Application Of Neoadjuvant Chemotherapy In The Treatment Of Advanced Cervical Cancer After 2018FIGO Correction Staging

Background and Objective: Cervical cancer is one of the most common malignant tumors worldwide.Incidence rate and mortality rate are second in female malignant tumors.More than half of patients are in the middle and advanced stage(tumor volume > 4cm).These patients often have poor prognosis and poor treatment effect.At present,cisplatin based concurrent chemoradiotherapy is the standard treatment mode for advanced cervical cancer,which can further improve the survival rate compared with radiotherapy alone.However,it is found that the 5-year survival rate of patients with advanced cervical cancer after concurrent chemoradiotherapy is still low.In theory,neoadjuvant chemotherapy can reduce tumor volume,eliminate subclinical metastases,and reduce tumor recurrence,which is expected to further improve the survival prognosis of patients with advanced cervical cancer.However,the existing retrospective studies are controversial.Some studies suggest that neoadjuvant chemotherapy before concurrent chemoradiotherapy can not improve the survival of patients with advanced cervical cancer.In the study of cervical cancer,lymph node metastasis has been identified as an important prognostic factor affecting the survival outcome of advanced cervical cancer.The commonly used 2009 FIGO staging system for cervical cancer does not include regional lymph node status,which means that lymph node metastasis will not change the staging of patients.After the correction of 2018 FIGO staging,lymph node metastasis affected the staging.Regardless of the primary tumor status,lymph node metastasis was included in the new IIIc stage.In this study,we retrospectively analyzed the efficacy of neoadjuvant chemotherapy before concurrent intensity-modulated radiotherapy and chemotherapy in patients with advanced cervical cancer by 2009 FIGO staging.Based on the new2018 FIGO staging,the efficacy and safety of neoadjuvant chemotherapy combined with concurrent intensity-modulated radiotherapy and chemotherapy and simple concurrent intensity-modulated radiotherapy and chemotherapy were compared.Univariate and multivariate analysis was performed to evaluate the feasibility and application value of neoadjuvant chemotherapy after adjusting the staging.Objective to explore the best mode of comprehensive treatment for advanced cervical cancer,and to provide a theoretical basis for further improving the survival of patients with advanced cervical cancer.Methods: From January 2013 to December 2017,406 patients with advanced cervical cancer treated in the Fourth Affiliated Hospital of Guangxi Medical University with complete follow-up data were collected.All patients were re-staging after 2018 FIGO staging correction.The patients were divided into two groups according to the combination or non-combination of neoadjuvant chemotherapy before concurrent intensity modulated radiotherapy and chemotherapy(NACT + CCRT group),205 patients received concurrent intensity modulated radiotherapy and chemotherapy alone(CCRT group).Both groups were treated with intensity modulated radiation therapy(IMRT)sequential afterloading.Objective to compare the short-term efficacy and toxicity of neoadjuvant chemotherapy combined with intensity-modulated radiotherapy and chemotherapy(IMRT)for advanced cervical cancer based on2018 FIGO stage,and analyze the survival prognosis,so as to preliminarily evaluate the clinical application value of neoadjuvant chemotherapy after2018 FIGO new stage correction.Results: 1.There were 406 cases of advanced cervical cancer in 2009 FIGO stage,81 cases in IB2 stage,119 cases in iia2 and IIB stage,119 cases in III stage and 87 cases in IVA stage.After recalibration of 2018 FIGO staging,there were 58 cases in IB3 stage,75 cases in IIA2 and IIB stage,186 cases in III stage and 87 cases in IVA stage.Baseline equalization was found in NACT +CCRT group and CCRT group(P > 0.05).2.Based on 2018 FIGO,the objective response rate(ORR)was 97.5% in the NACT + CCRT group and 94.1% in the CCRT group.There was no significant difference in the short-term efficacy between the NACT + CCRT group and the CCRT group(P > 0.05).3.Based on the 2009 FIGO staging,the 1-year,3-year and 5-year overall survival(OS)of the NACT + CCRT group compared with the CCRT group were 96.5% vs 94.6%,78.4% vs 75.1%,68.8% vs 65.0%,respectively.There was no significant difference in OS between the two groups(P = 0.301);The1-year,3-year,and 5-year progression free survival(PFS)rates of the two groups were 91.5% vs 88.3%,73.6% vs 65.1%,60.3% vs 57.6%,respectively,and there was no significant difference(P = 0.287).Based on 2018 FIGO staging,the results showed that the 1-year,3-year and 5-year OS of NACT +CCRT group compared with CCRT group were 96.5% vs 94.6%,78.4% vs75.1%,68.8% vs 65.0%,respectively,and the difference was not statistically significant(P = 0.301).The 1-year,3-year and 5-year PFS of the two groups were 91.5% vs 88.3%,73.6% vs 65.1%,60.3% vs 57.6%,respectively,and the difference was not statistically significant(P = 0.287).There was no significant difference in staging OS between the two groups.With the increase of stage,OS and PFS of patients decreased significantly(P < 0.05).4.Univariate analysis based on 2018 FIGO staging showed that tumor staging,pathological type and lymph node metastasis were the factors affecting the prognosis of patients with advanced cervical cancer(P < 0.05).COX multivariate analysis showed that tumor stage and pathological type were independent adverse prognostic factors for OS in patients with advanced cervical cancer(P < 0.05).Tumor stage,pathological type and lymph node metastasis were independent adverse prognostic factors for PFS in patients with advanced cervical cancer.5.Based on 2018 FIGO subgroup analysis,PFS in stage III of NACT +CCRT group was significantly higher than that of CCRT group by 57.6% vs45.4%(P=0.048).There was no significant difference in phase III OS between the two groups(71.9% vs 56.3%,P=0.053).NACT + CCRT significantly improved PFS in patients with pelvic lymph node metastasis,62.6% vs 42.0%(P=0.032).6.After recalibration based on 2018 FIGO staging,the efficacy of IIIC1 in stage III group was better than that of IIIA-B and IIIC2 groups,and the 5-year OS was IIIA-B 61.7%,IIIC1 81.9%,IIIC2 37.5%,respectively,the difference was statistically significant(P=0.004);The 5-year PFS was 48.8% for IIIA-B,62.6% for IIIC 1,and 38.4% for IIIC 2,respectively,and the difference was statistically significant(P=0.031)7.Based on 2018 FIGO staging,there was no difference in acute and long-term toxicity between NACT + CCRT group and CCRT group.Conclusion: 1.There is no difference in the short-term and long-term efficacy of neoadjuvant chemotherapy combined with concurrent intensity modulated radiotherapy and chemotherapy in the treatment of advanced cervical cancer after 2018 stage correction compared with concurrent intensity modulated radiotherapy and chemotherapy alone.2.After 2018 FIGO staging correction,subgroup analysis shows that the application of neoadjuvant chemotherapy before concurrent intensity modulated radiotherapy and chemotherapy for advanced cervical cancer may improve PFS of stage III patients and may improve PFS of pelvic lymph node metastasis patients.3.Tumor stage,pathological type and lymph node metastasis are independent prognostic factors of patients with advanced cervical cancer.4.After recalibration based on the 2018 FIGO staging,the efficacy of IIIC1 in stage III group was better than that in IIIA-B and IIIC2 groups.5.Based on 2018 FIGO staging,there is no difference in toxicity between neoadjuvant chemotherapy combined with concurrent intensity modulated radiotherapy and chemotherapy compared with concurrent intensity modulated radiotherapy and chemotherapy alone.