Locally Advanced Cervical Cancer Research Articles

Nomogram for Predicting Survival in Locally Advanced Cervical Cancer with Concurrent Chemoradiotherapy plus or Not Adjuvant Chemotherapy: A Retrospective Analysis Based on 2018 FIGO Staging.

Background: The comprehensive treatment mode of combining concurrent chemoradiotherapy (CCRT) with adjuvant chemotherapy (AC) is a commonly used mainstream model in the clinical practice of locally advanced cervical cancer (LACC). However, the necessity for AC after CCRT lacks sufficient evidence-based medical support. This study constructs a predictive model for the survival time dependence of CCRT ± AC for LACC based on the 2018 International Federation of Gynecology and Obstetrics (FIGO) staging with internal validation, the prognosis was assessed with intensity-modulated radiotherapy (IMRT) and concurrent cisplatin, and provides guidance for future stratified treatment. Materials and Methods: The retrospective analysis included 482 patients with LACC who CCRT from January 2016 to January 2023. Patients who used the 2009 FIGO staging were all standardized for the 2018 FIGO staging. The 482 patients with LACC were divided into a training set (n = 290) and a validation set (n = 192) at a ratio of 6:4. COX multivariate regression model and LASSO regression were used to screen for independent prognostic factors affecting progression-free survival (PFS) and overall survival (OS), and a nomogram clinical prediction model was constructed based on these factors. Evaluate the effectiveness of the model through the receiver operating characteristic curve, calibration curve, decision curve, risk heat map, and survival curves for risk stratification. Results: The PFS and OS independent prognostic risk factors affecting the 2018 FIGO staging of LACC during CCRT were validated to be similar to the 2009 FIGO staging prediction model reported in previous literature. In the training cohort, area under the curve (AUC) values at 1, 3, and 5 years were 0.941, 0.882, and 0.885 for PFS, and 0.946, 0.946, and 0.969 for OS, respectively. When applied to a test cohort, the model also showed accurate prediction result (AUC at 1, 3, and 5 years were 0.869, 0.891, and 0.899 for PFS, and 0.891, 0.941 and 0.878 for OS, respectively). Subgroup analysis suggests that patients with LACC, adenocarcinoma, stage IVA, pelvic lymph node metastasis, pretreatment hemoglobin ≤100 g/l and residual tumor diameter >2 cm, who received CCRT in the 2018 FIGO stage, may benefit more from adjuvant chemtherapy. Conclusions: Based on the 2018 FIGO staging, a nomogram prediction model for PFS and OS in patients with LACC undergoing CCRT was developed. The model, established by combining weighted clinical and pathological factors, can provide more personalized treatment predictions in clinical practice. For patients with high-risk factors such as residual tumor diameter > 2 cm after CCRT for LACC, AC may bring benefits.

Simultaneous integrated boost on pathologic lymph nodes safely improves clinical outcomes compared to sequential boost in locally advanced cervical cancer: a multicenter retrospective study.

This multicenter study aimed to retrospectively evaluate the impact of high boost simultaneous integrated boost (SIB) to pathologic lymph nodes compared to Sequential boost (Seq) in patients with locally advanced cervical cancer (LACC). 97 patients with pelvic and/or para-aortic (PAo) node-positive LACC treated by definitive chemoradiation were included. Two groups were analyzed: Sequential boost group and simultaneous integrated boost (SIB) group. Endpoints were Distant Recurrence Free Survival (DRFS), Recurrence Free Survival (RFS), Overall Survival (OS), locoregional pelvic and PAo control and toxicities. 3-years DRFS in SIB and Seq groups was 65% and 31% respectively (log-rank p < 0.001). 3-years RFS was 58% and 26% respectively (log-rank p = 0.009). DRFS prognostic factors in multivariable analysis were SIB, PAo involvement and maximum pelvic node diameter ≥ 2cm. Adenocarcinoma histology and absence of brachytherapy tended to be prognostic factors. SIB provided the best pelvic control at first imaging with 97%. There was no significant difference in terms of toxicities between groups. Nodal SIB seems to be unavoidable in the treatment of node-positive LACC. It provides the best DRFS, RFS and pelvic control without additional toxicity, with a shortened treatment duration.

PD-1 inhibitor plus concurrent chemoradiotherapy for high-risk locally advanced cervical cancer.

Aim: The prognosis of high-risk, locally advanced cervical cancer (LACC) remains poor following concurrent chemoradiotherapy (CCRT). We investigated whether the effect of CCRT can be enhanced by programmed cell death protein 1 (PD-1) inhibitor.Methods: A retrospective cohort study wasconducted to compare the efficacy and safety of CCRT group (n=82) and PD-1 inhibitor plus CCRT group (n=70).Results: Compared with the CCRT group, the PD-1 inhibitor plus CCRT group had significantly higher objective response rate, median progression-free survival, leukopeniaand fatigue. The addition of PD-1 inhibitor to CCRT showed a favorable trend in overall survival without statistical significance.Conclusion: PD-1 inhibitor plus CCRT presented a significant survival benefit and a manageable safety profile in high-risk LACC.

