Does histology influence prognosis in patients with early-stage cervical carcinoma?

Time Trends for Incidence and Net Survival of Cervical Cancer in Sweden 1960-2014-A Nationwide Population-Based Study

BACKGROUND

The aim was to investigate time trends for incidence and long-term net survival in the morphologic subtypes and stages of cervical cancer in Sweden during the period 1960 to 2014.

METHODS

Women with invasive cervical cancer were identified through the Swedish Cancer Registry. Incidence and net survival were calculated according to morphology, age at diagnosis, and FIGO stage at diagnosis.

RESULTS

In total, 29,579 cases of invasive cervical cancer between 1960 and 2014 were included. The age-standardized incidence for squamous cell carcinoma (SCC) decreased until 2000; thereafter, the incidence rate stagnated, and a small increase was found in 2014. The incidence of adenocarcinoma continuously increased. The age-standardized 5-year net survival increased. However, decreasing net survival with increasing age was found. A higher stage at diagnosis showed a worse net survival. SCC and adenocarcinoma did not statistically differ as regards net survival in the last years of the study.

CONCLUSIONS

Age-standardized 5-year net survival improved between 1960 and 2014. A positive trend for short- and long-term net survival was seen for women ages 18 to 64 years but long-term net survival for women ≥75 years decreased. In this study, age and FIGO stage at diagnosis were found to be important prognostic factors in determining net survival. The morphologies, SCC, and adenocarcinoma did not statistically differ as regards net survival in the last years of the study.

IMPACT

This study demonstrates longitudinal data on cervical cancer in Sweden for over 50 years with sub analyses on morphology, age, and stage at diagnosis.

Tumor histology is an independent prognostic factor in locally advanced cervical carcinoma: A retrospective study

Background

Even with different histologic origins, squamous cell carcinoma (SCC) and adenocarcinoma (AC) are considered a single entity, and the first-line treatment is the same. Locally advanced disease at the diagnosis of cervical cancer is the most important prognostic factor, the recurrence rate is high, making it necessary to evaluate prognostic factors other than clinical or radiological staging; histology could be one of them but continues to be controversial. The aim of this study was to evaluate tumor histology as a prognostic factor in terms of treatment outcomes, disease-free survival (DFS) and overall survival (OS) in a retrospective cohort of patients with Locally Advanced Cervical Carcinoma (LACC).

Methods

The records of 1291patients with LACC were reviewed, all of them were treated with 45–50 Gy of external beam radiotherapy with concurrent chemotherapy and brachytherapy. A descriptive and comparative analysis was conducted. Treatment response was analyzed by the chi-square test; DFS and OS were calculated for each histology with the Kaplan–Meier method and compared with the log-rank test; and the Cox model was applied for the multivariate analysis.

Results

We included 1291 patients with LACC treated from 2005 to 2014, of which 1154 (89·4%) had SCC and 137 (10·6%) had AC. Complete response to treatment was achieved in 933 (80·8%) patients with SCC and 113 (82·5%) patients with AC. Recurrence of the disease was reported in 29·9% of SCC patients and 31·9% of AC patients. Five-year DFS was 70% for SCC and 62·2% for AC. The five-year OS rates were 74·3% and 60% for SCC and AC, respectively. The mean DFS was 48·8 months for SCC vs 46·10 for AC (p = 0·043), the mean OS was 50·8 for SCC and 47·0 for AC (p = 0·002).

Conclusion

Our findings support the hypothesis that SCC and AC are different clinical entities.

Trial Registration

NCT04537273.

The association between expression of p53 and aggressiveness of serous adenocarcinoma of the uterine cervix

Background:

Serous adenocarcinoma of the uterine cervix is an extremely rare variant of cervical adenocarcinoma. This study aimed to evaluate the clinicopathological and molecular features and outcomes of serous adenocarcinoma of the uterine cervix (SACC).

Materials and Methods:

This was a retrospective study conducted based on the clinical and pathological data of seven patients diagnosed with SACC after hysterectomy, who were evaluated at the gynecologic oncologic centers between 2010 and 2019.

Results:

Five cases were diagnosed at Stage IB and two at Stage IV. All patients underwent radical hysterectomy with bilateral salpingo-oophorectomy and subsequently received postoperative radiotherapy or chemotherapy. One patient showed persistent disease, and two patients suffered recurrence. Immunohistochemical study showed that three (43%) of the seven patients were positive for p53, and among these three patients, two with diffuse strong p53 expression experienced an aggressive course with recurrences at pelvic lymph nodes, lung, and brain.

Conclusion:

High p53 expression and advanced stage may be associated with poorer clinical outcomes in SACC, which suggest that immunohistochemistry may contribute to the prediction of prognosis.

Cervical cancer in women aged 25 years or younger: a retrospective study

Purpose

The incidence of cervical cancer in young women is increasing. This study aimed to analyze the clinicopathological characteristics, treatment, and prognoses of women aged ≤25 years with cervical cancer.

Patients and methods

Medical record data of 60 cervical cancer patients aged ≤25 years treated at Peking Union Medical College Hospital between January 1986 and December 2017 were reviewed. The overall survival rate was estimated using the Kaplan–Meier method. Prognosis-related risk factors were analyzed using univariate and multivariate analyses.

Results

Among the 60 patients, 44 (73.3%) were diagnosed with cervical carcinoma and 16 (26.7%) with cervical sarcoma. In the cervical carcinoma group, the most common histology was squamous cell carcinoma (n=22, 50.0%) followed by adenocarcinoma (n=18, 40.9%). Notably, clear cell carcinoma dominated cervical adenocarcinomas at 61.1% (11/18). In the cervical sarcoma group, embryonal rhabdomyosarcoma comprised 50% of the cases (8/16). A total of eleven patients with cervical carcinoma underwent fertility-sparing surgeries, and the live birth rate approached 66.7%. The estimated 5-year overall survival rate of the entire cohort was 79.8% with no statistically significant difference between the carcinoma and sarcoma groups (74.3% vs 93.3%, P=0.14). Stage (RR 6.71, 95% CI 1.366–32.970, P=0.019) and lymph node metastasis (RR 9.09, 95% CI 1.050–78.732, P=0.045) were independent risk factors for poor prognosis in those young patients with cervical carcinoma.

Conclusion

Adenocarcinoma and sarcoma of the cervix comprise the majority of cervical cancer in young women; their overall prognoses are not worse than older patients; the survival rates tend to vary widely according to histologic subtypes.

Rare Pelvic Malignant Tumors in Adults: Treatment Features and Clinical Outcome in Nonmetastatic Disease (Single Institution Experience)

BACKGROUND

Nearly 200 cancers repertories are rare, and more than 20% are pelvic neoplasia. Diagnosis and treatment are challenging, even in reference centers, and survival is influenced by the aggressiveness of certain histologies and absence of a standard of care.

