• Is HDR brachytherapy for carcinoma of the uterine cervix high-throughput but high risk?

• High and low dose-rate brachytherapy for cervical carcinoma.

• Postsurgical pelvis: treatment follow-up.

• Current approaches of neoadjuvant chemotherapy in cervical cancer.

• Chemoradiation in cervical carcinoma: a must?

• Identifying local tumor variables for operable node-negative, margin-free patients with bulky cervical carcinoma of FIGO stage IB, IIA

• Piver's radical hysterectomy (type III): Endo-Gia 30 stapler versus traditional forcipressure for resection of the cardinal ligament.

• [Treatment protocol for cervical carcinoma]

• The effect of a metal hip prosthesis on the radiation dose in therapeutic photon beam irradiations.

• Chemoradiation in cervical cancer with cisplatin and high-dose rate brachytherapy combined with external beam radiotherapy. Results of a

• Postoperative low-pelvic irradiation for stage I-IIA cervical cancer patients with risk factors other than pelvic lymph node metastasis.

• Moving brachytherapy from art to science.

• Blood transfusion and the risk of recurrence in squamous cell carcinoma of the cervix: a gynecologic oncology group study.

• Long-term follow-up of concurrent radiotherapy and chemotherapy for locally advanced cervical cancer: 12-Year survival after

1
UI - 9636004
AU - Fowler JF
TI - Is HDR brachytherapy for carcinoma of the uterine cervix high-throughput but high risk?
SO - Acta Oncol 1998;37(2):113-5

2
UI - 9636005
AU - Orton CG
TI - High and low dose-rate brachytherapy for cervical carcinoma.
SO - Acta Oncol 1998;37(2):117-25
AD - Karmanos Cancer Institute, Detroit Medical Center and Wayne State University, MI, USA. ortonc@kci.wayne.edu
For the brachytherapy component of the radiation treatment of cervical carcinoma, high dose rate (HDR) is slowly replacing conventional low dose rate (LDR) due primarily to radiation safety and other physical benefits attributed to the HDR modality. Many radiation oncologists are reluctant to make this change because of perceived radiobiological disadvantages of HDR. However, in clinical practice HDR appears to be as effective as LDR but with a lower risk of late complications, as demonstrated by one randomized clinical trial and two comprehensive literature and practice surveys. The reason for this appears to be that the radiobiological disadvantages of HDR are outweighed by the physical advantages.

3
UI - 12117198
AU - Sugimura K; Okizuka H
TI - Postsurgical pelvis: treatment follow-up.
SO - Radiol Clin North Am 2002 May;40(3):659-80, viii
AD - Department of Radiology, Kobe University Graduate School of Medicine, Japan. sugimura@kobe-u.ac.jp
Imaging for recurrence and complications of gynecologic malignancies following treatment with radical hysterectomy, chemotherapy, and radiation therapy has become an important determinant for treatment options available to patients. MR imaging and computed tomography can be used to provide evidence of limited local disease recurrence and thereby identify disease that is still potentially curable with adjuvant treatments. This article examines the imaging modalities currently used to detect recurrence and assist in making treatment changes for gynecologic malignancies and presents specific patient findings following definitive primary treatment of uterine cancer and ovarian cancer with radical hysterectomy, radiation therapy, or chemotherapy.

4
UI - 12113071
AU - Aoki Y; Tanaka K
TI - Current approaches of neoadjuvant chemotherapy in cervical cancer.
SO - Expert Rev Anticancer Ther 2002 Feb;2(1):73-82
AD - Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi dori, Niigata 951-8510, Japan. yoichi@med.niigata-u.ac.jp
Despite remarkable improvement in clinical management, the survival of cervical cancer patients has shown only minor progress in the last decade, particularly in patients with advanced and high-risk disease. Multimodal treatment option has been investigated, such as the concurrent use of chemotherapy and radiation, neoadjuvant chemotherapy and radical hysterectomy, or neoadjuvant chemotherapy followed by radiotherapy. Recently, a flow of randomized clinical trials have demonstrated a benefit from the concurrent chemoradiation for the treatment of the cancer of the cervix. This review will summarize the role and benefit of neoadjuvant chemotherapy in combination with sequential or concurrent radiotherapy and radical surgery for treatment of cervical cancer.

