IIIC cervical cancer (CC) involving different local tumor factors who underwent abdominal radical hysterectomy (ARH), neoadjuvant chemotherapy and radical surgery (NACT), or radical chemoradiotherapy (R-CT).

METHODS

Based on tumor staging, patients with stage IIIC were divided into T1, T2a, T2b, and T3 groups. Kaplan-Meier and Cox proportional hazards regression analysis were used to compare their overall survival (OS) and disease-free survival (DFS) of 5 years.

RESULTS

We included 4,086 patients (1,117, 1,019, 869, and 1,081 in the T1, T2a, T2b, and T3 groups, respectively). In the T1 group, NACT was correlated with a decrease in OS (hazard ratio [HR] = 1.631, 95% confidence interval [CI]: 1.150-2.315, P = 0.006) and DFS (HR = 1.665, 95% CI: 1.255-2.182, P < 0.001) than ARH. ARH and NACT were not correlated with OS (P = 0.226 and P = 0.921) or DFS (P = 0.343 and P = 0.535) than R-CT. In the T2a group, NACT was correlated with a decrease in OS (HR = 1.454, 95% CI: 1.057-2.000, P = 0.021) and DFS (HR = 1.529, 95% CI: 1.185-1.974, P = 0.001) than ARH. ARH and NACT were not correlated with OS (P = 0.736 and P = 0.267) or DFS (P = 0.714 and P = 0.087) than R-CT. In the T2b group, NACT was correlated with a decrease in DFS (HR = 1.847, 95% CI: 1.347-2.532, P < 0.001) than R-CT nevertheless was not correlated with OS (P = 0.146); ARH was not correlated with OS (P = 0.056) and DFS (P = 0.676). In the T3 group, the OS rates of ARH (n = 10), NACT (n = 18), and R-CT (n = 1053) were 67.5%, 53.1%, and 64.7% (P = 0.941), and the DFS rates were 68.6%, 45.5%, and 61.1%, respectively (P = 0.761).

CONCLUSION

R-CT oncological outcomes were not entirely superior to those of NACT or ARH under different local tumor factors with stage IIIC. NACT is not suitable for stage T1, T2a, and T2b. Nevertheless ARH is potentially applicable to stage T1, T2a, T2b and T3. The results of stage T3 require confirmation through further research due to disparity in case numbers in each subgroup.

Quality of life of locally advanced cervical cancer patients after neoadjuvant chemotherapy followed by chemoradiation versus chemoradiation alone (CIRCE trial): a randomized phase II trial

OBJECTIVE

The CIRCE trial (NCT01973101) investigated the efficacy, safety, and quality of life of the addition of neoadjuvant chemotherapy with cisplatin and gemcitabine to standard chemoradiation for locally advanced cervical cancer (stages IIB-IVA). The impact of both treatment arms on quality of life is reported in the present study.

METHODS

Patients completed the European Organization of Research and Treatment of Cancer questionnaire QLQ-C30 and CX24 before treatment and at 3, 6, 9, and 12 months after treatment. Linear mixed models were fitted to analyze differences in quality of life over time and between groups. Differences in mean quality of life scales >10 points and p<0.05 were considered clinically relevant and statistically significant, respectively. Inclusion criteria were: (1) histological diagnosis of locally advanced invasive carcinoma of the uterine cervix, International Federation of Gynecology and Obstetrics stages IIB-IVA; (2) signed informed consent to participate in the CIRCE trial; and (3) answered at least one quality of life questionnaire. Excluded were patients who did not complete any quality of life questionnaire. Relevant exclusion criteria for the CIRCE trial included Eastern Cooperative Oncology Group performance status >2 and peripheral neuropathy >2. Mann-Whitney U tests were performed to assess differences between groups in quality of life at baseline. To evaluate differences between treatment arms, linear mixed models were fitted using the transformed quality of life scores as a dependent variable and time of follow-up and study arm as factors.

RESULTS

A total of 107 patients were enrolled (n=55 neoadjuvant chemotherapy arm; n=52 chemoradiation arm). Quality of life compliance rates were higher for the chemoradiation group at every assessment time (ranging from 75-86.5% in the chemoradiation arm vs 55-81.8% in the neoadjuvant chemotherapy arm). For quality of life results at baseline, no statistically significant difference between the groups was seen. For both groups, most scales showed improvements over time, except for worsening of the summary score, sexual enjoyment, peripheral neuropathy, and menopausal symptoms. For chemoradiation, body image was lower (p<0.001) and patients presented more lymphedema (p<0.001) and sexual worry (p<0.001) at 12 months compared with baseline. Comparing study arms, neoadjuvant chemotherapy showed significantly lower scores in the menopausal symptoms scale (p=0.03) and higher scores for sexual/vaginal functioning (p=0.01). At 12 months, clinical differences were seen only for body image and menopausal symptoms scale, with neoadjuvant chemotherapy presenting better body image scores and a lower burden of menopausal symptoms.

CONCLUSION

After treatment for locally advanced cervical cancer, patients improved in most quality of life aspects. However, worsening was observed in sexual enjoyment, peripheral neuropathy, and menopausal symptoms. To improve patients' quality of life, efforts should be made to prevent and treat these long term effects of locally advanced cervical cancer treatment.

Tolerability, Efficacy and Feasibility of Concurrent Gemcitabine and Cisplatin (CGP) Combined With Intensity Modulated Radiotherapy for Loco-Regionally Advanced Carcinoma of the Cervix

Background: Gemcitabine and cisplatin combined with conventional radiotherapy in treating patients with cervical cancer, resulted in a favourable conclusion but accompanied with high toxicity. The objective of our research was to assess the tolerability, efficacy and feasibility of dual chemotherapy in addition to image-guided adaptive brachytherapy and highly conformal external beam radiation therapy.

