NSUN6-mediated 5-methylcytosine modification of NDRG1 mRNA promotes radioresistance in cervical cancer.

BACKGROUND: Radioresistance is the leading cause of death in advanced cervical cancer (CC). Dysregulation of RNA modification has recently emerged as a regulatory mechanism in radiation and drug resistance. We aimed to explore the biological function and clinical significance of 5-methylcytosine (m5C) in cervical cancer radiosensitivity. METHODS: The abundance of RNA modification in radiotherapy-resistant and sensitive CC specimens was quantified by liquid chromatography-tandem mass spectrometry. The essential RNA modification-related genes involved in CC radiosensitivity were screened via RNA sequencing. The effect of NSUN6 on radiosensitivity was verified in CC cell lines, cell-derived xenograft (CDX), and 3D bioprinted patient-derived organoid (PDO). The mechanisms of NSUN6 in regulating CC radiosensitivity were investigated by integrative m5C sequencing, mRNA sequencing, and RNA immunoprecipitation. RESULTS: We found a higher abundance of m5C modification in resistant CC samples, and NSUN6 was the essential m5C-regulating gene concerning radiosensitivity. NSUN6 overexpression was clinically correlated with radioresistance and poor prognosis in cervical cancer. Functionally, higher NSUN6 expression was associated with radioresistance in the 3D PDO model of cervical cancer. Moreover, silencing NSUN6 increased CC radiosensitivity in vivo and in vitro. Mechanistically, NDRG1 was one of the downstream target genes of NSUN6 identified by integrated m5C-seq, mRNA-seq, and functional validation. NSUN6 promoted the m5C modification of NDRG1 mRNA, and the m5C reader ALYREF bound explicitly to the m5C-labeled NDRG1 mRNA and enhanced NDRG1 mRNA stability. NDRG1 overexpression promoted homologous recombination-mediated DNA repair, which in turn led to radioresistance in cervical cancer. CONCLUSIONS: Aberrant m5C hypermethylation and NSUN6 overexpression drive resistance to radiotherapy in cervical cancer. Elevated NSUN6 expression promotes radioresistance in cervical cancer by activating the NSUN6/ALYREF-m5C-NDRG1 pathway. The low expression of NSUN6 in cervical cancer indicates sensitivity to radiotherapy and a better prognosis.

Clinical significance of intensity-modulated radiotherapy (IMRT) to the distant metastatic lymph nodes for metastatic cervical cancer.

OBJECTIVE: To retrospectively explore the clinical significance of radiotherapy to the distant metastatic lymph nodes (cervical/ clavicular/ mediastinal et al.) in metastatic cervical cancer. Hereinto, these cervicothoracic lymph nodes were metastasized from IB1-IVA (initial stage at first treatment), and IVB initially had metastatic disease in these areas at diagnosis. METHODS: Metastatic cervical cancer only with the distant cervicothoracic metastatic lymph nodes (cervical/ clavicular/ mediastinal et al.), without distant parenchymal organs metastasis such as lung, liver, bone, and peritoneum, were enrolled in the analysis. These patients were classified into IB1-IVA and IVB based on their initial stage of first treatment. All patients received IMRT for the distant metastatic lymph nodes. The progression-free survival (PFS) and overall survival (OS) were analyzed using the Kaplan-Meier method. RESULTS: Overall, the median PFS was 9 months, and the median OS was 27 months. The subgroup analysis showed that for IB1-IVA, the median PFS was 11 months, and the median OS was 30.5 months. For IVB, the median PFS was 8 months, and the median OS was 16 months. CONCLUSION: Radiotherapy is beneficial to the distant metastatic lymph nodes (cervical/ clavicular/ mediastinal et al.), and could effectively bring the longer PFS and OS for metastatic cervical cancer.

Durvalumab versus placebo with chemoradiotherapy for locally advanced cervical cancer (CALLA): a randomised, double-blind, phase 3 trial.

