Nonsurgical management of cervical cancer: locally advanced, recurrent, and metastatic disease, survivorship, and beyond

The role of BATF2 deficiency in immune microenvironment rearrangement in cervical cancer - New biomarker benefiting from combination of radiotherapy and immunotherapy

Despite the significant progress in immunotherapy for certain cancers, including cervical cancer, most patients remain unresponsive or derive limited benefits from combined radiotherapy and chemotherapy. The factors underlying treatment resistance are unknown and there are few reliable predictive biomarkers. BATF2 is a member of the basic leucine zipper transcription factor family and is involved in immune response and immune cell development. However, the role of BATF2 in the immune microenvironment of patients with cervical cancer after radiotherapy remains unclear. In this study, immunohistochemistry and multicolour immunofluorescence analyses of patient tumor samples were used to assess BATF2 expression. We found that cervical cancer patients with high BATF2 expression had higher infiltration levels of CD4+ T cells, CD8+ T cells, and macrophages within the tumor than those with low expression levels. Furthermore, BATF2 expression was positively correlated with the prognosis of patients after concurrent chemoradiotherapy. A wild-type mouse model with BATF2-knockdown U14 cell-derived subcutaneous tumors and a Batf2-/- mouse model with wild-type U14 cell-derived subcutaneous tumors were used to assess CD8+ T cell infiltration and function. As expected, the knockdown of BATF2 in the U14 cell line substantially promoted tumor growth, which was mediated by a reduction in CD8+ T cell infiltration and antitumor function in vivo. Additionally, the Batf2-/- mouse model demonstrated that host BATF2 is also involved in controlling tumor growth. Furthermore, the combination of radiotherapy and anti-PD-1 therapy showed synergistic antitumour effects. These findings collectively suggest that BATF2 may serve as a potent positive regulator of the tumor immune microenvironment of cervical cancer after radiotherapy, and has the potential to be a prognostic biomarker to guide the application of a combination of radiotherapy and immunotherapy.

Stapled peptide PROTAC induced significantly greater anti-PD-L1 effects than inhibitor in human cervical cancer cells

Introduction

Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that target immune checkpoints that suppress immune cell activity. Low efficiency and high resistance are currently the main barriers to their clinical application. As a representative technology of targeted protein degradation, proteolysis-targeting chimeras (PROTACs) are considered to have potential for addressing these limitations.

Methods

We synthesized a stapled peptide-based PROTAC (SP-PROTAC) that specifically targeted palmitoyltransferase ZDHHC3 and resulted in the decrease of PD-L1 in human cervical cancer cell lines. Flow cytometry, confocal microscopy, protein immunoblotting, Cellular Thermal Shift Assay (CETSA), and MTT assay analyses were conducted to evaluate the effects of the designed peptide and verify its safety in human cells.

Results

In cervical cancer celllines C33A and HeLa, the stapled peptide strongly downregulated PD-L1 to < 50% of baseline level at 0.1 μM. DHHC3 expression decreased in both dosedependentand time-dependent manners. MG132, the proteasome inhibitor, can alleviate the SP-PROTAC mediated degradation of PD-L1 in human cancer cells. In a co-culture model of C33A and T cells, treatment with the peptide induced IFN-γ and TNF-α release in a dose-dependent manner by degrading PD-L1. These effects were more significant than that of the PD-L1 inhibitor, BMS-8.

Conclusions

Cells treated with 0.1 μM of SP-PROTAC or BMS-8 for 4 h revealed that the stapled peptide decreased PD-L1 more effectively than BMS-8. DHHC3-targeting SP-PROTAC decreased PD-L1 in human cervical cancer more effectively than the inhibitor BMS-8.

