RESUMO
OBJECTIVE: To describe the long-term outcomes of patients with stage IVA cervical cancer, a rare and deadly disease for which long-term toxicity data are scarce, to guide clinician counseling and survivorship support. METHODS: In a retrospective review of a prospectively maintained database, we identified 76 patients with stage IVA cervical cancer with biopsy- or MRI-proven bladder mucosal involvement who received definitive radiotherapy (external beam radiotherapy [EBRT] alone or EBRT plus brachytherapy) with or without chemotherapy at our institution between 2000 and 2020. We used Kaplan-Meier modeling to estimate recurrence-free survival (RFS) and overall survival (OS) and used proportional hazard modeling to identify clinical variables associated with recurrence or survival. We performed actuarial competing risk modeling for severe late toxicity (grades 3 to 5, occurring >6 months of follow-up) and vesicovaginal fistulae (VVF), censoring for pelvic recurrence and death, and made comparisons between potential predictors using Gray's test and binary logistic regression. RESULTS: The median follow-up time was 76 months (interquartile range 58-91). The median OS duration was 35 months (range, 18-not reached), and the 2- and 5-year OS rates were 53.6% and 40.9%, respectively. OS and RFS did not differ significantly between patients who received EBRT alone (N = 18) or EBRT plus brachytherapy (N = 49). Current smoking was a strong predictor of severe late toxicity, whose incidence was 14% at 2 years and 17% at 10 years. The VVF incidence was 24% at 2 years and 32% at 10 years. CONCLUSION: Patients with stage IVA cervical cancer, even those who receive EBRT alone, can have long-term survival. These patients should be followed closely for late radiation-related toxicity.
Assuntos
Braquiterapia , Neoplasias do Colo do Útero , Feminino , Humanos , Neoplasias do Colo do Útero/radioterapia , Neoplasias do Colo do Útero/etiologia , Bexiga Urinária , Braquiterapia/efeitos adversos , Pelve , Estudos RetrospectivosRESUMO
BACKGROUND: Gut microbiome community composition differs between cervical cancer (CC) patients and healthy controls, and increased gut diversity is associated with improved outcomes after treatment. We proposed that functions of specific microbial species adjoining the mucus layer may directly impact the biology of CC. METHOD: Metagenomes of rectal swabs in 41 CC patients were examined by whole-genome shotgun sequencing to link taxonomic structures, molecular functions, and metabolic pathway to patient's clinical characteristics. RESULTS: Significant association of molecular functions encoded by the metagenomes was found with initial tumor size and stage. Profiling of the molecular function abundances and their distributions identified 2 microbial communities co-existing in each metagenome but having distinct metabolism and taxonomic structures. Community A (Clostridia and Proteobacteria predominant) was characterized by high activity of pathways involved in stress response, mucus glycan degradation and utilization of degradation byproducts. This community was prevalent in patients with larger, advanced stage tumors. Conversely, community B (Bacteroidia predominant) was characterized by fast growth, active oxidative phosphorylation, and production of vitamins. This community was prevalent in patients with smaller, early-stage tumors. CONCLUSIONS: In this study, enrichment of mucus degrading microbial communities in rectal metagenomes of CC patients was associated with larger, more advanced stage tumors.
Assuntos
Microbioma Gastrointestinal , Neoplasias do Colo do Útero , Feminino , Microbioma Gastrointestinal/genética , Humanos , Redes e Vias Metabólicas , Metagenoma , MucoRESUMO
OBJECTIVE: Radiation therapy (RT) may improve outcomes for patients with oligometastatic cancer. We sought to determine if there are long-term survivors treated with definitive RT for recurrent or oligometastatic gynecological cancer (ROMGC), and to evaluate the clinical and disease characteristics of these patients. METHODS: We performed a landmark analysis in 48 patients with ROMGC who survived for ≥5 years following definitive RT of their metastasis. Patient characteristics were extracted from the medical record. DFS was modeled using the Kaplan-Meier method. RESULTS: This cohort included 20 patients (42%) with ovarian cancer, 16 (33%) with endometrial cancer, 11 (23%) with cervical cancer, and one (2%) with vaginal cancer. The sites of ROMGC were the pelvic (46%), para-aortic (44%), supraclavicular (7%), mediastinal (4%), axillary (4%) lymph nodes and the lung (5.5%). Median total RT dose and fractionation were 62.1 Gy and 2.1 Gy/fraction; one patient was treated with SBRT. 32 patients (67%) received chemoradiation; these patients had higher rates of median DFS than those treated with RT alone (93 vs. 34 months, P = 0.05). At median follow-up of 11.7 years, 11 (23%) patients had progression of disease. 20 (42%) patients had died, 9 (19%) died from non-gynecologic cancer and 8 (17%) from gynecologic cancer (three were unknown). 25 (52%) patients were alive and disease-free (10 initially had endometrial cancer [63% of these patients], eight had cervical cancer [73%], six had ovarian cancer [30%], one had vaginal cancer [100%]). CONCLUSIONS: Long-term survival is possible for patients treated with definitive RT for ROMG, however randomized data are needed to identify which patients derive the most benefit.
