Adenocarcinoma of the cervix: should we treat it differently?

Comparison of the clinical outcomes of patients with stage IA-IIA2 cervical adenocarcinoma and squamous cell carcinoma after radical hysterectomy: A propensity score-matched real-world analysis

OBJECTIVE

To compare the pathological findings and survival outcomes of patients with 2009 FIGO stage IA-IIA2 cervical cancer between groups with adenocarcinoma (ADC) and squamous cell carcinoma (SCC) using the Chinese Cervical Cancer Clinical (FOUR-C) study database.

METHODS

Patients from 2004 to 2018 with cervical ADC and SCC who underwent radical hysterectomy were identified through the FOUR-C database. Propensity score matching (PSM) was conducted to balance baseline clinicopathological characteristics. The Kaplan-Meier method and Cox regression analysis were used to evaluate the prognostic effect of ADC on the 5-year overall survival (OS).

RESULTS

We identified 1611 (9.8%) patients with ADC and 14 894 (90.2%) patients with SCC. Compared with SCC, ADC was significantly associated with an increased risk of death (odds ratio [OR] 1.40, 95% CI 1.12-1.74) and disease progression (OR 1.34, 95% CI 1.14-1.57). ADC had a greater propensity for lymph node metastasis, uterine corpus invasion, perineural invasion, and ovarian metastases than SCC (P < 0.05). After 1:2 PSM, significant differences were still observed between these two histology subtypes (OS: OR 1.43, 95% CI 1.10-1.86; DFS: OR 1.45, 95% CI 1.19-1.76). The subgroup analysis further showed a worse prognosis for patients with ADC than for patients with SCC among patients with any of the high- or intermediate- risk factors (OR 1.60, 95% CI 1.21-2.12), but no significant differences were observed for the patients with no risk factors (OR 0.71, 95% CI 0.32-1.58).

CONCLUSION

ADC is an independent prognostic factor for shorter survival in surgically treated patients with cervical cancer presenting intermediate- or high-risk factors but does not affect survival outcomes in patients without any risk factors.

Fertility Preservation in Cervical Cancer-Treatment Strategies and Indications

Cervical cancer is frequently diagnosed in women during their reproductive years, and fertility preservation is an essential part of their cancer treatment. In highly selected patients with early stage, low-risk cervical cancer and a tumor size ≤ 2 cm, several treatment strategies can be offered for patients wishing to preserve fertility, including radical/simple trachelectomy or conization with pelvic lymph node assessment. Trachelectomy can be performed through a vaginal, abdominal, or minimally invasive approach and has been shown to have an equivalent oncologic outcome compared to radical hysterectomy. All surgical approaches for radical trachelectomy seem to have excellent survival with comparable oncologic outcomes. Nevertheless, patients undergoing vaginal trachelectomy have better obstetric outcomes compared to the other routes. In patients with larger tumors (2-4 cm), neoadjuvant chemotherapy followed by fertility-sparing surgery is an alternative option. Several chemotherapy regimens have been used for this indication, with a pathologic complete response rate of 17-73%. For locally advanced diseases that require radical hysterectomy or primary chemoradiation, fertility preservation can be performed using oocyte, embryo, or ovarian tissue cryopreservation, as well as ovarian transposition. For these patients, future pregnancy is possible through surrogacy. In addition to fertility preservation, ovarian transposition, where the ovaries are repositioned outside of the radiation field, is performed to maintain ovarian hormonal function and prevent premature ovarian failure. In summary, fertility-preservation treatment strategies for patients with early stage cervical cancer are continuously evolving, and less radical surgeries are becoming more acceptable. Additional and ongoing evidence is helping determine the impact of conservative procedures on oncologic and obstetric outcomes in these patients.

Case Report: Pelvic mass and massive ascites as the first symptom in cervical adenocarcinoma: report of two cases and literature review

Cervical adenocarcinoma accounts for 10%-25% of total cases of cervical carcinoma. But in recent years, the incidence of adenocarcinoma has risen both proportionally and absolutely. Clinically, most cervical adenocarcinoma show no symptom or present with abnormal uterine bleeding or vaginal discharge, similar to squamous cell carcinoma. What different about it is that cervical cytological testing demonstrates a high false-negative rate of cervical adenocarcinoma, potentially leading to the failure in detecting in early stage. This report presents two cases both with pelvic masses, and massive ascites served as the initial symptom, which is similar to the clinical symptom of ovarian cancer, but ultimately diagnosed with cervical adenocarcinoma through surgical specimens. There are few literature reports on this situation. Hence, a literature review also has been performed to improve the recognition for cervical adenocarcinoma presenting with pelvic masses and massive ascites, and to avoid misdiagnosis.

Marital status is an independent prognostic factor for cervical adenocarcinoma: A population-based study

Marriage has been reported as a beneficial factor associated with improved survival among cancer patients, but conflicting results have been observed in cervical adenocarcinoma (AC). Thus, this study is aimed to examine the relationship between the prognosis of cervical AC and marital status. Eligible patients were selected from 2004 to 2015 using the surveillance, epidemiology and end results (SEER) database. Cancer-specific survival (CSS) and overall survival (OS) were compared between married and unmarried groups. A total of 3096 patients had been identified, with married ones accounting for 51.29% (n = 1588). Compared to unmarried groups, more patients in the married group were relatively younger (aged ≤ 45) and belonged to white race, with grade I/II, Federation of International of Gynecologists and Obstetricians (FIGO) stage I/II and tumor size ≤4 cm. Apart from that, more patients received surgery, whereas fewer patients received chemotherapy and radiotherapy (all P < 0.05). The 5-year CSS and OS rates were 80.16% and 78.26% in married patients, 68.58% and 64.62% in the unmarried group (P < .0001). Multivariate analysis showed that marital status was an independent prognostic factor, and the married group performed better CSS (hazard ratio [HR]: 0.770; 95% confidence interval [CI]: 0.663-0.895; P = .001) as well as OS (HR: 0.751; 95%CI: 0.653-0.863; P < .001). As demonstrated by the results of subgroup analysis, married patients had better CSS and OS survival than unmarried ones in nearly all the subgroups. Marital status was identified as an independent prognostic factor for improved survival in patients with cervical AC.

Development and validation of a deep learning survival model for cervical adenocarcinoma patients

BACKGROUND

The aim was to develop a personalized survival prediction deep learning model for cervical adenocarcinoma patients and process personalized survival prediction.

METHODS

A total of 2501 cervical adenocarcinoma patients from the surveillance, epidemiology and end results database and 220 patients from Qilu hospital were enrolled in this study. We created our deep learning (DL) model to manipulate the data and evaluated its performance against four other competitive models. We tried to demonstrate a new grouping system oriented by survival outcomes and process personalized survival prediction by using our DL model.

RESULTS

The DL model reached 0.878 c-index and 0.09 Brier score in the test set, which was better than the other four models. In the external test set, our model achieved a 0.80 c-index and 0.13 Brier score. Thus, we developed prognosis-oriented risk grouping for patients according to risk scores computed by our DL model. Notable differences among groupings were observed. In addition, a personalized survival prediction system based on our risk-scoring grouping was developed.

CONCLUSIONS

We developed a deep neural network model for cervical adenocarcinoma patients. The performance of this model proved to be superior to other models. The results of external validation supported the possibility that the model can be used in clinical work. Finally, our survival grouping and personalized prediction system provided more accurate prognostic information for patients than traditional FIGO stages.