Methods & Materials: From June 2011 to November 2013, 81 cervical cancer patients with FIGO stage IB2-IIIB medical records were retrospectively reviewed. All patients received whole pelvic radiotherapy (WPRT) to a total dose of 50.4 Gy/ 1.8 Gy Chemoradiotherapy prescription objectives were: concurrent gemcitabine (125 mg/m²) and cisplatin (30 mg/m²) during the 6 weeks of external beam radiation therapy (EBRT) followed by two cycles of gemcitabine (1 g/m², d1, d8) and cisplatin (25 mg/m² d1-d3) on the tenth week. External beam radiotherapy was followed by image-guided brachytherapy of 24 Gy/ 4 fractions. Version 4 of the common terminology criteria for adverse events (CTCAE v 4.0) was used in grading the toxicities.

Results: Sixty-nine patients obtained complete response (CR), six had a partial response (PR), and five patients had stable disease (SD). The disease control rate (DCR= SD and ORR) and overall response rate (ORR= PR, CR or PR) were 92.6% and 85.2% respectively. The 3-year and 5-year estimated overall survival (OS) was 75.4% and 66.3%, and the 3-year and 5-year estimated progression-free survival (PFS) were 78.2% and 65.4%. The median PFS time and OS time were 36.8 months and 45.5 months, respectively. Distance metastasis was evident in the lung (3 patients), pelvic wall (2 patients), liver (3 patients) and bone (2 patients). Six (6) had a local relapse, and two (2) patients had local relapse plus simultaneous systemic metastatic tumour.

Conclusions: Unlike past results, gemcitabine and cisplatin appear to be tolerable, efficient and feasible when combined with conformal radiotherapy.

A prospective study on neoadjuvant chemoradiotherapy plus anti-EGFR monoclonal antibody followed by surgery for locally advanced cervical cancer

Background

To investigate the efficacy and safety of neoadjuvant chemoradiotherapy plus anti-epidermal growth factor receptor monoclonal antibody followed by surgery for locally advanced cervical cancer (LACC).

Patients and methods

Patients with histologically proven LACC were enrolled into this prospective study. All patients received intensity-modulated radiation therapy with conventional fractionation. Weekly cisplatin or nedaplatin was administered concurrently with intensity-modulated radiation therapy. Nimotuzumab, a humanized anti-epidermal growth factor receptor monoclonal antibody, was given at a dose of 200 mg per week for 6 cycles. Approximately 1 month after the completion of neoadjuvant treatment, the patients were assessed for clinical tumor response and operability based on MRI and gynecological examination. For those who were considered to be candidates for surgery, radical hysterectomy, and pelvic lymph node dissection were performed 5–6 weeks after the completion of neoadjuvant therapy.

Results

Twenty-eight patients were enrolled. Clinical complete response and partial response were found in 8 (28.5%) and 20 (71.5%) patients, respectively. Four patients were not eligible for surgery and 2 patients refused surgery although they were assessed as surgical candidates. They were not included in this analysis. Radical hysterectomy and pelvic lymph node dissection were performed for the remaining 22 patients. Among them, 8 (36.4%) had complete pathology response, 9 (40.9%) presented with persistent atypical cells or cervical intraepithelial neoplasia, and 5 (22.7%) presented with macroscopic and/or microscopic residual disease, according to the pathological evaluation. Median follow-up time was 22 months (range, 5–39 months). The 2-year locoregional control rate, progression-free survival rate, distant metastasis-free survival rate, and overall survival rate were 95.0%, 85.2%, 84.0%, and 90.0%, respectively. Acute toxicities were mild in general and easily manageable. Chronic toxicities were mainly limited to grade 1. No severe late toxicities were observed.

Conclusion

Concurrent chemoradiotherapy plus nimotuzumab followed by surgery is highly effective and safe in LACC. Further studies are warranted to confirm the findings.

Highly conformal combined radiotherapy with cisplatin and gemcitabine for treatment of loco-regionally advanced cervical cancer - a retrospective study

BACKGROUND

Cisplatin and gemcitabine combined with conventional radiation therapy in the treatment of cervical cancer patients results in a favorable outcome but with excess toxicity. The purpose of this study was to evaluate the toxicity profile of dual chemotherapy and highly conformal external beam radiotherapy with image guided adaptive brachytherapy.

METHODS

Seventeen patients with cervical carcinoma FIGO stage IB2-IIIB were treated with curative intent between 2011 and 2015. A total dose of 50.4 Gy was prescribed to the elective pelvic nodal volume. Patients with ¹⁸FDG-PET/CT positive lymph nodes (n = 15; 83.3%) received an additional boost to a total dose of 62 Gy. Chemotherapy prescription goals were: concomitant during 5 weeks of external beam radiotherapy (EBRT) 40 mg/m2 cisplatin and 125 mg/m² gemcitabine, followed by adjuvant chemotherapy from week 10 (2 cycles 50 mg/m² cisplatin and 1000 mg/m² gemcitabine). EBRT was followed by 3-4 fractions (6 Gy per fraction) of intrauterine image guided adaptive brachytherapy. Toxicities were graded according to the common terminology criteria for adverse events (CTCAE v 4.0).

RESULTS

One (6%) patient developed acute grade 3 diarrhea. We did not record any other acute or late gastrointestinal or urogenital toxicity higher that grade 3. Most common acute hematological toxicity was anemia grade 2 recorded in 10 (59%) patients. There was only one case of grade 3 neutropenia (6%). The number of patients that received the complete chemotherapy regimen was gradually declining during the course of therapy. From week 2 to 5, gemcitabine was omitted in 4 (24%),7 (41%), 8 (47%), and 12 (71%) patients respectively, similarly, cisplatin was omitted in 2 (12%),3 (18%),1 (6%) and 7 (41%) patients respectively. Adjuvant chemotherapy was omitted in 8 patients (47%). During a median follow-up time of 20 months (5 to 63 months) 6 (35%) patients developed disease relapse with 5 (29%) of them in the form of systemic disease.