Phase II study of tislelizumab combined with concurrent chemoradiotherapy for locally advanced cervical cancer.

e17523 Background: Concurrent chemoradiotherapy (CRT) is the standard treatment for locally advanced cervical cancer (LACC). However, local recurrence and distant metastasis are the main modes of treatment failure in LACC, especially for patients with stage IIIA ~IVA as well as patients with large masses (&gt;4cm) and regional lymph node metastasis. This study aimed to evaluate the efficacy and safety of tislelizumab (anti-PD-1 antibody) combined with concurrent chemoradiotherapy for locally advanced cervical cancer. Methods: Eligible patients were age 18-75 years, ECOG performance status of 0-1 and untreated cervical cancer (2018 FIGO stage IIIA, IIIB, IVA, or cervical tumor diameter &gt; 4cm with regional lymph node metastasis, or paracervical invasion with regional lymph node metastasis). All patients received CRT plus tislelizumab 200mg Q3W for 1 year or disease progression or intolerable toxicity. The CRT includes at least 4 cycles of cisplatin 40mg/m2 QW + EBRT 45~50Gy/25f then BT 28~30Gy/4~5f. The primary endpoint was tumor regression ratio before brachytherapy. Secondary endpoints were 3-month and 6-month objective response rate (ORR), 1-year and 3-year OS and PFS, safety. Results: From August 24, 2022 to February 4, 2024, 30 patients were enrolled. 25 patients completed CRT and were available for evaluation. The median age was 59 years (range 40-75). The tumor regression ratio before brachytherapy was 90.6%. The ORR at 3 and 6 months were 100%, The OS and PFS rate at 1 year were 100%. The main adverse effect was neutropenia (36% for grade 3-4 and 20% for grade 1-2). Radiation enteritis incidence was 64% and were grade 1-2. Other adverse effect such as nausea, vomiting, and dizziness occurred during CRT and could be alleviated after symptomatic treatment. No immune-related adverse events were observed. Conclusions: Our results suggest that Tislelizumab combined with concurrent chemoradiotherapy showed valuable antitumor activity and controllable safety in LACC. We will keep strictly implementing our study protocol for further PFS and OS. Clinical trial information: NCT05588219 .

Immunotherapy in locally advanced cervical cancer: Integrating KEYNOTE-A18 into management strategies

In locally advanced cervical cancer (LACC), the benefit of PD-1 blockade was unknown. In KEYNOTE-A18, Lorusso etal.1 compared the efficacy and safety of adding pembrolizumab to chemoradiation in LACC and demonstrated favorable outcomes. Given multiple approved indications of pembrolizumab in cervical cancer, strategies for optimal integration into management will be needed to maximize overall survival.

Neoadjuvant chemo-immunotherapy following concurrent immuno-chemoradiotherapy and immune-maintenance therapy as primary treatment for locally advanced cervical cancer: A prospective, single-arm, phase 2 trial.

5533 Background: Immunotherapy in combination with chemoradiotherapy has shown good efficacy in locally advanced cervical cancer (LACC). We report on the efficacy of neoadjuvant camrelizumab plus chemotherapy (TP) following concurrent immuno-chemoradiotherapy and maintenance immunotherapy for LACC. Methods: Eligible participants were adults with histologically confirmed squamous cell carcinoma, adenosquamous cell carcinoma, or adenocarcinoma of the cervix (FIGO 2018 stage IIB-IVA disease), ECOG PS score 0-2, and adequate bone marrow and organ function. All pts received 2 cycles neoadjuvant camrelizumab (200 mg d1 q3w) plus TP (albumin-bound Paclitaxel 260mg/m2 d1 q3w; cisplatin 75 mg/m2 d1-3 q3w) treatment, following 5-week external beam radiotherapy (EBRT) protocol (45-50 Gy/25 fractions with concurrent triweekly camrelizumab and cisplatin) to the whole pelvis plus brachytherapy every 3 weeks for 2 cycles, and then maintenance therapy of camrelizumab (200mg q3w, up to one year). The primary endpoint was progression-free survival (PFS) at 2 years. PFS was evaluated when at least 13 events were observed using a stratified log-rank test with an overall one-sided significance level of 0.05. Results: 67 pts provided informed consent and 12 were excluded for not meeting eligibility. 55 pts received the investigational agent and were evaluable for safety and efficacy analyses. The median age was 54 years [IQR 50 to 60]; 51 [92.7%] were squamous cell carcinoma, and 4 [7.3%] were adenocarcinoma; 9 [16.4%] were stage IIB, 2 [3.6%] were IIIA, 5 [9.1%] were IIIB, 30 [54.5%] were IIIC1r, 6 [10.9%] were IIIC2r, and 3 [5.5%] were IVA. As of data cutoff (Jan. 15, 2024), median follow-up was 9.5 (IQR 7.1 to 10.3) months. Of the 55 pts, 1 (1.8%) pt underwent hysterectomy after EBRT because of pelvic empyema, and was excluded from response evaluation. At three months after brachytherapy, the overall remission rate was 100% (53 [98.1%] complete remission and 1 [1.9%] partial remission). We identified 3 (5.5%) pts with treatment failure (2 [3.6] distant metastasis, and 1 [(1.8%] para-aortic lymph node relapse) during follow-up; 1-year PFS was 90.6% (85.4%-95.8%). The most common clinically significant grade 3-4 adverse events (AEs) were decreased neutrophils (18.2%), thrombocytopenia (9.1%) and anemia (27.3%). Serious AEs occurred in 7 (12.7%), most commonly due to infectious complications. There were no treatment-related deaths. Conclusions: The interim data support Camrelizumab plus TP neoadjuvant chemo-immunotherapy following immuno-chemoradiotherapy and Camrelizumab maintenance therapy as an active go-forward regimen in LACC. No new safety signals were observed, and most AEs were mild to moderate. Clinical trial information: ChiCTR2200061097.

