Preoperative prognostic variables and the impact of postoperative adjuvant therapy on the outcomes of Stage IB or II cervical carcinoma patients with or without pelvic lymph node metastases: an analysis of 891 cases

Impact of different postoperative adjuvant therapies on the survival of early-stage cervical cancer patients with one intermediate-risk factor: A multicenter study of 14 years

OBJECTIVE

To compare survival outcomes of different postoperative adjuvant therapies (PATs) for early-stage cervical cancer (ECC) patients with one intermediate-risk pathological factor (IPF).

METHODS

A total of 2889 patients with stage IA1 to IIA2 cervical cancer were included in this study. Three PAT groups were identified, namely a no adjuvant therapy (NAT) group (n = 773), an adjuvant radiotherapy/chemoradiotherapy (ART) group (n = 1648) and an adjuvant chemotherapy (ACT) group (n = 468). Kaplan-Meier analysis and COX regression analysis were used to compare the overall survival (OS) and disease-free survival (DFS) among the three groups, before and after propensity score matching (PSM).

RESULTS

The recurrence and mortality rate rates in the NAT, ART and ACT groups were 9.2%, 8.6%, and 7.9%, respectively (p = 0.737). Kaplan-Meier analysis demonstrated no significant differences in the NAT, ART, and ACT groups in 5-year OS rates (92.8% vs. 93.6% vs. 94.7%, p = 0.594) and DFS rates (88.7% vs. 89.6% vs. 90.5%, p = 0.772). Post-hoc tests yielded similar results, with no differences in 5-year OS and DFS (NAT vs. ART, before and after matching, p > 0.05); (NAT vs. ACT, before and after matching, p > 0.05); and (ACT vs. ART, before and after matching, p > 0.05).

CONCLUSION

Postoperative adjuvant radiotherapy, chemoradiotherapy, and chemotherapy are not associated with survival outcomes of ECC patients with one IPF. Considering the side effects and impact on patients' quality of life, the PATs should be carefully considered.

Value of MRI and diffusion-weighted imaging in diagnosing normal-sized pelvic lymph nodes metastases in patients with cervical cancer

OBJECTIVES

To investigate the value of conventional MRI and diffusion-weighted imaging (DWI) in diagnosing normal-sized pelvic lymph nodes metastases in patients with cervical cancer.

METHODS

102 patients with cervical cancer who underwent MRI and DWI scan were included. 137 lymph nodes were analyzed, including 44 metastatic lymph nodes (MLNs) and 93 non-metastatic lymph nodes (non-MLNs). The morphology and apparent diffusion coefficient (ADC) value of lymph nodes were measured including short-axis diameter (DS), long-axis diameter (DL), ratio of short-to-long-axis diameter (DR), fatty hilum, asymmetry, ADCmax, ADCmean and ADCmin. The Mann-Whitney U-test, independent sample t-test and Chi-square test were employed to compare the differences of all criteria between MLNs and non-MLNs. Logistic regression and decision tree were used to develop the combined diagnostic model. ROC analyses were used to evaluate the diagnostic performance.

RESULTS

The DS and DR of MLNs were significantly higher than those of non-MLNs (p < 0.05), the ADCmax, ADCmean and ADCmin of MLNs were significantly lower than those of non-MLNs (p < 0.05). Presence of fatty hilum and asymmetric lymph nodes between MLNs and non-MLNs were significantly different (p＜0.05). Combined measurement of ADCmin, DS and DR had the highest AUC 0.937 with 90.9% sensitivity and 87.1% specificity. The accuracy of decision tree was 88.3%.

CONCLUSION

MRI with DWI had potential in diagnosing normal-sized pelvic lymph nodes metastases in patients with cervical cancer. The combined evaluation of DS, DR and ADCmin of lymph nodes and decision tree of the combined measure showed better diagnostic performances than sole criteria.

ADVANCES IN KNOWLEDGE

The short-axis diameter, ratio of short-to-long-axis diameter and ADCmin of lymph nodes have moderate value in the diagnosis of the metastases of the normal-sized lymph nodes for the patient with cervical cancer as the sole indices. The combined evaluation of DS, DR and ADCmin is much more valuable in the detection of metastatic lymph nodes.

Post-operative small pelvic intensity-modulated radiation therapy for early-stage cervical cancer with intermediate-risk factors: efficacy and toxicity

OBJECTIVE

The aim of the present study was to retrospectively evaluate the toxicity and efficacy of post-operative small pelvic intensity-modulated radiotherapy in early-stage cervical cancer patients with intermediate-risk factors.

METHODS

Between 2012 and 2016, 151 patients who had cervical cancer (International Federation of Gynecology and Obstetrics stage I-IIA) with intermediate-risk factors were treated with post-operative small pelvic intensity-modulated radiotherapy. The median dose of 50.4 Gy in 28 fractions with small pelvic intensity-modulated radiotherapy was prescribed to the planning target volume. The intensity-modulated radiotherapy technique used was conventional fixed-field intensity-modulated radiotherapy or helical tomotherapy.

RESULTS

The median follow-up was 37 months. The 3-year disease-free survival and overall survival rates were 89 and 96%, respectively. A total of 144 patients (95.3%) were alive at the last follow-up. In total, 6 patients (3.9%) had recurrence: locoregional recurrence in 3 patients (2%), distant metastasis in 2 (1.3%), and both in 1 (0.6%). Diarrhoea was the most common acute toxicity. There were no patients suffering from acute or late grade ≥ 3 toxicity. Only 4 patients (2.6%) had late grade 2 toxicities.

CONCLUSIONS

For early-stage cervical cancer patients with intermediate-risk factors, post-operative small pelvic intensity-modulated radiotherapy was safe and well tolerated. The rates of acute and late toxicities were quite satisfactory.

British Gynaecological Cancer Society (BGCS) cervical cancer guidelines: Recommendations for practice

Cervix cancer in many countries is declining and screening programmes and immunisation will reduce the incidence in the next few decades. This guideline attempts to cover management of invasive disease reflecting diagnosis and imaging including new imaging and sentinel lymph node biopsies. Smaller volume disease is usually managed surgically whereas advanced disease is treated with (chemo)- radiation. It also includes discussion of fertility sparing procedures. Practices are changing frequently for all aspects of care usually in attempts to reduce complications and improve quality of life. The management of advanced disease is treated by chemotherapy and the use of newer agents is also discussed. Other sections discuss specialist situations such as cancer in pregnancy, rare cervical tumours, late effects and supportive measures and fertility preserving approaches.

Outcome and Subsequent Pregnancy after Fertility-Sparing Surgery of Early-Stage Cervical Cancers

We aimed to investigate the outcomes and subsequent pregnancies of early-stage cervical cancer patients who received conservative fertility-sparing surgery. Women with early-stage cervical cancer who underwent conservative or fertility-sparing surgery in a tertiary medical center were reviewed from 2004 to 2017. Each patient's clinicopathologic characteristics, adjuvant therapy, subsequent pregnancy, and outcome were recorded. There were 32 women recruited, including 12 stage IA1 patients and 20 stage IB1 patients. Twenty-two patients received conization/LEEP and the other 10 patients received radical trachelectomy. Two patients did not complete the definite treatment after fertility-sparing surgery. There were 11 women who had subsequent pregnancies and nine had at least one live birth. The live birth rate was 73.3% (11/15). We conclude that patients with early-stage cervical cancer who undergo fertility-sparing surgery can have a successful pregnancy and delivery. However, patients must receive a detailed consultation before surgery and undergo definitive treatment, if indicated, and regular postoperative surveillance.

Prognostic Performance of the 2018 International Federation of Gynecology and Obstetrics Cervical Cancer Staging Guidelines

OBJECTIVE

To examine the prognostic performance of the revised 2018 International Federation of Gynecology and Obstetrics (FIGO) cervical cancer staging schema.

