Recent advances in invasive adenocarcinoma of the cervix

Analysis of related factors for pathological upgrading of cervical biopsy from CIN3 to cancer after conical resection

BACKGROUND

To investigate related factors for postoperative pathological upgrading of cervical biopsy to cervical cancer (CC) in patients with cervical intraepithelial neoplasia (CIN)3 after conical resection.

METHODS

This retrospective study collected data from patients diagnosed with CIN3 by cervical biopsies at the author's Hospital between January 2012 and December 2022. The primary outcome was the pathological results of patients after conical resection. The pathological findings were categorized into the pathological upgrading group if postoperative pathology indicated CC, while those with normal, inflammatory, or cervical precancerous lesions were classified into the pathological non-upgrading group. The factors associated with upgrading were identified using multivariable logistic regression analysis.

RESULTS

Among 511 patients, there were 125 patients in the pathological upgrading group (24.46%). The patients in the upgrading group were younger (47.68 ± 9.46 vs. 52.11 ± 7.02, P < 0.001), showed a lower proportion of menopausal women (38.40% vs. 53.02%, P = 0.0111), a lower proportion of HSIL (40.00% vs. 57.77%, P = 0.001), a higher rate of HPV-16/18 positive (25.60% vs. 17.36%, P = 0.011), a higher rate of contact bleeding (54.40% vs. 21.50%, P < 0.001), lower HDL levels (1.31 ± 0.29 vs. 1.37 ± 0.34 mmol/L, P = 0.002), higher neutrophil counts (median, 3.50 vs. 3.10 × 109/L, P = 0.001), higher red blood cell counts (4.01 ± 0.43 vs. 3.97 ± 0.47 × 1012/L, P = 0.002), higher platelet counts (204.84 ± 61.24 vs. 187.06 ± 73.66 × 109/L, P = 0.012), and a smaller platelet volume (median, 11.50 vs. 11.90 fL, P = 0.002).The multivariable logistic regression analysis showed that age (OR = 0.90, 95% CI: 0.86-0.94, P < 0.001), menopausal (OR = 2.68, 95% CI: 1.38-5.22, P = 0.004), contact bleeding (OR = 4.80, 95% CI: 2.91-7.91, P < 0.001), and mean platelet volume (OR = 0.83, 95% CI: 0.69-0.99, P = 0.038) were independently associated with pathological upgrading from CIN3 to CC after conical resection.

CONCLUSION

Age, menopausal, contact bleeding, and mean platelet volume are risk factors of pathological upgrading from CIN3 to CC after conical resection, which could help identify high risk and susceptible patients of pathological upgrading to CC.

Adenocarcinoma In Situ of the Uterine Cervix (AIS) Treated by Loop Electrosurgical Excision Procedure Strategy: An Observational Study

OBJECTIVES

Evaluation of the results of treatment of adenocarcinoma in situ by loop electrosurgical excision procedure and the safety of a conservative strategy.

METHODS

Identification of all cases of adenocarcinoma in situ treated by loop electrosurgical excision procedure at our institution and follow-up by a conservative strategy. Completeness of the identification of all cases was secured by data from the National Pathology Registry. The treatment strategy was based on cytologic follow-up performed by a general practitioner and, irrespective of margin status of the cone, only the results of the postoperative surveillance were indicative of further treatment.

RESULTS

A total of 224 patients were identified. The overall recurrence rate with a mean follow-up time of 87.8 months was 7.6% (17/224). The recurrence rate in patients with involved margins was significantly higher than in patients with uninvolved margins, 15.7% vs 5.2%, respectively. Six recurrences were diagnosed at first examination 6 months postconization in patients with involved margins. They were treated with hysterectomy in 4 cases and reconization in 1 case. If involvement of margins alone had been an indication of further therapy (hysterectomy or reconization) immediately after conization, the conservative management strategy prevented 46 surgical procedures. Two cases of invasive cancer were diagnosed during follow-up, 150 months and 196 months after primary treatment, and after normal follow-up examinations. These 2 cases must be considered de novo cases and cannot be considered treatment failures.

CONCLUSION

The conservative management strategy thus seems safe, and unnecessary surgical procedures were avoided.

Impact of histological subtypes on clinical outcome of endocervical adenocarcinoma

OBJECTIVE

This multicenter study aimed to investigate the disparity in clinical features and prognosis among different histopathologic subtypes of endocervical adenocarcinoma (EA) based on the 2014 World Health Organization (WHO) classification.

METHODS

We retrieved and analyzed data from the Chinese Four C Database between 2004 and 2018. 672EA patients with radical hysterectomies from 32 institutions were retrospectively reviewed. Clinicopathologic characteristics, five-year overall survival (OS), and disease-free survival (DFS) were compared based on histological subtypes.

RESULTS

The 5-year DFS and OS rates for usual, endometrioid, mucinous, gastric, villoglandular, clear cell/serous/mesonephric EAs were as follows: 81.3 %, 89.1 %, 63.0 %, 35.6 %, 88.6 %, 79.9 %, respectively (P < 0.0001); 87.4 %, 96.6 %, 74.7 %, 34.0 %, 96.7 %, 86.3 %, respectively (P < 0.0001). Gastric- and mucinous-type exhibited a higher frequency of lymph node metastasis, deep stromal invasion, uterine corpus invasion, and recurrence than the usual -type (recurrence rate:50.00 % vs 29.90 % vs 15.50 %, P < 0.0001). Multivariate analysis revealed gastric-type was significantly associated with inferior DFS (HR,3.018; 95 % CI, 1.688-5.397; P < 0.0001) and OS(HR, 4.114; 95 % CI, 2.002-8.453; P < 0.0001). Furthermore, compared to the usual -type, mucinous-type demonstrated significantly worse DFS (HR, 1.773; 95 % CI,1.123-2.8; P = 0.014) and OS (HR, 2.168; 95 % CI,1.214-3.873; P = 0.009) whereas endometrioid-type was an identified as independent factor for better DFS (HR, 0.365; 95 % CI,0.143-0.928; P = 0.034). Villoglandular subtype displayed similar features and favorable prognosis as the usual type.

CONCLUSIONS

Relevant clinical features and prognosis varied significantly among histological subtypes of EA, thus offering valuable guidance for the development of subtype-specific treatment strategies to optimize EA management.

Disparities in Survival Outcomes Between Locally Advanced Cervical Squamous Cell Carcinoma and Adenocarcinoma Treated with Chemoradiotherapy

Purpose

To determine the disparities in survival outcomes between stage IIB-IVA cervical squamous cell carcinoma (SCC) and adenocarcinoma (AC) treated with chemoradiotherapy.

Methods

Patients diagnosed between 2004 and 2015 were retrospectively included from the Surveillance, Epidemiology, and End Results databases. Propensity score matching (PSM) was used in this study. The primary endpoints were cervical cancer-specific survival (CCSS) and overall survival (OS).

Results

A total of 2752 patients were identified, including 87.5% (n=2408) were SCC and 12.5% (n=344) were AC. Patients with AC had inferior 5-year CCSS (67.5% vs 54.8%, P<0.001) and OS (58.4% vs 47.2%, P<0.001) compared to those with the SCC subtype. The hazard curve of cervical cancer-related death in AC peaked at 2 years (19%) and still small peaks in the 7 and 11 years of follow-up. Regarding SCC, cervical cancer-related deaths peaked at 2 years (15%) and the hazard rate was 2.0% during the six years of follow-up. The multivariate Cox regression analyses indicated that histology was an independent prognostic factor associated with survival outcomes. Patients with AC had significantly poor CCSS (P<0.001) and OS (P<0.001). Similar results were found after PSM.

Conclusion

Our study demonstrates a significantly better prognosis for cervical SCC patients compared to those with cervical AC undergoing chemoradiotherapy. These results highlight the importance of histological subtyping in predicting treatment outcomes and tailoring therapeutic strategies.

PCDHGB7 hypermethylation-based Cervical cancer Methylation (CerMe) detection for the triage of high-risk human papillomavirus-positive women: a prospective cohort study

BACKGROUND

Implementation of high-risk human papillomavirus (hrHPV) screening has greatly reduced the incidence and mortality of cervical cancer. However, a triage strategy that is effective, noninvasive, and independent from the subjective interpretation of pathologists is urgently required to decrease unnecessary colposcopy referrals in hrHPV-positive women.

METHODS

A total of 3251 hrHPV-positive women aged 30-82 years (median = 41 years) from International Peace Maternity and Child Health Hospital were included in the training set (n = 2116) and the validation set (n = 1135) to establish Cervical cancer Methylation (CerMe) detection. The performance of CerMe as a triage for hrHPV-positive women was evaluated.

RESULTS

CerMe detection efficiently distinguished cervical intraepithelial neoplasia grade 2 or worse (CIN2 +) from cervical intraepithelial neoplasia grade 1 or normal (CIN1 -) women with excellent sensitivity of 82.4% (95% CI = 72.6 ~ 89.8%) and specificity of 91.1% (95% CI = 89.2 ~ 92.7%). Importantly, CerMe showed improved specificity (92.1% vs. 74.9%) in other 12 hrHPV type-positive women as well as superior sensitivity (80.8% vs. 61.5%) and specificity (88.9% vs. 75.3%) in HPV16/18 type-positive women compared with cytology testing. CerMe performed well in the triage of hrHPV-positive women with ASC-US (sensitivity = 74.4%, specificity = 87.5%) or LSIL cytology (sensitivity = 84.4%, specificity = 83.9%).