Zimberelimab combined with concurrent chemoradiotherapy for patients with locally advanced cervical cancer: Early results of efficacy and safety.

e17507 Background: To assess the efficacy and safety of zimberelimab combined with concurrent chemoradiotherapy (CCRT) for locally advanced cervical cancer (LACC) patients (pts). Methods: This a single arm, open label, prospective phase II study. participants aged 18-75 years of FIGO 2018 IIB-IVA LACC, with histologically confirmed adenocarcinoma, adenosquamous carcinoma, or squamous cell carcinoma untreated with radiotherapy or immunotherapy for cervical cancer were included. Nineteen enrolled pts received zimberelimab (240 mg, IV, Q2W) for up to one year starting from the first week of radiotherapy, combined with CCRT, including cisplatin (25-40 mg/m2), paclitaxel (35 mg/m2), once a week for up to 5 cycles, intensity modulated radiation therapy (IMRT, 45-50 Gy/25-28 f), with a simultaneous integrated boost of 10-15 Gy to involved metastatic lymph nodes, followed by brachytherapy (30-40 Gy, 5-6 Gy/f, biw). All radiotherapy was completed within 8 weeks. The primary endpoint was objective response rate (ORR) assessed by investigators per Response Evaluation Criteria In Solid Tumours (RECIST) version 1.1. The secondary endpoints were disease control rate (DCR), progression-free survival (PFS), 3-year overall survival (OS) rate and safety. Results: The median age was 57 years (range, 32 to 71), with 6 pts in stage IIB, 2 pts in stage IIIB, 8 pts in stage IIIC, and 3 pts in stage IVA. All pts completed CCRT successfully, with 18 pts completed 5 cycles of chemotherapy, while only 1 pts received 4 cycles of chemotherapy. The median cycles with zimberelimab treatment was 15 (range, 6 to 26). Grade (G) 3 and higher treatment related adverse events (TRAEs) were observed in 13 pts (13/19, 68.4%), 1 pts had G4 lymphopenia (1/19, 5.3%). The most frequent ≥G3 TRAEs was lymphopenia (11/19, 57.9%), followed by leukopenia (7/19, 36.8%). The ORR was 100%, with complete responses in 18 pts (18/19, 94.7%) and partial responses in 1 pts (1/19, 5.3%). At data cutoff (October 31, 2023), 2 pts had disease progression (2/19, 10.5%), 17 pts have been remaining in disease remission (17/19, 89.5%). Conclusions: Zimberelimab combined with CCRT achieved promising anti-tumor effects and manageable toxicities in LACC pts. Further follow-up results are expected. Trial registration: ClinicalTrials.gov Identifier: NCT05437692. Clinical trial information: NCT05437692 . [Table: see text]

Effect of ionizing radiation on JAK/STAT pathway and immune microenvironment in cervical cancer.