METHODS

We used the National Cancer Database to identify women with cervical cancer diagnosed from 2004 to 2015. Using clinical and pathologic data, each patient's stage was classified using three staging schemas: American Joint Committee on Cancer 7th edition, FIGO 2009 and FIGO 2018. The FIGO 2018 revised staging classifies stage IB tumors into three substages based on tumor size (IB1-IB3) and classifies patients with positive lymph nodes (pathologically or clinically detected) as stage IIIC1 (positive pelvic nodes) or IIIC2 (positive para-aortic nodes). Five-year survival rates were estimated for each stage grouping. We sought to determine whether the 2018 FIGO staging system was able to offer improved 5-year survival rate differentiation compared with older staging schemas.

RESULTS

A total of 62,212 women were identified. The classification of stage IB tumors into three substages improved discriminatory ability. Five-year survival in the FIGO 2018 schema was 91.6% (95% CI 90.4-92.6%) for stage IB1 tumors, 83.3% (95% CI 81.8-84.8%) for stage IB2 neoplasms, and 76.1% (95% CI 74.3-77.8%) for IB3 lesions. In contrast, for women with stage III tumors, higher FIGO staging was not consistently associated with worse 5-year survival rates: stage IIIA (40.7%, 95 CI 37.1-44.3%), stage IIIB (41.4%; 95% CI 39.9-42.9%), stage IIIC1 (positive pelvic nodes) was 60.8% (95% CI 58.7-62.8%) and stage IIIC2 37.5% (95% CI 33.3-41.7%).

CONCLUSION

The FIGO 2018 staging schema provides improved discriminatory ability for women with stage IB tumors; however, classification of all women with positive lymph nodes into a single stage results in a very heterogeneous group of patients with highly variable survival rates.

Chemoradiotherapy is not superior to radiotherapy alone after radical surgery for cervical cancer patients with intermediate-risk factor

Objectives

There is no consensus on whether giving adjuvant concurrent chemoradiotherapy (CCRT) is more effective than adjuvant radiotherapy (RT) alone in patients with early stage cervical cancer and intermediate-risk factor(s). The purpose of this study was to evaluate survival difference according to adjuvant treatment in the intermediate-risk group.

Methods

From 2000 to 2014, the medical records of patients with stage IB–IIA cervical cancer and a history of radical hysterectomy with pelvic lymph node dissection, followed by pelvic RT at a dose ≥40 Gy were retrospectively reviewed. Among these, 316 patients with one or more intermediate-risk factor(s) and no high-risk factors were included. The criteria defined the intermediate-risk group as those patients with any of the following intermediate-risk factors: lymphovascular space involvement, over one-half stromal invasion, or tumor size ≥4 cm.

Results

The median follow-up duration was 70 months (range: 3–203 months). According to adjuvant treatment (adjuvant RT alone vs. adjuvant CCRT), the 5-year recurrence-free survival rates (90.8% vs. 88.9%, p=0.631) and 5-year overall survival rates (95.9% vs. 91.0%, p=0.287) did not show a significant difference in patients with any of the intermediate-risk factors. In multivariate analysis, a distinct survival difference according to adjuvant treatment was not found regardless of the number of risk factors.

Conclusion

The present study showed that giving RT together with chemotherapy is not more effective than RT alone for stage IB–IIA cervical cancer patients with intermediate-risk factor(s).

Trial Registration

ClinicalTrials.gov Identifier: NCT01101451

Prognostic Model for Survival and Recurrence in Patients with Early-Stage Cervical Cancer: A Korean Gynecologic Oncology Group Study (KGOG 1028)

PURPOSE

We aimed to develop and validate individual prognostic models in a large cohort of cervical cancer patients that were primarily treated with radical hysterectomy.

Materials and Methods

We analyzed 1,441 patients with early-stage cervical cancer treated between 2000 and 2008 from the Korean Gynecologic Oncology Group multi-institutional cohort: a train cohort (n=788) and a test cohort (n=653). Models predicting the risk for overall survival (OS), disease- free survival (DFS), lymphatic recurrence and hematogenous recurrence were developed using Cox analysis and stepwise backward selection and best-model options. The prognostic performance of each model was assessed in an independent patient cohort. Model-classified risk groups were compared to groups based on traditional risk factors.

RESULTS

Independent risk factors for OS, DFS, lymphatic recurrence, and hematogenous recurrence were identified for prediction model development. Different combinations of risk factors were shown for each outcome with best predictive value. In train cohort, area under the curve (AUC) at 2 and 5 years were 0.842/0.836 for recurrence, and 0.939/0.882 for OS. When applied to a test cohort, the model also showed accurate prediction result (AUC at 2 and 5 years were 0.799/0.723 for recurrence, and 0.844/0.806 for OS, respectively). The Kaplan-Meier plot by proposed model-classified risk groups showed more distinctive survival differences between each risk group.

CONCLUSION

We developed prognostic models for OS, DFS, lymphatic and hematogenous recurrence in patients with early-stage cervical cancer. Combining weighted clinicopathologic factors, the proposed model can give more individualized predictions in clinical practice.

A comprehensive analysis of the factors of positive pelvic lymph nodes on survival of cervical cancer patients with 2018 FIGO stage IIIC1p

Objective: To evaluate the factors associated with positive pelvic lymph nodes (LNs) on the survival of patients with 2018 FIGO stage IIIC1p cervical cancer. Methods: We retrospectively analyzed 155 patients with pelvic lymph node metastasis (LNM) confirmed by pathology after radical resection of cervical cancer treated at Zhejiang Cancer Hospital, China, between March 2008 and October 2011. We analyzed the influence of the factors associated with positive pelvic LNs on the survival of patients. Results: The 5-year progress-free survival (PFS) and overall survival (OS) of patients were 78.1% and 81.9%, respectively. The 5-year PFS and OS of patients with more than 2 LNM were worse compared with patients with 1 or 2 LNM (68.4% vs 83.7%, p=0.013; 72.4% vs 87.6%, p=0.017, respectively). The 5-year PFS and OS of patients with more than 2 LNM sites were worse than that of patients with 1 or 2 LNM sites (60.0% vs 82.4%, p=0.008; 70.0% vs 84.8%, p=0.045, respectively). The 5-year PFS and OS of patients with common iliac LNM was poorer than that of patients without common iliac LNM (60.7% vs 81.9%, p=0.008; 67.9% vs 85.0%, p=0.020, respectively). Compared with other patients, the survival of patients with these three factors (more than 2 LNM, more than 2 LNM sites, and common iliac LNM) was the worst (p<0.05). Conclusion: More than 2 LNM, more than 2 LNM sites, and common iliac LNM were predictive factors of poor survival in stage IIIC1p cervical cancer patients. Survival of patients with stage IIIC1p cervical cancer declined with increasing presence of such factors. The combined evaluation of the factors associated with positive pelvic LNs is a more comprehensive and pragmatic approach in evaluating the prognosis of cervical cancer.

Adjuvant external beam radiation and brachytherapy for vaginal resection margin positive cervical cancer

PURPOSE

To evaluate the treatment outcomes of adjuvant external beam radiation therapy (EBRT) and vaginal brachytherapy (VB) following radical hysterectomy in cervical cancer patients with involved vaginal resection margin (VRM). Materials and.

METHODS

We retrospectively reviewed the medical records of 21 patients treated with postoperative EBRT and VB for positive VRM FIGO stage IB-IIA cervical cancer between 2003 and 2015. Concurrent platinum-based chemotherapy was administered to all patients.

