Comparison of survival outcomes between radical hysterectomy and definitive radiochemotherapy in stage IB1 and IIA1 cervical cancer

Local treatment strategies in Stage IVB cervical squamous cell carcinoma and adenocarcinoma

OBJECTIVE

To evaluate the effect of different local treatment strategies on survival outcomes in patients with Stage IVB cervical squamous cell carcinoma (SCC) and adenocarcinoma.

METHODS

Patients diagnosed with Stage IVB cervical SCC and adenocarcinoma between 2004 and 2015 were included from the Surveillance, Epidemiology, and End Results (SEER) database. Subgroup analysis was performed in those diagnosed between 2010 and 2015 and available for the sites of distant metastases.

RESULTS

In total, 706 patients were identified in this study, including 378 (53.5%) and 328 (46.5%) diagnosed in 2004-2009 and 2010-2015, respectively. There were 525 (74.4%) and 181 (25.6%) patients with SCC and adenocarcinoma, respectively. Moreover, 274 (38.8%) and 432 (61.2%) patients received hysterectomy and primary radiotherapy, respectively. The results of the multivariate Cox regression analysis showed that histology and local treatment strategies were not related to cause-specific survival (CSS) and overall survival. In the SCC patients, patients who received primary radiotherapy had similar CSS (P = 0.312) and overall survival (P = 0.390) compared with those treated with surgery. In the adenocarcinoma patients, those who received primary radiotherapy had inferior CSS (P = 0.003) and overall survival (P < 0.001) compared with those treated with surgery. Similar results were found in those diagnosed 2004-2015 and 2010-2015 after propensity score matching.

CONCLUSIONS

For patients with Stage IVB cervical cancer who received local therapy, surgery, and primary radiotherapy had similar survival in cervical SCC, whereas surgery had better survival outcomes compared with primary radiotherapy in those with cervical adenocarcinoma.

A Diagnostic Nomogram Incorporating Prognostic Nutritional Index for Predicting Vaginal Invasion in Stage IB - IIA Cervical Cancer

INTRODUCTION

With the advancements in cancer prevention and diagnosis, the proportion of newly diagnosed early-stage cervical cancers has increased. Adjuvant therapies based on high-risk postoperative histopathological factors significantly increase the morbidity of treatment complications and seriously affect patients' quality of life.

OBJECTIVES

Our study aimed to establish a diagnostic nomogram for vaginal invasion (VI) among early-stage cervical cancer (CC) that can be used to reduce the occurrence of positive or close vaginal surgical margins.

METHODS

We assembled the medical data of early-stage CC patients between January 2013 and December 2021 from the Fujian Cancer Hospital. Data on demographics, laboratory tests, MRI features, physical examination (PE), and pathological outcomes were collected. Univariate and multivariate logistic regression analyses were employed to estimate the diagnostic variables for VI in the training set. Finally, the statistically significant factors were used to construct an integrated nomogram.

RESULTS

In this retrospective study, 540 CC patients were randomly divided into training and validation cohorts according to a 7:3 ratio. Multivariate logistic analyses showed that age [odds ratio (OR) = 2.41, 95% confidence interval (CI), 1.29-4.50, P = 0.006], prognostic nutritional index (OR = 0.18, 95% CI, 0.04-0.77, P = 0.021), histological type (OR = 0.28, 95% CI, 0.08-0.94, P = 0.039), and VI based on PE (OR = 3.12, 95% CI, 1.52-6.45, P = 0.002) were independent diagnostic factors of VI. The diagnostic nomogram had a robust ability to predict VI in the training [area under the receiver operating characteristic curve (AUC) = 0.76, 95% CI: 0.70-0.82] and validation (AUC = 0.70, 95% CI: 0.58-0.83) cohorts, and the calibration curves, decision curve analysis, and confusion matrix showed good prediction power.

CONCLUSION

Our diagnostic nomograms could help gynaecologists quantify individual preoperative VI risk, thereby optimizing treatment options, and minimizing the incidence of multimodality treatment-related complications and the economic burden.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Discussion on the Treatment Strategy for Stage ⅡA1 Cervical Cancer (FIGO 2018)

Objective

This study aimed to explore the best treatment strategy for International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IIA1 cervical cancer patients by comparing the survival outcomes of two treatment methods: abdominal radical hysterectomy (ARH) with standard postoperative therapy and radio-chemotherapy (R-CT).