BACKGROUND: Concurrent chemoradiotherapy has been the standard of care for locally advanced cervical cancer for over 20 years; however, 30-40% of treated patients have recurrence or progression within 5 years. Immune checkpoint inhibition has improved outcomes for patients with PD-L1 positive metastatic or recurrent cervical cancer. We assessed the benefit of adding durvalumab, a PD-L1 antibody, with and following chemoradiotherapy for locally advanced cervical cancer. METHODS: The CALLA randomised, double-blind, phase 3 trial included 105 hospitals across 15 countries. Patients aged at least 18 years with previously untreated locally advanced cervical cancer (adenocarcinoma, squamous, or adenosquamous; International Federation of Gynaecology and Obstetrics [FIGO] 2009 stage IB2-IIB lymph node positive, stage ≥III any lymph node status) and WHO or Eastern Cooperative Oncology Group performance status of 0 or 1 were randomly assigned (1:1) through an interactive web response system using a permuted block size of 4 to receive durvalumab (1500 mg intravenously once every 4 weeks) or placebo with and following chemoradiotherapy, for up to 24 cycles. Chemoradiotherapy included 45 Gy external beam radiotherapy at 5 fractions per week concurrent with intravenous cisplatin (40 mg/m2) or carboplatin (area under the concentration-time curve 2) once weekly for 5 weeks, followed by image-guided brachytherapy (high-dose rate, 27·5-30 Gy or low-dose/pulse-dose rate, 35-40 Gy). Randomisation was stratified by disease stage status (FIGO stage and node status) and geographical region. Chemoradiotherapy quality was continuously reviewed. The primary endpoint was progression-free survival, assessed by the investigator using Response Evaluation Criteria in Solid Tumors, version 1.1, in the intention-to-treat population. Safety was assessed in patients who received at least one dose of study treatment. This study is registered with ClinicalTrials.gov, NCT03830866. FINDINGS: Between Feb 15, 2019, and Dec 10, 2020, 770 women were randomly assigned (385 to durvalumab and 385 to placebo; median age 49 years [IQR 41-57]). Median follow-up was 18·5 months (IQR 13·2-21·5) in the durvalumab group and 18·4 months (13·2-23·7) in the placebo group. At data cutoff, median progression-free survival had not been reached (95% CI not reached-not reached) for either group (HR 0·84; 95% CI 0·65-1·08; p=0·17); 12-month progression-free survival was 76·0% (71·3-80·0) with durvalumab and 73·3% (68·4-77·5) with placebo. The most frequently reported grade 3-4 adverse events in both groups were anaemia (76 [20%] of 385 in the durvalumab group vs 56 [15%] of 384 in the placebo group) and decreased white blood cells (39 [10%] vs 49 [13%]). Serious adverse events occurred for 106 (28%) patients who received durvalumab and 89 (23%) patients who received placebo. There were five treatment-related deaths in the durvalumab group (one case each of urinary tract infection, blood loss anaemia, and pulmonary embolism related to chemoradiotherapy only; one case of endocrine disorder related to durvalumab only; and one case of sepsis related to both durvalumab and chemoradiotherapy). There was one treatment-related death in the placebo group (pneumonia related to chemoradiotherapy). INTERPRETATION: Durvalumab concurrent with chemoradiotherapy was well tolerated in participants with locally advanced cervical cancer, however it did not significantly improve progression-free survival in a biomarker unselected, all-comers population. Concurrent durvalumab plus chemoradiotherapy warrants further exploration in patients with high tumoral PD-L1 expression. Rigorous monitoring ensured high chemoradiotherapy compliance with advanced technology and allowed patients to receive optimal care. FUNDING: AstraZeneca.

Clinical Implication of Simultaneous Intensity-modulated Radiotherapy Boost to Tumor Bed for Cervical Cancer with Full-thickness Stromal Invasion.

OBJECTIVE: The objective of this study was to retrospectively explore the clinical implications of simultaneous intensity-modulated radiotherapy (IMRT) boost to the tumor bed in cervical cancer with full-thickness stromal invasion (FTSI). PATIENTS AND METHODS: Patients diagnosed with the International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB and IIA cervical cancer with confirmed FTSI were included. Patients received pelvic IMRT from a dose of 50.4 Gy in 28 fractions with (or without) a simultaneous integrated boost (SIB) to 58.8 Gy in 28 fractions for the tumor bed. The progression-free survival (PFS), overall survival (OS), and pelvic-PFS (p-PFS) were analyzed using the Kaplan-Meier method, and independent prognostic factors were explored by Cox regression analyses. RESULTS: Patients without a tumor bed boost had a poor prognosis. The 5-year OS was 81.3% versus 58.3% and the 5-year PFS rates were 75.0% versus 57.6% (boost vs non-boost). The FIGO stage, pathology, adjuvant chemotherapy, and tumor bed boost were independent factors affecting both the 5-year OS and PFS. Subgroup analysis showed that the SIB group had a higher 5-year OS, PFS, and p-PFS for different stages, lymph node status, and risk groups than the non-SIB group. Recurrence occurred in 268 of 910 (29.5%) patients without SIB and 49 of 293 (16.7%) with SIB. Among patients with recurrence, 113 of 282 (40.1%) in the non-boost group compared with 14 of 51 (23.0%) patients in the boost group had a pelvic recurrence. Tumor bed boost resulted in an increase in the mean radiation dose to the intestine, rectum, and bladder, although there were no differences in the rates of acute and late toxicities between the 2 groups. CONCLUSION: Tumor bed boost by external beam radiotherapy (EBRT) is an effective and safe method for patients with FTSI and risk factors. Compared with the standard prophylactic radiation, tumor bed boost by EBRT was not associated with increased acute and late toxicities.

Global challenges of radiotherapy for the treatment of locally advanced cervical cancer.