e17516 Background: STAT proteins play an important role in the development and progression of cervical cancer, and inhibition of the JAK/STAT pathway may be critical for enhancing tumor cell death. Delivering a certain dose of ionizing radiation (IR) directly to the lesion is one of the conventional treatments for cervical cancer. Whether IR will trigger changes in the JAK/STAT pathway and tumor immune microenvironment (TIME) is unknown and continues to be explored. Methods: We collected 30 patients received IR therapy with locally advanced cervical cancer (LACC) at the Affiliated Hospital of Qingdao University. Matched pre-IR and post-IR tumor tissue samples were collected from all patients, and the samples underwent RNA sequencing based on the nCounter platform (NanoString Technologies, Seattle, USA) and protein testing based on immunohistochemistry (IHC) staining. All tumor TIME cell infiltration scores were calculated as arithmetic mean of the constituent genes. P-values were calculated via the T Test. Results: RNA sequencing of tumor tissue from LACC patients before and after IR showed 35 differential genes. The results of GSEA pathway enrichment analysis of differential genes showed that compared with before IR, the IFN-α response pathway, IFN-γ response pathway and epithelial mesenchymal transition pathway were significantly up-regulated and enriched after IR. These three pathways collectively affect changes in the downstream JAK/STAT pathway. Moreover, compared with before IR, the cell infiltration abundance of overall macrophages (P=0.0087) and M2 macrophages (P=0.0043) increased significantly after IR. M1 macrophages also showed an increasing trend, but there was no statistically significant difference. In addition, further verification of changes in several proteins on the JAK/STAT pathway by IHC. The results showed that overall macrophages (P=0.0087) and M1 macrophages (P=0.026), PD-L1 (p=0.003), JAK1 (p=0.021) and STAT3 (p=0.018) were significantly increased after IR compared with before IR. M2 macrophages and STAT1 (p=0.734) also showed an increasing trend, but there was no statistically significant difference. It is worth noting that Kendall's tau-b correlation analysis was used to study the correlation of protein changes. The results found that the changes in PD-L1 expression before and after radiotherapy were related to STAT3 (Kendall's tau-b=0.487, P=0.02), JAK1 (Kendall's tau-b=0.513, P=0.015), there is a strong positive correlation. Conclusions: This study found that IR affects changes in cervical cancer TIME and these changes may promote the transition to an immunosuppressive phenotype. In addition, IR may affect changes in PD-L1 levels through the JAK1/STAT3 pathway. This needs to be further verified by designing large prospective clinical trials in the future.

Prognostic prediction of oxidative stress related hematological biomarkers in locally advanced cervical cancer patients undergoing chemoradiotherapy

Objective This investigation aimed to develop and validate a novel oxidative stress score for prognostic prediction in locally advanced cervical cancer (LACC) patients receiving chemoradiotherapy. Methods A total of 301 LACC patients were enrolled and randomly divided into a training and a validation set. The association between oxidative stress parameters and prognosis was analyzed for oxidative stress score (OSS) establishment. A Cox regression model was conducted for overall survival (OS) and progression-free survival (PFS). A nomogram prediction model was developed using independent prognostic factors from the training set and validated in the validation set. Results A novel OSS was established with four oxidative stress parameters, including albumin, total bilirubin, blood urea nitrogen, and lactate dehydrogenase. Multivariate regression analysis identified OSS as an independent prognostic factor for OS (p = 0.001) and PFS (p < 0.001). A predictive nomogram based on the OSS was established and validated. The C-indexes of the nomogram in the training set were 0.772 for OS and 0.781 for PFS, while in the validation set the C-indexes were 0.642 for OS and 0.621 for PFS. Conclusion This study confirmed that preoperative OSS could serve as a useful independent prognostic factor in LACC patients who received CCRT.

Predictive Value of Pretreatment Hematological Parameters for Response to Definitive Chemoradiotherapy in Locally Advanced Cervical Cancer: A Prospective Study

Background: More than 90% of cervical cancers are related to chronic inflammation caused by HPV. Several studies have shown that laboratory hematological parameters can detect the severity of systemic inflammation. Objectives: Our current cohort study investigated the predictive role of pretreatment hematological parameters for response to definitive chemoradiotherapy in patients with locally advanced cervical cancer (LACC). Methods: Prospectively, patients with LACC who candidates for definitive chemoradiation at Shohadaye Haftom-e-Tir and Firozgar Hospitals (Tehran, Iran) were included in our study between April 2021 and December 2022. Hematological parameters were obtained from the blood sample test and peripheral blood smear before treatment. All patients diagnosed in stage IB to IVA received a similar treatment protocol and follow-up. Patients were divided into complete clinical (CR) and non-complete clinical responses (Non-CR). Leukocyte, Lymphocyte, neutrophil, platelet, hemoglobin (Hb), platelet-to-lymphocyte ratio (PLR), and neutrophil-to-lymphocyte ratio (NLR), were documented and then compared between two groups of responders. We used receiver operating characteristic (ROC) analysis to investigate the predictive value of these hematological parameters. Results: Out of 34 patients who met the inclusion criteria, 25 (73/5%) patients were complete responders and 9 (26.5%) were non-complete responders. The average number of neutrophils, leukocytes, and NLR was significantly higher among Non-complete responders. Hemoglobin in patients with non-complete responses was significantly lower than that of the other group of responders. Receiver operating characteristic curve analysis showed that the optimized cut-off values for pretreatment Hb and NLR were 11 and 2.1, respectively. Neutrophil-to-lymphocyte ratio cut-off point &gt; 2.1 is significantly associated with larger tumor size, low Hb, high platelet, and high leukocyte. Conclusions: hematological markers such as NLR can be a simple and inexpensive predictive factor to evaluate therapeutic response to chemoradiation in LACC patients.

Efficacy of nimotuzumab in combination with immunotherapy for a young recurrent cervical cancer patient: a case report and literature review.

