Management for locally advanced cervical cancer: new trends and controversial issues

Why Is Surgery Still Done after Concurrent Chemoradiotherapy in Locally Advanced Cervical Cancer in Romania?

The incidence and mortality of cervical cancer are high in Romania compared to other European countries, particularly for locally advanced cervical cancer cases, which are predominant at the time of diagnosis. Widely accepted therapeutic guidelines indicate that the treatment for locally advanced cervical cancer consists of concurrent chemoradiotherapy (total dose 85-90 Gy at point A), with surgery not being necessary as it does not lead to improved survival and results in significant additional morbidity. In Romania, the treatment for locally advanced cervical cancer differs, involving lower-dose chemoradiotherapy (total dose 60-65 Gy at point A), followed by surgery, which, under these circumstances, ensures better local control. In this regard, we attempted to evaluate the role and necessity of surgery in Romania, considering that in our study, residual lesions were found in 55.84% of cases on resected specimens, especially in cases with unfavorable histology (adenocarcinoma and adenosquamous carcinoma). This type of surgery was associated with significant morbidity (28.22%) in our study. The recurrence rate was 24.21% for operated-on patients compared to 62% for non-operated-on patients receiving suboptimal concurrent chemotherapy alone. In conclusion, in Romania, surgery will continue to play a predominant role until radiotherapy achieves the desired effectiveness for local control.

Phytochemicals in cervical cancer: an epigenetic overview

Cervical cancer is the fourth most common female malignancy worldwide and a complex disease that typically starts with HPV infection. Various genetic and epigenetic alterations are implicated in its development. The current cervical cancer therapies have unsatisfactory outcomes due to their serious adverse effects, necessitating the need for safe, effective preventive and therapeutic modalities. Phytochemicals have been addressed in cervical cancer prevention and treatment, and further understanding the epigenetics of cervical cancer pathogenesis is critical to investigate new preventive and therapeutic modalities. Addressing the epigenetic mechanisms of potential phytochemicals will provide an overview of their use individually or in combination. The primary aim of this review is to highlight the epigenetic effects of the phytochemicals addressed in cervical cancer therapy.

Dosimetric correlation of bone marrow irradiation with acute hematological toxicity in concurrent chemoradiation of cervical carcinoma patients

Background

Many acute toxicities are associated with concurrent chemoradiation in cervical carcinoma, which includes burning micturition, burning defecation, pain lower abdomen, increased frequency of stools along with Acute Hematological Toxicity (AHT). AHT is often an expected adverse effect, which can lead to treatment interruptions and decreased response rates. The purpose of this study is to analyze if there are any dosimetric constraints on the volume of bone marrow irradiated with AHT in cervical carcinoma patients treated with concurrent chemoradiation.

Material and Methods

In this retrospective study of 215 patients, a total of 180 patients were eligible for analysis. Multiple parameters of bone marrow volumes (whole pelvis bone marrow and its sub-volumes--ilium, lower pelvis, and lumbosacral spine) which were contoured individually for all patients were assessed to have any statistically significant association with AHT.

Results

The median age of the cohort was 57 years and majority of cases were locally advanced (stage IIB-IVA: 88.3%). Grade I, II, III leukopenia was seen in 44, 25, and 6 patients, respectively. A statistically significant correlation between grade 2+ and 3+ leukopenia was seen if bone marrow V10, V20, V30, and V40 were more than 95%, 82%, 62%, and 38%, respectively. In subvolume analysis, volumes of lumbosacral spine V20, V30, and V40 more than 95%, 90%, and 65%, respectively, were statistically significant for AHT.

Conclusion

Bone marrow volumes should also be given a constraint and should be tried to be achieved so that it leads to minimal treatment breaks due to AHT.

Effect of pre-operative radiation therapy on surgical outcome in retroperitoneal sarcoma

Background

A high rate of locoregional recurrence is one of the major difficulties in successful treatment of retroperitoneal sarcoma (RPS). Although pre-operative radiation therapy (RT) is considered a potential way to improve local recurrence, concerns about the associated treatment toxicity and risk of peri-operative complications need to be addressed. Hence, this study investigates the safety of pre-operative RT (preRTx) for RPS.

Methods

A cohort of 198 patients with RPS who had undergone both surgery and RT was analyzed for peri-operative complications. They were divided into three groups according to the RT scheme: (1) preRTx group, (2) post-operative RT without tissue expander, and (3) post-operative RT with tissue expander.

Results

The preRTx was overall well tolerated and did not affect the R2 resection rate, operative time, and severe post-operative complications. However, the preRTx group was associated with higher incidence of post-operative transfusion and admission to intensive care unit (p = 0.013 and p = 0.036, respectively), where preRTx was an independent risk factor only for the post-operative transfusion (p = 0.009) in multivariate analysis. The median radiation dose was the highest in preRTx group, although no significant difference was demonstrated in overall survival and local recurrence rate.

Conclusion

This study suggests that the preRTx does not add significant post-operative morbidity to the patients with RPS. In addition, radiation dose elevation is achievable with the pre-operative RT. However, a meticulous intra-operative bleeding control is recommended in those patients, and further high-quality trials are warranted to evaluate the long-term oncological outcomes.

Intratumoral injection of oncolytic virus (H101) in combination with concurrent chemoradiotherapy for locally advanced cervical cancer

OBJECTIVES

To evaluate the efficacy of primary tumor bulk reduction and the safety of concurrent chemoradiotherapy in combination with H101, a type of oncolytic virus, for the treatment of locally advanced cervical cancer.

METHODS

Patients diagnosed with stage IIB or III cervical cancer according to the International Federation of Gynecology and Obstetrics (FIGO 2009), with tumor length ≥6 cm, were enrolled at Zhejiang Cancer Hospital from July 2015 to April 2017. All patients received concurrent chemoradiotherapy in combination with intratumoral H101 injection before and during external beam radiotherapy. Outcomes included progression free survival, overall survival, tumor regression after external beam radiotherapy, and side effects.

RESULTS

A total of 23 patients were included in the safety analysis and, of these, 20 were included in the efficacy analysis. Median follow-up time was 38 (range 10-58) months. The 3 year local, regional, and overall progression free survival rates for the 20 patients were 95%, 95%, and 65%, respectively, and the 3 year overall survival rate was 74.3%. Median tumor length was reduced from 6.6 cm (range 6-7.3) before treatment to 4.1 cm (range 2.2-5.5) after external beam radiotherapy. Median tumor volume was reduced from 88.4 cm³ (range 41.2-126) before treatment to 20.8 cm³ (range 11.1-47.4) after external beam radiotherapy. Median percentage reduction of tumor length and volume were 37.7% and 75.1%, respectively. The major adverse event related to H101 was fever (91.3%).

