Neoadjuvant Chemoradiation Followed by Radical Hysterectomy in FIGO Stage IIIB Cervical Cancer: Feasibility, Complications, and Clinical Outcome

Locally Advanced Cervical Cancer: Neoadjuvant Treatment versus Standard Radio-Chemotherapy-An Updated Meta-Analysis

BACKGROUND

The treatment of choice for patients with locally advanced cervical cancer (LACC) is definitive concurrent radio chemotherapy which consists of external beam radiotherapy (EBRT) and concurrent platinum-based chemotherapy (CCRT), with the possible addition of brachytherapy (BT). However, the benefits of adjuvant surgery after neoadjuvant treatments remain a debated issue and a still open question in the literature. This meta-analysis aims to provide an updated view on the controversial topic, focusing on comparing surgery after any adjuvant treatment and standard treatment.

METHODS

Following the recommendations in the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement, the PubMed and Embase databases were systematically searched in April 2023 for early publications. No limitations on the country were applied. Only English articles were considered. The comparative studies containing data about disease-free survival (DFS) and/or overall survival (OS) were included in the meta-analysis.

RESULTS

The CCRT + surgery group showed a significantly better DFS than CCRT (RR 0.69 [95% CI 0.58-0.81] p < 0.01) and a better OS (RR 0.70 [95% CI 0.55-0.89] p < 0.01). Nine studies comparing neoadjuvant chemotherapy (NACT) plus surgery and CCRT were also enrolled. The NACT + surgery group showed a significantly better DFS than CCRT (RR 0.66 [95% CI 0.45-0.97] p < 0.01) and a better OS (RR 0.56 [95% CI 0.38-0.83] p < 0.01). In the sub-analysis of three randomized control trials, the surgery group documented a non-significantly better DFS and OS than CCRT (OR 1.10 [95% CI 0.67-1.80] p = 0.72; I2 = 69% p = 0.72; OR 1.09 [95% CI 0.63-1.91] p = 0.75; I2 = 13% p = 0.32).

CONCLUSION

The results provide updated findings about the efficacy of neoadjuvant treatments, indicating significantly improved DFS and OS in patients undergoing hysterectomy after CCRT or NACT compared with patients undergoing standard treatments.

Assessment of Salvage Surgery in Persistent Cervical Cancer after Definitive Radiochemotherapy: A Systematic Review

Background and Objectives: The standard treatment approach in locally advanced cervical cancer (LACC) is exclusive concurrent chemoradiation therapy (RTCT). The risk of local residual disease after six months from RTCT is about 20-30%. It is directly related to relapse risk and poor survival, such as in patients with recurrent cervical cancer. This systematic review aims to describe studies investigating salvage surgery's role in persistent/recurrent disease in LACC patients who underwent definitive RTCT. Materials and Methods: Studies were eligible for inclusion when patients had LACC with radiologically suspected or histologically confirmed residual disease after definitive RTCT, diagnosed with post-treatment radiological workup or biopsy. Information on complications after salvage surgery and survival outcomes had to be reported. The methodological quality of the articles was independently assessed by two researchers with the Newcastle-Ottawa scale. Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, we systematically searched the PubMed, Scopus, Cochrane, Medline, and Medscape databases in May 2022. We applied no language or geographical restrictions but considered only English studies. We included studies containing data about postoperative complications and survival outcomes. Results: Eleven studies fulfilled the inclusion criteria and all were retrospective observational studies. A total of 601 patients were analyzed concerning the salvage surgery in LACC patients for persistent/recurrent disease after RTCT treatment. Overall, 369 (61.4%) and 232 (38.6%) patients underwent a salvage hysterectomy (extrafascial or radical) and pelvic exenteration (anterior, posterior, or total), respectively. Four hundred and thirty-nine (73%) patients had histologically confirmed the residual disease in the salvage surgical specimen, and 109 patients had positive margins (overall range 0-43% of the patients). The risk of severe (grade ≥ 3) postoperative complications after salvage surgery is 29.8% (range 5-57.5%). After a median follow-up of 38 months, the overall RR was about 32% with an overall death rate of 40% after hysterectomy or pelvic exenteration with or without lymphadenectomy. Conclusions: There is heterogeneity between the studies both in their design and results, therefore the effect of salvage surgery on survival and recurrence cannot be adequately estimated. Future homogeneous studies with an appropriately selected population are needed to analyze the safety and efficacy of salvage hysterectomy or pelvic exenteration in patients with residual tumors after definitive RTCT.