RESULTS

The median whole pelvis EBRT dose was 50.4 Gy (range, 45 to 50.4 Gy). In the VB, the median dose per fraction, number of fractions, and total dose delivered were: 4 Gy (range, 3.0 to 4.0 Gy), 4 fractions (range, 3 to 5 fractions), and 16 Gy (range, 12 to 20 Gy), respectively. At a median follow-up of 46 months (range, 9 to 122 months), local recurrence was observed in 2 patients, and distant metastasis was present in 7 patients. All patients with local recurrence subsequently developed distant metastases. The 5-year local control, disease-free survival, and overall survival rates were 89.1%, 65.9%, and 62.9%, respectively. Of the 21 patients, 7 patients (33.3%) reported grade 2 acute toxicity; however, there were no grade 3 or higher acute adverse events. Grade 1-2 late toxicities were observed in 8 patients. Late grade 3 urinary toxicity was reported in 1 patient. Conclusions: Adjuvant EBRT and VB showed excellent local control and low toxicity in cervical cancer patients with positive VRM. Although limited by its retrospective nature, the findings from our study provide evidence supporting the use of additional VB in pathologically involved VRM.

Perineural invasion in early-stage cervical cancer and its relevance following surgery

Perineural invasion (PNI) is the neoplastic invasion of nerves by cancer cells, a process that has attracted attention as a novel prognostic factor for cancer. The present study aimed to investigate the prognostic value of PNI in patients with early-stage cervical cancer (International Federation of Gynecology and Obstetrics stage IA2-IIA). A total of 210 patients who underwent radical hysterectomy and pelvic lymphadenectomy between 2007 and 2012 were included in the current study, of whom 8.57% (18/210) exhibited PNI. Patients with PNI were more likely to exhibit adverse histopathological features, such as increased tumor size, depth of stromal invasion, parametrial invasion, lymphovascular space invasion and lymph nodes metastases (all P<0.05). Patients with PNI exhibited shorter disease-free and overall survival (P=0.002 and P=0.017, respectively). However, PNI was not identified as an independent risk factor for either recurrence or death by multivariate analysis. Furthermore, 88.9% (16/18) of patients with PNI received adjuvant therapy following surgery. PNI was significantly associated with well-established indicators for adjuvant therapy. In conclusion, PNI was associated with multiple high-risk factors and its presence was indicative of a poor outcome in patients with early-stage cervical cancer, which may influence management decisions regarding adjuvant therapy.

Results from Survey to Assess Current Trends in Surgical Practice in the Management of Women with Early Stage Cervical Cancer within the BGCS Community with an Emphasis on Routine Frozen Section Examination

In the UK, more than 3,200 new cases of cervical cancer are diagnosed each year. Early stage cervical cancer (IA2-IB1) treatment comprises central surgery mainly in the form of radical hysterectomy or fertility sparing surgery including trachelectomy as well as systematic pelvic lymphadenectomy to detect metastases and adjust treatment accordingly. Given the variation in determining the lymph node (LN) status, a major prognosticator, we reviewed the current UK practice of LN assessment in women undergoing surgery for early cervical cancer. A 7-question, web-based survey, screened by the BGCS committee, was circulated amongst BGCS members. The overall response rate was 51%. Only 12.5% of the respondents routinely performed frozen section examination (FSE); the main reasons for not doing FSE were the pressure on theatre time (54.5%) and the lack of available facilities (48.5%). When positive pelvic nodal disease was detected, in 21 out of 50 (42%) the planned radical hysterectomy (RH) was aborted. More than 70% of the respondents routinely performed RH without any prior resort to pelvic lymphadenectomy. Pretreatment surgical para-aortic LN assessment was performed by 20% of the respondents. The survey confirms the diversity of the UK practice patterns in the surgical treatment of early cervical cancer.

Practice patterns of adjuvant therapy for intermediate/high recurrence risk cervical cancer patients in Japan

Objective

Although radiation therapy (RT) and concurrent chemoradiotherapy (CCRT) are the global standards for adjuvant therapy treatment in cervical cancer, many Japanese institutions choose chemotherapy (CT) because of the low frequency of irreversible adverse events. In this study, we aimed to clarify the trends of adjuvant therapy for intermediate/high-risk cervical cancer after radical surgery in Japan.

Methods

A questionnaire survey was conducted by the Japanese Gynecologic Oncology Group to 186 authorized institutions active in the treatment of gynecologic cancer.

Results

Responses were obtained from 129 facilities. Adjuvant RT/CCRT and intensity-modulated RT were performed in 98 (76%) and 23 (18%) institutions, respectively. On the other hand, CT was chosen as an alternative in 93 institutions (72%). The most common regimen of CT, which was used in 66 institutions (51%), was a combination of cisplatin/carboplatin with paclitaxel. CT was considered an appropriate alternative option to RT/CCRT in patients with risk factors such as bulky tumors, lymph node metastasis, lymphovascular invasion, parametrial invasion, and stromal invasion. The risk of severe adverse events was considered to be lower for CT than for RT/CCRT in 109 institutions (84%).

Conclusion

This survey revealed a variety of policies regarding adjuvant therapy among institutions. A clinical study to assess the efficacy or non-inferiority of adjuvant CT is warranted.

Adjuvant platinum-based chemotherapy for early stage cervical cancer

BACKGROUND

This is the second updated version of the original Cochrane review published in the Cochrane Library 2009, Issue 3. Most women with early cervical cancer (stages I to IIA) are cured with surgery or radiotherapy, or both. We performed this review originally because it was unclear whether cisplatin-based chemotherapy after surgery, radiotherapy or both, in women with early stage disease with risk factors for recurrence, was associated with additional survival benefits or risks.

OBJECTIVES

To evaluate the effectiveness and safety of adjuvant platinum-based chemotherapy after radical hysterectomy, radiotherapy, or both in the treatment of early stage cervical cancer.

SEARCH METHODS

For the original 2009 review, we searched the Cochrane Gynaecological Cancer Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library 2009, Issue 1), MEDLINE, Embase, LILACS, BIOLOGICAL ABSTRACTS and CancerLit, the National Research Register and Clinical Trials register, with no language restriction. We handsearched abstracts of scientific meetings and other relevant publications. We extended the database searches to November 2011 for the first update and to September 2016 for the second update.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing adjuvant cisplatin-based chemotherapy (after radical surgery, radiotherapy or both) with no adjuvant chemotherapy, in women with early stage cervical cancer (stage IA2-IIA) with at least one risk factor for recurrence.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently. Meta-analysis was performed using a random-effects model, with death and disease progression as outcomes.

MAIN RESULTS

For this second updated version we identified only one small trial reporting grade 4 toxicity results, without disease-free or overall survival data with a median follow-up of 16 months.From the first updated version, we identified three trials that were ongoing, and remain so in 2016.Four trials including 401 women with evaluable results with early cervical cancer were included in the meta-analyses. The median follow-up period in these trials ranged from 29 to 42 months. All women had undergone surgery first. Three trials compared chemotherapy combined with radiotherapy versus radiotherapy alone; and one trial compared chemotherapy followed by radiotherapy versus radiotherapy alone. It was not possible to perform subgroup analyses by stage or tumour size.Compared with adjuvant radiotherapy, chemotherapy combined with radiotherapy significantly reduced the risk of death (two trials, 297 women; hazard ratio (HR) = 0.56, 95% confidence interval (CI): 0.36 to 0.87) and disease progression (two trials, 297 women; HR = 0.47, 95% CI 0.30 to 0.74), with no heterogeneity between trials (I² = 0% for both meta-analyses). Acute grade 4 toxicity occurred significantly more frequently in the chemotherapy plus radiotherapy group than in the radiotherapy group (three trials, 321 women; risk ratio (RR) 6.26, 95% CI 2.50 to 15.67). We considered the evidence for all three outcomes to be of a moderate quality, using the GRADE approach due to small numbers and limited follow-up in the included studies. In addition, it was not possible to separate data for bulky early stage disease.In the one small trial that compared adjuvant chemotherapy followed by radiotherapy with adjuvant radiotherapy alone there was no difference in disease recurrence between the groups (one trial, 71 women; HR = 1.34; 95% CI 0.24 to 7.66) and overall survival was not reported. We considered this evidence to be of a low quality.No trials compared adjuvant platinum-based chemotherapy with no adjuvant chemotherapy after surgery for early cervical cancer with risk factors for recurrence.