Methods

Patients with FIGO2018 stage IIA1 cervical cancer who underwent ARH or received R-CT were screened from the clinical diagnosis and treatment for cervical cancer in China (Four C) database. The recurrence cases between the two groups were analyzed. The 5-year overall survival (OS) and disease-free survival (DFS) of patients diagnosed with stage IIA1 cervical cancer in 47 hospitals in mainland China between 2004 and 2018 were compared by using propensity score matching (PSM).

Results

A total of 724 patients met the inclusion criteria. In the total study population, The R-CT group had higher recurrence (22.8% for the R-CT group and 11.2% for the ARH group, P<0.001) rates compared to the ARH group.The 5-year OS and DFS of the ARH group (n=658) were significantly higher than those of the R-CT group (n=66) (OS: 85.9% vs. 71.2%, P=0.009; DFS: 79.2%vs. 70.5%, P=0.027). R-CT was associated with worse 5-year OS (HR=3.19, 95% CI: 1.592-6.956, P=0.001) and DFS (HR=2.089, 95% CI: 1.194-3.656, P=0.01). After 1:2 PSM, the 5-year OS and DFS of the ARH group (n=126) were significantly higher than those of the R-CT group (n=64) (OS:88.9% vs. 70.1%, P=0.04; DFS:82.8% vs. 69.8%, P=0.019). R-CT was still associated with worse 5-year OS (HR=2.391, 95% CI: 1.051-5.633, P=0.046) and DFS (HR=2.6, 95% CI: 1.25-5.409, P=0.011).

Conclusion

Our study demonstrated that for stage FIGO2018 stage IIA1 cervical cancer patients, ARH offers better oncological outcomes than R-CT.

Development and Validation of Novel Nomograms to Predict the Overall Survival and Cancer-Specific Survival of Cervical Cancer Patients With Lymph Node Metastasis

Objective

The objective of this study was to establish and validate novel individualized nomograms for predicting the overall survival (OS) and cancer-specific survival (CSS) in cervical cancer patients with lymph node metastasis.

Methods

A total of 2,956 cervical cancer patients diagnosed with lymph node metastasis (American Joint Committee on Cancer, AJCC N stage=N1) between 2000 and 2018 were included in this study. Univariate and multivariate Cox regression models were applied to identify independent prognostic predictors, and the nomograms were established to predict the OS and CSS. The concordance index (C-index), calibration curves, and receiver operating characteristic (ROC) curves were applied to estimate the precision and discriminability of the nomograms. Decision-curve analysis (DCA) was used to assess the clinical utility of the nomograms.

Results

Tumor size, log odds of positive lymph nodes (LODDS), radiotherapy, surgery, T stage, histology, and grade resulted as significant independent predictors both for OS and CSS. The C-index value of the prognostic nomogram for predicting OS was 0.788 (95% CI, 0.762–0.814) and 0.777 (95% CI, 0.758–0.796) in the training and validation cohorts, respectively. Meanwhile, the C-index value of the prognostic nomogram for predicting CSS was 0.792 (95% CI, 0.767–0.817) and 0.781 (95% CI, 0.764–0.798) in the training and validation cohorts, respectively. The calibration curves for the nomograms revealed gratifying consistency between predictions and actual observations for both 3- and 5-year OS and CSS. The 3- and 5-year area under the curves (AUCs) for the nomogram of OS and CSS ranged from 0.781 to 0.828. Finally, the DCA curves emerged as robust positive net benefits across a wide scale of threshold probabilities.

Conclusion

We have successfully constructed nomograms that could predict 3- and 5-year OS and CSS of cervical cancer patients with lymph node metastasis and may assist clinicians in decision-making and personalized treatment planning.

Optimal use of radiotherapy in the definitive treatment of non-bulky IB-IIA cervical cancer: A population-based long-term survival analysis

Purpose

Although current clinical guidelines recommend surgery or radiotherapy for non-bulky IB-IIA cervical cancer, clinical data supporting the curative role of radiotherapy in the early-stage disease are insufficient. We evaluated the prognostic implications of definitive radiotherapy and determined its optimal use in clinical practice.

