Study On Treatment Model And Evidence - Based Medicine Of Cervical Cancer ⅠB - Ⅱ

Cervical cancer is the fourth leading cause of cancer deaths in women worldwide, 5-year survival of some patients with stage IB or more is only about 50%, the major reasons for treatment failed in un-control local tumor or distant metastasis. The reasonable treatment play an important role to reduce the ecurrence of cervical cancer. In the past 20 years, the combined therapy and individual therapy for cervical cancer becomes a respected treatment pattern, and achieved some success, but there are still controversial. Various treatments have been used, including neoadjuvant chemotherapy,postoperative adjuvant chemotherapy,, concurrent chemotherapy and radiotherapy, three dimensional conformal intensity modulated radiation therapy, three dimensional intracavitary brachytherapy, lymph node sampling,sentinel lymph node biopsy, nerve-sparing radical hysterectomy.Recently,the best treatment mode of cervical cancer I b-Ⅱ b are still controversial.Surgery,radiationtherapy and(or) chemotherapy are applied reasonably and effectively in improving of prognosis and increasing survival rate of cervical cancer I b-Ⅱ b,but there are many complications at the same time.The surgery and radiotherapy are still traditional treatment pattern for patients with I b-II b stage. Over the past 10 years, with the domestic and foreign scholars to explore, it has developed that direct to the comprehensive and individualized treatment. But the best method of treatment is still controversial. In this paper, the status of the treatment of cervical cancer Ⅰb-Ⅱb mode period, including chemotherapy, surgery, radiotherapy and combined therapy were reviewed.OBJECTIVE:To evaluate the efficacy of neoadjuvant chemotherapy (NACT) and to evaluate the toxicity and efficacy of irinotecan plus cisplatin neoadjuvant chemotherapy for stages I B2, ⅡA, and ⅡB cervical cancer.METHODS:248 patients were screened for eligibility and 219 patients were eligible. They were randomly assigned to two groups:109 patients were treated with 1-2 cycles of chemotherapy (NACT group), and 110 patients in the control group were treated directly with surgery (DS group). Patients in the NACT group were randomly assigned to two groups: 50 patients were treated with 1-2 cycles of irinotecan 60 mg/m2 on days 1,8 and 15 plus cisplatin 70 mg/m2 on day 1 followed by surgery (IP group); 59 patients were treated with 1-2 cycles of paclitaxel 175 mg/m2 on day 1 plus cisplatin 70 mg/m2 on day 1 (TP group). Patients with pathological recurrent-risk factors received postoperative radiotherapy (RT).RESULTS:Survival analysis revealed that the 3-year disease-free survival (DFS) and the 3-year overall survival (OS) were 90.6% and 92.5% in the NACT group and 94.4% and 95.3% in the DS group with no significant differences. Analysis of clinicopathologic factors showed that the lymphovascular space invasion (LVSI) and deep stromal invasion rates were significantly lower in the NACT group. The rate of patients requiring adjuvant radiotherapy was 58.9% in NACT group and 63.3% in DS group.The overall clinical response rate was 72.0% in the NACT group, and there was no statistically significant difference in clinical effectiveness between the irinotecan plus cisplatin (IP) group and the paclitaxel plus cisplatin (TP) group (P=0.329). The 3-year DFS and OS in the IP and TP groups were not statistically different (P=0.296, P=0.212). Grade 3/4 neutropenia (P=0.005) and grade 3/4 diarrhea (P=0.008) were both higher in the IP group than in the TP group. Univariate analysis showed that LVSI was the only factor associated with DFS (p<0.05).CONCLUSION:Use of NACT did not improve overall survival, but reduced the number of patients who received postoperative radiotherapy. NACT using irinotecan plus cisplatin for cervical cancer has a similar efficacy and higher toxicity than the use of paclitaxel plus cisplatin, but the toxicity is tolerable.OBJECTIVE To systematically review the the clinical efficacy and safety of irinotecan as neoadjuvant chemotherapy (INAC) in cervical cancer.METHODS Databases including PubMed (1980 to 2014)、EMbase(1980 to 2014)、The Cochrane Library (Issue 10,2014)、CBM (1980 to 2014)、CNKI (1980 to 2014)、VIP (1989 to 2014)与WanFang Data (1990 to 2014) were search to collect clinical trials on INAC in cervical cancer versus radical surgery (RS) or other drugs used in the treatment of cervical cancer’s neoadjuvant chemotherapy. According to the inclusion and exclusion criteria, two reviewers identified literature, extracted data and assessed quality independently. Then meta-analysis was performed using RevMan 5.3 software.RESULTS Five RCTs and two case-control studies involving 728 patients were included. The results of meta-analysis showed that compared with the RS, INAC was shorter in the operation time, lower in the intraoperative blood loss, higher in 3-years OS, lower in the rate of positive parametrial involvement and lymphovascular space invasion, but there was no significant difference in the rates of lymph node metastasis, P=0.06] and positive surgical margin. There was no significant difference in the effectiveness rate and adverse effects’rate that more than grade III between INAC and paclitaxel as neoadjuvant chemotherapy(PNAC) in cervical cancer.CONCLUSION INAC is effective and tolerable. Due to the limitation of quantity and quality of the included studies, its long-term efficacy still needs more high-quality, large scale and multicentre RCTs to obtain more reliable evidence.OBJECTIVE:the study was to assessment of prognosis and quality of life about different treatment regimens, including neoadjuvant chemotherapy plus radical surgery (NACT), concurrent chemoradiation (CCRT) and direct with