CONCLUSION

H101 injection may enhance primary tumor regression for locally advanced cervical cancer, with an acceptable safety profile. This treatment regimen should undergo further prospective randomized controlled studies.ChiCTR-OPC-15006142.

Human papillomavirus infection, cervical cancer and the less explored role of trace elements

Cervical cancer is an aggressive type of cancer affecting women worldwide. Many affected individuals rely on smear tests for the diagnosis, surgery, chemotherapy, or radiation for their treatment. However, due to a broad set of undesired results and side-effects associated with the existing protocols, the search for better diagnostic and therapeutic interventions is a never-ending pursuit. In the purview, the bio-concentration of trace elements (copper, selenium, zinc, iron, arsenic, manganese, and cadmium) is seen to fluctuate during the occurrence of cervical cancer and its progression from pre-cancerous to metastatic nature. Thus, during the occurrence of cervical cancer, the detection of trace elements and their supplementation will prove to be highly advantageous in developing diagnostic tools and therapeutics, respectively. This review provides a detailed overview of cervical cancer, its encouragement by human papillomavirus infections, the mechanism of pathology, and resistance. Majorly, the review emphasizes the less explored role of trace elements, their contribution to the growth and inhibition of cervical cancer. Numerous clinical trials have been listed, thereby providing a comprehensive reference to the exploration of trace elements in the management of cervical cancer.

Recurrence risk stratification for locally advanced cervical cancer using multi-modality transformer network

Objectives

Recurrence risk evaluation is clinically significant for patients with locally advanced cervical cancer (LACC). We investigated the ability of transformer network in recurrence risk stratification of LACC based on computed tomography (CT) and magnetic resonance (MR) images.

Methods

A total of 104 patients with pathologically diagnosed LACC between July 2017 and December 2021 were enrolled in this study. All patients underwent CT and MR scanning, and their recurrence status was identified by the biopsy. We randomly divided patients into training cohort (48 cases, non-recurrence: recurrence = 37: 11), validation cohort (21 cases, non-recurrence: recurrence = 16: 5), and testing cohort (35 cases, non-recurrence: recurrence = 27: 8), upon which we extracted 1989, 882 and 315 patches for model's development, validation and evaluation, respectively. The transformer network consisted of three modality fusion modules to extract multi-modality and multi-scale information, and a fully-connected module to perform recurrence risk prediction. The model's prediction performance was assessed by six metrics, including the area under the receiver operating characteristic curve (AUC), accuracy, f1-score, sensitivity, specificity and precision. Univariate analysis with F-test and T-test were conducted for statistical analysis.

Results

The proposed transformer network is superior to conventional radiomics methods and other deep learning networks in both training, validation and testing cohorts. Particularly, in testing cohort, the transformer network achieved the highest AUC of 0.819 ± 0.038, while four conventional radiomics methods and two deep learning networks got the AUCs of 0.680 ± 0.050, 0.720 ± 0.068, 0.777 ± 0.048, 0.691 ± 0.103, 0.743 ± 0.022 and 0.733 ± 0.027, respectively.

Conclusions

The multi-modality transformer network showed promising performance in recurrence risk stratification of LACC and may be used as an effective tool to help clinicians make clinical decisions.

Prognostic values of the prognostic nutritional index, geriatric nutritional risk index, and systemic inflammatory indexes in patients with stage IIB-III cervical cancer receiving radiotherapy

Background

Growing evidence suggests that nutritional status and inflammation are associated with survival in various cancers. This study aimed to evaluate the prognostic value of the prognostic nutritional index (PNI), geriatric nutritional risk index (GNRI), and systemic inflammatory indexes (neutrophil/lymphocyte ratio [NLR], monocyte/lymphocyte ratio [MLR], and platelet/lymphocyte ratio [PLR]) in patients with stage IIB-III cervical cancer receiving radiotherapy.

Results

The ideal cutoff values for the PNI, GNRI, NLR, MLR, and PLR were 48.3, 97.04, 2.8, 0.41, and 186.67, respectively. Low PNI and GNRI scores were associated with poor OS and PFS. High NLR, MLR, and PLR also predicted inferior 5-year OS and PFS rates in patients with stage IIB-III cervical cancer. Multivariate Cox regression analysis identified tumor size, histological type, stage, number of metastatic lymph nodes, PNI, GNRI, NLR, PLR, and MLR as significant prognostic factors for OS and PFS.

Conclusions

The current findings suggest that the PNI, GNRI, NLR, PLR, and MLR are essential parameters for predicting prognosis in patients with stage IIB-III cervical cancer receiving radiotherapy.

Financial Toxicities Persist for Cancer Survivors Irrespective of Current Cancer Status: An Analysis of Medical Expenditure Panel Survey

This study estimates the out-of-pocket (OOP) expenditures for different cancer types among survivors with current vs no current cancer condition and across sex, which is understudied in the literature. This is a cross-sectional study of Medical Expenditure Panel Survey data for 2009-2018 where the primary outcome was the average per year OOP expenditure incurred by cancer survivors. Of 189 285 respondents, 15 010 (7.93%) were cancer survivors; among them, 46.28% had a current cancer condition. Average per year OOP expenditure for female survivors with a current condition of breast cancer ($1730), lung cancer ($1679), colon cancer ($1595), melanoma ($1783), non-Hodgkin lymphoma ($1656), nonmelanoma/other skin cancer (NMSC, $2118) and two or more cancers ($2310) were significantly higher than that of women with no history of cancer ($853, all P < .05). Similarly, average per year OOP expenditure for male survivors with a current condition of prostate cancer ($1457), lung cancer ($1131), colon cancer ($1471), melanoma ($1474), non-Hodgkin's lymphoma ($1653), NMSC ($1789), and bladder cancer ($2157) were significantly higher compared with the men with no history of cancer ($621, all P < .05). These differences persisted in survivors with no current cancer condition for breast cancer among women; prostate, lung, colon, and bladder cancer among men; and melanoma, NMSC, and two or more cancers among both sexes. OOP expenditure varied across cancer types and by sex for survivors with and without a current cancer condition. These findings highlight the need for targeted interventions for cancer survivors.

Indian Data on the Response of Positive Pelvic Lymph Nodes in Carcinoma Cervix Patients Treated with Simultaneous Integrated Boost Using Volumetric Modulated Arc Radiation Therapy

Background The percentage of pelvic lymph node (LN) positivity in cervical cancer patients varies from 19% in early stages to 68% in advanced cases. Thirty-three percent of patients will develop recurrence within 2 years following therapy, and 5-year relative survival for patients with affected regional LNs is 57%. Hence, pelvic LNs need to be included in the definitive plan of radiation treatment for better disease control and longer survival. With conventional radiation therapy, dose escalation was not possible because of small bowel constraints. With higher conformity of intensity-modulated radiotherapy technique, doses to pelvic and abdominal organs can be minimized. The added advantage of simultaneous integrated boost (SIB) is that high dose per fraction is delivered to the gross disease and low dose to the microscopic disease, thereby reducing the total treatment time and improving the therapeutic ratio.