Cervical cancer is one of the most common malignant tumors in women, and more than one-third of the patients have already developed to a locally advanced stage at initial diagnosis. After standard concurrent chemoradiotherapy, recurrence still occurs in 29-38% of patients with locally advanced cervical cancer (LACC), and the 5-year survival rate of patients with recurrence is only 3.8-13.0%, resulting in a poor prognosis and limited therapeutic choices. Currently, the recommended first-line systemic treatment for recurrent metastatic cervical cancer involves cisplatin or carboplatin in combination with paclitaxel-based chemotherapy, supplemented with the antivascular agent bevacizumab and the immune checkpoint inhibitor pembrolizumab. The use of these drugs, however, is limited due to side effects such as myelosuppression, gastrointestinal perforation, and bleeding, so new treatment modalities need to be explored. Anti-EGFR (epithelial growth factor receptor, anti-surface growth factor receptor antibody) targeted drugs have been demonstrated to have a significant radiosensitizing effect on synchronous chemoradiotherapy in LACC and are now considered to have potential for the treatment of recurrent cervical cancer. We represented a LACC patient who relapsed 6 months after concurrent chemoradiotherapy. The patient received six cycles of nimotuzumab combined with camrelizumab, and the efficacy was evaluated to be partial remission after two or four cycles of treatment, with progression-free survival up to 9 months, without significant side effects. Until March 2024, the patient was still undergoing treatment. Promising efficacy and tolerable side effects of nimotuzumab in combination with camrelizumab were observed in this case.

Efficacy and safety of different chemotherapy regimens concurrent with radiotherapy in the treatment of locally advanced cervical cancer

BackgroundEvaluate the efficacy and safety of different chemotherapy regimens concurrent with radiotherapy in treating locally advanced cervical cancer (LACC).MethodsRetrospective data was collected from LACC patients who were treated at our institution. These patients were categorized into three groups: the single-agent cisplatin (DDP) chemoradiotherapy group, the paclitaxel plus cisplatin (TP) chemoradiotherapy group, and the nanoparticle albumin-bound (nab-) paclitaxel combined with cisplatin (nPP) chemoradiotherapy group. The primary endpoints were overall survival (OS) and progression-free survival (PFS) and the secondary endpoints were objective response rate (ORR) and incidence of adverse events (AEs).ResultsA total of 124 patients were enrolled (32 in the DDP group, 41 in the TP group, and 51 in the nPP group). There were differences in OS (P = 0.041, HR 0.527, 95% CI 0.314–0.884) and PFS (P = 0.003, HR 0.517, 95% CI 0.343–0.779) between the three groups. Notably, the 2-year OS rate was significantly higher in the nPP group compared to the DDP group (92.2% vs. 85.4%, P = 0.012). The 2-year PFS rates showed a marked increase in the TP group (78.0% vs. 59.4%, P = 0.048) and the nPP group (88.2% vs. 59.4%, P = 0.001) relative to the DPP group, with multiple comparisons indicating that the 2-year PFS rate was significantly superior in the nPP group versus the DDP group (88.2% vs. 59.4%, P = 0.001). Moreover, the ORR was also significantly higher in the nPP group than in the DDP group (P = 0.013); and no statistically significant differences were found in the incidence of AEs among the groups (P > 0.05).ConclusionsIn LACC treatment, the two cisplatin-based doublet chemotherapy regimens are associated with better outcomes, with the nab-paclitaxel plus cisplatin regimen showing better efficacy than the paclitaxel plus cisplatin regimen. Furthermore, the AEs associated with these regimens were deemed tolerable. These findings could provide a reference for the clinical treatment of LACC. However, further prospective studies are needed to verify it.

Exclusion of non-Involved uterus from the target volume (EXIT-trial): An individualized treatment for locally advanced cervical cancer using modern radiotherapy and imaging techniques followed by completion surgery

Background and purposeChemoradiotherapy followed by brachytherapy is the standard of care for locally advanced cervical cancer (LACC). In this study, we postulate that omitting an iconographical unaffected uterus (+12 mm distance from the tumour) from the treatment volume is safe and that no tumour will be found in the non-targeted uterus (NTU) leading to reduction of high-dose volumes of surrounding organs at risk (OARs) Material and MethodsIn this single-arm phase 2 study, two sets of target volumes were delineated: one standard-volume (whole uterus) and an EXIT-volume (exclusion of non-tumour-bearing parts of the uterus with a minimum 12 mm margin from the tumour). All patients underwent chemoradiotherapy targeting the EXIT-volume, followed by completion hysterectomy. In 15 patients, a plan comparison between two treatment plans (PTV vs PTV_EXIT) was performed. The primary endpoint was the pathological absence of tumour involvement in the non-targeted uterus (NTU). Secondary endpoints included dosimetric impact of target volume reduction on OARs, acute and chronic toxicity, overall survival (OS), locoregional recurrence-free survival (LRFS), and progression-free survival (PFS). ResultsIn all 21 (FIGO stage I: 2; II: 14;III: 3; IV: 2) patients the NTU was pathologically negative. Ssignificant reductions in Dmean in bladder, sigmoid and rectum; V15Gy in sigmoid and rectum, V30Gy in bladder, sigmoid and rectum; V40Gy and V45Gy in bladder, bowel bag, sigmoid and rectum; V50Gy in rectum were achieved. Median follow-up was 54 months (range 7–79 months). Acute toxicity was mainly grade 2 and 5 % grade 3 urinary. The 3y- OS, PFS and LRFS were respectively 76,2%, 64,9% and 81 %. ConclusionMRI-based exclusion of the non-tumour-bearing parts of the uterus at a minimum distance of 12 mm from the tumour out of the target volume in LACC can be done without risk of residual disease in the NTU, leading to a significant reduction of the volume of surrounding OARS treated to high doses.