Cervical cancer represents a significant portion of the global cancer burden for women, with low- and middle-income countries carrying the bulk of this burden. Additionally, underserved populations in countries with sufficient resources may have a higher incidence of cervical cancer and poorer outcomes. Concurrent chemoradiotherapy is the standard-of-care treatment for locally advanced cervical cancer, which includes patients with stage IB3 to IVA disease, and it is effective for many patients; however, cervical cancer-related mortality remains high. The critical nature of cervical cancer treatment is underscored by the recent launch of the World Health Organization global initiative to accelerate the elimination of cervical cancer using a triple-intervention strategy of increased vaccination, screening, and treatment. The initiative calls for 90% of all patients diagnosed with cervical cancer to receive the appropriate treatment, but to reach this global goal there are significant barriers related to radiotherapy that must be addressed. We discuss and review evidence of the lack of adherence to guideline-recommended treatment, brachytherapy underutilization, limited access to radiotherapy in low- and middle-income countries, as well as regional limitations within high-income countries, as the major barriers to radiotherapy treatment for locally advanced cervical cancer. We further review ways these barriers are currently being addressed and, in some cases, make additional recommendations to address these issues. Finally, despite receiving recommended treatments, many patients with locally advanced cervical cancer have a poor prognosis. With effective administration of current standards of care, the global community will be able to shift focus to advancing treatment efficacy for these patients. We review several types of therapies under clinical investigation that are additions to concurrent chemoradiotherapy, including immune checkpoint inhibitors, antiangiogenic agents, DNA repair inhibitors, human papillomavirus vaccines, and radiosensitizing nanoparticles.

Clinicopathological and survival characteristic of mismatch repair status in ovarian clear cell carcinoma.

BACKGROUND AND OBJECTIVES: We sought to explore the expression of mismatch repair (MMR) status and its correlation with clinicopathologic and survival characteristics in ovarian clear cell carcinoma (OCCC). METHODS: Expression of four MMR proteins (MLH1, PMS, MSH2, and MSH6) were measured using tissue microarray-based immunohistochemistry in 120 OCCC patients. The associations of clinicopathologic parameters with recurrence-free survival (RFS) and overall survival (OS) were analyzed by the Kaplan-Meier method, and multivariate analysis was further performed by the Cox regression model. RESULTS: Overall, 120 OCCC patients met the entry criteria, and their MMR status was detected, consisting of 24 patients with dMMR and 96 patients with proficient MMR (pMMR). Patients with dMMR were strongly associated with platinum-sensitive disease (P = .006) and large tumor volume (P = .038). Among all the patients who have received surgery, tumors with dMMR had a better RFS and OS than those with pMMR (hazard ratio [HR] for recurrence: 0.459 [95% confidence interval {95% CI} = 0.224-0.940], P = .029; HR for death: 0.381 [95% CI = 0.170-0.853], P = .015). In subgroup analysis, dMMR patients experienced a better trend of RFS (HR = 0.273; P = .055) and OS (HR = 0.165; P = .040) than pMMR cases among early stages (I-II), but this difference was not observed in advanced stage (III-IV) patients. Meanwhile, pMMR was associated with a more favorable trend of prognosis than dMMR in platinum-resistant patients (RFS: HR = 0.317, P = .051; OS: HR = 0.370, P = .046). Multivariate analysis revealed that only advanced stages (III-IV) were adverse independent prognosticators for both RFS (HR = 5.938 [95% CI = 2.804-12.574]; P < .001) and OS (HR = 6.209 [95% CI = 2.724-14.156]; P < .001). CONCLUSION: Tumors with dMMR were related to better OS in OCCC on univariate analysis. Only the tumor stage was an independent prognosticator for both RFS and OS. MMR status is a potentially valuable prognostic index in OCCC patients, and larger prospective studies are required to validate its prognostic role.

Clinicopathologic and survival analysis of patients with adenoid cystic carcinoma of vulva: single-institution experience.

PURPOSE: The purpose of this study was to elucidate our experience in the diagnosis and treatment of adenoid cystic carcinoma of the vulva (ACC-vulva) and to assess the clinicopathological characteristics and prognosis among ACC-vulva patients. METHODS: A retrospective study of seventeen patients was performed to illustrate the demographic information, clinical performance, pathological characteristics, treatment modality, and development of local recurrence or distant metastasis, as well as the survival outcome. RESULTS: The median age at diagnosis was 56 years (range, 26-71 years). Radical local excision was performed on fifteen patients, and two patient received radical hemi-vulvectomy. Six patients received ipsilateral inguinal lymphadenectomy. Involvement of the resection margin was observed in six patients. The postoperative pathologic diagnosis showed no proof of inguinal lymph node metastasis in all the six patients receiving lymphadenectomy. However, the perineural invasion was observed in all patients. Postoperative adjuvant radiotherapy was applied to five patients who had positive resection margin. The mean survival time except for that in four patients (recent case) was 47.8 months (range, 23-78 months). CONCLUSION: Radical resection towards negative margins seems to be acceptable as initial treatment. Adjuvant radiotherapy is a preferable treatment modality for patients with high-risk factors pathologically or patients with local recurrence.

The Survival Rate and Surgical Morbidity of Abdominal Radical Trachelectomy Versus Abdominal Radical Hysterectomy for Stage IB1 Cervical Cancer.

