Phase I/II study of definitive radiotherapy and chemotherapy (cisplatin and 5-fluorouracil) for advanced or recurrent gynecologic malignancies. Preliminary report

MRI- and PET-Guided Interstitial Brachytherapy for Postsurgical Vaginal Recurrences of Cervical Cancer: Results of Phase II Study

PURPOSE

This phase II study evaluated the utility of magnetic resonance imaging (MRI) and positron emission tomography for planning radiation and brachytherapy in patients with postsurgical recurrence of cervical cancer.

METHODS AND MATERIALS

The study (NCT01391065) recruited patients with residual or recurrent disease after hysterectomy. Patients underwent baseline T2 weighted (T2W) MRI, ¹⁸F-flouro-deoxyglucose (¹⁸F-FDG), ¹⁸F-flouro thymidine (¹⁸F-FLT) and ¹⁸F-flouromisonidazole (¹⁸F-F Miso) positron emission tomography (PET) and received external radiation (50 Gy/25 fractions for 5 weeks) and weekly cisplatin (40 mg/m²). MRI was performed at brachytherapy and used for delineation of clinical target volume (CTV). Patients with parametrial disease at baseline received interstitial brachytherapy (16-20 Gy/4-5 fractions) and those with vaginal disease received intracavitary brachytherapy (12-14 Gy/2-4 fractions). Kaplan-Meier analysis was performed to evaluate locoregional relapse, disease free survival, and overall survival. Common Toxicity Criteria for adverse event reporting (CTCAE) v4.1 was used for toxicity scoring and European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questtionaire Core 30 (QLQC-30) and Cx 24 for quality-of-life reporting.

RESULTS

Between January 2011 and February 2016, 60 patients were included, of which 50 received study treatment. The mean gross tumor volume on T2 W MR was 20 (IQR 3.6-90) cc. The metabolic tumor volume was 15 (interquartile range [IQR] 2.1-56.1) cc. The median FLT volume was 10 (IQR 0-48) cc. A total of 8 patients had ^18-F F Miso uptake. The median CTV at brachytherapy was 38 (12-85) cc. The median CTVD90 and D 98 was 71 (53-74) and 74 (53-74) Gy. At a median follow-up of 60 (5-93) months, the 5-year local control, disease free survival, and overall survival were 84%, 73%, and 74.5%, respectively. Grade III and IV proctitis and cystitis were observed in 4% and 2% of patients. On multivariate analysis baseline tumor volume, on T2 W MR impacted disease free (91% vs 65%, P = .03) and overall survival (96% vs 77%, P = .06).

CONCLUSIONS

Image-guided assisted radiation and brachytherapy are associated with good to excellent local control and survival in patients with vaginal recurrences of cervical cancer.

5-Fluorouracil impairs attention and dopamine release in rats

Chemotherapy related cognitive impairment (CTRC; "chemobrain") is a syndrome that is associated with the impairment of various aspects of cognition, including executive function, processing speed, and multitasking. The role of neurotransmitter release in the expression of cognitive impairments is not well known. In this work we employed a newly developed behavioral paradigm to measure attentional shifting, a fundamental component of executive function, in rats treated with 5-fluorouracil (5-FU), a commonly used cancer chemotherapy agent. We found that one and two weeks of 5-FU treatment significantly impaired attentional shifting compared to baseline, while saline treatment had no effect. Post-mortem analysis of these rats revealed that 5-FU caused a significant overall decrease in dopamine release as well. Collectively, these results demonstrate the feasibility of our attentional shifting paradigm for evaluating the cognitive effects of chemotherapy treatment. Moreover, these results support the need for additional studies to determine if impaired dopamine release plays a role in chemobrain.

Concurrent Chemo- Radiobrachytherapy with Cisplatin and Medium Dose Rate Intra- Cavitary Brachytherapy for Locally Advanced Uterine Cervical Cancer

Objective:

Cervical carcinoma is the third most common gynecologic cancer, after ovarian and uterine cancers in Iran. The aim of this study was to evaluate the efficacy (response rate) and toxicity of adding Medium Dose Rate (MDR) brachytherapy with concurrent chemotherapy to External Beam Radiotherapy (EBRT) for the treatment of locally advanced uterine cervical carcinoma.