CONCLUSIONS

In contrast to previous findings cisplatin and gemcitabine in combination with highly conformal radiation therapy seems to have an acceptable toxicity profile. Further studies are needed to determine the optimal dosage of the proposed therapy concept.

Novel agents and treatment techniques to enhance radiotherapeutic outcomes in carcinoma of the uterine cervix

BACKGROUND

Survival of patients with locally advanced carcinoma cervix (LACC) using the current standard of concurrent chemo-radiotherapy (CCRT) has reached a plateau over the last two decades. Loco-regional failure in first two years of treatment completion and distant metastasis in the subsequent years has put the survival curves at a halt. Strategies of induction and adjuvant chemotherapy have yielded little as has any advancement in techniques of delivery of radiation therapy. This article aims at discussing the current existing literature as well as promising novel strategies to enhance radiotherapeutic outcomes in carcinoma of the uterine cervix.

METHODS

The review of English literature included phase I-III trials evaluating either a novel agent, novel application/modifications of an existing treatment regimen or an innovative treatment technique. The studies have been divided in to subsections with summary of most important findings at the end of each section.

RESULTS

Despite CCRT being the 'gold standard' treatment, several issues like optimum drug combination, schedule of drug delivery, combination with molecular targeted agents etc. remain undefined. Taxane, topoisomerase and gemcitabine based regimen needs to be further explored and compared with cisplatin based CCRT regimen. Several approaches like local delivery of cytotoxic agents, use of nano-medicine with CCRT are appearing on horizon with promises for the future. Therapies need to be designed based on the human papillomavirus titers of the patients and incorporation of radiosensitizers as an effective way of palliation with short course of radiotherapy may further enhance the radiotherapeutic outcomes.

CONCLUSIONS

The results of the studies with novel agents and treatment techniques appear promising. Further research in this arena including incorporation of cost-effectiveness analysis and quality of life issues in future trial designs are warranted.

Tumor invasion depth is a useful pathologic assessment for predicting outcomes in cervical squamous cell carcinoma after neoadjuvant radiotherapy

Background

To evaluate whether tumor invasion depth can be a reliable and easily applicable pathologic assessment strategy to predict outcomes using surgically resected cervical squamous cell carcinoma specimens from patients who have received neoadjuvant radiotherapy (RT) or concurrent chemoradiotherapy (CCRT).

Methods

We included 173 patients with cervical squamous cell carcinoma who received neoadjuvant CCRT (n = 125) or RT (n = 48) and underwent subsequent radical hysterectomy. Data for the pre-operative clinical International Federation of Gynecology and Obstetrics (FIGO) stage, post-operative pathologic FIGO stage, World Health Organization (WHO) double diameter measurement evaluation, response evaluation criteria in solid tumors (RECIST 1.1) criteria, tumor necrosis rate (TNR), and tumor regression grade (TRG) were investigated to identify correlations with outcomes related to distant metastasis and survival. The tumor invasion depth (TID) and the tumor invasion depth with cytokeratin immunostaining correction (TIDC) at the cervical internal surface were measured to assess their relations to patients’ outcomes.

Results

Based on measurements taken via transvaginal ultrasound, the pre-operative clinical and post-operative pathologic FIGO staging as well as the WHO double diameter measurement evaluation and RECIST 1.1 criteria were predictive of distant metastasis and survival-related outcomes. Also, lymph node involvement was found to be an independent prognostic factor for recurrence and distant metastasis. Finally, univariate analysis showed both the TID and TIDC were highly related to distant metastasis, overall survival, and progression-free survival, irrespective of the clinical stage of carcinomas.

Conclusion

The TID or TIDC measured at the cervical internal surface is a useful and easily applied pathologic prognostic factor for distant metastasis and survival outcomes in patients with cervical squamous cell carcinoma treated with neoadjuvant RT or CCRT.

Electronic supplementary material

The online version of this article (doi:10.1186/s13000-015-0426-6) contains supplementary material, which is available to authorized users.

The role of neoadjuvant chemotherapy in the management of locally advanced cervix cancer: a systematic review

Cervical cancer is the second most common cancer in women. Neoadjuvant chemotherapy for patients with locally advanced cervix cancer has comparable benefits to concurrent chemoradiotherapy (CCRT), but with fewer side effects. This systematic review aims to provide a comprehensive summary of the benefits of neoadjuvant chemotherapy for the management of locally advanced cervix cancer from stage IB2 (tumor >4.0 cm) to IIIB (tumor extending to the pelvic wall and/or hydronephrosis). Our primary objective was to assess benefits in terms of survival. The data source included the USA national library of medicine, Medline search, and the National Cancer Institute PDQ Clinical Protocols. Inclusion criteria for consideration in the current systematic review included studies published between January 1997 and December 2012. In terms of histology, they had to be focused on squamous cell carcinoma, adenosquamous carcinoma, and/or adenocarcinoma. Patients should be either chemotherapy naïve or cervix cancer chemotherapy naïve, and have a performance status ≤2. The search in the above-mentioned scientific websites led to identify 49 publications, 19 of which were excluded, as they did not meet the inclusion criteria of this systematic review. Therefore only 30 studies were deemed eligible. Data was collected from 1760 patients enrolled in the current systematic review study. The mean age was 45.2 years. The mean tumor size was 4.7 cm. The most commonly used chemotherapies were cisplatin doublets. Paclitaxel was the most commonly used chemotherapeutic agent in the doublets. The mean chemotherapy cycles were 2.7. After chemotherapy, patients underwent surgery after a mean time of 2.5 weeks. The standard operation was radical hysterectomy with pelvic lymphadenectomy. Chemotherapy achieved an objective response rate of 84%. The 5-year progression-free survival and overall survival were 61.9% and 72.8% respectively. The treatment protocol was associated with a mild early toxicity profile. Leucopenia and neutropenia were the most common side effects. Late toxicity was also generally mild and mainly associated with bladder dysfunction and vaginal dehiscence. The quality of the studies was assessed using the Newcastle-Ottawa quality assessment scale. Neoadjuvant chemotherapy achieved comparable survival results to CCRT, and was associated with less toxicity.