Neoadjuvant chemotherapy with paclitaxel plus cisplatin before radical surgery for locally advanced cervical cancer during pregnancy: A case series and literature review

RATIONALE

Despite the development of human papillomavirus vaccines and significant improvement in cervical cancer screening over the past few years, cervical cancer remains the fourth most common cancer in women of childbearing age after breast cancer, melanoma, and thyroid cancer.

PATIENT CONCERNS

In this case report, the patients are all cervical cancer with stage IB2 and IB3 during pregnancy, the management constitutes a major medical challenge related to the impact of treatment on both maternal and fetal outcomes. Neoadjuvant chemotherapy (NACT) is an innovative option for cervical cancer patients with stage IB2 and IB3 before cesarean delivery and radical hysterectomy, and many chemotherapeutic agents are available, cisplatin plus paclitaxel yielded good maternal and fetal outcomes to the authors' knowledge.

DIAGNOSES

Masses were discovered in the cervix of 4 pregnant women with a history of vaginal bleeding. Biopsy examination of the masses revealed cervical carcinoma, which was staged in accordance with the International Federation of Gynecology and Obstetrics (i.e., FIGO) system.

INTERVENTIONS

The patients were treated with paclitaxel plus cisplatin, followed by cesarean delivery and radical hysterectomy.

OUTCOMES

The 4 patients were treated successfully, with no recurrence during follow-up periods of 14 to 56 months, and all of the children were doing well with no anomalies.

LESSONS

Although further data are required, in pregnant women with invasive cervical cancer, NACT with cisplatin plus paclitaxel followed by cesarean delivery and radical hysterectomy was a practical treatment option.

Chemoradiotherapy alone vs. chemoradiotherapy and hysterectomy for locally advanced cervical cancer: A systematic review and updated meta-analysis

The benefit of adjuvant hysterectomy after definitive concurrent chemoradiotherapy (CCRT) for locally-advanced cervical cancer (LACC) is controversial. The purpose of the present study was to systematically search the literature and perform a meta-analysis to compare overall survival (OS) and disease-free survival (DFS) between patients subjected to CCRT with hysterectomy and those who underwent CCRT alone. The PubMed, Scopus, Embase and Google scholar databases were searched. A meta-analysis to determine hazard ratios (HRs) and odds ratios (ORs) with meta-regression was performed for the following moderators: Disease stage, histology and proportion of radical hysterectomy. Data from 14 studies were included. The results indicated that patients who received CCRT with hysterectomy had significantly better OS (HR, 0.72; 95% CI, 0.56 to 0.91; I²=19%; P=0.007) and DFS (HR, 0.72; 95% CI, 0.56 to 0.93; I²=27%; P=0.01) than those treated with CCRT alone. However, in a subgroup analysis by study type, the results were significant only for retrospective studies but not for randomized controlled trials (RCTs). However, only 2 RCTs were included with small sample size, heterogeneity and low overall quality. Subgroup analyses based on the use of brachytherapy in the CCRT with hysterectomy group demonstrated no difference in OS and DFS between the two groups. Regarding the absolute numbers of death and recurrence events, no significant difference in mortality (OR, 0.91; 95% CI, 0.62 to 1.33; I²=0%; P=0.64) was determined between the two groups, but a significantly reduced incidence of recurrence was observed in the CCRT with hysterectomy group (OR, 0.61; 95% CI, 0.47-0.79; I²=29%; P=0.0002). The meta-regression results point to a significant influence of the proportion of stage II patients on OS. Despite the overall analysis indicating improved OS and DFS with the use of adjuvant hysterectomy after CCRT, subgroup analysis based on similar treatment protocols failed to demonstrate any significant benefit of hysterectomy in LACC. However, the results indicated that the recurrence rate may be higher in patients undergoing CCRT without hysterectomy. The limited quality of the studies included and selection bias from retrospective studies restrict the possibility to draw strong conclusions.

Efficacy of neoadjuvant platinum-based chemotherapy during the second and third trimester of pregnancy in women with cervical cancer: an updated systematic review and meta-analysis

Purpose

To evaluate the efficacy and safety of neoadjuvant platinum-based chemotherapy during pregnancy in women with cervical cancer.

Methods

The PubMed, Embase, and Cochrane Library databases were fully searched to find eligible studies regarding platinum use during pregnancy in women with cervical cancer from January 1980 to September 2018. Data were extracted from the selected studies independently by two authors. Descriptive statistics were calculated for categorical data (frequency and percentage) and numeration data (mean and SD for normally distributed data and median and range for abnormally distributed data). Survival analyses were performed using Kaplan–Meier survival curves and log-rank tests to estimate overall survival and progression-free survival for all patients.