WASH regulates the oxidative stress Nrf2/ARE pathway to inhibit proliferation and promote apoptosis of HeLa cells under the action of Jolkinolide B

Jolkinolide B (JB), a diterpenoid compound isolated from the roots of Euphorbia fischeriana, has gained research attention for its antitumor effects. In recent years, JB reportedly displayed anti-tumor activity in solid tumors, such as breast, ovarian, and prostate cancer, and leukemia. In this study, we evaluated the effect of JB on HeLa cells with a focus on cell growth inhibition and related mechanisms. HeLa cells were cultured in vitro and divided into a blank control group, HeLa-Scramble (0, 0.25, 0.5 mM), and Wiskott-Aldrich syndrome protein and SCAR homolog (WASH) protein silenced group, HeLa-shWASH (0, 0.25, 0.5 mM). Morphological changes were observed using an inverted microscope. The inhibition rate of cell proliferation was detected using the WST-1 method. Flow cytometry Brdu+PI double standard method was used to detect cell replication ability and FITC+PI double standard method was used to detect cell apoptosis rate. Western blot was used to verify the expression of Nrf2, HO-1, WASH, Bax, Bcl-2, and PCNA. The mRNA expression of cytokines (IL-1α, IL-6, and IL-8) was detected using RT-qPCR. The results showed that JB induced cell apoptosis and arrested cells at the G2/M phase in HeLa-shWASH cells compared with HeLa-Scramble cells (P < 0.05, P < 0.01, respectively). In addition, JB upregulated IL-1α, IL-6, and IL-8 in HeLa-shWASH cells. We conclude that WASH protein participates in JB-induced regulation of the Nrf2/ARE pathway, aggravates inflammatory responses, and promotes cancer cell apoptosis, thus inhibiting the proliferation and invasion abilities of HeLa cells. JB may have anti-tumor effects and potential clinical value for the treatment of cervical cancer.

Combining Intravoxel Incoherent Motion Diffusion Weighted Imaging and Texture Analysis for a Nomogram to Predict Early Treatment Response to Concurrent Chemoradiotherapy in Cervical Cancer Patients

This study aimed to predict early treatment response to concurrent chemoradiotherapy (CCRT) by combining intravoxel incoherent motion diffusion weighted imaging (IVIM-DWI) with texture analysis (TA) for cervical cancer patients and to develop a nomogram for estimating the risk of residual tumor. Ninty-three cervical cancer patients underwent conventional MRI and IVIM-DWI before CCRT. We conducted TA using T2WI. The patients were allocated to partial response (PR) and complete response (CR) groups on the basis of posttreatment MRI. Multivariate logistic regression analysis on IVIM-DWI parameters and texture features was employed to filter the independent predictors and construct the predictive nomogram. Its discrimination and calibration performances were estimated. Multivariate analysis on the IVIM-DWI parameters showed that D and f were independent predictors (OR = 4.029 and 0.889, resp.; p < 0.05). However, the multivariate analysis on the texture features indicated that GLCM-correlation, GLRLM-LRE, and GLSZM-ZE were independent predictors (OR = 43.789, 9.774, and 23.738, resp.;p < 0.05). The combination of IVIM-DWI parameters and texture features exhibited the highest predictive performance (AUC = 0.975). The nomogram to identify the patients with high-risk residual tumors exhibited an acceptable predictive performance and stability with a C-index of 0.953. Decision curve analysis demonstrated the clinical use of the nomogram. The results demonstrate that D, f, GLCM-correlation, GLRLM-LRE, and GLSZM-ZE were independent predictors for cervical cancer. The nomogram combining IVIM-DWI parameters and texture features makes it possible to identify cervical cancer patients at a high risk of residual tumor after CCRT.

Radiomics in cervical and endometrial cancer

Radiomics is an emerging field of research that aims to find associations between quantitative information extracted from imaging examinations and clinical data to support the best clinical decision. In the last few years, some papers have been evaluating the role of radiomics in gynecological malignancies, mainly focusing on ovarian cancer. Nonetheless, cervical cancer is the most frequent gynecological malignancy in developing countries and endometrial cancer is the most common in western countries. The purpose of this narrative review is to give an overview of the latest published papers evaluating the role of radiomics in cervical and endometrial cancer, mostly evaluating association with tumor prognostic factors, with response to therapy and with prediction of recurrence and distant metastasis.