Machine learning-based radiomics for predicting outcomes in cervical cancer patients undergoing concurrent chemoradiotherapy

PurposesTo investigate the value of machine learning-based radiomics for predicting disease-free survival (DFS) and overall survival (OS) undergoing concurrent chemoradiotherapy (CCRT) for patients with locally advanced cervical cancer (LACC). Materials and methodsIn this multicentre study, 700 patients with IB2-IVA cervical cancer who underwent CCRT with ongoing follow-up were retrospectively analyzed. Three-dimensional radiomics features of primary lesions and its surrounding 5 mm region in T2WI sequences were collected. Six machine learning methods were used to construct the optimal radiomics model for accurate prediction of DFS and OS after CCRT in LACC patients. Eventually, TCGA and GEO databases were used to explore the mechanisms of radiomics in predicting the progression and survival of cervical cancer. This study adhered CLEAR for reporting and its quality was assessed using RQS and METRICS. ResultsIn the prediction of DFS, the RSF model combined tumor and peritumor radiomics demonstrated the best predictive efficacy, with the AUC for predicting 1-year, 3-year, and 5-year DFS in the training, validation, and test sets of 0.986, 0.989, 0.990, and 0.884, 0.838, 0.823, and 0.829, 0.809, 0.841, respectively. In the prediction of OS, the GBM model best performer, with AUC of 0.999, 0.995, 0.978, and 0.981, 0.975, 0.837, and 0.904, 0.860, 0.905. Differential genes in TCGA and GEO suggest that the prediction of radiomics model may be associated with KDELR2 and HK2. ConclusionMachine learning-based radiomics models help to predict DFS and OS after CCRT in LACC patients, and the combination of tumor and peritumor information has higher predictive efficacy, which can provide a reliable basis for therapeutic decision-making in cervical cancer patients.

Radiomics analysis for prediction of lymph node metastasis after neoadjuvant chemotherapy based on pretreatment MRI in patients with locally advanced cervical cancer.

This study aims to develop and validate a pretreatment MRI-based radiomics model to predict lymph node metastasis (LNM) following neoadjuvant chemotherapy (NACT) in patients with locally advanced cervical cancer (LACC). Patients with LACC who underwent NACT from two centers between 2013 and 2022 were enrolled retrospectively. Based on the lymph node (LN) status determined in the pathology reports after radical hysterectomy, patients were categorized as LN positive or negative. The patients from center 1 were assigned as the training set while those from center 2 formed the validation set. Radiomics features were extracted from pretreatment sagittal T2-weighted imaging (Sag-T2WI), axial diffusion-weighted imaging (Ax-DWI), and the delayed phase of dynamic contrast-enhanced sagittal T1-weighted imaging (Sag-T1C) for each patient. The K-best and least absolute shrinkage and selection operator (LASSO) methods were employed to reduce dimensionality, and the radiomics features strongly associated with LNM were selected and used to construct three single-sequence models. Furthermore, clinical variables were incorporated through multivariate regression analysis and fused with the selected radiomics features to construct the clinical-radiomics combined model. The diagnostic performance of the models was assessed using receiver operating characteristic (ROC) curve analysis. The clinical utility of the models was evaluated by the area under the ROC curve (AUC) and decision curve analysis (DCA). A total of 282 patients were included, comprising 171 patients in the training set, and 111 patients in the validation set. Compared to the Sag-T2WI model (AUC, 95%CI, training set, 0.797, 0.722-0.782; validation set, 0.648, 0.521-0.776) and the Sag-T1C model (AUC, 95%CI, training set, 0.802, 0.723-0.882; validation set, 0.630, 0.505-0.756), the Ax-DWI model exhibited the highest diagnostic performance with AUCs of 0.855 (95%CI, 0.791-0.919) in training set, and 0.753 (95%CI, 0.638-0.867) in validation set, respectively. The combined model, integrating selected features from three sequences and FIGO stage, surpassed predictive ability compared to the single-sequence models, with AUC of 0.889 (95%CI, 0.833-0.945) and 0.859 (95%CI, 0.781-0.936) in the training and validation sets, respectively. The pretreatment MRI-based radiomics model, integrating radiomics features from three sequences and clinical variables, exhibited superior performance in predicting LNM following NACT in patients with LACC.

