Prognostic factors of early stage cervical cancer treated by radical hysterectomy

The Polish Society of Gynecological Oncology Guidelines for the Diagnosis and Treatment of Cervical Cancer (v2024.0)

Background: Recent publications underscore the need for updated recommendations addressing less radical surgery for <2 cm tumors, induction chemotherapy, or immunotherapy for locally advanced stages of cervical cancer, as well as for the systemic therapy for recurrent or metastatic cervical cancer. Aim: To summarize the current evidence for the diagnosis, treatment, and follow-up of cervical cancer and provide evidence-based clinical practice recommendations. Methods: Developed according to AGREE II standards, the guidelines classify scientific evidence based on the Agency for Health Technology Assessment and Tariff System criteria. Recommendations are graded by evidence strength and consensus level from the development group. Key Results: (1) Early-Stage Cancer: Stromal invasion and lymphovascular space involvement (LVSI) from pretreatment biopsy identify candidates for surgery, particularly for simple hysterectomy. (2) Surgical Approach: Minimally invasive surgery is not recommended, except for T1A, LVSI-negative tumors, due to a reduction in life expectancy. (3) Locally Advanced Cancer: concurrent chemoradiation (CCRT) followed by brachytherapy (BRT) is the cornerstone treatment. Low-risk patients (fewer than two metastatic nodes or FIGO IB2-II) may consider induction chemotherapy (ICT) followed by CCRT and BRT after 7 days. High-risk patients (two or more metastatic nodes or FIGO IIIA, IIIB, and IVA) benefit from pembrolizumab with CCRT and maintenance therapy. (4) Metastatic, Persistent, and Recurrent Cancer: A PD-L1 status from pretreatment biopsy identifies candidates for Pembrolizumab with available systemic treatment, while triplet therapy (Atezolizumab/Bevacizumab/chemotherapy) becomes a PD-L1-independent option. Conclusions: These evidence-based guidelines aim to improve clinical outcomes through precise treatment strategies based on individual risk factors, predictors, and disease stages.

Cervical Cancer Genetic Profile through Circulating Tumor DNA: What Can We Learn from Blood?

Cervical cancer (CC) is one of the deadliest gynecological cancers worldwide. Human papillomavirus is the main etiological agent responsible for the initiation and development of most CC cases. The standard method utilized for CC screening in the global population is the cytological Pap smear test. Despite its effective validity in detecting precancerous lesions and its response to layer stages of this disease, greater screening and diagnostic reliability are needed, as well as an improvement in specificity and sensitivity. In this context, the use of liquid biopsies, like blood, for the isolation of circulating tumor DNA (ctDNA) in CC screening, diagnosis, prognosis, and surveillance could fill the gaps that still exist. In the present review, we aim to study the literature in order to collect knowledge on blood-based liquid biopsy based on descriptions of its precious molecular content and its utilization as a potential tool for CC patients' management. We will mainly focus on the important role of the novel ctDNA and the unique possibilities to additionally use HPV-ctDNA in CC at various stages of clinical application.

The role of neoadjuvant chemotherapy before radical surgery in stage IB2/IIA2 squamous cell cervical cancers

BACKGROUND

This study aimed to evaluate the outcomes of patients diagnosed with stage IB2/IIA2 cervical squamous cell carcinoma who underwent neoadjuvant chemotherapy (NACT) prior to radical hysterectomy compared to those who did not receive NACT before surgery.

MATERIALS AND METHODS

This is a multicenter study including data of 6 gynecological oncology departments. The study is approved from one of the institution's local ethics committee. Patients were stratified into two cohorts based on the receipt of NACT preceding their surgical intervention. Clinico-pathological factors and progression-free survival were analyzed.

RESULTS

Totally 87 patients were included. Lymphovascular space invasion (LVSI) was observed as 40% in the group receiving NACT, while it was 66.1% in the group not receiving NACT (p = 0.036). Deep stromal invasion (> 50%) was 56% in the group receiving NACT and 84.8% in the group not receiving NACT (p = 0.001). In the univariate analysis, application of NACT is statistically significant among the factors that would be associated with disease-free survival. Consequently, a multivariate analysis was conducted for progression-free survival, incorporating factors such as the depth of stromal invasion, the presence of LVSI, and the administration of NACT. Of these, only the administration of NACT emerged as an independent predictor associated with decreased progression-free survival. (RR:5.88; 95% CI: 1.63-21.25; p = 0.07).

CONCLUSIONS

NACT shouldn't be used routinely in patients with stage IB2/IIA2 cervical cancer before radical surgery. Presented as oral presentation at National Congress of Gynaecological Oncology & National Congress of Cervical Pathologies and Colposcopy (2022/ TURKEY).

The current status of cell‐free human papillomavirus DNA as a biomarker in cervical cancer and other HPV ‐associated tumors: A review

Tumor cells release fragments of their DNA into the circulation, so called cell-free tumor DNA (ctDNA), allowing for analysis of tumor DNA in a simple blood test, that is, liquid biopsy. Cervical cancer is one of the most common malignancies among women worldwide and high-risk human papillomavirus (HR-HPV) is the cause of the majority of cases. HR-HPV integrates into the host genome and is often present in multiple copies per cell and should thus also be released as ctDNA. Such ctHPV DNA is therefore a possible biomarker in cervical cancer. In this review, we first give a background on ctDNA in general and then a comprehensive review of studies on ctHPV DNA in cervical cancer and pre-malignant lesions that may develop in cervical cancer. Furthermore, studies on ctHPV DNA in other HPV related malignancies (eg, head-and-neck and anogenital cancers) are briefly reviewed. We conclude that detection of ctHPV DNA in plasma from patients with cervical cancer is feasible, although optimized protocols and ultra-sensitive techniques are required for sufficient sensitivity. Results from retrospective studies in both cervical cancer and other HPV-related malignancies suggests that ctHPV DNA is a promising prognostic biomarker, for example, for detecting relapses early. This paves the way for larger, preferably prospective studies investigating the clinical value of ctHPV DNA as a biomarker in cervical cancer. However, there are conflicting results whether ctHPV DNA can be found in blood from patients with pre-malignant lesions and further studies are needed to fully elucidate this question.