Methods

Patients with non-bulky (<4 cm) IB-IIA cervical cancer who underwent hysterectomy or primary radiotherapy between 1988 and 2015 were identified from the Surveillance, Epidemiology, and End Results database. Based on the use of brachytherapy and/or chemotherapy, the primary radiotherapy group was classified into three cohorts: hysterectomy vs. radiotherapy overall, with/without brachytherapy and/or chemotherapy (cohort A); radiotherapy and brachytherapy with/without chemotherapy (patients with external beam radiation alone were excluded, cohort B); radiotherapy with brachytherapy and chemotherapy (patients who did not receive chemotherapy were additionally excluded, cohort C). Disease-specific survival (DSS) after hysterectomy was compared to that after primary radiotherapy in each cohort.

Results

Among the 9,391 initially identified patients, 1,762, 1,244, and 750 patients were classified into cohorts A, B, and C, respectively, after propensity score matching. In cohort A, DSS after primary radiotherapy was inferior to that after hysterectomy (P = 0.001). In cohort B, a trend toward differential survival in favor of hysterectomy was observed with marginal significance (P = 0.061). However, in cohort C, DSS after primary radiotherapy was not significantly different to that after hysterectomy (P = 0.127). According to hazard rate function plots, patients receiving external beam radiation alone had an increased short-term risk of disease-specific mortality, whereas patients without evidence of chemotherapy had a distinct late risk surge at approximately 15 years of follow-up.

Conclusion

Optimizing radiotherapy methods with brachytherapy and the use of chemotherapy should be considered for the long-term curative efficacy of primary radiotherapy for non-bulky IB-IIA cervical cancer. Further studies are warranted to corroborate our results.

Timelines to Cervical Cancer Diagnosis and Treatment at a Tertiary Hospital in Botswana

Purpose

To describe the timelines leading to presentation, diagnosis and definitive treatment among cervical cancer patients at a tertiary treatment center in Botswana.

Patients and Methods

This was a retrospective study that evaluated timelines to diagnosis and linkage to definitive treatment among cervical cancer patients in Botswana. Medical records of 149 patients admitted at Princess Marina Hospital (PMH) from 2012 to 2014 were reviewed from August 2016 to February 2017. Data collected included socio-demographics, stage of disease at presentation, symptom duration at presentation, diagnosis to definitive treatment interval and treatment outcomes on discharge. STATA 12 was used for data analysis. Frequencies and percentages were used to analyse and present the data. This paper is limited to the analysis of records with documented duration of symptoms, histology turnaround time and the diagnosis to treatment interval.

Results

The median duration of symptoms at presentation (N= 80) was 120 days (range 1–1290). Women who were HIV seropositive, of secondary level education or higher, below 50 years and those with cervical cancer screening history reported shorter duration of symptoms at presentation. Median histopathology turnaround time (N=123) was 27 days (range 3–274), median diagnosis to definitive chemoradiation interval (N=81) was 89 days (range 16–305) while median waiting time for surgery (N=7) was 60 days (range 29–279). Overall, the patients’ journey from the community to definitive treatment was about six months.

Conclusion

Delayed cervical cancer diagnosis and treatment is multifactorial and entails a complex interplay between patient health-seeking behavioural patterns, robustness of the patient referral and follow-up mechanisms, availability of prompt histopathology services and relay of results, and timely linkage to definitive care. Prioritization of strategies to address hurdles in all these aspects will not only reduce waiting times but also ensure timely management and improved outcomes among patients with cervical cancer.

Pelvic Insufficiency Fractures in Cervical Cancer After Radiation Therapy: A Meta-Analysis and Review

AIM

The aim of the study was to estimate the prevalence of pelvic insufficiency fractures (PIFs) after radiation therapy (RT) in patients with cervical cancer.

PATIENTS AND METHODS

A total of 3,633 patients from 15 cohort studies were included. Proportion meta-analysis was performed to estimate prevalence and subgroup analysis was performed according to imaging modalities for diagnosis of PIF. For continuous variables (age and length of follow-up), meta-regression analysis was performed.

RESULTS

Pooled prevalence estimate of PIF was 14% (95% CI=10-19). Incidence of PIF was higher in studies that used MRI as a diagnostic tool (17%, 95% CI=12-22) than non-MRI (8%, 95% CI=2-14). In meta-regression, we found a significant association of prevalence of PIF with age (p=0.021) but not with length of follow-up (p=0.118).