Texture Analysis in Uterine Cervix Carcinoma: Primary Tumour and Lymph Node Assessment

The conventional magnetic resonance imaging (MRI) evaluation and staging of cervical cancer encounters several pitfalls, partially due to subjective evaluations of medical images. Fifty-six patients with histologically proven cervical malignancies (squamous cell carcinomas, n = 42; adenocarcinomas, n = 14) who underwent pre-treatment MRI examinations were retrospectively included. The lymph node status (non-metastatic lymph nodes, n = 39; metastatic lymph nodes, n = 17) was assessed using pathological and imaging findings. The texture analysis of primary tumours and lymph nodes was performed on T2-weighted images. Texture parameters with the highest ability to discriminate between the two histological types of primary tumours and metastatic and non-metastatic lymph nodes were selected based on Fisher coefficients (cut-off value > 3). The parameters' discriminative ability was tested using an k nearest neighbour (KNN) classifier, and by comparing their absolute values through an univariate and receiver operating characteristic analysis. Results: The KNN classified metastatic and non-metastatic lymph nodes with 93.75% accuracy. Ten entropy variations were able to identify metastatic lymph nodes (sensitivity: 79.17-88%; specificity: 93.48-97.83%). No parameters exceeded the cut-off value when differentiating between histopathological entities. In conclusion, texture analysis can offer a superior non-invasive characterization of lymph node status, which can improve the staging accuracy of cervical cancers.

Prognostic values of the prognostic nutritional index, geriatric nutritional risk index, and systemic inflammatory indexes in patients with stage IIB-III cervical cancer receiving radiotherapy

Background

Growing evidence suggests that nutritional status and inflammation are associated with survival in various cancers. This study aimed to evaluate the prognostic value of the prognostic nutritional index (PNI), geriatric nutritional risk index (GNRI), and systemic inflammatory indexes (neutrophil/lymphocyte ratio [NLR], monocyte/lymphocyte ratio [MLR], and platelet/lymphocyte ratio [PLR]) in patients with stage IIB-III cervical cancer receiving radiotherapy.

Results

The ideal cutoff values for the PNI, GNRI, NLR, MLR, and PLR were 48.3, 97.04, 2.8, 0.41, and 186.67, respectively. Low PNI and GNRI scores were associated with poor OS and PFS. High NLR, MLR, and PLR also predicted inferior 5-year OS and PFS rates in patients with stage IIB-III cervical cancer. Multivariate Cox regression analysis identified tumor size, histological type, stage, number of metastatic lymph nodes, PNI, GNRI, NLR, PLR, and MLR as significant prognostic factors for OS and PFS.

Conclusions

The current findings suggest that the PNI, GNRI, NLR, PLR, and MLR are essential parameters for predicting prognosis in patients with stage IIB-III cervical cancer receiving radiotherapy.

Prognostic analysis of pT1-T2aN0M0 cervical adenocarcinoma based on random survival forest analysis and the generation of a predictive nomogram

Background

The efficacy of adjuvant radiotherapy for postoperative patients with early-stage cervical adenocarcinoma who are lymph node-negative is still inconclusive. Establishing a nomogram to predict the prognosis of such patients could facilitate clinical decision-making.

Methods

We recruited 4636 eligible patients with pT1-T2aN0M0 cervical adenocarcinoma between 2004 and 2016 from the Surveillance, Epidemiology and End Results (SEER) database. Random survival forest (RSF) and conditional survival forest (CSF) model was used to assess the prognostic importance of each clinical characteristic variable. We identified independent prognostic factors associated with overall survival (OS) by univariate and multivariate Cox regression risk methods and then constructed a nomogram. We stratified patients based on nomogram risk scores and evaluated the survival benefit of different adjuvant therapies. To reduce confounding bias, we also used propensity score matching (PSM) to match the cohorts before performing survival analyses.

Results

The RSF and CSF model identified several important variables that are associated with prognosis, including grade, age, radiotherapy and tumor size. Patients were randomly divided into training and validation groups at a ratio of 7:3. Multivariate cox analysis revealed that age, grade, tumor size, race, radiotherapy and histology were independent prognostic factors for overall survival. Using these variables, we then constructed a predictive nomogram. The C-index value for evaluating the prognostic nomogram fluctuated between 0.75 and 0.91. Patients were divided into three subgroups based on risk scores, and Kaplan-Meier (K-M) survival analysis revealed that in the low-risk group, postoperative chemotherapy alone was associated with a significantly worse OS than surgery alone. Following PSM, survival analysis showed that compared with surgery alone, radiotherapy was associated with a worse OS in the training group although there was no significant difference in the validation group.

Conclusions

For patients with pT1-T2aN0M0 cervical adenocarcinoma, adjuvant treatments such as postoperative radiotherapy or chemotherapy, compared with surgery alone, are of no benefit with regards to patient survival. Our prognostic nomogram exhibits high accuracy for predicting the survival of patients with early-stage postoperative cervical adenocarcinoma.

Cervical cancer heterogeneity: a constant battle against viruses and drugs

Cervical cancer is the first identified human papillomavirus (HPV) associated cancer and the most promising malignancy to be eliminated. However, the ever-changing virus subtypes and acquired multiple drug resistance continue to induce failure of tumor prevention and treatment. The exploration of cervical cancer heterogeneity is the crucial way to achieve effective prevention and precise treatment. Tumor heterogeneity exists in various aspects including the immune clearance of viruses, tumorigenesis, neoplasm recurrence, metastasis and drug resistance. Tumor development and drug resistance are often driven by potential gene amplification and deletion, not only somatic genomic alterations, but also copy number amplifications, histone modification and DNA methylation. Genomic rearrangements may occur by selection effects from chemotherapy or radiotherapy which exhibits genetic intra-tumor heterogeneity in advanced cervical cancers. The combined application of cervical cancer therapeutic vaccine and immune checkpoint inhibitors has become an effective strategy to address the heterogeneity of treatment. In this review, we will integrate classic and recently updated epidemiological data on vaccination rates, screening rates, incidence and mortality of cervical cancer patients worldwide aiming to understand the current situation of disease prevention and control and identify the direction of urgent efforts. Additionally, we will focus on the tumor environment to summarize the conditions of immune clearance and gene integration after different HPV infections and to explore the genomic factors of tumor heterogeneity. Finally, we will make a thorough inquiry into completed and ongoing phase III clinical trials in cervical cancer and summarize molecular mechanisms of drug resistance among chemotherapy, radiotherapy, biotherapy, and 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.

