The presentation of adenocarcinoma of the uterine cervix

3D multifrequency magnetic resonance elastography in distinguishing endometrial and cervical adenocarcinoma

OBJECTIVES

To prospectively evaluate the value of tomoelastography in determining the underlying origins of uterine adenocarcinoma.

METHODS

This prospective work was approved by our institutional review board, and all patients provided informed consent. 64 patients with histopathologically confirmed adenocarcinomas originated either from the cervix (CAC: cervical adenocarcinoma) or endometrium (EAC: endometrial adenocarcinoma) underwent MRI and tomoelastography examination on a 3.0 T MR scanner. To biomechanically characterize the adenocarcinoma, two MRE-derived parameters maps were provided in the tomoelastography, namely shear wave speed (c, m/s) and loss angle (φ, radian), which represented the stiffness and fluidity, respectively. The MRE-derived parameters were compared by using a two-tailed independent-sample t-test or Mann-Whitney U test. Five morphologic features were also analyzed by using the χ2 test. Logistic regression analysis was used to develop diagnosis models. Delong test was used to compare the receiver operating characteristic curves whith different diagnostic models and evaluate the diagnostic efficiency.

RESULTS

CAC were significantly stiffer and behaved more fluid like than EAC (c: 2.58 ± 0.62 m/s vs.2.17 ± 0.72 m/s, p = 0.029, φ, 0.97 ± 0.19 rad vs.0.73 ± 0.26 rad, p < 0.0001). The diagnostic performance for distinguishing CAC from EAC was similar for c (AUC = 0.71) and for φ (AUC = 0.75). For distinguishing CAC from EAC, the AUC of tumor location was the higher than c and φ (AUC = 0.80). A cmobined model consisting of tumor location, c, and φ achieved the best diagnostic performance, with an AUC of 0.88 (77.27% sensitivity and 85.71% specificity).

CONCLUSIONS

CAC and EAC displayed their unique biomechanical features. 3D multifrequency MRE provided added value to the conventional morphologic features in distinguishing the two types of diseases.

New Insights in the Diagnosis of Rare Adenocarcinoma Variants of the Cervix—Case Report and Review of Literature

We report the case of a 29-year-old patient with low-grade squamous intraepithelial lesion (L-SIL), negative human papilloma virus (HPV), positive p16/Ki-67 dual-staining and colposcopy suggestive for severe dysplastic lesion. The patient underwent a loop electrosurgical excision procedure (LEEP), the pathology report revealing mesonephric hyperplasia and adenocarcinoma. The patient also opted for non-standard fertility-sparing treatment. The trachelectomy pathology report described a zone of hyperplasia at the limit of resection towards the uterine isthmus. Two supplementary interpretations of the slides and immunohistochemistry (IHC) were performed. The results supported the diagnosis of mesonephric adenocarcinoma, although with difficulty in differentiating it from mesonephric hyperplasia. Given the discordant pathology results that were inconclusive in establishing a precise diagnosis of the lesion and the state of the limits of resection, the patient was referred to a specialist abroad. Furthermore, the additional interpretation of the slides and IHC were performed, the results suggesting a clear cell carcinoma. The positive p16/Ki-67 dual-staining prior to LEEP, the non-specific IHC and the difficulties in establishing a diagnosis made the case interesting. Given the limitations of cytology and the fact that these variants are independent of HPV infection, dual staining p16/Ki-67 could potentially become useful in the diagnosis of rare adenocarcinoma variants of the cervix, however further documentation is required.

The spectrum of cervical glandular neoplasia and issues in differential diagnosis

CONTEXT

Premalignant and malignant glandular lesions of the cervix are known to often cause diagnostic problems with a variety of benign (more common) as well as other malignant mimics, the latter setting often being represented by secondary involvement by endometrioid endometrial carcinoma especially in small samplings.

OBJECTIVE

To highlight key histologic features and immunohistochemical markers that may be helpful in the distinction of in situ endocervical carcinoma from benign glandular proliferations, and those that separate different subtypes of invasive endocervical carcinoma, as well as invasive carcinoma from other carcinomas secondarily involving the cervix and nonneoplastic proliferations of the cervix.

CONCLUSIONS

Clinical and morphologic features as well as immunohistochemistry results should be used in conjunction in the differential diagnosis of glandular proliferations of the cervix, as correct interpretation has major clinical consequences for the patient in most instances (especially benign versus malignant). Immunohistochemical markers should be used as part of a panel of antibodies, as exceptions may occur to the usual pattern of staining, and if used singly, they may mislead the pathologist to establish a wrong diagnosis.

Differential clinical characteristics, treatment response and prognosis of locally advanced adenocarcinoma/adenosquamous carcinoma and squamous cell carcinoma of cervix treated with definitive radiotherapy

OBJECTIVE

To compare tumor characteristics and clinical outcome of patients with cervical locally advanced adenocarcinoma (AC)/adenosquamous carcinoma (ASC) and squamous cell carcinoma (SCC).

DESIGN

Retrospective study.

SETTING

National Taiwan University Hospital, Taipei, Taiwan.

POPULATION

All patients with cervical SCC (n = 35), AC or ASC (n = 194) with FIGO stage ≥IIB who received definitive radiotherapy or concurrent chemoradiotherapy (CCRT) from January 1995 to December 2009.

METHOD

Medical and histopathological record review.

MAIN OUTCOME MEASURES

Progression-free survival (PFS), local recurrence-free survival, distant metastasis-free survival, and overall survival (OS).

RESULTS

Compared with the SCC subgroup, patients with AC/ASC were significantly younger (p = 0.007), more of them without clinical symptoms were diagnosed by abnormal Pap smear findings (p = 0.043), and less responded to treatment (p = 0.018). After a median follow-up of 59.3 months, patients with AC/ASC had worse 5-year PFS (30.0% vs. 47.6%, p = 0.044), worse 5-year distant metastasis-free survival (41.5% vs. 69.9%, p = 0.005), and trends toward worse 5-year local recurrence-free survival (64.4% vs. 76.2%, p = 0.165) and worse 5-year OS (41.3% vs. 58.1%, p = 0.090) than patients with SCC. In univariate analysis, early FIGO stage and complete treatment response were significantly associated with PFS and OS. Histology of non-AC/ASC and Point A biologically equivalent doses in 2-Gy fractions >85 Gy were significantly associated with better PFS, and CCRT was significantly associated with better OS. In multivariate analysis, complete treatment response and early FIGO stage remained significant factors for predicting better PFS and OS.

CONCLUSIONS

Cervical AC/ASC may be more aggressive than is SCC. For cervical AC/ASC, more comprehensively effective treatments are warranted.

Primary surgery versus primary radiotherapy with or without chemotherapy for early adenocarcinoma of the uterine cervix

BACKGROUND

For early squamous cell carcinoma of the uterine cervix, the outcome is similar after either primary surgery or primary radiotherapy. There are reports that this is not the case for early adenocarcinoma (AC) of the uterine cervix: some studies have reported that the outcome is better after primary surgery. There are no systematic reviews about surgery versus chemoradiation in the treatment of cervical cancer. This is an updated version of the original Cochrane review published in Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD006248. DOI: 10.1002/14651858.CD006248.

OBJECTIVES

The objectives of this review were to compare the effectiveness and safety of primary surgery for early stage AC of the uterine cervix with primary radiotherapy or chemoradiation.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2009, MEDLINE (1950 to July week 5, 2009), EMBASE (1980 to week 32, 2009) and we also searched the related articles feature of PubMed and the Web of Science. We also checked the reference lists of articles. For this update, the searches were re-run in June 2012: MEDLINE 2009 to June week 2, 2012, EMBASE 2009 to 2012 week 24, CENTRAL Issue 6, 2012, Cochrane Gynaecological Specialised Register June 2012.

SELECTION CRITERIA

Studies of treatment of patients with early AC of the uterine cervix were included. Treatment included surgery, surgery followed by radiotherapy, radiotherapy and chemoradiation.

