High-resolution MR imaging of stage I cervical neoplasia with a dedicated transvaginal coil: MR features and correlation of imaging and pathologic findings

OBJECTIVE

The purposes of this study were to assess the appearance of stage 1 neoplasia of the cervix by high-resolution MR imaging with an enveloping transvaginal receiver coil and to correlate the imaging findings with the pathologic findings.

SUBJECTS AND METHODS

Fifteen patients (25-73 years old; mean, 40 years old) with clinical stage I disease were examined with a 37-mm-diameter ring-design solenoid receiver coil placed around the cervix. Axial 2.5-mm contiguous slices were obtained with a field of view of 10-15 cm on a 1.0-T HPQ Vista scanner with T1-weighted (660/20 msec [TR/TE]) and T2- weighted (2500/80 msec) spin-echo sequences and dynamic gradient-echo sequences during injection of gadopentetate dimeglumine (0.1 mmol/kg). Ten patients subsequently underwent Wertheim's hysterectomy, two underwent radiotherapy, two underwent extended cone biopsy for microinvasive disease, and one underwent a punch biopsy. For seven of 10 patients who had a hysterectomy, the widths of the tumor and the residual stroma were measured at eight radial points on the transverse images and at corresponding points on the histologic specimens at 5, 10, 15, 20, and 25 mm from the ectocervix. We then compared the widths of the tumor and the stroma on images and histologic specimens at each of these 40 points. Tumor volumes were calculated from the MR imaging and pathologic data and compared. For the other three patients, detailed MR imaging-pathology correlation was not possible because of multifocal tumor distribution (two patients) and insufficient detailed pathologic data (one patient).

RESULTS

Three carcinoma types were recognized. Squamous carcinoma (nine cases) was seen as a centrally expanding intermediate-signal-intensity mass, whereas oat (small)-cell carcinoma (one case) and clear-cell carcinoma (one case) showed a multifocal distribution. For patients who had a radical hysterectomy, we noted good agreement between the widths of the tumor and the stroma determined by MR imaging and histology. Tumor volumes were determined to be 0-28.2 cm3 by MR imaging and 0-18.4 cm3 by pathology. We observed tumor extension into the immediate parametrium in four patients by MR imaging; one of these cases was not confirmed at surgery. Parametrial extension was not underestimated by MR imaging in any case.

CONCLUSION

High-resolution imaging of the cervix with a transvaginal coil provides accurate assessment of the intra- and extracervical extents of tumors in clinical stage 1 cervical neoplasia.

Modulated expression of glycoprotein oligosaccharides identifies phenotypic differentiation in squamous carcinomas of the human cervix

This study has examined changes in expression of complex oligosaccharides during the development of invasive squamous carcinoma of the human cervix to determine whether particular oligosaccharide structures that might influence the phenotypic behavior of individual human cervical cancers were expressed during neoplasia. An extensive panel of lectins capable of identifying all the core and antennary oligosaccharide structures commonly encountered in human epithelia was chosen to probe a range of 11 benign and 26 malignant cervical tissues, all of the latter being clinically stage I. Lectin histochemistry was performed both before and after tissue desialylation using the enzyme neuraminidase to identify masking of oligosaccharide determinants by sialic acid. Nonneoplastic cervical epithelial cells were found to express only type I antennary structures (Gal beta 1-->3GalNAc-) usually modified by sialic acid linked 2-->6 to terminal Gal- or GalNAc residues. Type II oligosaccharide structures (Gal beta 1-->4GlcNAc-) were not identified in these normal tissues. No other terminal antennary modifications were detected on nonneoplastic cervical squamous epithelia. Conversely, neosynthesis of type II oligosaccharides was detected by Erythrina cristagalli (ECG) binding in 50% of the squamous carcinomas. Five terminal antennary modifications were commonly identified in the carcinomas that were not identified in normal cervical epithelia and comprised the oligosaccharides bound by lectins RCA, SBA, BS-1, LTA, and UEA-1. Synthesis of these oligosaccharides resulted in expression of structures similar to those recognized as ligands for extracellular matrix-binding proteins. We suggest that expression of such novel oligosaccharide structures may be an important promotor of local invasion and further dissemination of human cervical carcinomas through enhanced binding of malignant cells to stromal matrix proteins. This study has demonstrated that identification of expressed oligosaccharide structures is an objective method of identifying individual tumor cell phenotypes and may form the basis of a useful functional classification of human cervical squamous carcinomas.

The uterine cervix on in vitro and in vivo MR images: a study of zonal anatomy and vascularity using an enveloping cervical coil

OBJECTIVE

The purpose of this study was to characterize the normal zonal anatomy and vascularity of the cervix on in vivo and in vitro MR images obtained with a receiver coil surrounding the cervix. These appearances provide a normal data base from which to interpret subtle changes in early neoplasia.

SUBJECTS AND METHODS

Thirteen women of reproductive age with clinically and cytologically normal cervices were imaged with a ring-design solenoid receiver coil that was placed intravaginally and enveloped the cervix. T1- and T2-weighted axial images were obtained. Seven uterine specimens resected for benign disease were similarly studied, and imaging appearances were correlated with histologic findings.