Low Transforming Growth Factor-β Pathway Activity in Cervical Adenocarcinomas

Cervical cancer is the fourth most common cancer in women worldwide. Squamous cell carcinoma (SCC) and adenocarcinoma (AC) are the most common histological types, with AC patients having worse prognosis. Over the last two decades, incidence rates of AC have increased, highlighting the importance of further understanding AC tumorigenesis, and the need to investigate new treatment options. The cytokine TGF-β functions as a tumour suppressor in healthy tissue. However, in tumour cells this suppressive function can be overcome. Therefore there is an increasing interest in using TGF-β inhibitors in the treatment of cancer. Here, we hypothesize that TGF-β plays a different role in SCC and AC. Analysis of RNA-seq data from the TCGA, using a TGF-β response signature, resulted in separate clustering of the two subtypes. We further investigated the expression of TGF-β-signalling related proteins (TβR1/2, SMAD4, pSMAD2, PAI-1, αvβ6 and MMP2/9) in a cohort of 62 AC patients. Low TβR2 and SMAD4 expression was associated with worse survival in AC patients and interestingly, high PAI-1 and αvβ6 expression was also correlated with worse survival. Similar correlations of TβR2, PAI-1 and αvβ6 with clinical parameters were found in previously reported SCC analyses. However, when comparing expression levels between SCC and AC patient samples, pSMAD2, SMAD4, PAI-1 and αvβ6 showed lower expression in AC compared to SCC. Because of the low expression of core TβR1/2, (p-)SMAD2 and SMAD4 proteins and the correlation with worse prognosis, TGF-β pathway most likely leads to tumour inhibitory effects in AC and therefore the use of TGF-β inhibitors would not be recommended. However, given the correlation of PAI-1 and αvβ6 with poor prognosis, the use of TGF- β inhibitors might be of interest in SCC and in the subsets of AC patients with high expression of these TGF-β associated proteins.

Proteases and HPV-Induced Carcinogenesis

Simple Summary

Human papillomavirus (HPV) infection is a sexually transmitted disease with high prevalence worldwide. Although most HPV infections do not lead to cancer, some HPV types are correlated with the majority of cervical cancers, and with some anogenital and oropharyngeal cancers. Moreover, enzymes known as proteases play an essential role in the pathogenic process in HPV-induced carcinogenesis. This review highlights the role of proteases and recent epidemiological data regarding HPV-dependent carcinogenesis.

Abstract

Persistent infection with Human papillomavirus (HPV) is the main etiologic factor for pre-malignant and malignant cervical lesions. Moreover, HPV is also associated with oropharynx and other anogenital carcinomas. Cancer-causing HPV viruses classified as group 1 carcinogens include 12 HPV types, with HPV 16 and 18 being the most prevalent. High-risk HPVs express two oncoproteins, E6 and E7, the products of which are responsible for the inhibition of p53 and pRB proteins, respectively, in human keratinocytes and cellular immortalization. p53 and pRB are pleiotropic proteins that regulate the activity of several signaling pathways and gene expression. Among the important factors that are augmented in HPV-mediated carcinogenesis, proteases not only control processes involved in cellular carcinogenesis but also control the microenvironment. For instance, genetic polymorphisms of matrix metalloproteinase 1 (MMP-1) are associated with carcinoma invasiveness. Similarly, the serine protease inhibitors hepatocyte growth factor activator inhibitor-1 (HAI-1) and -2 (HAI-2) have been identified as prognostic markers for HPV-dependent cervical carcinomas. This review highlights the most crucial mechanisms involved in HPV-dependent carcinogenesis, and includes a section on the proteolytic cascades that are important for the progression of this disease and their impact on patient health, treatment, and survival.

Intravoxel Incoherent Motion (IVIM) MR Quantification in Locally Advanced Cervical Cancer (LACC): Preliminary Study on Assessment of Tumor Aggressiveness and Response to Neoadjuvant Chemotherapy

The aim of this study was to determine whether quantitative parameters obtained from intravoxel incoherent motion (IVIM) model at baseline magnetic resonance imaging (MRI) correlate with histological parameters and response to neoadjuvant chemotherapy in patients with locally advanced cervical cancer (LACC). Methods: Twenty patients with biopsy-proven cervical cancer, staged as LACC on baseline MRI and addressed for neoadjuvant chemotherapy were enrolled. At treatment completion, tumor response was assessed with a follow-up MRI evaluated using the revised response evaluation criteria in solid tumors (RECIST; version 1.1), and patients were considered good responders (GR) if they had complete response or partial remission, and poor responders/non-responders (PR/NR) if they had stable or progressive disease. MRI protocol included conventional diffusion-weighted imaging (DWI; b = 0 and 1000 s/mm²) and IVIM acquisition using eight b-values (range: 0–1500 s/mm²). MR-images were analyzed using a dedicated software to obtain quantitative parameters: diffusion (D), pseudo-diffusion (D*), and perfusion fraction (fp) from the IVIM model; apparent diffusion coefficient (ADC) from conventional DWI. Histologic subtype, grading, and tumor-infiltrating lymphocytes (TILs) were assessed in each LACC. Results: D showed significantly higher values in GR patients (p = 0.001) and in moderate/high TILs (p = 0.018). Fp showed significantly higher values in squamous cell tumors (p = 0.006). Conclusions: D extracted from the IVIM model could represent a promising tool to identify tumor aggressiveness and predict response to therapy.

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.

Clinical outcome of FIGO 2018 stage IB3/IIA2 cervical cancer treated by neoadjuvant chemotherapy followed by radical surgery due to lack of radiotherapy equipment: A retrospective comparison with concurrent chemoradiotherapy

This study aimed to assess neoadjuvant chemotherapy’s clinical outcomes such as efficacy, toxicity, and survival outcomes followed by radical hysterectomy ((NACT-RS) among women with cervical cancer stage IB3 and IIA2, by comparing concurrent chemoradiotherapy (CCRT) and NACT-RS. The study retrospectively reviewed patients with (2018 FIGO) stage IB3 and IIA2 cervical cancer who received preoperative neoadjuvant chemotherapy followed by NACT-RS or concurrent chemoradiotherapy (CCRT). The outcome measures were the 5-year survival and complication rates between the two groups. The median follow-up was 75 months. In total, 218 patients had stage IIA2, 136 patients had stage IB3, 201 patients received CCRT, and 153 patients received preoperative NACT-RS. In the CCRT group, the incidence of early complications (myelosuppression, gastrointestinal and urinary) was higher compared with that in the NACT-RS group (76.1 vs. 26.1%; p < 0.001, respectively). There was no significant difference between the two study groups concerning late complications. Five-year PFS was 79.9% and 85.5% in the NACT-RS and CCRT groups, respectively (p = 0.093). Five-year OS was 86.9% and 85.5% in the NACT-RS and CCRT groups, respectively (p = 0.97). In the multivariate clinicopathologic characteristics analysis for OS, initial tumor size > 4.3 cm (HR 5.11; p < 0.001), AC/ASC (HR 1.89; p = 0.02), histologic grade 2–3 (HR 2.25; p = 0.04), and 2018 FIGO stage IIA2 (HR 8.67; p < 0.001) were independent risk factors. The survival of patients with stage IB3 and IIA2 cervical cancer treated with NACT-RS was similar to that of patients treated with CCRT without increasing side effects.

Clinicopathological features and outcomes in gastric-type of HPV-independent endocervical adenocarcinomas

Background

We aimed to analyze the clinicopathological features and outcomes of patients with gastric-type of HPV-independent endocervical adenocarcinoma (GAS HPVI ECA), and compare them with non-GAS HPVI ECA cases.

Methods

Thirty-eight GASs [including 17 minimal deviation adenocarcinoma (MDA), 21 non-MDA GAS] and 17 non-GAS HPVI ECAs were studied. Data of clinical features, pathological characteristics, treatment, and outcomes were evaluated.

Results

The median age of patients with GAS and non-GAS HPVI ECA was 46 and 48 years, respectively (p = 0.93). Compared with non-GAS HPVI ECAs, GAS had more common complains of vaginal watery discharge (p = 0.04). GAS cases were also associated with higher clinical stage (p = 0.036), more common in deeper cervical stromal invasion (p = 0.002) and lymphoavascular invasion (p = 0.044). GAS was associated with worse median progression-free survival (PFS) (p = 0.02) and median overall survival (OS) (p = 0.03) over patients with non-GAS HPVI ECAs. MDA had similar clinical and pathological features and prognosis compared with non-MDA GAS. Of note, serum CA19–9 levels were significantly higher in GAS than that in non-GAS HPVI ECA cases.

