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ORIGINAL ARTICLE
Year : 2017  |  Volume : 13  |  Issue : 5  |  Page : 796-800

Clinical efficacy of preoperative vaginal intracavitary irradiation for Stage Ib2 and IIa cervical cancer


Department of Gynecological Oncology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100006, China

Date of Web Publication13-Dec-2017

Correspondence Address:
Jiandong Wang
No.17 Qihelou Road, Dongcheng District, Beijing
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_398_17

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 > Abstract 


Objective: The purpose of this study was to evaluate the clinical efficacy of preoperative vaginal intracavitary irradiation for Stage Ib2 and IIa cervical cancer.
Materials and Methods: From June 2008 to June 2014, data from 78 Stage Ib2 and IIa cervical cancer patients (age ≤75 years) with a diameter of local lesions >4 cm were collected in our hospital. Before treatment, all cases were confirmed by biopsy. The patients' general state was good, Karnofsky Performance Score ≥90, heart and lung functioning was normal, and patients were able to tolerate the surgery. The 78 patients were randomly divided into two groups: neoadjuvant radiotherapy group (NRG) (n = 38) and radical surgery group (n = 40). Patients in NRG received 2000~3000 cGy192 Ir irradiation of preoperatively intracavitary brachytherapy (radioactive source at 1 cm distance). After a rest of 10–14 days, radical hysterectomy with pelvic lymphadenectomy was performed. Surgery alone group (SAG) (n = 40) underwent radical surgery directly. The treatment outcomes between these two groups were compared, and the effect of preoperative intracavitary brachytherapy and presence of postoperative complications were evaluated.
Results: The total clinical efficacy for intracavitary brachytherapy was 94.7% (36/38) with complete response 13 (34.2%), partial response 23 (60.5%), and stable disease 2 (5.3%). Moreover, no patients developed progression disease; for SAG patients, 32 cases successfully finished the extensive hysterectomy and pelvic lymphadenectomy. Operation time <240 min was found in 19 patients. Moreover, the positive complication for lymphatic cyst and urinary retention was 20.0% and 15.0%, respectively. For NAG group, 36 patients successfully finished the extensive hysterectomy and pelvic lymphadenectomy. Operation time <240 min was found in 22 patients. Moreover, the positive complication for lymphatic cyst and urinary retention was 15.8% and 13.2%, respectively. The median follow-up time for NRG and SAG was 28 and 30 months, respectively. Three cases lost to follow-up in the SAG with the follow-up rate of 92.5% (37/40). In the NRG group, 3 cases lost to follow-up with the follow-up rate of 92.1% (35/38). The locoregional control rate for 1, 3, and 5 years was 80.0%, 61.3%, and 52.6%, respectively, for SAG group and 89.5%, 82.9%, and 76.9%, respectively, for NRG group with significant statistical difference for 3 and 5 years.
Conclusion: Preoperative intracavitary brachytherapy is an effective procedure for the treatment for Stage Ib2 and IIa cervical cancer and can significantly improve the locoregional control rate.

Keywords: Cervical cancer, intracavitary, prognosis, radiotherapy


How to cite this article:
Li F, Wu Y, Kong W, Wang J, Hao X, Niu J, Bai L. Clinical efficacy of preoperative vaginal intracavitary irradiation for Stage Ib2 and IIa cervical cancer. J Can Res Ther 2017;13:796-800

How to cite this URL:
Li F, Wu Y, Kong W, Wang J, Hao X, Niu J, Bai L. Clinical efficacy of preoperative vaginal intracavitary irradiation for Stage Ib2 and IIa cervical cancer. J Can Res Ther [serial online] 2017 [cited 2020 Oct 21];13:796-800. Available from: https://www.cancerjournal.net/text.asp?2017/13/5/796/220472




 > Introduction Top


Cervical cancer is a common gynecologic tumor; its incidence is only less than the breast cancer.[1] In recent years, the incidence of cervical cancer has a significantly rising trend among young women.[2] At present, patients with early stage cervical cancer mostly accept surgical treatment. However, surgery directly has certain difficulties for patients of Stage Ib2 and IIa cervical cancer with huge tumor diameter. Recently, some publications have showed that preoperative radiotherapy can shrink the tumor, which is good for the removal of parametrium and paracolpium, and obtaining tumor-free edge with the most wide resection edge. At the same time, preoperative radiotherapy can reduce activity and intraoperative spread tumor cells, which could reduce local recurrence.[3],[4],[5],[6] In our present, we performed a prospective clinical study about preoperative vaginal intracavitary irradiation for Stage Ib2 and IIa cervical cancer to further evaluate whether preoperative vaginal intracavitary irradia can improve the survival and locoregional control for patients with Ib2 and IIa cervical cancer.