5
UI - 12113072
AU - Cellini N; Morganti AG; Macchia G; Valentini V; Luzi S; Smaniotto D
TI - Chemoradiation in cervical carcinoma: a must?
SO - Expert Rev Anticancer Ther 2002 Feb;2(1):83-9
AD - Radiation Therapy Department Policlinico A. Gemelli, Universita Cattolica del S. Cuore 00168, Roma, Italy. ncellini@rm.unicatt.it
Cervical carcinoma is one of the most frequent gynecological malignancies. Literature shows that while the rate is exceedingly low in systematically screened populations, the incidence remains high because of large populations of at-risk women--particularly in underserved nations and in medically indigent subpopulations of Western nations--who are not screened. Recently, a series of randomized trials has demonstrated the possibility to dramatically improve the prognosis of these patients by using concurrent chemoradiation. In particular, concurrent chemoradiation represents a major treatment option in patients with bulky IB-IIA disease, IIB-IVA disease and resected IB-IIA disease with poor prognostic factors. However, further studies are necessary to optimize treatment schedules and particularly to define the best drug combination to be used during radiation therapy, improve patients selection by the analysis of anatomical (TNM stage) and non-anatomical (tumor oxygenation, genetic markers, tumor angiogenesis) prognostic factors, explore novel treatment strategies, such as use of neoadjuvant chemoradiation in locally advanced tumors, integration of antiangiogenetic therapies in chemoradiation schedules, use of supportive treatments aimed to overcome tumor hypoxia, to evaluate the possibility of 'cure' of locally recurrent tumors by chemoradiation and finally to define the best 'second-line' treatment for patients failing after chemoradiation with or without surgery.

6
UI - 11874072
AU - Loh TO; Wang PH; Yen MS; Chao KC; Ng HT; Yuan CC
TI - Identifying local tumor variables for operable node-negative, margin-free patients with bulky cervical carcinoma of FIGO stage IB, IIA and IIB without adjuvant therapies.
SO - Eur J Gynaecol Oncol 2001;22(6):420-2
AD - Department of Obstetrics and Gynecology, Veterans General Hospital-Taipei, National Yang-Ming University School of Medicine, Taiwan.
PURPOSE: To identify local risk factors for FIGO IB, IIA and IIB bulky cervical squamous cell carcinoma (tumor size > or = 4 cm) patients with node-negative, margin-free tumors treated by radical hysterectomy, pelvic lymph node and para-aortic lymph node dissections without adjuvant therapies. MATERIALS AND METHODS: Thirty-four patients were recruited between 1976 and 1989 because they all declined any postoperative adjuvant therapy. The pathology reports showed that all the specimen margins were free from cancer cells with no para-aortic or pelvic lymph node metastases. The survival interval was calculated starting from the time of surgical intervention to the time of death or the end of this study in the year 2000. RESULT: Tumor variables including cell differentiation, depth of stromal invasion, parametrial invasion, vaginal invasion, uterine body invasion, age, and FIGO stage were analyzed. Only vaginal invasion showed statistical significance for decreasing patient disease-free survival in both univariate and multivariate analyses with p values of 0.003 and 0.002, respectively. CONCLUSION: For node-negative and margin-free patients with bulky cervical squamous cell carcinoma with operable stage IB and IIB, surgical intervention alone could suffice when no vaginal invasion is noted plus an 85% survival rate could be achieved. A prospective pilot study should be initiated although this study showed an excellent survival rate which is perhaps due to the limited number of cases.

7
UI - 11874073
AU - Scollo P; Scibilia G; Nocera F; Ruggeri R; Caudullo S
TI - Piver's radical hysterectomy (type III): Endo-Gia 30 stapler versus traditional forcipressure for resection of the cardinal ligament.
SO - Eur J Gynaecol Oncol 2001;22(6):423-6
AD - Department of Obstetric-Gynecology, Cannizzaro Hospital, Catania, Italy.
OBJECTIVE: Morbidity and costs associated with Piver's radical hysterectomy (type III) are noteworthy. The Endo-Gia stapler method for resection of cardinal ligaments can reduce duration of surgery and hospitalization, blood loss, costs and postoperative infection rates. METHOD: Two groups of patients (homogeneous for age, weight and medical condition) were studied: one group was operated on using the Endo-Gia stapler method (n=52) and the other with the traditional forcipressure (n=13). The size of parametrial tissue removed, blood loss, duration of surgery, duration of hospitalization, cost of materials and postoperative fever were compared in the two groups. RESULT: Mean operative times were lower in the Endo-Stapler group than in the controls (mean 180 min versus 220 min). Mean blood loss was 300 cc in the stapler group versus 450 cc in the forcipressure group. Mean cost of surgery (considering costs of materials, hospital stay. duration of surgery), was lower in the stapler group (3,095 euros) than in the group who underwent traditional surgery (3,434 euros). CONCLUSION: Our data suggest the Endo-Gia stapler method significantly reduces blood loss, operative time and cost.