DATA COLLECTION AND ANALYSIS

Forty-three studies were selected by the search strategy and 30 studies were excluded. Twelve studies were considered for inclusion. Except for one randomised controlled trial (RCT), all other studies were retrospective cohort studies with variable methodological quality and had limitations of a retrospective study. Comparing the results from these retrospective studies was not possible due to diverging treatment strategies.

MAIN RESULTS

Analysis of a subgroup of one RCT showed that surgery for early cervical AC was better than radiotherapy. However, the majority of operated patients required adjuvant radiotherapy, which is associated with greater morbidity. Furthermore, the radiotherapy in this study was not optimal, and surgery was not compared to chemoradiation, which is currently recommended in most centres. Finally, modern imaging techniques (i.e. magnetic resonance imaging (MRI) and positive emission tomography - computed tomography (PET-CT) scanning) allow better selection of patients and node-negative patients can now be more easily identified for surgery, thereby reducing the risk of 'double trouble' caused by surgery and adjuvant radiotherapy.  

AUTHORS' CONCLUSIONS

We recommend surgery for early-stage AC of the uterine cervix in carefully staged patients. Primary chemoradiation remains a second best alternative for patients unfit for surgery; chemoradiation is probably first choice in patients with (MRI or PET-CT-suspected) positive lymph nodes. Since the last version of this review no new studies were found.

Histological correlation of glandular abnormalities in cervical liquid-based cytology

Conventional Papanicolaou smear method is still commonly used for cervical cancer screening in Japan, despite the liquid-based cytology (LBC) that has become a global tendency in the world recently. One of the obstacles in the way of popularization of this method seems to be the confusion as to diagnosis upon cervical glandular lesions. We performed comparison study between LBC and conventional Papanicolaou smear about cytological diagnosis using split-sample method in 4522 patients. In 13 cases analyses, which were reported with either AGC or adenocarcinoma by either method, LBC tends to be milder than that by conventional smear, however, the credibility of LBC is considered to be near to that of conventional smear with regard to screening for glandular abnormalities. These results indicate that cervical cancer screening should shift to LBC under the enough experience and appropriate dealing with the cytological diagnosis.

Outcomes after radical hysterectomy in patients with early-stage adenocarcinoma of uterine cervix

Background:

To determine the prognostic factors and treatment outcomes of patients with early-stage adenocarcinoma (AdCa) of uterine cervix who underwent radical hysterectomy (RH).

Methods:

Patients with early-stage squamous cell carcinoma (SCCa) of the uterine cervix who underwent RH were compared with patients with AdCa by multivariate analysis.

Results:

A total of 1218 patients were eligible, of which 996 (81.8%) had SCCa and 222 (18.2%) had AdCa. In multivariate analysis, parametrial involvement and lymph node metastasis were significant factors for both recurrence-free survival(RFS) and overall survival (OS) of patients with AdCa, whereas age, tumour size, parametrial involvement and lymph node metastasis were significant factors for both RFS and OS of patients with SCCa. After adjusting for significant prognostic factors, patients with AdCa had significantly poorer RFS (odds ratio (OR)=2.07, 95% confidence interval (CI)=1.37–3.12, P=0.001) and OS (OR=2.56, 95% CI=1.65–3.96, P<0.001) than patients with SCCa. Recurrence outside the pelvis was more frequent in AdCa than in those with SCCa (75 vs 57.8%, P=0.084).

Conclusion(s):

Although RH is still acceptable for treatment of patients with AdCa, a more effective systemic adjuvant therapy is required.

Primary surgery versus primary radiation therapy with or without chemotherapy for early adenocarcinoma of the uterine cervix

BACKGROUND

For early squamous cell carcinoma of the uterine cervix, the outcome is similar after either primary surgery or primary radiotherapy. There are reports that this is not the case for early adenocarcinoma (AC) of the uterine cervix: some studies have reported that the outcome is better after primary surgery. There are no systematic reviews about surgery versus chemoradiation in the treatment of cervical cancer.

OBJECTIVES

The objectives of this review were to compare the effectiveness and safety of primary surgery for early stage AC of the uterine cervix with primary radiotherapy or chemoradiation.

SEARCH STRATEGY

We searched Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2009, MEDLINE (1950 to July week 5, 2009), EMBASE (1980 to week 32, 2009) and we also searched the related articles feature of PubMed and the Web of Science. We also checked the reference lists of articles.

SELECTION CRITERIA

Studies of treatment of patients with early AC of the uterine cervix were included. Treatment included surgery, surgery followed by radiotherapy, radiotherapy and chemoradiation.

DATA COLLECTION AND ANALYSIS

Forty-three studies were selected by the search strategy and thirty studies were excluded. Twelve studies were considered for inclusion. Except for one randomised controlled trial (RCT), all other studies were retrospective cohort studies with variable methodological quality and had limitations of a retrospective study. Comparing the results from these retrospective studies was not possible due to diverging treatment strategies.

MAIN RESULTS

Analysis of a subgroup of one RCT showed that surgery for early cervical AC was better than RT. However, the majority of operated patients required adjuvant radiotherapy, which is associated with greater morbidity. Furthermore, the radiotherapy in this study was not optimal, and surgery was not compared to chemoradiation, which is currently recommended in most centres. Finally, modern imaging techniques, i.e. MR-imaging and PET-CT-scanning, allow better selection of patients and node negative patients can now be more easily identified for surgery, there by reducing the risk of 'double trouble' caused by surgery and adjuvant radiotherapy.

AUTHORS' CONCLUSIONS

We recommend surgery for early stage AC of the uterine cervix in carefully staged patients. Primary chemoradiation remains a second best alternative for patients unfit for surgery; chemoradiation is probably first choice in patients with (MRI or PET-CT-suspected) positive lymph nodes.

The abnormal glandular smear: cytologic prediction, colposcopic correlation and clinical management

We reviewed recent cytological reporting of abnormal glandular cells on cervical smears in order to assess the predictive value of these reports and the contribution of colposcopy in the assessment of these abnormalities. The study consisted of a 5-year retrospective review of the clinical management of 80 women with abnormal glandular cells on a cervical smear, with clinical and histopathological data available for review in the interval 1992-1996. There were two groups of women: (i) those referred with gynaecological symptoms and (ii) those with screen detected abnormalities who were asymptomatic and significantly younger than the first group. The predictive value of a glandular smear for malignancy was 42.5% and for premalignancy 28.8%. The most common lesions detected were cervical intraepithelial neoplasia (CIN) (13), endometrial cancer (13), cervical adenocarcinoma (10) and cervical intraepithelial glandular neoplasia (CIGN) (8). Four cases of endometrial carcinoma presented through screening. In the remainder a variety of benign conditions were identified as responsible for the abnormal smear. Failure to find an explanation for the abnormal smear only occurred in 8.8%. In developing a protocol for abnormal glandular smears, our observations indicate that: (a) those with abnormal bleeding require endometrial sampling; (b) for those with screen detected abnormality, colposcopy is valuable as it is a sensitive predictor of early invasion and can predict glandular abnormality; (c)diseases of the entire genital tract, non-gynaecological viscera and metastatic cancer can generate cytological abnormality; (d) screen detected borderline abnormality in endocervical cells is associated with CIN III.

Association d'un adénocarcinome du col de type endométrioïde à un cystadénocarcinome mucineux de l'ovaire

The authors report the case of a 40-year-old woman, who was operated for an ovarian mucinous cystadenocarcinoma. The pathologic findings of the hysterectomy specimen with bilateral salpingoophorectomy showed an ovarian mucinous cystadenocarcinoma associated with an endometrioid adenocarcinoma of the uterine cervix. The mucinous cystadenocarcinoma represents the third most common type of ovarian carcinoma. In the literature, this tumor had been found in association with endocervical adenocarcinoma or with minimal deviation adenocarcinoma (adenoma malignum) of the uterine cervix. However, its association with an endometrioid adenocarcinoma, to our knowledge, has not been reported.