Management of Early-Stage Cervical Cancer: A Literature Review

Simple Summary

Despite being a preventable disease, cervical cancer still causes morbidity and deaths worldwide. In the early stages (FIGO IA1 with lymph-vascular space invasion-IIA1), the disease is highly curable. The primary treatment for early-stage cervical cancer is radical hysterectomy with pelvic lymphadenectomy. This surgical treatment has changed during the past decades, and we aimed to review and discuss the advances in the literature. We performed a literature review through PubMed focusing on English articles about the topic of surgical management of early-stage cervical cancer. The emergent topics considered here are the FIGO 2018 staging system update, conservative management for selected patients, sentinel lymph node mapping, fertility preservation, surgical approach, and management of tumors up to 2 cm. These topics show an evolvement to a more tailored treatment to prevent morbidity and assure oncologic safety.

Abstract

Cervical cancer (CC) remains a public health issue worldwide despite preventive measures. Surgical treatment in the early-stage CC has evolved during the last decades. Our aim was to review the advances in the literature and summarize the ongoing studies on this topic. To this end, we conducted a literature review through PubMed focusing on English-language articles on the surgical management of early-stage CC. The emergent topics considered here are the FIGO 2018 staging system update, conservative management with less radical procedures for selected patients, lymph node staging, fertility preservation, preferred surgical approach, management of tumors up to 2 cm, and prognosis. In terms of updating FIGO, we highlight the inclusion of lymph node status on staging and the possibility of imaging. Regarding the preferred surgical approach, we emphasize the LACC trial impact worldwide in favor of open surgery; however, we discuss the controversial application of this for tumors < 2 cm. In summary, all topics show a tendency to provide patients with tailored treatment that avoids morbidity while maintaining oncologic safety, which is already possible in high-income countries. We believe that efforts should focus on making this a reality for low-income countries as well.

Prediction Models for Prognosis of Cervical Cancer: Systematic Review and Critical Appraisal

Objective: This work aims to systematically identify, describe, and appraise all prognostic models for cervical cancer and provide a reference for clinical practice and future research. Methods: We systematically searched PubMed, EMBASE, and Cochrane library databases up to December 2020 and included studies developing, validating, or updating a prognostic model for cervical cancer. Two reviewers extracted information based on the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modeling Studies checklist and assessed the risk of bias using the Prediction model Risk Of Bias ASsessment Tool. Results: Fifty-six eligible articles were identified, describing the development of 77 prognostic models and 27 external validation efforts. The 77 prognostic models focused on three types of cervical cancer patients at different stages, i.e., patients with early-stage cervical cancer (n = 29; 38%), patients with locally advanced cervical cancer (n = 27; 35%), and all-stage cervical cancer patients (n = 21; 27%). Among the 77 models, the most frequently used predictors were lymph node status (n = 57; 74%), the International Federation of Gynecology and Obstetrics stage (n = 42; 55%), histological types (n = 38; 49%), and tumor size (n = 37; 48%). The number of models that applied internal validation, presented a full equation, and assessed model calibration was 52 (68%), 16 (21%), and 45 (58%), respectively. Twenty-four models were externally validated, among which three were validated twice. None of the models were assessed with an overall low risk of bias. The Prediction Model of Failure in Locally Advanced Cervical Cancer model was externally validated twice, with acceptable performance, and seemed to be the most reliable. Conclusions: Methodological details including internal validation, sample size, and handling of missing data need to be emphasized on, and external validation is needed to facilitate the application and generalization of models for cervical cancer.

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.

A 70-Gene Signature for Predicting Treatment Outcome in Advanced-Stage Cervical Cancer

Cervical cancer is the fourth most common cancer in women worldwide. The current approaches still have limitations in predicting the therapy outcome of each individual because of cancer heterogeneity. The goal of this study was to establish a gene expression signature that could help when choosing the right therapeutic method for the treatment of advanced-stage cervical cancer. The 666 patients were collected from four independent datasets. The 70-gene expression signature was established using univariate Cox proportional hazard regression analysis. The 70-gene signature was significantly different between low- and high-risk groups in the training dataset (p = 4.24e-6) and in the combined three validation datasets (p = 4.37e-3). Treatment of advanced-stage cancer patients in the high-risk group with molecular-targeted therapy combined with chemoradiotherapy yielded a better survival rate than with only chemoradiotherapy (p = 0.0746). However, treatment of the patients in the low-risk group with the combined therapy resulted in significantly lower survival (p = 0.00283). Functional classification of 70 genes revealed involvement of the angiogenesis pathway, specifically phosphatidylinositol 3-kinase signaling (p = 0.040), extracellular matrix organization (p = 0.0452), and cell adhesion (p = 0.011). The 70-gene signature could predict the prognosis and indicate an optimal therapeutic modality in molecular-targeted therapy or chemotherapy for advanced-stage cervical cancer.

Survival outcomes of low-risk and intermediate-risk stage IB1 cervical cancer patients

Background

Survival for patients with early stage cervical cancer without any high-risk factors treated with radical hysterectomy is excellent. However, there are few data on the survival outcomes for low-risk and intermediate-risk early stage cervical cancer patients.

Objective

To determine survival outcomes and prognostic factors of low-risk and intermediate-risk stage IB1 cervical cancer patients.