8
UI - 12070925
AU - Vujkov T; Zivaljevic M; Novakovic P; Erak M; Rajovic J; Mandic A
TI - [Treatment protocol for cervical carcinoma]
SO - Med Pregl 2002 Mar-Apr;55(3-4):105-8
AD - Klinika za operativnu onkologiju, ginekolosko odeljenje, Institut za onkologiju, Sremska Kamenica.
INTRODUCTION: Cervical cancer is the second most common cancer in women worldwide and the second cause of cancer death among women. About 95% (90% in developed countries) of invasive carcinomas are of squamous types, and 5% (10% in developed countries) are adenocarcinomas. FIGO classification of cervical carcinomas, based on clinical staging and prognostic factor dictate therapeutic procedures and help in designing treatment protocols. THERAPEUTIC MODALITIES: Surgical therapy includes conization, radical hysterectomy with pelvic lymphadenectomy and palliative operation--urinary diversion and colostomy. Radiotherapy, brachytherapy and teletherapy are most recently combined with chemotherapy as concurrent chemoradiation. DISCUSSION AND CONCLUSION: No change in therapeutic modalities will ever decrease mortality rate of cervical carcinoma as much as education, prevention and early screening. The 5-year survival for locally advanced disease has not improved during the last 40 years as a result of failure to deliver therapy to the paraaortic region. Paraaortic lymph nodes should be evaluated before therapy planning by different imaging procedures, or more exactly by surgical staging: laparoscopy or laparotomy. Radical operations of cervical carcinoma should be performed by experienced surgeons, educated for this type of operation, with sufficient number of cases.

9
UI - 12137022
AU - Lin SY; Chu TC; Lin JP; Liu MT
TI - The effect of a metal hip prosthesis on the radiation dose in therapeutic photon beam irradiations.
SO - Appl Radiat Isot 2002 Jul;57(1):17-23
AD - Department of Nuclear Science, National Tsing Hua University, Hsinchu, Taiwan.
Prostate and cervical cancer patients are often treated with external X-ray beams of bi-lateral incidence. Such treatment may incur some dose effect that cannot be predicted precisely in commercial treatment planning systems (TPS) for patients having undergone total hip replacement. This study performs a Monte Carlo (MC) simulation and an analytical calculation (convolution superposition algorithm which is implemented in ADAC TPS) of a 6 MV, 5 x 5 cm2 X-ray beam incident into water with the existence of hip prosthesis, e.g. Ti6A14V and CoCrMo alloy. The results indicate that ADAC TPS cannot precisely account for the scatter and backscatter radiation that a metal hip prosthesis causes. For percent depth dose (PDD) curves, the maximum underdosage of ADAC TPS up to 5mm above the interface between dense material and water is 5%, 20% and 27% for PDD(Bone), PDD(Ti) and PDD(Co), respectively. The dose re-buildup, which occurs behind the hip region, becomes more and more obvious for denser medium existed in water. Increasing inhomogeneity also enhances the underdosage of ADAC for greater depth (> 10cm), as the figures of nearly 2% in PDD(Bone), PDD(Ti) and 4-5% in PDD(Co) reveal. Overestimating the attenuated power of high-density non-water material in ADAC TPS causes this underdosage. For dose profiles, no significant differences were found in Profile(Bone) at any depth. Profile(Ti) reveals that MC slightly exceeds ADAC at off-axis position 1.0-2.0 cm. Profile(Co) reveals this more obviously. This finding means that scatter radiation from these denser materials is significant and cannot be predicted precisely in ADAC.