PURPOSE: To compare the survival rates and morbidities of abdominal radical trachelectomy (ART) to abdominal radical hysterectomy (ARH) for stage IB1 cervical cancer and to evaluate the safety of ART for tumors measuring 2-4 cm. METHODS: We performed a retrospective study to compare the outcomes of patients with stage IB1 cervical cancer who underwent ART to patients treated with ARH who met the inclusion criteria of a fertility-sparing surgery. All of the patients were treated by the same surgeon at our institution in the same period. RESULTS: Of the 107 and 141 patients who underwent ART and ARH, respectively, 61 and 82 patients had a tumor ≥2 cm (P = NS). With a median follow-up of 30 and 49 months, 2 patients treated with ART and 3 patients treated with ARH recurred: the 5-year RFS rate was 96.5 and 94.8%, respectively, for tumors ≥2 cm (P = NS). Only 3 patients died in the ARH group: the 5-year OS rate was 100% for the ART and 94.8% for the ARH group for tumors ≥2 cm (P = NS). Incidence rates of intraoperative complications were similar in the two groups (1.9% for ART and 0.7% for ARH, P = NS). However, incidence rates of postoperative complications were higher in the ART group (36.4% for ART and 19.1% for ARH, P < 0.05). CONCLUSIONS: ART appears to have equal survival rates to ARH and can be performed safely in stage IB1 cervical cancers ≥2 cm. However, ART is associated with more postoperative morbidities compared with ARH.

Validation of the new FIGO staging system (2009) for vulvar cancer in the Chinese population.

OBJECTIVE: A new FIGO staging system for vulvar cancer was issued in 2009. The aim of this study was to identify its value in estimating the outcome of patients with vulvar squamous cell carcinoma (VSCC) in the Chinese population. METHODS: A total of 184 patients who underwent radical surgery for VSCC were recruited. Their medical records and pathology slides were reviewed. Disease reclassification was conducted according to the FIGO staging system (2009). The primary outcomes were cause-specific survival (CSS), relapse-free survival (RFS) and overall survival (OS). RESULTS: A total of 76 patients (41.3%) were downstaged and no patients were upstaged in the new FIGO staging system (2009). The stage distribution was as follows: stage I (99), stage II (13), stage III (65) and stage IV (7). According to CSS, the patients were classified into 4 groups: stage IA (group 1), stage IB/II/IIIA (group 2), stage IIIB (group 3), and stage IIIC/IV (group 4) (5-year CSS: 100%, 85%, 34.6% and 0%, respectively). The 5-year CSS was similar among the patients with stage IB, II and IIIA carcinomas (84.4%, 84.6% and 84.8%, respectively, p=0.986), whereas, significant decline of the CSS was found with increased substages of stages IIIA, IIIB and IIIC (84.8%, 34.6%, and 0 respectively, p<0.001). CONCLUSIONS: The 2009 FIGO staging system for VSCC displayed good performance for the subdivisions of stage III VSCC, but it failed to stratify survival well between stages IB, II and IIIA.

MicroRNA-181a enhances the chemoresistance of human cervical squamous cell carcinoma to cisplatin by targeting PRKCD.

MicroRNAs(miRNAs) are involved in regulating the response of cancer cells to various therapeutic interventions, but their involvement in the chemoresistance of human cervical squamous cell carcinoma is not fully understood. We found miR-181a was significantly up-regulated in specimens from patients with chemoresistant cervical squamous cell carcinoma. In this study, we aimed to clarify the role of miR-181a in regulating the chemoresistance of cervical cancer. Two human cervical squamous cancer cell lines, SiHa and Me180, were used. Enforced expression of miR-181a enhanced chemoresistance to cisplatin in cervical cancer cells through apoptosis reversion. In a nude mouse xenograft model, the overexpression of miR-181a markedly inhibited the therapeutic response to cisplatin. PRKCD, a target gene of miR-181a and a promoter of apoptosis, was negatively regulated by miR-181a. We found that the effect of miR-181a on chemoresistance was mediated by PRKCD. Additionally, silencing of PRKCD yielded an effect similar to that of miR-181a up-regulation and inhibited apoptosis in cervical cancer cells. Our findings suggest that miR-181a may function as an oncogene and induce chemoresistance in cervical squamous cell carcinoma cells at least in part by down-regulating PRKCD, thus may provide a biomarker for predicting chemosensitivity to cisplatin in patients with cervical squamous cancer.

Decreased expression of EIF4A1 after preoperative brachytherapy predicts better tumor-specific survival in cervical cancer.