Cervical Cancer Immunotherapy: Facts and Hopes

It is a sad fact that despite being almost completely preventable through human papillomavirus (HPV) vaccination and screening, cervical cancer remains the fourth most common cancer to affect women worldwide. Persistent high-risk HPV (hrHPV) infection is the primary etiologic factor for cervical cancer. Upward of 70% of cases are driven by HPV types 16 and 18, with a dozen other hrHPVs associated with the remainder of cases. Current standard-of-care treatments include radiotherapy, chemotherapy, and/or surgical resection. However, they have significant side effects and limited efficacy against advanced disease. There are a few treatment options for recurrent or metastatic cases. Immunotherapy offers new hope, as demonstrated by the recent approval of programmed cell death protein 1-blocking antibody for recurrent or metastatic disease. This might be augmented by combination with antigen-specific immunotherapy approaches, such as vaccines or adoptive cell transfer, to enhance the host cellular immune response targeting HPV-positive cancer cells. As cervical cancer progresses, it can foster an immunosuppressive microenvironment and counteract host anticancer immunity. Thus, approaches to reverse suppressive immune environments and bolster effector T-cell functioning are likely to enhance the success of such cervical cancer immunotherapy. The success of nonspecific immunostimulants like imiquimod against genital warts also suggest the possibility of utilizing these immunotherapeutic strategies in cervical cancer prevention to treat precursor lesions (cervical intraepithelial neoplasia) and persistent hrHPV infections against which the licensed prophylactic HPV vaccines have no efficacy. Here, we review the progress and challenges in the development of immunotherapeutic approaches for the prevention and treatment of cervical cancer.

Urologic Complications Requiring Intervention Following High-dose Pelvic Radiation for Cervical Cancer

OBJECTIVE

To identify the incidence of radiation-induced urologic complication requiring procedural intervention following high-dose radiotherapy for cervical carcinoma, and to identify predictors of complication occurrence.

MATERIALS AND METHODS

We performed a retrospective chart review of cervical cancer patients undergoing radiotherapy with primary focus on procedural complications (Clavien-Dindo ≥ III). Clinical data were collected including radiation dose, procedure performed, timing of complication, and need for additional procedures. Univariate and multivariate logistic regression modeling was performed to assess predictive value of demographic and clinical variables.

RESULTS

A total of 126 patients with FIGO stage 1A2-4B cervical cancer were included in study analysis, with 18 patients experiencing procedural complication (14.3%). A total of 22 complications were identified, representing an average of 1.2 complications per patient with complication. The most common complications were ureteral stricture and radiation cystitis. The most common nononcologic procedures performed in the treatment of these complications were ureteral stenting, percutaneous nephrostomy tube placement, and cystoscopy. Notably, a total of 259 procedures were performed in the treatment of urologic complications, representing 14.4 procedures per patient and 24.6 procedures per patient with ureteral stricture. Logistic regression demonstrated active smoking at the time of diagnosis to be a predictor of procedural complication.

CONCLUSION

Radiotherapy in the treatment of cervical cancer is associated with a high rate of urologic procedural complication. These complications often require numerous procedures and long-term management given their complexity. These findings suggest a need for awareness and plans for multidisciplinary management of urologic complications in this patient population.

SIRT2 expression exhibits potential to serve as a biomarker for disease surveillance and prognosis in the management of cervical cancer patients

This study aimed to compare the sirtuin 2 (SIRT2) expression between tumor tissue and adjacent tissue, and to investigate the association of tumor SIRT2 expression with clinical characteristics and survival profiles in cervical cancer patients.One hundred ninety-one cervical cancer patients were reviewed in this retrospective study. All patients underwent surgical resection and had well-preserved tumor tissue and adjacent tissue, which were obtained for SIRT2 expression detection by immunohistochemistry (IHC). Clinical parameters were obtained. Disease free survival (DFS) and overall survival (OS) were calculated.Both SIRT2 expression by IHC score (P < .001) and the percentage of SIRT2 high expression (defined as IHC score >3) (P < .001) were declined in tumor tissue compared with paired adjacent tissue. In addition, SIRT2 expression in tumor tissue was negatively correlated with tumor size (P = .047), lymph node metastasis (P = .009) and FIGO stage (P = .001). And the DFS (P = .007) as well as OS (P = .008) were better in patients with SIRT2 high expression compared with patents with SIRT2 low expression. Univariate Cox's proportional hazards regression model analyses revealed that high SIRT2 expression in tumor tissue was a predictive factor for more prolonged DFS (P = .009) and OS (P = .011), while multivariate Cox's proportional hazards regression model analysis disclosed that it lacks independent predictive value for DFS (P = .084) or OS (P = .132).SIRT2 expression exhibits potential to serve as a biomarker for disease surveillance and prognosis in the management of cervical cancer patients.