PATIENTS AND METHODS

The authors report the results of a retrospective analysis of patients that attended the Institute of Oncology, Bucharest, between 2004 and 2015, for nonmetastatic pelvic malignant tumor treatment and follow-up. The outcomes are compared between the rare and common histology groups.

RESULTS

Of the 60 cases analyzed, 17 patients (28.33%) bore a rare tumor, 33 (55%) were women, and the median age was 59 years. The majority was concerned by bladder (41.66%, 25 patients) and cervix (23.33%, 14 patients) neoplasms. For a median follow-up of 27.5 months, relapse was registered in 27 patients (45%), of whom 9 (33.33%) were from the rare group (53% of this subpopulation). The highest relapse rates were recorded in patients with rare bladder tumors (66.7%, 4 patients) compared with 42.1% (8 patients) in the common group (p = 0.294) and in prostate localization (66.7%, 2 patients) compared with 16.7% (1 patient) (p = 0.134). Estimated median relapse-free survival (RFS) was 60, 12 months in the rare group and 67 months for common tumors.

CONCLUSIONS

In nonmetastatic rare pelvic tumor patients, the outcome was found to be poorer than in those concerned by common histologies stratified by organ. A higher rate of relapse and the lowest median RFS were observed in bladder and prostatic cancers.

Pathology Consultation for the Gynecologic Oncologist: What the Surgeon Wants to Know

CONTEXT.—

Clinical management of gynecologic malignancies is often multimodal. Pathologic diagnoses, patient-related factors, and disease-related factors all contribute to clinical decision making.

OBJECTIVE.—

To review the role of surgical pathology in treatment planning among women with gynecologic malignancies.

DATA SOURCES.—

An analysis of relevant literature (PubMed Plus [National Center for Biotechnology Information, Bethesda, Maryland] and Medline [Ovid, New York, New York]) and the authors' clinical practice experience were used.

CONCLUSIONS.—

Pathologic evaluation of gynecologic malignancies with traditional histopathology, assessment of genetic alterations, and identification of tumor biomarkers are critical to traditional treatment planning as well as for ongoing clinical trials.

Extraperitoneal lymph node dissection in locally advanced cervical cancer; the prognostic factors associated with survival

Objective:

Surgical staging was recently recommended for the decision of treatment in locally advanced cervical cancer. We aimed to investigate clinical outcomes as well as factors associated with overall survival (OS) in patients with locally advanced cervical cancer who had undergone extraperitoneal lymph node dissection and were managed according to their lymph node status.

Material and Methods:

The medical records of 233 women with stage IIb-IVa cervical cancer who were clinically staged and underwent extraperitoneal lymph node dissection were retrospectively reviewed. Paraaortic lymph node status determined the appropriate radiotherapeutic treatment field. Surgery-related complications and clinical outcomes were evaluated.

Results:

The median age of the patients was 52 years (range, 26-88 years) and the median follow-up time was 28.4 months (range, 3-141 months). Thirty-one patients had laparoscopic extraperitoneal lymph node dissection and 202 patients underwent laparotomy. The number of paraaortic lymph nodes extracted was similar for both techniques. Sixty-two (27%) of the 233 patients had paraaortic lymph node metastases. The 3-year and 5-year OS rates were 55.1% and 46.5%, respectively. The stage of disease, number of metastatic paraaortic lymph nodes, tumor type, and paraaortic lymph node status were associated with OS. In multivariate Cox regression analyses, tumor type, stage, and presence of paraaortic lymph node metastases were the independent prognostic factors of OS.

Conclusion:

Paraaortic lymph node metastasis is the most important prognostic factor affecting survival. Surgery would give hints about the prognosis and treatment planning of the patient.

The prognostic impact of histological type on clinical outcomes of early-stage cervical cancer patients whom have been treated with radical surgery

The aim of this study was to determine the prognostic impact of histological type among squamous cell carcinoma (SCC), adenocarcinoma (AC) and adenosquamous carcinoma (ASC) on the treatment outcome of early-stage cervical cancer patients after radical hysterectomy. The cohort comprised of 626 patients, diagnosed with stages IA2-IB1 cervical cancer between 1987 and 2013. Four hundred and one patients had SCC, 190 had AC and 35 had ASC. The 5-year disease-free survival (DFS) rates for AC, SCC and ASC were 89.3% (95%CI 83.2-93.2), 88.7% (95%CI 84.8-91.7) and 82.1% (95%CI 61.9-92.2), respectively (p = .594). In multivariate analyses, only older age and deep stromal invasion were statistically significantly associated with DFS, whereas histologic cell type was not (p = .524). Subgroup analysis showed that in the intermediate-high-risk groups, the SCC group had a significantly longer DFS, compared with the AC group or the ASC group (p = .001) while there was no DFS difference in the low-risk group. We believe that histologic cell type had no impact in low-risk early-stage cervical cancer patients. However, in the intermediate-high-risk groups, SCC is a more favourable factor for survival than AC/ASC.

Clinical outcomes in patients treated with radiotherapy after surgery for cervical cancer

Purpose

The purpose of this study was to analyze clinical outcomes from cervical cancer and stratify patients into risk groups for prognostic factors for early-stage disease.

Materials and Methods

We retrospectively reviewed patients with stage IB or IIA cervical cancer treated with adjuvant radiotherapy (RT) or concurrent chemoradiotherapy (CCRT) following primary surgery at Samsung Medical Center from 2001 to 2011. Adjuvant RT was added for patients with intermediate-risk factors, and adjuvant CCRT was performed on high-risk patients after surgery.

Results

We reviewed 247 patients—149 in the high-risk group and 98 in intermediate-risk group. The median follow-up was 62 months. Loco-regional failure (LRF) alone occurred in 7 patients (2.8%), distant metastasis alone in 37 patients (15.0%) and LRF with DM in 4 patients (1.6%). The 5-year disease-free survival (DFS) and overall survival (OS) rates for both groups were 79.7% and 87.6%, respectively. In the high-risk group, the 5-year DFS and OS probabilities were 72.5% and 81.9%, respectively. Histologic type, pathologic tumor size, and the number of pelvic lymph node (PLN) metastasis were significant prognostic factors for DFS and OS. We suggest a scoring system (0–3) using these prognostic factors to predict poor prognosis in high-risk patients. Using this system, patients with higher scores have higher recurrence and lower survival rates.

Conclusion

In the high-risk cervical-cancer group who received primary surgery and adjuvant CCRT, non-squamous type, large tumor size and the number of PLN metastasis were significant prognostic factors, and the number of these factors was associated with survival rates.