OBJECTIVE: The aim of this study is to investigate whether EIF4A1, EIF4E, and EIF4G1 can serve as prognostic markers for patients with cervical cancer receiving preoperative brachytherapy. MATERIALS AND METHODS: Tissue microarrays composed of 35 normal cervix samples, 87 cervical cancers treated without preoperative therapy, and 50 pairs of cervical cancer tissues collected before and after preoperative brachytherapy were constructed and evaluated for the expression of EIF4A1, EIF4E, and EIF4G using immunohistochemistry. Immunohistochemical staining was scored by the staining intensity and the percentages of tumor cells. The χ test was used to analyze the association between the immunohistochemistry results and clinicopathologic variables. The Kaplan-Meier method was applied to analyze the disease-specific survival. RESULTS: Overexpression of EIF4A1, EIF4E, and EIF4G1 were detected in 83.9%, 84.7%, and 80.3% of cervical cancers, respectively, all of which were significantly related to advanced International Federation of Gynecology and Obstetrics stage, squamous cell histology, lymph node metastasis, and deep stromal invasion (P < 0.05). The altered expression pattern of EIF4A1 and EIF4E after preoperative brachytherapy was significantly correlated with the cervical cancer response to brachytherapy (P = 0.029 and 0.012, respectively). The decreased expression of EIF4A1 predicted better tumor-specific survival (P = 0.02). The alteration of EIF4A1 was an independent predictor for tumor-specific survival (P = 0.047; hazards ratio, 0.272; 95% confidence interval, 0.076-0.982). CONCLUSIONS: Overexpression of EIF4A1, EIF4E, and EIF4G1 were acquired malignant phenotypic features of cervical cancer. EIF4A1 might function as a novel prognostic indicator and a potential therapeutic target for cervical cancer.

[Value of MR diffusion-weighted imaging in diagnosis and outcome prediction for uterine cervical cancer].

OBJECTIVE: To investigate the clinical application of diffusion weighted imaging (DWI) in uterine cervical cancer and the apparent diffusion coefficient (ADC) value in diagnosis and predicting treatment response. METHODS: Twenty-eight patients with advanced primary cervical cancer confirmed by pathology and 10 cases of normal uterine cervix as control were recruited in this prospective clinical trial. To analyze the correlation between tumor volume measured in DWI and tumor maximum diameter measured according to the RECIST criteria. To compare the ADC value differences among the uterine cervical cancer, uterine myometrium, and normal uterine cervix. To compare the ADC values in 17 cancer patients before and after treatment. RESULTS: The illustration of tumor boundary in DWI was superior to conventional T2WI and post-enhancement T1WI. The DWI with higher b value (2000 s/mm(2)) had a better signal-to-noise ratio. The tumor volume measured in DWI has good correlation with tumor maximum diameter according to RECIST criteria (r = 0.759, P < 0.01). When b = 800 s/mm(2), the ADC values of the uterine cervical cancer, uterine myometrium, and normal uterine cervix were (9.85 ± 1.55)×10(-3) mm(2)/s, (14.20 ± 2.80)×10(-3) mm(2)/s, and (14.14 ± 0.45) ×10(-3) mm(2)/s. When b = 2000 s/mm(2), the ADC values of the uterine cervical cancer, uterine myometrium and normal uterine cervix were (7.38 ± 0.98)×10(-3) mm(2)/s, (8.52 ± 2.38)×10(-3) mm(2)/s, and (8.60 ± 0.63)×10(-3) mm(2)/s, respectively. There were significant differences between the cervical cancer and normal cervix or uterine myometrium (P < 0.001 for both). When b = 800 s/mm(2), the ADC value was (9.85 ± 1.55)×110(-3) mm(2)/s before and (13.41 ± 2.93)×10(-3) mm(2)/s after treatment (P < 0.001). When b = 2000 s/mm(2), the ADC value was (7.38 ± 0.98)×10(-3) mm(2)/s before and (8.93 ± 1.92)×10(-3) mm(2)/s after treatment (P = 0.008). Univariate logistic regression analysis showed that 25% ADC, 50%ADC, and 75%ADC in the tumor ADC value histogram before treatment were significantly correlated to the treatment outcome of cervical cancer (P < 0.05 for all). Multivariate regression analysis showed that 25%ADC, 50%ADC, and 75%ADC in the tumor ADC value histogram before treatment were not significantly correlated to the treatment outcome of cervical cancer (P > 0.05 for all). The values of ROC curves were 25%ADC = 0.818, 50%ADC = 0.775, and 75%ADC = 0.716 (P > 0.05), however, the 25% ADC showed a relatively stronger statistical power. CONCLUSIONS: DWI helps to confirm the morphology and exact target zone of the tumor for radiotherapy. DWI volume measurement is well correlated with RECIST criteria, particularly in volume measurement of irregular tumors. ADC value has a potential in quantitatively monitoring treatment response and predicting outcome of cervical cancers.

Application of Recombinant Human Superoxide Dismutase in Radical Concurrent Chemoradiotherapy for Cervical Cancer to Prevent and Treat Radiation-induced Acute Rectal Injury: A Multicenter, Randomized, Open-label, Prospective Trial.

