Chemoradiotherapy treatment with gemcitabine improves renal function in locally advanced cervical cancer patients with renal dysfunction

BACKGROUND

Cervical cancer (CC) in Mexico is diagnosed mainly in locally advanced (LACC) and advanced (ACC) stages, where ureteral obstruction is more frequent. The standard treatment for this population is concurrent chemoradiotherapy (CCRT) with cisplatin, which is nephrotoxic and could lead to further deterioration of renal function in LACC patients with renal function decline. We aimed to evaluate the effect of CCRT with Gemcitabine on renal function in LACC patients.

METHODS

This retrospective study included LACC patients treated with CCRT with Gemcitabine as a radiosensitizer from February 2003 to December 2018. Data were collected from medical archives and electronic records. We assessed renal function before and after CCRT treatment and analyzed the patient's response to treatment and survival.

RESULTS

351 LACC patients treated were included and stratified into two groups: 198 with Glomerular Filtration Rate (GFR) ≥60ml/min (group A) and 153 with GFR<60ml/min (group B). An improvement in GFR was observed after CCRT in patients in group B, from 33 ml/min to 57.5 ml/min (p<0.001). Complete response was observed in 64.1% of patients in Group A and 43.8% in Group B (p<0.0001). Factors associated with increased risk of death included having a GFR of 15-29 ml/min (HR: 2.17; 1.08-4.35), having GFR<15 ml/min (HR: 3.08; 1.63-5.79), and receiving Boost treatment (HR: 2.09; 1.18-3.69). On the other hand, receiving brachytherapy is a positive predictor for OS (HR:0.51; 0.31-0.84).

CONCLUSION

CCRT with gemcitabine is an appropriate treatment option for patients diagnosed with LACC who present impaired renal function due to the disease's obstructive nature or other comorbidities.

Hydronephrosis in patients with cervical cancer: An improved stent-change therapy for ureteral obstruction Stent-change for ureteral obstruction in cervical cancer

OBJECTIVE

Ureteral stent replacement is a routine treatment for hydronephrosis in patients with cervical cancer. We developed an improved ureteral stent-change operation for hydronephrosis in cervical cancer patients and compared its outcomes with traditional stent change procedures.

STUDY DESIGN

Clinical data of hydronephrosis in cervical cancer patients who were admitted to our hospital from August 2014 to October 2019 were analyzed. We retrospectively reviewed 131 cervical cancer patients, out of which 43 cases included patients in the improved operation group, whereas 88 patients with hydronephrosis followed the traditional ureteral stent-change operation for ureteral obstruction. The outcomes of the two procedures were compared using the propensity score matching method.

RESULTS

As opposed to the traditional ureteral stent change strategy, the patients in the improved group required shorter operation time (p = 0.001) and higher success rate (p = 0.004). The FIGO stage (p = 0.046), the level of ureteral obstruction (p = 0.027), radiotherapy history (p = 0.01), stent replacement times (≤2times or > 2times) (p = 0.001), and serum creatinine level (≤200 μmol/L or > 200 μmol/L) (p < 0.001) were significantly different between the two groups before propensity score matching. Propensity score matching analysis was used to eliminate the clinical differences of 43 patients in the traditional group; however, the span of visual hematuria during the surgical complications was not included (p = 0.026) in the results.

CONCLUSION

An improved ureteral stent change operation is an advanced treatment option for cervical cancer patients suffering from hydronephrosis. In contrast to traditional ureteral stent change techniques, our developed strategy lowers complications such as visual hematuria but improves the success.

Definitive pelvic radiation therapy improves survival in stage IVB neuroendocrine cervical carcinoma: A NeCTuR study

OBJECTIVE

To evaluate the survival impact of adding definitive pelvic radiation therapy (RT) to chemotherapy among patients with stage IVB neuroendocrine cervical carcinoma (NECC).

METHODS

We retrospectively studied patients with FIGO 2018 stage IVB NECC diagnosed during 1998-2020 who received chemotherapy with or without definitive whole pelvic RT (concurrent or sequential). Demographic, oncologic, and treatment characteristics were summarized. Progression-free (PFS) and overall survival (OS) were plotted using the Kaplan-Meier method, and hazard ratios (HRs) were calculated using Cox regression.