Targeted PI3K/AKT/mTOR therapy for metastatic carcinomas of the cervix: A phase I clinical experience

Background

Activated PI3K/AKT/mTOR pathway frequently occurs in metastatic or recurrent cervical carcinomas. However, the clinical benefits of matched therapy, a therapeutic approach targeting a specific mutational abnormality, have not yet been established.

Methods

We analyzed the outcomes of patients with metastatic or recurrent cervical carcinomas who had a test for PIK3CA mutation and/or PTEN loss/mutation, and received ≥1 phase I therapeutic regimen between January 2006 and June 2013.

Results

Patients with adenocarcinoma had fewer PIK3CA mutations (14%), and survived longer (median, 14.2 months) than those with squamous cell carcinoma (48% and 7.2 months; p = 0.016, and 0.001, respectively). Matched therapy targeting the activated PI3K/AKT/mTOR pathway led to a favorable rate of SD ≥ 6 months/CR/PR (53%) and significantly longer progression-free survival (median, 6.0 months) than non-matched therapy (11% and 1.5 months; p = 0.08 and 0.026; respectively). In patients with squamous cell carcinoma of the cervix, the presence of PIK3CA mutations was associated with a significantly longer overall survival (median, 9.4 months) than the absence of PIK3CA mutations (median, 4.2 months; p = 0.019).

Conclusions

Matched therapy targeting the activated PI3K/AKT/mTOR pathway provided meaningful clinical benefits. Thus, further evaluation of PI3K/AKT/mTOR pathway targeted therapy is warranted, especially in metastatic or recurrent squamous cell carcinoma.

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.

Surveillance epidemiology and end results analysis demonstrates improvement in overall survival for cervical cancer patients treated in the era of concurrent chemoradiotherapy

Background

In February 1999, the National Cancer Institute (NCI) issued a clinical alert based on five randomized trials that reported better overall survival (OS) with concurrent chemoradiotherapy (CCRT) than with surgery or radiation alone for locoregional cervical cancer. This study analyzes data from the surveillance epidemiology and end results (SEER) program to evaluate the improvement in survival in the era of CCRT.

Methods

The SEER database was queried for FIGO stages IB2–IVA cervical cancer patients treated with radiotherapy between 1995 and 2002. Patients diagnosed between 1999 and 2002 (CCRT era) were assumed to have received CCRT more frequently than patients diagnosed between 1995 and 1998 (RT era). Cases were stratified by period of diagnosis, age, and SEER region. OS and cause specific survival (CSS) were compared between the two time periods with chi-square log-rank tests. Multivariable Cox models were also used to compare OS and CSS between the two time periods, with adjustment for stratification variables and other covariates.

Results

The study included 3517 patients. Unadjusted OS and CSS were significantly improved in 1999–2002 compared with 1995–1998 (OS: p < 0.001, hazard ratio (HR): 0.81; CSS: p < 0.001, HR: 0.79). Significant improvements in OS and CSS were retained after adjustment for multiple variables (multivariable OS HR 0.78; CSS HR 0.76).

Conclusion

Cervical cancer patients treated with radiotherapy after 1999 had improved OS and CSS compared with patients treated before 1999, likely reflecting increased usage of CCRT. This study adds to the population-level evidence supporting the adoption of CCRT as the standard of care for locoregional cervical cancer.

Comparison of adenocarcinoma and adenosquamous carcinoma in patients with early-stage cervical cancer after radical surgery

OBJECTIVE

To compare outcomes after radical hysterectomy in patients with stage IB1 adenocarcinoma (AdCa) and adenosquamous carcinoma (AdSCCa) of the uterine cervix.

METHODS

We performed a retrospective analysis of 265 patients with AdCa and 72 patients with AdSCCa. Demographic, clinicopathologic, surgical, and follow-up data were compared.

RESULTS

There were no differences in demographic and clinicopathologic characteristics between the two histologic types (AdCa vs. AdSCCa). Only mean size of tumor and lymphovascular space invasion was larger and more frequent in AdSCCa (2.7 cm vs 2.3 cm, P=0.019 & 29.2% vs 14.7%, P=0.008). After a median follow-up time of 68 months, 39 (14.7%) and 13 (18.1%) AdCa and AdSCCa patients, respectively, had recurrent disease (P=0.467), and 33 (12.5%) and 11 (15.3%) patients, respectively, died of their disease (P=0.555). 5-year RFS rates were 89% and 85% (P=0.582), respectively, and 5-year OS rates were 93% and 89% (P=0.787). Histologic type had no clinical impact on RFS and OS in multivariate analysis adjusting for significant prognostic factors. There were no differences in pattern of recurrence and time to recurrence between the two histologic types. When patients were stratified into three risk groups according to the criteria of GOG protocols 92 and 109, histologic type had no clinical impact on RFS and OS in any of the risk groups.

CONCLUSION

There are no differences in clinicopathologic factors, patterns of recurrence, time to recurrence, RFS and OS between patients with AdCa and AdSCCa.

Comparison of outcomes between squamous cell carcinoma and adenocarcinoma in patients with surgically treated stage I-II cervical cancer

To improve our understanding of cervical adenocarcinoma (AD) and evaluate the clinical and pathological variables affecting its prognosis, we retrospectively reviewed the medical records of 455 patients with cervical cancer [International Federation of Gynecology and Obstetrics stage I/II; 91 cases with AD and 364 with squamous cell carcinoma (SCC)] who underwent surgery at our hospital between January, 1995 and August, 2012 and compared the characteristics and prognoses between AD and SCC cases, including age, clinical stage, histological type, lymph node metastasis, lymphovascular space invasion (LVSI), cervical stromal invasion, parametrial invasion, vaginal invasion, corpus invasion, ovarian metastasis and tumor diameter. We used Cox regression analysis to determine independent prognostic factors. AD was found to have a significantly poorer prognosis in all the patients (P=0.001), stage I patients (P=0.001) and stage IB patients (P<0.05). The prognosis did not differ in patients who did not require postoperative treatment; however, patients who received postoperative treatment exhibited a significantly poorer prognosis (P<0.05). Patients with AD who received postoperative irradiation alone had a significantly poorer prognosis (P<0.05). The multivariate analysis identified LVSI (P=0.008), stromal invasion (P=0.024) and ovarian metastasis (P=0.032) as independent predictors of shorter survival. AD was associated with a worse prognosis compared to SCC in patients with stage IB disease, particularly in those who required postoperative treatment. Such patients may benefit from individualized postoperative treatments that differ from those applied for SCC.

Intraoperative radiotherapy in stage IIB adenocarcinoma of the uterine cervix: a retrospective study

Objectives

Adenocarcinoma (AC) of the uterine cervix has a poor prognosis and is usually fatal. The aim of this study was to evaluate the clinical outcome and toxicity of intraoperative electron beam radiation therapy (IOERT) in advanced AC.