Materials and Methods Forty-one patients presenting to the Department of Radiation Oncology, between January 2016 and June 2017, with newly biopsy-proven carcinoma cervix Stage IB to IVA were enrolled in the study, and all the investigations were performed. The radiation dose was delivered using volumetric modulated arc therapy plan according to the dose of 5,000 cGy in 25 fractions to the whole pelvis and 5,500 cGy in 25 fractions to the involved nodes at 220 cGy per fraction using SIB along with weekly cisplatin at 40 mg/m2. After completion of external beam radiation, all the patients received three fractions of brachytherapy to a total dose of 21 Gy. Acute toxicities were assessed using Radiation Therapy Oncology Group criteria. At 3 months after completion of treatment, all the patients were followed up with diffusion-weighted magnetic resonance imaging of abdomen and pelvis to assess the response after 3 months.

Results Of 41 carcinoma cervix patients with significantly positive LNs treated with SIB VMAT, 9.8% of the patients (4 patients) had residual nodal disease and 87.8% of the patients (36 patients) had a complete response, and 19.5% (8 patients) had residual disease of primary and 78% (32 patients) had a complete response at 3 months after completion of treatment with only grade I and grade II toxicities.

Conclusion Treatment with SIB VMAT in carcinoma cervix patients with significant pelvic LNs shows a very good response with acceptable acute toxicities. But longer follow-up period is required to see if this response translates into better disease-free survival and overall survival.

Analysis of Treatment Outcomes and Prognosis After Concurrent Chemoradiotherapy for Locally Advanced Cervical Cancer

The aims of this study were to investigate the short-term and long-term efficacies and chronic radiotoxicity of concurrent chemoradiotherapy (CCRT) combined with image-guided adaptive brachytherapy (IGABT) in patients with locally advanced cervical cancer (LACC) and identify prognostic factors in this patient population. The clinical data of 204 patients with cervical cancer who completed CCRT and subsequent brachytherapy in our hospital between February 2015 and March 2017 were retrospectively analyzed. Short-term and long-term outcomes, chronic radiotoxicity, and prognostic factors were assessed. The median follow-up was 61.1 months. The short-term objective response (OR) rate was 85%. Lymph node metastasis before treatment was an independent predictor of OR (HR = 6.290, 95% CI: 2.211-17.897, p = 0.001). Fifty-two patients developed recurrence, with a median recurrence-free survival of 9.9 months (range, 2.4-52.2 months) and a post-recurrence survival of 12.1 months (range, 2.9-58.1 months). At 3 years, the cumulative incidence of overall recurrence was 26% (95% CI: 17-36). Multivariate analysis showed that Stage IIIB (HR = 2.332, 95% CI: 1.195-4.551, p = 0.013; reference, Stage IIB) and lymph node metastasis (HR = 4.462, 95% CI: 2.365-8.419, p < 0.001) were significant independent predictors of recurrence. Fifty-three patients developed chronic radiation proctitis (CRP). The incidence of severe CRP was approximately 5%, and the average rectal D2cm3 accumulation in patients with severe CRP was 73.4 Gy which is 3.9 Gy higher than that in patients without CRP (p = 0.013). At 4 years, the overall survival (OS) and disease-free survival rates were 65% and 62%, respectively, and lymph node metastasis before treatment was an independent prognostic risk factor for OS. The short-term and long-term efficacies of CCRT combined with IGABT for the treatment of LACC patients were relatively satisfactory. However, the short-term and long-term efficacies of patients with lymph node metastasis before treatment were poor. For patients with lymph node metastasis before treatment, more active individualized treatment strategies should be adopted. When designing a radiotherapy plan, it is necessary to strictly limit the rectal D2cm3 accumulation to prevent serious CRP.

Is the pathologic tumor size associated with survival in early cervical cancer treated with radical hysterectomy and adjuvant radiotherapy?

OBJECTIVE

In 2018 International Federation of Gynecology and Obstetrics (FIGO) staging system of uterine cervix cancer, size criteria of primary tumor has been revised. This study aimed to evaluate the validity of this new size criteria (<2, 2-4, and ≧4 cm) in patients who underwent radical hysterectomy and adjuvant radiation therapy (RT) for early cervical cancer.

MATERIALS AND METHODS

We retrospectively examined 312 patients who underwent radical hysterectomy and adjuvant RT for early cervical cancer (IB-IIA) from 2001 to 2014. The effects of clinical and pathological factors on disease-free survival (DFS) and overall survival (OS) were evaluated in univariate and multivariate analyses.

RESULTS

After a median follow-up of 71.5 months, the 5-year DFS and OS rates were 89.5% and 94.7%, respectively. The primary tumor size was not a significant factor for DFS (p = 0.382) or OS (p = 0.725) in all patients.

CONCLUSION

Primary tumor size was not a significant factor for survival in patients who received hysterectomy and adjuvant RT for early cervical cancer. Adequacy of new tumor size criteria (<2, 2-4, and ≧4 cm) in new 2018 FIGO stage needs to be validated in further studies.

Clinical outcomes after positron emission tomography/computed tomography-based image-guided brachytherapy for cervical cancer

INTRODUCTION

Although positron-emission tomography (PET) plays an integral role in cervix cancer diagnosis, there are limited data on PET-based image-guided brachytherapy (IGBT). We aimed to report the long-term outcomes of PET-based IGBT.

METHODS

We reviewed 151 patients treated with definitive radiotherapy (RT), including PET-based IGBT between 2009 and 2018. After median 45 Gy of external beam RT with the four-field technique, a median 24 Gy of high-dose-rate iridium-192 IGBT was delivered in six fractions with Fletcher-Suit tandem and ovoids. All patients underwent 18F-fluorodeoxyglucose-PET/computed tomography planning with a brachytherapy applicator. Multivariable analysis of local control (LC) was performed using Cox regression analysis.