PURPOSE: The purpose of this study was to evaluate the efficacy of recombinant human superoxide dismutase (rhSOD) enemas in radiation-induced acute rectal injury (RARI) in patients with locally advanced cervical cancer. METHODS AND MATERIALS: In this phase 3, randomized, open-label trial (NCT04819685) conducted across 14 medical centers in China from June 2021 to August 2023, all patients received concurrent chemoradiation therapy (CCRT). The experimental group was treated with a rhSOD enema during chemoradiation therapy, and the control group had no enema. The Common Terminology Criteria for Adverse Events (version 5.0) was used to evaluate radiation therapy-induced side effects. Endoscopic appearance was assessed using the Vienna Rectoscopy Score. The primary endpoint in the acute phase was the occurrence rate and duration of grade ≥1 (≥G1) diarrhea during CCRT. Secondary endpoints included the occurrence rate and duration of ≥G2 and ≥G3 diarrhea, ≥G1 and ≥G2 diarrhea lasting at least 3 days, and damage to the rectal mucosa due to radiation therapy measured by endoscopy. RESULTS: Two hundred and eighty-three patients were randomly divided into the experimental (n = 141) or control group (n = 142). The mean number of ≥G1 and ≥G2 diarrhea days were significantly lower in the experimental group than in the control group (3.5 and 0.8 days vs 14.8 and 4.5 days, respectively; P < .001). The incidence of ≥G2 diarrhea decreased from 53.6% to 24.1% when rhSOD enemas were used. Use of antidiarrheals was lower in the experimental group (36.2% vs 55.7%, P < .001). Three patients felt intolerable or abdominal pain after rhSOD enema. RARI grades in the experimental group tended to be lower than those in the control group (P = .061). Logistic regression analysis revealed that rhSOD enema was associated with a lower occurrence rate of ≥G1/2 diarrhea for at least 3 days (P < .001). CONCLUSIONS: The results of this study suggest that rhSOD enema is safe and significantly reduces the incidence, severity, and duration of RARI, protecting the rectal mucosa.

[Extended-field intensity modulated radiation therapy and intra-cavitary brachytherapy combined with chemotherapy for stage Ib1-IVa cervical cancer with positive para-aortic lymph nodes].

OBJECTIVE: To investigate the treatment effects and toxicities of extended-field intensity modulated radiation therapy (EF-IMRT) and intra-cavitary brachytherapy combined with chemotherapy for stageIb1-IVa cervical cancer with positive para-aortic lymph nodes. METHODS: A total of 46 stage Ib1-IVa cervical cancer patients with positive para-aortic lymph nodes treated at Fudan University Shanghai Cancer Center between 2009 and 2011 were reviewed. Neoadjuvant, concomitant and adjuvant chemotherapy with paclitaxel and carboplatin were administrated for one cycle before radiation therapy, two cycles during radiation therapy or three cycles after radiation therapy. All patients received EF-IMRT and intra-cavitary brachytherapy. The positive lymph nodes received an additional boost dose. RESULTS: All patients received EF-IMRT to 50.4 Gy (1.8 Gy per fraction). Twenty-six patients was treated with boost dose of 6.0-8.0 Gy in 2.0 Gy per fraction to positive para-aortic lymph nodes. Thirty-seven patients received a positive para-aortic lymph nodes boost or (and) parametrial boost. All patient also received a high-dose-rate intra-cavitary brachytherapy at the point "A" dose of 20.0-30.0 Gy in 5.0 Gy per fraction. Total chemotherapy cycles were 189, and the average patient received 4.1 courses. Two cases (4%, 2/46) experienced grade III gastrointestinal toxicities, no patients suffered grade IV gastrointestinal toxicities. Fifteen cases (33%, 15/46) experienced grade III hematological toxicities, and 3(7%, 3/46) experienced grade IV hematological toxicities.Late grade III-IV toxicity was seen in 3 cases (7%, 3/46). The 3 year progression- free survival rate was 46.2%, and the 3 years overall survival rate was 61.2%. CONCLUSION: EF-IMRT and intra-cavitary brachytherapy combined with chemotherapy is safe and effective for stageIb1-IVa cervical cancer with positive para-aortic lymph nodes.

Identifying tumor markers-stratified subtypes (CA-125/CA19-9/carcinoembryonic antigen) in cervical adenocarcinoma.