Prognostic factors and clinicopathologic characteristics of invasive adenocarcinoma of the uterine cervix

OBJECTIVE

The purpose of this study was to evaluate the outcome of patients with cervical adenocarcinoma and to determine the characteristics and the prognostic factors of this entity.

STUDY DESIGN

This retrospective study was done in the Department of Surgical Oncology of the Salah Azaiz Institute of Tunis with 79 cases of invasive adenocarcinoma of the uterine cervix that were collected from 1990 to 1999. Survival was analyzed according to the Kaplan-Meier method. Univariate analysis of prognostic factors was performed with the test of log rank. Cox regression model was used in multivariate analysis of prognostic factors.

RESULTS

Mean age was 50 years, and metrorrhagia was mostly revealing in 73% of the cases. Early stages (I, IIa, IIb with 1/3 proximal parametrial invasion) and "pure" type adenocarcinoma were found in 78% and 87% of the cases, respectively. Treatment consisted of a radiosurgical combination in 52 cases; exclusive radiotherapy was practiced with 17 patients. The 5 year-overall and disease-free survival percentages were, respectively, 68% and 72.4%. Poor prognostic factors were age >50 years, tumor size >4 cm, advanced stage, tumor grade, and lymph nodes and lymph-vascular space involvement. With the use of multivariate analysis, only stage and lymph node metastases remained significant prognostic factors.

CONCLUSION

This report shows survival and prognostic factors that are similar to those found in previous studies, but unlike the Western countries, our results demonstrate a high rate of early stages and no increase in frequency of cervical adenocarcinoma.

Cytological study of early cervical adenocarcinoma: special reference to the depth of invasion

OBJECTIVE

Early cervical adenocarcinoma (ECA) with a tumour depth of <3 mm has a good prognosis. To clarify the cytological features of ECAs with depth <3 mm, these were compared with those of ECA with 3-5 mm and invasive adenocarcinoma (IA) invading the cervical wall with more than 5 mm in depth.

METHODS

The cervical cytological features of ECAs with depth <3 mm (14 cases) were compared with those of ECA with 3-5 mm (four cases) and IA (13 cases). Cytologically, the presence or absence of tumour diathesis, number of atypical cells, crowded cell groups, groups with glandular structures, feathering, groups with palisading borders, rosettes, clusters, cell shape and size, nuclear shape and size, nucleolar shape and size, chromatin distribution, border and character of cytoplasm, and single cell pattern were evaluated.

RESULTS

A tumour diathesis was seen in five of 14 ECA <3 mm in depth (36%), all four ECA with 3-5 mm (100%) and 11 of 13 IA with more than 5 mm (85%). Single cells, macronucleoli and coarsely granular chromatin pattern were less frequent in ECA of <3 mm than that in ECA with 3-5 mm and IA. The number of atypical cells and glandular structures in ECA was significantly less than that in IA. Cell crowding, feathering, palisading and rosettes were common in both ECA and IA.

CONCLUSION

The characteristic cytological features of ECA with depth <3 mm, having a good prognosis, were clean background, fewer single cells and macronucleoli, and less frequent coarsely granular chromatin pattern compared with those in ECA with 3-5 mm and IA. The number of atypical cells and glandular structures in ECA was significantly less than that in IA. Familiarity with the cytological features of ECA and its mimics is essential.

Geographic disparities in cervical cancer mortality: what are the roles of risk factor prevalence, screening, and use of recommended treatment?

CONTEXT

Despite advances in early detection and prevention of cervical cancer, women living in rural areas, and particularly in Appalachia, the rural South, the Texas/Mexico border, and the central valley of California, have had consistently higher rates of cervical cancer mortality than their counterparts in other areas during the past several decades.

METHODS

This paper reviews the published literature from 1966 to July 2002 to assess three potential pathways underlying this excess mortality--high human papilloma virus (HPV) prevalence, lack of or infrequent screening and advanced disease at diagnosis, and under-use of recommended treatment and shorter survival.

FINDINGS

Living in rural areas may impose barriers to cervical cancer control, including lack of transportation and medical care infrastructures. Population characteristics that place women at greater risk for developing and dying from cervical cancer, such as low income, lack of health insurance, and physician availability, are concentrated in rural areas. Published data, however, are insufficient to identify the key reasons for the observed mortality patterns.

CONCLUSIONS

At this time, given the lack of definitive evidence in the published literature, decisions about priorities in areas with high rates of cervical cancer mortality will depend on knowledge of current levels of screening, incidence, and stage distribution; and service delivery infrastructures, resources, and acceptability of interventions to the target population.

Differential cyclooxygenase-2 expression in squamous cell carcinoma and adenocarcinoma of the uterine cervix

PURPOSE

To determine the differential expression of cyclooxygenase-2 (COX-2) in patients with squamous cell carcinoma (SCC) and adenocarcinoma (ADC) of the uterine cervix and the prognostic significance of COX-2 expression in these histologic types.

METHODS AND MATERIALS

A total of 105 International Federation of Gynecology and Obstetrics Stage IIB uterine cervical cancer patients were screened for COX-2 expression immunohistochemically. COX-2 expression was determined in invasive cervical SCC (n = 84) and invasive cervical ADC (n = 21). To determine the clinical significance of COX-2 expression by histologic type, the patients were arbitrarily divided into four groups: SCC/COX-2 negative (n = 64); SCC/COX-2 positive (n = 20); ADC/COX-2 negative (n = 9); and ADC/COX-2 positive (n = 12). The clinical response to treatment, patterns of treatment failure, and survival data by COX-2 expression were compared for these two major histologic types. Univariate and multivariate analyses were performed to identify the prognostic factors influencing survival.

RESULTS

Immunohistochemical examination showed that COX-2 expression was more frequently observed in ADC than in SCC (57% vs. 24%, p = 0.007). Moreover, COX-2 expression was an important predictor of treatment response, irrespective of the histologic type. All COX-2-negative patients achieved complete remission after initial treatment; 17% of SCC patients and 33% of ADC patients with COX-2 expression did not have complete remission after the initial treatment. The incidence of local failure for those with COX-2 expression was significantly greater than for COX-2-negative patients, regardless of histologic type. With a minimal follow-up of 60 months, the overall 5-year actuarial survival rate for SCC and ADC patients was 79% and 62%, respectively (p = 0.05). The 5-year disease-free survival rate for SCC and ADC patients was 73% and 56%, respectively (p = 0.13). Irrespective of the pathologic type, COX-2-positive patients had an unfavorable prognosis. The overall 5-year actuarial survival rate was 57% for COX-2-positive patients and 83% for COX-2-negative patients (p = 0.001). When patients were stratified into the four groups according to histologic type and COX-2 expression status, ADC/COX-2-positive patients had the worst prognosis, with an overall 5-year actuarial survival rate of 49% compared with 78% for ADC/COX-2-negative patients, 62% for SCC/COX-2-positive, and 84% for SCC/COX-2-negative patients (p = 0.007, log-rank test). Irrespective of histologic type, COX-2 expression was an independent prognostic factor by univariate and multivariate analyses.

CONCLUSION

In uterine cervical cancer, COX-2 was expressed in a greater proportion of ADC patients than SCC patients. COX-2 expression was also identified as a major determiner of a poor response to treatment and of an unfavorable prognosis, irrespective of the histologic type, reflecting the importance of the COX-2 protein in the acquisition of biologic aggressiveness and more malignant phenotype or increased resistance to the standard chemotherapy and radiotherapy in both histologic types. Given these observations, we believe that that ADC/COX-2-positive patients might be appropriate candidates for future trials of selective COX-2 inhibitor adjunctive therapy.

Severe cervical glandular cell lesions and severe cervical combined lesions

BACKGROUND

The purpose of the current study was to determine the accuracy of routinely screened cervical smears to predict a glandular cell lesion in histologically confirmed cases of cervical adenocarcinoma in situ (AIS), invasive adenocarcinoma (ADCA), adenosquamous carcinoma (ADSQCA), and severe combined glandular and squamous cell lesions.