Results

A total of 39 studies including 88 cervical cancer patients with platinum administration during pregnancy were selected in this meta-analysis, and 64 women provided International Federation of Gynecology and Obstetrics stage information. Among the latter, 56 of 64 (87.5%) were diagnosed with early stages (I and IIA) and the remaining 8 of 64 (12.5%) had advanced stages (IIB, III, and IV). In relation to cisplatin, 86 pregnant women were identified, whereas only 2 pregnant women with carboplatin application were retrieved. Overall, 88 newborns were delivered from 84 pregnancies, including two sets of twins and one set of triplets, among which 71 neonates (71 of 88, 80.7%) were completely healthy at birth. All children were healthy at the end of follow-up (median 17 months, range 0–149.5 months), except one who was diagnosed with retroperitoneal embryonal rhabdomyosarcoma at 5 years old and one who had acute myeloid leukemia at 22 months of age. At the end of follow-up (range 4.75–156 months), 16 of 81 (19.8%) patients were diagnosed with recurrence of cervical cancer, and 11 (90%) of those died because of cancer relapse. Neither median overall survival nor median progression-free survival were reached.

Conclusion

Our results demonstrated that neoadjuvant platinum-based chemotherapy could be a favorable choice for the management of patients with cervical cancer during the second and third trimesters. To reduce the side effects of chemotherapy, cisplatin might be good to use as monotherapy in these patients.

Locally Advanced Cervical Cancer in Pregnancy: Overcoming the Challenge. A Case Series and Review of the Literature

OBJECTIVE

Cervical cancer is the most common gynecological cancer occurring in pregnancy, creating a complex situation both for patient and physician. Neoadjuvant chemotherapy is an innovative way of managing cervical cancer in pregnancy.

METHODS

In our paper, we report a retrospective case series of 4 women treated with chemotherapy for invasive cervical cancer during pregnancy in our center over the last 5 years, and we summarize the available literature and guidelines.

RESULTS

All the cases were locally advanced cervical cancers that received chemotherapy with platinum and/or taxanes. All patients showed a good response to chemotherapy and a radical surgery was performed with no additional morbidities at the cesarean delivery time in 3 of 4 cases. Three of 4 patients are alive and have a good outcome with no recurrence of disease up to date. One patient died because of recurrent disease 2 years after the first-line treatment during pregnancy. All babies are alive and well up to date (maximum follow-up, 63 months).

CONCLUSIONS

Even if there are no standardized practices in the treatment of cervical cancer in pregnancy, in our opinion, neoadjuvant chemotherapy can be a very useful strategy for patients and physicians facing the challenge.

Multimodal treatment including hysterectomy improves survival in patients with locally advanced cervical cancer: A population-based, propensity score-matched analysis

BACKGROUND

To evaluate the therapeutic value of multimodal treatment including hysterectomy in locally advanced cervical squamous cell carcinoma (SCC).

METHODS

We retrospectively reviewed patients diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage IIB-III cervical SCC and received chemotherapy and radiotherapy with or without hysterectomy between 2000 and 2013 using the Surveillance, Epidemiology, and End Results program. Propensity score-matching was used to balance baseline characteristics of included patients. Univariate and multivariate Cox regression analyses were performed to determine prognostic factors for cervical cancer specific-survival (CCSS) and overall survival (OS).

RESULTS

We identified 2473 patients and 522 pairs of patients were completely matched with each other. In the unmatched population, patients with younger age, non-black race, poorly/undifferentiated disease, FIGO stage IIB disease, and node-positive disease were more likely to receive additional hysterectomy. Additional hysterectomy was associated with better CCSS and OS in unmatched and matched populations. Moreover, when evaluating the survival difference by FIGO stage, only stage IIB disease retained statistical significance but not for stage III disease in unmatched and matched populations.

CONCLUSIONS

Our results suggest that multimodal treatment including hysterectomy might improve survival outcomes in patients with locally advanced cervical SCC, especially for stage IIB disease.

Radical hysterectomy after chemoradiation in FIGO stage III cervical cancer patients versus chemoradiation and brachytherapy: Complications and 3-years survival

BACKGROUND

To compare patterns and rates of early and late complications, and survival outcome in FIGO stage III cervical cancer patients underwent to radical hysterectomy after chemo-radiation (CT-RT) vs. chemo-radiation alone.