 > Materials and Methods Top


Patients

From June 2008 to June 2014, data from 78 Stage Ib2 and IIa cervical cancer patients (age ≤75 years, median age 53 years) with a diameter of local lesions >4 cm were collected in our hospital. The inclusion criteria include (1) the patients' general state was good; (2) the Karnofsky Performance Score ≥90; (3) the heart and lung function was normal; and (4) the patients were able to tolerate the surgery. According to the 1995 International Federation of Obstetrics and Gynecology staging system, here are two deputy chief physician or chief physician at least to check the stage. The 78 included patients were randomly divided into two groups by table of random number. One group (surgery alone group [SAG], n = 40) underwent radical surgery directly and another group (neoadjuvant radiotherapy group [NRG], n = 38) received preoperative intracavitary radiotherapy. The general characteristics of the two groups are demonstrated in [Table 1].
Table 1: The general characteristics of the included two groups

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Treatment

Patients in the SAG received radical hysterectomy (extensive hysterectomy + pelvic lymphadenectomy). Patients in NRG received 2000~3000 cGy192 Ir irradiation of preoperative intracavitary brachytherapy (radioactive source at 1 cm distance), 2~3 times/2~3 weeks before surgery. After a rest of 10–14 days, radical hysterectomy with pelvic lymphadenectomy was performed.

Clinical efficacy evaluation

The tumor volume evaluation after irradiation

Mass changes were observed by the unaided eye and measured by pelvic computed tomography according to clinical criteria with reference to the International Union against Cancer Control. The clinical efficacy for intracavitary brachytherapy include complete response (CR, clinical disappearance of all target lesions and no new lesions); partial response (PR, >50% tumor shrinking and no new lesions); stable disease (SD, <50% tumor shrinking and no new lesions); and progressive disease (PD, no change in tumor size or the appearance of new lesions). CR and PR were considered effective, while SD and PD were considered ineffective.

Surgery effects' evaluation

The effect of surgery evaluation include the state of hysterectomy with pelvic lymphadenectomy, cancer infiltration of surgical specimens margin, surgery duration, and postoperative complications. Moreover, the overall effect of evaluation mainly include local control rate and survival rate.

Statistical analysis

The measurement data were expressed by ̄ ± s and the comparison between groups was made based on the t-test of the sample mean. The enumeration data were expressed with a relative number, and the comparison between groups was made based on Chi-square test. All the data were calculated through SPSS version 17.0 software (http://www.spss.com).


 > Results Top


Clinical efficacy for intracavitary brachytherapy

The total clinical efficacy for intracavitary brachytherapy was 94.7% (36/38) with CR 13 (34.2%), PR 23 (60.5%), and SD 2 (5.3%). Moreover, no patients developed progression disease.

Surgery outcome comparison between the two groups

For SAG patients, 32 cases successfully finished the extensive hysterectomy and pelvic lymphadenectomy. Operation time <240 min was found in 19 patients. Moreover, the positive complication for lymphatic cyst and urinary retention was 20.0% and 15.0%, respectively. For NAG group, 36 patients successfully finished the extensive hysterectomy and pelvic lymphadenectomy. Operation time <240 min was found in 22 patients. Moreover, the positive complication for lymphatic cyst and urinary retention was 15.8% and 13.2%, respectively [Table 2].
Table 2: Surgery outcome comparison between the two groups

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Prognosis analysis between the two groups

The median follow-up time for NRG and SAG were 28 and 30 months, respectively. Three cases lost to follow-up in the SAG with the follow-up rate of 92.5% (37/40). In the NRG group, 3 cases lost to follow-up with the follow-up rate of 92.1% (35/38). The locoregional control rate for 1, 3, and 5 years was 80.0%, 61.3%, and 52.6%, respectively, for SAG group and 89.5%, 82.9%, and 76.9%, respectively, for NRG group with significant statistical difference for 3 and 5 years (P < 0.05) [Figure 1] and [Figure 2]. However, there was no statistical difference of locoregional control and survival for 1 year between the SAG and NRG groups (P > 0.05) [Table 3].
Figure 1: Computed tomography scan of preoperative vaginal intracavitary irradiation for a 38-year-old women with locally advanced cervical cancer. (a and b) Coronary and sagittal position and of cervical cancer before radiation; (c and d) coronary and sagittal position and of cervical cancer after radiation