Methods

Twenty-seven women were treated with IOERT. Surgery consisted of gross negative surgical margins in 19 patients, positive surgical margins in two patients, and close surgical margins in six patients. Twenty-three patients received chemotherapy.

Results

The 5-year overall survival and disease-free survival rates were 21/27 (77.8%) and 19/27 (70.4%), respectively. A significantly better survival rate was found in patients with AC compared to patients with adenosquamous carcinoma. Tumor recurrence and metastasis were observed in seven patients (25.9%). No central failure occurred whether or not the resection margins were positive. Two (7.4%) patients developed peripheral neurotoxicity.

Conclusion

IOERT plus surgery may be feasible and effective with a low risk of toxicity, even in patients with positive resection margins.

Comprehensive clinic-pathological characteristics of cervical cancer in southwestern China and the clinical significance of histological type and lymph node metastases in young patients

OBJECTIVE

To analyze the clinic-pathological characteristics of women with cervical cancers in southwestern China and discuss the features and prognosis of young patients.

METHODS

A retrospective study was performed, which consisted of 1,543 patients diagnosed with cervical cancer and underwent treatment at West China Second University Hospital between November 2005 and December 2010. Among them, 154 young patients with surgical procedures between November 2005 and December 2008 were selected for a 5-year follow-up and prognostic analysis.

RESULTS

The proportion of advanced FIGO stage in patients aged over 35 years was higher than in patients aged 35 years or younger (55.1% vs 38.8%, P<0.001), and strong correlation was found between FIGO stages and the postoperative pathological risk factors (P<0.05). 312 patients (20.2%) were under 35 years old in the last 5 years. The proportion of cervical adenocarcinoma remained high in young patients (13.6%), and young women with adenocarcinoma had a higher rate of LN metastases, comparing with those with squamous cell carcinoma (42.9% vs 15.8%, P = 0.004). Young patients with adenocarcinoma had shorter progression-free survival than those who had squamous cell carcinoma (P = 0.024). Patients aged 35 years or younger with positive postoperative pathological risk factors had shorter progression-free survival, comparing with those with negative factors (P<0.01).

CONCLUSION

Patients over 35 years were preliminarily diagnosed as advanced FIGO stage and they were more likely to have deep stromal invasion, LVSI, LN metastases, parametrial and surgical margin involvement. Regarding to young patients, cervical adenocarcinoma increased the risk of LN metastases and positive postoperative pathological risk factors could apparently worsen the prognosis. Histological type and LN metastases were independent prognostic factors for young patients in southwestern China. We re-emphasize the importance of health education and regular smear screening for elder women, and more attention should be paid to young patients with adenocarcinoma or LN metastases.

Multivariate prognostic analysis of adenocarcinoma of the uterine cervix treated with radical hysterectomy and systematic lymphadenectomy

Objective

The aim of this study was to investigate the prognostic factors and treatment outcome of patients with adenocarcinoma of the uterine cervix who underwent radical hysterectomy with systematic lymphadenectomy.

Methods

A total of 130 patients with stage IB to IIB cervical adenocarcinoma treated with hysterectomy and systematic lymphadenectomy from 1982 to 2005 were retrospectively analyzed. Clinicopathological data including age, stage, tumor size, the number of positive node sites, lymphovascular space invasion, parametrial invasion, deep stromal invasion (>2/3 thickness), corpus invasion, vaginal infiltration, and ovarian metastasis, adjuvant therapy, and survival were collected and Cox regression analysis was used to determine independent prognostic factors.

Results

An estimated five-year survival rate of stage IB1 was 96.6%, 75.0% in stage IB2, 100% in stage IIA, and 52.8% in stage IIB. Prognosis of patients with one positive-node site is similar to that of those with negative-node. Prognosis of patients with multiple positive-node sites was significantly poorer than that of negative and one positive-node site. Multivariate analysis revealed that lymph node metastasis, lymphovascular space invasion, and parametrial invasion were independent prognostic factors for cervical adenocarcinoma. Survival of patients with cervical adenocarcinoma was stratified into three groups by the combination of three independent prognostic factors.

Conclusion

Lymph node metastasis, lymphovascular space invasion, and parametrial invasion were shown to be independent prognostic factors for cervical adenocarcinoma treated with hysterectomy and systematic lymphadenectomy.

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.

Fertility-preserving surgery in patients with early stage cervical carcinoma

Fertility preservation is an important issue for patients in reproductive age with early stage cervical cancer. In view of recent developments, our purpose was to review and discuss available surgical alternatives. A literature search was conducted using PUBMED, including papers between 1980 and December 2011. In patients with stage IA1 cervical cancer, conization is a valid alternative. Patients with stage IA2-IB1 disease can be conservatively treated by radical trachelectomy. This is as well-established conservative approach and appears to be safe and effective in allowing a high chance of conception. Prematurity is the most serious issue in pregnancies following trachelectomy. Less invasive options such as simple trachelectomy or conization seem to be feasible for stages IA2-IB1, but more and better evidence is needed. Neoadjuvant therapy might allow conservative surgery to be performed also in patients with more extensive lesions. Ovarian transposition is important when adjuvant radiation is needed. In conclusion, available literature shows that there are interesting fertility-sparing treatment alternatives to the “golden standard” for the management of early cervical cancer in young women.

Serous adenocarcinoma of the uterine cervix: a clinicopathological study of 12 cases and a review of the literature

BACKGROUND/AIMS

To determine the clinicopathological characteristics and potentially associated outcomes in patients diagnosed with serous adenocarcinoma of the uterine cervix.

METHODS

The records of surgically-treated patients with pathological stage pT1b-2b serous adenocarcinoma were reviewed.

RESULTS

Of 12 patients with serous adenocarcinoma who underwent radical hysterectomy, five had pT1b1N0 disease, two pT1b1N1, two pT1b2N0, and three pT2bN1. The 5-year overall survival rate for patients with or without parametrial involvement (pT2b vs. pT1b) was 0 and 89%, respectively. The 3-year recurrence-free survival rate for those with or without parametrial involvement was 33 and 89%, respectively. Four patients suffered recurrence, namely one of those who had pT1b (1/9, 11%) and 3 of those who had pT2b disease (100%). The sites of recurrence of pT2b disease were outside the pelvis in all 3 patients. Of these, 2 (67%) had peritoneal spread and 1 distant node metastasis.

CONCLUSION

While patients with pathological stage pT1b disease may have a relatively favorable outcome after radical surgery, those with more advanced disease have a poor prognosis because of extra-pelvic recurrence.