surgery (DS) for stage IIB cervical cancer.METHODS:From January 2007 to December 2012,224 patients with stage ⅡB cervical cancer were randomly assigned to 3 groups:56 patients in NACT group underwent 1-2 cycles chemotherapy(NACT group),56 patients in CCRT group were treated with external-beam radiotherapy (EBRT) and intracavitary irradiation,49 patients in control group were treated directly with surgery(DS group).RESULTS:Survival analysis revealed that the 5-year disease-free survival (DFS) and the 5-year overall survival (OS) was 81.7% and 85.4% in the NACT group,74.5% and 79.2% in the CCRT group, and70.8% and 74.9% in the DS group with no significant difference (DFS, P=0.587,OS,P=0.747). After neoadjuvant chemotherapy, patients who with positive lymph node metastasis were significantly decreased than DS(P=0.009), patients who with no postoperative treatment of patients have poor prognosis (P=0.004). Patients in NACT group reported significantly bester emotional functioning(P=0.005), cognitive functioning (p=0.009), sexual/vaginal functioning (P=0.000), and lower menopausal symptom (P=0.032)and diarrhoea (P=0.032) compared to CCRT group. NACT group is bester than DS in sexual/vaginal functioning(P=0.046) and menopausal symptoms(p=0.032).CONCLUSION:NACT is a good choice for stage ⅡB cervical cancer with negative lymph node metastasis, especially in young patients. It is not recommended NACT for stage ⅡB cervical cancer with positive lymph node metastasis before the treatment. It is more suitable for making treatment plan and prognosis deserves in further study to evaluate the status of retroperitoneal lymph node especially the status of abdominal aorta.OBJECTIVE:To compare the differences of surgical-pathological and clinical (FIGO 1995) staging of stages ⅠB-ⅡB cervical cancer. To discuss the feasibility and importance of surgical-pathological staging in stages ⅠB-ⅡB cervical cancer.METHODS:A total of 388 cases with stages ⅠB-ⅡB cervical cancer accepted surgical treatment from January 2007 to March 2013 were retrospectively in three hospitals. This patients were divided into preoperative neoadjuvant chemotherapy groups (NACT group) and directly with surgery group (DS group). All the patients were applied for both surgical-pathological and clinical staging. The differences of the rescults were compared and discussed.RESULTS:The total coincidence rate between surgical-pathological and clinical staging are 21.1% in DS groups and 10% in NACT groups. In DS groups, stage ⅠB is 28.6%, stage Ⅱ A is 3.7%, stage ⅡB is 2.1%. The match rate of pathological types after surgery are 86.7% in DS group and 84.1% in NACT group. The match rate of tumor grade after surgery are 83.3% in DS group and 83.7% in NACT group. For vaginal invasion and parametrial invasion,the sensitivity is 66.7%、20.0%, specificity is 67.5%、70.9% and accuracy is 67.4%、69.7% in DS group, respectively. For vaginal invasion and parametrial invasion,the sensitivity is 50.0%、85.7%, specificity is 58.0%、46.0% and accuracy is 57.6%、47.6% in DS group, respectively. The deep stromal invasion and vaginal invasion show the distinct difference between each stage in DS group. Tumor emboli could affect prognosis in PTNM staging of DS group (DFS:P=0.013, OS:P=0.004); but in FIGO staging, staging is closely related to the prognosis (DFS:P=0.024, OS:P=0.050). In NACT group, staging influenct the recurrence (P=0.023), Lymph node metastasis is closely related to the prognosis (DFS: P=0.004, OS:P=0.044).CONCLUSION:There is an obvious difference between surgical-pathological and clinical staging in stages ⅠB-ⅡB cervical cancer. There is a high percentage of discrepancy in clinical stage ⅡB, because of over-staging,many patients in clinical stage ⅡB lose the opportunities of surgery. There is a certain clinical significance in surgical-pathological staging, but further research and discussion are necessarily required.OBJECTIVE:To systematically review the clinical efficacy and safety of using using different treatments in stage ⅡB cervical cance.METHODS:Databases including PubMed、EMbase、The Cochrane Library (Issue 10, 2014)、CBM、CNKI、VIP与WanFang Data were search. According to the inclusion and exclusion criteria, two reviewers identified literature, extracted data and assessed quality independently. Then meta-analysis was performed using RevMan 5.3 software.RESULTS:Three RCTs, one prospective trials, seventeen case-control studies involving 2486 patients were included. NACT group compared with DS group, survival has not yet found statistically significant difference, the intraoperative blood loss, operation time, lymph node metastasis rate and postoperative complications of the former is lower than the latter. The 5-years OS and the rate of radioactive cystitis are not statistical differences between multimodality therapy of surgery and concurrent chemoradiation. The rate of radioactive cystitis of the former is less than the latter. The multimodality therapy of surgery compared with radiotherapy, there are no statistical differences in 3-year OS and the rate of fistula formation, but the 5-year OS of the former higher than the latter, the rate of radioactive enteritis of the former is lower than the latter. Radiotherapy alone is lower gastrointestinal reaction’s rate and hematological toxicity’rate than concurrent chemoradiation.CONCLUSION:The multimodality therapy of surgery treatment of stage ⅡB cervical cancer is the most effective treatment than RS. It could reduce the intraoperative blood loss, operation time, lymph node metastasis rate and postoperative complications than RS, and lower adverse reactions than radiotherapy or concurrent chemoradiation. Therefore the multimodality therapy of surgery is more beneficial to improve patient quality of life after treatment.