Methods

Stage IB1 cervical cancer patients with radical hysterectomy and pelvic lymphadenectomy were retrospectively reviewed. Patients with positive pelvic nodes, parametrial involvement, and positive margin who are classified as high-risk patients were excluded. Patients with squamous cell carcinoma or grade 1–2 adenocarcinoma, tumor size less than 2 cm, no lymphovascular space invasion (LVSI), and depth of stromal invasion (DSI) less than 10 mm were defined as low-risk patients. Survival was evaluated using the Kaplan–Meier method and compared by the log-rank test. Multivariate analysis was performed using Cox proportional-hazards regression.

Results

There were 82 (42.3%) low-risk patients and 112 (57.7%) intermediate-risk patients. More patients in intermediate risk received adjuvant treatment (3.6% and 14.3%, P = 0.07). Three (3.6%) low-risk patients and 18 (16.1%) intermediate-risk patients had recurrent disease (P = 0.004). At median follow-up of 86 months, 1.2% of low-risk patients and 8.9% of intermediate-risk had cancer-related deaths (P = 0.02). Low-risk patients had significantly better 5-year disease-free survival (98.2% vs 91.1%, P = 0.01) and estimated 5-year overall survival (98.5% vs 91.1%, P = 0.01). DSI more than 10 mm and presence of LVSI were significantly associated with recurrence. However, LVSI was an independent prognostic factor.

Conclusion

Stage IB1 cervical cancer patients had excellent survival. Low-risk patients had significantly better survival. Presence of LVSI was an independent prognostic factor.

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.

Role of Histopathological Differentiation as a Prognostic Factor for Treatment Response in Locally Advanced Squamous Cell Carcinoma Cervix Patients

Introduction: The aim of the study was to evaluate the prognostic significance of histopathological differentiation in treatment outcome of locally advanced carcinoma cervix. Materials and Methods: This retrospective study includes 167 patients of locally advanced carcinoma cervix treated between January 2006 and December 2008 who have received definitive chemoradiation. Results:: The number of patients with well (85 [50.9%]) and moderately differentiated (76 [45.5%]) carcinoma was nearly equal with poorly differentiated variety having only 6 (3.6%) patients. On completion of treatment out of the 167 patients, 133 (79.6%) had a complete response and 34 (20.4%) had residual disease. On mean follow-up of 11 months, 19 (14.2%) patients had local and 5 (3.7%) had a distant relapse. Histopathological differentiation and age had no association with treatment outcome, whereas early-stage disease showed trend favoring better treatment response. Conclusion: Advanced stage along with poor histopathological differentiation influences the aggressiveness of the tumor responsible for distant relapse. However, histopathological differentiation has no correlation with local treatment response and overall survival. The main factor influencing the treatment outcome is the intrinsic radiosensitivity of the tumor and volume of the disease.

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.

Identification of differentially expressed genes in cervical cancer by bioinformatics analysis

Cervical cancer is the most common gynecological malignancy. In recent years, the incidence of cervical cancer has had a younger trend. Cervical cancer morbidity and mortality rates have been significantly reduced due to recent decades of cervical cytology screening leading to the early detection and treatment of cervical cancer and precancerous lesions. There are a number of methods used to treat cervical cancer and improve the survival rate. However, the prevalence and recurrence rates of cervical cancer are increasing every year. There is an urgent requirement for a better understanding of the molecular mechanism cervical cancer development. The present study used scientific information retrieval from the Gene Expression Omnibus database to download the GSE26511 dataset, which contained 39 samples, including 19 cervical cancer lymph node-positive samples and 20 cervical cancer lymph node-negative samples. Using Gene Ontology analysis, Kyoto Encyclopedia of Genes and Genomes analysis, and weighted gene co-expression network analysis, 1,263 differentially expressed genes were found that affected the biological processes, including 'cell cycle process', 'signaling pathways', 'immune response', 'cell activation', 'regulation of immune system process' and 'inflammatory response'. These areas should be the focus of study for cervical cancer in the future.

Prognostic Value of Volume-Based Metabolic Parameters Obtained by 18F-FDG-PET/CT in Patients With Locally Advanced Squamous Cell Cervical Carcinoma

OBJECTIVE

The aim of the study was to assess the prognostic impact of volume-based metabolic F-fluorodeoxyglucose-positron emission tomography/ computed tomography (F-FDG-PET/CT) parameters in patients with stage IB-IVA squamous cell cervical carcinoma (SCCC).

MATERIALS AND METHODS

We reviewed the pretreatment F-FDG-PET/CT records of 67 patients with stage IB-IVA SCCC. The maximum standardized uptake value (SUVmax) of the primary tumor (PSUVmax), highest SUVmax of the whole malignant lesions (WSUVmax), metabolic tumor volume (MTV) of the primary tumor (PMTV), MTV of the whole malignant lesion (WMTV), total lesion glycolysis (TLG) of primary tumor (PTLG), and TLG of the whole malignant lesion (WTLG) were obtained. Univariate and multivariate analyses were performed to assess the predictive values of metabolic parameters.

RESULTS

Twenty-nine patients showed disease progression and 21 patients died during follow-up. In univariate analysis, positive lymph node, WSUVmax of greater than 11, WMTV of greater than 63 cm, and WTLG of greater than 373 adversely affected the progression-free survival (P = 0.004, 0.045, 0.023, and 0.005, respectively). A positive lymph node, WSUVmax of greater than 12, WMTV of greater than 68 cm, and WTLG of greater than 373 significantly adversely affected overall survival (P = 0.002, 0.032, 0.015, and 0.006, respectively). In multivariate analysis, independent prognostic factor for progression-free survival was WTLG (relative risk = 2.384, 95% confidence interval = 1.095-5.187, P = 0.029). Independent prognostic factors for overall survival was WTLG (relative risk = 2.763; 95% confidence interval = 1.107-6.896, P = 0.029).

CONCLUSIONS

Preliminary results indicated that pretreatment WTLG measured by F-FDG-PET/CT could independently predict survival in patients with locally advanced SCCC.