Assuntos
Neoplasias do Endométrio , Neoplasias Ovarianas , Neoplasias do Colo do Útero , Neoplasias Vaginais , Carcinoma Epitelial do Ovário , Intervalo Livre de Doença , Neoplasias do Endométrio/radioterapia , Feminino , Humanos , Metástase Linfática , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/radioterapia , Estudos Retrospectivos , Neoplasias do Colo do Útero/patologia , Neoplasias Vaginais/radioterapiaRESUMO
PURPOSE: To compare rates of complete response (no emesis, retching, or rescue antiemetics) in the late phase (days 4-7 post-chemotherapy) of cycle 1 between transdermal granisetron and oral ondansetron in cervical, endometrial, or vaginal cancer survivors undergoing chemoradiation at The University of Texas MD Anderson Cancer Center and LBJ Hospital in Houston, TX. METHODS: In this non-blinded parallel design trial, eligible patients received a granisetron patch replaced every 7 days or 8 mg of ondansetron thrice daily continued for 72 h after chemotherapy completion. Data were collected on medication compliance, episodes of chemotherapy-induced nausea and vomiting (CINV), use of rescue antiemetics, and effects of CINV on quality of life. RESULTS: Seventy-five survivors receiving chemoradiation for cervical (n = 61), endometrial (n = 12), or vaginal (n = 2) cancer were electronically randomized to transdermal granisetron (n = 41) or oral ondansetron (n = 34). In the late phase of cycle 1, the rate of complete response was 49.8% (95% CI, 35.2-64.3%) for transdermal granisetron and 39.7% (95% CI, 24.4-56.1%) for oral ondansetron. The posterior probability that transdermal granisetron achieved a higher success rate in controlling late-onset CINV compared with oral ondansetron was 82%. During the acute phase (day 1 post-chemotherapy) of cycles 2 and 3, transdermal granisetron patients used more rescue antiemetics than oral ondansetron patients (p = 0.006 and p = 0.003, respectively). Otherwise, no between-group differences in CINV events were observed. Medication compliance and the effect of CINV on quality of life were similar between groups. CONCLUSION: Transdermal granisetron was 82% more like to control CINV than oral ondansetron in the late phase of cycle 1 and performed similarly to oral ondansetron in all other cycles. Transdermal granisetron should be considered an option as prophylactic antiemetic therapy for gynecologic cancer survivors undergoing chemoradiation.
Assuntos
Antieméticos/uso terapêutico , Antineoplásicos/efeitos adversos , Granisetron/uso terapêutico , Náusea/prevenção & controle , Ondansetron/uso terapêutico , Vômito/prevenção & controle , Administração Cutânea , Adulto , Antineoplásicos/uso terapêutico , Sobreviventes de Câncer/estatística & dados numéricos , Neoplasias do Endométrio/tratamento farmacológico , Feminino , Granisetron/administração & dosagem , Humanos , Masculino , Pessoa de Meia-Idade , Náusea/induzido quimicamente , Náusea/tratamento farmacológico , Ondansetron/administração & dosagem , Qualidade de Vida/psicologia , Indução de Remissão , Neoplasias do Colo do Útero/tratamento farmacológico , Neoplasias Vaginais/tratamento farmacológico , Vômito/induzido quimicamente , Vômito/tratamento farmacológicoRESUMO
BACKGROUND: Advances in radiotherapy (RT) have led to improved oncologic outcomes for women with gynecologic cancers; however, the long-term effects and survivorship implications need further evaluation. The purpose of this study was to determine the incidence of pelvic fractures and changes in bone mineral density (BMD) after pelvic RT. METHODS: Two hundred thirty-nine women who had pelvic RT for cervical, endometrial, or vaginal cancer between 2008 and 2015 were prospectively studied. BMD scans and biomarkers of bone turnover were obtained at the baseline and 3 months, 1 year, and 2 years after RT. Imaging studies were assessed for pelvic fractures for up to 5 years. Patients with osteopenia, osteoporosis, or pelvic fractures at any point were referred to the endocrinology service for evaluation and treatment. RESULTS: The median age at diagnosis was 51 years; 132 patients (56%) were menopausal. The primary diagnoses were cervical (63.6%), endometrial (30.5%), and vaginal cancer (5.9%). Sixteen patients (7.8%; 95% confidence interval, 4.5%-12.4%) had pelvic fractures with actuarial rates of 3.6%, 12.7%, and 15.7% at 1, 2, and 3 years, respectively. Fractures were associated with baseline osteoporosis (P < .001), higher baseline bone-specific alkaline phosphatase (P < .001), and older age (P = .007). The proportion of patients with osteopenia/osteoporosis increased from 50% at the baseline to 58%, 59%, and 70% at 3 months, 1 year, and 2 years, respectively. CONCLUSIONS: A high proportion of women had significant decreases in BMD after pelvic RT, with 7.8% diagnosed with a pelvic fracture. BMD screening and pharmacologic intervention should be strongly considered for these high-risk women.