CONCLUSION

PIF after RT in patients with cervical cancer is not rare. Physicians need to pay attention to PIFs, especially in patients with high-risk factors for osteoporotic fracture.

Targeting HMGB3/hTERT axis for radioresistance in cervical cancer

BACKGROUND

Radiotherapy is regarded as a milestone for the cure of cervical cancer. However, clinical outcome heavily be hindered by radioresistance. So, exploring the underlying mechanism of radioresistance, and find potential target, well deserve fully emphasis.

METHODS

In this study, we developed two novel radiation resistance cervical cancer cell lines, which could mimic clinical radioresistance. In order to find new potential targets, RNA-Seq, database analysis, streptavidin-agarose and LC/MS were used. Pull-down, luciferase and rescue assays were conducted to explore the regulatory mechanisms. To further evaluate the correlation between therapeutic responses and HMGB3/hTERT expression, 172 cervical cancer patients were recruited.

RESULTS

Knockdown of HMGB3 significantly inhibit the DNA damage repair and induced more γH2AX foci, leading to enhanced chemo- and radio-sensitivity in vitro and in vivo, whereas HMGB3 overexpression has the opposite effects. HMGB3 promotes cell growth and radioresistance by transcriptionally up-regulating hTERT via the specifical binding of HMGB3 at the hTERT promoter region from - 902 to - 321. HMGB3 knockdown-mediated radiosensitization could be reversed by the overexpressed hTERT in both cervical cancer cell lines and xenograft tumor mouse model. Furthermore, clinical data from 172 cervical cancer patients proved that there was a positive correlation between HMGB3 and hTERT expression, and high expression of HMGB3/hTERT predicted poor response to radiotherapy, worse TNM stages and shorter survival time.

CONCLUSION

Here, we have identified HMGB3/hTERT signaling axis as a new target for cervical cancer radioresistance. Our results provide new insights into the mechanism of cervical cancer radioresistance and indicate that targeting the HMGB3/hTERT signaling axis may benefit cervical cancer patients.

Tailored radical hysterectomy for locally advanced cervical cancer

OBJECTIVE

The survival and prognostic factors for locally advanced cervical cancer treated with nerve-sparing Okabayashi-Kobayashi radical hysterectomy have not been elucidated. We aimed to evaluate the oncological outcomes of those patients after radical hysterectomy with adjuvant chemotherapy.

METHODS

This retrospective cohort study was conducted from January 2002 to December 2011. Treatment was conducted at a single tertiary center in northern Japan. We used the Okabayashi-Kobayashi radical hysterectomy with lymphadenectomy. We applied unilateral nerve preservation for stage IIA/IIB cancer if there was a one-sided extension of the disease outside the cervix. Indication for adjuvant therapy was based on Sedlis criteria. High-risk was defined as evidence of lymph node metastasis, pathological parametrial invasion, and a positive/close surgical margin. The choice of adjuvant therapy was chemotherapy which consisted of paclitaxel and cisplatin.

RESULTS

The study included 76 early-stage IB1 (≤4 cm) and IIA1 cervical cancer and 45 locally advanced stage IB2 (>4 cm), IIA2, and IIB disease treated consecutively. The median follow-up was 106 (range: 6-203) months. There were 18 (15%) patients with recurrence, with five of 76 in the early-stage (7%) and 13 of 45 in the locally advanced disease (29%) (P<0.001). For locally advanced cervical cancer, pT classification (P<0.001), lymph node metastasis (P=0.007), and histology (P=0.05) were associated with locoregional recurrence. The five-year locoregional recurrence rate in the locally advanced disease was 20% and 5% in the early-stage disease (P=0.01). The five-year disease-free survival in the locally advanced cervical cancer was 71% and 93% in the early-stage disease (P<0.001). The overall survival in locally advanced disease depended on the adeno-type histology and lymph node metastasis.

CONCLUSION

The tailored use of nerve-sparing Okabayashi-Kobayashi radical hysterectomy with adjuvant chemotherapy based on tumor histology and lymph node metastasis may be a possible option as a treatment of locally advanced cervical cancer in selected patients.