Analysis of prognostic factors for patients with bulky squamous cell carcinoma of the uterine cervix who underwent neoadjuvant chemotherapy followed by radical hysterectomy

BACKGROUND

Neoadjuvant chemotherapy (NAC) is not yet widely recommended for the treatment of stage I/II cervical cancer. However, it may be possible to achieve a favorable outcome by selecting appropriate patients. In the present study, prognostic factors were retrospectively investigated to obtain data for devising individualized NAC.

PATIENTS AND METHODS

The subjects were 33 patients with bulky stage Ib2-IIb squamous cell carcinoma (SCC) of the uterine cervix who gave consent and were scheduled to undergo radical hysterectomy. The patients intravenously received irinotecan 70 mg/m(2) on days 1 and 8 and cisplatin 70 mg/m(2) on day 1 of a 21-day course, and two courses were performed in principle. The potential prognostic factors investigated were age, performance status (PS), clinical stage, lymph node metastasis and tumor size before NAC, SCC antigen value, anti-tumor response, histological effect of NAC, lymph node metastasis in resected specimens, and postoperative adjuvant therapy after NAC. The impacts of these factors on overall survival (OS) were calculated with the Cox regression model.

RESULTS

According to the univariate analysis, lymph node metastasis before NAC, SCC antigen value after NAC, anti-tumor response, and histological effect of NAC significantly influenced OS. These factors were tested in a multivariate model, and significant prognostic factors were lymph node metastasis before NAC (hazard ratio 0.116, P = 0.027) and anti-tumor response (hazard ratio 0.025, P = 0.003).

CONCLUSION

The presence or absence of lymph node metastasis by computed tomography imaging was the only significant prognostic factor identified during the pre-NAC period.

Comparison of Neoadjuvant Intraarterial Chemotherapy Versus Concurrent Chemoradiotherapy in Patients With Stage IIIB Uterine Cervical Cancer

Background

The purpose of this study was to compare the long-term survival of patients with stage IIIB squamous cell carcinoma of the cervix treated with neoadjuvant intraarterial chemotherapy (IA-NAC) versus those treated with concurrent chemoradiotherapy (CCRT).

Methods

We retrospectively reviewed the clinical records of 38 patients with stage IIIB squamous cell carcinoma of the cervix admitted between January 1994 and December 1999 who received IA-NAC followed by abdominal radical hysterectomy (ARH) or radiotherapy (RT). IA-NAC consisted of bilateral infusion via the internal iliac artery of cisplatin, bleomycin and pirarubicin for 2-3 courses. A historical control group of 64 patients who underwent primary CCRT from January 2000 to September 2007 was used for comparison.

Results

In the IA-NAC group, 12 patients (31.6%) with operable tumors underwent ARH, and the remaining 26 patients (68.4%) received RT. The response rates were 86.8% (12 complete response + 21 partial response) for IA-NAC and 98.4% (26 complete response + 37 partial response) for CCRT (P = 0.077), respectively. The 5-year overall survival and disease-free survival rates were 62.4 and 44.5% for IA-NAC and 51.1 and 46.9% for CCRT (P = 0.247 and 0.776), respectively. The 5-year overall survival and disease-free survival rates were 75.0 and 58.3% for the patients receiving IA-NAC followed by ARH, and 55.3 and 37.6% for the patients receiving IA-NAC followed by RT (P = 0.368 and 0.262), respectively.

Conclusions

In the present study, IA-NAC followed by ARH or RT and primary CCRT showed similar survival rates for stage IIIB squamous cell carcinoma of the cervix.

The efficacy and safety of neoadjuvant chemotherapy in treatment of locally advanced carcinoma cervix

OBJECTIVE

A prospective cohort study in a teaching hospital to assess the efficacy and safety of neoadjuvant chemotherapy in the treatment of locally advanced carcinoma cervix.

METHOD

Neoadjuvant chemotherapy in the form of cisplatin 75 mg/m(2) and paclitaxel 135 mg/m(2) on day 1 and repeated at 14 days' interval for up to a maximum of three courses.

RESULTS

Neoadjuvant chemotherapy in cervical cancer was effective in the downstaging of the disease. Downstaging was observed in 19.23 % of patients after two cycles and in 50 % of patients after three cycle of NACT. Operability increases to 33.3 and 38.4 % after two and three cycles of NACT, respectively. Complete pathological response was observed in 37.5 % of patients after NACT. No significant adverse effect in the feasibility of surgery was observed.

CONCLUSION

The present study showed that neoadjuvant chemotherapy was an effective and well-tolerated mode of therapy with significantly less morbidity and mortality.

Neoadjuvant and adjuvant chemotherapy of cervical cancer: mature results of the phase 2 PBM-PFU protocol

OBJECTIVE

The mature results of the neoadjuvant and adjuvant chemotherapy arms of the nonrandomized, phase 2 Yale University cisplatin, bleomycin, methotrexate, and 5-FU protocol are presented.

METHODS

Sixty-seven patients were prospectively accrued with a median follow-up of 5.4 years, and standard parameters of toxicity and efficacy were studied. Both univariate and multivariate analyses were applied.

RESULTS

The 5-year disease-free survival of 78% for the 25 patients in the adjuvant group, of which 80% had high-risk features including positive margins, parametria, and lymph nodes and 28% had adenocarcinomas, was comparable to recent relevant literature. Only 64% of patients in this group received consolidation radiation therapy, which did not impact on survival. Only 12% of patients recurred distantly. Notably, those who received 4 months or more of chemotherapy had prolonged survival (P = 0.012). In the neoadjuvant group, chemotherapy response rate among 42 patients (with stages 1B-IIIB cancer) was 79% (50% partial response, 29% complete response), and no patient progressed. In the subgroup of 22 patients who underwent surgery after chemotherapy, 59% had nonsquamous histology. Forty-five percent of patients with stage IIB cancer were deemed operable after chemotherapy. Ninety-five percent received postoperative radiation therapy. There was a 9% pathologic complete response rate, with positive lymph nodes found in 27%. Notably, those who received 3 months or less of chemotherapy had improved overall survival (P = 0.030). Survival rates of these 22 patients at 3 and 5 years were 73% and 63%, respectively. Although not randomized, these survival rates were similar to those achieved with chemoradiation.

