Table 4.4 Correlation Between Stage Of Squamous Cell Cervical Carcinoma And Radiotherapy

Response (n=40)

Variable

Radiotherapy ResponseP

ValueWell Poorly

(n=32) (n=8)

Stage 0.204

IIB 16 (88,9%) 2 (11,1%)

IIIB 16 (72,7%) 6 (27,3%)

Table 4.4 shows the correlation between subject with advanced stage of squamous cell

cervical carcinoma and radiotherapy response. Stage IIB study subjects were 18 patients, after

receiving external radiotherapy, 16 patients (88.9%) respond well and 2 patients (11.1%) respond

poorly.

Total subjects with stage IIIB squamous cell cervical carcinoma has more number, which

is 22 patients, after receiving external radiotherapy, 16 patients (72.7%) respond well and 6

patients (27.3%) respond poorly.

Patients with squamous cells cervical carcinoma stage IIB that respond poorly to

radiotherapy has the same characteristics, including the mass size> 4 cm and well differentiated,

whereas 1 patient had a genotype HPV 18 infection, and another patient had infection with HPV

genotypes 16, 18.

From the results of calculations using the chi-squared, it can be stated there is no

significant correlation between the advanced stage of squamous cell cervical carcinoma and the

radiotherapy response, because of p value = 0.204 (p> 0.05).

Table 4.5 Correlation Between Degree of Differentiation and Radiotherapy Response (n=40)

Variable

Radiotherapy Response

P ValueWell Poorly

(n=32) (n=8)

Diferentiation <0.001

Well 1 (14,2%) 6 (85,8%)

Moderately 17 (89,5%) 2 (10,5%)

Poorly 14 (100%) 0

Table 4.5 shows the correlation between the degree of differentiation of advanced stage

squamous cell carcinoma of the cervix subject and response to radiotherapy. Patients with well

differentiated in this study has total 7 patients, after receiving external radiotherapy, 6 patients

(85.8%) respond poorly and only 1 patient (14.2%) respond well.

Research subjects with moderately differentiated has total 19 patients, 17 patients

(89.5%) respond well and 2 patients (10.5%) respond poorly. Research subjects with poorly

differentiated has total 14 patients, and overall (100%) respond well.

From the results of calculations using the chi square, there is significant correlation

between the degree of differentiation of advanced stage squamous cell cervical carcinoma and

radiotherapy response, because the p value <0.001 (p <0.05).

Table 4.6 Correlation Between The Size Of The Mass And Radiotherapy Response (n=40)

Variable

Radiotherapy Response

P ValueWell Poorly

(n=32) (n=8)

the size of the

mass0,018

< 4 cm 19 (95%) 1 (5%)

> 4 cm 13 (65%) 7 (35%)

Table 4.6 shows the correlation between the size of the mass of advanced stage squamous cell

cervical carcinoma on the subject and radiotherapy response. Research subjects with mass size

<4 cm has a total of 20 patients, after receiving external radiotherapy, 19 patients (95%) patients

respond well and 1 (5%) respond poorly.

      Research subjects with mass size> 4 cm totaling 20 patients, 13 patients (65%) respond well

and 7 patients (35%) respond poorly.

      From the results of calculations using the chi square there is a significant correlation between

the size of the mass of advanced stage squamous cell cervical carcinoma and the radiotherapy

response because the p value = 0.018 (p <0.05).

Table 4.7 Correlation Between HPV Genotype And Radiotherapy Response (n = 40)

Variable

Radiotherapy Response

P ValueWell Poorly

(n=32) (n=8)

Genotype

HPV0,350

HPV 16 4 (100%) 0

HPV 18 1 (50%) 1 (50%)

HPV 16, 18 1 (50%) 1 (50%)

 HPV

Multiple26 (81,3%) 6 (18,8%)

Table 4.7 shows the relationship between HPV genotypes with radiotherapy response.

From the 40 subjects with advanced stage squamous cells cervical carcinoma, HPV-16 consists

of 4 patients, the overall subjects (100%) respond well after receiving external radiotherapy.

      Patients with HPV-18, which amounts to 2 patients, 1 patient (50%) respond well, and 1

patient (50%) respond poorly. In patients with HPV 16, 18, which amounts to 2 patients, 1

patient (50%) respond well, and 1 patient (50%) respond poorly.