Methods:

This phase I-II study was conducted in 2007-2008 at the cancer institute, Tehran University of Medical Sciences. Patients were treated with pelvic EBRT (50 Gy in 25 Fraction) with concomitant chemotherapy to obtain tumor shrinkage and permit optimal intra-cavitary placement. One week after the completion of EBRT, patients were treated by 12 Gy MDR Intra-cavitary brachytherapy for two periods of one day with a one week interval and concomitant platinum based chemotherapy. Response rate was evaluated by gynecologic physical examination and pelvic MRI +- GD within three months of treatment. Acute and late toxicity were assessed using Radiation Therapy Oncology Group criteria.

Results:

A total of 33 patients with locally advanced cervical cancer were treated according to the above described treatment protocol. The patients mean age was 53.2 (range 31–78) years. Three months after the completion of treatment, the complete clinical, pathologic and radiologic response rate according to WHO-criteria was 81.8% (27 patients). Six cases had a partial response or stable disease. After 48 months, average disease free survival periods were 45.1, 23.0, 33.4 and 8 months for stage IIB, IIIA, IIIB and IVA lesions (according to The International Federation of Gynecology and Obstetrics staging system). The most frequently observed side effects were leukopenia, anemia, proctitis, cystitis, nausea and vomiting (mostly grade 1 and 2).

Conclusion:

Concomitant brachytherapy and chemotherapy with platinum compounds can be well tolerated and is effective in the treatment of locally advanced cervical cancer.

A randomized phase III trial of concurrent chemoradiotherapy in locally advanced cervical cancer: Preliminary results

OBJECTIVE

Concurrent chemoradiation is the standard treatment for locally advanced cervical cancer. This study was a preliminary result of a randomized two arms, prospective, open-label phase III trial comparing the activity and safety of the concurrent chemoradiation of Tegafur-Uracil and carboplatin or carboplatin alone in locally advanced cervical cancer.

MATERIALS AND METHODS

The stage IIB-IIIB cervical cancer patients were randomized to have Tegafur-Uracil 225 mg/m(2)/day orally, 5 days a week and carboplatin 100 mg/m(2) IV over 30-60 min, weekly on day 1 concurrent with standard radiotherapy (Group A) or carboplatin alone concurrent with standard radiotherapy (Group B).

RESULTS

Four hundred and sixty-nine patients were randomized to Group A (n=234) or Group B (n=235). The tumor response at 3-month follow-up time showed no significant difference. The only prognostic factor to improve the complete response rate was the hemoglobin level. The patients in Group A, who had Hb <10 gm/dL had the relatively better change to complete response of 1.48 compared to that in Group B (P 0.025, 95% CI 1.07, 2.04). No severe toxicity or adverse event had been reported. The median follow-up time for Group A and Group B was 12.6 and 11.8 months, respectively. There was no statistical difference in PFS and OS.

CONCLUSION

Concurrent chemoradiation by Tegafur-Uracil and carboplatin showed no difference in tumor response rate or treatment toxicity compared to carboplatin alone. The combination drugs might have benefit in poor prognostic patients such as the baseline Hb <10 gm/dL.

[Chemoradiotherapy in locally advanced cancers of the uterine neck. Retrospective study of 92 patients treated at the Institute Curie between 1986 and 1998]]

PURPOSE

The prognosis of locally advanced cervix cancers is poor with metastatic and local recurrence risks. Recent publications reported that concurrent chemotherapy and pelvic radiation increased local control compared to radiotherapy alone. Chemotherapy could also decrease metastatic recurrences. We report 92 cases of patients with locally advanced cervix cancer treated between 1986 and 1998 at the Institut Curie.

PATIENTS AND METHODS

Concurrent chemoradiation was exclusive in 51 cases and added to surgery in 41 cases. Chemotherapy with 5FU-Cisplatin-Mitomycin C-Vindesin (protocol A) was performed for 43% of patients and 57% of them received 5FU-Cisplatin alone (protocol B).