10
UI - 12163992
AU - Strauss HG; Kuhnt T; Laban C; Puschmann D; Pigorsch S; Dunst J; Koelbl
TI - H; Haensgen G Chemoradiation in cervical cancer with cisplatin and high-dose rate brachytherapy combined with external beam radiotherapy. Results of a phase-II study.
SO - Strahlenther Onkol 2002 Jul;178(7):378-85
AD - Department of Gynecology, Martin-Luther University, Halle-Wittenberg, Germany. hans.strauss@medizin.uni-halle.de
BACKGROUND: In 1999, five randomized studies demonstrated that chemoradiation with cisplatin and low-dose rate (LDR) brachytherapy has a benefit in locally advanced cervical cancer and for surgically treated patients in high-risk situations. We evaluated the safety and efficacy of concomitant chemoradiation with cisplatin and high-dose rate (HDR) brachytherapy in patients with cervical cancer. PATIENTS AND METHODS: 27 patients were included in our phase-II trial: 13 locally advanced cases (group A) and 14 adjuvant-therapy patients in high-risk situations (group B). A definitive radiotherapy was performed with 25 fractions of external beam therapy (1.8 Gy per fraction/middle shielded after eleven fractions). Brachytherapy was delivered at HDR schedules with 7 Gy in point A per fraction (total dose 35 Gy) in FIGO Stages IIB-IIIB. The total dose of external and brachytherapy was 70 Gy in point A and 52-54 Gy in point B. All patients in stage IVA were treated without brachytherapy. Adjuvant radiotherapy was performed with external beam radiotherapy of the pelvis with 1.8 Gy single-dose up to 50.4 Gy. Brachytherapy was delivered at HDR schedules with two fractions of 5 Gy only in patients with tumor-positive margins or tumor involvement of the upper vagina. The chemotherapeutic treatment schedule provided six courses of cisplatin 40 mg/m2 weekly recommended in the randomized studies GOG-120 and -123. RESULTS: A total of 18/27 patients (66.7%) completed all six courses of chemotherapy. Discontinuation of radiotherapy due to therapy-related morbidity was not necessary in the whole study group. G3 leukopenia (29.6%) was the only relevant acute toxicity. There were no differences in toxicity between group A and B. Serious late morbidity occurred in 2/27 patients (7.4%). 12/13 patients (92.3%) with IIB-IVA cervical cancer showed a complete response (CR). 13/14 adjuvant cases (92.8%) are free of recurrence (median follow up: 19.1 months). CONCLUSION: Concomitant chemoradiation with cisplatin 40 mg/m2 weekly x 6 using HDR brachytherapy represents a promising treatment of cervical cancer with an acceptable toxicity.

11
UI - 12128131
AU - Hong JH; Tsai CS; Lai CH; Chang TC; Wang CC; Lee SP; Tseng CJ; Hsueh S
TI - Postoperative low-pelvic irradiation for stage I-IIA cervical cancer patients with risk factors other than pelvic lymph node metastasis.
SO - Int J Radiat Oncol Biol Phys 2002 Aug 1;53(5):1284-90
AD - Department of Radiation Oncology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan. jihong@adm.cgmh.org.tw
PURPOSE: To retrospectively investigate whether postoperative low-pelvic radiotherapy (RT) is an appropriate treatment for node-negative, high-risk Stage I-IIA cervical cancer patients. METHODS AND MATERIALS: A total of 228 Stage I-IIA cervical cancer patients treated by radical surgery and postoperative RT were included in this study. All patients had histopathologically negative pelvic node metastasis, but at least one of the following risk factors: parametrial involvement, positive or close resection margins, invasion depth two-thirds or greater cervical stromal thickness. Seventy-nine patients (35%) received 30-50 Gy (median 44) to whole pelvis and a boost dose to the low pelvis (whole-pelvic RT group); the other 149 patients (65%) received low-pelvic RT only (low-pelvic RT group). For both groups, the total external RT dose to the low pelvis ranged from 40 to 60 Gy (median 50). The potential factors associated with survival, small bowel (gastrointestinal) complications, and leg lymphedema were analyzed, and patients who had a relapse in the upper pelvis were identified. RESULTS: The 5-year overall and disease-specific survival rate was 84% and 86%, respectively. After multivariate analysis, only bulky tumor (>or=4 cm) and non-squamous cell carcinoma were significantly associated with survival. Parametrial involvement, lymph-vascular invasion, 50.4 Gy to the low pelvis, but not old age and treatment technique (AP-PA vs. box), were significantly associated with gastrointestinal complications. Three patients (2%) in the low-pelvic RT group and 6 patients (8%) in the whole-pelvic RT group were found to have Grade III or higher small bowel complications (p = 0.023). Thirty-one percent of patients developed lymphedema of the leg. A dose to the low pelvis >50.4 Gy and an AP-PA field, but not whole-pelvic RT, old age, or the number of sampled lymph nodes, were associated with lymphedema of the leg. Five patients (3.6%) of the low-pelvic RT group and none of the whole-pelvic RT group developed upper pelvis relapse. Three of these 5 patients had upper pelvic relapse alone. CONCLUSION: Compared with whole-pelvic RT plus low-pelvic boost, low-pelvic RT alone significantly reduces the small bowel complications in node-negative, high-risk, Stage I-IIA cervical cancer patients. Although low-pelvic RT alone increases the incidence of upper pelvic relapse, its effect on survival is not substantial. Low-pelvic RT alone appears to be an appropriate treatment method for this group of patients.

