Leptomeningeal metastasis in primary uterine cervical cancer: a rare case and review of the literature

Objectives. Leptomeningeal metastasis (LM) of primary uterine cervical cancer is rare and treatment options are limited. In this case report and literature review, we aimed to present a patient with cervical cancer with LM and discuss previously reported cases in the literature.  Case presentation. Our case was a 58-year-old patient who was initially diagnosed with metastatic primary uterine cervical cancer and treated with chemotherapy and chemoradiotherapy. During follow-up, she developed neurological symptoms, and LM was detected in the craniospinal regions. Cerebrospinal fluid cytology examination has confirmed metastatic disease. The patient was treated with concurrent intrathecal methotrexate and whole-brain radiotherapy (WBRT). A good clinical and cytological response was obtained. However, while intrathecal methotrexate was being continued after WBRT, she succumbed to hematological toxicity before the radiological response could be evaluated. Conclusions. LM is an extremely rare and catastrophic distant spread pattern in patients with cervical cancer. In the literature, a total of 26 patients were reported up to date. Median survival after detection of LM was nine weeks, including our case. Multimodal treatment combinations such as systemic and intrathecal chemotherapy and radiotherapy (RT) were used. However, most of these reports did not have detailed information about toxicity. Despite the combined use of aggressive treatment modalities, patients have limited survival and very high risks of hematologic toxicity. Concurrent use of intrathecal chemotherapy and radiotherapy should be avoided due to increased risk of morbidity

Adjuvant Small Pelvic Radiotherapy in Patients with Cervical Cancer Having Intermediate Risk Factors Only - Is It Sufficient?

Background: We sought to determine the outcomes of adjuvant small pelvic external beam radiotherapy (EBRT) and prognostic factors for survival and disease control. Patients and Methods: We retrospectively evaluated 113 cervical cancer patients treated with postoperative median 50.4-Gy small pelvic EBRT. We treated the surgical bed, bilateral parametria, paravaginal soft tissues, upper third of the vagina, and presacral lymphatics. Results: Median follow-up of all patients and survivors was 58 and 67 months, respectively. The 2-and 5-year overall survival (OS) and disease-free survival rates were 91 and 82%, and 85 and 74%, respectively. The locoregional failure rate was 10%. Age was a significant predictor for OS and distant metastasis-free survival (DMFS) on univariate analysis. The number of dissected lymph nodes being = 3 toxicity developed in 8 patients. Conclusion: Small pelvic EBRT produces satisfactory survival and locoregional control with acceptable toxicity, and can be an alternative to whole pelvic EBRT in selected cervical cancer patients. (C) 2017 S. Karger GmbH, Freibur

Stereotactic body radiotherapy boost in patients with cervical cancer

Our aim was to evaluate the oncological outcomes of stereotactic body radiotherapy (SBRT) boost in patients with cervical cancer. The data of 21 patients who received SBRT boost after definitive radiotherapy (RT) or chemoradiotherapy (CRT) between March 2012 and April 2019 were retrospectively evaluated. External beam radiotherapy (EBRT) was applied to patients with a total dose of 50.4 Gy in 28 fractions. Kaplan–Meier method was used for survival analysis (IBM SPSS 23 software) and p < .05 value was considered significant. After definitive RT or CRT, there was a complete response in 9 (43%) patients, partial response in 11 (52%) patients and stable disease in 1 (5%) patient. The median follow-up period was 28 months (range, 7.5–88 months). Two-years cancer-specific survival rate was 80%. While 2-year LC rate was 75% in patients with residual tumour size <4 cm, it was 50% when there was ≥4 cm residual tumour after definitive CRT (p = .1). The treatment was well-tolerated and no acute or late toxicity was observed. Although brachytherapy (BRT) is an essential part of the treatment in locally advanced cervical cancer, SBRT may be used in patients with small residual disease who are not candidate for BRT. IMPACT STATEMENT Cervical cancer is one of the most common cancers in the world, and external beam radiotherapy (EBRT) and brachytherapy (BRT) are the main treatment options. However, in rare cases where BRT is not feasible, it has been questioned whether stereotactic body radiotherapy (SBRT) as an alternative to BRT. What is already known on this subject? Nowadays, BRT still appears to be the gold standard treatment. However, studies with a small number of patients and short follow-up periods in the literature show that SBRT can be a good alternative in cases where BRT cannot be performed. What do the results of this study add? Our study is one of the series with the largest number of patients in the literature and with the longest follow-up period. In this area where there is no prospective study, we think that retrospective data with high patient numbers are enlightening. What are the implications of these findings for clinical practice and/or further research? Our study shows that SBRT is an alternative option in cases with small residual disease where BRT cannot be applied, and it provides a basis for a prospective randomised study

