Fuquan Zhang

Timing of adjuvant radiotherapy for early-stage endometrial carcinoma: a single-center retrospective cohort study

To investigate the appropriate timing of radiotherapy (RT) after hysterectomy in women with early-stage endometrial cancer (EC). We analyzed the data of 1,062 patients with early-stage EC who underwent postoperative RT at our hospital between April 1999 and November 2020. Restricted cubic spline were used to explore the relationship between the surgery-radiotherapy interval (SRI) and local recurrence-free survival (LRFS). The maximally selected rank statistics method was used to identify the optimal threshold for SRI. The overall survival (OS), disease-free survival (DFS), LRFS, and distant metastasis-free survival (DMFS) rates were estimated using the Kaplan-Meier method. Multivariate analysis was performed using the Cox proportional hazards regression. In entire cohort, patients with SRI ≥42 days had worse survival. In multivariate analysis, SRI was an independent prognostic factor for OS (p=0.011), DFS (p=0.019), LRFS (p=0.013) and DMFS (p=0.050). However, in piecewise Cox regression, the significance of SRI for DMFS disappeared. In the subgroup analysis, the optimal cut-off value for SRI in the high-intermediate risk (HIR) and high-risk (HR) groups was 33 days. Multivariate analysis showed that SRI was an independent prognostic factor only for LRFS (p=0.033) and marginally associated with OS (p=0.055). The timing of postoperative RT is crucial in patients with early-stage EC. Adjuvant RT should be initiated as soon as the vaginal cuff is healed, while for HIR and HR patients, it should be initiated within 33 days.

Prognostic values of tumor size and location in early stage endometrial cancer patients who received radiotherapy

To investigate the correlation between tumor size, tumor location, and prognosis in patients with early-stage endometrial cancer (EC) receiving adjuvant radiotherapy. Data of patients who had been treated for stage I-II EC from March 1999 to September 2017 in 13 tertiary hospitals in China was screened. Cox regression analysis was performed to investigate associations between tumor size, tumor location, and other clinical or pathological factors with cancer-specific survival (CSS) and distant metastasis failure-free survival (DMFS). The relationship between tumor size as a continuous variable and prognosis was demonstrated by restricted cubic splines. Prognostic models were constructed as nomograms and evaluated by Harrell's C-index, calibration curves and receiver operating characteristic (ROC) curves. The study cohort comprised 805 patients with a median follow-up of 61 months and a median tumor size of 3.0 cm (range 0.2-15.0 cm). Lower uterine segment involvement (LUSI) was found in 243 patients (30.2%). Tumor size and LUSI were identified to be independent prognostic factors for CSS. Further, tumor size was an independent predictor of DMFS. A broadly positive relationship between poor survival and tumor size as a continuous variable was visualized in terms of hazard ratios. Nomograms constructed and evaluated for CSS and DMFS had satisfactory calibration curves and C-indexes of 0.847 and 0.716, respectively. The area under the ROC curves for 3- and 5-year ROC ranged from 0.718 to 0.890. Tumor size and LUSI are independent prognostic factors in early-stage EC patients who have received radiotherapy. Integrating these variables into prognostic models would improve predictive ability.

Weekly Image Guidance in Patients With Cervical Cancer Treated With Intensity‐Modulated Radiation Therapy: Results of a Large Cohort Study

ABSTRACTBackgroundImage guidance is recommended for patients undergoing intensity‐modulated radiation therapy (IMRT) for cervical cancer. In this study, we evaluated the feasibility of a weekly image guidance pattern and analyzed the long‐term outcomes in a large cohort of patients.MethodsThe study enrolled patients with Stage IB‐IVA cervical cancer who received definitive radiotherapy or concurrent chemoradiotherapy. IMRT was delivered at a dose of 50.4 Gy in 28 fractions, with weekly cone‐beam computed tomography (CBCT). Physicians advised patients on rectum and bladder preparation to help them prepare on nonimaging guidance days. When significant tumor regression was observed, a second computed tomography simulation and replanning were performed.ResultsThe median follow‐up periods were 63.4 months. The incidence rates of loco‐regional and distant failure were 9.9% and 13.6%. The 5‐year overall survival (OS), disease‐free survival (DFS), loco‐regional relapse‐free survival (LRFS), and distant metastasis‐free survival (DMFS) rates were 80.1%, 72.9%, 78.3%, and 74.8%, respectively. For patients with different stages, the 5‐year OS, DFS, LRFS, and DMFS rates were statistically significant. For patients with and without positive regional lymph nodes, the 5‐year OS, DFS, LRFS, and DMFS rates were 64.5% and 86.0%, 56.8% and 78.8%, 62.7% and 84.3%, and 58.8% and 81.0%, respectively. Multivariate analysis showed that age, histology, tumor size, cancer stage, pretreatment squamous cell carcinoma antigen level, and para‐aortic metastatic lymph nodes were independent prognostic factors of OS. Fifty‐six (4.0%) patients experienced late Grade 3/4 chronic toxicities.ConclusionsIMRT with weekly CBCT is an acceptable image guidance strategy in countries with limited medical resources.

Completion hysterectomy after chemoradiotherapy for locally advanced adeno-type cervical carcinoma: updated survival outcomes and experience in post radiation surgery

To compare patient survival outcomes between completion hysterectomy and conventional surveillance in locally advanced adenocarcinoma of the cervix after concurrent chemoradiotherapy (CCRT). Patients with adenocarcinoma of the cervix after CCRT were identified in a tertiary academic center database from 2004 to 2018. Patients received completion hysterectomy or surveillance after CCRT. We compared the progression-free survival (PFS) and overall survival (OS) between the patients with or without adjuvant hysterectomy. Surgery features, operative complications, and pathologic characteristics were documented. Patient outcomes were also analyzed according to clinicopathologic factors. A total of 78 patients were assigned to completion surgery and 97 to surveillance after CCRT. The PFS was better in the surgery group compared to the CCRT only group, at 3 years the PFS rates were 68.1% and 45.2%, respectively (hazard ratio [HR]=0.46; 95% confidence interval [CI]=0.282-0.749; p=0.002). Adjuvant surgery was also associated with a higher rate of OS (HR=0.361; 95% CI=0.189-0.689; p=0.002), at 3 years, 87.9% and 67%, respectively. Tumor stage, size, lymph-vascular space invasion (LVSI), lymphadenopathy were associated with PFS but not with OS. Hysterectomy specimens revealed 64.1% (50/78) of the patients had pathologic residual tumor. Patients age less than 60, tumor size over 4 cm, stage IIB and persistent residual disease after CCRT were most likely to benefit from hysterectomy. Hysterectomy was associated with a lower rate of locoregional recurrence but did not reach statistical significance (5.13% vs. 13.5%, p=0.067). Completion hysterectomy after CCRT was associated with better survival outcome compared with the current standard of care.