MR guided high intensity focused ultrasound (MRgHIFU) for treating recurrent gynaecological tumours: a pilot feasibility study

OBJECTIVE

To assess the feasibility of targeting recurrent gynaecological tumours with MR guided high intensity focused ultrasound (MRgHIFU).

METHODS

20 patients with recurrent gynaecological tumours were prospectively scanned on a Philips/Profound 3 T Achieva MR/ Sonalleve HIFU system. Gross tumour volume (GTV) and planning target volume (PTV) were delineated on T 2W and diffusion-weighted imaging (DWI). Achievable treatment volumes that (i) assumed bowel and/or urogenital tract preparation could be used to reduce risk of damage to organs-at-risk (TVoptimal), or (ii) assumed no preparations were possible (TVno-prep) were compared with PTV on virtual treatment plans. Patients were considered treatable if TVoptimal ≥ 50 % PTV.

RESULTS

11/20 patients (55%) were treatable if preparation strategies were used: nine had central pelvic recurrences, two had tumours in metastatic locations. Treatable volume ranged from 3.4 to 90.3 ml, representing 70 ± 17 % of PTVs. Without preparation, 6/20 (30%) patients were treatable (four central recurrences, two metastatic lesions). Limiting factors were disease beyond reach of the HIFU transducer, and bone obstructing tumour access. DWI assisted tumour outlining, but differences from T 2W imaging in GTV size (16.9 ± 23.0%) and PTV location (3.8 ± 2.8 mm in phase-encode direction) limited its use for treatment planning.

CONCLUSIONS

Despite variation in size and location within the pelvis, ≥ 50 % of tumour volumes were considered targetable in 55 % patients while avoiding adjacent critical structures. A prospective treatment study will assess safety and symptom relief in a second patient cohort.

ADVANCES IN KNOWLEDGE

Target size, location and access make MRgHIFU a viable treatment modality for treating symptomatic recurrent gynaecological tumours within the pelvis.

Texture Analysis as Imaging Biomarker for recurrence in advanced cervical cancer treated with CCRT

This prospective study explored the application of texture features extracted from T2WI and apparent diffusion coefficient (ADC) maps in predicting recurrence of advanced cervical cancer patients treated with concurrent chemoradiotherapy (CCRT). We included 34 patients with advanced cervical cancer who underwent pelvic MR imaging before, during and after CCRT. Radiomic feature extraction was performed by using software at T2WI and ADC maps. The performance of texture parameters in predicting recurrence was evaluated. After a median follow-up of 31 months, eleven patients (32.4%) had recurrence. At four weeks after CCRT initiated, the most textural parameters (four T2 textural parameters and two ADC textural parameters) showed significant difference between the recurrence and nonrecurrence group (P values range, 0.002~0.046). Among them, RunLengthNonuniformity (RLN) from T2 and energy from ADC maps were the best selected predictors and together yield an AUC of 0.885. The support vector machine (SVM) classifier using ADC textural parameters performed best in predicting recurrence, while combining T2 textural parameters may add little value in prognosis. T2 and ADC textural parameters have potential as non-invasive imaging biomarkers in early predicting recurrence in advanced cervical cancer treated with CCRT.

(18F)-FDG PET/CT parameters to predict survival and recurrence in patients with locally advanced cervical cancer treated with chemoradiotherapy

PURPOSE

To identify predictive (¹⁸F)-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT)-based parameters for locoregional control, disease-free survival and overall survival, by testing different thresholds of metabolic tumor volume and total lesion glycolysis in patients with locally-advanced cervical cancer.

PATIENTS AND METHODS

Thirty-seven patients treated with standard chemoirradiation underwent a pretreatment (¹⁸F)-FDG-PET/CT. Using different thresholds of maximum standardized uptake value, the following PET parameters were computed: maximum standardized uptake value, mean standardized uptake value, metabolic tumor volume and total lesion glycolysis for primary tumor and lymph nodes and a new parameter combining the metabolic tumor volume and the distance between lymph nodes and the primary tumor, namely metabolic node distance. Correlation between PET and clinical parameters with clinical outcome (overall survival, disease-free survival, and locoregional control) was assessed using univariate and multivariate analyses (Cox model).