Early adenocarcinoma of the cervix: is radical vaginal trachelectomy safe?

OBJECTIVE

Radical vaginal trachelectomy (RVT) is a revolutionary option for fertility preservation in young women with early cervical tumors. Several series have demonstrated outcomes comparable to radical hysterectomy (RH), but none has addressed the influence of histology. We evaluated the safety of RVT in adenocarcinomas.

METHODS

Data on surgically treated adenocarcinoma (AC) and squamous cell carcinoma (SCC) cases was taken from a centralized Toronto Cervical Cancer Database. Prognostically important tumor features, lymph node status, and the use of adjuvant therapies were compared. Adenocarcinoma cases treated with RVT were compared to AC cases treated with RH, and to SCC cases that had RVT. Recurrence-free survival was calculated from the date of surgery. Medians, proportions, and survival curves were compared with the Mann Whitney test, the Chi-square test, and the Log Rank test, respectively.

RESULTS

74 patients with AC and 66 patients with SCC undergoing RVT, and 187 cases of AC undergoing RH were analyzed. Patients undergoing RVT were younger than patients having RH (31 vs. 40, p<0.001). Tumor characteristics were similar, but depth of invasion and the frequency of high grade lesions were higher in the RH group (5 mm vs. 3 mm, p<0.001; and 36% vs. 22%, p=0.04). Adjuvant treatment was given more frequently after RH (12% vs. 3%, p<0.05). There was no significant difference in recurrence-free survival between RH and RVT for AC, or between AC and SCC patients treated by RVT.

CONCLUSIONS

RVT is a safe alternative for early stage cervical adenocarcinoma in appropriately selected patients wishing to preserve fertility.

Neoplastic Lesions of the Cervix

This review presents a discussion of the gross and microscopic features, diagnosis, differential diagnosis, and prognosis of neoplastic lesions of the cervix. Biomarkers are discussed for each entity presented - cervical intraepithelial neoplasia, squamous carcinoma, glandular neoplasms, adenocarcinoma in situ, adenosquamous carcinoma, and others.

A comparison of pure adenocarcinoma and squamous cell carcinoma of the cervix after radical hysterectomy in stage IB-IIA

OBJECTIVE

This study was designed to investigate the survival difference between pure adenocarcinoma (AC) and squamous cell carcinoma (SCC) in early cervical cancer (FIGO stage IB-IIA) after radical hysterectomy with or without adjuvant therapy performed at a single institution.

METHODS

Patients with AC or SCC between November 1994 and September 2007 at the Samsung Medical Center, Sungkyunkwan University School of Medicine in Seoul, Korea were evaluated.

RESULTS

Among the 775 patients, 636 patients had SCC, and 139 patients had pure AC. In basal characteristics, preoperative FIGO stage, adjuvant therapy after surgery, as well as chemotherapeutic regimens, were not different between the two groups. However, the median age was about 5 years younger in pure AC patients than in SCC patients (44 years vs. 49 years, P=.001). In the comparison of pathological findings after surgery between the two groups, there were no differences between the two groups, except for LVSI status. The recurrence rate was higher in the pure AC group than in the SCC group (SCC; 36/636; 5.7%, AC; 20/139; 14.4%, P=<0.001, respectively). The pure AC group had a higher recurrence rate in hematogenous/distant areas than the SCC group (SCC: 8/36; 22.2%, AC; 9/20; 45.0%, P=.076, respectively). In multivariable analysis, positive for pelvic LN and the pure AC cell type were independent factors in both DFS and OS.

CONCLUSION

We observed that pure AC of the cervix might entail a worse survival outcome than SCC in patients with early cervical cancer (IB-IIA).

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.

Prognostic factors in stage IB-IIB cervical adenocarcinoma patients treated with radical hysterectomy and pelvic lymphadenectomy

OBJECTIVES

The purpose of the present study was to identify prognostic factors and patterns of recurrence in patients with stage IB-IIB cervical adenocarcinoma who had undergone radical surgery and to compare these patterns with those observed in squamous cell carcinoma (SCC) patients.

METHODS

We retrospectively reviewed 303 patients (97 with adenocarcinoma and 206 with SCC) with stage IB-IIB cervical cancer who had undergone radical hysterectomy and pelvic lymphadenectomy.

RESULTS

In the case of the adenocarcinoma patients, lymph node metastasis and parametrial invasion were independent indicators of disease-free survival, whereas lymph node metastasis was the only independent prognostic factor for the overall survival of the patients. The sites of recurrence did not significantly differ between the adenocarcinoma and SCC patients. In parametrium-positive patients, adenocarcinoma was found to be an independent prognostic factor for disease-free survival. In patients with positive pelvic lymph node, adenocarcinoma was found to be an independent prognostic factor for both disease-free and overall survival.

CONCLUSIONS

Adenocarcinoma was found to be an independent prognostic factor for survival in patients with positive pelvic node or parametrial extension. Furthermore, the patterns of recurrence did not differ significantly between the adenocarcinoma and SCC patients.

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.

Adenocarcinoma: a unique cervical cancer

Adenocarcinoma of the cervix constitutes only approximately 20% of all cervical carcinomas; therefore, specific Level 1 evidence to guide patient management is lacking. Most trials have included this histologic subtype but in insufficient numbers to do more than generate hypotheses from subset analyses. As a consequence, our understanding of the natural history and optimal management of adenocarcinoma of the cervix is limited. The optimal management of adenocarcinoma of the cervix continues to be a subject of debate among practitioners as to whether or not it should be different from squamous cell carcinoma and what would constitute this management. The purpose of this review was to give an overview of the current knowledge on adenocarcinoma of the cervix and its differences from squamous cell carcinoma with regard to risk factors, prognosis, survival rates, patterns of recurrence, and response to treatment. This article will focus on possible specific therapeutic directions to explore in the management of locally advanced adenocarcinomas.

Aggressive characteristics of cervical cancer in young women in Taiwan

OBJECTIVE

To compare the characteristics and prognosis of cervical cancer in young women (under 30 years) with those of older women (over 30 years).

METHODS

A retrospective study of 2443 patients diagnosed with FIGO stage IA-IIA cervical cancer who underwent surgical procedures between January 1983 and December 2007.

RESULTS

Thirty patients (1.2%) were 30 years or younger. The proportion of non-squamous cell carcinoma was higher in patients 30 years or younger compared with in patients over 30 years (14/30, 46.7% vs 10/30, 33.3%; P=0.001). A higher rate of parametrial involvement was found in the younger group of patients compared with those over 30 years (10/30, 33.3% vs 289/2413, 12.0%; P=0.001). Patients under 30 years had a higher rate of distant metastases compared with older patients (60% vs 49.7%; P=0.036).

