NEOADJUVANT CHEMOTHERAPY IN GYNECOLOGIC ONCOLOGY

Abstract

Neoadjuvant AU2, AU3chemotherapy for gynecologic malignancies is considered to be in its infancy. Most prospective data available deal with cervical cancer. In the past few years, there has been work to investigate the potential benefit of neoadjuvant chemotherapy in ovarian cancer. Most studies are retrospective with limited numbers, however. Ongoing trials in the United States and Europe will better define its role in the near future. Neoadjuvant chemotherapy has no significant role in the management of any other gynecologic malignancy. For these reasons, this article reviews the available data on the role of neoadjuvant chemotherapy in the treatment of cervical cancer.

When cervical cancer treatment results published in the annual report by the International Federation of Gynecologic Oncology (FIGO) are analyzed, it can clearly be seen that there has not been a substantial change in the survival rates since 1950 despite all the advances achieved in the fields of surgery and radiobiology, which are the accepted foundations for its treatment.²⁶ For this reason, chemotherapy has been introduced by several centers to the primary treatment regimen of various modalities to improve patients' survival. Recently, chemotherapy was incorporated in the neoadjuvant mode, prior to conventional treatment, to reduce tumor volume and tumor extension, to irradiate in more favorable conditions, or to make surgery possible in those cases clinically inoperable.4, 14, 21 Other beneficial effects would theoretically be the possibility of treating micrometastasis and subsequently to help decide on the adjuvant treatment (after surgery and radiation) dependent on the primary tumor response. Opponents state as major disadvantages the delay in the curative treatment, development of radioresistant cellular clones, and cross-resistance with radiotherapy. All of them can be avoided, however, through a “quick” high-dose chemotherapy scheme administrated in a short period of time for the first situation and using surgery as choice treatment in the last two situations.³⁰

Chemotherapy also is used simultaneously with radiotherapy, especially in the United States, and is called concurrent chemoradiation. In theory, chemotherapy and radiotherapy can have a synergistic effect because chemotherapy may increase the sensitivity of the tumor to radiation, inhibiting the repair of sublethal cellular damage caused by radiation, synchronizing cells to a particularly radiosensitive phase of the cell cycle. Moreover, radiotherapy can be used for local disease, and chemotherapy can be used for systemic disease. The concurrent use of single-drug or multiple-drug regimens and radiotherapy has been tested in women with cervical cancer.38, 41 In this scope, I analyze hereafter my trial results employing neoadjuvant chemotherapy followed by radiotherapy and especially by surgery and compare my results regarding concurrent chemoradiation. Also, aspects about limiting factors for its use and the surgical technique and intraoperative management of theses patients are discussed.