Is there any benefit of paraaortic field irradiation in pelvic lymph node positive endometrial cancer patients? A propensity match analysis

We evaluated the survival outcomes and recurrence patterns of endometrial cancer (EC) patients with pelvic lymph node metastases who received postoperative radiotherapy (RT) to the pelvis (P-RT) or to the pelvis plus paraaortic lymph nodes (PA-RT) with or without systemic chemotherapy (ChT). The data from 167 patients with stage IIIC1 EC treated with postoperative RT or RT and ChT were collected retrospectively. Those patients with pelvic lymph node metastases were treated with either P-RT (106 patients, 63%) or PA-RT (61 patients, 37%). The median follow-up time for the entire cohort was 49 (range = 5–199) months. The patients receiving adjuvant ChT and RT had significantly higher 5-year OS rates (77% vs. 33%, p < .001) and 5-year PFS rates (71% vs. 30%, p < .001) when compared to those receiving adjuvant RT alone. The patients receiving P-RT and ChT had significantly higher 5-year OS rates and 5-year PFS rates when compared to those treated with adjuvant PA-RT in the entire cohort and matched cohort. Adjuvant ChT together with RT is the strongest predictor of the OS and PFS. Prophylactic PA-RT is unnecessary, even if ChT is used together with P-RT in EC patients with pelvic lymph node metastasis.Impact statement What is already known on this subject? Local and distant recurrence risks are relatively higher in patients with stage IIIC disease, postoperative adjuvant treatment is required to reduce the recurrence risk. Adjuvant RT is a common approach for patients with locally advanced EC. Optimal target volume for RT in patients with stage IIIC EC remains controversial. We demonstrated that extended field RT is unnecessary, even if ChT is used together with pelvic RT in stage IIIC EC patients. What do the results of this study add? We demonstrated that adjuvant ChT together with RT is the strongest predictor of the OS and PFS for EC patients with pelvic lymph node metastases. Extended field RT is unnecessary, even if ChT is used together with pelvic RT in EC patients with pelvic lymph node metastases. What are the implications of these findings for clinical practice and/or further research? Although adjuvant treatment modalities are associated with improvements in survival, distant metastasis still remains the most common site of recurrence in advanced EC patients. Thus, further research is warranted to identify improved combined modality strategies to optimise the outcomes for EC patients with pelvic lymph node metastasis

The Synergistic Effect Of Immune Checkpoint Blockade And Radiotherapy In Recurrent/Metastatic Sinonasal Cancer

Treatment options for recurrent/metastatic sinonasal cancer (RMSNC) patients are limited. We present two cases with RMSNC treated with a combination of immune checkpoint blockade and hypo-fractionated stereotactic radiotherapy (HSRT). , Case 1 presented with RMSNC three months after the primary treatment. The patient progressed under first-line chemotherapy and pembrolizumab was offered. The disease progressed after the sixth cycle. We performed reirradiation with HSRT to the primary site. Case 2 presented with local recurrence eight years after the primary treatment for maxillary sinus cancer. He refused surgery and chemotherapy and was offered nivolumab treatment. After two doses, we performed reirradiation with HSRT., Case 1 showed regression at both the local and the metastatic sites after radiotherapy. The second patient’s symptoms resolved completely three months after radiotherapy., The HSRT and immune checkpoint blockade combination is a promising treatment option for patients with RMSNC.PubMe

The impact of serum albumin-to-alkaline phosphatase ratio in cervical cancer patients treated with definitive chemoradiotherapy