OBJECTIVE: There is a lack of research evaluating the effect of tumor markers for prognosis in cervical adenocarcinoma. We aimed to develop and validate a preoperative tumor-marker-based model including clinicopathological factors to clarify the prognostic value of endocervical adenocarcinoma. METHODS: A total of 572 patients with cervical adenocarcinoma who were staged at the International Federation of Gynecology and Obstetrics (FIGO) IA-IIA were reviewed retrospectively. Preoperative serum carcinoembryonic antigen (CEA), carbohydrate antigen (CA)-125 and CA19-9 levels were measured. The survival and recurrence patterns were analyzed according to the tumor-marker-related stratification. The predictive values of biomarkers and clinical variables were assessed with Cox regression and competing risk models. RESULTS: Patients with elevated preoperative tumor markers had evidently poor overall survival and recurrence-free survival. The triple-elevated tumor marker (TETM) subgroup had the worst overall survival and progression-free survival than the triple-negative tumor marker (TNTM) subgroup and the single-elevated tumor marker (SETM) subgroup. The most important predictors for overall survival were elevated tumor markers, FIGO-stage, tumor differentiation, lymphovascular space invasion (LVSI) and lymph nodes metastasis. The most important predictors for recurrence-free survival were elevated tumor markers, FIGO-stage, tumor differentiation, LVSI and deep stromal invasion. Stratified analysis showed that elevated CA-125 and CA19-9 were significantly associated with postoperative distant metastasis. A decision curve analysis confirmed that a combination of tumor markers as predictors significantly outperformed the other common predictors used (FIGO-stage, intermediate and high-risk factors, tumor differentiation, lymph nodes). CONCLUSIONS: Elevated preoperative serum CEA, CA-125, and CA19-9 levels exhibited poor overall survival and recurrence-free survival in cervical adenocarcinoma patients. Combined preoperative serum CA-125 and CA19-9 independently predicted distant metastasis in patients with endocervical adenocarcinoma.

Efficacy and safety of apatinib in patients with recurrent uterine malignancy: a prospective, single-center, single-arm, phase 2 study.

Background: Apatinib, a small-molecule tyrosine kinase inhibitor that selectively targets vascular endothelial growth factor receptor-2, has clinical activity in recurrent/advanced gynecological cancers. However, its efficacy in uterine malignancy remains unclear. This study aimed to determine the efficacy and safety of single-agent apatinib in patients with recurrent uterine malignancy. Methods: This is a prospective single-center, single-arm, phase 2 study that enrolled patients aged 18-70 years with histopathologically confirmed recurrent endometrial cancer (EC) and recurrent uterine sarcoma (US), received at least 2 chemotherapy regimens, and an Eastern Cooperative Group performance status of 0-1. Apatinib (500 mg) was administered orally once daily. A treatment cycle was defined as 4 weeks. The patients were followed up every 2 cycles for tumor radiological assessment until disease progression. The primary endpoint was the overall response rate (ORR). The secondary endpoints were progression-free survival (PFS) and overall survival (OS). Adverse events (AEs) were recorded throughout the treatment and within 30 days of the last study treatment and graded as per the National Cancer Institute Common Toxicity Criteria Version 4.0. Results: A total of 33 patients (22 with EC and 11 with US) were enrolled between October 2018 and April 2021. Median follow-up duration was 11.7 months (interquartile range: 6.8-32.5 months). The patients received apatinib for a median of 4.79 cycles (range 2-13 cycles). In the EC and US cohorts, the ORRs were 27.2% [95% confidence interval (CI), 10.7% to 50.2%] and 9.1% (95% CI, 0.2% to 41.3%), the median PFS were 4.4 months (95% CI, 4.2 to 6.7 months) and 7.0 months (95% CI, 3.2 to 11.6 months), and the median OS were 11.7 months (95% CI, 6.8 months to not reached) and 18.1 months (95% CI, 9.2 months to not reached), respectively. The most common treatment-related AEs of all grades were hypertension (36.4%), proteinuria (33.3%), and hand-foot syndrome (30.3%). No treatment-related serious AEs or deaths occurred. Conclusions: To our knowledge, this is the first prospective study assessing the efficacy and safety of apatinib in patients with uterine malignancy. The results suggested that apatinib might be a potential treatment option for these patients.

Postoperative chylous ascites in patients with gynecologic malignancies.

OBJECTIVE: To evaluate the incidence and the effective treatment of postoperative chylous ascites in patients with gynecologic malignancies. METHODS: In this report, we retrospectively reviewed the cases of 4119 patients who underwent pelvic and/or para-aortic lymph node dissection for gynecologic malignancies in Fudan University Cancer Hospital. RESULTS: Among these 4119 cases, 7 (0.17%) patients had chylous ascites postoperatively. The average age of these patients was 52 years. The mean time interval between operation and the appearance of chylous ascites was 30 days (range, 5-75 days). The incidence of chylous ascites after para-aortic lymphadenectomy was approximately 0.32% (5/1540), whereas the rate after pelvic lymphadenectomy alone was 0.077% (2/2579). All cases with chylous ascites were resolved by conservative treatment. This included placement of a peritoneal drainage tube. The mean time to resolution was 13 days (range, 2-28 days). None of the cases had recurrent chylous ascites during follow-up. CONCLUSIONS: Para-aortic lymph node dissection may be associated with postoperative chylous ascites. Patients may have their chylous ascites successfully treated with conservative management. An abdominal drainage tube can be a simple and effective approach and should be considered in the treatment.

Prognostic Effect of Primary Recurrence Patterns in Squamous Cervical Carcinoma After Radical Surgery.