Assuntos
Densidade Óssea , Fraturas Ósseas/epidemiologia , Neoplasias dos Genitais Femininos/radioterapia , Ossos Pélvicos/lesões , Adulto , Idoso , Idoso de 80 Anos ou mais , Quimiorradioterapia/efeitos adversos , Neoplasias do Endométrio/radioterapia , Feminino , Humanos , Pessoa de Meia-Idade , Osteoporose/complicações , Modelos de Riscos Proporcionais , Estudos Prospectivos , Radioterapia de Intensidade Modulada/efeitos adversos , Neoplasias do Colo do Útero/radioterapia , Neoplasias Vaginais/radioterapia , Adulto JovemRESUMO
OBJECTIVE: To identify the optimal adjuvant treatment regimen for patients with endometrioid and non-endometrioid node-positive endometrial cancer. METHODS: We retrospectively identified 249 women with FIGO 2009 stage IIIC endometrial cancer at our institution who underwent surgical staging from 1985 to 2015 followed by external beam radiotherapy (RT), chemotherapy (CT), or a combination of CTâ¯+â¯RT. Survival rates were calculated using the Kaplan-Meier method. RESULTS: The 5-year disease-specific survival (DSS) rate for all patients was 65%. Adjuvant CTâ¯+â¯RT conferred higher rates of 5-year DSS as compared to CT alone in patients with grade 3 endometrioid and non-endometrioid tumors (61% vs. 27%, Pâ¯=â¯0.04 and 67% vs. 38%, Pâ¯=â¯0.02, respectively). Among patients with non-endometrioid tumors, treatment with concurrent chemoradiotherapy followed by additional sequential chemotherapy had higher 5-year DSS rates than with concurrent chemoradiotherapy alone (74% vs. 50%, Pâ¯=â¯0.02). The 3-year pelvic recurrence rate was 5% with RT⯱â¯CT and 35% with CT alone (Pâ¯<â¯0.001) for all patients. No paraaortic nodal failures were observed following extended-field RT, but 14% of patients who received pelvic-only RT or CT alone developed recurrences in the paraaortic nodes (Pâ¯<â¯0.001). CONCLUSIONS: Combined-modality therapy including adjuvant external beam pelvic radiotherapy yields excellent outcomes for patients with all subtypes of node-positive endometrial cancer. The most pronounced DSS advantage from adjuvant chemoradiotherapy was evident in women with non-endometrioid endometrial cancer.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Carcinoma Endometrioide/terapia , Cisplatino/uso terapêutico , Neoplasias do Endométrio/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carboplatina/administração & dosagem , Carcinoma Endometrioide/patologia , Quimiorradioterapia Adjuvante , Neoplasias do Endométrio/patologia , Feminino , Humanos , Metástase Linfática , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Paclitaxel/administração & dosagem , Prognóstico , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Cervical cancer is a malignant epithelial tumor that forms in the uterine cervix. Most cases of cervical cancer are preventable through human papilloma virus (HPV) vaccination, routine screening, and treatment of precancerous lesions. However, due to inadequate screening protocols in many regions of the world, cervical cancer remains the fourth-most common cancer in women globally. The complete NCCN Guidelines for Cervical Cancer provide recommendations for the diagnosis, evaluation, and treatment of cervical cancer. This manuscript discusses guiding principles for the workup, staging, and treatment of early stage and locally advanced cervical cancer, as well as evidence for these recommendations. For recommendations regarding treatment of recurrent or metastatic disease, please see the full guidelines on NCCN.org.