Conclusions

GAS cases were more likely to have high risk pathological factors and poorer PFS and OS compared with non-GAS HPVI ECAs. Serum CA19–9 may be helpful for diagnosis and screening in patients with GAS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08792-7.

Identifying Critical States of Complex Diseases by Single-Sample Jensen-Shannon Divergence

MOTIVATION

The evolution of complex diseases can be modeled as a time-dependent nonlinear dynamic system, and its progression can be divided into three states, i.e., the normal state, the pre-disease state and the disease state. The sudden deterioration of the disease can be regarded as the state transition of the dynamic system at the critical state or pre-disease state. How to detect the critical state of an individual before the disease state based on single-sample data has attracted many researchers' attention.

METHODS

In this study, we proposed a novel approach, i.e., single-sample-based Jensen-Shannon Divergence (sJSD) method to detect the early-warning signals of complex diseases before critical transitions based on individual single-sample data. The method aims to construct score index based on sJSD, namely, inconsistency index (ICI).

RESULTS

This method is applied to five real datasets, including prostate cancer, bladder urothelial carcinoma, influenza virus infection, cervical squamous cell carcinoma and endocervical adenocarcinoma and pancreatic adenocarcinoma. The critical states of 5 datasets with their corresponding sJSD signal biomarkers are successfully identified to diagnose and predict each individual sample, and some "dark genes" that without differential expressions but are sensitive to ICI score were revealed. This method is a data-driven and model-free method, which can be applied to not only disease prediction on individuals but also targeted drug design of each disease. At the same time, the identification of sJSD signal biomarkers is also of great significance for studying the molecular mechanism of disease progression from a dynamic perspective.

Clinicopathological characteristics and prognostic factors of cervical adenocarcinoma

We aimed to assess the clinicopathological features and to determine the prognostic factors of cervical adenocarcinoma (AC). Relevant data were extracted from surveillance, epidemiology and end results database from 2004 to 2015. The log-rank test and Cox proportional hazard analysis were subsequently utilized to identify independent prognostic factors. A total of 3102 patients were identified. The enrolled patients were characterized by higher proportion of early FIGO stage (stage I: 65.9%; stage II: 14.1%), low pathological grade (grade I/II: 49.1%) and tumor size ≤ 4 cm (46.8%). The 5- and 10-year cancer-specific survival rates of these patients were 74.47% and 70.00%, respectively. Meanwhile, the 5- and 10-year overall survival (OS) rates were 71.52% and 65.17%, respectively. Multivariate analysis revealed that married status, surgery as well as chemotherapy were independent favorable prognostic indicators. Additionally, aged > 45, tumor grade III/IV, tumor size > 4 cm, advanced FIGO stage and pelvic lymph node metastasis (LNM) were unfavorable prognostic factors (all P < 0.01). Stratified analysis found that patients without surgery could significantly benefit from chemotherapy and radiotherapy. In addition, chemotherapy could significantly improve the survival in stage II–IV patients and radiotherapy could only improve the survival in stage III patients (all P < 0.01). Marital status, age, grade, tumor size, FIGO stage, surgery, pelvic LNM and chemotherapy were significantly associated with the prognosis of cervical AC.

The Silva Pattern-based Classification for HPV-associated Invasive Endocervical Adenocarcinoma and the Distinction Between In Situ and Invasive Adenocarcinoma: Relevant Issues and Recommendations From the International Society of Gynecological Pathologists

The Silva pattern-based classification for human papilloma virus-associated invasive adenocarcinoma has emerged as a reliable system to predict risk of lymph node metastasis and recurrences. Although not a part of any staging system yet, it has been incorporated in synoptic reports as established by the College of American Pathologists (CAP) and the International Collaboration on Cancer Reporting (ICCR). Moreover, the current National Comprehensive Cancer Network (NCCN) guidelines include this classification as an "emergent concept." In order to facilitate the understating and application of this new classification by all pathologists, the ISGyP Endocervical Adenocarcinoma Project Working Group presents herein all the current evidence on the Silva classification and aims to provide recommendations for its implementation in practice, including interpretation, reporting, and application to biopsy and resection specimens. In addition, this article addresses the distinction of human papilloma virus-associated adenocarcinoma in situ and gastric type adenocarcinoma in situ from their invasive counterparts.

Therapeutic potential of p53 reactivation in cervical cancer

Cervical cancer (CC) is one of most common malignancies affecting women worldwide. To date, surgical resection is the only effective radical remedy for CC at its early stages, while the prognosis of metastatic or recurrent CC is very poor. Dysfunction of the tumor suppressor p53 due to aberrant expression, post-translational modification, mutations, SNPs, and LOH as well as sequestration by viral antigens and MDM2/HDM2-mediated degradation is closely associated with the therapeutic insensitivity and relapse of many malignancies, including CC. Accumulating studies have demonstrated that restoration of p53 activity can induce cell cycle arrest and apoptosis, eliminate radio- and chemotherapy resistance, and inhibit tumor growth in CC cells. Therefore, activation of wild-type p53 as well as restoration of p53 function seems appealing as a therapeutic strategy. In this review, we focus on the potential roles of p53 reactivation in CC treatment and their underlying molecular mechanisms towards the development of novel therapies.

Localized Delivery of Cisplatin to Cervical Cancer Improves Its Therapeutic Efficacy and Minimizes Its Side Effect Profile

PURPOSE

Cervical cancer represents the fourth most frequent malignancy in the world among women, and mortality has remained stable for the past 4 decades. Intravenous cisplatin with concurrent radiation therapy is the standard-of-care for patients with local and regional cervical cancer. However, cisplatin induces serious dose-limiting systemic toxicities and recurrence frequently occurs. In this study, we aimed to develop an intracervical drug delivery system that allows cisplatin release directly into the tumor and minimize systemic side effects.

METHODS AND MATERIALS

Twenty patient biopsies and 5 cell lines treated with cisplatin were analyzed for platinum content using inductively coupled plasma mass spectrometry. Polymeric implants loaded with cisplatin were developed and evaluated for degradation and drug release. The effect of local or systemic cisplatin delivery on drug biodistribution as well as tumor burden were evaluated in vivo, in combination with radiation therapy.

RESULTS

Platinum levels in patient biopsies were 6-fold lower than the levels needed for efficacy and radiosensitization in vitro. Cisplatin local delivery implant remarkably improved drug specificity to the tumor and significantly decreased accumulation in the blood, kidney, and other distant normal organs, compared with traditional systemic delivery. The localized treatment further resulted in complete inhibition of tumor growth.

CONCLUSIONS

The current standard-of-care systemic administration of cisplatin provides a subtherapeutic dose. We developed a polymeric drug delivery system that delivered high doses of cisplatin directly into the cervical tumor, while lowering drug accumulation and consequent side effects in normal tissues. Moving forward, these data will be used as the basis of a future first-in-human clinical trial to test the efficacy of localized cisplatin as adjuvant or neoadjuvant chemotherapy in local and regional cervical cancer.