RESULTS

Median follow-up was 64 months (6-149 months). Five-year disease-free survival rate was 47% and local control rate was 70%. Disease-free survival was correlated with therapeutic response. After exclusive chemoradiation, the good responsive patients had a better DFS (54% vs 26%, p = 0.018). In the surgery group, those patients with sterilized lymph nodes and tumours had also a higher DFS (76% vs 47%, p = 0.036). Toxicity was higher with protocol A.

CONCLUSION

From our study, it appears that local control of advanced cervix cancers is better with combined chemoradiotherapy but disease-free survival stays low according to the metastatic evolution. Metastasis without local recurrence remained frequent in our study. 5FU-CDDP chemotherapy has a lower toxicity and is as effective as 5FU-CDDP-Mitomycin C-Vindesin protocol, in association with radiotherapy.

Concurrent chemotherapy and radiation therapy in primary cancer of the cervix

Radiation therapy has been the most active agent for the treatment of patients with locally advanced cervical cancer for many years. Chemotherapy has shown some activity, but data has been lacking to support its routine use. Recently, data from five prospective, randomized trials evaluating this difficult population have matured. Reports from these trials are startlingly similar, leading to the common conclusion that concurrent cisplatin chemotherapy and radiation therapy substantially decrease the risk of relapse and increase the overall survival. These results are compelling evidence for the inclusion of cisplatin with irradiation as a new standard of care for patients with locally advanced cervical cancer.

Mature results of a pilot study of pelvic radiotherapy with concurrent continuous infusion intra-arterial 5-FU for stage IIIB-IVA squamous cell carcinoma of the cervix

PURPOSE

To evaluate the long-term results of continuous infusion intra-arterial 5-fluorouracil (CI IA 5-FU) given with concurrent pelvic radiotherapy (RT) for FIGO stage IIIB-IVA carcinoma of the cervix.

METHODS AND MATERIALS

Between 1965 and 1974, 27 patients with extensive FIGO Stage IIIB (22 patients) or Stage IVA (5 patients) squamous cell carcinoma of the cervix were treated with CI IA 5-FU and RT. Twenty-one patients (78%) had bilateral pelvic wall involvement, 25 (93%) had massive tumors (> or =8 cm in diameter), 7 (27%) had involvement of the lower one-third of the vagina, and 15 (56%) presented with hydronephrosis. All patients underwent routine clinical staging, transperitoneal para-aortic lymph node dissection, and bilateral hypogastric artery catheter placement. 5-FU was continuously infused at a dose rate of 10 mg/kg/day on Days 1-15 of RT. The median dose of 5-FU was 376 mg/m2/day (range 270-692). All patients received concurrent pelvic RT to a median dose of 50 Gy at 2.0 Gy per fraction. Only 4 patients received intracavitary RT. The median follow-up of surviving patients was 190 months.

RESULTS

The overall 5-year survival rate was 37%. For the 22 patients with FIGO Stage IIIB disease, the 5-year survival rate was 41%. The survival rate for 18 patients treated with only external beam radiation and chemotherapy for Stage IIIB disease was 33%. Four of 10 patients treated with only 50 Gy of external beam radiation and CI IA 5-FU were long-term survivors. Acute complications, including hematologic toxicity and skin reactions, were severe, with 1 death from neutropenic sepsis. Severe late complications were only observed in patients treated with > or =60 Gy of external beam radiation.

CONCLUSIONS

While this series is small, the fact that 4 patients with massive Stage IIIB tumors survived after a total radiation dose of only 50 Gy suggests that RT with CI IA 5-FU deserves further study. Modifications in dose, technique, and route of administration should reduce toxicity, and the addition of intracavitary RT should improve the local effectiveness of combined treatment.

Randomized comparison of fluorouracil plus cisplatin versus hydroxyurea as an adjunct to radiation therapy in stage IIB-IVA carcinoma of the cervix with negative para-aortic lymph nodes: a Gynecologic Oncology Group and Southwest Oncology Group study

PURPOSE

In 1986, a protocol comparing primary radiation therapy (RT) plus hydroxyurea (HU) to irradiation plus fluorouracil (5-FU) and cisplatin (CF) was activated by the Gynecologic Oncology Group (GOG) for the treatment of patients with locally advanced cervical carcinoma. The goals were to determine the superior chemoradiation regimen and to quantitate the relative toxicities.