CONCLUSIONS

Non-squamous histology, parametrial involvement, a higher rate of distant metastases, and poorer prognosis are more common in women aged 30 or younger with cervical cancer than in older women with the disease.

Radical hysterectomy for FIGO stage I-IIB adenocarcinoma of the uterine cervix

A retrospective analysis was carried out to identify risk factors for survival and relapse in patients with FIGO stage I–IIB cervical adenocarcinoma (AC), who underwent radical hysterectomy, and to compare outcome and spread pattern with those of squamous cell carcinoma (SCC). One hundred and twenty-three FIGO stage I–IIB patients with AC and 455 patients with SCC, who all underwent primary radical hysterectomy, were reviewed. Among the patients with AC, Cox model identified tumour size (95% CI: 1.35–30.71) and node metastasis (95% CI: 5.09–53.44) as independent prognostic factors for survival, and infiltration to vagina (95% CI: 1.15–5.76) and node metastasis (95% CI: 6.39–58.87) as independent prognostic factors for relapse. No significant difference was found in survival or relapse between the AC and SCC groups, after adjusting for other clinicopathological characteristics using Cox model. No significant difference was found in the positive rates of lymph nodes or location of initial failure sites between the two groups, but ovarian metastatic rate was significantly higher in patients with pathologic stage IIB AC (P=0.02). Positive node is a common independent prognostic factor for survival and relapse of patients with AC. FIGO stage I–IIB patients with AC or SCC, who underwent radical hysterectomy, have similar prognosis and spread pattern, but different ovarian metastasis rates.

Effectiveness of preoperative concurrent chemoradiation therapy (CCRT) for locally advanced adenocarcinoma of cervix

AIM

To determine the efficacy of preoperative concurrent chemoradiation therapy (CCRT) to improve the prognosis of locally advanced adenocarcinoma of the uterine cervix.

METHODS

Twenty-five patients with clinical stage IB2-IVB adenocarcinoma of the cervix were received preoperative CCRT. The CCRT protocol included: external radiotherapy to the pelvis: 39.6 Gy; intra-arterial or intravenous infusion of 70 mg/m2 cisplatin, days 1 and 22; 24-h continuous intravenous infusion of 700 mg/m2 5-FU, days 1-4 and 22-25. Two weeks after the end of CCRT, patients underwent restaging followed by appropriate surgery with pelvic lymphadenectomy.

RESULTS

The overall clinical response rate was 96% (24/25), with a complete response (CR) in 12/25 patients and partial response (PR) in 12/25. On pathological examination, 5 of 19 patients (26%) undergoing surgery showed a pathological CR, 13 patients showed a PR, and 1 patient no change (NC) in their disease. Grade 3 or 4 hematological toxicity was observed in 15 patients. Grade 3 gastrointestinal toxicity was observed in 8 patients. The median follow-up period was 34 months (range, 6-69). The 5-year overall survival (OS) rate was 84%, and the progression-free survival (PFS) rate was 76%.

CONCLUSIONS

Preoperative CCRT improves the survival of patients with locally advanced adenocarcinoma of the cervix, with manageable toxicities.

Cap43/NDRG1/Drg-1 is a molecular target for angiogenesis and a prognostic indicator in cervical adenocarcinoma

Cap43 is a nickel- and calcium-inducible gene that plays important roles in the primary growth of malignant tumors, as well as in invasion and metastasis, most likely through its ability to induce cellular differentiation. This study investigated associations of Cap43 expression with angiogenesis and other clinicopathological factors in cervical adenocarcinoma. The clinical records of 100 women who underwent surgery for cervical adenocarcinoma were reviewed retrospectively. Microvessel density and the expression of Cap43 and VEGF in the surgical specimens were evaluated immunohistochemically. The Cap43 expression level was significantly associated with angiogenesis, tumor diameter, stromal invasion, lymphovascular space invasion, lymph node metastasis, and histopathological differentiation. Kaplan-Meier analysis showed a significant association between the Cap43 expression level and survival: high Cap43 expression was related to poor survival. Our results suggest that increased expression of Cap43 is associated with angiogenesis and may be a poor prognostic indicator in women with cervical adenocarcinoma.

Salvaging locoregional recurrence with radiotherapy after surgery in early cervical cancer

AIMS

To determine the outcome and morbidity after radiotherapy for locally recurrent cervical cancer.

MATERIALS AND METHODS

Women who presented with locally recurrent cervical cancer after surgery alone during 1985 and 1997 were identified from the hospital database. Data were collected and analysed to include the stage at first diagnosis, staging investigations before surgery, the surgical procedure, the indication for radiotherapy, the type of radiotherapy, morbidity and survival.

RESULTS

In total, 130 women had radical external beam radiotherapy and/or intracavitary brachytherapy for locoregional recurrence during the defined study period. The 5-year disease-specific survival for the study population was 40.2%. Women who were treated for vault recurrence had a significantly better 5-year disease-free survival compared with women who developed nodal recurrence alone (55.4% vs 12.5%). This group of women also had a significantly slower rate of disease progression after radiotherapy than women with nodal recurrence (48.7% vs 87.5%, P=0.0001).

CONCLUSION

Radical radiotherapy alone is able to salvage 55% of vaginal vault recurrences after surgery for cervical cancer with minimal late toxicity. Salvage rates in women with pelvic nodal recurrences are considerably lower. Chemoradiotherapy using intensity-modulated radiotherapy to deliver an escalated radiotherapy dose needs to be pursued to improve locoregional control.

Prognosis of adenocarcinoma of the uterine cervix: p53 expression correlates with higher incidence of mortality

We investigated the significance of prognostic markers-estrogen receptor, progesterone receptor, p53, MIB-1 and bcl-2 - in adenocarcinoma of the uterine cervix. In 101 patients with primary cervical adenocarcinoma, treated from 1989 to 2000, we evaluated clinical parameters in relation to these prognostic markers. Mean age of patients was 45 years. Seventy eight percent of the patients were in FIGO stage I, 16% stage II, 7% stage III and IV. estrogen receptor, progesterone receptor, p53 and bcl-2 immunoreactivity was scored as 0 (up to 5% positive cells), 1+ (5-25% of cells positive), 2+ (26-50% of cells positive), 3+ (51-75% of cells positive) or 4+ (>76% of cells positive). MIB-1 was scored in 10 categories: 0-10, 11-20, 21-30, 31-40, 41-50, 51-60, 61-70, 71-80, 81-90, 91-100. The overall survival rate was 67%. Survival was not influenced by estrogen receptor, progesterone receptor, MIB-1, or bcl-2 strongly positive staining. Only p53 showed significant influence on survival, even when adjusted for stage or tumor grade. In conclusion, it does not seems useful to determine estrogen receptor, progesterone receptor, MIB-1 or bcl-2 in cervical adenocarcinomas as an indication of prognosis: survival is not influenced by presence or absence. However, if p53 staining is strongly positive survival is significantly worse than in tumors scored as negative or weak positive.