AUTHORS' CONCLUSIONS

The addition of platinum-based chemotherapy to adjuvant radiotherapy (chemoradiation) may improve survival in women with early stage cervical cancer (IA2-IIA) and risk factors for recurrence. Adjuvant chemoradiation is associated with an increased risk of severe acute toxicity, although it is not clear whether this toxicity is significant in the long term due to a lack of long-term data. This evidence is limited by the small numbers and low to moderate methodological quality of the included studies. We await the results of three ongoing trials, which are likely to have an important impact on our confidence in this evidence.

A prospective study of the value of pre- and post-treatment magnetic resonance imaging examinations for advanced cervical cancer

BACKGROUND AND AIM

Cervical cancer has high incidence and mortality in developing countries. It is the only gynecological malignancy that is clinically staged. Staging at the time of diagnosis is crucial for treatment planning. After radiation therapy, clinical examination is limited because of radiation changes. An imaging method relatively unaffected by radiation changes would be useful for the assessment of therapy results and for management. We sought to demonstrate the value of magnetic resonance imaging (MRI) in the pre- and post-treatment assessment of cervical cancer.

METHODS

This was a prospective study, carried out between November 2012 and October 2014 on 18 subjects with advanced-stage cervical cancer diagnosed by colposcopy. The disease stage was determined clinically according to the International Federation of Gynecology and Obstetrics (FIGO) criteria. Only patients with disease stage ≥ IIB or IIA with one of the tumor dimensions > 4 cm were enrolled in the study. All patients underwent abdominal-pelvic contrast-enhanced MRI as part of the workup. Tumor size, local invasion, involved pelvic lymph nodes, and staging according to MRI criteria were evaluated. Clinical and MRI examinations were also performed after chemoradiotherapy. After chemoradiotherapy, 94% of the patients (17 of 18) were treated surgically.

RESULTS

Eighteen patients aged 32-67 met the inclusion criteria and were enrolled: 10 stage IIB, 6 stage IIIA, 1 stage IIA and 1 stage IIIB, according to clinical staging. Using histopathological findings as a reference, MRI staging accuracy was 83.3%. The concordance of the clinical stage with MRI stage at the first examination was 56%. Parametrial involvement was assessed on pretreatment and post-treatment MRI, with post-treatment MRI compared with histology. There was no statistically significant difference between the pre- and post-therapy gynecological examinations (GYN) and the corresponding MRI assessments as to tumor size measurements (p>0.05). The post-therapy restoration of the cervical stroma ruled out tumor recurrence.

CONCLUSIONS

For a detailed characterization of loco-regional extension, the calculation of tumor volume, and the evaluation of distant metastatic changes, clinical examination is insufficient. Magnetic resonance imaging is helpful aftertherapy.

Routine Intraoperative Frozen Section Examination to Minimize Bimodal Treatment in Early-Stage Cervical Cancer

Objective

In early-stage cervical cancer, single modality therapy is the main objective, to minimize patient morbidity while offering equivalent cure rates. Intraoperative frozen section examination (FSE) of lymph nodes (LNs) can facilitate this aim, ensuring that radical surgery is avoided in patients requiring adjuvant therapy for metastatic LN involvement. We aimed to evaluate the accuracy of routine intraoperative FSE of pelvic LNs during the surgical staging of early-stage cervical cancers and identify a group at low risk for nodal metastases.

Methods

A retrospective cohort study of 94 women aged 23 to 80 years who underwent primary surgery and planned intraoperative FSE of the pelvic LNs at the gynecological cancer center in Oxford was performed. The diagnostic value of FSE and the prediction of metastatic nodal disease were assessed by use of preoperative and intraoperative variables.

Results

A total of 1825 LNs were submitted for FSE. Of 94 women (13.8%), 13 had positive LNs at FSE. Two false-negative cases were reported with micrometastases but no false-positive cases. Frozen section examination as a diagnostic test reached a sensitivity of 86.7% and a specificity of 100%. A regression model including grade I to II and tumor size of less than 20 mm identified a low-risk group for LN involvement.

Conclusions

In light of diverse practice patterns, FSE should be routinely offered to women with early-stage cervical cancer in a 1-step protocol. We equally devised a model to predict those patients at least risk of nodal disease, who may be spared of FSE.

Prognostic risk model development and prospective validation among patients with cervical cancer stage IB2 to IIB submitted to neoadjuvant chemotherapy

This study was designed to develop a risk model for disease recurrence among cervical cancer patients who underwent neoadjuvant chemotherapy and radical surgery. Data for 853 patients were obtained from a retrospective study and used to train the model, and then data for 447 patients from a prospective cohort study were employed to validate the model. The Cox regression model was used for calculating the coefficients of the risk factors. According to risk scores, patients were classified into high-, intermediate-, and low-risk groups. There were 49 (49/144, 34%) recurrences observed in the high-risk group (with a risk score ≥ 2.65), compared with 3 (3/142, 2%) recurrences in the low-risk group (with a risk score < 0.90). Disease-free survival (DFS) was significantly different (log-rank p < 0.001) among the three risk groups; the risk model also revealed a significant increase in the accuracy of predicting 5-year DFS with the area under the ROC curve (AUC = 0.754 for risk model vs 0.679 for FIGO stage system); the risk model was also validated with data from the prospective study (log-rank p < 0.001, AUC = 0.766). Both high-risk and intermediate-risk patients can be more effectively identified by this risk model.

Risk model in stage IB1-IIB cervical cancer with positive node after radical hysterectomy

The purpose of this study was to identify risk factors in patients with surgically treated node-positive IB1-IIB cervical cancer and to establish a risk model for disease-free survival (DFS) and overall survival (OS). A total of 170 patients who underwent radical hysterectomy and bilateral pelvic lymphadenectomy as primary treatment for node-positive International Federation of Gynaecology and Obstetrics (FIGO) stage IB1-IIB cervical cancer from January 2002 to December 2008 were retrospectively analyzed. Five published risk models were evaluated in this population. The variables, including common iliac lymph node metastasis and parametrial invasion, were independent predictors of outcome in a multivariate analysis using a Cox regression model. Three distinct prognostic groups (low, intermediate, and high risk) were defined using these variables. Five-year DFS rates for the low-, intermediate-, and high-risk groups were 73.7%, 60.0%, and 25.0%, respectively (P<0.001), and 5-year OS rates were 81.9%, 42.8%, and 25.0%, respectively (P<0.001). The risk model derived in this study provides a novel means for assessing prognosis of patients with node-positive stage IB1-IIB cervical cancer. Future study will focus on external validation of the model and refinement of the risk scoring systems by adding new biologic markers.

CPE overexpression is correlated with pelvic lymph node metastasis and poor prognosis in patients with early-stage cervical cancer

PURPOSE

Elevated carboxypeptidase E (CPE) levels play crucial roles in tumorigenesis and metastasis. This study investigated the expression and clinicopathological significance of CPE in early-stage cervical cancer.

METHODS

Elevated carboxypeptidase E expression was analyzed using quantitative polymerase chain reaction and western blotting in normal cervical tissue, cervical cancer cell lines, and in cervical cancer tissues and adjacent noncancerous tissues (ANTs) from the same patient. Immunohistochemistry (IHC) was used to examine CPE expression in tissue samples from 112 patients with early-stage cervical cancer (FIGO stages Ia2-IIa2), 60 patients with cervical intraepithelial neoplasia, and 19 patients with normal cervical tissues (NCTs). Associations between CPE expression and prognostic and diagnostic factors were evaluated statistically.