CONCLUSIONS

PCDHGB7 hypermethylation-based CerMe detection can be used as a triage strategy for hrHPV-positive women to reduce unnecessary over-referrals.

TRIAL REGISTRATION

ChiCTR2100048972. Registered on 19 July 2021.

Development and validation of nomograms to recurrence and survival in patients with early-stage cervical adenocarcinoma

PURPOSE

Cervical adenocarcinoma is one of the most common types of cervical cancer and its incidence is increasing. The biological behavior and treatment outcomes of cervical adenocarcinoma (CA) differ from those of squamous cell carcinoma (SCC). We sought to develop a model to predict recurrence and cancer-specific survival (CSS) deaths in CA patients.

METHODS

131 patients were included in model development and internal validation, and patients from the SEER database (N = 1679) were used for external validation. Multivariable Cox proportional hazards regression analysis was used to select predictors of relapse-free survival (RFS) and CSS and to construct the model, which was presented as two nomograms. Internal validation of the nomograms was performed using the bootstrap resampling method.

RESULTS

Age, FIGO (International Federation of Gynecology and Obstetrics) stage, size of the tumor, lymph metastasis and depth of invasion were identified as independent prognostic factors for RFS, while age, FIGO stage, size of the tumor and number of positive LNs were identified as independent prognostic factors for CSS. The nomogram of the recurrence model predicted 2- and 5-year RFS, with optimism adjusted c-statistic of 75.41% and 74.49%. Another nomogram predicted the 2- and 5-year CSS with an optimism-adjusted c-statistic of 83.22% and 83.31% after internal validation; and 68.6% and 71.33% after external validation.

CONCLUSIONS

We developed and validated two effective nomograms based on static nomograms or online calculators that can help clinicians quantify the risk of relapse and death for patients with early-stage CA.

Assessment of the relationships between invasive endocervical adenocarcinoma and human papillomavirus infection and distribution characteristics in China: According to the new WHO classification criteria in 2020

OBJECTIVE

To assess the association between endocervical adenocarcinoma (ECA) and HPV (Human papillomavirus) infection, as well as the characteristics of ECA distribution in China.

METHODS

A total of 756 specimens were collected from seven geographic regions across China. All cases were histologically categorized according to the 2020 WHO classification of female genital tract cancers, and 496 cases were included. We performed the SPF10-DEIA-LiPA25 assay on all specimens' whole tissue sections using PCR (WTS-PCR) to detect HPV DNA and 141 WTS-PCR HPV-positive specimens were selected for the laser capture microdissection (LCM).

RESULTS

Four predominant prevalent histological categories of ECA in China were usual type (51.8%, 257), invasive stratified mucin-producing carcinoma (iSMILE) (11.5%, 57), mucinous NOS (not otherwise specid) (10.3%, 51), and gastric type (7.9%, 39). HPV positivity was 91.4% (235/257), 100.0% (57/57), and 90.2% (46/51) in usual type, iSMILE, and mucinous NOS by WTS-PCR detection, respectively (P < 0.001). LCM-PCR results showed a decreasing trend in HPV DNA positivity, and 21 (95.5%) patients with HPV-I were negative for HPV-DNA in glandular epithelial tissue. The most prevalent HPV genotypes in ECA were HPV16 (47.5%), 18 (40.8%), and 52 (6.5%). The average age of patients with HPVA was 44.9 years, while that of patients with HPV-I was 49.1 years, HPVA is more prevalent in younger females in China (P < 0.001).

CONCLUSIONS

In China, the predominant prevalent histological category of ECA is the usual type of adenocarcinoma, followed by iSMILE. Additionally, patients with HPVA tended to be younger than those with HPV-I.

A rare case of signet ring cell carcinoma with diffuse cutaneous systemic sclerosis: A case report

Systemic sclerosis, an autoimmune disease characterized by fibrosis and vasculopathy of the skin and other multiple organs has been associated with an increased risk of malignancy. We present the case of a 74-year-old woman who had diffused cutaneous systemic sclerosis and uterine cervical cancer. The patient was initially diagnosed with stage IIB squamous cell carcinoma and concurrent chemoradiotherapy was planned. However, cisplatin could not be administered due to acute renal failure, so the patient was treated solely with radiotherapy. However, complications of systemic sclerosis progressed rapidly, and the patient died 63 days later from pulmonary edema. An autopsy later revealed that uterine cervix had primary signet ring cell carcinoma. We suspected that this patient had a combination of signet ring cell carcinoma and squamous cell carcinoma, with squamous cell carcinoma disappearing after radiotherapy. This case highlighted the importance of systemic management for cancers associated with systemic sclerosis.

Antiproliferative and Antimetastatic Properties of 16-Azidomethyl Substituted 3-O-Benzyl Estrone Analogs

Four diastereomers of 16-azidomethyl substituted 3-O-benzyl estradiol (1-4) and their two estrone analogs (16AABE and 16BABE) were tested for their antiproliferative properties against human gynecological cancer cell lines. The estrones were selected for additional experiments based on their outstanding cell growth-inhibiting activities. Both compounds increased hypodiploid populations of breast cancer cells, and 16AABE elicited cell cycle disturbance as evidenced by flow cytometry. The two analogs substantially increased the rate of tubulin polymerization in vitro. 16AABE and 16BABE inhibited breast cancer cells' migration and invasive ability, as evidenced by wound healing and Boyden chamber assays. Since both estrone analogs exerted remarkable estrogenic activities, as documented by a luciferase reporter gene assay, they can be considered as promising drug candidates for hormone-independent malignancies.

Carcinogenesis and management of human papillomavirus-associated cervical cancer

Approximately 95% of cervical cancer are caused by human papillomavirus (HPV) infection. Although it is estimated that HPV-associated cervical cancer will decrease with the widespread use of HPV vaccine, it may take time for HPV-associated cervical cancer to be eliminated. For the appropriate management of HPV-associated cervical cancer, it is important to understand the detailed mechanisms of cervical cancer development. First, the cellular origin of most cervical cancers is thought to be cells in the squamocolumnar junction (SCJ) of the uterine cervix. Therefore, it is important to understand the characteristics of SCJ for cervical cancer screening and treatment. Second, cervical cancer is caused by high risk HPV (HR-HPV) infection, however, the manner of progression to cervical cancer differs depending on the type of HR-HPV: HPV16 is characterized by a stepwise carcinogenesis, HPV18 is difficult to detect in precancerous lesions, and HPV52, 58 tends to remain in the state of cervical intraepithelial neoplasia (CIN). Third, in addition to the type of HPV, the involvement of the human immune response is also important in the progression and regression of cervical cancer. In this review, we demonstrate the carcinogenesis mechanism of HPV-associated cervical cancer, management of CIN, and the current treatment of CIN and cervical cancer.

In Situ/Microinvasive Adenocarcinoma of the Uterine Cervix and HPV-Type Impact: Pathologic Features, Treatment Options, and Follow-Up Outcomes-Cervical Adenocarcinoma Study Group (CAS-Group)

It is unknown whether human papillomavirus (HPV) status impacts the prognosis of early stage cervical glandular lesions. This study assessed the recurrence and survival rates of in situ/microinvasive adenocarcinomas (AC) according to HPV status during a 5-year follow-up. The data were retrospectively analyzed in women with available HPV testing before treatment. One hundred and forty-eight consecutive women were analyzed. The number of HPV-negative cases was 24 (16.2%). The survival rate was 100% in all participants. The recurrence rate was 7.4% (11 cases, including four invasive lesions (2.7%)). Cox proportional hazards regression showed no difference in recurrence rate between HPV-positive and HPV-negative cases (p = 0.148). HPV genotyping, available for 76 women and including 9/11 recurrences, showed a higher relapse rate for HPV-18 than HPV-45 and HPV-16 (28.5%, 16.6%, and 9.52%, p = 0.046). In addition, 60% and 75% of in situ and invasive recurrences, respectively, were HPV-18 related. The present study showed that most ACs were positive for high-risk HPV, and the recurrence rate was unaffected by HPV status. More extensive studies could help evaluate whether HPV genotyping may be considered for recurrence risk stratification in HPV-positive cases.

Menopause hormone treatment after cancer

Regular improvement in survival of women after treatment for cancer has been reached in these last years. Menopause hormone therapy (MHT) remains the most efficient treatment to alleviate climacteric symptoms and improve quality of life in symptomatic women. The long-term effects of estrogen deficiency can be, at least partially, prevented by MHT. However, using MHT in an oncologic context can be associated with contraindications. Patients who have experienced breast cancer frequently face severe climacteric symptoms, but results from randomized trials are not in favor of using MHT in these women. Three randomized trials are available in women treated by MHT after ovarian cancer, and report better survival rates in the active group of treatment, suggesting that, at least in serous high-grade ovarian carcinoma, MHT could be allowed. No robust data are available for MHT after endometrial carcinoma. According to various guidelines, MHT could be possible in low grades with good prognosis. Progestogen, however, is not contraindicated and can help to alleviate climacteric symptoms. Squamous cell cervical carcinoma is not hormone-dependent and therefore patients can be treated with MHT without restrictions, whereas cervical adenocarcinoma is likely to be estrogen-dependent, despite lack of robust data, and thus only progesterone or progestin might be potentially used. It is possible that, in future, better molecular characterization of genomic profiles of various cancers may allow MHT to be used with some patients.