METHODS

All patients had biopsy-proven invasive squamous cell carcinoma, adenocarcinoma, or adenosquamous carcinoma of the uterine cervix. Patients underwent standard clinical staging studies and their tumors were found to be International Federation of Gynaecology and Obstetrics stages IIB, III, or IVA. Negative cytologic washings and para-aortic lymph nodes were required for entry. Patients were randomized to receive either standard whole pelvic RT with concurrent 5-FU infusion and bolus CF or the same RT plus oral HU.

RESULTS

Of 388 randomized patients, 368 were eligible; 177 were randomized to CF and 191 to HU. Adverse effects were predominantly hematologic or gastrointestinal in both regimens. Severe or life-threatening leukopenia was more common in the HU group (24%) than in the CF group (4%). The difference in progression-free survival (PFS) was statistically significant in favor of the CF group (P = .033). The sites of progression in the two treatment groups were not substantially different. Survival was significantly better for the patients randomized to CF (P = .018).

CONCLUSION

This study demonstrates that for patients with locally advanced carcinoma of the cervix, the combination of 5-FU and CF with RT offers patients better PFS and overall survival than HU, and with manageable toxicity.

Concurrent cisplatin-based radiotherapy and chemotherapy for locally advanced cervical cancer

BACKGROUND AND METHODS

On behalf of the Gynecologic Oncology Group, we performed a randomized trial of radiotherapy in combination with three concurrent chemotherapy regimens -- cisplatin alone; cisplatin, fluorouracil, and hydroxyurea; and hydroxyurea alone -- in patients with locally advanced cervical cancer. Women with primary untreated invasive squamous-cell carcinoma, adenosquamous carcinoma, or adenocarcinoma of the cervix of stage IIB, III, or IVA, without involvement of the para-aortic lymph nodes, were enrolled. The patients had to have a leukocyte count of at least 3000 per cubic millimeter, a platelet count of at least 100,000 per cubic millimeter, a serum creatinine level no higher than 2 mg per deciliter (177 micromol per liter), and adequate hepatic function. All patients received external-beam radiotherapy according to a strict protocol. Patients were randomly assigned to receive one of three chemotherapy regimens: 40 mg of cisplatin per square meter of body-surface area per week for six weeks (group 1); 50 mg of cisplatin per square meter on days 1 and 29, followed by 4 g of fluorouracil per square meter given as a 96-hour infusion on days 1 and 29, and 2 g of oral hydroxyurea per square meter twice weekly for six weeks (group 2); or 3 g of oral hydroxyurea per square meter twice weekly for six weeks (group 3).

RESULTS

The analysis included 526 women. The median duration of follow-up was 35 months. Both groups that received cisplatin had a higher rate of progression-free survival than the group that received hydroxyurea alone (P<0.001 for both comparisons). The relative risks of progression of disease or death were 0.57 (95 percent confidence interval, 0.42 to 0.78) in group 1 and 0.55 (95 percent confidence interval, 0.40 to 0.75) in group 2, as compared with group 3. The overall survival rate was significantly higher in groups 1 and 2 than in group 3, with relative risks of death of 0.61 (95 percent confidence interval, 0.44 to 0.85) and 0.58 (95 percent confidence interval, 0.41 to 0.81), respectively.

CONCLUSIONS

Regimens of radiotherapy and chemotherapy that contain cisplatin improve the rates of survival and progression-free survival among women with locally advanced cervical cancer.

Interstitial brachytherapy in the management of primary carcinoma of the cervix and vagina

PURPOSE

The purpose of this study was to determine the role of interstitial brachytherapy in the management of selected primary cancers of the cervix and the vagina.