RESULTS

CPE expression was significantly higher in cervical cancer cell lines and tissues than in normal tissues and ANTs. Semi-quantitative analysis of IHC indicated that CPE gradually increased from CIN I to cervical cancer, but was absent in NCTs. CPE expression was seen in 40.2 % (45/112) of the cervical cancer samples. CPE expression was significantly associated with FIGO stage (P = 0.003), tumor size (P = 0.012), stromal invasion (P < 0.001), lymphovascular space invasion (P = 0.016), parametrial infiltration (P = 0.027), vaginal involvement (P = 0.007), postoperative adjuvant therapy (P = 0.024), recurrence (P < 0.001), survival (P < 0.001), and pelvic lymph node metastasis (PLNM) (P < 0.001), and it was significantly higher in tissues from patients with PLNM than without PLNM. Logistic regression analysis identified high-level CPE expression as an independent risk factor for PLNM (P = 0.001). Patients with higher CPE expression had shorter overall survival duration than patients with lower CPE expression. Univariate and multivariate Cox-regression analyses suggested that high-level CPE expression is an independent prognostic factor for overall survival in early-stage cervical cancer.

CONCLUSIONS

High-level CPE expression was associated with a poor prognosis in early-stage cervical cancer. CPE may serve as a biomarker for predicting PLNM and survival in these patients.

A phase I study of adjuvant intensity-modulated radiotherapy with concurrent paclitaxel and cisplatin for cervical cancer patients with high risk factors

The aim of the study is to determine the maximum tolerated dose (MTD) and acute dose-limiting toxicities (DLTs) of adjuvant concurrent paclitaxel and cisplatin (TP) with pelvic intensity-modulated radiotherapy (IMRT) for early-stage cervical cancer patients with high risk factors. Women who underwent radical hysterectomy and pelvic lymphadenectomy for stages IB-IIA cervical cancer and had high risk factors were enrolled. One cycle of TP was delivered before and after concurrent chemoradiotherapy, respectively. Then 3 weeks after the start of the initial cycle of the chemotherapy, patients received IMRT in a total dose of 50-50.4 Gy in 25-28 fractions with two cycles of concurrent TP, which was administered with escalating doses. Eighteen patients were enrolled at three dose levels. At dose level 1 (paclitaxel 90 mg/m(2), cisplatin 40 mg/m(2)) and level 2 (paclitaxel 90 mg/m(2), cisplatin 50 mg/m(2)), DLT (grade 3 leukopenia) was observed in one patient, respectively. At level 3 (paclitaxel 105 mg/m(2), cisplatin 50 mg/m(2)), two DLTs (grade 3 leukopenia) were observed in two patients. The MTD of paclitaxel and cisplatin was then defined as 90 and 50 mg/m(2), respectively. Pelvic IMRT and concurrent TP is a safe and tolerable adjuvant treatment regimen for cervical cancer patients with high risk factors. The MTD of concurrent chemotherapy is paclitaxel 90 mg/m(2) and cisplatin 50 mg/m(2). Trial registration Current controlled trials ChiECRCT-2014025.

Standardized Uptake Value on F-FDG PET/CT as a Prognostic Factor for Survival of Women with Malignant Uterine Tumors: A Meta-Analysis

BACKGROUND

Malignant uterine tumors are crucial in the evaluation of prognosis and the determination of therapeutic strategy.

AIM

This meta-analysis of the available literature aimed to investigate the prognostic value of standardized uptake value (SUV) on fluorine-18-fluorodeoxyglucose positron emission tomography with computed tomography (18F-FDG PET/CT) in uterine malignancies before treatment.

METHODS

The PubMed, MEDLINE and EMBASE databases (1990 to February 2014) were searched to identify studies evaluating SUV on 18F-FDG PET/CT as a prognostic tool for predicting long-term survival in patients with carcinomas of the uterus. The χ2 test and the I2 index were used to estimate heterogeneity among the trials selected in the meta-analysis. The combined hazard ratio was calculated by using a fixed- or random-effects model according to heterogeneity.

RESULTS

Thirteen studies with a total of 1,196 patients were eligible for analysis. High pretreatment SUVmax was significantly associated with poorer event-free survival and overall survival, and the summarized hazard ratio was 3.33 (95% confidence interval 2.34-4.74) and 1.31 (95% confidence interval 1.03-1.67), respectively.

CONCLUSION

The present evidence indicates that SUV on 18F-FDG PET/CT seems to be a valuable prognostic indicator for survival of patients with malignant uterine tumors. Given that 18F-FDG PET/CT can provide both morphologic and functional information, we suggest utilizing PET/CT and its quantitative marker in uterine malignancies before treatment. © 2015 S. Karger AG, Basel.

Prognostic analysis of uterine cervical cancer treated with postoperative radiotherapy: importance of positive or close parametrial resection margin

Purpose

To analyze prognostic factors for locoregional recurrence (LRR), distant metastasis (DM), and overall survival (OS) in cervical cancer patients who underwent radical hysterectomy followed by postoperative radiotherapy (PORT) in a single institute.

Materials and Methods

Clinicopathologic data of 135 patients with clinical stage IA2 to IIA2 cervical cancer treated with PORT from 2001 to 2012 were reviewed, retrospectively. Postoperative parametrial resection margin (PRM) and vaginal resection margin (VRM) were investigated separately. The median treatment dosage of external beam radiotherapy (EBRT) to the whole pelvis was 50.4 Gy in 1.8 Gy/fraction. High-dose-rate vaginal brachytherapy after EBRT was given to patients with positive or close VRMs. Concurrent platinum-based chemoradiotherapy (CCRT) was administered to 73 patients with positive resection margin, lymph node (LN) metastasis, or direct extension of parametrium. Kaplan-Meier method and log-rank test were used for analyzing LRR, DM, and OS; Cox regression was applied to analyze prognostic factors.

Results

The 5-year disease-free survival was 79% and 5-year OS was 91%. In univariate analysis, positive or close PRM, LN metastasis, direct extension of parametrium, lymphovascular invasion, histology of adenocarcinoma, and chemotherapy were related with more DM and poor OS. In multivariate analysis, PRM and LN metastasis remained independent prognostic factors for OS.

Conclusion

PORT after radical hysterectomy in uterine cervical cancer showed excellent OS in this study. Positive or close PRM after radical hysterectomy in uterine cervical cancer correlates with poor prognosis even with CCRT. Therefore, additional treatments to improve local control such as radiation boosting need to be considered.

Diagnostic performance of diffusion-weighted MRI for detection of pelvic metastatic lymph nodes in patients with cervical cancer: a systematic review and meta-analysis

In recent years, diffusion-weighted (DW) MRI has emerged as a new technique for detecting the pelvic lymph metastases in patients with cervical cancer. The aim of this meta-analysis was to assess the diagnostic value of DW imaging (DWI) for benign/malignant discrimination of pelvic lymph nodes (LNs). Studies about DWI for the detection of metastatic LNs were searched in the PubMed, EMBASE, Web of Science, EBSCO, the Cochrane Library and three Chinese databases. Based on the extracted data, we determined pooled sensitivities, specificities and diagnostic odds ratios (DORs) across studies, calculated positive and negative likelihood ratios (LRs) and constructed summary receiver operating characteristic curves with area under the curve (AUC) and Q* obtained. We also analysed the heterogeneity between studies based on subgroup analysis, threshold effect and publication bias. In total, 15 studies involving 1021 patients met the inclusion criteria. The pooled sensitivity, specificity and DOR of DWI were 0.86 [95% confidence interval (CI), 0.84-0.89], 0.84 (95% CI, 0.83-0.86) and 47.21 (95% CI, 25.67-86.81), respectively. LR syntheses yielded overall positive LR of 6.55 (95% CI, 4.77-9.01) and negative LR of 0.17 (95% CI, 0.12-0.23). The AUC and Q* index were 0.9384 and 0.8754, respectively. The heterogeneity was relatively high between studies; however, there was no evidence for threshold effect and publication bias. DWI is beneficial in the pelvic nodal assessment in patients with cervical cancer. Large-scale, high-quality trials with standard protocols are required to evaluate its clinical value for discrimination of metastatic from non-metastatic pelvic LNs in patients with cervical cancer. Advances in knowledge include providing evidence to assess the role of DWI in nodal staging of cervical cancer.

