Chemoradiation and the Role of Adjuvant Chemotherapy in Lymph Nodal-Metastatic Cervical Cancer

Efficacy of treatment patterns based on concurrent chemoradiotherapy in patients with stage IIB cervical squamous cell carcinoma

PURPOSE

To assess survival of treatment patterns based on concurrent chemoradiotherapy (CCRT) in patients with stage IIB cervical squamous cell carcinoma (CSCC).

MATERIALS AND METHODS

Patients with stage IIB CSCC receiving CCRT were investigated from June 2012 to June 2019 in Guangxi Medical University Cancer Hospital. Baseline characteristics and treatment patterns were described. Survival between treatment patterns were compared using Kaplan-Meier methods.

RESULTS

A total of 232 patients were included: 39.7% of patients received CCRT alone, 6.5% of patients received neoadjuvant chemotherapy (NACT) + CCRT, 45.6% of patients received CCRT + adjuvant chemotherapy (AC), and 8.2% of patients received NACT + CCRT + AC. CCRT + AC showed similar overall survival (OS; hazard ratio [HR] = 0.95, 95% confidence interval [CI]: 0.41-2.17; P = 0.894) and locoregional-free survival (LRFS; HR = 2.39, 95% CI: 0.45-12.63; P = 0.303) compared with CCRT. However, CCRT + AC had a worse distant metastasis-free survival (DMFS; HR = 5.39, 95% CI: 1.14-25.57; P = 0.034). After propensity score matching, CCRT + AC had comparable OS (HR = 0.89, 95% CI: 0.29-2.70; P = 0.833), LRFS (HR = 3.26, 95% CI: 0.30-35.38; P = 0.331), and DMFS (HR = 4.80, 95% CI: 0.55-42.26; P = 0.157) compared to CCRT.

CONCLUSION

AC did not improve survival in patients with stage IIB CSCC receiving CCRT.

Concurrent chemoradiotherapy followed by adjuvant chemotherapy versus concurrent chemoradiotherapy alone in locally advanced cervical cancer: A systematic review and meta-analysis

Objective

This study aimed to assess the efficacy and safety of adjuvant chemotherapy (ACT) after concurrent chemoradiation (CCRT) in patients with locally advanced cervical cancer (LACC) via meta-analysis.

Methods

A systematic literature search of MEDLINE, PubMed, Web of Science, EMBASE, and the Cochrane Central Register of Controlled Trials was conducted from January 10, 1966 to May 20, 2022. Randomized controlled trials and observational studies comparing the CCRT alone with CCRT plus ACT were included. The literature search, quality assessment, and data extraction were conducted by two reviewers independently. The primary endpoints were 3-year rates of overall survival (OS) and progression-free survival (PFS). Complete response rate, local recurrence, distant metastasis, and adverse events were secondary outcomes. The hazard ratios (HRs) and relative risk (RR) were pooled.

Results

Nine studies with a total of 2732 patients were included in this meta-analysis, including 1411 patients in the CCRT group and 1321 in the CCRT plus ACT group. The HR for 3-year rates of OS and PFS of the CCRT group compared with the CCRT plus ACT group was 0.72 [95%confidence interval (CI) = 0.44-1.17] and 0.78 (95%CI = 0.5-1.75), respectively. No significant differences were observed between the two groups in the complete response rate (RR = 1.06, 95%CI = 0.96-1.16). However, local recurrence and distant metastasis were significantly lower in the CCRT plus ACT group than in the CCRT group (RR = 0.63, 95%CI = 0.44 -0.91 and RR = 0.64, 95%CI = 0.47-0.88). Grade 3-4 acute toxicities were more frequent in the CCRT plus ACT group (RR = 1.73, 95%CI =1.19-2.52).

Conclusion

Although associated with a decreased risk of local recurrence and distant metastasis, ACT did not significantly improve the survival rate and the complete response rate with increasing grade 3-4 acute toxicities in patients with LACC. Thus, this ACT regimen cannot be recommended for patients with LACC.

Systematic review registration

https://inplasy.com/inplasy-2022-9-0089/, identifier INPLASY202290089.

Integration of Consolidation Chemotherapy After Concurrent Chemoradiation in the Treatment of Locally Advanced Uterine Cervical Cancer

Background

Despite the current standard of concurrent chemoradiation (CCRT), around 30–40% are still dying from locally advanced cervical cancer. Increasing the radiation dose further was not a feasible option, but addition of chemotherapy further was tried due to the different toxicity profiles of it. So, the use of consolidation chemotherapy beyond CCRT has been studied.