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Figure 2: Coronary position computed tomography scan of preoperative vaginal intracavitary irradiation. (a and c) Before and after radiation of cervical cancer for a 27-year-old woman; (b and d) before and after radiation of cervical cancer for a 28-year-old woman

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Table 3: The locoregional control and survival rate comparison between the two groups

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 > Discussion Top


Surgery and radiotherapy are the main treatments for cervical cancer.[7],[8],[9] For locally advanced cervical cancer patients, surgery directly is difficult.[10],[11] Preoperative radiation can decrease the tumor diameter and make operation easy.[12] Because that the vagina and uterus are the natural channels to place applicator, radioactive sources can be put in there to directly irradiate primary tumors. The radiation tolerance of vaginal fornices and cervical itself greatly exceed the tumor death dose. At the same time, based on brachytherapy dosimetry characteristics, preoperative intracavitary radiotherapy forms high dose in a smaller area of local cervical tumor, vaginal vault and up 1/3 vagina and parametrium. Dose declines sharply outside the area; then, radiation makes less injury to the surrounding normal tissue. Preoperative intracavitary radiotherapy dose is 1/3~1/2 of radical cure dose. Because of the low dose, the cervical area will not appear edema and fibrosis when surgery around 2 weeks after radiotherapy. Fangyu et al.[13] believed that preoperative intracavitary radiotherapy with appropriate dose does not affect the proceedings of radical hysterectomy and increase the risk of surgical complications, associated injury, and intraoperative blood loss. In the present study, we found preoperative radiotherapy plus surgery have a slight advantage in the surgical success rate, average operation time, postoperative cut edge carcinoma infiltration, and others than those of surgery directly. Due to that, cervical local tumor significantly shrinked and the difficulty of operation decreases. However, no statistical difference has been found between two groups. In the aspect of the incidence of various common radical hysterectomy postoperative complications, this study shows that in preoperative radiotherapy plus surgery group, the incidence of pelvic lymphocele is 15.8% and the incidence of urinary retention is 13.2% with no ureteral fistula. There is no statistical differences compared with surgery alone.

Yang et al.[14] reported that effective rate of tumor regression was 92.9% in cervical cancer patients treated with preoperative vaginal intracavitary irradiation. Our study showed that the total clinical efficacy for intracavitary brachytherapy was 94.7% (36/38) with CR 13 (34.2%), PR 23 (60.5%), and SD 2 (5.3%) which was in accordance with Yang.

For locoregional control and survival rate, we found that the 3- and 5-year locoregional control rates of the preoperative radiotherapy group were significantly improved compared to those of SAG (P < 0.05). In terms of survival rate, Atlan et al.[15] reported that both preoperative radiotherapy and surgery alone had no influence on prognosis of patients with Ib2 and IIa cervical cancer. Our results were consistent with previous study with no statistical difference for long-term survival between the NRG and SAG. However, we also found that compared with SAG, the 1-, 3-, and 5-year survival rates in the preoperative radiotherapy group were slightly increased. Zhang et al.[16] reported 111 Stage Ib2 and IIa cervical cancer patients who received preoperative brachytherapy and found that preoperative brachytherapy can significantly increase the local control rate. In this study, the 5-year survival rate of patients with Stage Ib2 cervical cancer who received preoperative radiotherapy was 90.7%, which was similar to those with Stage Ib1 cervical cancer (89.1%). These results indicated that patients undergoing preoperative radiotherapy may be helpful to the improvement of survival rate. Our study showed that preoperative vaginal intracavitary irradiation played little role on pelvic lymph node and systemic metastasis. Feng Yanling et al.[17] reported that compared with patients received preoperative brachytherapy alone, recent effective rate of patients received preoperative brachytherapy + platinum-based neoadjuvant chemotherapy improved significantly. However, the research did not mention the result of long-term survival rate. Xiaoxia[18] used DDP + BLM + HCPT regimen for bulky cervical cancer as neoadjuvant chemotherapy; the report showed that the effective rate was 95%, and this treatment programs extended the survival time of patients. However, because of fewer cases and shorter follow-up time, the research still needs further confirmation by well-designed prospective, randomized controlled trials.


 > Conclusion Top


Preoperative intracavitary brachytherapy is an effective procedure of the treatment for patients with Stage Ib2 and IIa cervical cancer and it can significantly improve the locoregional control rate.

Financial support and sponsorship

This work was supported by Beijing Municipal Science and Technology Commission (D131100005313009).

Conflicts of interest

There are no conflicts of interest.



 
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