Construction and Validation of a MRI‑Based Radiomic Nomogram to Predict Overall Survival in Patients with Local Advanced Cervical Cancer: A Multicenter Study

BackgroundCervical cancer is the fourth most common cancer among women. Radiomics has emerged as a new approach providing valuable information for cancer management. The aim of this study was to construct a radiomics nomogram to accurately predict survival outcomes in patients with locally advanced cervical cancer. MethodsThis retrospective study enrolled a total of 582 locally advanced cervical cancer patients from three center (training cohort: n=228; internal validation cohort: n=98; external validation cohort: n=256). Radiomic features were extracted from pretreatment MRI images. Least absolute shrinkage and selection operator logistic regression (LASSO) was applied to select radiomic features and calculated the radiomic scores. Univariate and multivariate Cox proportional hazards regression analyses were used to identify the independent prognostic clinic-radiological factors for cervical cancer, which were incorporated into the nomogram. ResultsA total of 6 radiomic features were found to be associated with overall survival of locally advanced cervical cancer patients. The AUC of radiomic scores in the training cohort was 0.634-0.708 for the training cohort, 0.725-0.762 for internal validation cohort and 0.788-0.881 for the external validation cohort. Age, parametrial invasion, and radiomic score were the independent prognostic indicators for cervical cancer patients (Age: HR=1.041, 95% CI=1.012-1.071, p=0.006; Parametrial invasion: HR=4.755, 95% CI=1.493-15.144, p=0.008; HR=2.324, 95% CI=1.050-5.143, p=0.037). The nomogram model incorporating these factors showed favorable discrimination in predicting the overall survival rates of cervical cancer patients, with the AUC values of 0.809, 0.808, and 0.862 for 1-, 2-, and 3-year predictions. The decision curve analysis (DCA) indicated that the nomogram model achieved the highest clinical net benefit across the entire range of reasonable threshold probabilities. ConclusionThe nomogram, incorporating clinicopathological factors and radiomic features derived from MRI images, showed satisfactory discrimination in predicting the overall survival rates of locally advanced cervical cancer patients.

A novel nomogram based on inflammation biomarkers for predicting radiation cystitis in patients with local advanced cervical cancer.

Platelet-to-albumin ratio (PAR) is a new systemic inflammatory prognostic indicator associated with many inflammatory diseases. However, its role in radiation cystitis (RC) is obscure. This study aimed to explore whether PAR could be used as an effective parameter for predicting the RC risk in local advanced cervical cancer (CC) treated with radiotherapy. A total of 319 local advanced CC patients who received radical radiotherapy at Fujian Cancer Hospital were enrolled between December 2018 and January 2021. Demographics and clinical parameters were retrospectively analyzed. Univariate and multivariate analyses were used to identify the risk factors for RC. Backward and stepwise regression was applied to construct two monograms-one with primary significant factors and the other with extra inflammatory biomarkers. A DeLong test was applied to compare the prediction abilities of two nomograms. Calibration curves and decision curve analysis (DCA) evaluated its prediction consistency, discrimination ability, and clinical net benefit. Univariate analysis showed that age, tumor size, stage, total radiation dose, pelvic radiation dose, Systemic Immune-Inflammation Index (SII), platelet-to-lymphocyte ratio (PLR), and PAR were significantly associated with RC occurrence (all p < 0.05). Multivariate analyses indicated that age, tumor size, stage, total radiation dose, and PAR were independent factors (all p < 0.05). Then, the area under curve (AUC) value of the nomogramSII+PAR was higher (AUC = 0.774) compared to that of the baseline nomogram (AUC = 0.726) (pDelong = 0.02). Also, the five-cross validation confirmed the stability of the nomogramSII+PAR. Moreover, the calibration curve and DCA exhibited the nomograms' good prediction consistency and clinical practicability. PAR and SII could be valued for CC patients who are treated with radiation therapy. The nomogram based on PAR and SII could stratify patients who need extra intervention and nursing care to prevent bladder radiation damage and improve patients' quality of life.

Concurrent Chemoradiotherapy Compared With Neoadjuvant Chemotherapy Followed by Radical Hysterectomy for FIGO Stage IIB Cervical Cancer Patients: A Systematic Review and Meta-analysis [ID 2683429