RESULTS

The median high-risk clinical target volume (HRCTV) and HRCTV D90% were 51.8 (interquartile range [IQR] 35.9-79.4) cm³ and 77.7 (IQR 74.7-81.2) Gy, respectively. With a median follow-up of 57 (IQR 24.3-81.4) months, the 5-year LC rate was 89.2%. HRCTV ≥72 cm³ was associated with inferior LC (hazard ratio, 3.72, p = .017) after multivariable analysis: the 5-year LC rates were 94.0% and 77.9% for HRCTVs ≥72 and < 72 cm³ , respectively (p = .002). The impact of HRCTV D_90% ≥70 Gy on LC was significant in patients with an HRCTV ≥72 cm³ compared to that in those with HRCTV < 72 cm³ . Patients with adeno/adenosquamous carcinoma demonstrated inferior LC in both groups. There were 13 (8.6%) and 11 (7.3%) patients with acute and late severe toxicities after RT.

CONCLUSION

PET-based IGBT leads to favorable LC, and HRCTV ≥72 cm³ requires further dose escalation to improve outcomes.

Pretreatment Immune Status, Predicts Response to Definite Chemo Radiotherapy in Advanced Stages of Cervical Cancer Patients

Objective

To evaluate the prognostic role of pretreatment CD4 + , CD8 + T lymphocytes in predicting response to definite chemo radiotherapy in advanced cervical cancer. Design: A hospital-based prospective one-year follow-up study.

Method

This observational study was conducted on 74 patients with advanced cervical cancer. Pretreatment CD4 + and CD8 + levels in cervical cancer tissue and peripheral blood was noted and quantitatively assessed in patients with complete remission or persistent disease after one year of follow-up.

Results

There was a statistically significant association of tumour volume with the remission or persistence of disease. In peripheral blood, mean CD4 + score and CD4 + /CD8 + ratio were significantly higher while mean CD8 + score is significantly lower in patients with remission. Similar results were seen in tumour tissue as well. On Receiver Operating Curve analysis, the cut-off value of CD4 + , CD8 + and CD4 + /CD8 + ratio in predicting remission or persistent disease in peripheral blood was 20.09, 18.51 and 0.41 while in tumor tissue was 19.71, 20.99 and 0.20, respectively.

Conclusion

The patients with tumor volume < 100 cm 2 have much higher chances of remission. The patients with higher CD4 + and CD4 + / CD8 + ratio, both in peripheral blood as well as tumor tissue, have higher chances of remission. The cut-off value of CD4 + , CD8 + and CD4 + /CD8 + ratio in predicting remission or persistent disease in peripheral blood was 20.09, 18.51 and 0.41 while in tumor tissue was 19.71, 20.99 and 0.20, respectively.

The value of metabolic parameters and textural analysis in predicting prognosis in locally advanced cervical cancer treated with chemoradiotherapy

Objective

The aim of the study was to assess the impact of clinical and metabolic parameters derived from ¹⁸F-FDG PET/CT (positron emission tomography–computed tomography) in patients with locally advanced cervical cancer (LACC) on prognosis.

Methods

Patients with LACC of stage IB2-IVA treated by primary radiochemotherapy followed by brachytherapy were enrolled in this retrospective study. Indexes derived from standardized uptake value (SUV), metabolic tumor volume (MTV), total lesion glycolysis (TLG), and textural features of the primary tumor were measured for each patient. Overall survival (OS) and recurrence-free survival (RFS) rates were calculated according to Kaplan–Meier and survival curves were compared using the log-rank test. Uni- and multivariate analyses were performed using the Cox regression model.

Results

A total of 116 patients were included. Median follow-up was 58 months (range: 1–129). A total of 36 (31%) patients died. Five-year OS and RFS rates were 69 and 60%, respectively. Univariate analyses indicated that FIGO stage, the presence of hydronephrosis, high CYFRA 21.1 levels, and textural features had a significant impact on OS and RFS. MTV as well as SCC-Ag concentration were also significantly associated with OS. On multivariate analysis, the presence of hydronephrosis, CYFRA 21.1, and sphericity were independent prognostics factors for OS and RFS. Also, SCC-Ag level, MTV, and GLZLM (gray-level zone length matrix) ZLNU (zone length non-uniformity) were significantly associated with OS.

Conclusion

Classical prognostic factors and tumor heterogeneity on pretreatment PET/CT were significantly associated with prognosis in patients with LACC.

GAGE mediates radio resistance in cervical cancers via the regulation of chromatin accessibility

Radiotherapy (RT) resistance is a major cause of treatment failure in cancers that use definitive RT as their primary treatment modality. This study identifies the cancer/testis (CT) antigen G antigen (GAGE) as a mediator of radio resistance in cervical cancers. Elevated GAGE expression positively associates with de novo RT resistance in clinical samples. GAGE, specifically the GAGE12 protein variant, confers RT resistance through synemin-dependent chromatin localization, promoting the association of histone deacetylase 1/2 (HDAC1/2) to its inhibitor actin. This cumulates to elevated histone 3 lysine 56 acetylation (H3K56Ac) levels, increased chromatin accessibility, and improved DNA repair efficiency. Molecular or pharmacological disruption of the GAGE-associated complex restores radiosensitivity. Molecularly, this study demonstrates the role of GAGE in the regulation of chromatin dynamics. Clinically, this study puts forward the utility of GAGE as a pre-screening biomarker to identify poor responders at initial diagnosis and the therapeutic potential of agents that target GAGE and its associated complex in combination with radiotherapy to improve outcomes.

Adjuvant radiotherapy for cervical cancer in South Korea: a radiation oncology survey of the Korean Radiation Oncology Group (KROG 20-06)

OBJECTIVE

Radiation therapy plays an important role in adjuvant treatment for surgically treated cervical cancer with adverse pathological findings. This was the first study to evaluate current practices of adjuvant radiation therapy among centres affiliated with the Korean Radiation Oncology Group.

METHODS

A survey containing specific questions on the demographics in 2019, indications of adjuvant treatment, radiation therapy field, prescription radiation therapy dose, boost radiation therapy and chemotherapy was sent out by e-mail to 93 centres.

RESULTS

The overall response rate was 62.4%. Regarding radiation therapy techniques, intensity-modulated radiation therapy was adopted in most institutions (41/58, 70.7%). Various risk group criteria were selected for adjuvant radiation therapy and concurrent chemoradiation therapy. One or two risk factors among tumour size, depth of invasion and lymphovascular invasion were considered for adjuvant radiation therapy by 20.7 and 60.3% of the respondents, respectively. The following criteria for concurrent chemoradiation therapy were considered by 60.3% of the respondents: parametrial extension, positive resection margin or lymph node metastasis. Various upper borders were preferred for pelvic radiation therapy by the institutions, and a total dose of 50.4 Gy in 28 fractions was the most prescribed dose scheme (37/58, 63.8%). Lymph node bed boost radiation therapy and vaginal cuff brachytherapy were considered for selected patients by 22.4% (13/58) and 60.3% (35/58) of the institutions.