Nerve-Sparing Radical Hysterectomy: A Pilot Study

Nerve-sparing radical hysterectomy has increasingly been used for cervical cancer, with less morbidity. We aimed with this study: i) to describe an alternative technique of nerve-sparing radical Piver III hysterectomy, using the CUSA®, in which attention was given to the uterosacral ligament and cardinal ligament; ii) to evaluate the feasibility of this new nerve-sparing technique; iii) to describe the surgical anatomy of the autonomic nervous system; iv) to assess the early incidence of bladder dysfunction. Twelve consecutive patients with local-regional advanced cervical cancer were enrolled in the study on nerve-sparing radical hysterectomy with extended pelvic lymphadenectomy. The mean age was 44 years (range, 30–59), mean body mass index was 24 kg/m2 (range, 18–30), mean operating time was 217 mins (range, 195–240), and mean blood loss was 437 cc (range, 200–750). The average hospitalization time was 9 days (range, 5–15 days). Two patients presented pathologically positive parametrium. Two of 12 (17%) patients were discharged with self-catheterism. In the first outpatient follow-up, 1 patient had recovered spontaneous voiding. The nerve-sparing technique with CUSA® can be an option to reduce radical hysterectomy-related morbidity. The technique proved to be feasible, with promising results in terms of preventing bladder dysfunction. An elevated body mass index and large tumors can impair the performance of the technique. Further studies clarifying neuroanatomy and neurophysiology of autonomic nervous structures, as well as a prospective controlled trial on nerve-sparing radical hysterectomy should be carried out to confirm our data.

Impact of (chemo)radiotherapy on immune cell composition and function in cervical cancer patients

New treatments based on combinations of standard therapeutic modalities and immunotherapy are of potential use, but require a profound understanding of immune modulatory properties of standard therapies. Here, the impact of standard (chemo)radiotherapy on the immune system of cervical cancer patients was evaluated. Thirty patients with cervical cancer were treated with external beam radiation therapy (EBRT), using conventional three-dimensional or intensity modulated radiation therapy without constraints for bone marrow sparing. Serial blood sampling for immunomonitoring was performed before, midway and at 3, 6 and 9 weeks after EBRT to analyze the composition of lymphocyte and myeloid-cell populations, the expression of co-stimulatory molecules, T-cell reactivity and antigen presenting cell (APC) function. Therapy significantly decreased the absolute numbers of circulating leukocytes and lymphocytes. Furthermore, the capacity of the remaining T cells to respond to antigenic or mitogenic stimulation was impaired. During treatment the frequency of both CD4⁺ and CD8⁺ T cells dropped and CD4⁺ T cells displayed an increased expression of programmed cell death-1 (PD-1). In vitro blocking of PD-1 successfully increased T-cell reactivity in all five samples isolated before radiotherapy but was less successful in restoring reactivity in samples isolated at later time points. Moreover, (chemo)radiotherapy was associated with an increase in both circulating monocytes and myeloid-derived suppressor cells (MDSCs) and an impaired capacity of APCs to stimulate allogeneic T cells. T-cell reactivity was slowly restored at 6–9 weeks after cessation of therapy. We conclude that conventional (chemo)radiotherapy profoundly suppresses the immune system in cervical cancer patients, and may restrict its combination with immunotherapy.

[S3 guidelines on diagnostics and treatment of cervical cancer: Demands on pathology]

Between 2011 and the end of 2014 the former consensus S2k guidelines for the diagnostics and treatment of cervical cancer were updated and upgraded to S3 level, methodologically based on the regulations of the German Cancer Society (DKG). The present article summarizes the relevant aspects for the sectioning, histopathological workup, diagnostics and reporting for the pathology of invasive cancer of the uterine cervix. The recommendations are based on the most recent World Health Organization (WHO) and TNM classification systems and consider the needs of the clinician for appropriate surgical and radiotherapeutic treatment of patients. Detailed processing rules of colposcopy-guided diagnostic biopsies, conization and trachelectomy as well as for radical hysterectomy specimens and lymph node resection (including sentinel lymph node resection) are given. In the guidelines deep stromal invasion in macroinvasive cervical cancer is defined for the first time as tumor infiltration of > 66% of the cervical stromal wall. Furthermore, morphological prognostic factors for microinvasive and macroinvasive cervical cancer are summarized.

Uterine cervical cancer volumetry using T2- and diffusion-weighted MR images in patients treated by primary surgery and neoadjuvant chemotherapy

BACKGROUND

Tumor volumetry with magnetic resonance imaging (MRI) is very common; however, the accuracy of such measures remains unclear, especially after treatment.

PURPOSE

To determine the accuracy of preoperative volume measurements of uterine cervical carcinomas resected with and without neoadjuvant chemotherapy (NAC) on T2-weighted (T2W) and diffusion-weighted (DWI) MRI.

MATERIAL AND METHODS

Twenty-nine consecutive patients with surgically confirmed uterine cervical carcinoma were included in this study. MRI scans were performed before preoperative treatment in 17 patients and after two courses of NAC in 12 patients. In all patients, T2W images and DWI were obtained to measure the tumor diameters. The maximum diameter of the surgical specimens was macroscopically measured. The correlation coefficients between the measured tumor size using T2W imaging and DWI and the size measured on the surgical specimens were calculated for all specimens.

RESULTS

The correlation coefficient of the three-dimensional (3D) tumor volume measurement using T2W imaging and DWI was 0.97 in the primary surgery group and was 0.96 in the NAC group. The 3D tumor volume measurement using MRI and the measurement of the actual surgical specimen was 0.55 for T2WI and 0.48 for DWI in the primary surgery group and 0.88 for T2WI and 0.95 for DWI in the NAC group.

CONCLUSION

T2WI and DWI can provide accurate 3D tumor volume measurements of uterine cervical carcinomas in patients with and without preoperative chemotherapy, suggesting that tumor volumetry using 3 T MRI after uterus-preserving treatment is feasible.