Investigation of the Antineoplastic Effects of 2-(4-Chlorophenyl)-13α-Estrone Sulfamate against the HPV16-Positive Human Invasive Cervical Carcinoma Cell Line SiHa

Cervical carcinoma is one of the most frequent malignant gynecological cancers in women of reproductive age. Because of the poor tolerability of currently available chemotherapeutic agents, efforts have been focused on developing innovative molecules, including steroids, that exert antineoplastic effects with a better safety profile. In addition to their endocrine properties, certain estrogens exhibit additional biological activities, such as antiangiogenic and anticancer effects. Based on previous studies, the antineoplastic properties of 13α-estrone sulfamate derivatives (13AES1-3) were investigated, and the mechanism of action for the most promising compound 13AES3 was explored. Based on their effects on the viability of different human adherent gynecological cancer cells, the SiHa cervical cell line was used for mechanistic experiments. The most active analog 13AES3 was shown to exert considerable proapoptotic effects, as evidenced by a colorimetric caspase-3 assay and fluorescent double staining. It also elicited antimigratory and anti-invasive effects in a concentration-dependent manner, as evidenced by wound healing and Boyden chamber assays, respectively. Regarding their mechanism of action, 13AES derivatives were shown to inhibit tubulin polymerization, and computer simulations provided a possible explanation for the importance of the presence of the chlorophenyl ring on the estrane skeleton. 13AES3 is considered to be the first 13α-estrone derivative with a significant antineoplastic potency against SiHa cancer cells. Therefore, it might serve as a valuable lead molecule for the design of anticancer agents targeting cervical carcinomas.

Incidence and treatment outcomes of uterine cervical cancer in Korea 1999-2018 from the national cancer registry

OBJECTIVE

To describe the incidence and survival outcomes of uterine cervical cancer during 1999-2018.

METHODS

Patients who were diagnosed with cervical cancer during 1999-2018 were identified in the Korea Central Cancer Registry. Age-standardized incidence rates (ASRs) and annual percent changes (APCs) were calculated. Survival rates by histology, year of diagnosis (1999-2008 vs. 2009-2018), stage, and age at diagnosis were analyzed.

RESULTS

The absolute incidence of cervical cancer decreased over 20 years from 4,488 in 1999 to 3,500 in 2018, with an APC of -3.42% (p<0.0001). While ASR of squamous cell carcinoma (SCCA) more than halved from 13.27 per 100,000 in 1999 to 6.16 in 2018 (APC, -4.04%), adenocarcinoma continued to rise (ASR, 1.30 per 100,000 to 1.92; APC, 1.52%; p<0.0001). Patients with adenocarcinoma were younger than those with SCCA (mean, 49.9±12.7 vs. 52.9 ±14.6 years; p<0.0001). Five-year survival rate of cervical cancer patients overall was 78.0%. Adenocarcinoma had poorer survival than SCCA (5-year survival rate, 76.8% vs. 79.8%; p<0.0001). There was no survival difference between patients who were diagnosed between 1999-2008 and 2009-2018. Earlier-stage disease had better survival (5-year survival rate for localized, regional, and distant disease, 90.0% vs. 69.9% vs. 26.5%; p<0.0001). Younger patients aged <50 years had better survival than those aged ≥50 years (87.1% vs. 69.8%; p<0.0001).

CONCLUSION

The incidence of SCCA of the uterine cervix declined while adenocarcinoma continued to increase slowly but significantly from 1999 to 2018 in Korea. Adenocarcinoma was diagnosed at a younger age, but had poorer survival outcome than SCCA.

Insulin-induced gene 2 expression is associated with cervical adenocarcinoma malignant behavior

BACKGROUND

The incidence of cervical adenocarcinoma (CA) as a malignant tumor has increased over the past few decades due to its low detection rate and malignant biological behaviors. Insulin-induced gene 2 (INSIG2), a membrane protein of the endoplasmic reticulum (ER), plays a crucial role in cancer progression. However, there is little known about the connection between INSIG2 and CA.

METHODS

The Human Protein Atlas (HPA) and the Cancer Genome Atlas (TCGA) Cervical Cancer (CESC) data were applied to study the alteration in INSIG2 expression. Biological functions were performed to test the change of malignant behavior. Bioinformatics analysis was conducted to explore the potential affection of INSIG2 in CA progression.

RESULTS

Our study confirmed that the high INSIG2 expression levels had a poor prognosis. INSIG2-knockdown inhibited the CA cell proliferation, migration, and invasion of CA cells while downregulating the epithelial-mesenchymal transition (EMT)-associated gene expression levels. Moreover, the enrichment analysis of DEGs showed more potential functions of INSIG2 in the CA progression.

CONCLUSION

We found that INSIG2 knockdown may play a suppressor role in the CA progression, and may provide the potential functional influence in inhibiting of CA development.

Risk factors for additional postoperative adjuvant therapy in patients with locally advanced cervical cancer and construction of a risk model

OBJECTIVE

To investigate the influencing factors of postoperative adjuvant therapy for stage IB1-IIA2 cervical cancer, and establish a nomogram model to predict the risk of postoperative adjuvant therapy for locally advanced cervical cancer (LACC).

METHODS

A retrospective analysis was conducted on 144 patients with stage IB1-IIA2 cervical squamous cell carcinoma treated in Wuhan No.1 Hospital from June 2015 to January 2017, and their clinical data were analyzed. The clinical application value of the nomogram risk model was evaluated by receiver operating characteristic curve (ROC).

RESULTS

Through logistic regression analysis, we found that squamous cell carcinoma antigen (SCC-Ag), International Federation of Gynecology and Obstetrics (FIGO) stage ≥ IIA1, and laparoscopic surgery were independent influencing factors for additional adjuvant therapy after laparoscopic surgery. The nomogram model for predicting the risk of postoperative adjuvant therapy for cervical cancer constructed according to the selected variables had good predictive performance (with C-index of 0.798) and conformity. The area under the curve of established model in predicting 1-, 3- and 5-year survival time was 0.730, 0.810 and 0.830, respectively, indicating that the model has good performance.

CONCLUSION

History of diabetes, tumor size, FIGO stage ≥ IIA1, and SCC-Ag >1.5 are independent influencing factors for additional adjuvant therapy after laparoscopic surgery of LACC patients. In addition, the constructed risk model is effective in predicting the postoperative risk of additional adjuvant therapy, which is expected to provide a reference for clinical treatment selection.

Silva cumulative score and its relationship with prognosis in Endocervical adenocarcinoma

Background

The Silva system has been demonstrated to have a good predictive value of lymph node metastasis (LNM) in endocervical adenocarcinoma (EAC). Tumours were classified based on the highest identified pattern of invasion in this system, this may not exactly reflect the true situation when it presents with a “mixed pattern” in some cases. Recent study has shown that patients with lymphovascular invasion (LVI) have worse prognosis in EAC. Here we design a Silva cumulative score (SCS) system which also combined the LVI status to explore its prognostic role in EAC patients.

Methods

A total of 120 patients with EAC were included in this study. Clinicopathological characteristics were retrospectively retrieved from the medical records and follow-up data were obtained. The clinicopathological information included age at diagnosis, depth of invasion (DOI), LNM, LVI, Silva classification, and SCS. SCS is a classification system based on the sum score of different Silva pattern which is founded on morphological phenomena. The relationships between the pathological characteristics and prognoses were analyzed.

Results

According to the Silva system, 11 (9.2%), 22 (18.3%) and 87 (72.5%) patients had patterns A, B, and C, respectively. Patients with pattern C had the highest incidence of LVI and LNM (p < 0.05). Although the Kaplan-Meier curves demonstrated that survival decreased with increasing Silva classification for A-C cancers, there was no statistically significant difference [disease-free survival (DFS): p = 0.181; overall survival (OS): p = 0.205]. There were 45 cases presented as mixed-type of Silva patterns. According to the SCS, 23 cases (19.2%) were rated as grade I, 31 cases (25.8%) as grade II and 66 (55.0%) cases as grade III. Patients with SCS grade III had the highest incidence of LVI and LNM (p < 0.05). Kaplan–Meier analysis revealed that patients with higher SCS had significantly shorter DFS and OS than those with lower SCS (p < 0.05). High SCS was an independent predictor of poorer OS and DFS (p < 0.05) in patients with EAC.

Conclusions

The application of the Silva system could effectively predict the LNM of patients and may be helpful in selecting an appropriate surgical procedure. The SCS system we designed showed a good predictive value for DFS and OS in EAC.

Preliminary Analysis of Cervical Cancer Immunotherapy

Cervical cancer is one of the most common gynecologically malignancies worldwide. Although vaccine and cervical cancer screening including human papillomavirus testing, cytology testing, and colposcopy have developed rapidly in recent years, effectively reducing cervical cancer mortality, cervical cancer remains a malignancy with higher female fatality rates worldwide and has a high risk for socioeconomically disadvantaged groups. The combination of platinum-paclitaxel and chemotherapy, possibly with the addition of bevacizumab, is currently the treatment of choice for advanced cervical cancer, but it only has remission purposes. Therefore, new therapeutic strategies are needed for both locally advanced and metastatic cervical cancer. Here, we make a preliminary analysis of cervical cancer immunotherapy.