Preoperative PET/CT FDG standardized uptake value of pelvic lymph nodes as a significant prognostic factor in patients with uterine cervical cancer

PURPOSE

Using integrated PET/CT, we evaluated the prognostic relevance in uterine cervical cancer of preoperative pelvic lymph node (LN) [(18)F]FDG uptake.

METHODS

Patients with FIGO stage IB to IIA uterine cervical cancer were imaged with FDG PET/CT before radical surgery. We used Cox proportional hazards regression to examine the relationship between recurrence and the FDG maximum standardized uptake value (SUV(max)) in the pelvic LN (SUVLN) on PET/CT.

RESULTS

Clinical data, treatment modalities, and results in 130 eligible patients were reviewed. The median postsurgical follow-up was 34 months (range 6 to 109 months). Receiver operating characteristic analysis identified SUVLN 2.36 as the most significant cut-off value for predicting recurrence. SUV(LN) was correlated with SUV(tumour) (P = 0.002), primary tumour size (P = 0.004), and parametrial invasion (P = 0.013). Univariate analyses showed significant associations between recurrence and SUV(LN) (P = 0.001), SUV(tumour) (P = 0.007), pelvic LN metastasis (P = 0.002), parametrial invasion (P < 0.001), primary tumour size (P = 0.007), suspected LN metastasis on MRI (P = 0.024), and FIGO stage (P = 0.026). Multivariate analysis identified SUV(LN) (P = 0.013, hazard ratio, HR, 4.447, 95 % confidence interval, CI, 1.379 – 14.343) and parametrial invasion (P = 0.013, HR 6.728, 95 % CI 1.497 – 30.235) as independent risk factors for recurrence. Patients with SUV(LN) ≥ 2.36 and SUV(LN) <2.36 differed significantly in terms of recurrence (HR 15.20, P < 0.001).

CONCLUSION

Preoperative pelvic LN FDG uptake showed a strong significant association with uterine cervical cancer recurrence.

Prognostic model in patients with early-stage squamous cell carcinoma of the uterine cervix: a combination of invasive margin pathological characteristics and lymphovascular space invasion

BACKGROUND

This study aimed to develop a prognostic model in patients with early-stage cervical squamous cell carcinoma based on clinicopathological features, including invasive margin characteristics.

MATERIALS AND METHODS

Clinicopathological features and outcomes of 190 patients with FIGO stage IB-IIA cervical squamous cell carcinoma treated by surgery were collected and analyzed for factors associated with tumor recurrence. In addition to well-recognized pathological risk factors, the pathological characteristics of invasive margin (type of invasive pattern and degree of stromal desmoplasia and peritumoral inflammatory reaction) were also included in the analysis. Multiple scoring models were made by matching different clinicopathological variables and/ or different weighting of the score for each variable. The model with the best performance in the prediction of recurrence and decreased survival was selected.

RESULTS

The model with the best performance was composed of a combined score of invasive pattern, lymphovascular space invasion (LVSI), and degree of inflammatory reaction and stromal desmoplasia (total score =10). Compared to those with score ≤ 8, the patients with score 9-10 had a significantly higher recurrence rate in the overall group (p<0.001) and the subgroup without adjuvant therapy (p<0.001), while the significance was marginal in the subgroup with adjuvant therapy (p=0.069). In addition, the patients with score 9-10 had a higher rate of tumor recurrence at distant sites (p=0.007). The disease-free survival was significantly lower in the patients with score 9-10 than those with score ≤ 8 among the overall patients (p<0.001), in the subgroup without adjuvant therapy (p<0.001), and the subgroup with adjuvant therapy (p=0.047).

CONCLUSIONS

In this study, a prognostic model based on a combination of pathological characteristics of invasive margin and LVSI proved to be predictive of tumor recurrence and decreased disease-free survival in patients with early-stage cervical squamous cell carcinoma.

Postoperative outcomes of MR-invisible stage IB1 cervical cancer

OBJECTIVE

Tumor volume is a significant prognostic factor of cervical cancer. It is still unknown about outcome of biopsy-proven IB1 cervical cancer, which is invisible on preoperative magnetic resonance imaging (MRI). The aim was to evaluate retrospectively the postoperative outcomes of MR-invisible stage IB1 cervical cancers.

STUDY DESIGN

Between January 2001 and December 2007, we reviewed the medical records of 86 patients with biopsy-proven IB1 cervical cancer that was invisible on MRI. During the same period, we also reviewed the medical records of 260 patients with biopsy-proven IB1 cervical cancer that was visible on MRI. Both of these cancer groups were treated with radical hysterectomy and lymph node dissection. MR-invisible and MR-visible IB1 cancers were compared in terms of pathologic parameters and long-term survival rate.

RESULTS

The median sizes and depths of stromal invasion of MR-invisible vs MR-visible IB1 cancers were 4.5 ± 7.1 mm and 33.3% ± 20.1% vs 30 ± 14 mm and 66.7% ± 26.6%, respectively (P = .000). The incidences of lymph node metastasis, parametrial invasion, and lymphovascular invasion were 1.1% (1/86 cases) and 18.8% (49/260 cases; P = .000; odds ratio, 19.7), 0% (0/86 cases) and 6.5% (17/260 cases; P = .009; odds ratio, 12.4), and 4.7% (4/86 cases) and 26.9% (70/260 cases; P = .000; odds ratio, 7.6) in the MR-invisible and MR-visible IB1 cancers, respectively. Recurrence-free and overall 5-year survival rates of MR-invisible vs MR-visible IB1 cancers were 98.8% (85/86 cases) vs 91.2% (237/260 cases) and 100% (86/86 cases) vs 95.8% (249/260 cases), respectively (P = .011 and .045).

CONCLUSION

MR-invisible IB1 cancer provides better postoperative outcomes than MR-visible IB1 cancer because of the much lower tumor burden.

Can Pelvic Lymphadenectomy be Omitted in Stage IA2 to IIB Uterine Cervical Cancer?

Objectives

The aims of this study were to predict pelvic lymph node metastasis in uterine cervical cancer before surgery and to evaluate the potential efficacy of omitting pelvic lymphadenectomy.

Materials and Methods

A total of 163 patients with invasive uterine cervical cancer in FIGO stage IA2 to IIB, all of whom underwent primary radical hysterectomy with pelvic lymphadenectomy, participated in this study.

Results

The incidences of pelvic lymph node metastasis in stage IA2, stage IB1, stage IB2, stage IIA, and stage IIB cervical cancer were 0% (0/12), 17% (13/76), 22% (6/27), 33% (8/24), and 63% (15/24), respectively. A significant difference was observed in overall survival with nodal metastasis status (P< 0.0001). Univariate analysis revealed that parametrial invasion (P< 0.0001), tumor markers (P= 0.0006), tumor size greater than 2 cm (P< 0.0001), tumor size less than 3 cm (P= 0.0009), and tumor size greater than 4 cm (P= 0.0024) were correlated with pelvic lymph node metastasis. However, multivariate analysis revealed that parametrial invasion (P= 0.01; odds ratio, 3.37; 95% confidence interval, 1.31–9.0) and tumor size greater than 2 cm (P= 0.005; odds ratio, 4.93; 95% confidence interval, 1.54–22.01) were independently associated with nodal metastasis.

Conclusions

Pelvic lymphadenectomy may be avoided in patients with negative parametrial invasion and a tumor size less than 2 cm, thereby minimizing postoperative complications.

