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

Identification of CD8+ T cell infiltration-related genes and their prognostic values in cervical cancer

Cervical cancer is a female-specific cancer with relatively high morbidity and mortality. As known to all, immune cell infiltrations in the cancer microenvironment are closely related to the cancer diagnosis and prognosis. Here we revealed that the CD8+ T cell infiltration was significantly upregulated in cervical cancer versus normal cervix uteri samples. Through univariate and multivariate cox analyses, we discovered that the CD8+ T cell infiltration was the only independent beneficial factor for the prognosis of cervical cancer. To explore the genes associated with the CD8+ T cell infiltration in cervical cancer, we performed the WGCNA analysis on the differentially expressed genes (DEGs) of cervical cancer versus normal cervix uteri tissues. As a result, 231 DEGs were found to be associated with CD8+ T cell infiltration in cervical cancer. Subsequently, with the Cytoscape analysis, we identified 105 hub genes out of the 231 DEGs. To further explore the genes that might be responsible for the prognosis of cervical cancer, we performed a univariate cox analysis followed by a LASSO assay on the 105 hub genes and located four genes (IGSF6, TLR10, FCRL3, and IFI30) finally. The four genes could be applied to the prediction of the prognosis of cervical cancer, and relatively higher expression of these four genes predicted a better prognosis. These findings contributed to our understanding of the prognostic values of CD8+ T cell infiltration and its associated genes in cervical cancer and thus might benefit future immune-related therapies.

Gynecological cancers and urinary dysfunction: a comparison between endometrial cancer and other gynecological malignancies

The purpose of this paper is to provide a narrative overview of the available literature about voiding dysfunction in women with gynecological cancer before and after surgical, chemo- and radiotherapy treatments. Radical surgery, radiotherapy, and chemotherapy may cause lower urinary tract dysfunction such as stress and urge urinary incontinence, and voiding difficulties. However, nerve-sparing radical hysterectomy may be a valid surgical approach in order to reduce bladder innervation impairment and maintain normal urinary function. Also, newer radiotherapy techniques significantly reduce the number of adverse effects, including bladder dysfunction. Pelvic floor muscle physiotherapy and training with biofeedback and urethral bulking agents represent some additional therapies that can be used in oncologically treated patients with urinary symptoms in order to improve a significant aspect of their quality of life. Considering the important impact on the patients' quality of life, a full urogynecological evaluation should be considered as an important part of oncological treatment and follow-up.

Results of image guided brachytherapy for stage IB cervical cancer in the RetroEMBRACE study

OBJECTIVE

Multiple treatment options are used in early local-stage cervical cancer, including combinations of surgery with neoadjuvant/adjuvant radiotherapy and chemotherapy. Our aim was to determine the outcome for definitive chemoradiation with image guided brachytherapy (IGBT).

METHODS

FIGO₁₉₉₄ staging system was used in our study. We included 123 patients with stage IB cervical cancer, treated at 12 centers with external beam radiotherapy (EBRT) ± Chemotherapy and IGBT. Three- and 5-year actuarial local control (LC), pelvic control (PC), overall survival (OS), cancer-specific survival (CSS) and late morbidity (CTCAE v 3.0) were computed.

RESULTS

Median age was 48 (23-82) years. FIGO₁₉₉₄ stage distribution was: IB1 68% and IB2 32%; 41% of the entire cohort had nodal metastases and 73% squamous-cell carcinoma. MRI-based tumor size was >40 mm in 63%. Median EBRT dose was 45 (40-50) Gy; 84% received chemotherapy. At IGBT, mean CTV-HR D90 was 93 ± 17 Gy (EQD2₁₀). D2cc for bladder was 76 ± 14 Gy, rectum 66 ± 11 Gy, sigmoid 66 ± 10 Gy, bowel 67 ± 7 Gy (EQD2₃). At 43-months median follow-up, 9% of patients had systemic, 6% paraaortic, 3% pelvic-nodal and 2% local failure. Five-year LC was 98%, PC 96%, CSS 90%, OS 83%. Intestinal G3--4 morbidity was 8%, urinary 7% and vaginal 0%.

CONCLUSIONS

Chemoradiation with IGBT for FIGO₁₉₉₄ stage IB cervical cancer leads to excellent loco-regional control with limited morbidity. In IB node-negative disease, it can be regarded equivalent to surgery in terms of oncologic outcome. In tumors with unfavorable pre-treatment characteristics, chemoradiation is the first choice to avoid combining surgery with adjuvant therapy.

A preoperative radiomics model for the identification of lymph node metastasis in patients with early-stage cervical squamous cell carcinoma

OBJECTIVES

To develop and validate a radiomics model for preoperative identification of lymph node metastasis (LNM) in patients with early-stage cervical squamous cell carcinoma (CSCC).