METHODS

Between 1989-2000, a total of 1,141 women with a histologic diagnosis of cervical AIS, ADCA, ADSQCA, and combined lesions (glandular cell lesion with a coexistent squamous cell lesion) were registered in the Dutch National Pathology Archive (PALGA). In 1054 of these 1,141 histologic cases, an additional conventional Papanicolaou (Pap) smear diagnosis was registered from the same patient. Material was evaluated with regard to the accuracy of cytologic diagnosis, the percentage of combined lesions, the mean age of the patients, and the time interval between AIS and ADCA.

RESULTS

Of 1,141 registered histologic cases, 57.5% were registered as having an "intraepithelial" lesion, whereas 42.5% were registered as having an "invasive" process. A combined process was diagnosed in 63.2% of cases. From the same patients, a cytologic diagnosis of a severe cervical epithelial lesion was registered in PALGA for 91.2% (n = 961) of 1054 cases. A cytologic registration of a severe glandular cell lesion (with or without a squamous cell component) was made in 547 cases (51.9%). Prediction of a severe glandular cell lesion on the Pap smear was found to be more accurate in cases of histologically confirmed pure glandular cell abnormalities than in cases with a histologic diagnosis of a combined lesion. The cytologic prediction was found to be correct in 75.2% of cases of pure AIS and 47.3% of cases of AIS with coexistent high-grade squamous intraepithelial lesion (HGSIL) (cervical intraepithelial lesion [CIN] type 2 [CIN 2] or CIN 3). The mean ages of the patients with AIS and AIS + HGSIL were 37.3 years and 34 years, respectively, whereas the mean age of the patients with ADCA and ADCA + HGSIL was 41.9 years and 38.1 years, respectively. The interval between the average ages of patients with AIS and ADCA and those with AIS + HGSIL and ADCA + HGSIL was 4.6 years and 4.1 years, respectively.

CONCLUSIONS

On the basis of a data search of the PALGA registry, it can be concluded that in a relatively large number of cases a severe cervical glandular cell lesion was not diagnosed on the Pap smear. Furthermore, data demonstrated that the prediction of a glandular abnormality is less accurate in cases of combined squamoglandular cell lesions than in pure glandular cell lesions.

A comparison of prognoses of FIGO stage IB adenocarcinoma and squamous cell carcinoma

OBJECTIVES

The objective of this study was to compare clinical and pathologic variables and prognosis of FIGO stage IB adenocarcinoma and squamous cell carcinoma of uterine cervix.

METHODS

A retrospective review was performed of 521 patients with stage IB squamous cell carcinoma and adenocarcinoma of cervix who treated primarily by type 3 hysterectomy and pelvic and/or para-aortic lymphadenectomy at Hacettepe University Hospitals between 1980 and 1997.

RESULTS

Age, tumor size, grade, depth of invasion, lymph node metastasis, parametrial, vaginal, and lymphvascular space involvement (LVSI) were not different between two cell types except number of the lymph nodes involved. Metastasis to three or more lymph nodes was significantly higher in adenocarcinoma. Overall and disease-free survival were 87.7%, 84.0% versus 86.4%, 83.1% for squamous cell carcinoma and adenocarcinoma, respectively (P > 0.05). The rate and site of recurrence were not different between two cell types. Multivariate analysis of disease-free and overall survival revealed independent prognostic factors as tumor size, LVSI, number of involved lymph node, and vaginal involvement.

CONCLUSION

Prognosis of FIGO stage IB cervical cancer patients who were treated by primarily radical surgery was found to be same for those with adenocarcinoma and squamous cell carcinoma.

Adenocarcinoma of the uterine cervix: the presence of human papillomavirus and the method of detection

BACKGROUND

Effective screening programs have contributed to a decrease in the incidence of cervical squamous cell carcinomas but have had a limited sensitivity in the detection of adenocarcinoma precursor lesions. The aim of our study was to analyze cervical adenocarcinoma in greater detail: symptoms preceding the detection, the method of detection and the prevalence of human papillomavirus (HPV) with respect to age at diagnosis.

MATERIAL AND METHODS

Clinical data were abstracted from the medical records of 82 women with pure invasive cervical adenocarcinomas. As diagnostic tools we used polymerase chain reaction (PCR)-based single-strand conformation polymorphism (SSCP) and/or direct DNA sequencing for HPV detection.

RESULTS

Age at diagnosis predicting factors were HPV status, positive lymph nodes, histology and stage. HPV-negativity, lymph node metastases, advanced stage and poor differentiation were all associated with a high diagnostic age. In the multivariate analysis only HPV status was shown to have an independent impact on age at diagnosis, while stage showed only borderline significance. Twenty-three percent of the cancers were detected by screening and the remaining were due to different symptoms. Among the women considered, 93% had a normal Papanicolaou (Pap) smear 3 years before diagnosis and 60% within 1 year. There was no significant correlation between smoking, oral contraceptives and HPV-positivity.

CONCLUSIONS

The absence of HPV was significantly associated with a high age at diagnosis. Pap screening had a limited effect in detecting adenocarcinoma at an early stage.

The significance of p53 codon 72 polymorphism for the development of cervical adenocarcinomas

Infection with the human papillomavirus is an important co-factor in the development of cervical carcinomas. Accordingly, HPV DNA is recognised in most of these tumours. Polymorphism of the p53 gene, codon 72, is also considered a risk factor in the development of cervical carcinoma. However, this finding is contradicted by several observers. In the present investigation, 111 cases of adenocarcinoma of the cervix collected through the Swedish Cancer Registry and 188 controls (females with normal cytology at organised gynaecological screening) were analysed with regard to p53, codon 72, polymorphism using a PCR- and SSCP-based technique. In the controls, 9% showed pro/pro, 44% pro/arg and 47% arg/arg, whereas in the invasive adenocarcinomas, the corresponding figures were 0%, 29% and 71%, respectively. The difference was statistically significant (P = 0.001). HPV DNA was identified in 86 tumours (HPV 18 in 48, HPV 16 in 31 and HPV of unknown type in 7 cases) and 25 tumours were HPV negative. The p53, codon 72, genotypes observed in HPV-positive and HPV-negative cervical adenocarcinomas were not statistically different (P = 0.690). The results indicate that women homozygotic for arg/arg in codon 72 of the p53 gene are at an increased risk for the development of cervical adenocarcinomas. However, this genetic disposition seems to be unrelated to the HPV infection.

Adenocarcinoma of the uterine cervix compared with squamous cell carcinoma: a 12-year study in Southampton and South-west Hampshire

In a 12-year study of the population of Southampton and South-west Hampshire (SSWH), there was no rise or fall in the incidence of adenocarcinoma of the uterine cervix, although the incidence of squamous cell carcinoma fell from 14 to 7.2 per 100000 women years and the overall fall in age-adjusted incidence of cervical carcinoma was commensurate with that of England and Wales. The majority (59%) of adenocarcinomas were seen in women aged less than 50, supporting the concept of a higher risk in young women. Screen-detected carcinomas accounted for 50% of adenocarcinomas and 41% of squamous cell carcinomas in women aged 20-64 (the difference was not significant). There were more screen-detected adenocarcinomas of less than 3 mm depth of invasion and 7 mm lateral extension during the third period of the study (1991-1993). The results are consistent with reports of an increased risk of cervical cancer in women born since 1940, and lesser effectiveness of screening in preventing adenocarcinoma compared with squamous cell carcinoma. High prevalence of early screen-detected carcinomas may have been a factor in recent reports of increased incidence of adenocarcinoma.