CONCLUSION

This survey demonstrated the practice patterns of adjuvant treatment that are prevalent in the field of radiation oncology among members of the Korean Radiation Oncology Group. These findings warrant further consensus on radiation therapy guidelines in the context of adjuvant treatment for cervical cancer.

Reproducibility of vaginal immobilization balloons in situ overnight for cervical cancer brachytherapy

Purpose

The use of vaginal immobilization balloons placed into the vagina for immobilization of tandem and ovoid (T+O) applicator during high-dose-rate (HDR) brachytherapy delivery has been used at our institution, and seems to have improved our patient comfort, decreased procedure time, and minimized applicator misplacement. We aimed to show that these balloons, while originally marketed for single-day use, are safe and maintain applicator positioning/dosimetry when left in situ overnight for treatment delivery on sequential days.

Material and methods

Forty-two paired computed tomography (CT) scans from thirteen patients who underwent T+O HDR treatments on sequential days with vaginal immobilization balloons in situ overnight were retrospectively compared to calculate mean change of balloon volumes and balloon/T+O distance to bony landmarks. Dosimetric planning was retroactively performed on day 2 using CT scan of each pair, and the change in estimated radiation delivery to the bladder and rectum was compared.

Results

No statistically significant overnight changes were found in balloon volumes or anterior balloon positioning. The posterior balloon shifted -0.29 ±0.46 cm (p = 0.03) to the anterior public symphysis and 0.32 ±0.50 cm (p = 0.01) to the right femoral head. The tandem shifted 0.37 ±0.39 cm (p = 0.002) to the pubic symphysis. There was no significant difference found in radiation delivered to the bladder or rectum between the paired scans.

Conclusions

This study showed minimal change in balloon volumes, balloons/T+O positioning, or in radiation dose to bladder and rectum when the applicator remained overnight. These findings support that inflatable vaginal immobilization balloons remaining in situ overnight for additional HDR T+O treatments on sequential days, is safe and provides stable dosimetry.

Dosimetric analysis of cervical cancer stage IIB patients treated with volumetric modulated arc therapy using plan uncertainty parameters module of Varian Eclipse treatment planning system

Introduction. The present study aims to investigate the dosimetric and radiobiological impact of patient setup errors (PSE) on the target and organs at risk (OAR) of the cervix carcinoma stage IIB patients treated with volumetric-modulated arc therapy (VMAT) delivery technique using plan uncertainty parameters module of Varian Eclipse treatment planning system and in-house developed DVH Analyzer program.Materials and Methods. A total of 976 VMAT plans were generated to simulate the PSE in the base plan that varies from -10 mm to 10 mm in a step size of 1 mm in x- (lateral), y- (craniocaudal), and z- (anteroposterior) directions. The different OAR and tumor (PTV) volumes were delineated in each case. Various plan quality metrics, such as conformity index (CI) and homogeneity index (HI), as well as radiobiological quantities, such as tumor control probability (TCP) and normal tissue control probability (NTCP), were calculated from the DVH bands generated from the cohort of treatment plans associated with each patient case, using an in-house developed 'DVH Analyzer' program. The extracted parameters were statistically analyzed and compared with the base plan's dosimetric parameters having no PSE.Results. The maximum variation of (i) 2.4%, 21.5%, 0.8%, 2.5% in D_2ccof bladder, rectum, small bowel and sigmoid colon respectively; (ii) 19.3% and 18.9% in D_maxof the left and right femoral heads (iii) 16.9% in D_95%of PTV (iv) 12.1% in NTCP of sigmoid colon were observed with change of PSE in all directions. TCP was found to be considerably affected for PSEs larger than 4 mm in x⁺, y⁺, z⁺directions and 7 mm in x^-, y^-and z^-directions, respectively.Conclusion. This study presents the effect of PSE on TCP and NTCP for the cervix carcinoma cases treated with VMAT technique and also recommends daily image guidance to mitigate the effects of PSE.

Dosimetric and clinical outcomes of CT based HR-CTV delineation for HDR intracavitary brachytherapy in carcinoma cervix - a retrospective study

Background

Brachytherapy for carcinoma cervix has moved from Point A based planning to optimization of dose based on HR-CTV. Guidelines have been published by GEC ESTRO on HR-CTV delineation based on clinical gynecological examination and MR sequences. These have given significant clinical results in terms of local control. However, many centers around the country and worldwide still use CT based planning, which restricts HR-CTV delineation, as disease and cervix can rarely be differentiated on a planning CT. Various studies have been done to develop CT based contouring guidelines from the available data, but enough evidence is not available on the clinical outcome when treatment is optimized to HR-CTV contoured on CT images. The purpose of this study is to find out the relation between local control and dosimetry of HR-CTV as delineated on CT images.

Materials and methods

Patients of locally advanced carcinoma cervix treated radically with EBRT of 50 Gy in 25# and at least 4 cycles of concurrent weekly Cisplatin having a complete or partial response to EBRT were taken for study. All patients had completed CT based Intracavitary brachytherapy to 21 Gy in 3# of 7 Gy per # with dose prescription at point A and optimizing dose to reduce bladder and rectal toxicity. Follow up data on locoregional recurrence was obtained. HR-CTV delineation was done retrospectively on the treatment plan following guidelines by Viswanathan et al. EQD2 doses for EBRT+BT were calculated for point A and HR-CTV D90. The dosimetric data to HR-CTV and to Point A were then compared with patients with locoregional control and with local recurrence.

Results

48 patients were taken, all had squamous cell carcinoma. The median age was 48 years. 33.33% were stage IIA, the rest were stage IIB. Median follow-up was 30 months with 25% developing recurrence of the disease. HR-CTV D90 EQD2 dose was significantly higher in patients with locoregionally controlled disease than in patients with local recurrence (83.97 Gy₁₀ vs. 77.96 Gy₁₀, p = 0.002). Patients with HR-CTV D90 EQD2 dose greater than or equal to 79.75 Gy 10 had better locoregional control than patients receiving dose less than 79.75 Gy₁₀ (p = 0.015). Kaplan Meier plot for PFS showed significantly improved PFS for patients receiving HR-CTV D90 dose of at least 79.75 Gy₁₀ (log-rank p-value = 0.007). Three year progression free survival was 87.1% in patients receiving HR-CTV D90 dose of at least 79.75 Gy₁₀.

Conclusion

CT based HR-CTV volume delineation with the help of pre brachytherapy clinical diagrams and MRI imaging may be feasible in a select subgroup of patients with complete or near-complete response to external beam radiation.

Optimal treatment strategies for small cell carcinoma of the uterine cervix: A retrospective multi-center study (KROG 19-03)

OBJECTIVE

This multi-institutional study aimed to identify the optimal treatment strategy for small cell carcinoma of the cervix.