METHODS

Between May 1996 and April 2013 150 FIGO stage III cervical cancer patients were treated. We divide patients according to type of treatment: 77 were submitted to standard treatment (Group A), and 73 to completion hysterectomy after chemo-radiation (Group B).

RESULTS

The baseline characteristics of the 2 groups were superimposable. We observed lower intra-operative and treatment-related early urinary and gastro-intestinal complications in Group B with respect to Group A (p < 0.001). Vascular complications were registered only in Group B (p < 0.001). We found a significantly higher rate of local recurrences in the Group A than in the Group B (p < 0.002). We registered 29 deaths in the Group A and 22 in the Group B (p = 0.021). The 3-years disease-free survival rate in the Group A and in the Group B was 62.9% and 68.3%, respectively (p = 0.686), and the 3-years overall survival rate in the Group A and in the Group B was 63.2% and 67.7%, respectively (p = 0.675).

CONCLUSIONS

This study confirms that radical hysterectomy after CT-RT is an effective therapeutic approach for advanced cervical cancer. Further prospective and randomized studies should be performed in order to solve the question about the standard approach, and how the different pattern of complication could impact on the quality of life.

Intraoperative radiation therapy (IORT) for gynecologic malignancies

Every year almost 95,000 women are diagnosed with a gynecologic malignancy and over 28,000 women will succumb to their disease. For patients with an isolated locoregional recurrence after primary therapy, surgical resection may sometimes provide a chance of cure. To optimize the chance of local control intraoperative radiation therapy (IORT) has been used. The combination of salvage surgery and IORT has resulted in reasonable control in the IORT field. The addition of external beam radiation to limited volumes seems to result in improved disease control over surgery and IORT alone. Side effects are closely related to radical surgery, although neuropathy is seen more frequently after IORT; especially if doses of >20Gy are prescribed. Margin status remains critical, even with IORT.

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.

Robotic radical hysterectomy following neoadjuvant chemotherapy in FIGO stage IIIB cervical cancer: a case report

BACKGROUND

The management of advanced cervical cancer is challenging. The administration of neoadjuvant chemotherapy (NACT) followed by radical hysterectomy has proved to be safe in selected cases. Nevertheless, data on the use of minimally invasive surgery is lacking with this clinical application.

METHODS

A 31 year-old woman was diagnosed with a FIGO stage IIIB squamous cell cervical carcinoma. During multidisciplinary consultation it was decided that she should receive NACT, followed by robotic hysterectomy.

RESULTS

After three cycles of TIP (paclitaxel, ifosfamide and cisplatin), the patient achieved a complete clinical and radiological response. She underwent robotic type III/C2 radical hysterectomy with bilateral salpingo-oophorectomy and bilateral systematic pelvic lymphadenectomy. No complications were recorded. The complete response was confirmed at pathological examination. Two additional cycles of adjuvant chemotherapy were administered, and the patient is currently without evidence of disease at 18 months of follow-up.

CONCLUSIONS

In selected patients, robotics is a viable option to accomplish radical hysterectomy, including cases of advanced cervical cancer. Further experiences are needed to confirm our findings.

Patterns of care in patients with cervical cancer 2012: results of a survey among German radiotherapy departments and out-patient health care centers

BACKGROUND

Platinum-based primary or adjuvant chemoradiation is the treatment of choice for patients with cervical cancer. However, despite national guidelines and international recommendations, many aspects in diagnosis, therapy, and follow-up of patients with cervical cancer are not based on valid data.

METHODS

To evaluate the current patterns of care for patients with cervical cancer in Germany, a questionnaire with 25 items was sent to 281 radiooncologic departments and out-patient health care centers.

RESULTS

The response rate was 51%. While 87% of institutions treat 0-25 patients/year, 12 % treat between 26 and 50 and only 1% treat more than 50 patients/year. In 2011, the stage distribution of 1,706 treated cervical cancers were IB1, IB2, IIA, IIB, IIIA/IIIB, and IV in 11, 12, 11, 22, 28, and 16%, respectively. CT (90%) and MRI (86%) are mainly used as staging procedures in contrast to PET-CT with 14%. Interestingly, 27% of institutions advocate surgical staging prior to chemoradiation. In the majority of departments 3D-based (70%) and intensity-modulated radiotherapy (76%) are used for percutaneous radiation, less frequently volumetric arc techniques (26%). Nearly all colleagues (99.3%) apply conventional fractioning of 1.8-2 Gy for external-beam radiotherapy, in 19% combined with a simultaneous integrated boost. Cisplatinum mono is used as a radiosensitizer with 40 mg/m(2) weekly by 90% of radiooncologists. For boost application in the primary treatment, HDR (high-dose rate) brachytherapy is the dominant technique (84%). In patients after radical hysterectomy pT1B1/1B2, node negative and resection in sound margins adjuvant chemoradiation is applied due to the occurrence of 1-4 other risk factors in 16-97%. There is a broad spectrum of recommended primary treatment strategies in stages IIB and IVA.