Local and Systemic STAT3 and p65 NF-KappaB Expression as Progression Markers and Functional Targets for Patients With Cervical Cancer

Cervical cancer, which main etiologic factor is Human Papillomavirus (HPV) infection, continues to be a burden for public health systems in developing countries. Our laboratory has been working with the hypothesis that signals generated in the tumor microenvironment can modulate local and systemic immune responses. In this context, it would be reasonable to think that tumors create pro-tumoral bias in immune cells, even before they are recruited to the tumor microenvironment. To understand if and how signaling started in the tumor microenvironment can influence cells within the tumor and systemically, we investigated the expression of key proteins in signaling pathways important for cell proliferation, viability, immune responses and tolerance. Besides, we used detection of specific phosphorylated residues, which are indicative of activation for Akt, CREB, p65 NFκB, and STAT3. Our findings included the observation of a significant STAT3 expression increase and p65 NFκB decrease in circulating leukocytes in correlation with lesion grade. In light of those observations, we started investigating the result of the inhibition of STAT3 in a tumor experimental model. STAT3 inhibition impaired tumor growth, increased anti-tumor T cell responses and decreased the accumulation of myeloid cells in the spleen. The concomitant inhibition of NFκB partially reversed these effects. This study indicates that STAT3 and NFκB are involved in immunomodulatory tumor effects and STAT3 inhibition could be considered as therapy for patients with cervical cancer.

Transcriptome analysis uncovers the diagnostic value of miR-192-5p/HNF1A-AS1/VIL1 panel in cervical adenocarcinoma

Despite the fact that the incidence of cervical squamous cell carcinoma has decreased, there is an increase in the incidence of cervical adenocarcinoma. However, our knowledge on cervical adenocarcinoma is largely unclear. Transcriptome sequencing was conducted to compare 4 cervical adenocarcinoma tissue samples with 4 normal cervical tissue samples. mRNA, lncRNA, and miRNA signatures were identified to discriminate cervical adenocarcinoma from normal cervix. The expression of VIL1, HNF1A-AS1, MIR194-2HG, SSTR5-AS1, miR-192-5p, and miR-194-5p in adenocarcinoma were statistically significantly higher than that in normal control samples. The Receiver Operating Characteristic (ROC) curve analysis indicated that combination of miR-192-5p, HNF1A-AS1, and VIL1 yielded a better performance (AUC = 0.911) than any single molecule -and could serve as potential biomarkers for cervical adenocarcinoma. Of note, the combination model also gave better performance than TCT test for cervical adenocarcinoma diagnosis. However, there was no correlation between miR-192-5p or HNF1A-AS1 and HPV16/18 E6 or E7. VIL1 was weakly correlated with HPV18 E7 expression. In summary, our study has identified miR-192-5p/HNF1A-AS1/VIL1 panel that accurately discriminates adenocarcinoma from normal cervix. Detection of this panel may provide considerable clinical value in the diagnosis of cervical adenocarcinoma.

Combined Evaluation of Preoperative Serum CEA and CA125 as an Independent Prognostic Biomarker in Patients with Early-Stage Cervical Adenocarcinoma

Purpose

There is currently a lack of research on preoperative prognostic analysis of early-stage cervical adenocarcinoma (ADC). The purpose of our study was to clarify whether preoperative serum tumor-marker levels were of prognostic value in early-stage ADC.

Patients and Methods

We performed a retrospective study of patients with International Federation of Gynecology and Obstetrics (FIGO) stage IA1–IIA1 and pathology-proven invasive ADC. We evaluated the relationship between preoperative serum tumor-marker levels and clinicopathological characteristics, and identified the relative preoperative risk factors affecting disease-free survival (DFS) and overall survival (OS). The optimal cut-off point of meaningful tumor markers was determined by the analysis of receiver operating characteristics (ROC), and the accuracy of the results was evaluated by the area under the curve (AUC).

Results

Elevated carcinoembryonic antigen (CEA), carbohydrate antigen 125 (CA125), squamous cell carcinoma antigen (SCC-Ag), alpha-fetoprotein (AFP), carbohydrate antigen 153 (CA153) and carbohydrate antigen 199 (CA199) were associated with certain clinicopathologic features of early-stage ADC. The combination of elevated serum CEA and CA125 was significantly associated with FIGO stage, body mass index (BMI) and LNM. Kaplan–Meier survival curve and Cox regression analyses revealed that CEA and CA125 might have significant prognostic implications in early-stage ADC patients, and the combination of elevated serum CEA and CA125 served as an independent predictor of early-stage ADC. The optimal cut-off point of serum CA125 for prediction DFS and OS was 32.60 U/mL and of serum CEA were 2.85 ng/mL and 2.05 ng/mL, respectively. The AUC showed that serum CEA was a moderate predictor of OS.

Conclusion

The preoperative serum levels of CEA and CA125 might have significant prognostic implications in early-stage ADC patients. Combined preoperative serum CEA and CA125 levels independently predicted the prognosis of early-stage ADC.

Significance of concurrent use of weekly cisplatin in carbon-ion radiotherapy for locally advanced adenocarcinoma of the uterine cervix: A propensity score-matched analysis

BACKGROUND

Although carbon-ion radiotherapy (C-ion RT) with concurrent chemotherapy (chemo-C-ion RT) is a promising treatment for adenocarcinoma (AC) of the uterine cervix, its long-term efficacy remains unclear. We evaluated the long-term significance of concurrent weekly cisplatin and C-ion RT for locally advanced AC of the uterine cervix.

METHODS

We performed a pooled analysis of patients with stage IIB-IVA AC of the uterine cervix who underwent C-ion RT alone or chemo-C-ion RT between September 2007 and December 2018 at our institution. Patients received 74.4 Gy (relative biological effectiveness) with or without cisplatin (40 mg/m² per week for up to 5 weeks), underwent no prior pelvic RT or systemic therapy, and had a performance status of 0-2. Propensity score matching was based on the year of diagnosis, regional lymph node metastasis, and stage.

RESULTS

The matched cohort contained 26 patients who underwent C-ion RT and 26 who underwent chemo-C-ion RT. The median age and follow-up period were 57 (range, 28-79) years and 34 (range, 2-126) months, respectively. The 5-year overall survival rate was significantly better in the chemo-C-ion RT group (72%) than in the C-ion RT group (46%; P = .041). The 5-year distant metastatic-free rate was also significantly better in the chemo-C-ion RT group (66%) than in the C-ion RT group (41%; P = .048). The incidence of grade ≥ 3 late toxicities was comparable between the two groups.

CONCLUSIONS

Chemo-C-ion RT for locally advanced AC of the uterine cervix is associated with a long-term survival benefit.

Characterization of women with cervical cancer assisted at Inca by histological type

OBJECTIVE

To determine the distribution of sociodemographic, reproductive, clinical and lifestyle habits in the cohort of women diagnosed with cervical cancer, assisted at Inca between 2012 and 2014, according to the histological type.

METHODS

Retrospective observational study of a hospital cohort of 1,004 women diagnosed with cervical cancer. Data were obtained from the Inca hospital cancer registry, physical and electronic records.

RESULTS

The most frequent histological type was squamous cell carcinoma (83.9%). Approximately 70% of the women aged more than 40 years. The study includes non-white women (67.4%), with less than 8 years of education (51.9%), with onset of sexual activity up to 16 years of age (40.7%), who were pregnant before (95.5%), with more than one pregnancy (82.9%), and more than two children (52.7%); 45.8% of the women were smokers or former smokers. Cervical adenocarcinoma was positively associated with earlier staging (IA-IIA) (OR = 1.79; 95%CI 1.03–3.13), as well as women with ≥ 12 years of education (OR = 6.30; 95%CI 1.97–20,13), who had no children (OR = 3.81; 95%CI 1.20 – 12,08) or who had up to two children (OR = 1.74; 95%CI 1.05 – 2,87).