STUDY DESIGN

We retrospectively collected the medical records of 166 patients diagnosed with small cell carcinoma of the uterine cervix from January 2000 to December 2015 from 13 institutions of the Korean Radiation Oncology Group. After excluding 18 (10.8 %) patients who initially had distant metastasis, the treatment outcomes of 148 patients were analyzed.

RESULTS

After a median 46.4 (1.4-231.9) months of follow-up, the 5-year progression-free survival (PFS) and overall survival (OS) rates of all patients were 45.9 % and 63.5 %, respectively. Distant metastasis was the dominant pattern of failure occurring in 67 patients (45.3 %). We stratified the patients according to the primary local treatment: primary surgery (n = 119), primary radiotherapy (RT) (n = 26), and no local treatment group (n = 3). Although the primary RT group had advanced disease (FIGO stage ≧ IIB) more frequently than the primary surgery group (80.8 % vs. 47.9 %), the PFS and OS did not differ between the groups in multivariate analysis.

CONCLUSION

Definitive RT is a reasonable local treatment option for small cell cervical cancer, particularly for advanced cases. Given the high rates of distant relapse, an effective systemic therapy protocol is warranted for small cell cervical cancer patients.

A dummy-run evaluation of postoperative hypofractionated intensity-modulated radiation therapy (POHIM-RT) trials for cervical cancer

The postoperative hypofractionated intensity-modulated radiation therapy (POHIM-RT) trial is a phase II study to evaluate toxicity following hypofractionated intensity modulated radiation therapy (IMRT) for cervical cancer. This study describes the results of a benchmark procedure for RT quality assurance of the POHIM-RT trial. Six participating institutions were provided computed tomography for RT planning and an IMRT plan for a sample and were instructed to delineate volumes, create a treatment plan and quality assurance (QA) plan, and submit the results of all procedures. The inter-institutional agreements on RT volume and plan results were evaluated using the kappa value and dice similarity coefficients. The simultaneous truth and performance level estimation (STAPLE) method was employed to generate a consensus target volume. The treatment volumes, organs-at-risk volumes, and results of the RT plan and QA reported by the institutions were acceptable and adhered well to the protocol. In terms of clinical target volume (CTV) delineation, there were differences between the institutions, particularly in vaginal cuff and paracolpium subsites. Consensus CTV was generated from the collected CTVs with the STAPLE method. The participating institutions showed considerable agreement regarding volume, dose and QA results. To improve CTV agreement in CTV, we provided feedback with images of the consensus target volume and detailed written guidelines for specific subsites that were the most heterogeneous.

Patterns of definitive radiotherapy practice for cervical cancer in South Korea: a survey endorsed by the Korean Radiation Oncology Group (KROG 20-06)

Objective

The Korean Radiation Oncology Group conducted a nationwide questionnaire survey to evaluate the patterns of clinical practice for patients with cervical cancer receiving definitive radiation therapy (RT) in South Korea.

Methods

Practicing radiation oncologists from 93 centers in South Korea were administered a questionnaire survey via e-mail. The survey focused on demographic characteristics, diagnostic evaluation, indications for definitive RT, RT techniques, RT field and dose prescription, lymph node (LN) boost RT, brachytherapy, and chemotherapy.

Results

The response rate was 62.4% (58/93 institutions). Of the 2,134 patients treated at the radiation oncology department in 2019, 48.8% underwent definitive RT. The selection of patients for definitive concurrent chemoradiation therapy and RT field, and RT dose prescription varied greatly. The upper border of the pelvis was commonly used as the bony landmark for external beam RT (81%–88% of respondents). Most (96.6%) centers performed LN boost RT with median total doses of 59 Gy and 59.2 Gy for pelvic and retroperitoneal LN, respectively. With 50% of the centers offering brachytherapy, image-guided brachytherapy and volume-based prescription were applied in 48.3% and 37.9%, respectively. Upfront concurrent chemoradiation therapy with varying prescription doses was considered by 60.4% respondents in cases of supraclavicular LN metastasis.

Conclusion

Most differences were noted in the indications for treatment, RT field, and prescription dose. This finding can serve as a reference for establishing practical RT guidelines for the management of locally advanced cervical cancer.

Efficacy and Safety of Image-Guided Intensity-Modulated Radiation Therapy and Volumetric Modulated Arc Therapy Combined with Paclitaxel Liposomes and Cisplatin for Locally Advanced Stage IIB-IIIB Cervical Cancer: A Retrospective Study at a Single Center

BACKGROUND This retrospective study aimed to investigate the efficacy and safety of image-guided intensity-modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT) combined with administration of paclitaxel liposomes and cisplatin for locally advanced stage IIB-IIIB cervical cancer at a single center in China. MATERIAL AND METHODS The clinical data of 126 patients with stage IIB-IIIB cervical cancer treated in our hospital were retrospectively analyzed. The patients were divided into the IMRT group (n=63) and the VMAT group (n=63). The short-term clinical efficacy, the incidence of adverse reactions, the quality-of-life score, and the changes in levels of T-lymphocyte subsets, serum inflammatory factors, and tumor markers were compared pre- and posttreatment between the 2 groups. RESULTS The clinical response rate was 90.5% and 96.8% in the IMRT group and the VMAT group, respectively; the difference was not statistically significant. After treatment, the levels of CD3⁺, CD4⁺, and CD4⁺/CD8⁺ subsets rose significantly, while the CD8⁺ level declined significantly in both groups compared with the pretreatment levels. After treatment, the levels of serum vascular endothelial growth factor, squamous cell carcinoma antigen, interleukin-8, tumor necrosis factor-a, carcinoembryonic antigen, and carbohydrate antigen 125 declined in both groups compared with pretreatment levels. After treatment, the Karnofsky performance scale score rose in both groups, and it was higher in the VMAT group than in the IMRT group. CONCLUSIONS IMRT and VMAT combined with paclitaxel liposomes and cisplatin have similar short-term clinical efficacy and long-term survival rates in the treatment of stage IIB-IIIB cervical cancer.

Significance of para-aortic lymph node evaluation in patients with FIGO IIIC1 cervical cancer

OBJECTIVE

This study investigated the effect of para-aortic lymph node sampling or dissection in recently revised International Federation of Gynecology and Obstetrics IIIC1p cervical cancer treated with primary surgery and adjuvant radiation therapy with concurrent chemotherapy.

METHODS

We retrospectively reviewed the records of 343 patients with early-stage cervical cancer and pathologically proven pelvic lymph node metastasis following curative surgery from 2001 to 2014. No patient had imaging evidence of para-aortic lymph node involvement, and all patients received adjuvant concurrent chemotherapy with or without concurrent chemotherapy. We investigated the significance of para-aortic lymph node sampling or dissection on disease-free survival and overall survival.