      In patients with multiple HPV infections, which totaled 32 people, 26 people (81.3%)

respond well, and 6 (18.8%) respond poorly. From the results of calculations using the chi square

there is no significant relationship between genotype HPV of advanced stage squamous cell

cervical carcinoma and response to radiotherapy because p value = 0.350 (p> 0.05).

Discussion

Characteristics of Study

      Characteristics of the study included age, stage, size of the mass and the degree of

differentiation of cervical cells from patients who had tissue samples in this study. It was

concluded that patients with advanced stages squamous cell cervical carcinoma of this study, the

vast majority were aged> 50 years (60%). This is consistent with the data 11 Anatomical

Pathology Center in Indonesia in 2005, cervical carcinoma is the leading cause of the most

common malignancy in women aged 35-55 years. 3

      In this study of 40 patients with squamous cell cervical carcinoma who received radiotherapy

advanced stage, 32 patients (80%) respond well and 8 patients (20%) respond poorly. These

results are similar to the results of research in Beijing, China that after therapy for cervical

carcinoma, the number of persistent disease or recurrence number as many as 21.7% .17 In a

study conducted in Jakarta, in patients with squamous cell cervical carcinoma who had

radiotherapy, 25 % showed a partial response.

The most common stage of advance stage squamous cell cervical carcinoma of this study

were stage IIIB, total 22 patients (55%). Radiotherapy response of 22 subjects (72.7%), of the

studies which included in stage IIIB had well respond while 27.3% respond poorly. In stage IIB

cervical carcinoma numbering 18 patients (45%), after receiving external radiation, 88.9% and

11.1% respond well respond poorly. Based on statistical calculations, there is no correlation

between clinical staging of cervical carcinoma and radiotherapy response because p value =

0.204 (p> 0.05). This result is similar with research conducted in Jakarta, that after statistical

analysis there was no correlation between therapeutic response with squamous cell cervical

carcinoma stage. 12

      Based on the degree of differentiation of squamous cell cervical carcinoma advanced stage in

these patients, the vast majority were moderately differentiated with total 19 people. The whole

subject of the study (100%) of squamous cell cervical carcinoma with poorly differentiated

advanced stage have a well response. Radiotherapy response responds poorly in well

differentiated, 85.8% in this study. Research subjects who respond poorly after being given 25

times the overall external radiation included in a partial response.

The biological effects of the radiation depends not only on the total dose given, but also

the duration of radiation and the amount of fractionation. The principle of fractionation is based

on classic four factors commonly referred to as the four R's of Radiobiology. These four factors

are related to time, dose, and fractionation which including repair, redistribution, repopulation,

and reoxygenation.

      Cells that have a high proliferation (rapid cycling cells), such as the skin and mucosal cells,

will experience better redistribution than cells with low proliferation power (slowly cycling

cells), such as brain cells, blood vessels, and tissue connective. Thus, cells with high

proliferation will have faster reactions or side effects of radiation when compared to low

proliferation cells. 18

     This is similar to research which conducted in Goyang, Korea, in cervical carcinoma with

poorly differentiated, partial response after radiotherapy was known to be 8.3%. In cervical

carcinoma with well / moderately differentiated, partial response after radiotherapy is higher,

21.7%. 19

      In this study, research subjects with advanced stages squamous cell cervical carcinoma and

size <4 cm obtain a better response to radiotherapy, which was known to be 19 out of 20 people

(95%) and only 5% who respond poorly to radiotherapy, whereas when the mass size> 4 cm

there are 4 of 20 people with a poor response (35%). From the results of calculations using the

chi square there is a significant correlation between the size of the mass of advanced stage

squamous cell cervical carcinoma and response radiotherapy because the p value = 0.018 (p

<0.05).

Tumor volume is an important factor in predicting therapeutic success but not dependent

on the therapy given. Large volume and increased stage associated with poor outcome after

radiotherapy. Lowery and his colleagues reported that there is 20% chance of decreasing in

cervical carcinoma survival rate with size more than 6 cm mass compared with the mass size less

than 3 cm. 20

      In studies in Goyang, Korea, the mass of cervical carcinoma with size <4 cm partial response

in 10.5%, lower than a partial response in cervical carcinoma with mass size> 4 cm, ie 19.3%. 19