Assuntos
Oncologia/normas , Infecções por Papillomavirus/terapia , Neoplasias do Colo do Útero/terapia , Protocolos de Quimioterapia Combinada Antineoplásica/normas , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Braquiterapia/métodos , Braquiterapia/normas , Colo do Útero/diagnóstico por imagem , Colo do Útero/patologia , Colo do Útero/virologia , Quimiorradioterapia Adjuvante/normas , Feminino , Preservação da Fertilidade/métodos , Preservação da Fertilidade/normas , Humanos , Histerectomia/normas , Programas de Rastreamento/métodos , Programas de Rastreamento/normas , Oncologia/métodos , Estadiamento de Neoplasias , Tratamentos com Preservação do Órgão/métodos , Tratamentos com Preservação do Órgão/normas , Teste de Papanicolaou/normas , Papillomaviridae/isolamento & purificação , Papillomaviridae/patogenicidade , Infecções por Papillomavirus/diagnóstico , Infecções por Papillomavirus/patologia , Infecções por Papillomavirus/virologia , Sociedades Médicas/normas , Estados Unidos , Neoplasias do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/patologia , Neoplasias do Colo do Útero/virologiaRESUMO
Gestational trophoblastic neoplasia (GTN), a subset of gestational trophoblastic disease (GTD), occurs when tumors develop in the cells that would normally form the placenta during pregnancy. The NCCN Guidelines for Gestational Trophoblastic Neoplasia provides treatment recommendations for various types of GTD including hydatidiform mole, persistent post-molar GTN, low-risk GTN, high-risk GTN, and intermediate trophoblastic tumor.
Assuntos
Doença Trofoblástica Gestacional , Feminino , Humanos , Gravidez , OncologiaRESUMO
OBJECTIVE: To evaluate the effectiveness and long-term side effects of definitive groin radiotherapy for vulvar cancer with grossly involved inguinal lymph nodes. METHODS: The records of 407 women with vulvar squamous cell carcinoma treated with radiotherapy at one institution during 1992-2014 were reviewed to identify patients who had radiographic or histologic evidence of grossly involved inguinal lymph nodes. Patients with lymphadenectomy before radiotherapy and patients treated for recurrent disease were excluded. Actuarial incidences of vulvar, inguinal, and distant recurrences, the relationship between vulvar recurrence and inguinal recurrence, and overall survival were analyzed using the Kaplan-Meier method. RESULTS: Thirty-three patients were identified. The median age at diagnosis was 64â¯years. The median long-axis radiographic diameter of the largest inguinal lymph node or lymph node mass was 2.5â¯cm (range, 1.4-8.7). Sixteen patients (48%) also had evidence of pelvic lymph node metastasis. The median radiation dose delivered to grossly involved nodes was 66.0â¯Gy (range, 60.0-70.0). The 3-year actuarial incidences of vulvar, groin, and distant recurrences were 24.2%, 17.7%, and 30.3%, respectively. With a median follow-up time of 28â¯months (range, 2-196), four patients (12%) had groin recurrence, of whom three also had vulvar recurrence. There were few major late adverse effects of regional radiotherapy. The 3-year overall survival rate was 51%. CONCLUSIONS: High-dose volume-directed radiotherapy achieves a high rate of local control with low risk of serious long-term toxic effects in patients with vulvar squamous cell carcinoma and grossly involved inguinal lymph nodes.
Assuntos
Carcinoma de Células Escamosas/radioterapia , Linfonodos/patologia , Linfadenopatia/patologia , Neoplasias Vulvares/radioterapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Escamosas/patologia , Intervalo Livre de Doença , Feminino , Virilha , Humanos , Estimativa de Kaplan-Meier , Linfadenopatia/complicações , Metástase Linfática , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/epidemiologia , Pelve , Dosagem Radioterapêutica , Taxa de Sobrevida , Resultado do Tratamento , Neoplasias Vulvares/complicações , Neoplasias Vulvares/patologiaRESUMO
PURPOSE: Survival rates for women with metastatic cervical cancer are low, with limited management options. Definitive radiation therapy (RT) for oligometastatic disease has led to prolonged survival in other malignancies, but this approach has yet to be systematically studied for cervical cancer. METHODS AND MATERIALS: We evaluated 38 patients who received definitive RT to oligometastatic sites of cervical cancer at a single institution from 2002 to 2015. Patients presented with synchronous (n=9) or metachronous (n=15) oligometastatic disease to supraclavicular (SCV) nodes, or with recurrent disease in mediastinum (n=10) or lung (n=7). Three patients were treated for both SCV and mediastinal sites, and six patients were treated for para-aortic or pelvic recurrences along with oligometastatic sites. Most received chemotherapy: induction (n=5), concurrent (n=24), or adjuvant (n=5). Outcomes were evaluated via Kaplan-Meier, and associations were examined via Cox proportional hazards modeling. RESULTS: Median follow-up was 35.2months (range 3.1-94.7). Median overall survival (OS) was 50.7months from end of RT, with 2-year and 3-year OS rates of 74% and 65%. Median progression-free survival (PFS) was 21.7months, with 1-year and 2-year PFS rates of 63% and 48%. Of the 38 patients, 21 (55%) experienced progression, at a median time of 24.8months. There was one in-field failure. Other relapses occurred regionally (n=10) and distally (n=12), with two patients experiencing both. The most common site of recurrence following treatment of SCV disease was mediastinum (n=7). The incidence of grade≥3 toxicity from treatment of oligometastatic sites was <3%. CONCLUSIONS: Definitive RT to sites of oligometastatic cervical cancer can result in excellent local control, favorable outcomes, and even achieve long-term survival for carefully selected patients, with minimal RT-associated toxicity.