INTRODUCTION: Cervical cancer is the fourth most common malignant disease and cause of cancer death in women worldwide. FIGO stage IIB includes cervical carcinomas with invasion of the parametria. Despite innovative treatment approaches, recurrence and mortality rates among patients with locally advanced cervical cancer (LACC) have not been significantly reduced. The current treatment recommendation for FIGO stage IIB is concurrent chemoradiotherapy (CCRT). Neoadjuvant chemotherapy followed by radical hysterectomy (NACT+HE) represents a valid alternative. METHODS: According to the PRISMA guidelines and Cochrane handbook recommendations, we systematically searched the following databases up to January 2023: PubMed, Scopus, Web of Science, and Cochrane CENTRAL for relevant studies and reports that compare NACT+HE versus CCRT for patients with LACC and specifically with FIGO stage IIB. RESULTS: Our search results revealed 1,034 records, of them only 6 studies (n=2,055); 2 clinical trials and 4 observational cohorts were eligible to be included in both qualitative and quantitative analyses. Patients with FIGO stage IB2–IVA showed no advantage for 5-year overall survival (OS), disease-free survival (DFS), or progression-free survival (PFS) with NACT+HE compared to CCRT (hazard ratio [HR] 0.66 [95% CI: 0.43–1.01]; HR 0.62 [95% CI: 0.23–1.65]; and HR 0.88 [95% CI: 0.51–1.50]). A subgroup analysis for patients with FIGO stage IIB showed a significantly better 5-year DFS for CCRT compared to NACT+HE (HR 1.86 [95% CI: 1.23–2.81]); however, no significant improvement was shown for 5-year OS and 5-year PFS (HR 0.88 [95% CI: 0.52–1.49] and HR 0.85 [95% CI: 0.56–1.29]), respectively. CONCLUSION: This meta-analysis did not show any advantage for women with LACC treated with the NACT+HE approach compared to those treated with the CCRT approach. However, in a stage-specific analysis of patients with FIGO stage IIB cervical cancer, CCRT was superior to NACT+HE in terms of DFS, whereas no significant difference was shown for OS or PFS.

Cell-free human papillomavirus (HPV) DNA is a sensitive biomarker for prognosis and for early detection of relapse in locally advanced cervical cancer.

Human papillomavirus (HPV) is the cause of the majority of cervical cancers and has been showed to be released as cell-free tumour DNA (ctHPV DNA) into the circulation. We here analyse if ctHPV DNA could be used as a prognostic biomarker and/or to detect relapse earlier than traditional methods in locally advanced cervical cancer (LACC). 74 patients with LACC were included, 66/74 were positive for 13 high-risk HPV-types using a bead-based assay on tumour biopsies. HPV-type-specific droplet digital PCR (ddPCR) assays were developed. Longitudinal plasma samples were then analysed for the biopsy-verified HPV-type for each patient. 418 plasma samples were analysed. Patients were followed for a median of 37 months. Results were correlated to tumour- and clinical characteristics. 92.4% of pre-treatment plasma samples were positive for ctHPV DNA. Persistent ctHPV DNA in end-of-treatment, early follow-up (1-2 months after end-of-treatment) or tumour evaluation (3-4 months after end-of-treatment) plasma was correlated with worse progression-free survival (p < 0.001) compared to if ctHPV DNA was not found. The positive predictive value of ctHPV-status at early follow-up for predicting disease progression was 87.5% and the negative predictive value was 89.3%. ctHPV DNA was found in plasma before relapse was diagnosed on radiology in all patients (n=10) who experienced relapse after complete clinical response to treatment with a median 315 days lead time. ctHPV DNA in follow-up plasma is a promising prognostic biomarker in patients with LACC, useful for analysis of response to therapy and for early detection of relapse.

Monocentric Retrospective Study: Efficacy, Feasibility, and Prognostic Factors of Single-Insertion High-Dose-Rate Brachytherapy With 4 Sessions for Locally Advanced Cervical Cancer

ObjectiveThis study aims to assess the feasibility and efficacy of high-dose-rate (HDR) brachytherapy (BT) administered in a single insertion with four treatment sessions for locally advanced cervical cancer (LACC), and to identify the prognostic factors influencing outcomes. MethodsWe retrospectively analyzed the clinical data of cervical cancer patients with locally advanced disease (International Federation of Gynecology and Obstetrics 2018 (FIGO) IB-IVB), treated at our institution from January 2014 through December 2021. Each patient received definitive radiotherapy with an external irradiation dosage between 45-50.4 Gy along with concurrent chemotherapy (CCRT). HDR-BT (24 Gy) was prescribed to a high-risk clinical target volume (HR-CTV). Results139 patients were included and HDR-BT program could be fully performed in 136 patients (98%). Over a median follow-up duration of 40.5 months, the two-year local control (LC), overall survival (OS), and disease-free survival (DFS) rates stood at 79.4%, 77.7%, and 61.7% respectively, with five-year rates at 78.2%, 61.6%, and 55.7%. Multivariate analysis revealed the primary determinant of LC as the tumor's response to external beam radiotherapy (EBRT) as determined via magnetic resonance imaging (MRI) prior to BT. Parametrial involvement demonstrated a significant multivariate association with DFS (p = 0.04). Regarding OS, parametrial invasion (p = 0.01) and the tumor's response post-chemoradiotherapy (p = 0.02) emerged as significant factors. Regarding chronic toxicities, 18% (25 patients) experienced grade 3 complications. An optimal D2cc (Bowel) threshold of 70 Gy (p = 0.001) was identified to limit chronic digestive complications of grade 3 or higher. ConclusionThe implementation of single-insertion, four-session HDR-BT could be performed in 98% of the patients. It yields favorable LC and OS rates, coupled with tolerable toxicity in patients with LACC. Response to initial chemoradiotherapy evaluated on pre-BT MRI is an important prognostic factor and could help to individualized therapeutic strategies.