Laparoscopic Nerve-Sparing Radical Hysterectomy for Cervical Carcinoma: Emphasis on Nerve Content in Removed Cardinal Ligaments

Objective

To evaluate the histopathology of autonomic nerve removal within the cardinal ligaments (CLs), patients’ postoperative urinary function, and the feasibility and safety of laparoscopic nerve-sparing radical hysterectomy (LNSRH) for treatment of early-stage cervical cancer.

Methods

Perioperative and postoperative parameters were compared between patients with biopsy-proven, early-stage cervical carcinoma treated with LNSRH (n = 64) versus those treated with laparoscopic radical hysterectomy (LRH, n = 42) in a retrospective study. Nerves within CLs were identified by hematoxylin-eosin staining. Rates of the following complications were compared: bladder function, sexual dysfunction, and defecation problems.

Results

Duration of surgery, intraoperative blood loss, duration of hospitalization, and morbidity did not differ significantly between the LNSRH and LRH groups. Patients who underwent LNSRH had a significantly earlier return of bladder and bowel functions, with an average time to achieve residual urine of 50 mL or less of 10.22 days and a mean first defecation time of 3.58 days. Nerves were observed mainly in the CLs of the LRH group. Disease-free survival rate did not differ between the LNSRH (90.6%) and LRH (88.1%) groups (P = 0.643).

Conclusions

The LNSRH is a safe, feasible, and easy procedure for trained laparoscopic surgeons. Patients who underwent LNSRH had a more satisfactory quality of life than patients who underwent LRH.

Molecular staging of gynecological cancer: What is the future?

The purpose of cancer staging is to classify cancers into prognostic groups and to allow for comparison of treatment results and survival between patients and institutions. Staging for gynecologic cancers is based on extent of disease and metastasis, which was historically determined by physical examination and is now based on surgical and histologic examination of tumor specimens. Although the extent of disease is currently considered the most important predictor of recurrence and survival, current staging does not include molecular features that are associated with tumor aggressiveness, response to therapy, and prognosis. This review focuses on genomic and proteomic features of gynecologic cancers and the future of biomarkers in staging classification.

Satellite lymphovascular space invasion: An independent risk factor in early stage cervical cancer

OBJECTIVE

This study was performed to determine whether satellite LVSI in women with early stage cervical carcinoma is an independent prognostic factor for recurrence and survival.

METHODS

A total of 210 eligible patients with FIGO stages IA2 and IB1 cervical carcinoma, who underwent radical hysterectomy or radical trachelectomy with pelvic lymphadenectomy between January 2000 and December 2012, were included. Variables studied included age, histology type, differentiation grade, tumor size (TS), depth of invasion (DI), lymph node metastasis (LNM), conjoined lymphovascular space invasion (LVSI) and satellite LVSI. Univariate and multivariate analyses were performed to define variables that best predict recurrence and survival.

RESULTS

Univariate analysis showed that differentiation grade, depth of invasion, tumor size, lymph node metastasis, and both conjoined LVSI and satellite LVSI were significantly associated with recurrence and survival. Using multivariate analysis, differentiation grade (HR 3.63, 95%-CI 1.51-8.72), conjoined LVSI (HR 5.95, 95%-CI 1.57-22.53) and satellite LVSI (HR 7.45, 95%-CI 3.03-18.27) were independent prognostic factors for recurrence; LNM (HR 5.55, 95%-CI 1.52-20.26) and satellite LVSI (HR 8.94, 95%-CI 2.43-32.95) were prognostic factors for overall survival. For patients with low-risk cervical cancer without LNM only satellite LVSI correlated significantly with disease-free and overall survival.

CONCLUSION

Differentiation grade, DI, TS, LNM, and conjoined LVSI as well as satellite LVSI were prognostic factors for DFS and OS. Satellite LVSI is the most important factor predicting DFS and OS in early stage cervical cancer, especially when lymph nodes are negative.

Correlation of chitinase 3-like 1 single nucleotide polymorphisms and haplotypes with uterine cervical cancer in Taiwanese women

Background

This study aimed to investigate the relationships of chitinase 3-like 1 (CHI3L1) single nucleotide polymorphisms (SNPs) and haplotypes with the development of uterine cervical cancer in Taiwanese women. The SNPs frequencies and haplotypes were also correlated with the clinicopathologic variables of cervical cancer, cancer recurrence, and patient survival.

Methodology and Principal Findings

Ninety-nine patients with invasive cancer and 61 with pre-cancerous lesions of the uterine cervix were compared to 310 healthy control subjects. Three SNPs rs6691378 (−1371, G/A), rs10399805 (−247, G/A) and rs4950928 (−131, C/G) in the promoter region, and one SNP rs880633 (+2950, T/C) in exon 5 were analyzed by real time polymerase chain reaction and genotyping. The results showed that the mutant homozygous genotype AA of CHI3L1 SNP rs6691378 and AA of rs10399805, and haplotypes AACC and AACT increased the risk of developing pre-cancerous lesions and invasive cancer. The patients with these risk haplotypes had higher than stage I tumors, larger tumors, and vaginal invasion. In logistic regression model, they also tended to have poor survival event [p = 0.078; odds ratio (OR): 2.99, 95% confidence interval (CI): 0.89–10.08] and a higher probability of recurrence event (p = 0.081; OR: 3.07, 95% CI: 0.87–10.81). There was a significant association between the CHI3L1 risk haplotypes and probability of recurrence (p = 0.002; hazard ratio: 6.21, 95% CI: 1.90–20.41), and a marginal association between the risk haplotypes and overall survival (p = 0.051; hazard ratio: 3.76, 95% CI: 0.99–14.29) in the patients with SCC, using Cox proportional hazard model.