Aim

To evaluate the efficacy, toxicity, tumour response and loco-regional control following consolidation chemotherapy after concurrent chemoradiation in locally advanced carcinoma cervix (LACC).

Methods

The patients were randomized into two arms: the conventional arm (control arm, n = 30) patients received conventional treatment with weekly injection cisplatin (35 mg/m²) concurrently with pelvic external beam radiation (50 Gy/25 fraction, 2 Gy/fraction, 5 fraction weekly) followed by intracavitary radiotherapy of 21 Gy in 3 fractions of 7 Gy each by HDR brachytherapy. In the interventional arm (study arm, n = 30), patients received the standard treatment followed by 3 cycles of consolidation chemotherapy (paclitaxel + carboplatin) every three weekly.

Results

Haematological toxicity (grade 3 anaemia and grade 1 leucopenia, grade 1 and 2 thrombocytopenia) was higher in the study group. Renal, hepatic and gastrointestinal toxicity was more in the study arm. Peripheral neuropathy was mostly seen in the study arm. Median follow-up was 9 months. Treatment response was better, and the rate of recurrence was less in the study arm.

Conclusion

Addition of few cycles of consolidation chemotherapy after standard treatment is beneficial in patients with LACC with manageable toxicity and good compliance.

Long-Term Toxicity and Efficacy of Intensity-Modulated Radiation Therapy in Cervical Cancers: Experience of a Cancer Hospital in Pakistan

PURPOSE

To report the chronic toxicity and disease outcomes attributable to intensity-modulated radiation therapy (IMRT) in patients with cervical cancer.

METHODS AND MATERIALS

Between January 2014 and December 2018, a retrospective review of medical records of patients with cervical cancer who received radiation therapy with IMRT was performed. Disease and treatment-related details were documented. Follow-up notes were reviewed, and severity of late toxicities was recorded. Overall survival (OS) and disease-free survival (DFS) at 3 years were estimated.

RESULTS

A total of 222 patients’ records were reviewed. Mean age was 50.7 years. Median follow-up duration was 33 months (range, 2-70 months). The most common toxicity was vaginal stricture (grade 2, n = 59, 26.6%; grade 3, n = 4, 1.80%), followed by proctitis (grade 2, n = 24; 10.8%; grade 3, n = 7; 3.20%). Seven patients (grade 2, n = 5, 2.3%; grade 3, n = 2; 0.90%) developed cystitis, and only 5 (grade 2; 2.3%) were found to have colitis. None of the patients had grade 4 or grade 5 toxicities. There was a significant difference in late complications in patients with nodal disease or those who underwent prior surgery (P < .05). Three-year OS and DFS rates were 79.7% and 81.9%, respectively. Patients with tumor size > 5 cm and those with pelvic lymph node metastasis had poor survival rates (P < .05).

CONCLUSION

IMRT is an effective and well-tolerated technique that should be considered in patients with lymph node disease and in postoperative patients. There is an inverse relationship between tumor size and nodal involvement with respect to OS and DFS.

Prognostic Nomograms Predicting Survival in Patients With Locally Advanced Cervical Squamous Cell Carcinoma: The First Nomogram Compared With Revised FIGO 2018 Staging System

Objectives

To develop nomograms to assess prognostic factors for 5-year overall survival (OS) and 5-year progression-free survival (PFS) in locally advanced cervical squamous cell carcinoma (LACSC).

Methods

Overall, 618 patients with LACSC were included in this retrospective analysis. Nomograms for 5-year OS and PFS were developed based on Cox proportional hazards regression models. Concordance index (C-index) and calibration curves were used to define the predictive and discriminatory capacity of the nomogram. A comparison between the nomogram and the International Federation of Gynecology and Obstetrics (FIGO) staging system was conducted using time-dependent receiver operating characteristic (tROC) and area under the curve (tAUC).

Results

Multivariate analysis identified several prognostic factors for OS including squamous cell carcinoma antigen (SCC-Ag), body mass index (BMI), tumor size, pelvic wall involvement, and para-aortic lymph node metastasis (PALNM). Prognostic factors for PFS included BMI, hemoglobin (HGB), tumor size, pelvic wall involvement, pelvic lymph node metastasis (PLNM) and PALNM. Following bootstrap correction, the C-index of OS and PFS was 0.713 and 0.686, respectively. These nomograms showed superior performance compared with the FIGO 2009 and 2018 staging schema.

Conclusions

Nomograms were developed to identify prognostic factors for 5-year OS and PFS in patients with LACSC. These nomograms showed good prognostication and are more comprehensive in predicting survival outcomes than existing staging criteria.