The role of human papillomavirus in cervical adenocarcinoma carcinogenesis

Human papillomavirus (HPV) is considered the single most important co-factor in the development of cervical squamous cell carcinomas. Adenocarcinomas of the cervix are also related to HPV, but the correlation is reported to be less pronounced. In the present study, 131 cervical adenocarcinomas were identified through the Swedish Cancer Registry, examined morphologically and then analysed with sensitive polymerase chain reaction (PCR)-based HPV methods for a study of age-related prevalence of HPV. HPV was identified in 64% of the tumours after PCR amplification of the HPV L1 gene only and in 71% following PCR amplification of both the L1 and E6 genes of HPV. HPV 18 was the most prevalent (52%), followed by HPV 16 (33%) and other types of HPV (15%). The prevalence of HPV was shown to be age-dependent. In women younger than 40 years, HPV was present in 89%, whereas in women 60 years and older, HPV was observed in only 43%. The difference was statistically significant, P<0.005. The HPV-positive adenocarcinomas were represented by an age distribution similar to that of cervical squamous carcinomas with a maximum age, in the 40-49 year old group, whereas the frequency of HPV-negative adenocarcinomas increased with age, typical of most carcinomas occurring in elderly women.

A comparison of prognoses of pathologic stage Ib adenocarcinoma and squamous cell carcinoma of the uterine cervix

OBJECTIVES

The influence of the histology of adenocarcinoma on recurrence and survival for patients treated with radical hysterectomy and diagnosed as having pathologic stage Ib cervical cancer was investigated.

METHODS

Five hundred and nine patients (405 squamous cell carcinomas, 104 adenocarcinomas) with pathologic stage Ib cervical cancer treated initially at the Aichi Cancer Center between 1976 and 1995 were studied.

RESULTS

Multivariate analysis identified the prognostic variables as histology of adenocarcinoma, number of lymph nodes involved, and tumor size beyond 4 cm. Five-year overall survival and disease-free survival of patients with adenocarcinoma in the presence of lymph node metastasis were 63.2 and 47.4%, respectively, significantly poorer than for squamous cell carcinoma (83.6 and 80.6%; P < 0.001 and P = 0.002, respectively). These were not different in the absence of lymph node metastasis (adenocarcinoma, 93.9 and 92.7%; squamous cell carcinoma, 97.9% and 96.1%; P = 0.067 and P = 0.250, respectively).

CONCLUSIONS

The independent significant risk factors for the recurrence and survival of pathologic stage Ib cervical cancer were the presence of lymph node metastasis, large tumor size beyond 4 cm, and histology of adenocarcinoma. The prognosis of patients with adenocarcinoma was poorer than of patients with squamous cell carcinoma in the presence of lymph node metastasis, while the prognosis of pathologic stage Ib cervical cancer was equivalent when there was no metastasis.

Overall 5-year survival rate and prognostic factors in patients with stage IB and IIA cervical cancer treated by radical hysterectomy and pelvic lymph node dissection

The objective of this paper was to analyze the 5-year survival rate and prognostic factors for stage Ib and IIa cervical cancer treated by radical hysterectomy. A total of 366 patients with invasive cervical cancer treated by radical hysterectomy from June 1985 to June 1994 at Chonnam National University Hospital, Kwangju, Korea were retrospectively analyzed. Survival analysis was performed using the Kaplan-Meier estimator. Multivariate analysis was performed using the Cox proportional hazards regression model. The overall 5-year survival rate was 92% in stage Ib and 87% in stage IIa. Factors assessed for prognostic value included age, FIGO stage, cell type, tumor size, depth of invasion, lymphovascular space invasion (LVSI), and pelvic lymph node metastases (LNM). In the multivariate analysis, age, cell type, and lymph node metastases were independent predictors of survival. Lower survival was associated with age greater than 50 years, adenocarcinoma, and presence of lymph node metastases. The higher survival rates in patients with single lymph node involvement or lymph node metastases below the level of the common iliac nodes (85 and 84.6%, respectively) versus multiple or extrapelvic lymph node metastases (50 and 20%, respectively) were statistically significant (P < 0.01). In conclusion, patients who had lymph node metastases, adenocarcinoma, and were older than 50 years had a poorer survival rate. Such patients require more intense postoperative treatment and closer surveillance. Low-risk patients with a single lymph node metastasis below the level of the common iliac nodes may benefit from thorough lymphadenectomy without adjuvant therapy to prevent unpleasant complications.

High-risk group in node-positive patients with stage IB, IIA, and IIB cervical carcinoma after radical hysterectomy and postoperative pelvic irradiation

OBJECTIVE

The goal of this study was to identify risk factors in patients with node-positive stage IB, IIA, and IIB cervical carcinoma after radical hysterectomy with pelvic lymph node dissection and postoperative irradiation.

METHODS

Two hundred forty-two patients with FIGO stage IB, IIA, and IIB cervical carcinoma underwent radical hysterectomy with pelvic lymph node dissection; pathological analysis of the surgical specimen showed positive lymph nodes in 59 patients. These 59 patients were further treated with postoperative radiotherapy. Eighteen patients were in stage IB, 4 in stage IIA, and 37 in stage IIB. Histological tumor type, tumor size, lymph-vascular space invasion, parametrium infiltration, number of positive nodes, and involvement of common iliac nodes were assessed for correlation with cancer recurrence.

RESULTS

When all these variables were assessed in the Cox proportional regression analysis, parametrium infiltration (P = 0. 0199) and number of positive nodes (two or more nodes) (P = 0.0483) revealed the factor correlating significantly with disease-specific survival. Based on these two factors, node-positive patients could be divided into low-risk (n = 11), intermediate-risk (n = 29), and high-risk (n = 19) groups. The 5-year disease-specific survival for the low-risk group was 100% which was significantly better than the 39.1% for the high-risk group (P = 0.0012).

CONCLUSION

For patients in the high-risk group, it may be worthwhile to consider new strategies to improve survival.

Expression of MN/CA9 protein in Papanicolaou smears containing atypical glandular cells of undetermined significance is a diagnostic biomarker of cervical dysplasia and neoplasia

BACKGROUND

Despite the enormous impact that Papanicolaou (Pap) smear screening has had on the incidence of cervical carcinoma in developed countries, there is still an unacceptably high frequency of occurrence of this cancer. In part, this is due to human error associated with cytologic diagnoses of Pap smears. Also, the use of new sampling devices, such as the cytobrush, has increased the complexity of diagnosing benign and neoplastic cervical cytology. This is particularly apparent in the diagnosis of atypical glandular cells of undetermined significance (AGUS). Approximately 40% of AGUS diagnoses have a corresponding significant lesion at biopsy follow-up, and 60% do not. There is clearly a need for an adjunct to cytologic diagnosis that can readily identify AGUS smears that are diagnostic of significant lesions. The authors have identified the MN/CA9 antigen as a strong candidate for an adjunct biomarker.

METHODS

A total of 245 Pap smears of all AGUS diagnostic categories with histologic confirmation were studied. The median age of the patients was 39 years. The Bethesda system classification (AGUS-favor reactive, AGUS-not otherwise specified, and AGUS-favor neoplastic) was used. All of the Pap smears were decolorized and immunostained with monoclonal antibody to MN/CA9 antigen by the immunoperoxidase technique. The results of MN/CA9 immunoreactivity were correlated with the histologic data in a semiblinded fashion.

RESULTS

The follow-up biopsies showed that a high percentage (70%) of patients had low and high grade cervical intraepithelial neoplasia lesions, respectively (CIN I and CIN II or III). Clinically significant lesions-adenocarcinoma in situ/carcinoma (AIS/CA) and CIN II or III-were found in 50% of the cases. Among these, 11% were AIS/CA. In the three subcategories of AGUS diagnosis, the AGUS-not otherwise specified showed the broadest range of lesions in the follow-up biopsies. Three patterns of MN/CA9 immunoreactivity were observed in the Pap smears: 1) atypical cells, 2) normal endocervical cells only, and 3) all cells negative. All Pap smears that were MN/CA9 positive were histologically confirmed to be clinically significant lesions or CIN I; in addition, there were a very small number (n = 12) of cases of atypia. None of the benign lesions showed MN/CA9 expression in the corresponding Pap smears. Furthermore, the pattern of atypical cell immunostaining identified all cases with significant lesions (AIS/CA and CIN II or III) in the cervices. Conversely, the majority of CIN I cases (82%) and all cases of atypia showed positive immunostaining restricted to normal endocervical cells only.