METHODS

Thirty-nine previously untreated patients with histologically confirmed carcinoma of the cervix (31 patients) and of the vagina (8 patients) were treated by a combination of external beam radiotherapy and fluoroscopic-guided interstitial brachytherapy between November 1989 and May 1995 at the Ohio State University Medical Center because they were not suitable for standard intracavitary brachytherapy. Clinical indications for interstitial brachytherapy were extensive parametrial involvement in 22 patients, extensive vaginal involvement in 10, and poor vaginal anatomy in 7.

RESULTS

With a median follow-up of 36 months (range 12-66 months), 16 patients (51%) with cervical carcinomas and 5 patients (62.5%) with vaginal carcinomas have experienced local control of their tumor. The local control was better for tumors < 4 cm in largest diameter compared to tumors > 6 cm in largest diameter. The 5-year actuarial survival was 34 and 38% for cervical and vaginal cancers, respectively. Only 1 patient experienced grade 3 complications (2.5%).

CONCLUSIONS

Interstitial brachytherapy can be safely used to treat patients unsuitable for standard intracavitary brachytherapy. When intracavitary dose distribution is expected to be suboptimal, interstitial brachytherapy is a good alternative.

A pilot study on concurrent platinum chemotherapy and intracavitary brachytherapy for locally advanced cancer of the uterine cervix

This study aims to evaluate the feasibility, toxicity and efficacy of concurrent chemotherapy with platinum compounds and brachytherapy, for locally advanced carcinoma of the cervix (Stages IIA/B, IIIA). The hypothesis was that synchronous chemo-brachytherapy may be sufficient to cause down-staging of the tumour, to render it operable, and hopefully improve the prognosis. 36 women with locally advanced cervical cancer were treated with concomitant brachytherapy and chemotherapy before surgery and/or definitive external radiotherapy. All patients received two caesium-137 Selectron MDR applications, 1 week apart. The dose calculated to point A for each implant was 20-25 Gy. Chemotherapy consisting of continuous cisplatin infusion (50 mg m2) and of carboplatin (300 mg m-2) was given simultaneously with intracavitary irradiation during the first and second application, respectively. The combined therapy was followed when feasible by radical hysterectomy, pelvic lymphadenectomy and pelvic radiotherapy. Patients deemed ineligible for surgery because of poor response were given full dose external radiotherapy. 31/36 patients were treated by Wertheim hysterectomy of whom 10 had negative lymph nodes and resection margins. Definitive external radiotherapy was given in the remaining five patients. Overall, 83% were disease free at 2.8 years mean follow-up. The most frequent acute side-effects of chemobrachytherapy were nausea and vomiting. No renal toxicity was observed. Thrombocytopenia was seen in five patients and was responsible for delayed surgery in four patients. Concerning late effects, two patients developed grade 2 intestinal sequelae, two mild frequency and two vaginal stenosis. One rectovaginal and one vesicovaginal fistula developed in two patients; and a third patient had a fistula associated with tumour recurrence. Concurrent brachytherapy and chemotherapy with platinum compounds is well tolerated and effective in reducing tumour bulk before definitive local treatment (surgery or external radiotherapy), in patients with locally advanced carcinoma of the uterine cervix.

Phase I-II study of combined 5-fluorouracil and cisplatin chemotherapy and altered fractionation radiotherapy for advanced squamous cell carcinoma of the cervix

Forty patients with advanced carcinoma of the cervix were prospectively treated by an intermodality approach using chemotherapy combination concomitant with split-course hyperfractionated radiation therapy (RT). Cisplatin (CDDP) (60 mg/m2) was administered before radiotherapy initiation followed by 5-fluorouracil (5-FU) (750 mg/m2) for 5 days during the first week of irradiation. The same schedule was repeated in the last week of the RT, with 5-FU administration (1,000 mg/m2) for only 3 days. RT consisted of 5,020 cGy to the pelvis, followed by two intracavitary applications for a total of 5,000-5,500 mg/h radium equivalent when possible: 140 cGy/fraction was administered in the morning and evening, with a 6-h interval. The remainder of the external beam radiation was delivered at a standard daily fractionation of 180 cGy/fraction to a total dose of 5,020 cGy. This regimen of RT with concomitant chemotherapy had minimal toxicity and did not cause significant prolongation of the treatment program. However, a high rate of late complications was noted in patients who had extended-field RT due to paraaortic lymph node involvement. Thirty-two patients had complete response (CR) (80%). 24 (75%) of whom have no evidence disease (NED), with a median follow-up of 24 months. Our study suggests that this regimen of combined chemotherapy and RT in this group of patients with poor prognosis is effective and well tolerated, with acceptable acute toxicity and late morbidity.