CONCLUSIONS

The difference between histological types is highlighted, suggesting that women with cervical adenocarcinoma may represent a distinct clinical entity of cervical neoplasia, which may require different approaches from those used in squamous cell carcinoma.

Adenocarcinoma of the uterine cervix: Pathologic features, treatment options, clinical outcome and prognostic variables

Adenocarcinoma accounts for 10-25% of all cervical cancers, and its relative and absolute rate has raised over the past decades. Most, but not all the authors, reported that adenocarcinoma has a greater propensity to lymph node, ovarian and distant metastases and a worse prognosis compared with squamous cell carcinoma. However, whether histologic type is an independent prognostic factor is still a debated issue. Moreover, adenocarcinoma is a very heterogenous disease, including different histological subtypes. Whereas radical hysterectomy and definitive radiotherapy achieve the same clinical outcome in early stage squamous cell carcinoma, surgery seems to obtain better survival compared with definitive radiotherapy in early stage adenocarcinoma. Chemoradiation is the standard treatment for locally advanced cervical cancer regardless of histologic type, although several retrospective studies showed that patients with adenocarcinoma were more likely to die than those with squamous cell carcinoma both before and after concurrent chemoradiation era. The prognostic relevance of biological variables, such as cyclin-dependent kinase inhibitors, p53, cyclooxygenase-2 [COX-2], cell surface tyrosine-kinases and programmed death-ligand [PD-L1], is still under investigation. Palliative chemotherapy is the only treatment option for persistent or recurrent cervical adenocarcinoma not amenable with surgery and radiotherapy. The use of immune checkpoint inhibitors as well as a therapeutic strategy targeting cell surface tyrosine kinases should be adequately explored in this clinical setting.

Pretreatment neutrophil to lymphocyte and platelet to lymphocyte ratios as predictive factors for the survival of cervical adenocarcinoma patients

Objective

Our study assessed the clinical utility and prognostic value of pretreatment hematological parameters and calculated coefficients including the platelet to lymphocyte ratio (PLR), neutrophil to lymphocyte ratio (NLR), and monocyte to lymphocyte ratio (MLR) in patients with cervical adenocarcinoma (CA).

Materials and methods

Among 738 cervical cancer patients with International Federation of Gynecology and Obstetrics (FIGO) stages IA–IV treated at our institution, 96 (13%) presented with CA histology. The blood samples, collected within 10 days before treatment, were analyzed using a Sysmex XN-2000 system. The statistical tests included Mann–Whitney U-tests, log-rank tests, and Cox regression models. The cutoff points for the calculated hematological coefficients (NLR, PLR, and MLR) were determined using the MedCalc statistical program.

Results

The prognostic factor for overall survival (OS) and recurrence-free survival (RFS) in CA was clinical stage according to FIGO classification (FIGO IIB–IV vs I–IIA) (P=0.0001; P=0.002). Among patients with FIGO stage IIB–IV treated with radiotherapy/chemoradiotherapy, an elevated PLR was a negative prognostic factor for OS (P=0.017; HR: 2.96; 95% CI: 2.069–3.853). Among all patients, an elevated pretreatment NLR was a poor prognostic factor for OS (P=0.014; HR: 2.85; 95% CI: 2.011–3.685) and RFS (P=0.049; HR: 4.0; 95% CI: 2.612–5.392). The white blood cell count (WBC) before treatment was significantly higher in patients who died during follow-up (P=0.009).

Conclusion

Elevated NLR values before treatment may be associated with a shorter time of RFS and OS, while PLR index may have prognostic significance for OS in patients with advanced disease (FIGO IIB–IV). Both indexes and WBC may be a cost-effective biomarker that can be used conveniently for stratification of recurrence risk and death.

The safety of fertility preservation for microinvasive cervical adenocarcinoma: a meta-analysis and trial sequential analysis

PURPOSE

This study sought to evaluate the safety of conservative treatment in the management of patients with microinvasive cervical adenocarcinoma.

METHODS

The PubMed, PMC, EMBASE, Web of Science and Cochrane databases were searched to collect correlational studies published in English between January 1949 and May 2018. Series reports that evaluating the oncological prognoses of patients with microinvasive cervical adenocarcinoma who were treated with fertility-sparing surgery versus hysterectomy were pooled for meta-analysis and trial sequential analysis.

RESULTS

A total of 8 articles with 1256 patients were collected, including 7 retrospective reviews and 1 prospective study. Only one (0.08%) patient had parametrial involvement. Positive margins of surgical specimens were identified in 6 patients (2.2%). Lymph node metastasis was found in 5 patients (0.4%). The progression-free survival and overall survival rates were 99.3 and 98.2%. Fertility-sparing surgery had no adverse impact on recurrence or survival (P = 0.524 and 0.485, respectively). Regarding potential selection bias, significantly more patients with stage IA2 tumors than those with stage IA1 disease were treated with hysterectomy (P < 0.001). The trial sequential analysis indicated that the cumulative number of patients failed to meet the required sample size (number of patients).

CONCLUSIONS

The prognosis for patients with microinvasive cervical adenocarcinoma is excellent. Fertility preservation is at least appropriate for young women with stage IA1 adenocarcinoma. Further studies are still warranted to evaluate the safety of this procedure in managing patients with microinvasive cervical adenocarcinoma.

Chemoresistance of Gastric-Type Mucinous Carcinoma of the Uterine Cervix: A Study of the Sankai Gynecology Study Group

OBJECTIVE

Gastric-type mucinous carcinoma (GAS) is a novel variant of mucinous carcinoma of the uterine cervix, characterized by aggressive clinical behavior and absence of high-risk human papillomavirus. We conducted this study to evaluate the chemosensitivity of GAS compared with that of usual-type endocervical adenocarcinoma (UEA) in patients who had been enrolled in our previous study.

METHODS

Of 52 patients from our previous phase 2 study (SGSG005) of neoadjuvant chemotherapy with docetaxel and carboplatin for stage IB2 to IIB nonsquamous cervical cancer, 47 (stage IB2, 12; stage IIA2, 7; stage IIB, 28) were enrolled in this study with written informed consent. The biopsy specimens before neoadjuvant chemotherapy and surgical specimens after chemotherapy were centrally reviewed based on the updated World Health Organization classification (2014).

RESULTS

Of 47 patients with nonsquamous cell carcinoma, 20 (42.6%) were diagnosed with UEA, 13 (27.7%) with GAS, 12 (25.5%) with adenosquamous carcinoma, and 1 patient each (2%) with small cell carcinoma and serous carcinoma. Consequently, 33 patients, consisting of 20 patients with UEA and 13 patients with GAS, were eligible for the current study. The response rate of GAS was significantly lower than that of UEA (46.2% vs 85.0%, P = 0.048). Of 16 cases of stage II UEA, 11 (68.8%) were downstaged on microscopic examination of postsurgical specimens, but none of the 8 patients with stage II GAS showed any response (P < 0.01). Two inoperative tumors were GAS. With a median follow-up duration of 56 months, the 5-year progression-free and overall survival rates of GAS were significantly worse than those of UEA (38.5% vs 75.0% [P = 0.011] and 36.9% vs 90.0% [P < 0.001], respectively).