Prognostic significance of perineural invasion in cervical cancer

Perineural invasion (PNI) has attracted attention as a new prognostic factor for cancer. We aimed to investigate the prognostic value of PNI in patients with cervical cancer. Clinical data of 185 patients with early-stage cervical cancer (stages IA2-IIA2) who underwent radical hysterectomy and pelvic lymphadenectomy between 2003 and 2011 were investigated. PNI was detected in 7% (13 of 18 cases) of patients. Moreover, 92% (12 of 13 cases) of patients with PNI received radiation therapy or concurrent chemoradiation therapy after surgery. We investigated whether PNI can be a new indication for adjuvant therapy for cervical cancer. In our study, PNI had a significant association with well-known indications for adjuvant therapy (92.3% sensitivity, 50% specificity, odds ratio 12.0, P = 0.003). Multivariate analysis showed that parametrial invasion and lymphovascular invasion were independently associated with PNI (P < 0.05). However, statistical analysis did not show differences in disease-free survival (P = 0.292) or overall survival (P = 0.346) according to the presence of PNI. In conclusion, PNI as an independent predictor for prognosis was limited, but PNI had a significant association with prognostic factors. PNI may be a new risk factor candidate for cervical cancer. PNI is expected to help in decision making for the need for adjuvant therapy.

Significance of the absolute number and ratio of metastatic lymph nodes in predicting postoperative survival for the International Federation of Gynecology and Obstetrics stage IA2 to IIA cervical cancer

PURPOSE

This study aimed to evaluate the ratio of metastatic and removed lymph nodes (RPL) and the number of metastatic lymph nodes (MLNs) in predicting postoperative survival for International Federation of Gynecology and Obstetrics stage IA2 to IIA cervical cancer after radical hysterectomy and pelvic lymphadenectomy (RHPL).

METHODS

A retrospective study was conducted in which 120 patients with lymph node metastasis who underwent RHPL for cervical cancer from 2000 to 2006 was analyzed to identify the prognostic indicators by using Kaplan-Meier and Cox proportional hazard methods.

RESULTS

Of 588 patients with cervical cancer who underwent RHPL, the 5-year survival rate (YSR) of 120 with lymph node metastasis was much lower than that of 468 without lymph node metastasis (22.4% vs 84.4%, P < 0.001). By cut-point survival analysis, RPL cutoff was designed as 10%, with the 5-YSR of 42.9% and 11.8%, and MLN count cutoffs were designed as 1 and 5, with the 5-YSR of 62.5%, 20.8%, and 7.8%, respectively. With univariate analysis, increasing RPL and MLN counts were associated with a poorer survival in women with node metastasis cervical cancers. Stage, histologic grade, RPL, and MLN count were significant independent prognostic factors for survival in a multivariate Cox proportional hazard model. In addition, RPL was verified superior to MLN count in prognostic evaluation for patients with IA2 to IIA cervical cancer after RHPL because the hazard ratio of RPL (3.195) was higher than that of MLN count (1.578).

CONCLUSIONS

The RPL and MLN count may be used as the independent prognostic parameters in patients with cervical cancer with lymph node metastasis after RHPL. Comparison of the superiority of RPL and MLN count for better predicting the survival of patients with cervical cancer deserves to be investigated further.

Adjuvant platinum-based chemotherapy for early stage cervical cancer

BACKGROUND

This is an updated version of the original Cochrane review published in The Cochrane Library 2009, Issue 3. Most women with early cervical cancer (stages I to IIA) are cured with surgery or radiotherapy, or both. We performed this review originally because it was unclear whether cisplatin-based chemotherapy after surgery, radiotherapy or both, in women with early stage disease with risk factors for recurrence, was associated with additional survival benefits or risks.

OBJECTIVES

To evaluate the effectiveness and safety of platinum-based chemotherapy after radical hysterectomy, radiotherapy, or both in the treatment of early stage cervical cancer.

SEARCH METHODS

For the original 2009 review, we searched the Cochrane Gynaecological Cancer Group Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2009, Issue 1), MEDLINE, EMBASE, LILACS, BIOLOGICAL ABSTRACTS and CancerLit, the National Research Register and Clinical Trials register, with no language restriction. We handsearched abstracts of scientific meetings and other relevant publications. We extended the database searches to November 2011 for this update.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing adjuvant cisplatin-based chemotherapy (after radical surgery, radiotherapy or both) with no adjuvant chemotherapy, in women with early stage cervical cancer (stage IA2-IIA) with at least one risk factor for recurrence.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently. Meta-analysis was performed using a random-effects model, with death and disease progression as outcomes.

MAIN RESULTS

For this updated version, we identified three additional ongoing trials but no new studies for inclusion. Three trials including 368 evaluable women with early cervical cancer were included in the meta-analyses. The median follow-up period in these trials ranged from 29 to 42 months. All women had undergone surgery first. Two trials compared chemotherapy combined with radiotherapy to radiotherapy alone; and one trial compared chemotherapy followed by radiotherapy to radiotherapy alone. It was not possible to perform subgroup analyses by stage or tumour size.Compared with adjuvant radiotherapy, chemotherapy combined with radiotherapy significantly reduced the risk of death (two trials, 297 women; hazard ratio (HR) = 0.56, 95% confidence interval (CI): 0.36 to 0.87) and disease progression (two trials, 297 women; HR = 0.47, 95% CI 0.30 to 0.74), with no heterogeneity between trials (I² = 0% for both meta-analyses). Acute grade 4 toxicity occurred significantly more frequently in the chemotherapy plus radiotherapy group than in the radiotherapy group (risk ratio (RR) 5.66, 95% CI 2.14 to 14.98). We considered this evidence to be of a moderate quality due to small numbers and limited follow-up in the included studies. In addition, it was not possible to separate data for bulky early stage disease.In the one small trial that compared adjuvant chemotherapy followed by radiotherapy with adjuvant radiotherapy alone there was no significant difference in disease recurrence between the groups (HR = 1.34; 95% CI 0.24 to 7.66) and OS was not reported. We considered this evidence to be of a low quality.No trials compared adjuvant platinum-based chemotherapy with no adjuvant chemotherapy after surgery for early cervical cancer with risk factors for recurrence.

AUTHORS' CONCLUSIONS

The addition of platinum-based chemotherapy to adjuvant radiotherapy (chemoradiation) may improve survival in women with early stage cervical cancer (IA2-IIA) and risk factors for recurrence. Adjuvant chemoradiation is associated with an increased risk of severe acute toxicity, although it is not clear whether this toxicity is significant in the long-term due to a lack of long-term data. This evidence is limited by the small numbers and poor methodological quality of included studies. We await the results of three ongoing trials, that are likely to have an important impact on our confidence in this evidence.

Comparison of DWI and PET/CT in evaluation of lymph node metastasis in uterine cancer

AIM: To investigate diffusion-weighted imaging (DWI) and positron emission tomography and computed tomography (PET/CT) with IV contrast for the preoperative evaluation of pelvic lymph node (LN) metastasis in uterine cancer.

METHODS: Twenty-five patients with endometrial or cervical cancer who underwent both DWI and PET/CT before pelvic lymphadenectomy were included in this study. For area specific analysis, LNs were divided into eight regions: both common iliac, external iliac, internal iliac areas, and obturator areas. The classification for malignancy on DWI was a focally abnormal signal intensity in a location that corresponded to the LN chains on the T1WI and T2WI. The criterion for malignancy on PET/CT images was increased tracer uptake by the LN.

RESULTS: A total of 36 pathologically positive LN areas were found in 9 patients. With DWI, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy for detecting metastatic LNs on an LN area-by-area analysis were 83.3%, 51.2%, 27.3%, 93.3% and 57.0%, respectively, while the corresponding values for PET/CT were 38.9%, 96.3%, 70.0%, 87.8% and 86.0%. Differences in sensitivity, specificity and accuracy were significant (P < 0.0005).

CONCLUSION: DWI showed higher sensitivity and lower specificity than PET/CT. Neither DWI nor PET/CT were sufficiently accurate to replace lymphadenectomy.