Cisplatin, hyperthermia and radiation treatment in human cisplatin-sensitive and resistant glioma cell lines

In this study, the effects of mild protracted hyperthermia, combined with prolonged exposure to cisplatin and low dose-rate irradiation (LDRI), were examined in two human cell lines. The cell lines are human glioma parental and cisplatin-resistant variant cells. The results show that mild hyperthermia at 40 degrees C was able to sensitize both the parental and the variant cisplatin-resistant cells to cisplatin treatments (1 microgram/ml for up to 20 h) when the two treatments were given concurrently. When mild hyperthermia and cisplatin were given with LDRI concurrently, additional enhanced cell killing was observed in both the parental and the cisplatin-resistant variant cells. Further analysis of the results showed that when the effects of the trimodality treatment were normalized to the effects of the combined treatment of mild hyperthermia with cisplatin, the residual cell killing was still greater than that observed for radiation alone, indicating a synergistic interaction. This synergistic interaction was greater for the parental line compared to the cisplatin-resistant line. Thus, these data show that the concurrent application of mild hyperthermia, low concentration, long duration, cisplatin and low-dose rate irradiation may be an effective form of treatment in both normally responding and cisplatin-resistant variant human tumour cell lines.

Concurrent chemo- and radiotherapy in patients with locally advanced carcinoma of the cervix

BACKGROUND

The feasibility of concurrent chemotherapy and radiotherapy for advanced primary carcinoma of the cervix was evaluated and the results were compared to historical controls.

PATIENTS AND METHODS

In a single institution study, patients (n = 74) with primary cervical carcinoma received 3 cycles carboplatin/5-fluorouracil concurrent with radiotherapy followed by salvage hysterectomy (group I). Treatment results were compared with those of a historical control group (n = 39) (group II), treated similarly but without chemotherapy.

RESULTS

In group I median follow-up is 28 months (12-68+) and in group II 23 months (14-90+ months). The 5-year overall survival, progression-free survival and local recurrence free survival for group I and II are, respectively, 69% versus 38% (P < 0.003), 67% versus 38% (P < 0.005) and 84% versus 43% (P < 0.0001). Two patients in each group developed posttreatment enteritis.

CONCLUSIONS

Radiotherapy with concurrent carboplatin and 5-fluorouracil resulted in a better overall survival, disease free survival and local disease free survival compared to historical controls. The toxicity of this schedule did not exceed that of radiation alone in historical controls.

Concurrent 5-fluorouracil, daily low-dose cisplatin, and radiotherapy in stage IIIB cervical cancer. A phase II prospective study

Between June 1987 and May 1991, 30 patients with Stage IIIB cervical cancers were treated using synchronous radiotherapy, 5-fluorouracil (5-FU), and daily low-dose cisplatin. External radiotherapy (3,600-3,960 cGy) was given to the whole pelvis in 4 weeks. Two courses of intracavitary brachytherapy were given 2 weeks later. Parametrial boost was then given. Continuous infusion of 5-FU 750 mg/m2 was given for 5 days during the first and third week of pelvic irradiation. Cisplatin (6 mg/m2) was given 30 min before every irradiation in the second and fourth week. The complete response rate was 87%. The 3-year local control rate was 77%. The 3-year overall and disease-free survival rate was 66% and 56%, respectively. Distant metastases were the major causes of treatment failure. Toxicities were acceptable. Our preliminary results indicate that this synchronous combination treatment is feasible. Further follow-up is required to determine whether this regimen has a genuine favorable impact on survival and chronic toxicity.