Conclusion

The CHI3L1 SNPs rs6691378 and rs10399805 and CHI3L1 haplotypes all correlated with the development of cervical pre-cancerous lesions and invasive cancer. The cervical cancer patients with the CHI3L1 haplotypes AACC or AACT had poor clinicopathologic characteristics and poor recurrence and survival events. These risk haplotypes were associated with higher recurrence, especially in the patients with SCC.

A cut-off value of 2 cm in tumor size is of prognostic value in surgically treated FIGO stage IB cervical cancer

OBJECTIVES

Limited knowledge exists about the value of tumor size in surgically treated cervical cancer (CX) using a tumor size of 2 cm as cut-off value.

METHODS

A total of 366 cases of CX FIGO stage IB who received upfront surgery were evaluated regarding tumor size, the prediction of pelvic lymph node involvement, and recurrence-free and overall survival during a median follow-up time of 94 months. Tumors ≤2.0 cm were defined as small, tumors 2.1-4.0 cm as medium sized and those larger than 4 cm as bulky disease.

RESULTS

Small tumors were seen in 28.7%, medium sized in 52.5% and bulky tumors in 18.9%. There was a significant higher frequency of pelvic lymph node involvement with increasing tumor size (13.3% vs. 23.4% vs. 43.5%, respectively; p<0.001) and an increase of recurrent disease (6.7% vs. 18.8% vs. 29.4%, respectively; p<0.001). The 5-year overall survival rate was significantly reduced with increasing tumor size (94.0% vs. 85.1% vs. 69.9%, respectively; p<0.001). Pelvic lymph node involvement and maximal tumor size were independent prognostic factors for both recurrence-free and overall survival in multivariate analysis.

CONCLUSIONS

The results support that tumor size is of prognostic impact in FIGO stage IB cervical carcinomas. A further substaging is suggested for tumors up to 4.0 cm maximum dimension using a cut-off value of 2.0 cm as discriminator. Patients with tumors ≤2.0 cm may represent low risk disease.

The expression of ribonucleotide reductase M2 in the carcinogenesis of uterine cervix and its relationship with clinicopathological characteristics and prognosis of cancer patients

Background

To investigate the implication of ribonucleotide reductase M2 (RRM2) in the carcinogenesis of uterine cervix and its relationship with clinicopathological characteristics and prognosis of cancer patients.

Methodology and Principal Findings

The impact of RRM2 on cell viability was investigated in SiHa cervical cancer cells after RRM2 knockdown and the addition of cisplatin, which induces inter- and intra-strand DNA crosslinks. RRM2 immunoreactivity was evaluated by semi-quantitative H score among 29 normal, 30 low-grade dysplasia, 30 high-grade dysplasia and 103 invasive cancer tissue specimens of the uterine cervix, using tissue microarrays. RRM2 was then correlated with the clinicopathological variables of cervical cancer and patient survival. A greater toxic effect on cell viability using cisplatin was reflected by the greater reduction in RRM2 protein expression in SiHa cells. The RRM2 expression in cancer tissues was higher than that in high-grade dysplasia, low-grade dysplasia or normal cervical tissues. RRM2 upregulation was correlated with deep stromal invasion, large tumors and parametrial invasion and predicted poor survival.

Conclusions

RRM2 is a new molecular marker for the diagnosis and clinical outcomes of cervical cancer. It is involved in cervical carcinogenesis and predicts poor survival, and may be a potential therapeutic target including in cisplatin treatment.

Clinical implications of aldo-keto reductase family 1 member C3 and its relationship with lipocalin 2 in cancer of the uterine cervix

OBJECTIVE

Over-expression of the aldo-keto reductase family 1 member C3 (AKR1C3) has been demonstrated in many human cancers. Lipocalin 2 (LCN2) is reported to inhibit cervical cancer metastasis but little is known regarding its relationship with AKR1C3 in the development and progression of uterine cervical cancer. This study aimed to investigate the involvement of AKR1C3 and its relationship with LCN2 in cervical cancer.

METHODS

The roles of AKR1C3 and LCN2 were investigated using the lentivirus shRNA system in SiHa and Caski cervical cancer cells. LCN2 and matrix metalloproteinase-2 (MMP-2) promoters were constructed to demonstrate transcriptional regulation by shAKR1C3 and shLCN2, respectively. The influences of metastatic phenotypes were analyzed by wound healing, Boyden chamber, and immunofluorescence assays. The activity of MMP-2 was determined by zymography assay. The impacts of AKR1C3 and LCN2 on patient prognosis were evaluated using tissue microarrays by Cox regression and Kaplan-Meier models.

RESULTS

Silencing of the AKR1C3 gene increased the expression of LCN2 and decreased the migratory and invasive abilities and changed the cytoskeleton of cervical cancer cells. When AKR1C3 was over-expressed, it decreased LCN2 promoter activity and LCN2 expression and increased cell migration. The mRNA level and enzyme activity of MMP-2 increased in silenced LCN2 cells. Positive AKR1C3 and negative LCN2 were correlated with higher recurrence and poorer survival of cervical cancer patients.

CONCLUSIONS

Silencing of AKR1C3 increases LCN2 expression and inhibits metastasis in cervical cancer. Both AKR1C3 and LCN2 serve as molecular targets for cancer therapy to improve the clinical outcome of cervical cancer patients.

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.

Combining the negative lymph nodes count with the ratio of positive and removed lymph nodes can better predict the postoperative survival in cervical cancer patients

BACKGROUND

To evaluate the impacts of the negative lymph nodes (NLNs) count on the prognostic prediction of the ratio of positive and removed lymph nodes (RPL) in cervical cancer patients after radical hysterectomy and pelvic lymphadenectomy (RHPL).

METHODS

The positive and negative lymph node counts were calculated for 609 postoperative cervical cancer patients. The 5-year survival rate (5-YSR) was examined according to clinicopathologic variables. Cox regression was used to identify independent prognostic factors.