Assuntos
Neoplasias do Colo do Útero/radioterapia , Intervalo Livre de Doença , Feminino , Humanos , Linfonodos/diagnóstico por imagem , Linfonodos/efeitos da radiação , Metástase Linfática , Pessoa de Meia-Idade , Metástase Neoplásica , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento , Neoplasias do Colo do Útero/diagnóstico por imagem , Neoplasias do Colo do Útero/patologiaRESUMO
Endometrial carcinoma is a malignant epithelial tumor that forms in the inner lining, or endometrium, of the uterus. Endometrial carcinoma is the most common gynecologic malignancy. Approximately two-thirds of endometrial carcinoma cases are diagnosed with disease confined to the uterus. The complete NCCN Guidelines for Uterine Neoplasms provide recommendations for the diagnosis, evaluation, and treatment of endometrial cancer and uterine sarcoma. This manuscript discusses guiding principles for the diagnosis, staging, and treatment of early-stage endometrial carcinoma as well as evidence for these recommendations.
Assuntos
Neoplasias Uterinas/diagnóstico , Neoplasias Uterinas/terapia , Feminino , Humanos , Neoplasias Uterinas/etiologiaRESUMO
OBJECTIVES: This study aimed to evaluate the impact of radiation therapy on outcomes for patients with uterine carcinosarcoma (UC). METHODS/MATERIALS: We retrospectively reviewed the records of 155 women with stage I (98), II (11), or III (46) UC who underwent total abdominal hysterectomy/bilateral salpingo-oophorectomy at our institution between 1990 and 2011. Survival rates were assessed using the Kaplan-Meier method and log-rank test. Univariate and multivariate Cox regression analyses were performed. RESULTS: Seventy-six patients (49%) received radiation therapy: 38 (50%) had vaginal cuff brachytherapy (VBT) alone and 38 had external beam radiation therapy (EBRT) ± VBT. Seventy patients (45%) received chemotherapy (12 concurrent, 49 adjuvant, 9 both). The 5-year overall survival rate was 48.6% (stage I, 53.8%; II, 30.0%; and III, 42.5%). The disease-specific survival (DSS) rate was 57.2% (stage I, 60.9%; II, 44.4%; and III, 51.8%). Patients treated with EBRT had a higher 5-year pelvic disease control rate (88.3%) than did patients treated with VBT only (67.4%) or no radiation (71.2%; P = 0.04). In stage III patients, EBRT was associated with higher 5-year pelvic disease control (90.0% vs 55.5%, P = 0.046), DSS (64.6% vs 46.4%, P = 0.13), and overall survival (64.6% vs 34.0%, P = 0.04) rates. For all 155 patients, age at least 65 years, cervical involvement, and lymph vascular space invasion were correlated with lower DSS on univariate and multivariate analyses. In addition, treatment with concurrent chemoradiation therapy was independently associated with a higher DSS rate on multivariate analysis. CONCLUSIONS: Patients with UC have a high rate of relapse in the regional nodes and distant sites. External beam radiation therapy improves locoregional control in all stages and may improve survival in stage III patients who are at the highest risk of pelvic relapse.