RESULTS

After median follow-up of 58.3 months, 5-year disease-free survival and overall survival in all patients were 69.9 and 80.2%, respectively. Disease-free survival and overall survival did not differ between the para-aortic lymph node dissection group and the No para-aortic lymph node dissection group (P = 0.700 and P = 0.605). However, patients with para-aortic lymph node-positive disease had poorer disease-free survival and overall survival compared with those with para-aortic lymph node-negative disease (P < 0.001 and P < 0.001).

CONCLUSIONS

This study found no survival benefit of para-aortic lymph node evaluation among patients with International Federation of Gynecology and Obstetrics IIIC1p cervical cancer who were clinically para-aortic lymph node-negative. Although para-aortic lymph node metastasis is a poor prognosticator, the benefit of para-aortic lymph node dissection in terms of survival needs further investigation.

Prognostic Significance of Tumor Regression Rate during Concurrent Chemoradiotherapy in Locally Advanced Cervix Cancer: Analysis by Radiation Phase and Histologic Type

This study aimed to evaluate the prognostic significance of tumor regression rate according to radiation phase and histologic subtype in patients with locally advanced cervical cancer (LACC) treated with chemoradiation. We retrospectively reviewed the medical records of 398 patients with FIGO stage IIB-IVA cervical cancer treated with concurrent chemoradiotherapy (CCRT) between 2001 and 2019. Tumor response was assessed using serial magnetic resonance imaging (MRI) at three time points: pre-treatment, post-external beam radiotherapy (EBRT), and post-intracavitary radiotherapy (ICR). Tumor regression pattern according to histologic subtype and radiation phase (EBRT and ICR) was evaluated. Overall survival (OS) and progression-free survival (PFS) were the primary outcomes. Of 398 patients, 44 patients had adenocarcinoma/adenosquamous carcinoma (AC/ASC) and 354 patients had squamous cell carcinoma (SCC). AC/ASC was associated with significantly worse PFS and OS than SCC (p < 0.001). AC/ASC had a relatively poorer regression rate in response to EBRT than SCC (p < 0.001), whereas there was no significant difference in overall tumor regression rate after completion of RT (EBRT and ICR) between the two histologic subtypes. Multivariable analysis demonstrated AC/ASC histology to be an independent prognostic factor of decreased PFS and OS. Moreover, tumor regression rate after completion of EBRT (post-EBRT tumor regression rate (EBRT_regression ≤ 26%) and proportion of tumor regression during EBRT to overall tumor regression (EBRT_proportion ≤ 40%) were independent predictors of poor survival in patients with LACC. Tumor regression pattern of LACC in response to CCRT differs according to histologic subtype. AC/ASC histology and poor tumor response to EBRT are independent prognostic factors for worse survival in patients with LACC. Further studies are needed to develop a CCRT protocol that is specialized for patients with AC/ASC.

Overall survival, locoregional recurrence, and distant metastasis of definitive concurrent chemoradiotherapy for cervical squamous cell carcinoma and adenocarcinoma: before and after propensity score matching analysis of a cohort study

PURPOSE

To estimate the outcomes of definitive concurrent chemoradiotherapy (CCRT) for bulky or advanced-stage cervical squamous cell carcinoma (SCC) and adenocarcinoma (ADC).

PATIENTS AND METHODS

We enrolled patients who had been diagnosed as having cervical SCC or ADC and received definitive CCRT. A Cox regression analysis was performed to determine the hazard ratio (HR) and 95% confidence intervals (95% CI); independent predictors were stratified or controlled for in the analysis, and the endpoint was all-cause mortality among patients with cervical SCC and ADC who received CCRT. Propensity score matching was performed to create well-balanced groups.

RESULTS

we enrolled 3258 patients who had International Federation of Gynecology and Obstetrics (FIGO) stage IB2-IVA cervical cancer without distant metastasis. Among them, 2927 patients with cervical SCC and 331 patients with cervical ADC received definitive CCRT. The results of multivariate Cox regression analysis indicated that ADC, advanced FIGO stage, no intracavitary brachytherapy, old age, earlier year of diagnosis, and higher comorbidity scores were significant independent poor prognostic factors of all-cause mortality in patients with cervical cancer who received definitive CCRT. Patients with cervical ADC who received definitive CCRT had higher all-cause mortality, locoregional recurrence (LRR), and distant metastasis (DM) (adjusted HR [95% CI]: 2.10 [1.79-2.46], 1.79 [1.35-2.37], and 1.97 [1.54-2.53] for all-cause mortality, LRR, and DM, respectively) compared with patients with cervical SCC who received CCRT.

CONCLUSION

Definitive CCRT in patients with cervical ADC resulted in lower overall survival, higher LRR, and higher DM rate compared with patients with cervical SCC.

Dosimetric and radiobiological comparison of simultaneous integrated boost and sequential boost of locally advanced cervical cancer

Introduction Some patients with locally advanced cervical cancer (LACC) cannot undergo brachytherapy (BT). Possible treatment includes two-stage external beam radiotherapy (sequential boost - SEQ) or single-stage external beam radiotherapy (simultaneous integrated boost - SIB). The goal of this paper was to carry out dosimetric and radiobiological comparison of these techniques with respect to tumour and organs-at-risk (OARs) irradiation. Methods The anatomic data of six patients with LACC were used for this study. The single-stage SIB-VMAT (25, 27 or 30 fractions) and double-stage SEQ-VMAT (25 + 6 fractions) plans were developed to deliver EQD₂=50 Gy to the pelvic region and EQD₂=90 Gy to the tumour. The developed plans were compared with respect to an EQD₂ dose delivered to a tumour and to the OARs, expected tumour control probability and normal tissue complications probability. Results The developed SIB-VMAT and SEQ-VMAT plans had physical coverage of the CTV tumours with more than 95% of the prescribed dose delivered to more than 95% of the volume. The irradiation of the tumour for both SIB-VMAT and SEQ-VMAT has comparable EQD₂ values close to 87-88 Gy. SIB-VMAT treatment plans provided lower levels of irradiation of OARs than SEQ-VMAT plans. The optimal number of fractions for SIB-VMAT was 27. Conclusion SIB-VMAT is a better treatment option for patients with LACC that are not eligible for BT. Results show that both SIB-VMAT and SEQ-VMAT allowed good coverage of the tumour and high-quality dose delivery. SIB-VMAT allowed minimising irradiation of OARs and shortening the overall treatment time by a week.