CONCLUSIONS

These findings suggest that GAS should be distinguished from UEA by its chemoresistance, necessitating an alternative treatment strategy established for this distinct subtype of endocervical adenocarcinoma.

Findings of multiple HPV genotypes in cervical carcinoma are associated with poor cancer-specific survival in a Swedish cohort of cervical cancer primarily treated with radiotherapy

Cervical cancer (CC) is one of the most common cancers in women and virtually all cases of CC are a result of a persistent infection of human papillomavirus (HPV). For disease detected in early stages there is curing treatment but when diagnosed late with recurring disease and metastasis there are limited possibilities. Here we evaluate HPV impact on treatment resistance and metastatic disease progression. Prevalence and distribution of HPV genotypes and HPV16 variants in a Swedish CC patient cohort (n=209) was evaluated, as well as HPV influence on patient prognosis. Tumor samples suitable for analysis (n=204) were genotyped using two different real-time PCR methods. HPV16 variant analysis was made using pyrosequencing. Results showed that HPV prevalence in the total series was 93%. Of the HPV-positive samples, 13% contained multiple infections, typically with two high-risk HPV together. Primary cure rate for the complete series was 95%. Recurrence rate of the complete series was 28% and distant recurrences were most frequent (20%). Patients with tumors containing multiple HPV-strains and particularly HPV genotypes belonging to the alpha 7 and 9 species together had a significantly higher rate of distant tumor recurrences and worse cancer-specific survival rate.

Factors Contributing to the Low Survival Among Women With a Diagnosis of Invasive Cervical Cancer in Ghana

: Cervical cancer is one of the most common cancers among women worldwide, and more than 85% of the disease occurs in low- and middle-income countries. Although it ranks as the most common cancer in Ghanaian women, there are no data available on cervical cancer survival.

METHODS

Information on women with a diagnosis of cervical cancer from 2010 to 2013 was collected from the Komfo Anokye and Korle-Bu Teaching Hospitals through review of paper-based and electronic medical records (including pathology records) at the oncology units and the departments of obstetrics and gynecology. Telephone interviews were conducted with patients and relatives to gather further information. Data were recorded using a standardized questionnaire and analyzed using summary statistics.

RESULTS

Information for 821 women was available for the survival analysis. Of these, 497 (60.5%) died during follow-up. At 3 years after diagnosis, survival was 39%. Survival was lowest in women with stage IV disease. Women with squamous cell carcinoma had a survival advantage over those with adenocarcinoma. Furthermore, women who received surgery, radiotherapy, and chemotherapy had better survival than did women with other forms of treatment.

CONCLUSIONS

In conclusion, cervical cancer survival is low in Ghana and is likely to be improved if a greater proportion of the disease is detected early. Improving knowledge of the disease for early diagnosis, reducing financial barriers, and greater organization of health care delivery are likely to improve survival from cervical cancer in Ghana.

Ovarian conservation is associated with better survival in young patients with T1N0M0 cervical adenocarcinoma: a population-based study

PURPOSE

Ovarian conservation is controversial in patients with cervical adenocarcinoma due to the risk of ovarian metastasis. The aim of this study is to evaluate the association of ovarian conservation with survival outcomes in young patients with T1N0M0 cervical adenocarcinoma.

METHODS

Women who were 45 years of age or younger with T1N0M0 cervical adenocarcinoma from 1988 to 2013 recorded in the Surveillance, Epidemiology, and End Results (SEER) database were included. Propensity score weighting was used to balance the intragroup differences. Cause-specific survival (CSS) and overall survival (OS) were compared using Kaplan-Meier estimates. A multivariate Cox model was used to adjust for covariates including propensity score. A stratified analysis was then conducted.

RESULTS

Totally, 1090 (79.7%) patients underwent oophorectomy and 278 (20.3%) patients whose ovaries were preserved were identified. Patients with preserved ovaries were younger, with a lower T classification and less likely to undergo pelvic lymphadenectomy (all p < 0.05). After propensity weighting, ovarian conservation group had better cause-specific survival (CSS) (5-year 98.8 versus 97.1%, 10-year 98.0 versus 95.2%, p = 0.0370) and overall survival (OS) (5-year 98.8 versus 97.1%, 10-year 96.5 versus 93.5%, p = 0.0025). After adjustment, the CSS benefit of ovarian conservation was marginally significant (p = 0.051) and OS benefit was still significant (p = 0.006). Stratified analysis showed that the CSS benefit was found in T1b classification (HR, 0.23; 95% CI 0.06-0.89, p = 0.033) and histological grade > 1 (HR 0.12; 95% CI 0.02-0.87; p = 0.035).

CONCLUSION

Among young women with T1N0M0 cervical adenocarcinoma, ovarian conservation is associated with better survival.

The role of ROS and NF-κB pathway in olmesartan induced-toxicity in HeLa and mcf-7 cell lines

We have recently shown that olmesartan could induce toxicity in HeLa and MCF-7 cell lines. In this study we investigated toxicity mechanism of olmesartan in HeLa and MCF-7 cell lines. HeLa and MCF-7 cells were cultured in DMEM in optimum conditions. Cells were pretreated with rutin as an antioxidant and treated with olmesartan as a cytotoxic agent. Cell proliferation was determined by MTT assay. The role of ROS was determined using DCFH-DA by flow cytometry analysis. Also, cells were treated with olmesartan (5mM) and Bay 11-7-82 (25μM) for 24h, then expression of apoptotic proteins including Bax, caspase3 and IκB were investigated in both cell lines by western blotting. Cell viability decreased with olmesartan in malignant cell lines. Kinetic of ROS assay showed increment of ROS generation starting at 2h which peaked at 4h after treatment. Pretreatment with antioxidant rutin decreased ROS increment which was consistent with improved viability of olmesartan-treated cells. Apoptosis results showed that olmesartan and Bay 11-7082 increased expression of apoptotic proteins such as Bax, caspase3 and IκB. Results proposed ROS increment and apoptosis could be involving mechanisms in olmesartan-induced toxicity in HeLa and MCF-7 cell lines.

Possible role of nanocarriers in drug delivery against cervical cancer

Introduction: Cervical cancer is the second most common cancer and the largest cancer killer among women in most developing countries including India. Although, various drugs have been developed for cervical cancer, treatment with these drugs often results in a number of undesirable side effects, toxicity and multidrug resistance (MDR). Also, the outcomes for cervical cancer patients remain poor after surgery and chemo radiation. Methods: A literature search (for drugs and delivery systems against cervical cancer) was performed on PubMed and through Google. The present review discuss about various methods including its current conventional treatment with special reference to recent advances in delivery systems encapsulating various anticancer drugs and natural plant products for targeting towards cervical cancer. The role of photothermal therapy, gene therapy and radiation therapy against cervical cancer is also discussed. Results: Systemic/targeted drug delivery systems including liposomes, nanoparticles, hydrogels, dendrimers etc. and localized drug delivery systems like cervical patches, films, rings etc. are safer than the conventional chemotherapy which has further been proved by the several drug delivery systems undergoing clinical trials. Conclusion: Novel approaches for the aggressive treatment of cervical cancer will optimistically result in decreased side effects as well as toxicity, frequency of administration of existing drugs, to overcome MDR and to increase the survival rates.