Assuntos
Carcinossarcoma/radioterapia , Neoplasias Uterinas/radioterapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinossarcoma/tratamento farmacológico , Carcinossarcoma/cirurgia , Quimiorradioterapia Adjuvante , Quimioterapia Adjuvante , Feminino , Humanos , Estimativa de Kaplan-Meier , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Radioterapia Adjuvante , Estudos Retrospectivos , Salpingo-Ooforectomia , Neoplasias Uterinas/tratamento farmacológico , Neoplasias Uterinas/cirurgiaRESUMO
OBJECTIVE: To examine adjuvant radiation therapy (RT) use, patterns of RT delivery, and clinical outcomes in older patients with node-positive vulvar cancer. METHODS: Using SEER-Medicare linked data, we identified 444 patients (age≥66years) with node-positive squamous cell vulvar carcinoma, without distant metastases, and treated with primary surgery between 1991 and 2009. We used claims to examine RT use and the following delivery metrics: 1) completion of ≥20 fractions, 2) treatment duration <8weeks, 3) <1week of intra-treatment break, and 4) treatment interval from surgery to start of RT <8weeks. We tested associations between RT use and metrics with overall (OS) and cause-specific survival (CSS) using multivariate proportional hazards regression. RESULTS: Median age was 78years (interquartile range [IQR]=74-83). Median follow-up was 17months (IQR=9-40). Three hundred six patients (69%) received RT. Three delivery metrics were associated with improved outcomes: completion of ≥20 fractions, treatment duration <8weeks, and <1week of intra-treatment break. Patients who achieved these 3 metrics demonstrated better disease outcomes compared with surgery alone (OS hazard ratio [HR] for death=0.62, 95% confidence interval [CI]=0.46-0.82, P=0.001; CSS HR=0.58, 95% CI=0.40-0.85,P=0.005). Patients not achieving RT metrics demonstrated marginal improvements in disease outcomes over surgery alone (OS HR=0.73, 95% CI=0.55-0.99,P=0.04; CSS HR=0.76, 95% CI=0.52-1.11, P=0.16). Notably, only 51% of patients who received RT achieved all benchmarks. CONCLUSIONS: In this cohort of older women with node-positive vulvar cancer, achieving metrics for RT delivery was an important factor for optimizing disease benefits from treatment.
Assuntos
Neoplasias Vulvares/patologia , Neoplasias Vulvares/radioterapia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Escamosas/epidemiologia , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/radioterapia , Estudos de Coortes , Feminino , Humanos , Linfonodos/patologia , Metástase Linfática , Medicare/estatística & dados numéricos , Radioterapia Adjuvante , Programa de SEER , Estados Unidos/epidemiologia , Neoplasias Vulvares/epidemiologiaRESUMO
Vulvar cancer is a rare gynecologic malignancy. Ninety percent of vulvar cancers are predominantly squamous cell carcinomas (SCCs), which can arise through human papilloma virus (HPV)-dependent and HPV-independent pathways. The NCCN Vulvar Cancer panel is an interdisciplinary group of representatives from NCCN Member Institutions consisting of specialists in gynecological oncology, medical oncology, radiation oncology, and pathology. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Vulvar Cancer provide an evidence- and consensus-based approach for the management of patients with vulvar SCC. This manuscript discusses the recommendations outlined in the NCCN Guidelines for diagnosis, staging, treatment, and follow-up.
Assuntos
Carcinoma de Células Escamosas/diagnóstico , Carcinoma de Células Escamosas/terapia , Recidiva Local de Neoplasia/diagnóstico , Infecções por Papillomavirus/diagnóstico , Infecções por Papillomavirus/terapia , Neoplasias Vulvares/diagnóstico , Neoplasias Vulvares/terapia , Antineoplásicos/uso terapêutico , Biópsia , Carcinoma de Células Escamosas/epidemiologia , Carcinoma de Células Escamosas/patologia , Quimiorradioterapia , Feminino , Humanos , Oncologia/normas , Recidiva Local de Neoplasia/terapia , Estadiamento de Neoplasias , Infecções por Papillomavirus/epidemiologia , Infecções por Papillomavirus/patologia , Radioterapia Adjuvante , Fatores de Risco , Taxa de Sobrevida , Neoplasias Vulvares/epidemiologia , Neoplasias Vulvares/patologiaRESUMO
OBJECTIVE: To analyze patterns of recurrence and survival and identify prognostic factors in women with neuroendocrine cervical cancer (NECC). METHODS: We reviewed patients with International Federation of Gynecology and Obstetrics stage I-IVA NECC who were enrolled in the Neuroendocrine Cervical Tumor Registry and treated with curative intent. Event-free survival (EFS) and overall survival (OS) according to disease and treatment characteristics were analyzed using the Kaplan-Meier method. RESULTS: Among 40 patients with NECC, 25 (62%) had small cell NECC, eight (20%) had large cell NECC, and seven (18%) had unspecified neuroendocrine histology. With a median follow-up of 21.5months, 32 patients (80%) experienced progression, and 28 (70%) died. For all patients, the 5-year EFS rate was 20%, and the 5-year OS rate was 27%. Patients with large cell NECC had significantly better median EFS (median not reached vs. 10.0months, p=0.02) and showed a trend toward better median OS (153months vs. 21months, p=0.08) than patients with other histologic types. In patients with early-stage clinically node-negative disease, chemoradiation was associated with significantly better median EFS than surgery (median not reached vs. 18.0months, p=0.04). CONCLUSIONS: Patients with large cell NECC have better outcomes than patients with other subtypes of NECC. In early-stage node-negative NECC, chemoradiation yields better EFS than surgery. Most patients with NECC, even those with no evidence of nodal disease at diagnosis, rapidly develop widespread hematogenous metastases and die of their disease.