CONCLUSIONS

Although there are several logistical/design features of the cisplatin, bleomycin, methotrexate, and 5-FU regimen that are not in line with the current chemotherapy era, our experience with this well-tolerated regimen can serve as a proof of principle. Our data suggests that both neoadjuvant and adjuvant cisplatin-based neoadjuvant chemotherapy may have their place. It also raises the possibility that the optimal duration of chemotherapy in adjuvant cases should be longer than in neoadjuvant cases.

Neoadjuvant docetaxel combined with cisplatin and followed by radical surgery for the treatment of locally advanced (stage IB2 - IIB) cervical cancer: preliminary results of a single-institution experience

OBJECTIVES

We aimed to determine the efficacy and toxicity of treating locally advanced cervical cancer (LACC) with a neoadjuvant chemotherapy (NAC) regimen combining docetaxel and cisplatin followed by radical surgery.

METHODS

We retrospectively reviewed the clinical records of patients with stage IB2 - IIB (tumor diameter ≥ 4 cm) disease admitted between January 2007 and July 2009 who, before radical hysterectomy and pelvic lymph node dissection, received two to three courses of an NAC regimen comprising docetaxel (75 mg/m²) and cisplatin (70 - 75 mg/m²).

RESULTS

Fifty-two patients with LACC received 109 cycles of NAC. The objective response rate was 86.5% (26.9% CR and 17.3% pathological CR). Stage IB2 disease had a more favorable response to NAC (95.7%, p = 0.019). Deep stromal invasion and lymph-vascular space metastasis rates were significantly lower in NAC responders (p = 0.033) than in nonresponders (p = 0.012). Most side effects of NAC were mild or moderate. Log-rank test showed the 2-year overall survival and progression-free survival rates were 100 and 90.3% for NAC responders, compared with only 57.1% (p = 0.000) and 68.6% for nonresponders (p = 0.012), respectively.

CONCLUSION

Neoadjuvant docetaxel combined with cisplatin yielded a high response rate with well tolerable toxicity for LACC and could decrease pathological risk factors in NAC responders.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Pharmacotherapy options for locally advanced and advanced cervical cancer

Cervical cancer continues to be a significant health burden worldwide. Globally, the majority of cancers are locally advanced at diagnosis; hence, radiation remains the most frequently used therapeutic modality. Currently, the value of adding cisplatin or cisplatin-based chemotherapy to radiation for the treatment of locally advanced cervical cancer is strongly supported by randomized studies and meta-analyses. Nevertheless, despite these significant achievements, therapeutic results are far from optimal; thus, novel therapies need to be investigated. A recent, randomized, phase III trial has shown for the first time that combination chemotherapy with cisplatin and gemcitabine concurrently with radiation improves parameters of survival over cisplatin alone and establishes a new standard for the management of locally advanced cervical cancer. On the other hand, advanced disease, presenting either as an International Federation of Gynecology and Obstetrics (FIGO) stage IVB or as persistent or recurrent to primary therapy without local curative options, remains a devastating group of diseases with no options other than palliative chemotherapy. Recent results from the GOG (Gynecologic and Oncologic Group)-204 study demonstrate that cisplatin-doublets with paclitaxel, vinorelbine, gemcitabine or topotecan only produce small improvements in survival, although with different toxicity patterns; hence, patient-related factors are important when choosing any one of these regimens. The role of targeted therapies both in locally advanced and advanced disease is promising, but still at an investigational stage.

Phase II study of neoadjuvant chemotherapy with mitomycin-c, vincristine and cisplatin (MVC) in patients with stages IB2–IIB cervical carcinoma

OBJECTIVE

The efficacy and toxicity of neoadjuvant chemotherapy (NAC) with mitomycin-C, vincristine and cisplatin (MVC) were assessed in bulky cervical carcinoma patients.

METHODS

Forty-six patients with stage IB2 to IIB cervical cancer were treated with intravenous combination of mitomycin-C 10 mg/m(2), vincristine 1 mg/m(2) and cisplatin 75 mg/m(2) every 3 weeks. After three cycles of NAC, the patients either underwent surgery or radiation therapy, depending on their suitability for radical hysterectomy.

RESULTS

All 46 patients enrolled in this study were suitable for surgery after NAC. Twenty (44%) patients had risk factors after surgery and received postoperative radiation. Toxic nonhematologic reactions consisted primarily of grades 1-2 nausea and vomiting (87%) and the most common hematologic toxicity was anemia (60%). Clinical responses occurred in 83% (38/46) of patients, including 24% (11/46) with a complete response (CR) and 13% (6/46) with a pathologically determined complete response. For a median follow up period of 28 months, the 3-year disease-free and overall survival rates were 74% and 80%, respectively. Pathologically confirmed lymph node metastasis or parametrial involvement and an initial tumor size > or =4 cm were associated with shorter disease-free survival (P=0.040, P=0.000, P=0.025, respectively).

CONCLUSION

Intravenous administration of MVC as a NAC seems to be well tolerated and beneficial in patients with stage IB2 to IIB cervical cancer.