RESULTS

In the in vivo studies, the endocervical mucosa and two stromal zones surrounding the high-signal central canal were identified. Unlike the uterine body, they could be differentiated on both T1- and T2-weighted images, on which the inner ring had a low signal and the outer ring had an intermediate signal intensity. The outer zone was highly vascularized, with inflow effects from large vessels visible on single-slice scans. On administration of gadopentetate dimeglumine, the endocervical mucosa enhanced rapidly, whereas the outer stroma showed more gradual enhancement. The inner zone enhanced slowly relative to the outer zone. The parametrium was visualized up to 6 cm from the center of the coil, and adjacent colon, fat, and blood vessels were identified. Up to four lymph nodes less than 1 cm in diameter were seen in the parametrium of three subjects. In the in vitro studies, the endocervical mucosa was of high signal intensity. In the fibromuscular cervix, an inner low-signal ring correlated with a region of tightly packed stroma (fibroblasts and smooth muscle cells; cell count, 5900 +/- 2376 nuclei/mm2) and the intermediate-signal-intensity outer zone corresponded to a region of more loosely packed stroma (cell count, 2199 +/- 558 nuclei/mm2). Retention cysts were present in two multiparous cervices.

CONCLUSION

These detailed appearances and enhancement patterns of the normal cervix need to be recognized so that subtle changes in locally invasive cervical neoplasia can be identified.

Invasive cancer of the cervix in women with mild dyskaryosis followed up cytologically

Mildly dyskaryotic smears are common, and women with such results are often followed up with further cervical smear tests. An important consideration in evaluating this practice would be the annual incidence of invasive cervical cancer. A reanalysis of five previous studies of the cytological follow up of women with mildly abnormal smear test results was undertaken to calculate this incidence. The annual incidence of invasive cancer in these women ranged from 0 to 420 per 100,000 women years. The large studies providing the most precise estimates had annual rates of 143 to 420 per 100,000 women years. This is 16 to 47 times greater than in women aged 15-34 years in England and Wales. The average rate was 208 per 100,000 women years. Women with mild dyskaryosis are at high risk of developing invasive cervical cancer despite cytological follow up. A full appraisal of the costs and benefits of colposcopy in this situation is urgently required.

Adjuvant therapy of ovarian cancer with radioactive monoclonal antibody

Fifty-two patients with epithelial ovarian cancer were treated with yttrium-90-labelled monoclonal antibody HMFG1 administered intraperitoneally following conventional surgery and chemotherapy as part of an extended phase I-II trial. The treatment was well tolerated and the only significant toxicity observed was reversible myelosuppression as previously described. Following conventional surgery and chemotherapy, 21 out of the 52 patients had no evidence of residual disease and were regarded as receiving treatment in an adjuvant setting. To date, two of these patients have died of their disease (follow-up 3-62 months, median follow-up 35 months). This extended phase I-II study suggests that patients with advanced ovarian cancer who achieve a complete remission following conventional therapy may benefit from further treatment with intraperitoneal radioactive monoclonal antibody.

Lack of effect of topical iodostearic acid on cervical intraepithelial neoplasia II-III

Stearic and iodostearic acid inhibit growth of a cervical carcinoma cell line in vitro. This study was performed to determine if iodostearic acid would induce regression of cervical intraepithelial neoplasia (CIN). Women with histologically-proven CIN II or III were randomised into two groups. Those in the first group were given pessaries composed of iodostearic acid in polyethylene glycol (PEG) base. Women in the second group were given pessaries containing only the PEG base. One pessary was inserted into the vagina nightly for 30 nights, and each woman then had the CIN lesion removed by CO2 laser cone excision. There was no difference in the histology of the cone biopsies between the groups, demonstrating that this regime of iodostearic acid has no useful role in the treatment of CIN II-III.

The human squamous cervical carcinoma cell line, HOG-1, is responsive to steroid hormones

Growth of the human squamous cervical carcinoma cell line, HOG-I, was stimulated in response to oestradiol in serum-containing and chemically defined medium. The oestradiol-stimulated growth could be inhibited by 4-OH tamoxifen, progesterone and medroxyprogesterone acetate; the last 2 compounds also inhibited basal cell growth in serum-containing and chemically defined media. The data are consistent with the sensitivity of human squamous cervical cancer to sex-steroid hormones and suggest that endocrine therapies may be of benefit in this disease.

Magnetic resonance imaging of the uterine cervix using an intravaginal coil

Cylindrical receiver coils designed for intravaginal use were utilized to image the uterine cervix. Good quality images of the cervix, vaginal wall, and parametrium were obtained and patient tolerance of the procedure was good.

Meta-analysis of surgery in advanced ovarian carcinoma: is maximum cytoreductive surgery an independent determinant of prognosis?

OBJECTIVE

If maximum cytoreductive surgery benefits the survival of women with advanced ovarian cancer, the median survival time of groups of such women will improve as the proportion of women undergoing maximum cytoreductive surgery is increased.