RESULTS

The study included 71 patients. Median age was 43 years (range, 24-75). Fifty-nine patients (83%) had pure neuroendocrine histology, and 57 (80%) had pretreatment tumor size >4 cm. Fifty-six patients (79%) received chemotherapy alone with (n = 15) or without (n = 41) palliative pelvic RT, and 15 (21%) received chemotherapy and definitive pelvic RT (chemo+RT). Median follow-up time was 20.1 months (range, 11.3-170.3) for the chemo+RT group and 13.5 months (range, 0.9-73.6) for the chemotherapy-alone group. Median PFS was 10.3 months (95% CI, 7.5-∞) for the chemo+RT group vs 6.6 months (95% CI, 6.1-8.7) for the chemotherapy-alone group (p = 0.0097). At 24 months, the PFS rate was 24% for chemo+RT vs 7.8% for chemotherapy alone. Median OS was 20.3 months (95% CI, 18.5-∞) for the chemo+RT group vs 13.6 months (95% CI, 11.3-19.2) for the chemotherapy-alone group (p = 0.0013). At 24 months, the OS rate was 49.2% for chemo+RT vs 21.5% for chemotherapy alone. In a Cox regression model, definitive RT was associated with improved PFS (HR, 0.44; 95% CI, 0.23-0.83; p = 0.0119) and OS (HR, 0.31; 95% CI, 0.14-0.65; p = 0.0022).

CONCLUSIONS

Addition of definitive pelvic RT to chemotherapy may improve survival in patients with stage IVB NECC.

Impact of hydronephrosis and kidney function on survival in newly diagnosed advanced cervical cancer

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38% of women with advanced cervical cancer have hydronephrosis on diagnosis.

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Hydronephrosis had a negative impact on survival.

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Every effort must be made to ensure that patients can perform standard treatment for cervical cancer.

Objectives

To assess the impact of hydronephrosis and kidney function in newly diagnosed advanced cervical cancer patients.

Methods

A retrospective cohort study of newly diagnosed cervical cancer stage IIIB to IVB was conducted in a tertiary hospital in Brazil. Data from clinical records between 2014 and 2018 were reviewed.

Results

A total of 285 women with advanced cervical cancer and no previous cancer treatment were included. 108 (37.9%) patients were diagnosed with hydronephrosis (HN) before or during the first treatment, 49 (17.2%) patients underwent ureteral obstruction relief, and emergency hemodialysis was performed in 17 patients due to uremia. The median overall survival (mOS) was 46.9 months for non-HN, 19.2 months for unilateral-HN, and 10.0 months for bilateral-HN (non-HN vs HN-groups, p = 0.0001). Patients with eGFR >= 60 mL/min/1.73 m², before or during the first cancer treatment, had mOS of 46.9 months, 23.5 months, and 11.1 months for non-HN, unilateral-HN and bilateral-HN, respectively (non-HN vs bilateral-HN, p = 0.002). Patients with eGFR < 60 mL/min/1.73 m² had mOS 23.4 months, 19.2 months, and 10.0 months for non-HN, unilateral-HN and bilateral-HN, respectively (non-HN vs bilateral-HN, p = 0.003). In the HN group, mOS was 11.2 months among those who underwent urinary diversion and 15.6 months among those who did not; p = 0.2. On multivariate analysis, cancer treatment, FIGO stage, and HN were prognostic factors for OS; however eGFR < 60 mL/min/1.73 m² does not appear to be associated with worse survival by itself (p = 0.7).

Conclusion

HN seems to have a negative effect on survival of patients with cervical cancer even after adjustment for FIGO stage and cancer treatment. The mOS does not appear to be worse in patients with HN who required urinary diversion compared to those who did not.

Longitudinal Outcomes from Conservative Management of Cervical Cancer Associated Ureteral Obstruction

OBJECTIVE

To identify predictors of hydronephrosis (HN) resolution and HN treatment failure. HN is a common comorbid condition with cervical cancer (CCa). Treatments for CCa continue to improve and long-term management strategies of HN are becoming increasingly necessary.

METHODS

A query of a single hospital (2004 - 2019) ICD-9 and CPT codes was made to develop a cohort of CCa patients with HN. A retrospective review was performed. The effects of patient, renal/HN, and cancer covariates on time to HN treatment failure, treatment complications and time to HN resolution were evaluated using logistic regression and competing risk Cox regression models.

RESULTS

Of the 1670 women treated for CCa during the study period, 179 (10.7%) developed HN (n = 72 (40%) bilateral), 78 (44%) at time of CCa diagnosis and 101 (56%) as a result of treatment, of which 145 (81%) underwent initial treatment with a PCN (n = 77, 53%) or US (n = 68, 47%). Complication rates were similar between PCN (56%) and US (61%) when adjusting for treatment time. Initial treatment failure was more likely with US vs PCN (HR 3.2, P <0.01). HN resolution (n = 32, 22%) without reconstruction was predicted by HN concurrent with CCa diagnosis (HR 3.1, P <0.01) and bilateral HN (HR 0.2, P <0.01).

