Neo-adjuvant chemotherapy and fertility sparing surgery for stage IB1 cervix cancer (2-4 cm) Marie Plante (NCIC) Jeffrey Goh & Vivek Arora (ANZGOG)
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1 Neo-adjuvant chemotherapy and fertility sparing surgery for stage IB1 cervix cancer (2-4 cm) Marie Plante (NCIC) Jeffrey Goh & Vivek Arora (ANZGOG) GCIG Meeting Chicago May 2015
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3 NACT and Fertility Sparing How to best manage women with larger size lesions / bulky IB1-IB2 (2-4 cm) Preservation of fertility and ovarian function Oncologic outcome Obstetrical outcome
4 NACT and Fertility Sparing Management options for patients with larger size lesions Upfront Radical Trachelectomy NACT followed by fertility-preserving surgery (FPS)
5 Upfront ART: lesions > 2 cm Wethington, 2013 Lintner, 2013 N Fertility spared Node Positivity Recurrences Pregnancies 29 9 (31%) 13 (45%) * 1/29 (11%) 1/ (69%) 13 (29%) 4/31 (13%) ** 4/8 Liu, (89%) 6 (9.8%) 0 3/ (70%) 32 (24%) 5/122 (5.3%) 8/20 (40%) 8/95 (8.9%) 8/136 (5.8%) MSKCC: SLN mapping and ultra staging Hungarian series: 14 ptes who had rad hyst excluded from analysis Plante M. Internat J Gynecol Cancer 2015 May;25(4):722-8.
6 Indications for adjuvant RT LVSI Stromal Invasion Tumor Size Positive Deep 1/3 Any Positive Middle 1/3 > 2 Negative Superficial 1/3 > 5 Negative Deep or Middle 1/3 > 4 Sedlis criteria : needing 2 or more of these factors - LVSI involvement - Deep stromal invasion (middle or deep third) - Size > 4 cm
7 Abdominal Trachelectomy Upfront ART technically feasible in bulky stage I cervical cancer Oncologic outcome good Obstetrical outcome limited High rate of adjuvant Tx post trachelectomy Impact on fertility and ovarian function Impact on QoL
8 NACT + FPS NACT option followed by fertilitypreserving surgery (FPS)
9 Neoadjuvant chemotherapy Pre-chemo Post-chemo
10 NACT + fertility preserving surgery N Chemotherapy Regimen Procedure Optimal Response to NACT (CR + OPR) Node Positivity Maneo 21 TIP x 3 LPLND + 17/21 (81%) 2 cone Plante 3 TIP x 3 LPLND + 3/3 (100%) 0 RVT Marchiole 7 TIP/TEP x 3 LPLND + 4/7 (57%) 0 RVT Lanowska 18 TIP/TP x 2-3 LPLND + 14/18 (78%) 2 RVT Robova 28 CI q 10d x 3 LPLND + 17/28 (61%) 2 CA q 10d x 3 SVT Total 77 55/77 (71%) 6/77 (7.8%) Plante M. Internat J Gynecol Cancer 2015 May;25(4):722-8.
11 Recurrences Death Fertility Preserved Pregnancy/ Attempted Pregnancy Outcome Maneo /21 (76%) 10/9 1 FTM 5 preterm 2 SVD (term) 2 CS (term) Plante 0 0 3/3 (100%) 4/3 1 FTM 1 preterm, 2 term Marchiole 0 0 6/7 (86%) 1/1 1 ongoing Lanowska 1/18 (5.5%) 0 17/18 (94%) 7/5 1 FTM 1 ectopic 1 ongoing 2 preterm, 2 term Robova 4/20 (20%) 2/20 (10%) 20/28 (71%) 13/10 1 FTM 2 STM All in suboptimal responders 2 ongoing 3 preterm, 5 term Total 5/69 (7.2%) 2/69 (2.9%) 62/77 (80%) 35/28 11 FT loss (31%) 11 preterm (31%) 13 term (37%) Plante M. Internat J Gynecol Cancer 2015 May;25(4):722-8.