Assuntos
Carcinoma Neuroendócrino/terapia , Quimiorradioterapia/métodos , Histerectomia/métodos , Recidiva Local de Neoplasia/epidemiologia , Sistema de Registros , Neoplasias do Colo do Útero/terapia , Adulto , Idoso , Neoplasias Encefálicas/prevenção & controle , Neoplasias Encefálicas/secundário , Carcinoma Neuroendócrino/patologia , Carcinoma Neuroendócrino/secundário , Irradiação Craniana , Intervalo Livre de Doença , Feminino , Humanos , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Neoplasias do Colo do Útero/patologia , Adulto JovemRESUMO
OBJECTIVE: To evaluate treatment outcomes for patients with vulvar cancer with grossly positive pelvic lymph nodes (PLNs). METHODS: From a database of 516 patients with vulvar cancer, we identified patients with grossly positive PLNs without distant metastasis at initial diagnosis. We identified 20 patients with grossly positive PLNs; inclusion criteria included PLN 1.5cm or larger in short axis dimension on CT/MRI (n=11), FDG-avid PLN on PET/CT (n=3), or biopsy-proven PLN disease (n=6). Ten patients were treated with chemoradiation therapy (CRT), 4 with RT alone, and 6 with various combinations of surgery, RT or CRT. Median follow-up time for patients who had not died of cancer was 47months (range, 4-228months). RESULTS: Mean primary vulvar tumor size was 6.4cm; 12 patients presented with 2009 AJCC T2 and 8 with T3 disease. All patients had grossly positive inguinal nodes, and the mean inguinal nodal diameter was 2.8cm. The 5-year overall survival and disease specific survival rates were 43% and 48%, respectively. Eleven patients had recurrences, some at multiple sites. There were 9 recurrences in the vulva, but no isolated nodal recurrences. Four patients developed distant metastasis within 6months of starting radiation therapy. CONCLUSIONS: Aggressive locoregional treatment can lead to favorable outcomes for many patients with grossly involved PLNs that is comparable to that of grossly involved inguinal nodes only. We recommend modification of the FIGO stage IVB classification to more accurately reflect the relatively favorable prognosis of patients with PLN involvement.
Assuntos
Linfonodos/patologia , Neoplasias Vulvares/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Excisão de Linfonodo , Linfonodos/cirurgia , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Pelve , Prognóstico , Análise de Sobrevida , Resultado do Tratamento , Neoplasias Vulvares/mortalidade , Neoplasias Vulvares/radioterapia , Neoplasias Vulvares/cirurgiaRESUMO
OBJECTIVE: Pelvic and paraortic lymph nodal regions are frequent sites of relapse in women with endometrial cancer who have not undergone adjuvant external beam radiation. We investigated outcomes after definitive management of nodal relapses of endometrial cancer with intensity modulated radiation therapy (IMRT). METHODS: Between 2002-2012, 38 patients with endometrial cancer who had no prior external beam radiation were treated definitively using IMRT for regionally confined pelvic or paraortic nodal recurrences. Thirteen (34%) had chemotherapy prior to radiation, and 21 (55%) received concurrent chemotherapy. The nodal basins were typically treated to 45-50Gy, with a boost to the gross tumor to a median total of 64.7Gy (range 59-73Gy). RESULTS: The median overall survival from date of recurrence was 46.1months and the 2-year survival was 71%. Patients who received concurrent chemotherapy had a significantly longer median survival (61.9months versus 28.7months, p=0.034). In-field failures were more frequent in patients who received chemotherapy prior to radiation, had a shorter recurrence-free interval, received a lower radiation dose, and had higher tumor grade. Three patients (8%) experienced grade 3-4 late gastrointestinal (GI) toxicity. CONCLUSIONS: Long-term survival can be achieved in women with nodal recurrences of endometrial cancer. The use of concurrent chemotherapy and dose escalation with IMRT as feasible may improve survival for women with isolated nodal recurrences of endometrial cancer.