Comparison of biological behavior between early-stage adenocarcinoma and squamous cell carcinoma of the uterine cervix

OBJECTIVES

(1) To compare the anatomopathological variables and recurrence rates in patients with early-stage adenocarcinoma (AC) and squamous cell carcinoma (SCC) of the uterine cervix; (2) to identify the independent risk factors for recurrence.

STUDY DESIGN

This historical cohort study assessed 238 patients with carcinoma of the uterine cervix (IB and IIA), who underwent radical hysterectomy with pelvic lymph node dissection between 1980 and 1999. Comparison of category variables between the two histological types was carried out using the Pearson's chi(2)-test or Fisher exact test. Disease-free survival rates for AC and SCC were calculated using the Kaplan-Meier method and the curves were compared using the log-rank test. The Cox proportional hazards model was used to identify the independent risk factors for recurrence.

RESULTS

There were 35 cases of AC (14.7%) and 203 of SCC (85.3%). AC presented lower histological grade than did SCC (grade 1: 68.6% versus 9.4%; p<0.001), lower rate of lymphovascular space involvement (25.7% versus 53.7%; p=0.002), lower rate of invasion into the middle or deep thirds of the uterine cervix (40.0% versus 80.8%; p<0.001) and lower rate of lymph node metastasis (2.9% versus 16.3%; p=0.036). Although the recurrence rate was lower for AC than for SCC (11.4% versus 15.8%), this difference was not statistically significant (p=0.509). Multivariate analysis identified three independent risk factors for recurrence: presence of metastases in the pelvic lymph nodes, invasion of the deep third of the uterine cervix and absence of or slight inflammatory reaction in the cervix. When these variables were adjusted for the histological type and radiotherapy status, they remained in the model as independent risk factors.

CONCLUSION

The AC group showed less aggressive histological behavior than did the SCC group, but no difference in the disease-free survival rates was noted.

Pathological characteristics of cervical adenocarcinoma in a multi-center U.S.-based study

OBJECTIVE

Difficulties in detecting cervical adenocarcinoma early are well known. We report a detailed pathology review of cervical adenocarcinoma subtypes, comparing growth patterns and appearance of non-neoplastic epithelium to inform possible clues for disease progression and early detection.

METHODS

This analysis includes 154 women aged 18-69 years and diagnosed with incident in situ or invasive adenocarcinoma (AC), adenosquamous (AS), or other rare cervical glandular tumors from 1992-1996 in six U.S. medical centers. A pathology review panel evaluated histological features from original diagnostic slides.

RESULTS

Higher tumor grade (P < 0.001) and vascular invasion (P = 0.002) were more common in AS compared to AC. Adenocarcinoma in situ (AIS) was also more common among AC than AS (P = 0.002). Among AC with cervical intraepithelial carcinoma (CIN), AIS and cribriform patterns were more common than AC without CIN (P = 0.01). Further, non-endometrioid AC had higher tumor grade (P = 0.01) and stromal responses (P = 0.02) than endometrioid AC. Finally, although microglandular hyperplasia is historically thought to be related to oral contraceptive (OC) use, our data do not support this notion.

CONCLUSION(S)

AS appears to be either diagnosed later or histologically more aggressive than AC, and among AC subtypes, there are distinct histologic characteristics. Further research is needed to identify precursor lesions for early detection of AC and particularly for AS where AIS may not be a common precursor.

Immunohistochemical characterization of endocervical papillary serous carcinoma

Endocervical adenocarcinomas are rare and aggressive neoplasms. Papillary serous endocervical adenocarcinomas are the rarest form of endocervical adenocarcinomas. This tumor exhibits morphologic similarities to its counterparts commonly seen in the endometrium, fallopian tubes, ovaries, and peritoneum, which are known to have an aggressive behavior. Because of the rarity of this tumor, little is known about its immunophenotyping. In this study, we included ten cases of papillary serous carcinomas arising from the uterine cervix (PSCC) diagnosed in the absence of a primary endometrial malignancy. We studied their immunohistochemical profile, using a panel of antibodies against Ki67, bcl-2, p53, carcinoembryonic antigen (CEA), and CD10, and compared them to 20 consecutive cases of cervical adenocarcinoma of conventional cell subtypes (CAC) (15 mucinous, 3 adenosquamous, and 2 endometrioid). Immunostaining was recorded semiquantitatively. Patients with PSCC ranged in age from 27 to 79 years (mean = 51.6 +/- 19.1), while the conventional cell subtypes control group were 28-90 years old (mean = 47.5 +/- 16.9). Only p53 and CEA immunostaining significantly correlated with the PSCC morphology (P= 0.001 and P= 0.016, respectively) as shown by Cochran-Mantel-Haenszel Statistics (Modified Ridit Scores). PSCC is a distinctive immunophenotypic subtype of endocervical adenocarcinoma with significantly higher p53 and lower CEA reactivity than other more common histologic subtypes.

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.

Survival in cervix cancer patients treated with radiotherapy followed by radical surgery

AIM

To determine the incidence and predictive value of residual disease in the hysterectomy specimens of cervical cancer patients treated with primary radiotherapy, with or without chemotherapy, followed by surgery and to determine whether pathologically confirmed residual disease is a surrogate marker of outcome.

METHODS

The medical records of patients treated for stage IB/II carcinoma of the cervix in a single institution between 1985 and 2000 were retrospectively analysed into two different groups, depending on whether they had received radiotherapy or concurrent chemo-radiotherapy. Six to 8 weeks after irradiation, all patients underwent radical or extrafascial hysterectomy and pelvic and para-aortic lymphadenectomy.

RESULTS

A total of 403 patients were included in the study (360 in the radiotherapy only group and 43 in the chemo-radiotherapy group). One hundred and seventy-eight patients had residual disease on hysterectomy specimens in the radiotherapy group. Considering only the stages IB2 and II, 126 (52%) and 16 (37%) patients had residual disease on hysterectomy specimens in the radiotherapy group and in the chemo-radiotherapy group, respectively (P=0.08). Residual disease was associated with pelvic and para-aortic nodal metastases. The 5-year local control and overall survival rates were 88 and 86%, respectively, in the patients with complete pathologic response and 73 and 62%, respectively, in the patients with residual disease (P<0.001). In multivariate analysis, FIGO stage, residual disease, and pathologic nodal involvement were independent predictive factors of both local recurrence and overall survival.

