Hyung Moon

Two-year survival: Preoperative adjuvant chemotherapy in the treatment of cervical cancer stages Ib and II with bulky tumor

The effect of preoperative adjuvant chemotherapy on the 2-year survival rate of patients with locally advanced cervical cancer (stages Ib and II with bulky tumour) was evaluated. The 54 patients first received initial chemotherapy of vinblastine, bleomycin, and cis-platinum in a combined regimen (VBP) and then radical hysterectomy. The overall histologic response rate to chemotherapy of the primary tumor confirmed in the surgical specimen was 81% including microscopic or no evidence of disease (41%, Grade III or IV). A lower than expected incidence of lymph node metastasis (20%) was found. All nodal metastasis was noted in patients with Grades I or II (P = 0.0034). Median follow-up was 36 months (range 26-60 months). Three recurrences (6%) appeared and those patients died of the disease within 24 months. Thus the 2-year tumour-free survival rate was 94%. The patients who had positive nodes more often experienced recurrence (27 vs 0%) and a lower 2-year survival rate (72 vs 100%) (P = 0.0067). All of these recurrences were found in patients with three or more positive nodes. This preliminary study suggest that preoperative adjuvant chemotherapy (VBP) is effective (1) in reducing tumour volume or the stage of the disease, (2) in curing the lymph node involvement, and (3) in improving the 2-year tumour-free survival rate. A prospective randomized study comparing radical surgery alone with preoperative adjuvant chemotherapy followed by radical surgery is in progress.

Preoperative adjuvant chemotherapy in the treatment of cervical cancer stage Ib, IIa, and IIb with bulky tumor.

Thirty-five previously untreated patients with stage Ib, IIa, and IIb squamous cell carcinoma of uterine cervix with bulky mass (more than 4 cm) were treated with initial chemotherapy of vinblastine, bleomycin, and cis-platinum combined regimen (VBP, one to five courses) and subsequent radical surgery. The effectiveness of the preoperative chemotherapy was evaluated in the surgical specimen. The overall clinical response rate was 89% and included a complete response in 16 (46%) and a partial response in 15 patients (43%). There were no differences in the response rate by age, stage, or the geographic contour of the tumor. The number of chemotherapeutic courses correlated well with the response of the primary tumor (P = 0.0004) up to three courses. Histologic examination of the resected primary tumor revealed no evidence of disease (Grade IV) in 44% of complete responders, microscopic foci (Grade III) in 38% (6), and macroscopic disease (Grade II) in 18% (3). Of 15 patients with stage IIb, 11 (73%) had a stage-down. Lymphnode metastases after chemotherapy were found in 26% (9/35) of the patients. All nodal metastases were found among the patients who had a partial response or a stable disease, and none was found in those with a complete response (P = 0.0029). This preliminary study suggests that initial chemotherapy before surgery is effective in reducing tumor volume or stage of the disease providing better circumstances for surgery, offers selection of high-risk groups of patients requiring additional chemotherapy, and might be able to eliminate effectively diseases in lymphnodes and possibly micrometastases. This regimen is now being evaluated to test its impact on survival.

Effects of prophylactic chemotherapy for persistent trophoblastic disease in patients with complete hydatidiform mole.

Seventy-one patients with complete hydatidiform mole were prospectively randomized into two groups: one group (39 patients) was treated with a single course of methotrexate and citrovorum factor rescue as chemoprophylaxis; the other group (32 patients) was not treated. After molar evacuation, four patients from the treated group (10.3%) and ten patients from the untreated group (31.3%) developed persistent trophoblastic disease. The time interval from evacuation of the mole to diagnosis of persistent trophoblastic disease was longer in the treated group than in the untreated group (9.5 +/- 2.4 weeks versus 5.1 +/- 1.6 weeks, P less than .05). Among high-risk patients, there was a lower incidence of persistent trophoblastic disease in the treated group than in the untreated group (14.3 versus 47.4%, P less than .05). Among low-risk patients there was no difference between the groups (5.6 versus 7.7%, P greater than .05). All 14 patients with persistent trophoblastic disease achieved complete remission with therapeutic chemotherapy. More courses of chemotherapy were required until complete remission in the treated group than in the untreated group (2.5 +/- 0.5 versus 1.4 +/- 0.5, P less than .005). These findings suggest that even though chemoprophylaxis reduces the incidence of persistent trophoblastic disease in patients at high risk, it increases tumor resistance and morbidity. Although prophylactic chemotherapy with methotrexate and citrovorum factor rescue may be helpful for high-risk patients who cannot be followed or whose compliance is in question, careful follow-up remains the most important way to identify patients who should receive chemotherapy.

Primary chemotherapy and postoperative adjuvant chemotherapy in the treatment of squamous cell carcinoma of the uterine cervix

Two cases with squamous cell carcinoma of the cervix stage IIB with primary tumor mass about 2 X 2 X 2 cm were treated with primary chemotherapy of cis-platinum, 20 micrograms/m2 body surface intravenously daily for 5 consecutive days. Papanicolaou smear turned negative after two courses of chemotherapy in both cases. One of those was followed by radical hysterectomy with lymphadenectomy which confirmed that there was no evidence of disease by histopathology. The third case with stage IIIB and bulky tumor with involvement of pelvic and left common iliac lymph nodes was treated with simple hysterectomy followed by adjuvant chemotherapy with the same medication described above. Complete responses were obtained in all three cases and they are now doing well in a tumor-free state for 26, 30, and 28 months, respectively.

Histologic disappearance of locally advanced vaginal cancer after combination chemotherapy

Clinically and histologically complete disappearance of local tumor and pelvic sidewall involvement was achieved in a patient with primary advanced squamous cell carcinoma of the vagina administered combination chemotherapy prior to operation. Radical hysterectomy, total vaginectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymphadenectomy, and paraaortic lymph node biopsy were performed after seven courses of combination chemotherapy with vinblastine, bleomycin, and cis-platinum. This encouraging result warrants further investigation of combination chemotherapy in other patients.