Increased High-Risk Human Papillomavirus Viral Load Is Associated With Immunosuppressed Microenvironment and Predicts a Worse Long-Term Survival in Cervical Cancer Patients

OBJECTIVES

To evaluate the correlation between tumor-infiltrating lymphocytes (TILs) and the viral load of high-risk human papillomavirus (HR-HPV) in cervical cancer patients.

METHODS

A total of 62 cervical cancer patients were recruited during 1993-1994 and assigned into four groups treated with radiotherapy alone or radiotherapy combined with chemotherapy and/or thermotherapy. Ki67+ tumor cells, CD4+, CD8+, FoxP3+, OX40+ and granzyme B+ TILs were detected by immunohistochemistry. The viral load of HR-HPV in biopsy tissues before therapy was detected by in situ hybridization.

RESULTS

The patients with high HPV viral load showed a significantly lower 15-year survival rate and an advanced International Federation of Gynecology and Obstetrics (FIGO) stage and increased recurrence rate. The distribution of Ki67+ tumor cells, FoxP3+ TILs, and CD8+/FoxP3+ ratio was obviously different between low and high HPV viral load groups. A worse clinical outcome was also implicated with increased HPV viral load tested by Cox regression analysis.

CONCLUSIONS

Patients with increased HR-HPV viral load tend to be resistant to therapy with decreased immune surveillance in the immune microenvironment. Thus, HR-HPV viral load would influence the local immune microenvironment, and then further affect the survival of cervical cancer patients.

Significance of the number of high-risk factors in patients with cervical cancer treated with radical hysterectomy and concurrent chemoradiotherapy

OBJECTIVE

The purpose of this study was to evaluate the impact of high-risk factors on the survival of patients with cervical cancer treated with surgery followed by adjuvant chemoradiotherapy.

METHODS

From 2000 to 2014, medical records of 897 patients with International Federation of Gynecology and Obstetrics stage IB-IIA disease treated with surgery were retrospectively reviewed. Among them, 483 patients with high-risk factors, including pelvic lymph node metastasis, parametrial invasion, or resection margin involvement, were analyzed.

RESULTS

The median follow-up time was 57 months (range, 6-205 months). For patients with single and multiple high-risk factors, the 5-year DFS rates were 80.4% and 65.7%, respectively (p < 0.001), and 5-year OS rates were 87.3% and 75.1%, respectively (p = 0.001). Distant metastasis was the most common pattern of recurrence (86.1%). Furthermore, distant metastasis-free survival significantly differed with the number of high-risk factors present (single 82.7% vs. multiple 68.8%, p < 0.001). In the multivariate analysis, while parametrial invasion and resection margin involvement showed no association, the adenocarcinoma histology, pelvic lymph node metastasis, higher metastatic lymph node ratio, and multiple high-risk factors were independent prognosticators associated with poor DFS and OS.

CONCLUSIONS

Patients with early-stage cervical cancer having multiple high-risk factors, adenocarcinoma histologic type, and pelvic lymph node metastasis accompanied by a higher lymph node ratio after surgery are more likely to have occult distant metastasis. Further, consolidation with systemic chemotherapy after adjuvant therapy might be considered to improve the survival outcome in this patient population.

Dosimetric comparison of two different applicators and rectal retraction methods used in inverse optimization-based intracavitary brachytherapy for cervical cancer

Purpose

The purpose of this study was to evaluate the dosimetric differences between two different applicators and rectal-retraction methods used in image-guided brachytherapy (IGBT) for locally advanced cervical cancer (LACC).

Material and methods

Ten patients with LACC treated with definitive chemoradiotherapy and inverse optimization-based IGBT were included in this study. In each patient, at least one fraction of IGBT was performed using tandem-ovoids (TO) with vaginal gauze packing (VGP) or tandem-ring (TR) with rectal-retractor (RR). High-risk clinical target volume (CTV_HR) and intermediate-risk CTV (CTV_IR) were defined as CTVs, and bladder, rectum, sigmoid, small bowel, urethra, and vaginal mucosa were defined as organs at risk (OARs). All patients received 50.4 Gy external beam radiotherapy (EBRT) in 28 fractions. After EBRT, 28 Gy high-dose-rate (HDR) IGBT in 4 fractions was delivered to central disease. A plan comparison was performed using dose-volume histogram (DVH) and treatment planning parameters for CTVs and OARs.

Results

There were no significant differences in D₉₀ values of CTV_HR. In terms of rectum dose, TR with RR was found to be significantly better than TO with VGP (p < 0.0001 for D_2cm3 and p < 0.013 for V_5Gy). Although, there were no statistically significant differences in D_2cm3 value of bladder, sigmoid, small bowel, upper vaginal mucosa, and urethra, mean value of D_2cm3 for all defined OARs were found lower in TR than in TO. Bladder V_7Gy, upper vaginal mucosa V_7Gy, middle and lower vaginal mucosa D_2cm3 values were all found to be significantly lower for TR than for TO (p < 0.035). CTV_HR and CTV_IR volumes contoured in TR were approximately 11% and 9% smaller than TO, respectively.

Conclusions

The results showed that there were no statistically differences in D₉₀ value of CTV_HR and CTV_IR. However, all DVH parameters for OARs in TR with RR were found to be better than in TO with VGP.

Neoadjuvant chemotherapy does not improve the prognosis and lymph node metastasis rate of locally advanced cervical squamous cell carcinoma: A retrospective cohort study in China

Locally advanced cervical carcinoma has a poor prognosis. Neoadjuvant chemotherapy (NACT) can reduce tumor size and improve tumor resection rate, but its use in large locally advanced cervical carcinoma is controversial. This study aimed to evaluate the treatment and prognosis of NACT in patients with cervical carcinoma stage IB2 or IIA2.This was a retrospective cohort study of patients who underwent type-C radical surgery and pelvic lymphadenectomy due to cervical carcinoma stage IB2/IIA2 between 2/2014 and 12/2016 at the Second Hospital of Jilin University. The patients were grouped according to whether they received NACT (paclitaxel and a platinum salt) or not. Overall survival (OS) and progression-free survival (PFS) were compared between the 2 groups.Of the 144 patients, 60 (41.7%) received NACT. A total of 119 patients underwent postoperative radiation therapy, of which 97 received radiation therapy alone and 22 received concurrent chemoradiotherapy. The adverse reactions in the NACT group were mainly hematologic toxic reactions, but were tolerated. No grade ≥III adverse reactions were observed. NACT did not significantly affect the PFS (P = .453) and OS (P = .933) between the 2 groups. No factor was found to be independently associated with OS or PFS (all P > .05).Compared with patients who underwent surgery with/without radiotherapy and/or chemotherapy, NACT using paclitaxel and a platinum salt does not improve the prognosis and lymph node metastasis rate of locally advanced cervical carcinoma in Chinese patients.