CONCLUSIONS

There is a clear association between MN/CA9 immunostaining of atypical cells and the presence of significant lesions in the cervix. Similarly, there is a clear association between lack of expression of MN/CA9 and the absence of cervical lesions. However, the screen does not allow discrimination between CIN I and atypia. The authors also found that, based on the combined patterns of morphology and immunostaining, they are able to discriminate between AIS and CIN II or III in AGUS Pap smear diagnoses. Thus, expression of the MN/CA9 antigen is indeed a discriminator of significant lesions in AGUS Pap smear diagnoses.

Development of a scale to measure psychosocial concerns of Mexican women with advanced cancer

This descriptive study was undertaken to explore the perceptions and attitudes of 143 women (mean age+/-51) with advanced cancer. Outcome measures were the Perceptions and Attitudes Scale (PAS), a 65-item instrument validated as part of the study, and the Karnofsky Performance Status Scale. Internal consistency (Cronbach alpha) and factor analytic techniques (principal component and orthogonal rotation) were performed. The scale has an internal consistency of 0. 79. Factor analysis revealed six factors which explained 39.6% of the variance (1) loneliness; (2) family and social sphere; (3) limitations and dependence conditions; (4) perceptions about their lives; 5) perceptions about their health and pain; and (6) perceptions of pain and anguish. These results point out the necessity of a multivariate approach to women with advanced cancer.

Neuroendocrine signet ring cell adenocarcinoma of the endocervix

Signet ring cell morphology in mixed carcinoma of the uterine cervix is not uncommon. It is rare for such morphology to predominate, however, and there are no reported cases of a signet ring cell adenocarcinoma (SRCA) of the endocervix with neuroendocrine differentiation. A 53-year-old woman presented with abnormal perimenopausal bleeding, and uterine curettings revealed a signet ring cell carcinoma. After clinical evaluation to eliminate a metastasis from an extra-uterine primary, the patient underwent surgical therapy and staging, and was treated with postoperative adjuvant chemoradiation. Pathologic evaluation found the tumor to arise from the endocervix and to be of predominant signet ring cell morphology. Immunohistochemical staining revealed that the tumor exhibited neuroendocrine differentiation and helped confirm its endocervical origin. The patient remains without evidence of disease 6 months after primary therapy. This is the first case report of endocervical SRCA with neuroendocrine differentiation (SRCA with features of carcinoid tumor). Discussion of this entity is provided.

Trends in cancer of the cervix uteri in Sweden following cytological screening

Trends in cervical cancer incidence following the introduction of screening have mostly been studied using cross-sectional data and not analysed separately for squamous cell cancer and adenocarcinomas. Using Swedish nationwide data on incidence and mortality, we analysed trends during more than 3 decades and fitted Poisson-based age-period-cohort models, and also investigated whether screening has reduced the incidence of adenocarcinomas of the cervix. The incidence of reported cancer in situ increased rapidly during 1958-1967. Incidence rates of squamous cell cancer, fairly stable before 1968, decreased thereafter by 4-6% yearly in women aged 40-64, with a much smaller magnitude in younger and older women. An age-cohort model indicated a stable 70-75% reduction in incidence for women born 1940 and later compared with those born around 1923. The incidence of adenocarcinomas doubled during the 35-year study period. The mortality rate increased by 3.6% before 1968 and decreased by 4.0% yearly thereafter. Although a combination of organized and opportunistic screening can reduce the incidence of squamous cell cancer substantially, the incidence of adenocarcinomas appears uninfluenced by screening.

Prognostic factors of adenocarcinoma of the uterine cervix

OBJECTIVE

The prognostic importance of adenocarcinoma of the uterine cervix was investigated. Methods. One hundred ninety-three patients (144 had stage I disease, 41 stage II, and 8 stage III-IV) with invasive adenocarcinoma of the uterine cervix treated initially at the Aichi Cancer Center between 1964 and 1995 were studied.

RESULTS

Of all the invasive cervical cancers, 8.8% were adenocarcinomas that had been increasing during the past decade. The overall 5-year survival for stage I was 88.8%, stage II 44.9%, and stage III-IV 0% In univariate analysis, the clinicopathological factors associated with overall survival and disease-free survival were age of patient, stage of disease, presence of nodal metastasis, number of lymph nodes involved, lymph-vascular space invasion, tumor size, and intraperitoneal metastasis. Multivariate analysis performed in all cases identified the clinical stage of disease, the presence of nodal metastasis, number of lymph nodes involved, lymph-vascular space invasion, and tumor size as the independent risk factors for recurrence and survival. In the analysis of stage I disease, lymph node metastasis and tumor size were the significant prognostic factors, while lymph-vascular space invasion and tumor size were the factors in advanced disease. Tumor grade and histological type were not associated with recurrence and survival.

CONCLUSION

These results suggested the association of lymph node metastasis with the prognosis of early stage adenocarcinoma of the uterine cervix and lymph-vascular space invasion with the advanced stage. Tumor size was an independent risk factor throughout all stages.

Survival of patients with adenocarcinoma of the uterine cervix in western Sweden

Survival in adenocarcinoma of the uterine cervix varies between different reports. In our study the patients have been treated in a similar way as those with squamous cell carcinoma. One hundred twenty-one adenocarcinomas were diagnosed between 1987 and 1994 in the West Sweden Health Care Region. One hundred of the patients with adenocarcinoma were treated at Sahlgrenska University Hospital and studied retrospectively. The median age was 54 years (range 27-91). Histopathologic differentiation was relatively evenly distributed between well (34%), intermediately (38%), and poorly differentiated (28%). All FIGO stages were represented, but stage I predominated (65%). Depending mainly on tumor stage and age, the patients had either surgery, surgery + radiotherapy, or radiotherapy only. In our study, the five-year survival for adenocarcinoma was 64% and for squamous/adenosquamous carcinoma was 66% (NS). The five-year survival for different stages of adenocarcinomas was for stage I 86%, stage II 38%, stage III 23%, and stage IV 0%, the difference between stage I and stage II being highly significant. Treated in a similar way, the five-year survival for adenocarcinoma is equal to that for squamous/adenosquamous carcinoma in our study.

Are adenocarcinomas and adenosquamous carcinomas different from squamous carcinomas in stage IB and II cervical cancer patients undergoing primary radical surgery?

The aim of this study was to define clinicopathologic features and to investigate prognostic factors in early-stage cervical adenocarcinomas and adenosquamous carcinomas in patients undergoing primary radical surgery. One hundred thirty-four patients with stage IB or II cervical adenocarcinoma or adenosquamous carcinomas treated at a single institution were reviewed and compared to squamous carcinomas (N = 757) treated in the same period. Among adeno-adenosquamous carcinomas, stage II disease, parametrial extension, and deep cervical stromal invasion (>2/3) were associated with increased risk of pelvic lymph node metastases, while only clinical stage II, DNA index >1.3 (by flow cytometry), and pelvic node metastases were significantly associated with decreased survival by multivariate analyses. The five-year recurrence-free and overall survival rates of patients with adeno-adenosquamous vs squamous carcinoma were 72.2% vs 81.2% (P = 0.0109), and 74.1% vs 82.8% (P = 0.0136), respectively by Mantel-Cox test. After controlling confounding factors, histologic type (adeno-adenosquamous vs squamous) was confirmed as an independent prognostic factor for recurrence-free survival [relative risk (RR): 1.2792; 95% confidence interval (CI): 1.0628-1.5399, P = 0.0092) and overall survival (RR: 1.2594, 95% CI: 1.0467-1.5155, P = 0.0146) in the whole series (N = 891). Although pattern of relapse by histologic type was not significantly different, patients with recurrent adeno-adenosquamous carcinoma did significantly worse than those with recurrent squamous carcinoma. In conclusion, the prognosis of adeno-adenosquamous carcinoma of the cervix is slightly worse than squamous tumors. Since salvage of recurrent adeno-adenosquamous carcinoma after primary radical surgery is generally ineffective using conventional treatment, innovative strategies are necessary for the high-risk group after primary surgery and all recurrent adeno-adenosquamous carcinomas regardless of size or site.