STUDY DESIGN

Fifty-eight suitable studies that encompass 6962 patients with advanced ovarian cancer were identified. Multiple linear regression was used to analyze the effects on median survival time of the following variables: the proportion of each cohort undergoing maximum cytoreductive surgery, the use of platinum-containing chemotherapy, the dose intensity of chemotherapy, the proportion of each cohort with stage IV disease, and the year of publication of the study.

RESULTS

Maximum cytoreductive surgery was associated with only a small improvement in median survival time, but platinum-containing chemotherapy improved median survival time substantially. Increased dose intensity also conferred a useful survival benefit.

CONCLUSION

Cytoreductive surgery probably has only a small effect on the survival of women with advanced ovarian cancer. The type of chemotherapy used is more important.

Evidence that patients presenting with dyskaryotic cervical smears should be screened for genital-tract infections other than human papillomavirus infection

One hundred and fifty-four women with dyskaryotic cervical smears were referred for colposcopy from two distinct population groups, namely those who initially had attended a sexually transmitted disease (STD) clinic, and those who came from general practitioners and family planning and gynaecology clinics (non-STD group). They were investigated to determine the prevalence and pattern of concomitant lower genital-tract infections. The mean age in each group was 25 years. Microbiological studies revealed that 79 (51%) of the women were infected, more than one infection occurring in 16 (10%) of them. Infection was present in 40% of the non-STD group and 66% of the STD group. The pattern of infection was remarkably similar in each group. Bacterial vaginosis was the most common disease in each group and accounted for more than one-third of all infections detected. Six patients had genital warts, 15 harboured Chlamydia trachomatis and 4 had gonorrhoea. Two-thirds of those with C. trachomatis and half of those with gonorrhoea were asymptomatic. We conclude that an abnormal cervical smear is frequently a marker of concomitant lower genital tract infection. Comprehensive microbiological investigations in order to effect appropriate treatment are easily achieved on women in the STD group, but the cost may be seen as prohibitive for those in the non-STD group. For these women we suggest a less comprehensive microbiological approach that provides a compromise strategy of management.

Computerization of a colposcopy clinic

The first phase of a paperless computer record has been developed at Hammersmith Hospital. The system was designed around the work practices of the clinic staff. In this phase the data are collected on forms which replace the normal case notes. This information is entered onto an IBM compatible computer by the secretary using a quick, user-friendly program written in a dBASE dialect and compiled with Quicksilver. The program produces letters to patients and their doctors and a printed record of the clinic findings for the case sheet to replace the handwritten form. When funding for hardware becomes available the data will be entered directly into the system by the medical staff in the clinic. Clinic appointment lists are maintained and patients "lost to follow-up' can be identified. Ad hoc enquiries can be made using dBASE III Plus or any similar program. This approach has integrated the computerized recording of data in a colposcopy clinic with the normal work of the staff involved so that no extra effort is required from medical or secretarial staff. The immediate accessibility of patient data and the ability to audit the work of the clinic have been particularly useful.

Long term results of cyclophosphamide, adriamycin and platinum chemotherapy in advanced epithelial ovarian cancer

Between January 1980 and December 1983, 57 consecutive patients with advanced epithelial ovarian cancer (FIGO Stage IIc n = 5; III n = 45; IV n = 7) were treated with 6 cycles of cyclophosphamide 600 mg/m2, adriamycin 30-45 mg/m2 and platinum 50 mg/m2 (CAP) at 3 weekly intervals. Pathological complete remission (CR) was documented in 10 (18%) and 4 with no residual disease after primary cytoreductive surgery were free from progression (FFP). There were 19 partial remissions (PR) giving a 51% overall response rate. The median duration of CR was 33 months from second look surgery. Median survival (MS) for all patients was 22 months. Multivariate analysis indicated that response to chemotherapy was the most important prognostic factor, with MS for CR of 53 months, PR 23 months and stable or progressive disease 11 months (p = 0.001). Most CR (8 of 10) occurred in patients with minimal residual disease (no single lesion greater than 2.0 cm), but extent of disease, though significant in univariate analysis of prognostic factors was not an independent predictor of survival. Six patients (11%) are alive and tumour free with a minimum follow-up of 7 years. All had FIGO Stage III disease at presentation and four had no residual tumour after primary surgery.

Reliability of colposcopy and directed punch biopsy

A group of 118 women underwent laser cone biopsy. Data were collected routinely on proforma case notes and entered into a computerized database. The histology of the cone biopsies was compared with that of previous, colposcopically directed punch biopsies, with the cytology of smears taken in the clinic and with the colposcopic diagnosis. The punch biopsy had a 54% false negative rate and neither of the two microinvasive carcinomas biopsied in this way were detected by the biopsy. Ten of 24 women with negative punch biopsies had CIN III in the cone. When the punch biopsy showed CIN II or worse, the cone biopsy confirmed the presence of CIN in 86%. There was some evidence of false negative cone biopsies. The data suggest that management should not be based solely upon the punch biopsy result but should include consideration of the cytology and colposcopy findings. Excisional methods of treatment are more likely to reveal early invasion and adenocarcinoma-in-situ.