Correlation between HPV Genotypes and Radiotherapy

Most type of advanced stage squamous cell of cervical carcinoma in this study was a multiple

type, which happen to about 32 patients. PCR kit from Roche Linear Array was used in this

study which were able to detect 37 high-risk and low-risk HPV genotypes, for example

genotypes 6, 11, 16, 18, 26, 31, 33, 35, 39, 40, 42, 45, 51, 52, 53, 54, 55, 56, 58, 59, 61, 62, 64,

66, 67, 68, 69, 70, 71, 72, 73, 81, 82, 83, 84, IS39 and CP6108. Briefly, PCR amplicons were

denatured with denaturation solution and hybridization performed on a single HPV genotype

strip to be coated with a specific marker genotypes of HPV and β-globin probes humans,

suggesting well isolated human DNA. 11

An overview of HPV 16,18 genotype and other type, consisting of 4 patients had HPV

genotypes 16, 18, 52/33/35/58. A total of 3 patients had HPV genotypes 16, 18, 45, 52/33/35/58,

3 patients had genotype HPV 16,18 and 45, 2 patients had HPV genotypes 16, 18, 67,

52/33/35/58, 2 patients had HPV genotypes 16, 18, 33 and 52, 1 patient had HPV genotypes 16,

18, 51, 52/33/35/58, 1 patient had HPV genotypes 16, 18, 45 and 82. A total of 11 patients (27 ,

5%) had HPV genotypes 16 and other types, which is 7 patients had genotype HPV 16, HPV

52/33/35/58, 2 patients had HPV genotypes 16, 33 and 52, 1 patient had HPV genotypes 16 and

45, 1 patients had HPV genotypes 16 and 31. In addition, a total of 4 patients (10%) had multiple

HPV genotypes other than 16 and 18, ie 2 patients had genotype HPV 52/33/35/58, 2 patients

had HPV genotypes 33, 52. A total of 1 patient (2.5%) had HPV genotypes 18 and other types,

which is HPV genotypes 18, 51 and 67.

The second most research subjects of advanced stage squamous cell cervical carcinoma

patients was having HPV genotypes 16, ie a total of 4 patients (10%), HPV genotype 18 were 2

patients (5%) and HPV genotypes 16, 18 by 2 patients (5%).

This finding is similar to research which conducted in Bandung, using the PCR kit from

Roche Linear Array showed a 78.6% infection of multiple HPV genotypes in cervical carcinoma

patients stage IIA / B in Oncology Polyclinic, Department of Obstetrics and Gynecology RSHS

the period from July to November 2010. 21

      HPV vaccination is the primary prevention of cervical carcinoma with HPV vaccine

injected. Currently, available vaccine is bivalent vaccine for HPV 16, 18, and a quadrivalent

vaccine for HPV 6,11,16 and 18 HPV genotypes. Description of HPV genotypes in this study is

different with the pattern of genotypes that exist in the world today, so the chances of HPV

vaccine can be developed with additional new genotypes of HPV antigens specific to the region

of Indonesia.

      In advanced stages of squamous cell cervical carcinoma which infected by multiple

HPV genotypes with a total of 32 patients, 81.3% respond well after received radiotherapy and

18.8% respond poorly. This is similar to research that conducted in Vienna, Austria, stated from

88 cervical carcinoma patients who had been given radiotherapy completely, there were 8

patients (8.3%) respond persistent. 22

Human Papilloma Virus infection has been proven related to early stage cervical cancer

carcinogenesis through oncogenes E6 and E7. Oncoprotein E6 binds to the tumor suppressor

gene p53 so (TSG) will lose p53 function. The ability of E6 to degrade p53 is different for each

HPV genotype. Thus, differences in HPV genotype may influence cervical cancer treatment

response. HPV E6 oncoprotein binds to p53 so that p53 is free to decline, then the tumor cells

will continue to proliferate in a hypoxic state. 16

Tissue hypoxia is an important factor in several pathological processes, including tumor

formation, resistance to radiation, malignant progression, and metastasis. Tumors become

hypoxic because new blood vessels are formed poorly, so blood flow becomes worse. Cancer

cells that have undergone genetic change and adapt will survive and proliferate in the hypoxic

state of the environment. 15

Poor radiotherapy response happened to advanced stage squamous cell cervical

carcinoma with HPV genotypes 18 infection, where 1 patient (50%) of 2 patients respond

partially to radiotherapy. This findings was similar to a studies which conducted in Beijing,