Prognostic factors of the uterine cervix adenocarcinoma

BACKGROUND

Prognosis factors for adenocarcinoma of the uterine cervix after primary treatment are poorly established.

METHODS

A retrospective study of 45 cases of adenocarcinoma of the cervix with a follow-up of 96 months on average was performed. The primary treatment consisted in combined radical surgery and radiotherapy for stage I-II patients while patients with advanced disease were treated by radiotherapy. In case of poor prognosis factors, they were given chemotherapy. Survival rates were established and prognosis factors influencing survival and recurrences were studied.

RESULTS

Fifteen women remained alive without evolutive disease. FIGO stage and pelvic node involvement were the most important parameters influencing overall survival. Local failures (27%, average period of 30 months) were unpredictable and led to a dramatic outcome. Histological grade and pelvic node status were significant predictive factors for metastatic recurrence (40%, average period of 29 months).

CONCLUSIONS

Local recurrence and metastatic dissemination of cervical adenocarcinoma after primary treatment prove to be rapidly fatal although life expectancy can be prolonged with adjuvant treatment of the recurrence. In the event of aggressive tumors with high histological grade and pelvic node involvement, an attempt to assess adjuvant systemic chemotherapy could be useful.

Evaluation of immunostaining for MIB1 and nm23 products in uterine cervical adenocarcinoma

In this study, we evaluated whether proliferative activity and metastatic potential are prognostic factors in adenocarcinoma of the cervix. Formalin-fixed, paraffin-embedded sections from 34 patients with cervical adenocarcinoma or adenosquamous carcinoma were immunostained with monoclonal antibody MIB1, expressed in proliferating cells, and anti-nm23 antibody, reacts with metastasis suppression gene products. MIB1 positivity ranged from 0.2 approximately 54.7% with a mean of 21.4%. The level did not differ significantly between various clinicopathological categories. Although patient survival of high or low MIB1 expressing tumor was not significantly different, the disease-free interval of high (> or =25%) expressing tumor was significantly lower than that of low (<25%) expressing tumor. Strong and medium expression for nm23 were detected in 7 (21%) and 3 (9%) of patients. Tumor with strong nm23 expression tended to have a higher relapse rate. Although the survival of strong and weakly nm23 expressing tumor was not significantly different, the disease-free survival of strong nm23 expressing tumor was lower than that of weakly nm23 expressing tumor. MIB1 and nm23 immunostaining might be some of prognostic indicators of recurrence in cervical adenocarcinoma. In cervical adenocarcinoma, the nm23 gene products may not function as metastatic suppression but reflect proliferative activity.

Prognostic factors of primary adenocarcinoma of the uterine cervix

OBJECTIVE

To determine which clinicopathological factors influence the prognosis of cervical adenocarcinoma.

METHODS

Three hundred and two cases of primary adenocarcinoma of the uterine cervix, treated between 1977 and 1994, were studied retrospectively. Clinical data and pathological findings with respect to primary therapy were reviewed and evaluated.

RESULTS

The 5-year survival rates for stages I, II, and III/IV were 75.9, 62.9, and 25.1%, respectively. International Federation of Gynecology and Obstetrics stage (P < 0. 0001), cell type (P = 0.0176), tumor grade (P = 0.023), lymph node status (P = 0.018), and bulky tumor (P = 0.007) were found to be independent factors using the stepwise Cox proportional hazards model. Old age (P = 0.0581), presence of hypertension (P = 0.46), diabetes mellitus (P = 0.18), obesity (P = 0.15), and oral contraceptive use (P = 0.42) were not found to adversely influence survival rates for cervical adenocarcinoma after adjusting for other covariates. Adenosquamous adenocarcinoma had a better prognosis than endocervical columnar cell adenocarcinoma in stages I and II (P = 0. 0235). Also, in cervical adenocarcinoma's early stages, multivariate modeling revealed that chances of survival were significantly better for patients treated by radical surgery than for patients treated by radiation therapy (P < 0.001).

CONCLUSIONS

Survival rates for cervical adenocarcinoma were significantly influenced by stage, histologic subtype, tumor grade, the presence of a positive lymph node, and tumor size. Although a randomized prospective study is needed, our data imply that radical surgery may be considered a better primary modality of treatment than radiation therapy for the early stages of cervical adenocarcinoma. Further, the presence of hypertension, diabetes mellitus, or obesity may not adversely influence survival rates.

PAPNET computer-aided rescreening for detection of benign and malignant glandular elements in cervicovaginal smears: a review of 61 cases

An increasing proportion of the recent cytodiagnostic literature has focused on automation of the Pap smear screening process in hopes of finding a feasible system to aid in the reduction of the number of reported false-negative cases. In a sense, these systems can be thought of as computer-driven sensitivity enhancers for better detection of abnormalities in smeared cervicovaginal specimens. The PAPNET system (Neuromedical Systems, Inc., Suffern, NY) relies on a neural network of artificial-intelligence technology to recognize the complex cellular arrays present in Pap smears, and was originally intended to aid in the identification of morphologically abnormal cells of squamous origin. Herein, we present the results of 61 smears containing a mixture of known diagnostically important benign, dysplastic, and malignant glandular cellular abnormalities which were reviewed by the PAPNET technology. The PAPNET system detected the diagnostic glandular material in 44 of the 45 benign cases reviewed (98% detection rate). In addition, the PAPNET technology identified abnormal cellular material in 15 of the 16 studied smears from patients with malignant/dysplastic morphology (94% detection rate). These data indicate that the PAPNET neural networks are capable of detecting cells with aberrant glandular cytomorphology. In both cases missed by the PAPNET system, the number of abnormal cells per slide was very low, indicating that as with human screeners, the capabilities of this semiautomated method may be exceeded when an extreme paucity of diagnostic cellular material is present in a given slide. Further and larger reviews of glandular abnormalities by automated technologies are needed to assess these systems for their true efficacy at diminishing false-negative cases.

Cervical carcinoma and pregnancy. A national patterns of care study of the American College of Surgeons

BACKGROUND

The American College of Surgeons conducted a national patient care and evaluation study of invasive cervical carcinoma in pregnant patients.

METHODS

Invasive cervical carcinoma was diagnosed in 161 patients who were pregnant at the time of diagnosis. A long term study of 78 patients diagnosed in 1984 was compared with a short term study of 83 patients diagnosed in 1990.

RESULTS

The mean age of the patients was 31.8 years. Clinical stages were: IA (29%); IB (54%); IIA (6%); IIB (4%); IIIA (0%); IIIB (3%); IV (1%; AND IVB 3%). Thirty-one percent of patient were diagnosed in the first trimester, 34% in the second, and 35% in the third. A tumor size of 4 cm or larger in diameter was found in 36% of the patients diagnosed in the first trimester, 40% of the patients diagnosed in the second, and 38% of the patients diagnosed in the third. Patients were treated with surgery alone (86), radiotherapy alone (30), or with combination therapy (45). The overall 5-year survival rate for patients diagnosed in 1984 was 82%. In this group, the 5-year survival rate for patients diagnosed in the first trimester was 94.6%, in the second, 76.9%, and in the third, 68.9%. Comparing the two time periods, surgical therapy was performed more often by gynecologic oncologists in 1990 (69% vs. 42%), and a greater percentage of patients were diagnosed with a tumor size of 4 cm or larger in diameter (43% vs. 26%) as well as with stage IIB-IVB disease (15% vs. 6.7%).

CONCLUSIONS

The prognosis of pregnant patients with invasive cervical carcinoma is similar to that for nonpregnant patients. The significant number of patients diagnosed in the second and third trimesters and the frequent finding of large tumors in all trimesters emphasize the need for patient education and early prenatal evaluation, including cervical cytology and biopsy of any clinically abnormal cervix.