Predicting prognosis according to the updated WHO classification in patients with endocervical adenocarcinoma treated with surgery and radiotherapy

OBJECTIVE

The recently updated World Health Organization classification divides endocervical adenocarcinomas (ADCs) into human papillomavirus (HPV)-associated (HPVA) and HPV-independent (HPVI) ADCs. This study aimed to investigate the differences in the clinical features and treatment outcomes between patients with HPVA and HPVI.

METHODS

We retrospectively reviewed the electronic medical records and pathology slides of 123 patients with endocervical ADC who underwent radical hysterectomy and adjuvant radiation therapy. Tumor characteristics, patterns of failure, and survival outcomes were compared between HPVA and HPVI ADCs.

RESULTS

Eighty-one (65.9%) and 42 (34.1%) patients were diagnosed with HPVA and HPVI ADCs, respectively. HPVI ADC showed more frequent positive vaginal resection margin (VRM) and peritoneal seeding than HPVA ADC. After a median follow-up of 58.1 months, local recurrence and distant metastasis were more frequently observed in HPVI ADC than in HPVA ADC. Both local recurrence-free survival (77.3% vs. 91.8%) and distant metastasis-free survival (50.1% vs. 73.7%) rates of HPVI ADC were lower than those of HPVA ADC. Disease-free survival was not significantly different between HPVI and HPVA ADCs.

CONCLUSION

We demonstrated that HPVI ADC exhibited higher rates of VRM involvement and peritoneal seeding than those of HPVA ADC, resulting in higher rates of local recurrence and distant metastasis. Further studies with larger populations are warranted to explore optimal treatment strategies based on the histological subtypes of endocervical ADC.

Recurrent WWTR1 S89W mutations and Hippo pathway deregulation in clear cell carcinomas of the cervix

Clear cell carcinoma (CCC) of the cervix (cCCC) is a rare and aggressive type of human papillomavirus (HPV)-negative cervical cancer with limited effective treatment options for recurrent or metastatic disease. Historically, CCCs of the lower genital tract were associated with in utero diethylstilbestrol exposure; however, the genetic landscape of sporadic cCCCs remains unknown. Here we sought to define the molecular underpinning of cCCCs. Using a combination of whole-exome, targeted capture, and RNA-sequencing, we identified pathogenic genetic alterations in the Hippo signaling pathway in 50% (10/20) of cCCCs, including recurrent WWTR1 S89W somatic mutations in 40% (4/10) of the cases harboring mutations in the Hippo pathway. Irrespective of the presence or absence of Hippo pathway genetic alterations, however, all primary cCCCs analyzed in this study (n = 20) harbored features of Hippo pathway deregulation at the transcriptomic and protein levels. In vitro functional analysis revealed that expression of the WWTR1 S89W mutation leads to reduced binding of TAZ to 14-3-3, promoting constitutive nuclear translocation of TAZ and Hippo pathway repression. WWTR1 S89W expression was found to lead to acquisition of oncogenic behavior, including increased proliferation, migration, and colony formation in vitro as well as increased tumorigenesis in vivo, which could be reversed by targeted inhibition of the TAZ/YAP1 complex with verteporfin. Finally, xenografts expressing WWTR1 S89W displayed a shift in tumor phenotype, becoming more infiltrative as well as less differentiated, and were found to be composed of cells with conspicuous cytoplasmic clearing as compared to controls. Our results demonstrate that Hippo pathway alterations are likely drivers of cCCCs and likely contribute to the clear cell phenotype. Therapies targeting this pathway may constitute a new class of treatment for these rare, aggressive tumors. © 2022 The Pathological Society of Great Britain and Ireland.

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

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

Survival Comparison Between Squamous Cell Carcinoma and Adenocarcinoma for Radiotherapy-Treated Patients with Stage IIB-IVA Cervical Cancer

Objective

To compare the prognostic significance of adenocarcinoma (AC) with squamous cell carcinoma (SCC) on overall survival (OS) in patients with stage IIB-IVA cervical cancer (CC) treated by external beam radiotherapy (EBRT) and brachytherapy (BRT) with/without chemotherapy registered in the Surveillance, Epidemiology, and End Results database.

Methods

Data of eligible patients were extracted between 2004 and 2016. A univariate analysis was conducted using the cumulative incidence function (CIF) by considering competing events and compared using Gray’s test. The significant variables in univariate analysis were further evaluated in a multivariate analysis performed with the Fine-Gray regression model. Propensity score matching (PSM) analysis was also employed to reconfirm the results found in the present study.

Results

A total of 2,243 patients with SCC and 176 patients with AC were extracted from the database. The 5-year OS rates were 57.8% in the SCC group and 52.8% in the AC group. 149 patients died of causes other than CC—considered as competing events. Compared with the SCC group, patients diagnosed with AC had statistically significant worse 5-year OS rate before and after PSM. In the multivariate Fine-Gray regression model, the histological subtype of AC was proven as an independent prognostic factor associated with poorer OS before [hazard ratio (HR) = 1.340; 95% confidence interval (CI): 1.081-1.660; P = 0.007] and after [HR = 1.376; 95% CI: 1.107-1.711; P = 0.004] PSM.

Conclusions

The histological subtype of AC is significantly correlated with impaired OS as an independent prognostic variable in patients with stage IIB-IVA CC who received EBRT and BRT compared to patients with SCC. Future studies should incorporate effective and individualized treatment strategies into clinical decision-making to improve the unsatisfactory survival outcomes for patients with AC.

[Revised German guidelines on the diagnosis and treatment of carcinoma of the uterine cervix-what's new for pathologists in 2021?]

In 2021, the 2015 German consensus guideline for the diagnosis and treatment of uterine cervical carcinoma was updated. The present article summarises the new recommendations for pathologists: the incorporation of the International Endocervical Adenocarcinoma Classification (IECC), which morphologically separates HPV-associated and non-HPV-associated adenocarcinomas, as well as the reporting of the prognostic relevant growth pattern of the adenocarcinoma of the endocervical subtype (Silva pattern). Histologically, multifocality has been defined as the presence of clearly invasive foci with a minimum distance between each focus of 0.2 cm. Because of its intratumoural heterogeneity, all carcinomas ≤ 2 cm in their largest dimension should be processed completely, and tumours > 2 cm should be processed with one block per centimetre of their greatest dimension. In cases of (radical) trachelectomy/hysterectomy, the distal vaginal resection margin and all parametrial tissue should be processed completely. Sentinel lymph nodes have to be processed completely by lamellation along its long axis in 0.2 cm intervals. Immunohistochemical ultrastaging is mandatory. Staging should be performed using the 2009 FIGO classification and 2017 TNM classification. Reporting the revised 2018 FIGO classification is optional. To date, molecular markers have not been relevant for prognostication and treatment decision making.

Not Your Typical Adenocarcinoma: A Case of Mesonephric Adenocarcinoma of the Cervix With Fibroblast Growth Factor Receptor 2 (FGFR2) Mutation

Cervical cancer is one of the leading causes of cancer mortality in women. However, there have been great advances in its prevention and treatment. Nevertheless, there are certain rare forms of this cancer that are under-recognized, underreported, and have a paucity of evidence in terms of treatment. Mesonephric adenocarcinoma (AC) is one such rare disease, with less than 50 cases reported in the literature so far. We report a case of mesonephric AC of the cervix in a 73-year-old female who presented with abnormal vaginal bleeding. Our case is unique in that the patient had recurrence with lung metastases as well as fibroblast growth factor receptor 2 (FGFR2) mutation on genetic sequencing. She responded well to platinum-based chemotherapy and is currently on maintenance therapy with lenvatinib and bevacizumab. We aim to bring this patient’s disease course and treatment options chosen to the attention of the medical community as this is only the second reported case of mesonephric AC with FGFR2 mutation, and probably the first one to be treated with tyrosine kinase inhibitors and immunotherapy with a favorable response.

CDK6 increases glycolysis and suppresses autophagy by mTORC1-HK2 pathway activation in cervical cancer cells

Cervical carcinoma is a leading malignant tumor among women worldwide, characterized by the dysregulation of cell cycle. Cyclin-dependent kinase 6 (CDK6) plays important roles in the cell cycle progression, cell differentiation, and tumorigenesis. However, the role of CDK6 in cervical cancer remains controversial. Here, we found that loss of CDK6 in cervical adenocarcinoma HeLa cell line inhibited cell proliferation but induced apoptosis as well as autophagy, accompanied by attenuated expression of mammalian target of rapamycin complex 1 (mTORC1) and hexokinase 2 (HK2), reduced glycolysis, and production of protein, nucleotide, and lipid. Similarly, we showed that CDK6 knockout inhibited the survival of CDK6-high CaSki but not CDK6-low SiHa cervical cancer cells by regulation of glycolysis and autophagy process. Collectively, our studies indicate that CDK6 is a critical regulator of human cervical cancer cells, especially with high CDK6 level, through its ability to regulate cellular apoptosis and metabolism. Thus, inhibition of CDK6 kinase activity could be a powerful therapeutic avenue used to treat cervical cancers.