China, stated on cervical carcinoma with HPV type 18, which had been given radiotherapy

showed persistent responses or persistent disease, 21.7%. 17 In some studies, it was reported that

patients with genotype HPV 18 infection adaptation in cervical carcinoma have a higher rate of

recurrence compared to patients with HPV infection 16. 15

      In this study, poor response of radiotherapy was also found in advanced stages

squamous cell cervical carcinoma of infection with HPV genotypes 16 and 18, where 1 patient

(50%) of 2 patients respond partially to radiotherapy. This is similar to studies in Chennai, India,

stated that 44.4% of infection with HPV genotypes 16 and 18 in cervical carcinoma responds

poorly to radiotherapy. 23

      Based on the results of statistical calculations, it can be stated that there is no

correlation between HPV genotypes with response to radiotherapy in advanced stage squamous

cell cervical carcinoma.

      The interesting thing about the results of HPV genotypes in cervical squamous cell

carcinomas are found mostly (80%) of multiple HPV genotypes. Genotypes of HPV that most

often appear are co-infected with HPV genotypes 16 and 18, there are 16 samples, which most of

them are HPV genotypes 16, 18, HPV 52/33/35/58 consists of 4 patients (10%). In this study

used PCR kit from Roche Linear Array, the kit detected 52 can not be distinguished with HPV

genotypes 33, 38 and 58 as described in the handbook issued by the manufacturer. 21

Most HPV genotypes (80%) in squamous cell cervical cancer is multiple HPV genotypes.

Genotypes of HPV that appears most frequently are co-infected to HPV genotypes 16 and 18,

there are 16 samples, which majority of them are HPV genotypes 16, 18, HPV 52/33/35/58

consists of 4 patients (10%). This study used a PCR kit from Roche Linear Array. In the kit

detected 52 can not be distinguished to HPV genotypes 33, 38 and 58 as described in the

handbook issued by producer. 21

      This findings fits with the data that high-risk HPV genotypes, especially genotype HPV 16,

18, 31, 52 and 58 is the highest prevalence in the world and other high-risk HPV genotypes,

including HPV genotypes 33, 35, 39, 45, 51, 56, 59, 68, 73 and 82 are also considered as most

types of carcinogenesis, in which HPV genotypes 26, 55 and 66 were also considered to have the

possibility of causing carcinogenesis and HPV genotypes 6, 11, 40, 42, 43, 44, 54, 61 , 70, 72, 81

is a low-risk HPV. 21 High-risk HPV genotypes can infect in a short time that will heal by itself

and cause cervical cytology of normal tissue, which we know is a major gateway infection of

cervical high-risk HPV genotypes. 16

This provides the rationale for the early detection of high risk HPV genotypes to prevent

cervical cancer developing into an advanced stage. Geographic variation in HPV genotype

results may have implications for determining the molecular epidemiology of HPV prevalence

and distribution of HPV genotypes as should provide sufficient information to assess the impact

of prophylactic HPV vaccines. 23

In this study, 6 (75%) of 8 patients advanced stage squamous cell cervical cancer responds

poorly included in multiple HPV genotypes. Majority multiple HPV genotypes, which respond

poorly in this study were squamous cell cervical cancer which infected by HPV genotypes 16,

18, 45, 52/33/35/58 contained in 2 (33.3%) of 6 samples to multiple HPV that response poorly.

This finding is similar to recent research which indicating that co-infection of HPV

genotypes which detected probably contribute to the development or progression of cervical

cancer. In a study that conducted Chennai, India, found 4 (57%) of 7 patients has a poor response

to radiotherapy of cervical cancer to multiple HPV infections. 23 Based on research in Vienna,

Austria on the study of 96 patients with cervical cancer, there were 8 patients has persistent

response and 7 patients (87.5%) is a cervical cancer with multiple HPV infections. 22

Conclusion

General conclusions

There was no significant correlation between human papillomavirus genotypes and radiation

response in advanced stage of squamous cell cervical carcinoma

Specific conclusion

1. There is no significant corerelation between stage and radiotherapy response in squamous

cell cervical carcinoma.

2. There is a significant correlation between the degree of differentiation and radiotherapy

response in advanced stage of squamous cell cervical carcinoma .

3. There is a significant correlation between the size of the mass and radiotheraphy response

in advanced stage of squamous cell cervical carcinoma

4. There is no significant correlation between HPV genotypes and the degree of

differentiation in an advanced stage of cervical squamous cell carcinoma