Invasive cervical cancer in Southampton and South West Hampshire: effect of introducing a comprehensive screening programme

A study of invasive cervical cancer in Southampton and South West Hampshire is reported, covering three consecutive three year periods during which the screening coverage increased from an estimated 60% to a recorded 87% of eligible women aged 20-64. From the first to the third periods of the study in that age group registrations of fully invasive squamous cell carcinoma (stage lb and above) fell from 64 to 30 (53%), which was largely counteracted by an increase in microinvasive squamous cell carcinoma (linear trend: P<0.0001). In the same age group registrations of adenocarcinoma rose slightly, which resulted from an increase in the number diagnosed at a depth of invasion of less than 3 mm. There were no significant changes in the numbers of stage III and IV cancers or among cancers in women aged 65 and over. A strong inverse association was found between stage of both histological types of cancer and their likelihood of being screen detected rather than symptomatic: 91% of screen detected cancers were diagnosed at stage I compared with 38% of symptomatic cancers. There was a slight downward trend in the incidence of cancer per 100,000 total female population across the three periods of the study with a significant trend towards low stage disease, which is likely to reduce mortality in years to come. The trend towards screen detected cancers and cancers of less than 3 mm depth of invasion is presented as a positive outcome to be expected in early rounds of increasing the screening coverage.

Patterns of care for invasive cervical cancer. Results of a national survey of 1984 and 1990

BACKGROUND

The American College of Surgeons conducted a national patient care and evaluation study of invasive cervical cancer to measure any changes in patterns of care for the years 1984 and 1990.

METHODS

Hospitals with cancer programs were invited to submit data on up to 25 consecutive patients with newly diagnosed invasive cervical cancer for each of the two study years. Data were obtained from 684 hospitals on 5904 patients diagnosed in 1984 and from 700 hospitals on 5817 patients diagnosed in 1990. A long term study of patients diagnosed in 1984 was compared with a short term study of patients diagnosed in 1990. Survival data were described only for patients diagnosed in 1984.

RESULTS

Of a total of 11,721 patients, 59.4% were diagnosed and treated at the reporting institution in 1984 and 54.8% in 1990. The remaining patients were referred for treatment after diagnosis elsewhere. The diagnosis was established by cervical biopsy for 69.8% of patients, by conization alone for 9.3%, and by both procedures for 11.8%. The histopathologic diagnoses were squamous cell carcinoma (79.8%), adenocarcinoma (15.8%), and other (4.4%). The stage distributions were as follows: IA, 15.9%; IB, 36.8%; IIA, 8.2%; IIB, 15.5%; IIIA, 2.5%; IIIB, 13.3%; IVA, 2.6%; and IVB, 5.2%. The stage was listed as unknown for 20.3% of patients. Patients were treated with surgery alone (29.2%), radiation alone (40.7%), chemotherapy alone (0.7%), or combination therapy (21.5%), and 7.9% received no treatment at the reporting institution. The overall survival for patients diagnosed in 1984 was 68.3%. Survival by stage in this group was as follows: IA, 93.7%; IB, 80.0%; IIA, 67.2%; IIB, 64.7%; III, 37.9%; and IV, 11.3%.

CONCLUSIONS

These data indicate that invasive cervical cancer is highly curable when diagnosed early. During the 5-year period, stage distributions were similar, the use of extended hysterectomy increased, and gynecologic oncologists were more often the primary surgeons. The use of radiation alone decreased.

Is there really a difference in survival of women with squamous cell carcinoma, adenocarcinoma, and adenosquamous cell carcinoma of the cervix?

BACKGROUND

The authors' aim was to assess whether there is a difference in biologic behavior and survival in comparing adenocarcinoma (AdCA), squamous cell carcinoma (SCC), and adenosquamous carcinoma (Ad/SC) of the cervix.

METHODS

Cancer registrars at 703 hospitals submitted anonymous data on 11,157 patients with cervical cancer diagnosed and/or treated in 1984 and 1990 for a Patient Care Evaluation Study of the American College of Surgeons. Among these patients, 9351 (83.8%) had SCC; 1405 (12.6%), AdCA; and 401 (3.6%), Ad/SC cancers. There were no significant changes in percentages of the different histologic types between the study years 1984 and 1990, nor was the patient distribution different regarding age, race/ethnicity, and socioeconomic background for each histologic group. Furthermore, the distribution of patients who had had a hysterectomy did not change between 1984 and 1990.

RESULTS

A larger percent of patients with SCC (63.8%) than those with Ad/SC (59.8%) or AdCA (50.2%) had tumors larger than 3 cm at greatest dimension. Early stage patients (IA, IB, IIA) often were treated by hysterectomy alone (45.5%) or combined with radiation (21.1%). The remaining patients (21.9%) received radiation alone. Of the patients with clinical stage I disease, 7.6% of Ad/CA patients, 15.5% of Ad/SC patients and 12.6% of SCC patients had positive nodes. Although patients with SCC had higher survival rates for all four clinical stages (I-IV), the differences were only significant for Stage II patients. Patients with clinical stage IB SCC and AdCA treated by surgery alone were found to have significantly better survival rates (93.1% and 94.6% at 5 years, respectively) than women treated by either radiation alone or a combination of surgery and radiation (P < 0.001, both histologic comparisons). For women with Ad/SC tumors, however, the 5-year survival rate was 87.3% for those receiving combined treatment compared with those receiving surgery alone (69.2%) or radiation alone (79.2%). However, these survival curves were not significantly different (P = 0.496). One hundred six patients with positive nodes were available for analysis. The 5-year survival rate of patients with SCC and positive nodes was 76.1%. Surprisingly, patients with Ad/SC and positive nodes had the highest 5-year survival rate (85.7%), whereas, women with AdCA and positive nodes had a sharply reduced 5-year survival rate (33.3%). The curves were significantly different (P < 0.01). For patients with clinical stage I, the risk factors for age, tumor size, nodal status, histologic features, and treatment were analyzed with Cox's multivariate regression. In this analysis, subset IB, greater tumor size, age 80 or older, and positive nodal status were each independently significant for poorer survival. Patients who were treated by surgery alone had a significantly better survival than patients who had other types of treatment or no treatment. Histologic characteristics had no significant effect on survival. In the analysis of patients with pathologic stage I disease, those with SCC had significantly poorer survival and those with Ad/SC had significantly better survival than patients with Ad/CA. Positive nodes had no significant independent effect on survival. In another analysis, tissue type was not found to be an important factor in recurrence time.

CONCLUSIONS

1. Ad/CA and Ad/SC tumors were found to represent 12.6% and 3.6%, respectively, of a large series (N = 11,157) of cervical cancers diagnosed in 1984 and 1990 and reported to the Commission on Cancer of the American College of Surgeons. 2. Two thirds of women with early clinical stage disease (IA, IB, IIA) had hysterectomy as all or part of their primary therapy. 3. No significant differences were found in 5-year survival among the three tissue types in any clinical stage except American Joint Committee on Cancer stage II.

Artifactual endocervical atypia induced by endocervical brush collection

The cytologic distinctions between artifactual atypia induced by endocervical brush collection, endocervical glandular repair, and endocervical glandular dysplasia or neoplasia are often difficult. This difficulty is amplified by the lack of accepted cytologic criteria for endocervical glandular dysplasia, and the fact that earlier studies defining the significant cytologic features of endocervical adenocarcinoma in situ and endocervical adenocarcinoma (endocervical neoplasia) utilized a swab for endocervical cell retrieval. With the almost universal adoption of the endocervical brush, it is important to redefine those cytologic characteristics that differentiate true endocervical glandular dysplasia or neoplasia from reactive or reparative processes and instrument artifact. From our data, it appears that the classically described cytologic discriminators between a negative smear and smears of endocervical dysplasia or neoplasia are basically unchanged with some minor modifications for endocervical brush-collected samples.