A preliminary results of a randomized trial comparing monthly 5-flourouracil and cisplatin to weekly cisplatin alone combined with concurrent radiotherapy for locally advanced cervical cancer

American Brachytherapy Task Group Report: A pooled analysis of clinical outcomes for high-dose-rate brachytherapy for cervical cancer

PURPOSE

Advanced imaging used in combination with brachytherapy (BT) has revolutionized the treatment of patients with cervical cancer. We present a comprehensive review of the literature for definitive radiation with high-dose-rate (HDR) BT. In addition, we investigate potential outcome improvement with image-based brachytherapy (IBBT) compared to studies using traditional Point A dosing. This review extensively investigates acute and late toxicities.

METHODS AND MATERIALS

This study reviews the literature from 2000 to 2015 with an emphasis on modern approaches including concurrent chemotherapy (chemoRT), radiation, and HDR BT and IBBT. Descriptive statistics and pelvic control (PC), disease-free survival (DFS), and overall survival (OS) outcomes were calculated using weighted means to report pooled analysis of outcomes.

RESULTS

Literature search yielded 16 prospective, 51 retrospective studies that reported survival outcomes, and 13 retrospective studies that focused on acute and late toxicity outcomes regardless of applicator type. There are 57 studies that report Point A dose specification with 33 having chemoRT, and 10 studies that use IBBT, 8 with chemoRT. Patients receiving radiation and chemoRT with HDR BT in the prospective studies, with >24 months followup, rates of PC were: for RT: 73%, SD: 11; CRT: 82%, SD: 8; DFS-RT: 55%, SD: 10; CRT: 65%, SD: 7; OS-RT: 66%, SD: 7; CRT: 70%, SD: 11. In the retrospective studies, the PC rates (weighted means) for the radiation and chemoradiation outcomes are 75% vs. 80%, and for DFS, the values were 55% vs. 63%, respectively. Comparing patients receiving chemoRT and IBBT to traditional Point A dose specification, there is a significant improvement in PC (p < 0.01) and DFS (p < 0.01) with IBBT. The range of genitourinary late toxicity reported for radiation was Grade 3: 1-6% and for chemoRT 2-20%. The range of late gastrointestinal toxicity for radiation was Grade 3: 4-11% and for chemoRT, 1-11%. For the late gynecologic toxicity, only 1 of the 16 prospective trials report a Grade 1-2 of 17% for radiation and 9% for chemoRT effects.

CONCLUSIONS

We present concise outcomes of PC, DFS, OS, and toxicity for cervical cancer patients treated with chemoradiation and HDR BT. Our data suggest an improvement in outcomes with the use of IBBT compared with traditional Point A dose prescriptions. In conclusion, HDR BT is a safe, effective modality when combined with IBBT.

Efficacy of concurrent single-agent chemotherapy using radiotherapy in patients with cervical cancer: a meta-analysis

Concurrent chemoradiotherapy has proven to be more effective on patients with advanced cervical cancer than radiotherapy alone. Although cisplatin has been recommended to be the standard agent in chemotherapy, it has some limitations in clinical use because of its strong side effects. Moreover, the optimal chemotherapy regimen remains unclear. A comprehensive electronic search was conducted via the Internet retrieval system to identify eligible trials. The ending points included response, overall survival (OS), local recurrent, and distant metastasis rates. Odds ratios and 95% confidence interval were calculated to compare the effects. Fifteen trials with 1142 patients were eligible. With regard to the response rate, only nedaplatin showed a significant improvement compared with cisplatin. Docetaxel, pacitaxel, fluoropyrimidine, paclitaxel liposome, and irinotecan did not show any advantages. When targeted on OS or local recurrent rate, no significant advantage was found when these single-drug regimens were compared with cisplatin. However, when aimed at distant metastasis rate, fluoropyrimidine showed a disadvantage to cisplatin, whereas others showed equal efficacy. Nedaplatin, docetaxel, pacitaxel, and fluoropyrimidine showed a better effect on reducing chemotherapy toxicity than cisplatin. Single-drug chemotherapy concurrent with radiotherapy, except for nedaplatin, may have no advantage on clinical outcomes when compared with cisplatin but showed a better effect on reducing chemotherapy toxicity, which could be used as an alternative to patients who can not tolerate the side effects of cisplatin. Nedaplatin is also effective and safe, and may be highly valuable in clinical applications.

Laparoscopy-Assisted Intracavitary Radiotherapy Tandem Placement for Patients With Cervical Cancer

Objective:

To determine the requirement and benefit of laparoscopy-assisted surgical procedures for optimal placement of intracavitary radiotherapy (ICR) tandem in patients with cervical cancer patients.

Methods:

We reviewed a database of 231 cervical cancer patients who underwent radiotherapy and computed tomography-based 3-dimensional ICR planning at our institute between July 2003 and December 2007.

Results:

Misplacement of ICR tandem was identified in 12 patients. Optimal placement of ICR tandem was possible in 6 patients under sonographic guidance at the second attempt. Laparoscopy-assisted placement of an ICR tandem was required in 6 patients (2.6%) because of failures of ICR tandem insertion. As a result of this procedure, tandem insertions were corrected in all patients, with the exception of 1 patient who initially presented with fixed pelvic wall disease with an acute angle between the uterine body and the cervical axis. Laparoscopic procedures were tolerable with a median operative time of 68 minutes and an estimated blood loss of less than 20 mL. There were no complications related to the laparoscopic procedures. All the patients remain free of local disease at the time of this writing. There was 1 patient with grade 4 late radiation toxicity of the bowel who developed a rectovaginal fistula 3 months after completion of ICR.

Conclusions:

Laparoscopy-assisted placement of an ICR tandem was required in 2.6% of the patients with primary advanced cervical cancer. Laparoscopy-assisted placement of an ICR tandem allows optimal implementation of ICR in difficult cases without causing significant morbidity and without delaying the planned ICR.

Adoptive transfer of human papillomavirus E7-specific CTL enhances tumor chemoresponse through the perforin/granzyme-mediated pathway

Adoptive cytotoxic T lymphocyte (CTL) therapy has an important implication in treating cancer patients. Here, we investigate whether adoptive transfer of human papillomavirus (HPV) E7-specific CTL can enhance tumor chemoresponse using an established cervical cancer animal model. Cisplatin-based chemotherapy plus CTL therapy showed an improved therapeutic effectiveness, along with antitumor protective responses to a parental tumor cell rechallenge. Cisplatin treatment dose-dependently increased the expression of Fas, intercellular adhesion molecule (ICAM)-1, and major histocompatibility complex (MHC) class I antigens (Ags) on tumor cells in vitro. However, CTL-expressing FasL failed to improve antitumor activity in vitro and in animals, resulting from nonfunctional Fas expressed on tumor cells. In contrast, ethylene glycol tetraacetic acid (EGTA) treatment blocked increased sensitivity of cisplatin-treated tumor cells to CTL-mediated killing in vitro, suggesting an important role of the perforin/granzyme-mediated pathway for improved therapeutic effectiveness. This notion was further confirmed by perforin knockout animal studies. Thus, this study shows that (i) modulation of Ag (Fas, ICAM-1) expression by tumor cells has little effect on their increased sensitivity to CTL-mediated killing, (ii) improved therapeutic effectiveness is mediated mainly through the perforin/granzyme-mediated tumor killing pathway, and (iii) a combination of chemotherapy and adoptive E7-specific CTL transfer augments antitumor therapeutic activity in vivo. This finding may have important implications for treating HPV-associated cervical cancer.