We retrospectively analysed the prognostic significance of serum albumin, alkaline phosphatase (ALP) and albumin to ALP ratio (AAPR) and other prognostic factors affecting the overall survival (OS) and progression-free survival (PFS) in 200 cervical cancer patients treated with definitive chemoradiotherapy (CRT). The prognostic factors for OS and DFS, in addition to the predictive factors of albumin, ALP and AAPR, were investigated. Older age, lymph node metastasis, non-complete response (CR) to treatment and low serum albumin levels emerged as predictors of poor OS and PFS in multivariate analysis. However, with a cut-off value of 0.51, AAPR was not a significant prognostic factor of survival in multivariable analysis. There were no significant differences in clinicopathological factors between patients with low and high AAPR, except for lymph node metastasis, where lymph node metastasis rate was significantly higher in patients with a low AAPR compared to those with a high AAPR. Patients with CR had a significantly higher serum albumin level and AAPR compared to patients without CR. The pre-treatment serum albumin level was independent predictive for survival; therefore, it could be a suitable biomarker to guide systemic therapy and predict patient outcomes. Impact Statement What is already known on this subject? Two major determinants of tumour progression are nutritional status and inflammation. The albumin-to-alkaline phosphatase ratio (AAPR), which was originally proposed as a marker for nutritional status and immune response, was recently discovered to be a prognostic factor for various cancer types. However, its utility in the treatment of cervical cancer has not been established. What do the results of this study add? Low serum albumin levels were associated with a significantly shorter OS and PFS in cervical cancer patients treated definitively with CRT. AAPR, on the other hand, was not a significant prognostic factor for survival with a cut-off value of 0.51. Regional lymph node metastasis was significantly more common in patients with a low AAPR than in those with a high AAPR. What are the implications of these findings for clinical practice and/or further research? Patients with multiple clinicopathological risk factors and low serum albumin levels had an increased risk of disease recurrence and a poorer prognosis, highlighting the importance of additional adjuvant treatment strategies in these patients. Due to the preliminary nature of our findings, additional research is required to corroborate them

A Multi-Institutional Analysis Of Sequential Versus `Sandwich' Adjuvant Chemotherapy And Radiotherapy For Stage Iiic Endometrial Carcinoma

Objective: To analyze the outcomes of sequential or sandwich chemotherapy (ChT) and radiotherapy (RT) in patients with node-positive endometrial cancer (EC). Methods: Data from 4 centers were collected retrospectively for 179 patients with stage IIIC EC treated with postoperative RT and ChT (paclitaxel and carboplatin). Patients were either treated with 6 cycles of ChT followed by RT (sequential arm; 96 patients) or with 3 cycles of ChT, RT, and an additional 3 cycles of ChT (sandwich arm; 83 patients). Prognostic factors affecting overall survival (OS) and progression-free survival (PFS) were analyzed. Results: The 5-year OS and PFS rates were 64% and 59%, respectively, with a median followup of 41 months (range, 5-167 months). The 5-year OS rates were significantly higher in the sandwich than sequential arms (74% vs. 56%; p=0.03) and the difference for 5-year PFS rates was nearly significant (65% vs. 54%; p=0.05). In univariate analysis, treatment strategy, age, International Federation of Gynecology and Obstetrics (FIGO) stage, pathology, rate of myometrial invasion, and grade were prognostic factors for OS and PFS. In multivariate analysis, non-endometrioid histology, advanced FIGO stage, and adjuvant sequential ChT and RT were negative predictors for OS, whereas only non-endometrioid histology was a prognostic factor for PFS. Conclusion: Postoperative adjuvant ChT and RT for stage IIIC EC patients, either given sequentially or sandwiched, offers excellent clinical efficacy and acceptably low toxicity. Our data support the superiority of the sandwich regimen compared to the sequential strategy in stage IIIC EC patients for OS.Wo

Multi-institutional validation of the ESMO-ESGO-ESTRO consensus conference risk grouping in Turkish endometrial cancer patients treated with comprehensive surgical staging