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

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

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

Neoadjuvant chemotherapy in cervical cancer: a 67 patients experience

The purpose of this study was to evaluate the efficacy and toxicity of neoadjuvant chemotherapy in patients with locally advanced cervical cancer. Between 1992 and 2003, all consecutive women with locally advanced cervical cancer receiving neoadjuvant chemotherapy were identified. Sixty-seven patients received neoadjuvant chemotherapy: 34 had stage I disease, 28 had stage II disease, and 5 had stage III disease. Clinical response to neoadjuvant chemotherapy occurred in 61 patients, including six with complete and 55 with partial response; five women showed stable disease and one progressed. After neoadjuvant chemotherapy, 58 women underwent surgery, whereas the remaining nine received radiation. Hematologic toxicity was seen in 14 patients, with most of them consisting in severe anemia. The 5-year survival rate and median survival were 63% and 93 months. In univariate analysis, response to neoadjuvant chemotherapy, treatment after neoadjuvant chemotherapy, cervical stromal invasion >50%, and lymph node involvement were important prognostic factor responsible for survival. Neoadjuvant chemotherapy followed by surgery seems to be tolerated and active in the treatment of locally advanced cervical cancer and might be an alternative choice of therapy to chemoradiation. A prospective randomized trial with a larger number of cases is needed.

Prognostic significance of pathological response after neoadjuvant chemotherapy or chemoradiation for locally advanced cervical carcinoma

Background

Cisplatin-based chemoradiation is the standard of care for locally advanced cervical cancer patients; however, neoadjuvant modalities are currently being tested. Neoadjuvant studies in several tumor types have underscored the prognostic significance of pathological response for survival; however there is a paucity of studies in cervical cancer investigating this issue.

Methods

Four cohorts of patients with locally advanced cervical carcinoma (stages IB2-IIIB); included prospectively in phase II protocols of either neoadjuvant chemotherapy with 1) cisplatin-gemcitabine, 2) oxaliplatin-gemcitabine, 3) carboplatin-paclitaxel or 4) chemoradiation with cisplatin or cisplatin-gemcitabine followed by radical hysterectomy were analyzed for pathological response and survival.

Results

One-hundred and fifty three (86%) of the 178 patients treated within these trials, underwent radical hysterectomy and were analyzed. Overall, the mean age was 44.7 and almost two-thirds were FIGO stage IIB. Pathological response rates were as follows: Complete (pCR) in 60 cases (39.2%), Near-complete (p-Near-CR) in 24 (15.6 %) and partial (pPR) in 69 cases (45.1%). A higher proportion rate of pCR was observed in patients treated with chemoradiotherapy (with cisplatin [19/40, 47.5%]; or with cisplatin-gemcitabine [24/41, 58.5%] compared with patients receiving only chemotherapy, 6/23 (26%), 3/8 (37.5%) and 8/41 (19.5%) for cisplatin-gemcitabine, oxaliplatin-gemcitabine and carboplatin-paclitaxel respectively [p = 0.0001]). A total of 29 relapses (18.9%) were documented. The pathological response was the only factor influencing on relapse, since only 4/60 (6.6%) patients with pCR relapsed, compared with 25/93 (26.8%) patients with viable tumor, either pNear-CR or pPR (p = 0.001). Overall survival was 98.3% in patients with pCR versus 83% for patients with either pNear-CR or pPR (p = 0.009).

Conclusion

Complete pathological response but no Near-complete and partial responses is associated with longer survival in cervical cancer patients treated with neoadjuvant chemotherapy or chemoradiotherapy.

Traitement par radio-chimiothérapie néoadjuvante et chirurgie du cancer du col utérin localement avancé

OBJECTIVES

Concomitant chemoradiation is the "new gold standard" for dealing with locally advanced cervical carcinoma, but what about surgery? We don't know yet to what extent surgery is necessary and how radical it must be when it is performed. In this study, we present the analysis of the results obtained in patients treated by concomitant chemoradiation followed by radical surgery.

MATERIALS AND METHODS

Twenty-two patients, median age 49 years, with I(b) - III(a) cervical tumors were enrolled to be treated by concomitant chemoradiation followed by radical surgery. The chemoradiation protocol included external radiotherapy to the pelvis: 45 Gy; Cisplatin 40 mg/m(2) in continuous intravenous infusion once a week (5 weeks) followed by brachytherapy one week later. Surgery was performed 4 to 6 weeks later and consisted in radical hysterectomy with pelvic lymphadenectomy.

RESULTS

20/22 patients underwent surgery after chemoradiation because of a diagnosis of lung metastases in one and presence of a nonresectable metastasis for the other. A complete pathological response was demonstrated in 12/20 patients (60%), a microscopic residual tumor in 7 patients (35%), and residual disease <1cm in 1 patient (5%).

CONCLUSION

This study showed a particularly high rate of pathologic responses (T(0)+T(mic): 95%) and of local control. We don't know yet if surgery is a real necessity or if it could be less extended after concomitant chemoradiation.

Anti-Progressive Effect of Neutral Endopeptidase 24.11 (NEP/CD10) on Cervical Carcinoma in vitro and in vivo

OBJECTIVES

Neutral endopeptidase 24.11 (NEP) is known to play important roles in the maintenance of homeostasis or in neoplastic transformation and tumor progression in certain human malignancies through the enzymatic inactivation of bioactive peptides such as endothelin-1 (ET-1), angiotensin-II, and bombesin.

METHODS

In this study, we first investigated NEP expression in cervical carcinoma by immunohistochemical staining and Western blot analysis. Next, we examined NEP functions in vitro and in vivo by generating NEP-overexpressing cervical carcinoma cells.

RESULTS

We found a significant decrease in cellular proliferative and invasive abilities with a reduced ET-1 concentration in the conditioned medium by NEP overexpression in cervical carcinoma CaSki cells, which have an ET-1 autocrine loop. In addition, these potentials were cancelled by blockade of NEP activity with a specific inhibitor. Although vector-transfected CaSki cells could grow even in serum-free media, NEP-overexpressing cells failed to proliferate in these media. Furthermore, we demonstrated that NEP suppressed tumor formation of subcutaneous xenografts using nude mice.

CONCLUSIONS

Our results indicated that NEP functions as a tumor-suppressor gene in cervical carcinoma cells, and its expression may have prognostic significance. Further elucidation of the mechanism underlying the observed effect of NEP will contribute to a better understanding of its role in the pathophysiology of cervical carcinoma.