Comparison of survival outcomes between radio-chemotherapy and radical hysterectomy with postoperative standard therapy in patients with stage IB1 to IIA2 cervical cancer: long-term oncological outcome analysis in 37 Chinese hospitals

Background

This study aimed to compare the survival outcomes of radio-chemotherapy (R-CT) and radical hysterectomy with postoperative standard therapy (RH) in stage IB1-IIA2 cervical cancer patients.

Methods

Based on the large amount of diagnostic and treatment cervical cancer data in China, a real-world study and 1:1 case-control matching were used to compare overall survival (OS) and disease-free survival (DFS) in cervical cancer patients.

Results

In this real-world study, the 5-year OS and DFS in the R-CT group (n = 8949) were lower than those in the RH group (n = 18,152). After applying the inclusion criteria, the OS and DFS in the R-CT group (n = 582) were lower than those in the RH group (n = 4308). After 1:1 case-control matching, the 5-year OS and DFS in the R-CT group (n = 535) were lower than those in the RH group (n = 535) (OS: 76.1% vs. 84.6%, p < 0.001, HR = 1.819; DFS: 75.1% vs. 81.5%, p < 0.001, HR = 1.462, respectively). Further stratification showed that for stage IB1 and IIA1 patients, the 5-year OS and DFS in the R-CT group (n = 300) were lower than those in the RH group (n = 300) (OS: 78.9% vs. 87.0%, p < 0.001, HR = 2.160; DFS: 77.0% vs. 84.9%, p < 0.001, HR = 2.053, respectively). In stage IB2 and IIA2 patients, the 5-year OS in the R-CT group (n = 235) was lower than that in the RH group (n = 235) (72.5% vs. 81.5%, p = 0.039; HR = 1.550), but no difference in the 5-year DFS was found between the two groups (72.6% vs. 76.9%, p = 0.151).

Conclusions

Our study found that for stage IB1-IIA2 cervical cancer patients, RH offers better overall survival and disease-free survival outcomes than R-CT, however, due to the inherent biases of retrospective study, it needs to be confirmed by randomized trials. In addition, we need to further understand the quality of life of the two treatments.

Trial registration

registration number: CHiCTR1800017778; International Clinical Trials Registry Platform Search Port, http://apps.who.int/trialsearch/. registration date: August 14, 2018.

Maternal embryonic leucine zipper kinase: A novel biomarker and a potential therapeutic target of cervical cancer

Maternal embryo leucine zipper kinase (MELK) is highly expressed in a variety of malignant tumors and involved in cell cycle regulation, cell proliferation, apoptosis, tumor formation etc However, the biological effects of MELK in cervical cancer are still uninvestigated. This study aimed to explore the expression of MELK in cervical cancer, as well as its effects on the proliferation, apoptosis, DNA damage repair on cervical cancer cell line in vitro and to provide novel ideas for further improving the clinical efficacy of cervical cancer. Immunohistochemistry, Western blot, RT‐qPCR, CCK8, and immunofluorescence techniques were used to detect the expression of MELK in cervical cancer tissues, paracancerous tissues, and cervical cancer cell lines. Several cervical cancer cell lines were treated with MELK knockdown by siRNA and MELK selective inhibitor OTSSP167. The effects on proliferation, apoptosis, and colony formation capacity, and tumor cell DNA damage repair‐related factor were detected in cell lines. Our data showed that the high expression rate of MELK in cervical cancer patients was 56.92%. MELK expression in cervical cancer samples was significantly higher than that in paraneoplastic tissues. Highly expressed MELK correlated with the cervical histopathological grading and greatly increased with the cervical histopathological grading, from normal cervix and cervical intraepithelial neoplasia to cervical cancer. Moreover, the abnormal expression of MELK was related to cervical cancer metastasis at early stage. The knockdown of MELK with siRNA and OTSSP167 had strong inhibition effects on the proliferation, apoptosis, and colony formation of cervical cancer cells. MELK knockdown could also aggravate the DNA damage of cervical cancer cells possibly by homologous recombination repair pathway. Therefore, MELK may be a predicting marker of poor prognosis of cervical cancer and may also be a new therapeutic target for cervical cancer, providing ideas for improving the therapeutic effect of cervical cancer.