12 NACT + fertility preserving surgery Substantial response to NACT CR/OPR: 71% Recurrence rate Worrisome in suboptimal responders Fertility preservation high: 80% Obstetrical outcome: good
13 Unresolved issues Staging lymph node dissection prior to NACT? Radical vs simple trachelectomy vs cone post NACT? Best chemotherapy regimen?
14 NACT + fertility preserving surgery Should a staging lymph node evaluation be done prior to NACT?
15 NACT + fertility preserving surgery Advantage of LN staging Allows triaging of pts with metastatic disease Option of non-surgical treatment (CT/RT) Disadvantage of LN staging Exclude some patients with minimal LN involvement who might have cleared the LN metastasis with NACT
16 NACT + fertility preserving surgery Should a radical or a simple trachelectomy (cone) be done post NACT?
17 NACT + fertility preserving surgery Simple / radical trachelectomy / cone Very little data available Trend towards less radical surgery in small volume cervical cancer (< 2 cm)
18 NACT + fertility preserving surgery In good chemotherapy responders Node negative patients Minimal / no residual disease post NACT Gyn exam & MRI The chances of finding occult parametrial infiltration are probably very low Simple trach / cone sufficient?
19 NACT + fertility preserving surgery Optimal chemotherapy regimen
20 Optimal chemotherapy regimen Taxol / Ifosfamide / Platinum (TIP) Most widely used regimen Toxicity of triple chemo regimen Ifosfamide (alkylating agent) gonadotoxicity
21 Optimal chemotherapy regimen Systematic review 17 studies / 1181 patients Recurrent or metastatic cervical cancer Comparing cisplatin and carbo + taxol Conclusion: carboplatin represents a valid and less toxic alternative compared to cisplatin Lorusso D. Gynecol Oncol 2014;133(1):
22 Optimal chemotherapy regimen A randomized, phase III trial of paclitaxel plus carboplatin (TC) versus paclitaxel plus cisplatin (TP) in stage IVb, persistent or recurrent cervical cancer: Japan Clinical Oncology Group study (JCOG0505) (n=253) Taxol 175 & Carbo AUC 5 q 3 wks Non-inferior in terms of OS More feasible Less toxic Kitagawa R et al. J Clin Oncol Mar
23 Optimal chemotherapy regimen Dose-dense NACT chemo regimen Weekly Taxol/Carbo Taxol mg/m2 and Carbo AUC 2 Locally advanced cervical cancer Objective response rate (complete & partial) Ranges from % McCormack M. Br J Cancer 2013;108(12): Singh RB. Gynecol Oncol 2013;129(1):124-8.
24 Optimal chemotherapy regimen Another dose-dense chemo regimen Taxol 80mg/m2 weekly (d 1,8,15) Carbo AUC 6 q 3 weeks (d 1) JGOG 3016 trial in ovarian cancer Katsumata N. Lancet Oncol 2013;14(10): 2014.
25 Chemotherapy regimen Taxol Ifosfamide Cis Platinum Taxol Cis Platinum Taxol Carbo Platinum Dose Dense Taxol-Carbo - Weekly TC - Weekly Taxol/3W Carbo
26 Optimal chemotherapy regimen Adding GnRHa during chemo? Breast cancer data suggest a benefit of adding goserelin with chemotherapy Protect against ovarian failure Reduce the risk of early menopause Improve prospects for fertility Moore HCF. N Engl J Med 2015;372:
27
28 Outcome measures Primary end point Successful fertility preservation defined as intact uterine corpus with no adjuvant XRT Secondary end points Response rates to chemotherapy Toxicity Proportion requiring trimodality treatment QoL indices / Ovarian function indices 3 and 5 year disease free survival
29 Phase II: Sample Size All cases N=100 20% nodes + NACT N=80 30% SO response FPS N= 56
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