Tumoral Morphologic Features From Cervical Biopsies That Are Predictive of a Negligible Risk for Nodal Metastasis and Tumor Recurrence in Usual-type Cervical Adenocarcinomas: A Multi-institutional Study

The metastatic or recurrent potential of localized human papillomavirus-associated endocervical adenocarcinoma (HPVA EAC) is difficult to predict, especially based upon biopsy alone. Recent analyses of small cohorts indicate that high tumor nuclear grade (TNG) and the presence of necrotic tumor debris (NTD) from HPVA EACs in cervical biopsy specimens are highly predictive of nodal metastasis (NM). In the present study, we aimed to investigate how reliably tumoral morphologic features from cervical biopsy specimens predict NM or tumor recurrence (TR) and patient outcomes in a large cohort of endocervical adenocarcinoma patients. A cohort comprised of 397 patients with HPVA EAC treated at 18 institutions was identified, and cervical biopsies were paired with their associated complete tumor resections for a total of 794 specimens. A variety of tumoral histologic features were examined for each paired specimen, including TNG (assessed on a 3-tiered scale of increasing abnormalities-TNG1, TNG2, TNG3) and NTD (defined by the presence of necrotic and apoptotic tumor cells within tumor glandular lumens admixed with granular and eosinophilic amorphous material and inflammatory cells), which were correlated with outcomes. The distribution of TNG in biopsies was as follows: 86 (21.7%) TNG1, 223 (56.2%) TNG2, and 88 (22.2%) TNG3. NTD was identified in 176 (44%) of the biopsy specimens. The sensitivity, specificity, positive predictive value, and negative predictive value of a TNG1 assignment in the biopsy being predictive of the same assignment in the full resection were 0.82 (95% confidence interval [CI]: 0.7-0.9), 0.895 (0.86-0.93), 0.593 (0.48-0.696), and 0.96 (0.94-0.98), respectively. Respective values for an NTD-negative status were 0.89 (95% CI: 0.83-0.92), 0.715 (0.64-0.77), 0.72 (0.65-0.77), and 0.89 (0.83-0.93), respectively. Compared with the other cases in each category, both TNG1 and an NTD-negative status were each significantly associated with lower rates of NM (odds ratio for TNG1=0.245, 95% CI: 0.070-0.857, P=0.0277; for NTD=0.199, 95% CI: 0.094-0.421, P<0.0001) and TR (odds ratio for TNG1=0.225, 95% CI: 0.051-0.987, P=0.0479; for NTD=0.367, 95% CI: 0.171-0.786, P=0.0099) independent of depth of stromal invasion, lymphovascular invasion, tumor size, FIGO stage, and Silva pattern. Overall, 73/379 (19%) cases were both TNG1 and NTD-negative on the biopsy, and none of these 73 cases showed NM (0%), but a single case (1.4%) showed TR. In contrast, among the 324 biopsies with TNG2/3 and/or presence of NTD, 62 (19.1%) had NM, and 41 (12.9%) had TR. In summary, 2 variables in combination (ie, TNG1 and NTD-negative) identified a subset of HPVA EAC patients-∼19%-with a 0% frequency of nodal metastases and only 1.4% frequency of recurrence. Biopsies highly but imperfectly predicted these features. Nonetheless, these findings may potentially be of clinical utility in the risk stratification of patients with HPVA EACs. This may allow some patients with a minimal risk of nodal metastases and TR to be identified at the biopsy phase, thereby facilitating more personalized, possibly less aggressive treatment.

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.

Oncologic outcomes of patients with FIGO 2014 stage IB-IIA cervical adenocarcinoma who underwent radical surgery

PURPOSE

To identify prognostic factors of early-stage cervical adenocarcinoma in patients with FIGO IB-IIA, who were treated with radical surgery.

MATERIALS AND METHODS

Clinical data of 64 patients with stage IB-IIA cervical adenocarcinoma who underwent radical hysterectomy and lymphadenectomy with or without adjuvant therapy between 1993 and 2019 were retrospectively reviewed. The clinicopathologic factors that affect the oncological outcomes were evaluated. The Kaplan-Meier method was used for the assessment of survival outcomes. Survival curves were compared using the log-rank test.

RESULTS

The 5-year recurrence-free survival and 5-year disease-specific survivals were 83% and 98%, respectively. Tumor size, stage of disease and uterine spread were significantly related prognostic factors for shorter recurrence-free survival. During the follow-up, nine (14.1%) patients recurred. Five of them were extrapelvic recurrence. No correlation was identified between histopathologic subtype and extrapelvic recurrence (p = 0.265). There was no difference between adjuvant only radiotherapy and concurrent chemoradiotherapy on recurrence-free survival in a univariate analysis adjusting for prognostic factors.

CONCLUSION

It is important to determine the prognostic factors that predict disease outcome in surgically treated cervical adenocarcinoma for tailored adjuvant treatment. Tumor size, stage and uterine spread are determinant factors for recurrence. Risk stratifications, including uterine spread may especially be useful for patients with AC.

Estrogen receptor-positive adenocarcinoma of the cervix presenting during pregnancy: Two case reports and review of the literature

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Estrogen receptor or progesterone receptor positivity are unusual in cervical adenocarcinomas.

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Estrogen receptor positivity in pregnancy could be associated with a faster growth rate.

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Both patients presented remain free of recurrence after definitive treatment.

The incidence of adenocarcinoma of the cervix in pregnancy is exceptionally rare, and thus there is no consensus on its management. Here, we report two cases of adenocarcinoma of the cervix diagnosed in the context of pregnancy. In our first case, a patient referred to colposcopy for atypical glandular cells of undetermined significance was subsequently diagnosed with well differentiated endocervical adenocarcinoma on cone biopsy. Just prior to the cone biopsy, she was incidentally found to have a first trimester pregnancy loss. The patient subsequently underwent a radical hysterectomy and bilateral sentinel lymph node dissection. Final pathology revealed a stage 1B1 (FIGO 2009) well differentiated adenocarcinoma of the cervix. Interestingly, the tumour was positive for estrogen receptor, which is unusual for cervical adenocarcinoma.

In our second case, a patient presented with a pedunculated, exophytic cervical neoplasm at 31 weeks GA with self-limiting antepartum hemorrhage. The primary lesion measured 52 mm in diameter on MRI and was amputated at the base during the patient’s elective repeat cesarean section. Final pathology revealed a stage IB2 (FIGO 2009) mucinous adenocarcinoma of the cervix. The patient subsequently underwent a radical hysterectomy and bilateral pelvic lymph node dissection 17 weeks after initial presentation. The depth of invasion was 2.2 mm, restricted to the inner third of the cervical wall, and there was no lymphovascular space invasion in the surgical specimen. Surgical margins, parametria, and lymph nodes were all negative for adenocarcinoma. This tumour was also found to be estrogen receptor/progesterone receptor (ER/PR) positive, again unusual for cervical adenocarcinoma. P16 was strongly positive and HPV DNA studies were also positive for human papilloma virus 18. The patient received adjuvant external beam radiotherapy to the pelvis and currently remains in remission.

Cervix-Online computer program: 27 years of hospital-based clinical registry for cervical cancer at the University Medical Centre Maribor

BACKGROUND

Clinical registries are designed to collect quality data about the care for cancer patients in order to improve it. They gather data that are generated during diagnosis and cancer treatment and also post-treatment follow-up. Analysis of collected data allows an improvement in the quality of patient care and a comparison with other health care providers. The aim of the present article is to describe the current version and practice of hospital-based cervical cancer registry in UKC Maribor.

MATERIALS AND METHODS

The first questionnaire for monitoring patients with cervical cancer was introduced at the Department of Gynecologic and Breast Oncology of the Maribor General Hospital in 1994. Since then, the principles for treating cervical cancer have been revised on several occasions. Therefore, based on our experience and new approaches to treatment, we have frequently amended the questionnaire content. It was redesigned into a form that is currently in use and transformed into a Cervix-Online computer program in 2014.

RESULTS

Over the last 27 years, we have collected data on cervical cancer patients treated at the University Medical Centre Maribor and former Maribor General Hospital. The Cervix-Online computer program that was developed for this purpose enabled a rapid and reliable collection, processing and analysis of 116 different data of patients with cervical cancer, including general data, history, diagnostic procedures, histopathological examination results, treatment methods, and post-treatment follow-ups.

CONCLUSIONS

The hospital-based cervical cancer registry with Cervix-Online computer program enables the collection of data to enhance diagnosis and the treatment of cervical cancer patients, the organization of day-to-day service, as well as the comparison of our treatment results with national and international standards. Incomplete or incorrect data entry, however, might pose a limitation of the clinical registry, which depends on several healthcare professionals involved in the diagnostic procedures, treatment, and follow-up of cervical cancer patients.

A meta-analysis of XRCC1 single nucleotide polymorphism and susceptibility to gynecological malignancies

BACKGROUND

Gynecological malignant tumor is a serious threat to women's health, cervical cancer, endometrial cancer and ovarian cancer are the most common. The eponymous protein encoded by the XRCC1 (X-ray repair cross complementation 1) gene is an important functional protein in the process of single-stranded DNA damage. Non-synonymous mutations of XRCC1 gene cause amino acid sequence changes that affect protein function and DNA repair ability, and may affect the interaction with other DNA repair proteins, leading to increased risk of tumor development. Many studies have assessed the association between XRCC1 gene polymorphism and the risk of cancer in the female reproductive system, but the results have been inconclusive. In this study, the relationship between XRCC1 Arg399Gln, Arg194Trp, Arg280His single nucleotide polymorphisms and susceptibility to gynecological malignancies was further explored by meta-analysis.