METHODS

Total of 190 eligible patients were randomly divided into training (n = 100) and validation (n = 90) cohorts. Handcrafted features and deep-learning features were extracted from T2W fat suppression images. The minimum redundancy maximum relevance algorithm and LASSO regression with 10-fold cross-validation were used for key features selection. A radiomics model that incorporated the handcrafted-signature, deep-signature, and squamous cell carcinoma antigen (SCC-Ag) levels was developed by logistic regression. The model performance was assessed and validated with respect to its calibration, discrimination, and clinical usefulness.

RESULTS

Three handcrafted features and three deep-learning features were selected and used to build handcrafted- and deep-signature. The model, which incorporated the handcrafted-signature, deep-signature, and SCC-Ag, showed satisfactory calibration and discrimination in the training cohort (AUC: 0.852, 95% CI: 0.761-0.943) and the validation cohort (AUC: 0.815, 95% CI: 0.711-0.919). Decision curve analysis indicated the clinical usefulness of the radiomics model. The radiomics model yielded greater AUCs than either the radiomics signature (AUC = 0.806 and 0.779, respectively) or the SCC-Ag (AUC = 0.735 and 0.688, respectively) alone in both the training and validation cohorts.

CONCLUSION

The presented radiomics model can be used for preoperative identification of LNM in patients with early-stage CSCC. Its performance outperforms that of SCC-Ag level analysis alone.

ADVANCES IN KNOWLEDGE

A radiomics model incorporated radiomics signature and SCC-Ag levels demonstrated good performance in identifying LNM in patients with early-stage CSCC.

Comparison of adenocarcinoma and adenosquamous carcinoma prognoses in Chinese patients with FIGO stage IB-IIA cervical cancer following radical surgery

BACKGROUND

To compare adenocarcinoma (AC) and adenosquamous carcinoma (ASC) prognoses in patients with FIGO stage IB-IIA cervical cancer who underwent radical hysterectomy.

METHODS

We performed a retrospective analysis of 240 patients with AC and 130 patients with ASC. Kaplan-Meier curves, Cox regression models, and log-rank tests were used for statistical analysis.

RESULTS

Patients with ASC had higher frequencies of lymphovascular space invasion (LVSI) and serum squamous cell carcinoma antigen (SCC-Ag) > 5 ng/ml (p = 0.049 and p = 0.013, respectively); moreover, they were much older (P = 0.029) than patients with AC. There were no clinically significant differences in overall survival (OS) between the groups. When stratified into three risk groups based on clinicopathological features, survival outcomes did not differ between patients with AC and those with ASC in any risk group. Multivariate analysis showed that lymph node metastasis (LNM) was an independent risk factor for recurrence-free survival (RFS) and OS in patients with AC and in patients with ASC. Carcinoembryonic antigen (CEA) > 5 ng/ml and SCC-Ag > 5 ng/ml were independent predictors of RFS and OS in patients with AC. In addition, among those stratified as intermediate-risk, patients with ASC who received concurrent chemoradiotherapy (CCRT) had significantly better RFS and OS (P = 0.036 and P = 0.047, respectively).

CONCLUSIONS

We did not find evidence to suggest that AC and ASC subtypes of cervical cancer were associated with different survival outcomes. CCRT is beneficial for survival in intermediate-risk patients with ASC, but not in those with AC. Serum tumour markers can assist in evaluating prognosis and in providing additional information for patient-tailored therapy for cervical AC.

A case of non-HPV related primary endometrioid adenocarcinoma of the cervix

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Primary endometrioid adenocarcinoma of the endocervix can masquerade as endometrial cancer (80).

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Case illustrates IECC classification of endometrioid endocervical adenocarcinoma, rare subtype (85).

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Diagnosis based on moderate nuclear atypia, low grade glands, focal positive p16, negative HPV (81).

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NHPVA endocervical adenocarcinomas tend to be more advanced stage, greater chance of nodal spread (84).

Objective

Primary endometrioid adenocarcinoma of the cervix is a rare subtype of adenocarcinoma that has often been misclassified in the literature due to the lack of clear-cut diagnostic criteria. A new classification system has recently been developed that aims to provide clarity and reproducibility when diagnosing subtypes of endocervical adenocarcinoma. This case report demonstrates the difficulty in diagnosing primary endometroid adenocarcinoma, application of the new diagnostic guidelines, and a review of the literature of this rare non-HPV subtype.

Case

A 76 year-old women presented with postmenopausal bleeding and was found to have an exophytic cervical mass. Biopsies showed an adenocarcinoma of probable endometrial origin. She underwent a robotic-assisted simple hysterectomy with bilateral pelvic lymph node sampling and omental biopsy. Final pathology report demonstrated a primary endometrioid adenocarcinoma of the cervix, measuring 2.4 cm in size, diagnosed using the recently developed International Endocervical Adenocarcinoma Criteria and Classification (IECC) system. Patient was then treated with external beam radiation therapy and concurrent chemotherapy, followed by vaginal brachytherapy. She had no evidence of disease at her 15-month follow-up visit.

Conclusion

Primary endometrioid adenocarcinoma of the cervix is a rare and diagnostically challenging tumor of the cervix. This case illustrates the challenges associated with diagnosis of this endocervical carcinoma subtype and the need for a multi-disciplinary approach when determining treatment.