Assuntos
Neoplasias do Endométrio/radioterapia , Recidiva Local de Neoplasia/radioterapia , Idoso , Quimiorradioterapia , Neoplasias do Endométrio/tratamento farmacológico , Neoplasias do Endométrio/patologia , Neoplasias do Endométrio/cirurgia , Feminino , Humanos , Linfonodos/patologia , Irradiação Linfática , Metástase Linfática , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/tratamento farmacológico , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Radioterapia de Intensidade Modulada , Resultado do TratamentoRESUMO
OBJECTIVE: The ratio of positive to negative lymph nodes, or lymph node ratio (LNR), is an important prognostic factor in several solid tumors. The objective of this study was to determine if LNR can be used to define a high-risk category of patients with node-positive early stage cervical cancer. METHODS: We performed a retrospective review of patients diagnosed with node-positive stage I or II cervical cancer who underwent radical hysterectomy and pelvic +/- para-aortic lymphadenectomy at MD Anderson from January 1990 to December 2011. Univariate and multivariate analyses were used to identify prognostic factors for progression-free (PFS) and overall survival (OS). RESULTS: Ninety-five patients met the inclusion criteria and were included in the analysis. Median total nodes removed were 19 (range 1-58), and median number of positive nodes was 1 (range 1-12). Fifty-eight patients (61%) received radiation with concurrent cisplatin and 27 patients (28%) received radiotherapy alone. Twenty-one (22%) patients recurred. On multivariate analysis, a LNR > 6.6% was associated with a worse PFS (HR = 2.97, 95% CI 1.26-7.02, p = 0.01), and a LNR > 7.6% with a worse OS (HR = 3.96, 95% CI 1.31-11.98, p = 0.01). On multivariate analysis, positive margins were associated with worse PFS (p = 0.001) and OS (p = 0.002), and adjuvant radiotherapy (p = 0.01) with improved OS. CONCLUSIONS: LNR appears to be a useful tool to identify patients with worse prognosis in node-positive early stage cervical cancer. LNR may be used in addition to pathologic risk factors to tailor adjuvant treatment in this population.
Assuntos
Linfonodos/patologia , Neoplasias do Colo do Útero/patologia , Adulto , Idoso , Análise de Variância , Intervalo Livre de Doença , Feminino , Humanos , Histerectomia , Excisão de Linfonodo , Linfonodos/cirurgia , Metástase Linfática , Pessoa de Meia-Idade , Análise Multivariada , Estadiamento de Neoplasias , Estudos Retrospectivos , Risco , Taxa de Sobrevida , Neoplasias do Colo do Útero/cirurgia , Adulto JovemRESUMO
The NCCN Guidelines for Cervical Cancer provide interdisciplinary recommendations for treating cervical cancer. These NCCN Guidelines Insights summarize the NCCN Cervical Cancer Panel's discussion and major guideline updates from 2014 and 2015. The recommended systemic therapy options for recurrent and metastatic cervical cancer were amended upon panel review of new survival data and the FDA's approval of bevacizumab for treating late-stage cervical cancer. This article outlines relevant data and provides insight into panel decisions regarding various combination regimens. Additionally, a new section was added to provide additional guidance on key principles of evaluation and surgical staging in cervical cancer. This article highlights 2 areas of active investigation and debate from this new section: sentinel lymph node mapping and fertility-sparing treatment approaches.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Guias de Prática Clínica como Assunto , Neoplasias do Colo do Útero/tratamento farmacológico , Neoplasias do Colo do Útero/patologia , Feminino , Preservação da Fertilidade , Humanos , Estadiamento de Neoplasias , Neoplasias do Colo do Útero/cirurgiaRESUMO
The NCCN Guidelines for Uterine Neoplasms provide interdisciplinary recommendations for treating endometrial carcinoma and uterine sarcomas. These NCCN Guidelines Insights summarize the NCCN Uterine Neoplasms Panel's 2016 discussions and major guideline updates for treating uterine sarcomas. During this most recent update, the panel updated the mesenchymal tumor classification to correspond with recent updates to the WHO tumor classification system. Additionally, the panel revised its systemic therapy recommendations to reflect new data and collective clinical experience. These NCCN Guidelines Insights elaborate on the rationale behind these recent changes.