METHODS

English database: Pubmed, Medline, Excerpta Medica Database, Cochrance, etc; Chinese database: China national knowledge infrastructure, Wanfang Database, etc. STATA14 was used for statistical analysis, such as odd ratio (OR) value, subgroup analysis, heterogeneity test, sensitivity analysis, and publication bias.

RESULTS

In gynecologic cancers, the allele frequency difference of Arg399Gln case control group was statistically significant (GvsA: P = .007). There was no significant difference in allele frequency in the Arg194Trp and Arg280His case control groups (P = .065, 0.198). In different gene models, Arg399Gln was significantly correlated with gynecologic cancers susceptibility (GGvs AA: OR 0.91; 95% confidence interval [CI], 0.85 0.98); Arg194Trp was significantly correlated with gynecologic cancers susceptibility (CCvs TT: OR 0.94; 95% CI 0.88,1.00; CCvs CT: OR 0.97; 95% CI 0.90, 1.05); Arg280His was significantly correlated with gynecologic cancers susceptibility (GGvs AA: OR 0.98; 95% CI 0.94, 1.02; GGvs GA: OR 1.00;95% CI 0.97, 1.04). In the subgroup analysis, Arg399Gln and Arg194Trp were significantly correlated with gynecologic cancers susceptibility in the Asian race (P = .000, 0.049). In the analysis of different cancer subgroups, Arg399Gln and cervical cancer susceptibility were statistically significant (P = .039). Arg194Trp and endometrial cancer susceptibility were statistically significant (P = .033, 0.001).

CONCLUSIONS

XRCC1 Arg399Gln, Arg194Trp, Arg280His single nucleotide polymorphisms were associated with gynecologic cancer susceptibility. Arg399Gln genotype was statistically significant in relation to cervical cancer susceptibility. Arg194Trp genotype was statistically significant in relation to endometrial cancer susceptibility.

Gynaecological or gastrointestinal origin? Recognising Müllerian neoplasms with gastrointestinal phenotype and determining the primary site in selected entities

Recognising metastatic gastrointestinal and pancreatobiliary tumours to gynaecological sites may be challenging, as primary Müllerian tumours can demonstrate similar histological features. Endocervical adenocarcinomas can be of gastric and intestinal types, endometrial lesions may show gastrointestinal phenotype, and finally, mucinous tumours with secondary involvement of the ovaries may mimic primary neoplasms. The aim of this review is to address selected neoplastic entities of the gynaecological tract with gastric and intestinal differentiation and provide helpful clinical and pathological parameters for the diagnosis. A brief overview of metastatic tumours originating from the gastrointestinal and pancreaticobiliary tracts is also provided, including the most common pathological features.

Fertility Sparing Treatment in Gastric-Type Endocervical Carcinoma

Simple Summary

Due to a trend toward late childbearing, fertility preservation has become a major issue in young patients with gynecological cancer. Surgical fertility sparing management is universally acknowledged as an acceptable option in eligible patients with cervical cancer. Excisional cone biopsy or trachelectomy are now standard surgical procedures offered to selected patients with gynecological malignancies who wish to preserve their fertility. Neoadjuvant chemotherapy followed by surgery is another therapeutic option studied currently in numerous clinical trials. However, fertility preserving treatment is generally not recommended in rare histological types of cervical cancer, including clinically aggressive gastric-type endocervical carcinoma. Due to controversies in this emerging topic, a review of literature and international database was carried out, in search of solid evidence on fertility sparing management in gastric-type endocervical carcinoma.

Abstract

Fertility sparing management of cancer is one of the main components of quality-of-life issues. Early-stage cervical cancer, frequently diagnosed in women of reproductive age, can potentially be treated conservatively. However, some rare histological types of cervical cancer present with aggressive clinical behavior. Particularly, in the newly introduced concept of gastric-type endocervical carcinoma, fertility sparing management is ‘a priori’ not recommended. Even so, this issue remains undocumented. For this reason, a selected review of the current literature on gastric type endocervical carcinoma was carried out through PubMed. The keywords included “gastric-type cervical cancer”, “gastric-type endocervical carcinoma”, “conservative surgery”, “conservative treatment”, “fertility sparing surgery”, “radical trachelectomy”, “laparoscopic trachelectomy”, “robotic trachelectomy”, “laparotomic trachelectomy”, “abdominal trachelectomy”, “trachelectomy”, “neoadjuvant chemotherapy”, “conisation”, and “cone resection”. A search in the European Network on Cancer, Infertility and Pregnancy (INCIP) database was performed. The rarity of gastric-type endocervical carcinoma does not allow for conclusions on fertility sparing management with solid evidence. However, diffuse character of the disease and aggressive clinical behavior contraindicate a conservative treatment in young women with gastric type cervical cancer.

Online MR evaluation of inter- and intra-fraction uterus motions and bladder volume changes during cervical cancer external beam radiotherapy

Purpose/objective(s)

The purpose of the study was to assess the uterus motions and bladder volume changes of fractional movements in cervical sites throughout the external beam radiotherapy (EBRT) treatment.

Materials/methods

A prospective online MR imaging tracking study was conducted in EBRT 43 patients with at least 4 scans during each treatment (before: ultrasound scan, MRI scan, CBCT scan, after: MRI scan) were included. In order to improve the treatment repeatability, each patient was instructed to empty the bladder and drink 500 ml water 1 h before CT simulation and each treatment. If the ultrasound scan result reached the CT simulation volume of bladder, the treatment began. Bladder was outlined on the T2 weighted axial sequence and CBCT image by the two observers to avoid the influence of contouring. The data of bladder volume and scanning time were accurately recorded. The bladder volumes, filling rates and uterus motion were retrospectively analyzed by MIM software.

Results

Inter-fraction variation of the bladder volume was significant (p < 0.0001). Intra-fraction mean increase of the bladder volume was modest (30 cc) but significant (p < 0.001). Both inter- and intra-fraction of the uterus motion were significant. The average time between the pre-and post-fraction MRI scans was 27.82 ± 7.12 min (range 10–55 min) for IMRT plans and 24.14 ± 5.86 min (range7-38 min) for VMAT plan. Average bladder filling rate was 3.43 ml/min. The bladder filling rate did not change significantly with the course of treatment, but the bladder was more intolerant.

Conclusion

This is the most detailed assessment of intra-fraction and inter-fraction motion during EBRT for cervical cancer. Finally, this study will inform appropriate treatment margins for online adaptive radiotherapy. We suggest that at least one image scan is needed before the EBRT. The portable US scanner provides a quick but unreliable measurement of the bladder volume. There is a significant statistical difference between the results of ultrasonic scanning and that of image scanning.

A retrospective study on incidence, diagnosis, and clinical outcome of gastric-type endocervical adenocarcinoma in a single institution

Background

Gastric-type endocervical adenocarcinoma is rare but the most common subtype of cervical adenocarcinoma not associated with human papillomavirus. It is more aggressive with a shorter five-year survival rate compared to human papillomavirus-associated usual type endocervical adenocarcinoma. The objectives of our study were to determine the incidence and clinical-pathological characteristics of Gastric-type endocervical adenocarcinoma in a single institution.

Methods

Twenty four cases of invasive cervical adenocarcinoma were identified between January 2000 and December 2015, from the Saskatoon Health Region pathology database using International Endocervical Adenocarcinoma Criteria and Classification to retrospectively classify endocervical adenocarcinoma. Immunohistochemistry was performed with antibodies for Gastric mucin-6 (MUC-6), p16^INK4a, cyclin-dependent kinase inhibitor 2A (p16), p53 protein (p53), estrogen and progesterone receptors. Clinical and pathological data was retrieved from pathology reports and charts. Statistical analysis was performed using Mann-Whitney U test and Chi-Square test.

Results

Using the International Endocervical Adenocarcinoma Criteria and Classification criteria, 19 cases (79.2%) were classified as human papillomavirus-associated usual type endocervical adenocarcinoma, and five cases (20.8%) as Gastric-type endocervical adenocarcinoma. In our study 40% of Gastric-type endocervical adenocarcinoma cases presented at stage III compared to none of the usual type endocervical carcinoma cases. All the Gastric-type endocervical adenocarcinoma cases were positive for MUC-6, and negative for p16. 60% Gastric-type endocervical adenocarcinoma cases demonstrated mutant type p53 staining. In contrast, 84.2% of human papillomavirus-associated usual type endocervical adenocarcinoma cases showed block like nuclear and cytoplasmic positivity with p16 antibodies. The Gastric-type endocervical adenocarcinoma group had significantly shorter median survival time than human papillomavirus-associated usual type endocervical adenocarcinoma group, Gastric-type endocervical adenocarcinoma is 22 months compared to human papillomavirus-associated usual type endocervical adenocarcinoma at 118 months (p = 0.043).