RESULTS

In univariate analyses, PET/CT parameters associated with overall survival and disease-free survival were: metabolic tumor volume and total lesion glycolysis of the primary tumor, total lesion glycolysis of lymph nodes and metabolic node distance. The most predictive threshold segmentation for metabolic tumor volume and total lesion glycolysis was 48% of maximum standardized uptake value for the primary tumor and 30% for the lymph nodes. In multivariate Cox analysis, the total lesion glycolysis of primary tumor 48% and metabolic node distance were the two independent risk factors for overall survival (P<0.01), disease-free survival (P<0.01) and locoregional control (P=0.046).

CONCLUSION

Total lesion glycolysis of primary tumor and distance between the invaded positive lymph node and the primary tumor seem to have the highest predictive value when compared to classical clinical prognostic parameters and may be useful to identify high risk groups at time of diagnosis and to tailor the therapeutic approach in locally-advanced cervical cancer.

[18F]-2-Fluoro-2-Deoxy-D-glucose-PET Assessment of Cervical Cancer

This article provides an overview of PET in cervical cancer, primarily with regard to the use of ¹⁸F-2-fluoro-2-deoxy-d-glucose-PET/computed tomography. A brief discussion of upcoming technologies, such as PET/MR imaging, is presented.

The clinical and prognostic value of CXCL8 in cervical carcinoma patients: immunohistochemical analysis

Cysteine-X-cysteine ligand 8 (CXCL8) was originally discovered as a proinflammatory chemokine. Recently, CXCL8 has been shown to act as an oncogene in several types of human cancers. However, the clinical and prognostic significance of CXCL8 in cervical cancer is poorly understood. In our study, we found that CXCL8 was highly expressed in cervical cancer tissues compared with normal cervical tissues in microarray datasets (GSE9750 and GSE7803). CXCL8 mRNA and protein expressions were increased in cervical cancer tissues and cell lines compared with normal cervical tissues and cervical epithelial cell lines. CXCL8 protein expression was significantly correlated with clinical stage, distant metastasis, histological type, and histological grade. CXCL8 high expression was a poor independent prognostic parameter for cervical cancer patients. In conclusion, CXCL8 is highly expressed in cervical cancer tissues and cell lines, and correlated with malignant status and prognosis in cervical cancer patients.

Glut-1 expression in small cervical biopsies is prognostic in cervical cancers treated with chemoradiation

BACKGROUND/PURPOSE

Chemoradiation (CRT) is standard therapy for locally advanced cervical cancer (LACC). However, there is a lack of biomarkers to identify patients at high relapse-risk. We examine metabolic (glucose transporter-1 [Glut-1]), hypoxic (hypoxia inducible factor [HIF-1α]; carbonic anhydrase [CA-9]) and proliferative (Ki-67) markers for prognostic utility in LACC.

MATERIALS/METHODS

60 LACC patients treated with CRT had pre-treatment biopsies. Immunohistochemistry was performed for Glut-1, HIF-1a and CA-9, to generate a histoscore from intensity and percentage staining; and Ki-67 scored by percentage of positive cells. For each biomarker, treatment response and survival was compared between low and high-staining groups by logrank testing and multivariate analyses.

RESULTS

High Glut-1 expression was associated with inferior progression-free survival (PFS), (hazard ratio [HR] 2.8, p = 0.049) and overall survival (OS), (HR 5.0, p = 0.011) on multifactor analysis adjusting for stage, node positivity, tumour volume and uterine corpus invasion. High Glut-1 correlated with increased risk of distant failure (HR 14.6, p = 0.001) but not local failure. Low Glut-1 was associated with higher complete metabolic response rate on post-therapy positron emission tomography scan (odds ratio 3.4, p = 0.048). Ki-67 was significantly associated with PFS only (HR 1.19 per 10 units increase, p = 0.033). Biomarkers for hypoxia were not associated with outcome.

CONCLUSIONS

High Glut-1 in LACC is associated with poor outcome post CRT. If prospectively validated, Glut-1 may help select patients for more intensive treatment regimens.