Neoadjuvant chemotherapy for locally advanced cervical cancer--where does it stand?: a review

Platinum-based combination chemotherapy has been utilized in the neoadjuvant setting in locally advanced inoperable cervical cancer with the aim of improving response and survival. Neoadjuvant chemotherapy can be followed by either radiation therapy (RT) or by surgery in cases in which it seems to be appropriate. Available data indicate that preradiation chemotherapy yields no survival advantage over RT alone. However, presurgery chemotherapy may increase resectability in women with locally advanced cervical cancer to around 70 percent. Nonrandomized trials of neoadjuvant chemotherapy followed by surgery have shown some improvement in the outcome. Prospective randomized trials are needed to evaluate this approach as compared with RT alone and to define its precise role in locally advanced cervical cancer.

Prospective phase I/II studies of definitive irradiation and chemotherapy for advanced gynecologic malignancies

PURPOSE

This is a prospective study to evaluate toxicity and efficacy of concurrent irradiation and three cycles of chemotherapy bolus cisplatin and infusion 5-fluorouracil (5FU) in patients with advanced gynecologic malignancies.

MATERIALS AND METHODS

Patients received cisplatin, 50 mg/m2 I.V. rapid infusion, and 5-day continuous infusion of 5FU (750 mg/m2 per day (schedule A); or cisplatin 75 mg/m2 i.v. rapid infusion, and 4-day continuous infusion of 5FU 1,000 mg/m2 per day (schedule B). Schedule A was given to 25 patients in the first 36 months of the study and was changed to schedule B in an additional 42 patients. All patients received irradiation, which usually consisted of 20 Gy whole pelvis, 30-40 Gy split field, and two intracavitary insertions for a total of 80-90 Gy to point A. Primary cervical cancer occurred in 40 patients with 3 having stage IB bulky, 2 with stage IIA, 5 with stage IIB, 2 with stage IIIA, 23 with stage IIIB, 4 with stage IV, and 1 with stage IVB. Recurrent cervical carcinoma after radical hysterectomy occurred in 18 patients. The remainder of the patients consisted of two each with stages III and IV endometrial carcinoma, two with stage III vaginal carcinoma, two with stage III vulvar carcinoma, and one with recurrent vulvar carcinoma. Patients were treated from 1985 through 1992.

RESULTS

The 5-year overall survivals for patients with stages IB (bulky)-IIB cervical cancer was 70%, 25% for stages IIIA-IVA, and 39% for patients with recurrent cervical carcinoma. All four patients with endometrial carcinoma have recurred and died. Two patients with vulvar carcinoma are alive and free of disease, and one is dead of intercurrent disease. One patient with stage III vaginal carcinoma is alive and free of disease, while the other recurred and died. No significant differences were observed in the toxicity of the two chemotherapy schedules. There were 9/39 (23%) grade 4 and one fatal complication in those with primary cervical carcinoma. The overall fistulae rate was 11% (4/39) with three patients developing rectovaginal fistulae and one having vesicovaginal fistula.

CONCLUSION

Concurrent chemotherapy and irradiation for advanced gynecologic malignancies as administered in this study is highly toxic and fails to demonstrate an obvious survival improvement.

Endometrial carcinoma. Influence of prognostic factors on radiation management

The earliest intracavitary radium treatment for uterine cancer was reported in 1908. Refinements reported during the next 20 years, using an intrauterine tube and colpostats or radium capsules, established a treatment philosophy of preoperatively irradiating uterine and parauterine tissues. Thus, preoperative intracavitary irradiation became entrenched as therapy for all endometrial cancers for the better part of four decades. In the 1950s and 1960s, the ability of external irradiation to eradicate cancer in regional lymphatic vessels prompted the use of pelvic field irradiation in Stage II and III and recurrent disease. The results of surgical exploratory studies in the 1970s established more refined criteria for preoperative or postoperative external pelvic irradiation in high-grade infiltrating Stage I cancers. In the 1980s, it became apparent that, for tumors with lymphovascular invasion, clear cell, and serous papillary histologic types, the disease spread to the upper abdomen and the paraaortic nodes might benefit from extended field and/or whole abdominal irradiation, with or without systemic bolus or concomitant continuous-infusion chemotherapy. In the 1980s, a subset of patients was identified with high-grade lymphovascular invasion clear cell and papillary serous histologic types or with positive peritoneal cytologic findings who were at high risk of failing in the paraaortic nodes and/or the upper abdomen for whom extended field or whole abdominal irradiation have been advocated. Given the fraction and dose limitation for a large abdominal field, the addition of systemic concomitant bolus or continuous infusion of chemotherapy currently is proposed to improve the control of intraabdominal failure in these high-risk patients.