CONCLUSION

Results of the survey underline the leading role but also differences in the use of chemoradiation in the treatment of cervical cancer patients in Germany.

Aspects of Therapy for Cervical Cancer in Germany 2012 - Results from a Survey of German Gynaecological Hospitals

Introduction: In spite of the existence of guidelines and international recommendations, many aspects in the diagnosis, therapy and follow-up of patients with cervical cancer are not based on validated data. A broad spectrum of different opinions and procedures concerning the therapy for patients with cervical cancer is under controversial discussion by the responsible gynaecologists in German hospitals. Methods: The present study is intended to picture the current treatment situation for cervical cancer in Germany. For this purpose a specially developed questionnaire with questions divided into 19 subsections was sent to all 688 gynaecological hospitals in Germany. Results: The response rate to the questionnaire was 34 %. 91 % of the hospitals treated between 0 and 25 patients with cervical cancer per year. 7.5 % treated between 26 and 50 and 1.4 % of the hospitals more than 50 patients per year. The bimanual examination was the most frequently used staging method (98 %); PET-CT was the least used staging method (2.3 %). Interestingly 48 % of the hospitals used surgical staging. The great majority of the hospitals (71 %) used abdominal radical hysterectomy (Wertheim-Meigs operation) to treat their patients. TMMR via laparotomy was used by 13 %. 16 % of the hospitals performed laparoscopic or robot-assisted radical hysterectomies. The sentinel concept was hardly used even in the early stages. It must be emphasised that in 74 % of the hospitals radical hysterectomies were performed even in cases with positive pelvic lymph nodes and in 43 % also in cases with positive paraaortic lymph nodes. The therapy of choice for FIGO IIB cancers is primary radiochemotherapy (RCTX) in 21 % of the hospitals; operative staging followed by radiochemotherapy in 24 % and treatment by radical hysterectomy followed by adjuvant RCTX was employed in this situation by 46 % of the hospitals. In 15-97 % of the hospitals for node-negative and in sano resected patients in stage pT1B1/1B2 after radical hysterectomy, an adjuvant RCTX is recommended when further risk factors exist (LVSI, tumour > 4 cm, age < 40 years, adenocarcinoma, S3). Conclusion: A broad spectrum of differing staging and therapy concepts is in use for patients with cervical cancer in Germany. A standardisation of therapy is needed. An update of national guidelines could help to achieve more transparency and a standardisation of treatment for patients with cervical cancer.

Long-term analysis of clinical outcome and complications in locally advanced cervical cancer patients administered concomitant chemoradiation followed by radical surgery

OBJECTIVE

Preoperative chemoradiation (CT/RT) has been shown to achieve encouraging results in terms of clinical outcome in locally advanced cervical cancer (LACC). The study aims at analyzing the long-term results of this multimodal approach in a single institution series of 184 cases.

METHODS

Patients underwent whole pelvic irradiation combined with cisplatin and 5-fluorouracil. After evaluation of clinical response, patients were triaged to surgery. Surgical morbidity was classified according to Chassagne grading system. Univariate and multivariate analyses were used to assess the prognostic and predictive role of clinicopathological parameters.

RESULTS

Clinical response was observed in 96.1% of cases. A total of 174 cases were submitted to radical surgery: 124 patients (71.3%) showed complete/microscopic pathological response. In multivariate analysis, clinical response, stage of disease, and histotype predicted response to CT/RT. With a median follow-up of 58 months, recurrence and death of disease were observed in 42 and 40 patients, respectively. The 5-year DFS was 75.5%, while the 5-year OS was 77.4%. Patients with no residual disease showed a significant longer DFS than patients with microscopic (p value = 0.0128), and macroscopic (p value = 0.0001) residual tumor after treatment. In multivariate analysis, residual tumor and stage of disease were the two most relevant prognostic factors for DFS and OS. As far as long-term toxicity is concerned, 8 out of 22 complications were grade 3/4.

CONCLUSION

Preoperative CT/RT is worth further investigation in LACC patients, providing encouraging survival outcomes and a favourable long-term toxicity profile.