CONCLUSION

CCa associated HN has a resolution rate of only 19% at 12 months. Those presenting with HN after CCa treatment are less likely to resolve without reconstruction. PCN and US have similar complication rates but initial US placement has a nearly three times increased risk of failing than PCN.

Different prognosis of stage IIIB cervical cancer patients with lower third of vaginal invasion and those without

OBJECTIVE

Previous studies have evaluated the prognostic factors of patients with stage IIIB cervical cancer. However, there was only one study evaluating the relationship between LTI (lower third of vaginal invasion) and the prognosis of the patients with stage IIIB cervical cancer. Our research aimed to assess different therapeutic outcomes of the stage IIIB CCP (cervical cancer patients) with or without LTI.

METHODS

From December 2007 to December 2014, patients with FIGO (International Federation of Gynecology and Obstetrics, 2009) stage IIIB cervical cancer admitted and treated in Zhejiang Cancer Hospital were enrolled and evaluated in this retrospective research. Different clinicopathological variables and treatment outcomes were analyzed by using multivariate and univariate Cox regression models and chi-square or Fisher's exact test.

RESULTS

The number of enrolled patients was 622, among which 74 cases were with LTI and 548 without. The two- and five-year OS (overall survival) rates in non-LTI group were 79.9% and 58.9%, and the OS rates in LTI group were 68.9% and 38.8%, respectively (P = 0.001). The two- and five-year PFS (progression-free survival) rates in non-LTI group were 63.3% and 53.1%, and the PFS rates in LTI group were 45.9% and 37.0% respectively (P = 0.002). Multivariate Cox regression analysis indicated that histological type, total treatment time, hydronephrosis, and treatment protocol were factors significantly affecting the PFS rates in stage IIIB CCP, and OS rates were associated with histological type, hydronephrosis, treatment protocol, and LTI.

CONCLUSIONS

Our study showed that stage IIIB CCP with LTI had worse prognosis than those without LTI.

Transvaginal ultrasound assessment of urinary tract in gynecological oncology patients: A multicenter prospective study

INTRODUCTION

The aim of this study was to assess the prevalence of urinary tract involvement diagnosed on transvaginal ultrasound examination in women gynecological cancers. The diagnostic performance of transvaginal ultrasound in detecting ureteral and bladder involvement was also evaluated.

METHODS

This is a multicenter prospective study. Women with gynecological cancers or recurrence undergoing ultrasound examination were included. Transvaginal ultrasound is simple and non-invasive method. Ureters, vesico-uterine septum, bladder involvement were evaluated. Sensitivity, specificity, positive predictive values (PPV), negative predictive value (NPV) of ultrasound were calculated. Surgery or imaging methods (MRI or CT scan) were considered as reference standard.

RESULTS

A total of 569 patients were enrolled and 547 of them had diagnosis of malignancy. 56/547 (10.2%) had a diagnosis of urinary tract infiltration at ultrasound examination. On ultrasound examination, both ureters were clearly visualized in the vast majority of cases (507/547, 92.7%), whereas only one ureter was identified in 21/547 (3.8%) patients and both ureters were not visualized in 19/547 (3.5%). Ultrasound examination demonstrated high specificity (>99.0%) and high NPV (>97.0%) for all ultrasound parameters; sensitivity was good for bladder wall infiltration (83.3%) and for vesico-uterine septum infiltration (80.8%), and low for right (69.23%) and left (65.4%) ureter infiltration.

CONCLUSIONS

The prevalence of pelvic urinary tract infiltration on transvaginal ultrasound examination in women with gynecologic malignancy was 10%. We believe that pelvic urinary tract assessment plays a key role during transvaginal ultrasound examination, in order to plan the management of patients with gynecologic cancers.

Incorporation of whole pelvic radiation into treatment of stage IVB cervical cancer: A novel treatment strategy

OBJECTIVES

Chemotherapy is the standard treatment in stage IVB cervical cancer (CC). However, given that many women have a significant pelvic disease burden, whole pelvic radiation (WPR) in addition to chemotherapy for primary treatment may have utility. The aim of this study was to compare the overall survival (OS) and complication rates between women who received both WPR and chemotherapy (CT) versus CT alone in the management of stage IVB CC.