Objective: To examine the effect of primary recurrence patterns on the prognosis of squamous cervical cancer after initial treatment. Methods: Primary recurrence patterns and prognostic factors were examined in stage IB-IIA cervical cancer patients after initial treatment. Recurrence site (locoregional recurrence and distant metastasis or in-field and out-field recurrence for patients receiving adjuvant radiotherapy) and subtype (nodal and organ recurrence) were examined. Clinicopathological characteristics and survival rates were evaluated to generate a prognostic nomogram. Results: A total of 472 patients were included. The median follow-up period, 5-year overall (OS) rate, and median OS were 59.1 months, 33.7%, and 24.0 months, respectively. Overall, 38.8% and 61.2% of the patients had locoregional recurrence and distant metastasis, respectively, and survival rates were comparable in these groups. Patients with nodal recurrence had better OS than those with organ recurrence (38.3% vs 30.7%, respectively; P = 0.001). Patients not receiving adjuvant radiotherapy had increased risk of pelvic recurrence [odds ratio (OR) = 0.148; 95% confidence interval[(CI): 0.075-0.291, P = 0.000]. Positive lymph-vascular space invasion (OR= 1.928; 95% CI: 1.151-3.229, P = 0.013) and no chemotherapy (OR = 0.521; 95% CI: 0.317-0.733, P = 0.040) increased the risk of distant metastasis. Positive lymph node status after initial treatment were associated with nodal recurrence (OR = 3.729; 95% CI: 1.838-7.563, P = 0.000), while elevated preoperative squamous cell carcinoma antigen (SCC-Ag) levels were associated with organ recurrence (OR = 1.642; 95% CI: 1.325-2.265, P = 0.002). Recurrence subtype, therapy for relapse, the International Federation of Gynecology and Obstetrics stage, adjuvant radiotherapy, preoperative SCC-Ag levels, and risk subgroup were independently associated with OS. Conclusions: Primary recurrence patterns were associated with specific clinicopathological characteristics of cervical cancer. Recurrent cervical cancer prognosis was mainly affected by recurrence location and subtype.

Radical abdominal trachelectomy for cervical malignancies: surgical, oncological and fertility outcomes in 62 patients.

OBJECTIVE: To report our experience of radical abdominal trachelectomy for patients with cervical malignancies. METHODS: We conducted a retrospective review of a prospectively maintained database of patients undergoing fertility-sparing radical abdominal trachelectomy for cervical malignancies at our institution from 04/2004 to 09/2010. RESULTS: Sixty-four patients with cervical malignancies underwent laparotomy for planned radical abdominal trachelectomy. Two patients needed immediate completion of radical hysterectomy due to unfavorable intraoperative findings. Median age was 29.5 years (range, 11-41). Histology included 8 (12.9%) with adenocarcinoma, 50 (80.65%) with squamous carcinoma, 1 (1.61%) with adenosquamous carcinoma and 3 (4.84%) with botryoid sarcoma. Median number of nodes evaluated was 25 (range, 12-53); Ten (16.13%) patients with pathologic risk factors received adjuvant therapy. Fourteen of 36 IB1 cases had tumor size >2cm. No recurrences were observed at a median follow-up of 22.8 months. Five (8.06%) patients developed postoperative cervical stenosis--all occurred before we started to routinely install T-IUDs during the procedure. Thirty-eight patients completed the survey which aimed to understand what factors influenced these patients' reproductive outcomes. For various reasons, only 10 patients attempted to conceive and 2 of them succeeded. One of them delivered by cesarean section after 39 weeks and the other is currently pregnant. CONCLUSIONS: Radical abdominal trachelectomy seems to be a reasonable option for selected patients whose tumors are no larger than 4cm when conducted by experienced gynecologic oncologists. The main perioperative complication is postoperative cervical stenosis, which could be effectively prevented by installation of a tailed T-IUD during the surgery. Social, familial and physical factors can largely influence the patients' reproductive outcomes. The issues of reproductive concerns and quality of life require further investigation.

Intravesical Instillation of Kangfuxin Liquid Combined with Thrombin and Epidermal Growth Factor for Radiation-induced Hemorrhagic Cystitis in Patients with Cervical Cancer: A report of 34 cases.

This study aimed to assess the effectiveness and safety of intravesical instillation treatment of Kangfuxin liquid (KFL) combined with thrombin and epidermal growth factor (EGF) for radiation-induced hemorrhagic cystitis (HC) in patients with cervical cancer. A total of 34 patients with radiation-induced HC of grade 2-4 were treated with intravesical instillation of KFL combined with thrombin and EGF until the complete disappearance of hematuria and lower urinary tract symptoms (LUTS). Gentamicin was added if white blood cells were detected and bacterial culture was positive in the urine. All patients were followed up for 2 years to evaluate the clinical efficacy and safety of the treatment regimen. Patients with and without recurrent hematuria (n = 3, 9% and n = 31, 91%, respectively) were completely recovered from hematuria and LUTS by intravesical instillation treatment for 6-22 days. No adverse event was reported during the treatment and the 2-year follow-up for all patients. Thus, intravesical instillation of KFL combined with thrombin and EGF is an effective and safe therapeutic regimen for radiation-induced HC of grade 2-4 in patients with cervical cancer.