New advances in radiation oncology for gynecologic cancer

In 1992, the American Cancer Society anticipates that there will be 1,130,000 new cases of invasive cancer diagnosed in the United States. About 66,500 will be invasive cancers of the cervix, uterus, and ovary. About 22,400 patients will die during 1992, with 50-60% of those deaths being due to persistent local regional disease. Data are available to suggest that a reduction in local failure will be reflected by an increase in survival free of disease. In 1992, major efforts are being made to reduce the incidence of local failure. Three areas in this regard are innovative uses of brachytherapy, intraarterial chemotherapy and radiation therapy, and continuous infusion chemotherapy and radiation therapy. These new techniques show significant reduction in local failure with associated improvement in survival. The data will be presented to illustrate the impact of these techniques.

A phase II trial of didemnin B (NSC No. 325319) in advanced and recurrent cervical carcinoma: a Gynecologic Oncology Group study

Didemnin B was administered to 24 women with recurrent squamous cell cervical carcinoma. The initial dose was 4.2 mg/m2, intravenously, repeated every 28 days. Twenty-three patients were evaluable for toxicity and twenty-one for response. Toxicity was mild, consisting mainly of nausea and vomiting. There were no objective responses; 43% had stable disease for at least 3 months. Didemnin B, when given in this dosage schedule, appears to have minimal effect against this tumor.

Distant metastases after irradiation alone in carcinoma of the uterine cervix

This is a retrospective analysis of 1211 patients with invasive carcinoma of the uterine cervix treated with irradiation alone from 1959 through 1986, of whom 322 developed distant metastases during the course of the disease. The 10-year actuarial incidence of distant metastases was 3% in Stage IA (34 patients), 16% in Stage IB (384 patients), 31% in Stage IIA (128 patients), 26% in Stage IIB (353 patients), 39% in Stage III (292 patients), and 75% in Stage IVA (20 patients). A multivariate analysis of factors influencing the incidence of distant metastases showed clinical stage, endometrial extension noted by dilatation and curettage (D&C) prior to therapy, and pelvic tumor control within each stage to be significant indicators of distant dissemination; histology, volume of disease, and age of patient were not significant. The frequency of metastases in all stages except IVA was greater when endometrial tumor extension was detected by D & C before to definitive irradiation (Stage IB, 28%; Stage IIA, 48%; Stage IIB, 42%; Stage III, 72%; and Stage IVA, 75%). In contrast, with normal D & C findings, the incidence of distant metastases was 15% in Stage IB, 29% in Stage IIA, 25% in Stage IIB, 45% in Stage III, and 84% in Stage IVA. The incidence of metastases in patients with pelvic tumor control was 11% in Stage IB, 22% in Stage IIA, 21% in Stage IIB, 34% in Stage III, and 50% in Stage IVA; in contrast, the corresponding incidence in patients failing in the pelvis was 76% in Stage IB, 88% in Stage IIA, 62% in Stage IIB, 87% in Stage III, and 74% in Stage IVA. The frequency of metastases per histology was comparable in squamous cell carcinoma and other histologic types. The incidence of metastases to other organs was 56%: Most frequent sites were lung, abdominal cavity, liver, and gastrointestinal tract. The incidence of clinically apparent lymph node involvement was 22%, predominantly to paraaortic, supraclavicular, and inguinal nodes. Bone metastases occurred in 16% of the patients, most commonly to the lumbar and thoracic spine. Despite aggressive local therapy with excellent local control, the incidence of distant metastases in patients with invasive carcinoma of the uterine cervix is high. The management of these patients and their response to salvage therapy are discussed. The need for effective adjuvant systemic therapy in the management of patients with invasive carcinoma of the cervix is also discussed.