Conclusions

In this study, Gastric-type endocervical adenocarcinoma accounted for 20.8% of all cervical adenocarcinoma with higher stage at presentation and shorter overall survival. Criteria proposed by International Endocervical Adenocarcinoma Criteria and Classification (IECC) are simple and reproducible in differentiating between, HPV- associated (HPVA) and non HPV associated (NHPVA) endocervical adenocarcinoma. Although none of the IHC assays is specific for GAS, but p16, MUC-6, ER, PR and p53 may further aid in confirming GAS and to differentiate it from benign and malignant mimics.

Minimal deviation adenocarcinoma with elevated CA19-9: A case report

BACKGROUND

Minimal deviation adenocarcinoma is a rare malignancy with a high rate of misdiagnosis and high aggressiveness, and its diagnosis relies on histopathology. Surgical resection is the preferred and most effective treatment, but the outcomes are often unsatisfactory.

CASE SUMMARY

A 60-year-old perimenopausal woman was admitted to the hospital and found to have elevated CA19-9 on physical examination without abdominal pain or vaginal bleeding. Clinical examination and positron emission tomography/computed tomography examination were unremarkable, magnetic resonance imaging examination was suggestive of dominant cervical lesions, and methylation examination was suggestive of malignant lesions. Tissue samples were taken from the suspected cervical lesion, and the final pathologic diagnosis was minimal deviation adenocarcinoma. Based on the pathologic diagnosis of suspected minimal deviation adenocarcinoma, radical abdominal total hysterectomy, bilateral oophorectomy, and pelvic and para-aortic lymph node dissection were performed. The final histological report confirmed minimal deviation adenocarcinoma of the cervix, stage IB2, with lymph node metastasis. Minimal deviation adenocarcinoma is a tumor with aggressive clinical behavior.

CONCLUSION

Patients with minimal deviation adenocarcinoma have a lower survival rate than patients with conventional human papillomavirus-related cervical adenocarcinoma. A precise preoperative pathologic diagnosis may reduce the mortality rate due to missed optimal treatment with multiple surgical interventions. To date, there is no therapeutic consensus; therefore, each case must be treated individually.

Emerging technologies for cervical cancer screening

Cervical cancer remains a concern worldwide, and cervical cancer screening plays an important role in reducing the burden of this disease. Although cytology is still the main strategy for cervical cancer screening, it has gradually changed to human papillomavirus testing. The specificity of human papillomavirus testing is lower than that of cytology, which leads to an increased rate of colposcopy after positive results. To decrease colposcopic examinations, an efficient triage method is needed for human papillomavirus screening. New biomarkers have been developed and evaluated for primary screening and triage of abnormal cytology or human papillomavirus-positive results. Their sensitivity and specificity were estimated and compared with those of cytology. In the present study, the following new techniques were examined: p16/Ki67 dual staining, DNA methylation, micro-ribonucleic acid, chromosomal abnormalities, Claudins and DNA ploidy. Evaluation studies of p16/Ki67 dual staining and DNA methylation were more advanced than those of other options. When p16/Ki67 dual staining was used for triage for human papillomavirus testing, the sensitivity of 2 or greater cervical intraepithelial neoplasia (CIN2+) detection was higher than that of cytology without decreased specificity. Although there are several types of DNA methylation, sensitivity and specificity were moderate for detecting CIN2+. S5 classifier is a commercialized product that consists of viral methylation, and high sensitivity with decreased specificity has been reported. Considering its combination with self-sampling, DNA methylation is a highly anticipated technique along with human papillomavirus testing for the next generation of cervical cancer screening. However, the backgrounds for cervical cancer screening differ among countries and further study is needed to identify the best available method.

Cervical stromal involvement by endometrial 'hyperplasia': a previously unreported phenomenon with recommendations to report as stage II endometrial carcinoma

A subtle 'burrowing' pattern of cervical stromal involvement by low-grade endometrioid adenocarcinoma of the uterine corpus is described in the literature. We report a small case series in which this pattern of cervical stromal involvement, warranting a diagnosis of endometrioid adenocarcinoma in the cervix, occurred in association with sometimes subtle endometrioid proliferations within the endometrium which fall short of the criteria for endometrioid adenocarcinoma and are in keeping with atypical hyperplasia or hyperplasia without atypia. In reporting this phenomenon, which has not been described previously, we highlight the importance of immunohistochemistry in the differential diagnosis, particularly in the exclusion of primary cervical glandular lesions, including those of mesonephric type. We discuss the differential with primary endometrioid adenocarcinoma (including minimal deviation type) of the cervix and other lesions and stress the importance of sampling the endometrium and lower uterine segment in their entirety in order to exclude an atypical hyperplasia or an adenocarcinoma in these locations. Although the pathogenesis of the cervical lesion we report is controversial, we believe that it is most likely a result of spread from the endometrium and results in the unusual occurrence of the malignant nature of the lesion being only apparent in the secondary rather than the primary lesion. We provide recommendations for reporting such cases and recommend designating them as stage II endometrial carcinoma, although the prognostic and management implications of such cases will only be clear once further cases with follow-up are reported.

[Clear Cell Carcinoma of Cervix in a 12-Year-Old Girl: A Case Report]

The 12-year-old patient was admitted to the hospital on September 19, 2019 for "vaginal bleeding for 2 + months and pelvic mass to be diagnosed". The patient and her family explicitly denied any previous history of diethylstilbestrol exposure. After admission, relevant examinations were conducted and hysteroscopic exploration was performed under general anesthesia. During the procedure, cervical neoplasms were extracted and pathology results indicated cervical cancer. Then, extensive transabdominal hysterectomy+bilateral salpingectomy+bilateral ovarian transposition+pelvic lymph node dissection+para-aortic lymph node sampling were performed. Postoperative pathology analysis of the removed tissue showed that clear cell carcinoma of cervix (CCAC) had infiltrated into 1/3 of the cervical stroma and there was downward involvement of the vaginal wall; the cancer metastasized to the left obturator lymph node and the left internal and external iliac lymph nodes. Immunohistochemical staining of the removed tissue showed the following results: cytokeratin 7 (+), cytokeratin 20 (-), Napsin-A (+), cell adhesion molecule CD15 (+), heatocyte nuclear factor-1 β (+), Sal-like protein 4 (-), tumor suppressor gene P16 protein (+), estrogen receptor (+), progesterone receptor (-), tumor suppressor gene P53 protein (focal positive), tumor suppressor gene WT-1 protein (-) and Ki67 antigen (about 40% positive). The patient was diagnosed with CCAC stage ⅢC1p. Four cycles of postoperative systemic chemotherapy (fluorouracil+cisplatin) and 25 times of three-dimensional afterloading radiotherapy were performed. The patient did follow-up visits and did not show obvious signs of recurrence. The clinical manifestations of this disease are basically the same as those of cervical squamous cell carcinoma, and if the patient is younger, it can be easily misdiagnosed as dysfunctional uterine bleeding, indicating the need for differential diagnosis.

Locoregional recurrence via mucus-mediated extension following lung resection for mucinous tumors

BACKGROUND

Clinically, locoregional recurrences following mucinous tumor resection are often experienced. However, it remains unclear whether mucinous tumors directly affect local recurrence or not, and if so, the mechanism is not known. Therefore, we investigated whether mucinous tumors are associated with locoregional recurrence after pulmonary resection and whether mucus extension is a risk factor for locoregional recurrence.

METHODS

The data of 152 patients who underwent pulmonary resection for metastases were reviewed. When mucus was partially or wholly present in the tumor based on macro- or microscopic identification, we assigned the tumor as mucinous. In mucinous tumors, when mucus was identified within the air spaces in the normal lung parenchyma, beyond the edge of the tumor, we assigned the tumor as positive for "mucus extension."

RESULTS

The 5-year cumulative incidence of locoregional recurrence in patients with mucinous tumors was 48.1%, which was significantly higher than that observed in those with non-mucinous tumors (14.9%). Within the mucinous tumor, the presence of mucus extension beyond the tumor edge was an independent risk factor for locoregional recurrence after pulmonary resection (hazard ratio, 5.52; P = 0.019).

CONCLUSIONS

During the resection of mucinous cancer, surgeons should maintain sufficient distance from the tumor edge to prevent locoregional recurrences.

Incidence, clinical risk and prognostic factors for liver metastasis in patients with cervical cancer: a population-based retrospective study

BACKGROUND

Cervical cancer is one of the most frequent malignancies in women, particularly metastasis resulting in a poor prognosis. However, the clinical characteristics of cervical cancer patients with advanced liver metastasis have not been well investigated. We aimed to evaluate the incidence, clinical risk and prognostic factors for hepatic metastasis in cervical cancer patients.

MATERIALS AND METHODS

The clinical features of patients diagnosed with cervical cancer were collected from the Surveillance, Epidemiology and End Result (SEER) public cancer database between 2010 and 2015. Multivariate logistic and Cox regression models were performed to identify potential risk and prognostic factors for liver metastasis in patients with cervical cancer.

RESULTS

A total of 431 patients (2.32%) developed liver metastasis in our analysis. The following characteristics were significantly associated with the development of liver metastasis: black ethnicity, uninsured status, higher tumor stage, poorer differentiated grade, non-squamous histology, non-surgery of primary site, patients with any additional lung, bone, and brain metastasis. Multivariate Cox regression showed that patients with additional lung metastasis, without radiotherapy, and without chemotherapy were negatively correlated with overall survival. Concurrent chemotherapy and radiotherapy was a favorable prognostic factor to improve overall survival, and chemotherapy showed to increase cause-specific survival. Additional lung metastasis was an independent characteristic for both risk and prognostic factors for hepatic metastasis in patients with cervical cancer.

