PD-L1 expression and prognosis in definitive radiotherapy patients with neuroendocrine cervical carcinoma

BACKGROUND: Neuroendocrine carcinoma of the cervix (NECC) is more prone to lymphatic infiltration, lymph node involvement, local recurrence, and distant metastasis. Using concurrent chemoradiotherapy (CCRT) with or without adjuvant chemotherapy as the standard treatment for locally advanced NECCs and CCRT for patients with early lesions confined to the cervix. However, the prognosis of NECC patients treated with definitive radiotherapy (RT) is unknown. Immune checkpoint inhibitors are a promising therapeutic strategy for locally advanced cervical cancer. Some reports suggest that the expression of PD-L1 in solid tumors correlates with prognosis. AIM: This study investigates prognostic factors for survival in patients with neuroendocrine cervical carcinoma (NECC) treated with definitive RT and the relationship between PD-L1 expression and prognosis in these patients. METHODS: This retrospective study included 66 patients with histologically confirmed NECC who received RT with or without chemotherapy. From January 2015 to December 2020, patients received routine extended-field irradiation (EFI), and PD-L1 expression was assessed by immunohistochemistry. The most commonly used chemotherapy agents were etoposide-platinum and paclitaxel-platinum. RESULTS: PD-L1 expression was positive in 17 of 45 (37.8%) patients. There were 52 cases of pure NECC and 14 cases of mixed carcinoma. Sixty stage IB-III patients received definitive RT. The 3- and 5-year progression-free survival (PFS) was 39.8% and 34.1%, and 3- and 5-year overall survival (OS) was 48.0% and 40.2%, respectively. There was no significant difference in 3 and 5-year PFS and 3 and 5-year OS between patients with pure and mixed carcinoma. Positive PD-L1 expression was associated with higher 3-year PFS in patients with mixed histology. Univariate analysis showed that lymph node metastasis (LNM) and the International Federation of Gynecology and Obstetrics stages predicted 3- and 5-year PFS in patients who received definitive RT. The median OS in patients receiving less than four cycles and at least four cycles of chemotherapy (CT) was 26.0 and 44.0 months, respectively (P = 0.038); moreover, 3- and 5-year PFS was 34.1% and 25.7% in the former and 46.4% and 40.4% in the latter. There were no significant differences in OS and PFS between pelvic irradiation and prophylactic EFI in patients treated with definitive RT. There were no significant differences in para-aortic failure rate after concurrent chemoradiotherapy between patients who underwent pelvic irradiation or prophylactic EFI (P = 0.147). CONCLUSION: In patients with mixed NECC, positive PD-L1 expression is correlated with higher 3-year PFS. Chemoradiotherapy was effective for NECCs. The LNM and stage predicted PFS. Four or more cycles of chemotherapy improve prognosis. Prophylactic EFI did not significantly improve PFS and OS. RELEVANCE FOR PATIENTS: This study is relevant to patients as it confirms that chemoradiotherapy is effective for both early and locally advanced NECC and that four or more cycles of chemotherapy improved prognosis. The regimen should be carefully evaluated to ensure that patients receive the most effective radiation therapy for the prophylactic of para-aortic LNM. Potential risk factors for the recurrence of radical radiotherapy should be fully understood to minimize these risks. This study observed that PD-L1 expression positive in patients with mixed NECC types is correlated with higher 3-year PFS.