In this study, 683 patients with endometrial cancer (EC) after comprehensive surgical staging were classified into four risk groups as low (LR), intermediate (IR), high-intermediate (HIR) and high-risk (HR), according to the recent consensus risk grouping. Patients with disease confined to the uterus, ≥50% myometrial invasion (MI) and/or grade 3 histology were treated with vaginal brachytherapy (VBT). Patients with stage II disease, positive/close surgical margins or extra-uterine extension were treated with external beam radiotherapy (EBRT)±VBT. The median follow-up was 56 months. The overall survival (OS) was significantly different between LR and HR groups, and there was a trend between LR and HIR groups. Relapse-free survival (RFS) was significantly different between LR and HIR, LR and HR and IR and HR groups. There was no significant difference in OS and RFS rates between the HIR and HR groups. In HR patients, the OS and RFS rates were significantly higher in stage IB – grade 3 and stage II compared to stage III and non-endometrioid histology without any difference between the two uterine-confined stages and between stage III and non-endometrioid histology. The current risk grouping does not clearly discriminate the HIR and IR groups. In patients with comprehensive surgical staging, a further risk grouping is needed to distinguish the real HR group.Impact statement What is already known on this subject? The standard treatment for endometrial cancer (EC) is surgery and adjuvant radiotherapy (RT) and/or chemotherapy is recommended according to risk factors. The recent European Society for Medical Oncology (ESMO), European Society of Gynaecological Oncology (ESGO) and European Society for Radiotherapy and Oncology (ESTRO) guideline have introduced a new risk group. However, the risk grouping is still quite heterogeneous. What do the results of this study add? This study demonstrated that the current risk grouping recommended by ESMO-ESGO-ESTRO does not clearly discriminate the intermediate risk (IR) and high-intermediate risk (HIR) groups. What are the implications of these findings for clinical practice and/or further research? Based on the results of this study, a new risk grouping can be made to discriminate HIR and IR groups clearly in patients with comprehensive surgical staging

Revisiting the Radical Radiotherapy-Radiochemotherapy Results in Anal Canal Cancers: (TROD Gastrointestinal Group Study 02-005).

Background and Aim: This study aimed to determine treatment outcomes and factors affecting prognosis in patients diagnosed with anal canal cancer who received radical radiotherapy (RT) or radiotherapy combined with chemotherapy (CT-RT) in radiation oncology centers in Turkey and compare the results with literature. Material and Method: The study included 193 patients with anal canal cancer reported between 1995 and 2019, of which 162 had complete data. The study was conducted in 11 radiation oncology centers, and a joint database was shared among them. Patients received radiotherapy doses of 45 Gy to 60 Gy. Data analysis was done using SPSS for Windows version 20. Results: Median follow-up was 48.51 months (2-214). All patients received radiotherapy, and 140 (86.4%) received concurrent chemotherapy. Radiotherapy doses of 50.4 Gy to 60 Gy were administered to 74 patients (45.7%) using 2-dimensional-3-dimensional (2D-3D) conformal therapy and 70 patients (43.2%) using intensity modulated radiotherapy technique (IMRT). Acute phase hematologic toxicity was observed in 62 patients (38.3%), and nonhematologic toxicity in 123 patients (75.9%). The 5-year overall survival (OS) rate was 75.1% and disease-specific survival (DSS) rate was 76.4%. OS without colostomy was achieved in 79,8 % at 5 years, and complete response in 112 patients (69.1%). OS rate was significantly higher in 142 patients with positive response (P < .000) and 112 with complete response (P < .000). Anemia (P < .002), local progression, and systemic progression (P < .000) resulted in lower OS (P < .002). In univariate analysis, factors affecting OS rate were: gender, age, stage, lymph node status, T stage, RT treatment duration, and treatment planning with PET fusion, which were found to be statistically significant. Completing radiotherapy in less than 45 days, concurrent chemotherapy, and continued administration of mitomycin and 5 FU as chemotherapy had a significant positive effect on overall survival. OS rate was higher in patients receiving RT dose of 58 Gy or less and undergoing IMRT planning in radiotherapy. IMRT was associated with lower acute and late side effects. Conclusion: Radiochemotherapy is the primary treatment for anal canal cancer and advanced radiotherapy techniques may increase survival by reducing side effects and improving treatment continuation. Higher treatment doses require further investigation. The efficacy of treatment can be improved by including patients treated with modern radiotherapy techniques in multicenter prospective studies using new and more effective chemotherapy and immunotherapy agents