CONCLUSION

Pathologically confirmed residual disease on hysterectomy specimen is an independent and strong predictive factor of both local recurrence and overall survival.

The pathology of cervical tumours

Carcinomas of the cervix may be categorized on morphological grounds into four main groups: squamous carcinomas; adenocarcinomas; neuro-endocrine tumours; and others including adenosquamous carcinomas. Each group contains several morphological subvariants. Invasive squamous carcinomas and adenocarcinomas are preceded by cervical intra-epithelial neoplasia and cervical glandular intra-epithelial neoplasia, respectively. Each is graded into low and high grade. Micro-invasive carcinomas with stromal invasion less than 3mm in depth have a minimal chance of lymph node metastasis. When there is lymph node involvement, the obturator node may be the most common. Presence or absence of lymph node involvement, tumour size and depth of invasion are the important independent histopathological indicators of prognosis. The presence or absence of vascular space invasion is a valuable prognostic indicator. Small cell carcinomas, large cell neuro-endocrine carcinomas and possibly adenoid cystic carcinomas are aggressive. With these exceptions, it is doubtful whether tumour type is of much clinical significance. Tumour grade, as currently assessed, is of no significant value.

Histopathologic parameters of prognosis in cervical cancer--a review

Apart from clinical stage and lymph node status, acknowledged to be among the most powerful predictors of outcome in cervical cancer, the determination of prognosis and thereby the need for adjuvant therapy in surgically treated patients currently relies on a variety of histopathologic factors. The role of many of these is controversial. This may be because histopathology is genuinely lacking in sensitivity for predicting tumor behavior in vivo. There is, however, wide variation in histopathologic definitions and criteria. This is probably the major reason for both the lack of reproducibility in the reporting of certain factors and in their diminished value in predicting behavior. Tumor type, grade, vascular invasion, pattern of invasion, and depth are all extremely important prognostic indicators when used individually or as a part of a scoring system.

Les adénocarcinomes du col utérin ont-ils un plus mauvais pronostic que les carcinomes épidermoïdes ?

OBJECTIVE

The objective of this study was to examine the influence of histology on the outcome of patients with cervix carcinoma, treated with radiotherapy and radical surgery.

PATIENTS AND METHODS

Clinical, histological, therapeutical and outcome data of 360 patients with stage IB-II cervix carcinoma patients (45 adenocarcinomas and 315 squamous cell carcinoma) managed between 1985 and 1998 were collected from the database of the Institut Gustave-Roussy.

RESULTS

The incidence of adenocarcinomas slightly increased during the study period (P =0.07). Histological grade was higher for squamous cell carcinoma than for adenocarcinoma (P =0.08). Adenocarcinomas were smaller than squamous cell carcinoma (P =0.06). With only 38% of sterilized hysterectomy specimen vs 52% for squamous cell carcinomas (P =0.07), adenocarcinoma seemed to be less radiosensitive. With a median follow-up of 67 months, histological type did not influence survival.

DISCUSSION AND CONCLUSIONS

Our study demonstrates that radiosensitivity is different between adenocarcinoma and squamous cell carcinoma of the cervix and that surgery may compensate the low radiosensitivity of adenocarcinoma.

Adenosquamous histology predicts poor outcome in low-risk stage IB1 cervical adenocarcinoma

OBJECTIVE

The purpose of this study was to identify poor prognostic factors of low-risk stage IB1 cervical adenocarcinoma

METHODS

. All women diagnosed with stage IB1 cervical adenocarcinoma between 1982 and 2002 were identified at our three institutions. Data were extracted from medical records. Patients were retrospectively assigned to a low- or intermediate/high-risk cohort based on the surgical-pathologic eligibility criteria of two randomized controlled trials of adjuvant therapy in early stage cervical cancer, Gynecologic Oncology Group protocols 92 and 109. Multivariate analysis was performed.

RESULTS

Two hundred thirty women diagnosed with stage IB1 cervical adenocarcinoma had an overall 5-year survival of 89%. Adenosquamous cell type (P < 0.01) was the only independent risk factor of disease recurrence in the low-risk group (n = 178). The 5-year disease-free survival for low-risk adenosquamous patients was 79%, compared to 96% for other histologic subtypes (P < 0.01). Low-risk case subjects developed fewer disease recurrences than those in the intermediate/high-risk (n = 52) category (7% vs 46%; P < 0.01). The 5-year disease-free survival for intermediate/high-risk patients was 51% and no additional risk factors were identified.

CONCLUSION

Adenosquamous histology is predictive of disease recurrence and decreased survival in low-risk stage IB1 cervical adenocarcinoma. This risk factor should be considered in future clinical trials of adjuvant therapy.

Incidence and survival rate of women with cervical cancer in the Greater Amsterdam area

To evaluate the effect of population-based cervical cancer screening on the occurrence of cervical cancer in The Netherlands, we investigated the incidence and survival of cervical cancer registered by a cancer registry in the Greater Amsterdam area. The incidence rate of squamous cell carcinoma decreased significantly from 9.2/100,000 women in 1988 to 5.9/100,000 in 2000 (P<0.001). The incidence rate of adenocarcinomas remained stable. After adjustment for age, stage and lymph node involvement, the relative risk of death was 1.6 times higher for patients with adenocarcinomas than for patients with squamous cell carcinoma (95% CI 1.2-2.1). The decreased survival was related to histological type, as the effect remained significant after correction for confounding factors. Over time, the prognosis of women with squamous cell carcinoma improved significantly. No significant change was observed for women diagnosed with adenocarcinoma. These results suggest that the screening programme in The Netherlands as executed in the Greater Amsterdam area is associated with a decreased incidence and increased survival of patients with squamous cell carcinoma, but fails to detect (pre)malignant lesions of adenocarcinoma. Since more than 92% of adenocarcinomas and its precursors contain high-risk HPV, adding HPV testing to cytologic screening might improve the present screening programme in detecting adenocarcinoma and its precursor lesions.

Cervical cancer

Cervical cancer is a serious health problem, with nearly 500000 women developing the disease each year worldwide. Most cases occur in less developed countries where no effective screening systems are available. Risk factors include exposure to human papillomavirus, smoking, and immune-system dysfunction. Most women with early-stage tumours can be cured, although long-term morbidity from treatment is common. Results of randomised clinical trials have shown that for women with locally advanced cancers, chemoradiotherapy should be regarded as the standard of care; however, the applicability of this treatment to women in less developed countries remains largely untested. Many women with localised (stage IB) tumours even now receive various combinations of surgery and radiotherapy, despite unresolved concern about the morbidity of this approach compared with definitive radiotherapy or radical surgery. Treatment of recurrent cervical cancer remains largely ineffective. Quality of life should be taken into account in treatment of women with primary and recurrent cervical cancer.