METHODS

A multi-institutional, IRB-approved, retrospective review of patients (pts) with stage IVB CC, diagnosed between 2005 and 2015, was performed. Descriptive statistics of the demographic, oncologic, and treatment characteristics were performed. OS was estimated using the Kaplan Meier method.

RESULTS

A total of 126 pts met inclusion criteria. Thirty one patients elected for hospice care at diagnosis and were excluded from further analysis. In the remaining population, median age was 53 yrs. The majority (72%) had squamous cell carcinoma and 82% had FIGO grade 2 or 3 tumors. Thirty four patients (35.8%) received WPR in addition to CT as a part of planned primary therapy and 64.2% (n = 61) received CT alone, with 88.2% and 80.3% receiving a cisplatin-based chemotherapy regimen, respectively. The OS was significantly longer in the WPR with CT group (41.6 vs 17.6 mo, p < 0.01). The rates of ureteral obstruction, vaginal bleeding, pelvic infection, pelvic pain, and fistula were not significantly different between the 2 groups (all p > 0.05).

CONCLUSION

This study found WPR in addition to CT gives a significant OS benefit. Further study is warranted to determine which subgroups may benefit the most from this novel treatment strategy.

Ureteral stent placement and percutaneous nephrostomy in the management of hydronephrosis secondary to cervical cancer

OBJECTIVE

This study aimed to evaluate the efficacy of ureteral stent placement for the treatment of hydronephrosis secondary to cervical cancer and analyze factors that may predict failure of ureteral stent placement and the differences between ureteral stent placement and percutaneous nephrostomy.

STUDY DESIGN

Clinical data of patients with cervical cancer complicated with hydronephrosis admitted to our hospital from July 2008 to August 2018 were retrospectively analyzed. To evaluate the efficacy of ureteral stent placement and percutaneous nephrostomy in the management of hydronephrosis secondary to cervical cancer.

RESULTS

A total of 89 patients were analyzed. A ureteral stent was successfully placed in 60 patients. Indwelling stent failed in 29 patients, and then percutaneous nephrostomy was performed. Both surgical procedures were safe and effective. There was a significant correlation between the success rate of ureteral stent placement and the degree of hydronephrosis and the length of the ureteral obstruction. There was no significant difference in the incidence of complications following ureteral stent placement and percutaneous nephrostomy, while there were significant differences between the two treatment modalities in terms of surgical time, hospitalization time, and surgical cost.

CONCLUSION

Ureteral stent placement is the preferred method for the treatment of hydronephrosis secondary to cervical cancer. However, in patients with more severe hydronephrosis and ureteral obstruction >3 cm in length, percutaneous nephrostomy may be more appropriate.

Survival outcomes of patients with cervical cancer and accompanying hydronephrosis: A systematic review of the literature

Hydronephrosis is a sign of advanced stage disease in patients with cervical cancer. Its presence is believed to negatively affect the survival of patients. To date, however, consensus in this field is still lacking. The purpose of the present systematic review is to gather the available data and to provide directions for future research in the field. We systematically searched Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRA and Google Scholar databases from inception till June 2018. Overall, 22 studies were included in the present systematic review that evaluated outcomes from 8521 patients with cervical cancer. The findings of our systematic review support that hydronephrosis negatively affects the overall survival of cervical cancer patients. Specifically, the reported 5- year OS hazards ratio for hydronephrosis ranged between 1.34 and 3.74. Outcomes concerning the disease-free survival of these patients were, however, less discrete. None of the included studies reported whether the decreased survival of patients with hydronephrosis was attributed to complications of obstructive uropathy such as uremia and sepsis. Thus, it remains, to date, unclear whether placement of ureteral stents or percutaneous nephrostomy may actually benefit these patients. More studies are needed to evaluate the actual impact of hydronephrosis on survival rates at the various stages of cervical cancer and to help establish consensus regarding the optimal mode of management of these patients.

Bladder and Ureteral Dysfunction Leading to Hydronephrosis and Hydroureteronephrosis in Adults

Chronic non-stone-related hydronephrosis from supravesical or bladder dysfunction in adults is often detected incidentally. This study aims to review the literature regarding supravesical obstruction or bladder dysfunction leading to bilateral hydronephrosis in adults and to develop an algorithm to identify patients at risk of renal failure. Cross-sectional studies, retrospective and prospective cohorts, clinical trials, and systematic reviews from 1980 to 2017 were included. From 8115 articles screened, 39 met the inclusion criteria. Despite the lack of studies addressing this issue, this review brings up a rational evidence-based algorithm to diagnose and manage adults with bilateral hydronephrosis due to supravesical or bladder disease or dysfunction.