Multimodal Treatment of Locally Advanced Cervical Cancer

BACKGROUND

Radiation therapy with concomitant chemotherapy is the standard treatment for locally advanced cervical cancer. In Mexico, most patients are still treated with radiation therapy alone. The aim of this work was to demonstrate that results obtained with combined treatments in the Mexican population are similar to those reported in the literature.

METHODS

Survival was analyzed in three sequential phase II studies of combined treatment: neoadjuvant chemotherapy followed by surgery (NEOCT+Sx) -February to July 1999; concomitant chemoradiotherapy (CT/RT) -August to December 1999; and neoadjuvant chemotherapy followed by surgery plus adjuvant chemoradiotherapy (NEOCT+Sx+CT/RT) -December 2000 to June 2001. These results were compared with a historical control group treated with radiation therapy alone between September and December 1998. The Kaplan-Meier product-limit method, log-rank test and Cox proportional hazards model were used for analysis.

RESULTS

Results showed that the three combined modalities significantly reduced the risk of death. Treatment with NEOCT+Sx reduced the risk to 0.452 (95% CI 0.246-0.830), p=0.010. The risk reduction with CT/RT was 0.408 (95% CI 0.218-0.762), p=0.005, and for the group of patients receiving NEOCT+Sx+CT/RT risk was reduced to 0.365 (95% CI 0.169-0.787), p=0.010. The corresponding absolute survival benefit was 14% for patients in stages IB2-IIA, 24% for IIB, and 21% for stage IIIB.

CONCLUSIONS

Within the limitations of a non-randomized study, our results are in agreement with those obtained from published randomized phase III trials which state that radiation therapy alone is a suboptimal treatment for locally advanced cervical cancer; hence, patients should receive cisplatin-based chemoradiotherapy as a standard treatment.

Chemoradiation: A new approach for the treatment of cervical cancer

Despite advances in screening, cervical cancer remains a major health problem worldwide. In an effort to improve loco-regional control, both neoadjuvant and chemoradiation have been trialed. Recently, five randomized clinical trials performed by the Gynecologic Oncology Group, the Radiation Therapy Oncology Group and the Southwest Oncology Group have demonstrated a significant advantage both in progression-free and overall survival when cisplatin-based chemotherapy was administered during radiation for advanced stages of cervical cancer. Based on the results of these trials, the US National Cancer Institute released a Clinical Announcement supporting the concurrent use of cisplatin-based chemotherapy with radiation therapy for high-risk early stage and locally advanced stage cervical cancer. Subsequently, an additional prospective randomized trial performed by the National Cancer Institute of Canada was not able to show benefit with the use of chemoradiation compared with radiation alone for patients with locally advanced stage cervical cancer. This article will analyze these six clinical trials in order to determine the role of chemoradiation in the management of patients with cervical cancer. Furthermore, as anemia is one of the most powerful prognostic factors in patients with cervical cancer, we propose to evaluate the relationship between a decreased level of hemoglobin and treatment outcome.

Usefulness of Preoperative Chemoradiation in Locally Advanced Cervical Carcinoma

This study investigated response rate, toxicity, and influence on intra- and postoperative complications of neoadjuvant concurrent chemoradiation in locally advanced (Figo IB2-IIIB) cervical carcinomas. Twenty-eight patients (median age 46.5 years, age range 29-73 years), diagnosed as having squamous cell carcinomas (n=21), adenocarcinomas (n=6), and undifferentiated carcinoma (n=1), entered this study. The chemoradiation protocol included external radiotherapy to the pelvis (39.6 Gy), intra-arterial or intravenous infusion of cisplatin (70 mg/m2 on days 1 and 22), and 24-hour continuous intravenous infusion of 5-fluorouracil (700 mg/m2 on days 1-4 and 22-25). Two weeks after the end of chemoradiotherapy, the patients underwent restaging followed by suitable operation including pelvic lymphadenectomy. The median follow-up period in the surviving patients was 13.1 months. The response rate for chemoradiation was 93% (26/28). The 2-year disease free survival was 85.2%. Grade 3-4 neutropenia was observed in 14 patients (50%), 4 patients (14%) showed grade 3 anemia, and 5 patients (17.8%) showed grade 3-4 thrombocytopenia. Nineteen patients (67.8%) could undergo surgery after concurrent chemoradiation. Pathological examination revealed a complete response (pT0) in 7 patients, and 5 patients showed only microscopic residual disease (pTmic). In 4 patients, there were intraoperative complications: vesical lesions in 2 (10%) and small intestine lesions in 2 (10%). Neoadjuvant therapy with concurrent chemoradiation for locally advanced cervical carcinoma is effective, safe, and useful for increasing operability rates as well as decreasing intra- and postoperative complications. Therefore, neoadjuvant concurrent chemoradiation should be considered for treatment in patients with locally advanced cervical carcinomas who could not undergo primary operation.

Modern management of locally advanced cervical carcinoma

Radiation was until recently the key and only modality for the routine treatment of locally advanced cervical carcinoma. However after years of studying multi-modality treatments as an alternative to radiation alone in randomized phase III trials, the standard treatment has changed to chemo-radiation based on cisplatin. Three recent meta-analyses have confirmed that cisplatin-based chemo-radiation adds an absolute 12% benefit in five-year survival over radiation therapy alone. Neoadjuvant chemotherapy followed by radiation has not been of proven benefit, but when neoadjuvant chemotherapy is followed by surgery, an absolute increase of 15% in five-year survival over radiation alone is seen. This benefit in survival is comparable to that obtained with the current chemo-radiation schedules based on cisplatin. Despite these encouraging results there remains room for improvement as the five-year survival of patients treated with chemo-radiation ranges from nearly 80% in bulky IB tumours to only 25% in stage IVA disease. Other therapeutic approaches need to be fully evaluated including the use of chemo-radiation after neoadjuvant chemotherapy; the use of new drug combinations and the multi-modality combination of neoadjuvant chemotherapy followed by radical surgery plus adjuvant chemo-radiation. Likewise, the addition of radiosensitizers to cisplatin, preoperative chemo-radiation and/or adjuvant chemotherapy may eventually improve the currents results of cisplatin-based chemo-radiation. Nevertheless, it is hard to foresee a dramatic increase in cure rate, even with the most optimal combination of cytotoxic drugs, surgery and radiation, and thus the testing of molecular targeted therapies against cervical cancer is a logical step to follow.