Embryologically based resection of cervical cancers: a new concept of surgical radicality

Objectives With the objective of improving outcomes in oncological surgery, a new concept of surgical anatomy deduced from embryonic development, called ontogenetic anatomy and compartment theory of local tumor spread, is proposed by Michael Höckel from Germany. Hypothesis Compartment resection enables the preservation of functionally important tissues of different embryonic origin despite its close proximity to the tumor and incomplete resection of the compartment results in increase in local recurrences. This approach should maximize local tumor control and minimize treatment-related morbidity. Total Mesometrial Resection (TMMR) This new surgical technique has been developed and standardized over past 12 years for cervical cancer with a high local control rate without need for adjuvant radiotherapy. Conclusion This Embryological based surgery holds a great promise for management of cervical cancer. However this novel surgery needs confirmation in multi institutional settings to translate research into practice for an excellent therapeutic index.

Analysis of Prognostic Variables, Development of Predictive Models, and Stratification of Risk Groups in Surgically Treated FIGO Early-Stage (IA–IIA) Carcinoma Cervix

Objectives

The objectives of the study were to evaluate clinicopathologic prognostic variables in surgically treated International Federation of Obstetrics and Gynecology early-stage (IA–IIA) cervical cancer, develop prognostic models, and note the role of adjuvant treatment, patterns of failure, and salvage survival (SS) in each group.

Methods

Records of 542 patients who received primary surgical treatment for International Federation of Obstetrics and Gynecology (IA–IIA) cervical cancer were reviewed. Ninety-eight patients who relapsed after primary treatment were identified and matched for stage and age with a control group. Clinicopathologic prognostic variables were identified and used to develop a prognostic model with 3 risk groups for overall survival (OS) and relapse-free survival (RFS). The roles of adjuvant treatment, relapse sites, and SS were also noted in the groups.

Results

The 5-year OS was 70% for the whole group, 97% in the control group, and 44% in the relapse group. There was a statistically significant decrease in survival in patients 70 years or older, those with positive lymphovascular space invasion (LVSI), and in patients with positive LVSI and increasing depth of invasion in both univariate and multivariate analyses (P < 0.001). Positive lymph node status and tumor size of 31 mm or greater showed only a trend toward lower OS and RFS, respectively, in multivariate analysis. An additive model using regression coefficients from multivariate Cox model stratified patients into low-, medium-, and high-risk groups. Relapse-free survival and OS were significantly different in all 3 groups (P < 0.001). Salvage survival was better in low-risk group relative to medium- and high-risk groups, (P = 0.05) as well as between the medium- and high-risk groups (P = 0.03). More distant and locoregional relapses were noted in the medium- and high-risk groups, and SS was better with a local versus locoregional or distant recurrence (P < 0.001).

Conclusions

In this study, age 70 years or older and positive LVSI were found to be statistically significant prognostic factors for both OS and RFS. Positive lymph nodes status showed only a trend toward lower OS. Positive LVSI status had significant adverse prognostic effects on RFS and OS in tumors with increasing depth of invasion. Additive prognostic model helps identify predictors and stratify patients into low-, medium-, and high-risk groups for survival. Many of these factors can be identified preoperatively and may assist in decision to offer primary surgery or alternative therapies in patients with potentially operable cervix cancer. Prognostic model can be used as a tool to design clinical trials and select the group of patients who are the appropriate target for a trial.

HPV-18 is a poor prognostic factor, unlike the HPV viral load, in patients with stage IB-IIA cervical cancer undergoing radical hysterectomy

OBJECTIVES

This study was conducted to determine the prognostic significance of the human papillomavirus (HPV) genotype using the HPV DNA chip (HDC) test and the HPV viral load by the hybrid capture II assay (HC2) in FIGO stage IB-IIA cervical cancer undergoing radical hysterectomy.

METHODS

Between January 2001 and December 2005, 204 consecutive patients who underwent radical hysterectomy with pelvic lymphadenectomy for International Federation of Gynecology and Obstetrics (FIGO) stage IB1-IIA cervical cancer were retrospectively reviewed. The Cox proportional hazard models adjusted for covariates were used for analyses and a receiver operating characteristic (ROC) curve was used to determine the HPV viral load in predicting disease progression.

RESULTS

Of the 204 cases, the HDC was positive in 195 (95.6%) and the HC2 was positive in 192 (94.1%). The 5-year progression-free survival (PFS) was 78.4%. On multivariate analysis, HPV-18 positivity was an independent prognostic factor predictive for disease progression. The risk of recurrence was higher for HPV-18 positivity (hazard ratio=2.664; 95% confidence interval [CI], 1.437-4.938; P=0.003). The 5-year PFS rate for patients who were HPV-18-negative was 83.8%, which was higher than the 5-year PFS for patients who were HPV-18-positive (54.1%; P<0.001). The area under the ROC curve for the HPV viral load was 0.550 (P=0.314; 95% CI, 0.455-0.644).

CONCLUSIONS

The HPV-18 genotype is a reliable prognostic factor of early-stage cervical cancer; however, the HPV viral load may not be helpful in predicting disease prognosis.

Established, emerging and future applications of FDG-PET/CT in the uterine cancer

Integrated positron emission tomography/computed tomography (PET/CT) with 2-[¹⁸F]fluoro-2-deoxy-D-glucose (FDG) is a useful technique to acquire both glucose metabolic and anatomic imaging data using a single device in a single diagnostic session and has opened a new field in clinical oncologic imaging. FDG-PET/CT has been used successfully for the staging, optimization of treatment, re-staging, therapy monitoring, and prognostic prediction of uterine cervical cancer and endometrial cancer as well as various malignant tumours. The present review discusses the current role of FDG-PET/CT in the management of uterine cancer, discussing its usefulness and limitations in the imaging of these patients.

Parametrial Involvement in FIGO Stage IB1 Cervical Carcinoma: Diagnostic Impact of Tumor Diameter in Preoperative Magnetic Resonance Imaging

Background:

In the surgical treatment for early-stage cervical carcinoma, it is important to identify preoperatively a low-risk group of patients as candidates for less radical surgery to avoid the morbidity associated with radical hysterectomy. The aim of this study was to evaluate the correlation between tumor diameter measured preoperatively using magnetic resonance imaging (MRI) and pathological prognostic factors in International Federation of Gynecology and Obstetrics (FIGO) stage IB1 cervical carcinoma.

Methods:

A total of 125 patients with FIGO stage IB1 cervical cancer were included in this study. Clinical records, pathology reports, and MRI findings were retrospectively reviewed.

Results:

Histological diagnosis was squamous cell carcinoma in 57 patients and nonsquamous cell carcinoma in 68 patients. All patients underwent preoperative evaluation by MRI within a median period of 13.5 days before surgery. The tumor diameter measured by MRI ranged from zero (no tumor detected) to 42 mm, with a median of 23 mm. Pathological prognostic factors included parametrial involvement, lymph node metastasis, deep stromal invasion, and lymphovascular space invasion. All these factors were found less frequently in patients with a smaller tumor diameter. Most notably, parametrial involvement was seen in none of the patients with tumors 20 mm or less and was detected only in patients with tumors greater than 20 mm (P= 0.01).

Conclusions:

In the FIGO stage IB1 cervical carcinoma, the tumor diameter measured preoperatively by MRI correlates well with other pathological prognostic factors, especially with parametrial involvement. This finding suggests that the tumor diameter measured in preoperative MRI may serve as a strong predictor of parametrial involvement in FIGO stage IB1 cervical carcinoma, which can be used to select a candidate population for less radical surgery without the need for a cone biopsy before hysterectomy.

Radical hysterectomy with pelvic lymphadenectomy: indications, technique, and complications

Radical hysterectomy with pelvic lymphadenectomy remains the treatment of choice for women with Stages IA(2) and IB(1) carcinoma of the cervix, and selected patients with Stage II endometrial cancer. Improvement in surgical techniqe, administration of prophylactic antibiotics, thromboemolic prophylaxis, and advances in critical care medicine have resulted in lower operative morbidity associated with this procedure. Major urinary tract complications such as ureteral injury or vesico-vaginal fistula are now extremely rare (<1%). Five-year survival rates following this procedure vary according to a number of clinical and histologic variables, and may be as high as 90% in women without lymph node metastases.