CONCLUSION

Our results found several potential clinical features that may be used to assess the risk and prognosis of liver metastasis in patients with cervical cancer. These associated factors may provide clinical indications for the early identification and treatment of cervical cancer patients with hepatic metastasis.

Tumor Necrotic Debris and High Nuclear Grade: Newly Identified High-risk Factors for Early-stage Endocervical Adenocarcinoma

OBJECTIVE

Invasive pattern of endocervical adenocarcinomas (EACs) is known to influence lymph node metastasis and cancer recurrence. In this study we describe the prognostic significance of necrotic tumor debris (NTD) and tumor nuclear grade on recurrence risk stratification of early-stage cervical adenocarcinoma.

METHODS

Patients who underwent surgery from 2007 to 2018 for International Federation of Gynecology and Obstetrics (FIGO) stage IA1-IB2 EAC, for whom pathology was available for review were included in this study. Clinico-pathologic variables and clinical recurrence risk stratification (low, intermediate, or high risk) were correlated to intraluminal NTD and tumor nuclear grade (N3).

RESULTS

Among 50 patients meeting inclusion criteria, all were managed surgically and clinically risk stratified as low (n=33), intermediate (n=13), and high risk (n=4). Twenty-three patients (46%) were NTD-N3 negative and 27 (54%) were NTD-N3 positive. NTD-N3 was significantly associated with higher stage, tumor grade, larger tumor size, positive lymphovascular space invasion, and recurrence of disease (P=0.025). Patients with stage IB1 EAC who were stratified as intermediate or high-risk for recurrence were positive for NTD-N3. Lack of NTD-N3 had 100% negative predictive value for disease recurrence.

CONCLUSIONS

NTD-N3, a novel pathologic finding, may be used to further stratify overall recurrence risk, and may play a role in individualization of patient care in early-stage EAC.

Tumor Typing of Endocervical Adenocarcinoma: Contemporary Review and Recommendations From the International Society of Gynecological Pathologists

The incidence of endocervical adenocarcinoma, the second most common cervical cancer in the world, has been on the rise. While most cervical cancers are squamous cell carcinomas and associated with high-risk oncogenic human papillomavirus (HPV), approximately 15% of endocervical adenocarcinomas, which now represent about one quarter of all cervical cancers, are HPV-independent. In this review, we will focus on the shortcomings of historical histologic classification systems of female genital tract tumors as they pertain to endocervical adenocarcinomas, and we will highlight the advantages of the new International Endocervical Adenocarcinoma Criteria and Classification system, which forms the basis for the WHO 2020 classification. We will cover the various histologic types, subtypes, and variants of endocervical adenocarcinoma with regard to morphology, immunophenotype, molecular genetics, HPV status and differential diagnosis, and we will provide International Society of Gynecological Pathologists recommendations for diagnosing these tumors.

Analysis of Clinicopathological Features of Cervical Mucinous Adenocarcinoma with a Solitary Ovarian Metastatic Mass as the First Manifestation

Purpose

To avoid misdiagnosis, clinicopathological features were analyzed in cases of cervical mucinous adenocarcinoma with solitary ovarian metastatic masses.

Patients and Methods

Three cases misdiagnosed as primary ovarian adenocarcinoma before surgery were filtered from the database of the Cancer Hospital/Chinese Academy of Medical Sciences from January 1998 to December 2016. The clinical data were thoroughly collected and compared, and both frozen and paraffin-embedded pathological sections were reviewed by two expert pathologists.

Results

None of the patients experienced cervical contact bleeding, and no typical cervical neoplasms were found. The cervical canals were slightly thickened in two patients, as detected by either palpation or imaging. The high-risk human papillomavirus (HPV) test results were all negative, and the thin-prep cytologic test (TCT) screened only one case of atypical glandular epithelial cells. All cases were indicative of higher serum CA19-9 levels (79.49-6124 U/mL). The ovarian masses showed no regular laterality, while they were all cystic or solid-cystic. Their pathological sections indicated a benign appearance of the capsule tissue with well-differentiated mucinous glands infiltrating the ovarian cortex with focal necrosis.

Conclusion

Attention should be paid to cervical examinations before and during surgery for cervical mucinous adenocarcinoma with a metastatic ovarian mass as the first manifestation. Such patients may gain a better prognosis after active treatment.

Evaluation of human papillomavirus (HPV) prediction using the International Endocervical Adenocarcinoma Criteria and Classification system, compared to p16 immunohistochemistry and HPV RNA in-situ hybridization

Background

The International Endocervical Adenocarcinoma Criteria and Classification (IECC) separated endocervical adenocarcinomas into human papillomavirus (HPV) associated (HPVA) and non–HPV-associated (NHPVA) categories by morphology alone. Our primary objective was to assess the accuracy of HPV prediction by the IECC system compared to p16 immunohistochemistry and HPV RNA in-situ hybridization (RISH). Our secondary goal was to directly compare p16 and HPV RISH concordance.

Methods

Cases were classified by IECC and stained for p16 and HPV RISH on tissue microarray, with discordant p16/HPV RISH cases re-stained on whole tissue sections. Remaining discordant cases (p16/HPV, IECC/p16, IECC/HPV discordances) were re-reviewed by the original pathologists (n = 3) and external expert pathologists (n = 2) blinded to the p16 and HPV RISH results. Final IECC diagnosis was assigned upon independent agreement between all reviewers.

Results

One hundred and eleven endocervical adenocarcinomas were classified originally into 94 HPVA and 17 NHPVA cases. p16 and HPV RISH was concordant in 108/111 cases (97%) independent of the IECC. HPV RISH and p16 was concordant with IECC in 103/111 (93%) and 106/111 (95%), respectively. After expert review, concordance improved to 107/111 (96%) for HPV RISH. After review of the eight discordant cases, one remained as HPVA, four were reclassified to NHPVA from HPVA, two were unclassifiable, and one possibly represented a mixed usual and gastric-type adenocarcinoma.

Conclusions

p16 and HPV RISH have excellent concordance in endocervical adenocarcinomas, and IECC can predict HPV status in most cases. Focal apical mitoses and apoptotic debris on original review led to the misclassification of several NHPVA as HPVA.

Metastases to the ovary arising from endometrial, cervical and fallopian tube cancer: recent advances

The introduction of genomic studies has enabled assessment of the clonality of synchronous tumours involving the ovary and other sites in the female genital tract in a definitive way. This has led to the abandonment of conventional approaches to primary site assignment, and the recognition that most such synchronous neoplasms are clonally related single tumours with metastatic spread, rather than independent primary tumours. These discoveries have implications for diagnostic practice, analogous to the gradual change over the last few decades in our approach to mucinous neoplasms of the ovary metastatic from the gastrointestinal tract. In this review, we first examine the routes of metastasis to the ovary, and then discuss the diagnostic and clinical implications of concurrent ovarian carcinomas arising in combination with endometrial, endocervical and tubal carcinomas. It is proposed that cases of primary low-grade endometrioid endometrial carcinoma with a secondary unilateral ovarian tumour, both with indolent characteristics, may be classified as 'FIGO stage IIIA-simulating independent primary tumours', with a comment that conservative management would be appropriate. It should be recognised that human papillomavirus-associated endocervical adenocarcinomas may result in synchronous or metachronous ovarian metastases that appear to be unrelated to the primary tumour, and that these may be managed conservatively in the absence of other sites of disease. In cases of tubo-ovarian high-grade serous carcinoma, tubal intraepithelial or contralateral adnexal involvement should count as a pelvic disease site for staging purposes.

Immunotherapy in cervix cancer

The treatment approach to cervix cancer has remained unchanged for several decades and new therapeutic strategies are now required to improve outcomes, as the prognosis is still poor. In the last years, a better understanding of HPV tumor-host immune system interactions and the development of new therapeutics targeting immune checkpoints generated interest in the use of immunotherapy in cervix cancer. Preliminary phase I-II trials demonstrated the efficacy, the duration of responses and the manageable safety of this approach. Currently, many phase II and III studies are ongoing in both locally advanced and metastatic cervical cancer, assessing immunotherapy as a single agent or in combination with chemotherapy and radiotherapy. We reviewed the published data and the therapeutic implications of the most promising novel immunotherapeutic agents under investigation in cervix cancer.

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.

A case of cervical adenocarcinoma arising from endometriosis in the absence of human papilloma virus infection

Endometriosis-related cervical neoplasms are rare, and their clinicopathological features and association with human papilloma virus infection are unclear. A postmenopausal woman with recently diagnosed cervical adenocarcinoma was referred to our hospital. After further investigation, we suspected a stage IIB neoplasm that originated from endometriosis of the cervix or left parametrium. A radical hysterectomy was performed, and pathological examination confirmed a stage IIB cervical endometrioid carcinoma arising from the endometriosis in the cervix to the left parametrium that invaded the cervix; human papilloma virus infection of tumor cells was not detected. Endometriosis-related neoplasms can occur in the cervix or parametrium and present as cervical cancer. The neoplasm described here was not associated with human papilloma virus infection.