RESULTS

The NLNs count cutoffs were determined to be 10 and 25 with 5-YSR of 62.8% and 80.5%. The RPL of 13 patients who had the NLNs count of 10 or fewer was >20%. Among 242 patients who had 10 < NLNs count ≤ 25, 194 without positive nodes had the 5-YSR of 77.8%, 31 with 0% < RPL ≤ 5% had the 5-YSR of 3.2%, 15 with RPL > 20% had died when follow-up was completed. Among 354 patients who had NLNs count >25, 185 without positive nodes had the 5-YSR of 87.6%, 6 with 0% < RPL ≤ 5% had the 5-YSR of 25%, 15 with 5% < RPL ≤ 20% had the 5-YSR of 4.5%, and 2 with RPL >20% had died when follow-up was completed. Furthermore, stage, histologic grade and RPL were independently correlated with overall survival of cervical cancer patients after RHPL in the multivariate analysis.

CONCLUSIONS

RPL was an independent prognostic factor. The NLNs count is a key factor for improvement of survival prediction of RPL in cervical cancer.

18F-FDG PET/CT can predict nodal metastases but not recurrence in early stage uterine cervical cancer

OBJECTIVES

To evaluate the role of the metabolic characteristics of cervical tumor uptake as predictors of a) lymph node (LN) metastases, b) recurrence, in the preoperative staging of early-stage cervical cancer.

METHODS

89 patients with FIGO stage IB1 and IIA<4 cm cervical cancer were imaged with FDG-PET/CT before radical hysterectomy and pelvic lymphadenectomy. PET/CT images were analyzed and correlated to histological findings. Maximum and mean standardized uptake value (SUVmax, SUVmean), metabolic tumor volume (MTV), total lesion glycolysis (TLG) of cervical lesions were calculated by an iterative adaptive algorithm. These parameters were correlated to the presence of: a) LN metastases, b) relapse after primary treatment.

RESULTS

Out of the 89 patients who underwent preoperative PET/CT scan for staging purpose, 16 were negative at cervical level: they were all pN0 and without recurrence during follow-up (mean 34.1±14.5 months). In 69 patients MTV and TLG were significantly higher (p=0.0006 and p=0.03) in pN1 patients in comparison to pN0 patients, while SUV values did not show significant differences between the two groups. No significant correlations were found between SUVmax, SUVmean, MTV, TLG and the evidence of relapse (mean follow-up 29.2±15.5 months).

CONCLUSIONS

In early-stage cervical cancer MTV and TLG correlate with the presence of nodal metastases, but their clinical impact on patients management has to be clarified. The absence of pathological cervical uptake could be a good prognostic factor, while SUVmax, SUVmean, MTV, TLG of the cervical uptake have not been found predictors of recurrence.

Involvement of the TGF-beta and beta-catenin pathways in pelvic lymph node metastasis in early-stage cervical cancer

PURPOSE

Presence of pelvic lymph node metastases is the main prognostic factor in early-stage cervical cancer patients, primarily treated with surgery. Aim of this study was to identify cellular tumor pathways associated with pelvic lymph node metastasis in early-stage cervical cancer.

EXPERIMENTAL DESIGN

Gene expression profiles (Affymetrix U133 plus 2.0) of 20 patients with negative (N(0)) and 19 with positive lymph nodes (N(+)), were compared with gene sets that represent all 285 presently available pathway signatures. Validation immunostaining of tumors of 274 consecutive early-stage cervical cancer patients was performed for representatives of the identified pathways.

RESULTS

Analysis of 285 pathways resulted in identification of five pathways (TGF-β, NFAT, ALK, BAD, and PAR1) that were dysregulated in the N(0), and two pathways (β-catenin and Glycosphingolipid Biosynthesis Neo Lactoseries) in the N(+) group. Class comparison analysis revealed that five of 149 genes that were most significantly differentially expressed between N(0) and N(+) tumors (P < 0.001) were involved in β-catenin signaling (TCF4, CTNNAL1, CTNND1/p120, DKK3, and WNT5a). Immunohistochemical validation of two well-known cellular tumor pathways (TGF-β and β-catenin) confirmed that the TGF-β pathway (positivity of Smad4) was related to N(0) (OR: 0.20, 95% CI: 0.06-0.66) and the β-catenin pathway (p120 positivity) to N(+) (OR: 1.79, 95%CI: 1.05-3.05).

CONCLUSIONS

Our study provides new, validated insights in the molecular mechanism of lymph node metastasis in cervical cancer. Pathway analysis of the microarray expression profile suggested that the TGF-β and p120-associated noncanonical β-catenin pathways are important in pelvic lymph node metastasis in early-stage cervical cancer.

Prognostic model for survival in patients with early stage cervical cancer

BACKGROUND

In the management of early stage cervical cancer, knowledge about the prognosis is critical. Although many factors have an impact on survival, their relative importance remains controversial. This study aims to develop a prognostic model for survival in early stage cervical cancer patients and to reconsider grounds for adjuvant treatment.

METHODS

A multivariate Cox regression model was used to identify the prognostic weight of clinical and histological factors for disease-specific survival (DSS) in 710 consecutive patients who had surgery for early stage cervical cancer (FIGO [International Federation of Gynecology and Obstetrics] stage IA2-IIA). Prognostic scores were derived by converting the regression coefficients for each prognostic marker and used in a score chart. The discriminative capacity was expressed as the area under the curve (AUC) of the receiver operating characteristic.

RESULTS

The 5-year DSS was 92%. Tumor diameter, histological type, lymph node metastasis, depth of stromal invasion, lymph vascular space invasion, and parametrial extension were independently associated with DSS and were included in a Cox regression model. This prognostic model, corrected for the 9% overfit shown by internal validation, showed a fair discriminative capacity (AUC, 0.73). The derived score chart predicting 5-year DSS showed a good discriminative capacity (AUC, 0.85).