12
UI - 11417532
AU - Beitler JJ
TI - Moving brachytherapy from art to science.
SO - Int J Radiat Oncol Biol Phys 2001 Jul 1;50(3):837-8

13
UI - 12151973
AU - Spirtos NM; Westby CM; Averette HE; Soper JT
TI - Blood transfusion and the risk of recurrence in squamous cell carcinoma of the cervix: a gynecologic oncology group study.
SO - Am J Clin Oncol 2002 Aug;25(4):398-403
AD - Women's Cancer Center of Northern California, Palo Alto, California, U.S.A.
The objective of this study was to determine whether perioperative blood transfusion adversely affected risk of recurrence in 504 evaluable patients with stage I squamous cell carcinoma of the cervix accessioned prospectively in a Gynecologic Oncology Group study. After eliminating patients with advanced-stage disease, wrong cell type, and those without transfusion information available, 504 of 1,125 patients accrued to Gynecologic Oncology Group Protocol 49 were included in this study. Seventy-seven percent of the patients received blood products within 2 weeks of surgery. Either the Pearson chi-square or Fisher exact test assesses the association of categorical clinical-pathologic factors with respect to transfusion status. Cox's proportional hazards model was used to identify and simultaneously evaluate the independent prognostic factors associated with survival and recurrence-free interval (RFI). The number of units transfused was found to be significantly related to RFI and survival using univariate analysis. When adjusted for clinical tumor size, capillary-lymphatic space involvement, and depth of tumor invasion using multivariate analysis, the number of units transfused was no longer statistically significant with respect to either RFI or survival. Recurrence and survival in patients with squamous cell cancer of the cervix could not be shown to be independently related to transfusion status.

14
UI - 12012015
AU - Berclaz G; Gerber E; Beer K; Aebi S; Greiner R; Dreher E; Buser K
TI - Long-term follow-up of concurrent radiotherapy and chemotherapy for locally advanced cervical cancer: 12-Year survival after radiochemotherapy.
SO - Int J Oncol 2002 Jun;20(6):1313-8
AD - Department of Obstetrics and Gynecology, University Hospital, Inselspital Bern, Schanzeneckstrasse 1, 3012, Switzerland. gilles.berclaz@insel.ch
Recently randomized trials show an overall survival advantage of 30% for cisplatin-based chemotherapy given concurrently with radiation therapy. Current data do not allow to conclude which drugs could be best combined with cisplatin. Here we report the very long-term results of a prospective phase II trial of concurrent radiochemotherapy in advanced cancer of the cervix. Psychological impact has been evaluated with long-term survivors. Patient with squamous cell carcinoma of the cervix FIGO stage IIB, III or IVA received a concomitant chemotherapy with rate was 82%. All 22 patients treated showed acute hematological toxicity and two patients developed severe late bowel toxicity. Ten patients (45%) were alive after a median observation time of 145.5 months. Intolerance to certain food and vaginal changes due to radiotherapy remain problematic. The lack of improvement compared to cisplatin alone and late bowel toxicity do not support the use of mitomycin C in the combination of the concurrent treatment of chemoradiation. The psychological impact of this treatment should not be minimized. Most problems tend to diminish with time with the exception of intestinal side effects and vaginal changes.

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