A phase I study of carboplatin concurrent with radiation in FIGO stage IIIB cervix uteri carcinoma

PURPOSE

Chemoradiation based on cisplatin, most commonly weekly, is the standard treatment of locally advanced cervical cancer; however, the nephrotoxic potential and the requirement for hydration of cisplatin somewhat restrains its use. The objective of this study was to determine the recommended dose of carboplatin when administered weekly during pelvic radiation (RT).

METHODS AND MATERIALS

Twenty-four histologically proven, International Federation of Gynecology and Obstetrics Stage IIIB patients were treated with standard pelvic RT concurrently with six weekly applications of carboplatin at the following dose levels: 100 mg/m(2), 116 mg/m(2), 133 mg/m(2), and 150 mg/m(2). Six patients per level were treated. Acute toxicity was assessed according to the Radiation Therapy Oncology Group Acute Radiation Morbidity Scoring Criteria. The recommended dose was defined as the one that was one level below the level at which dose-limiting toxicity was present in more than one-third of patients.

RESULTS

Between September 2001 and July 2002, 24 patients were accrued. All but two completed external beam radiotherapy and intracavitary treatment. The treatment was well tolerated. The median number of weekly applications of carboplatin was six, and the mean dose to points A and B was 85.6 Gy (range 75.2-91.6) and 62.9 Gy (range 58.2-74.6), respectively. RT was delivered within 41.7 days (range 33-70). Dose-limiting toxicity (leukopenia and/or neutropenia) was present in 50% of patients treated at the higher dose level (150 mg/m(2)). At the recommended dose of 133 mg/m(2), 33% of patients presented with Grade 3 leukopenia. At treatment completion, 75% of patients had a complete clinical response.

CONCLUSION

Carboplatin at 133 mg/m(2), weekly for 6 weeks, is a well tolerated and effective radiosensitizer in cervical cancer patients.

A phase II study of multimodality treatment for locally advanced cervical cancer: neoadjuvant carboplatin and paclitaxel followed by radical hysterectomy and adjuvant cisplatin chemoradiation

BACKGROUND

Our aim was to evaluate the efficacy and safety of neoadjuvant chemotherapy followed by radical hysterectomy and adjuvant radiation concurrent with weekly cisplatin for locally advanced cervical carcinoma.

PATIENTS AND METHODS

Forty-three patients staged as IB2-IIIB were treated with three 21-day courses of carboplatin (area under the time-concentration curve 6 mg.min/ml) and paclitaxel at 175 mg/m(2) by 3-h infusion both on day 1 followed by radical type III hysterectomy and adjuvant radiation concurrent with 6-weekly doses of cisplatin at 40 mg/m(2). Response rate, resectability, toxicity and survival were evaluated.

RESULTS

From December 2000 to June 2001, 43 patients were recruited. All were evaluated for response and toxicity to neoadjuvant chemotherapy. A total of 129 courses were administered. Clinical responses were seen in 41 patients (95%) [95% confidence interval (CI) 89.2% to 100%] with four (9%) complete and 37 (86%) partial. Forty-one patients underwent surgery (resectability 95%); pathologically complete or near-complete responses were seen in seven (17%) and eight (20%), respectively, positive surgical margins in five (12%), and positive pelvic lymph nodes in eight (20%). Twenty-six patients were scheduled for adjuvant chemoradiation. External radiation was delivered for 42.8 days (range 33-61), with a mean dose of 49.3 Gy (range 46-56), and a median of five cisplatin courses (two to six). The mean dose of brachytherapy was 32 Gy (range 25.5-35.6). Neoadjuvant therapy was well-tolerated with neutropenia grade 3 and 4 in 12% and 3% of the courses, respectively. Toxicity to adjuvant chemoradiation was mainly hematological and gastrointestinal, mostly grades 1/2. A total of 39 patients completed all scheduled treatment. At a median follow-up of 21 months (range 3-26), the projected overall survival in the intention-to-treat analysis was 79% (95% CI 62% to 88%).

CONCLUSIONS

The triple modality of neoadjuvant chemotherapy followed by radical hysterectomy and adjuvant radiation concurrent with cisplatin is a highly active treatment for locally advanced cervical carcinoma with acceptable toxicity.

Gemcitabine in cervical cancer

OBJECTIVE

Recurrent and advanced cervical cancers are associated with high mortality and a lack of effective treatment options, especially for women who are poor candidates for surgery or radiation therapy. The broad clinical effectiveness and low toxicity of gemcitabine in other human malignancies suggest that it might be useful in treating cervical tumors.

METHODS

Fifteen phase I/II clinical trials on the use of gemcitabine, both as a single agent and in combination with cisplatin, in patients with recurrent or advanced carcinoma of the cervix were reviewed. Data from studies in which gemcitabine was used in combination with radiotherapy for induction therapy and with cisplatin for neoadjuvant chemotherapy were also evaluated.

RESULTS

Although single-agent gemcitabine was generally inferior to cisplatin, when used concurrently with cisplatin and/or radiation therapy, objective response rates were high and survival was prolonged. The drug also showed promise when used with cisplatin as neoadjuvant therapy.

CONCLUSIONS

Initial studies suggest that gemcitabine may be useful in the management of recurrent or advanced cervical cancer when used concurrently with cisplatin. Accordingly, a large phase III study will compare cisplatin/gemcitabine with the current standard, and further evaluation of gemcitabine appears to be warranted in conjunction with radiotherapy and in the neoadjuvant setting.