CONCLUSIONS

In patients with early stage cervical cancer, DSS can be predicted with a statistical model. Models, such as that presented here, should be used in clinical trials on the effects of adjuvant treatments in high-risk early cervical cancer patients, both to stratify and to include patients.

The Role of Neoadjuvant Chemotherapy and Surgery in Cervical Cancer

The role of neoadjuvant chemotherapy (NAC) in "bulky" and locally advanced cervical cancer has been of interest for the last 25 years, and in many countries, NAC has become the standard of care. In the present paper, we review our 10 years' experience with high-dose-density NAC in cervical cancer management in 141 women (CervNAC I protocol). High-dose-density neoadjuvant chemotherapy and radical surgery has resulted in high clinical response rates and seems to be feasible in the management of stage IB bulky cervical cancer. Neoadjuvant chemotherapy reduces tumor volume and positivity of lymph nodes and thus minimizes the need for postoperative radiotherapy or chemoradiotherapy. Tumor size reduction and node negativity allows less radical surgical procedures such as modified radical hysterectomy or nerve-sparing radical hysterectomy. Early and especially late toxicity of our high-dose density chemotherapy is acceptable. Neoadjuvant chemotherapy followed by surgery represents a valid alternative to primary chemoradiotherapy in young and sexually active patients. Five-year survival in patients who underwent surgery in our study was 80.6%.

Currently, 3 papers with 3 approaches have been published on NAC before fertility-sparing surgery. One of the limitations of fertility-preserving surgery is deep stromal invasion and tumors larger than 2 cm. The idea underlying NAC is to reduce the size of the cervical tumor to preserve fertility. In the present paper, we also review our experience with high-dose-density NAC in fertility-sparing surgery in 15 women (LAP3-NAC protocol).

Combined adverse effect of African American race and deep stromal invasion on survival following radical hysterectomy for cervical cancer

OBJECTIVE

The objective of the study was to explore the effect of African American race on survival following radical hysterectomy for cervical cancer.

STUDY DESIGN

We reviewed all cases of stage IA-IIA cervical cancer treated with radical hysterectomy at our institution (1987-2001). Characteristics between races were compared using Mann Whitney U and chi(2) tests. Hazard ratios (HR) of survival were calculated using Cox regression.

RESULTS

We identified 134 Caucasian and 66 African American patients. There was a trend toward worse survival among African Americans (81.8% vs 88.8%, P = .165). An interaction effect between race and depth of stromal invasion was observed (P = .005), and the combination of African American race and deep stromal invasion had a powerful, independent effect on survival (HR of death 7.04 [95% confidence interval 2.48 to 19.94]).

CONCLUSION

The combination of African American race and deep stromal invasion has an adverse effect on survival following radical hysterectomy for cervical cancer and may warrant use of adjuvant therapy.

Expressions of EphA2 and EphrinA-1 in early squamous cell cervical carcinomas and their relation to prognosis

By using immunohistochemistry we investigated the expression of EphA2 and EphrinA-1 in 217 early squamous cell cervical carcinomas and examine their prognostic relevance. For EphA2 expression, 21 tumors (10%) showed negative, 108 (50%) weak positive, 69 (32%) moderate positive and 19 (9%) strong positive, whereas for EphrinA-1 expression, 33 tumors (15%) showed negative, 91 (42%) weak positive, 67 (31%) moderate positive and 26 (12%) strong positive. In univariate analysis high expression (strong staining) of EphrinA-1 was associated with poor disease-free (P = 0.033) and disease-specific (P = 0.039) survival. However, in the multivariate analyses neither EphrinA-1 nor EphA2 was significantly associated to survival. The increased levels of EphA2 and EphrinA-1 in a relative high number of early stage squamous cell carcinomas suggested that these two proteins may play an important role in the development of a subset of early cervical cancers. However, EphA2 and EphrinA-1 were not independently associated with clinical outcome.

Small cell carcinoma of the cervix: a case report

Small cell carcinoma of the uterine cervix accounts for 1-3% of all cervix cancers. It is an aggressive disease with a poor prognosis. To date, no effective treatment protocol has been determined. Surgery, radiotherapy, and chemotherapy have been used either alone or in combination. Recent data suggests that survival in patients with early staged small cell carcinoma of the cervix is better with surgery combined with chemo-radiotherapy. Here, we presented two patients with stage IB1 small cell carcinoma of the uterine cervix. For both patients, definitive surgery was performed with pelvic and para-aortic lymphadenectomy. Subsequently, they were treated with pelvic external radiotherapy and high-dose-rate intracavitary brachytherapy with concurrent cisplatin based chemotherapy. They were alive with no evidence of disease at 91 and 65 months, respectively.

Intraoperative techniques and tumor margin status--room for improvement for cervical cancer patients of childbearing age

OBJECTIVE

Inadequate tumor margin status in cervical cancer and pre-cancer patients is associated with repeat procedures and an increased risk of recurrence and progression. This review will outline information regarding the current treatment options for women who wish to maintain fertility, the methods currently used in practice to evaluate tumor margin involvement, and a look at potential solutions to this critical issue.

METHOD

We performed a PUBMED literature search of relevant research articles pertaining to tumor margin evaluation for multiple cancers, current treatment options for patients of cervical dysplasia and the effects of those treatments on fertility.

RESULTS

Previous studies have correlated cancer recurrence and progression to obtaining clear margins upon resection. The most common need to obtain clear margins with respect to conservative treatment in patients with cervical neoplasia occurs with women who wish to preserve fertility. However, current detection methods are limited and current treatments present additional fertility concerns.

CONCLUSION

In order to provide the best care for patients wishing to retain fertility post-treatment for cervical dysplasia, a superior option for detecting tumor margins accurately at the microscopic scale must be further explored.