Management of Stage IIB Cervical Cancer: an Overview of the Current Evidence

PURPOSE OF REVIEW

To review and discuss the present evidence of surgery- and radiation-based treatment strategies for stage IIB cervical cancer.

RECENT FINDINGS

Recently, two randomized controlled trials compared the efficacy of neoadjuvant chemotherapy followed by radical hysterectomy (NACT + RH) with that of concurrent chemoradiotherapy (CCRT) for stage IB3-IIB cervical cancer. When these studies were combined (N = 1259), NACT + RH was associated with a shorter disease-free survival [hazard ratio (HR) 1.36, 95% confidence interval (CI) 1.13-1.64], but with a similar overall survival (HR 1.11, 95% CI 0.90-1.36) when compared with the findings for CCRT. Stage-specific analysis for stage IIB cervical cancer demonstrated that disease-free survival was significantly worse with NACT + RH than with CCRT (HR 1.90, 95% CI 1.25-2.89); however, no significant difference was observed for stage IB3-IIA cervical cancer. Based on the results of recent level I evidence, the standard treatment for stage IIB cervical cancer remains CCRT.

Can We Be Less Radical with Surgery for Early Cervical Cancer?

Although a rare cancer in the developed world due to the success of cervical screening programmes, cervical cancer remains one of the most common cancers diagnosed in women under the age of 35 years old. Radical hysterectomy and more recently radical trachelectomy have been highly effective in curing the majority of women with early stage disease. Many, however, are left with long-term 'survivorship' issues including bowel, bladder and sexual dysfunction. In view of these chronic co-morbidities, many clinicians now consider whether a less radical approach to surgery may be an option for some women. This review focuses on the current evidence for the safety of conservative surgery for early stage cervical cancer with regard to cure rates in comparison to standard management, as well as any improvement in short and long-term morbidity associated with a more conservative approach.

The Role of Laparoscopic Radical Hysterectomy in Early-Stage Adenocarcinoma of the Uterine Cervix

OBJECTIVE

To compare long-term survival outcomes and patterns of recurrence of laparoscopic radical hysterectomy (LRH) and open radical hysterectomy (ORH) in early-stage cervical adenocarcinoma.

METHODS

The medical records of 293 patients with stage IA2-IIA cervical adenocarcinomas who underwent radical hysterectomy were retrospectively reviewed.

RESULTS

In total, 186 patients underwent LRH and 107 underwent ORH. There was no difference between the two surgery groups in clinicopathologic characteristics. There were no differences in disease-free survival (DFS) and overall survival (OS) between the LRH and ORH groups (88.7 vs. 84.1 %, P = 0.725; and 93.0 vs. 86.9 %, P = 0.735) for univariate analysis and multivariate analysis after adjusting for other significant prognostic factors. There was no difference in the patterns of recurrence between the two surgery groups (P = 0.220). The median time interval between surgery and the first recurrence were 25 months (range, 3-100 months) for LRH group and 14 months (range, 3-128 months) for ORH group (P = 0.230). The LRH group showed significantly fewer postoperative complications (P < 0.001), less estimated blood loss (P < 0.001), faster bowel movement recovery (P < 0.001), shorter postoperative hospital stay (P < 0.001), and a lower rate of wound dehiscence, ileus, lymphedema, infected lymphocele, and pelvic abscess (P = 0.004, 0.011, 0.017, and 0.040, respectively).

CONCLUSIONS

LRH has comparable survival outcomes with ORH and did not affect the pattern of recurrence in early-stage adenocarcinoma of the uterine cervix. The surgical outcomes were more favorable than ORH.

From prospective biobanking to precision medicine: BIO-RAIDs - an EU study protocol in cervical cancer

Background

Cervical cancer (CC) is -second to breast cancer- a dominant cause of gynecological cancer-related deaths worldwide. CC tumor biopsies and blood samples are of easy access and vital for the development of future precision medicine strategies.

Design

BIO-RAIDs is a prospective multicenter European study, presently recruiting patients in 6 EU countries. Tumor and liquid biopsies from patients with previously non-treated cervical cancer (stages IB2-IV) are collected at defined time points. Patients receive standard primary treatment according to the stage of their disease. 700 patients are planned to be enrolled. The main objectives are the discovery of -dominant molecular alterations, -signalling pathway activation, and -tumor micro-environment patterns that may predict response or resistance to treatment. An exhaustive molecular analysis is performed using 1° Next generation sequencing, 2° Reverse phase protein arrays and 3° Immuno-histochemistry.

Discussion

The clinical study BIO-RAIDs is activated in all planned countries, 170 patients have been recruited till now. This study will make an important contribution towards precision medicine treatments in cervical cancer. The results will support the development of clinical practice guidelines for cervical cancer patients to improve their prognosis and their quality of life.

Trial registration

Clinicaltrials.gov: NCT02428842, registered 10 February 2015.