Preinvasive and Invasive Cervical Adenocarcinoma: Preceding Low-Risk or Negative Pap Result Increases Time to Diagnosis

OBJECTIVES

The aims of the study were to investigate screening histories of women with adenocarcinoma in situ (AIS) and adenocarcinoma (AdCa) of the cervix and to further evaluate screening for glandular disease.

MATERIALS AND METHODS

Screening histories were retrospectively collected for patients with AIS or AdCa at a single large-volume academic institution from 2005 to 2015. Fisher exact and Wilcoxon rank sum tests were used to compare AIS with AdCa patient characteristics, distribution of preceding Pap (i.e., trigger Pap) results, and high-risk human papillomavirus testing. The association between Pap result and time to diagnosis was evaluated.

RESULTS

Eighty-seven cases, 50 AIS and 37 AdCa, met study criteria; median age was 31 and 43 years, respectively. Among the AIS cohort, 52.0% had a negative or low-risk trigger Pap result versus 24.3% of those with AdCa (p = .001). The time to diagnosis of AIS ranged from 8.4 to 18.8 weeks for those with high- versus low-risk or negative trigger Pap results, respectively (p = .002). The time to diagnosis of AdCa ranged from 14.6 to 44.7 weeks for those with high- versus low-risk or negative trigger Pap results, respectively (p = .003). Among those with high-risk human papillomavirus testing, 89.7% tested positive at the time of trigger Pap with 100% positivity among those with low-risk or negative trigger Pap results.

CONCLUSIONS

Cervical AIS and AdCa affect many young nulliparous women and commonly preceded by low-risk or negative Pap testing. The interval to diagnosis increases with low-risk and negative Pap results, and therefore, further investigation into optimal screening for glandular lesions is needed.

Human Leukocyte Antigen-DR Expression is Significantly Related to an Increased Disease-Free and Disease-Specific Survival in Patients With Cervical Adenocarcinoma

OBJECTIVES

Human leukocyte antigen (HLA) class II antigens are expressed on antigen-presenting cells, that is, macrophages, dendritic cells, and B lymphocytes. Under the influence of IFN-γ, HLA class II molecules can also be expressed on T lymphocytes, epithelial and endothelial cells. In addition, HLA class II antigens can be expressed in a variety of malignancies; however, the link with prognosis and ultimately patient survival is controversial.

METHODS

The pattern of HLA-DRA expression in cervical carcinoma was studied using immunohistochemistry. In total, 124 cervical carcinomas were examined, of which 60 (48.4%) were squamous cell carcinomas and 64 (51.6%) were adenocarcinomas.

RESULTS

In squamous cell carcinoma, HLA-DRA was expressed in 41 (68.3%) of 60 tumors, whereas in adenocarcinoma, HLA-DRA was expressed in 60 (93.8%) of 64 tumors (P < 0.001). In adenocarcinoma, HLA-DRA expression was associated with an increased disease-free survival (211.0 ± 13.0 vs 53.3 ± 30.5 months; P = 0.004) and disease-specific survival (226.45 ± 11.5 vs 75.8 ± 27.6 months; P = 0.002).

CONCLUSIONS

Upregulation of HLA-DRA is significantly related to an increased disease-free and disease-specific survival in cervical adenocarcinoma. These data warrant further analysis of the functional role of HLA-DRA in these tumors.

Fertility-sparing surgery for uterine cervical cancer

The standard treatment for early cervical cancer of the uterus (CC) is radical hysterectomy with resection of the parametrium and pelvic lymphadenectomy. At least 40% of patients develop early-stage CC during child-bearing age, therefore preserving the uterus to maintain fertility has been an important consideration. Several surgical procedures including conization and vaginal or abdominal radical trachelectomy have been reported. These procedures are safe for removing lymph node negative CC tumors with <2 cm diameter. Recently, less radical surgical procedures that maintain fertility, such as conization, simple trachelectomy, minimally invasive surgery and neoadjuvant chemotherapy, have been indicated for tumors greater than 2 cm in diameter. In this review, we discuss the currently accepted surgical approaches for treating CC while maintaining fertility.

The Safety of Ovarian Preservation in Early-Stage Adenocarcinoma Compared With Squamous Cell Carcinoma of Uterine Cervix: A Systematic Review and Meta-Analysis of Observational Studies

Objective

The aim of this study was to compare the incidence of ovarian metastasis (OM) in adenocarcinoma (ADC) and squamous cell carcinoma (SCC) in early-stage cervical cancer and evaluate the safety of ovarian preservation in early-stage ADC.

Methods

To perform a meta-analysis to compare the incidence of OM between early-stage ADC and SCC, we searched PubMed, EMBASE, and Cochrane for observational studies that compared it with pathological evidence after radical hysterectomy and oophorectomy. Odds ratios with 95% confidence intervals were calculated with a fixed effects model. We also found a few articles evaluating the oncological prognosis of patients with ovarian preservation to perform a systematic review.

Results

A total of 5 studies were included in the meta-analyses. The incidence of OM of patients with early-stage ADC and SCC were 2% and 0.4%, respectively (odds ratio, 5.27; 95% confidence interval, 2.14–13.45). In 1427 patients with ADC or SCC of the cervix FIGO stage (CIS-IIA) who underwent hysterectomy, no ovarian recurrences were observed after unilateral or bilateral ovarian preservation in ADC patients in the follow-up (30–68 months); however, 15 patients with SCC developed pelvic recurrence.

Conclusions

Although the incidence of OM was higher in early-stage ADC than SCC according to ovarian pathology, it might be relatively safe to perform ovarian preservation with early-stage ADC because of low ovarian recurrence rate in short-term follow-ups.

Drug Delivery Approaches for the Treatment of Cervical Cancer

Cervical cancer is a highly prevalent cancer that affects women around the world. With the availability of new technologies, researchers have increased their efforts to develop new drug delivery systems in cervical cancer chemotherapy. In this review, we summarized some of the recent research in systematic and localized drug delivery systems and compared the advantages and disadvantages of these methods.

Different Prognostic Implications of 18F-FDG PET Between Histological Subtypes in Patients With Cervical Cancer

This study aimed to investigate whether the predictive values of intensity- and volume-based PET parameters are different between histological subtypes in patients with cervical cancer. Ninety patients, 65 with squamous cell carcinoma (SCC) and 25 with non-SCC (NSCC), who underwent pretreatment ¹⁸F-FDG PET/CT and pelvic MRI, were studied retrospectively. In addition to SUVmax and SUVmean, metabolic-tumor-volume (MTV) was determined by thresholding of 40% SUVmax and total-lesion-glycolysis (TLG) was calculated. Clinical factors and PET metabolic indices were compared between SCC and NSCC. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method with cut-offs determined by ROC analyses to stratify SCC and NSCC patients separately. Factors associated with survival were assessed with univariate and multivariate analyses using the Cox regression model. No significant differences were observed in clinical factors other than tumor size or ¹⁸F-FDG PET metabolic indices between SCC and NSCC. The Kaplan-Meier estimates of 2-year PFS and OS rates were 60% and 70% for SCC and 40% and 76% for NSCC, respectively. Multivariate analyses showed that MTV and TLG were the independent prognostic factors for PFS and OS in SCC; in contrast, SUVmax was the independent prognostic factor for PFS and OS in NSCC. Metabolic burden (MTV and TLG) could be beneficial for the prognostic prediction of cervical SCC patients; in contrast, metabolic intensity (SUVmax) could be beneficial for the prognostic prediction of NSCC patients. The different prognostic implications might be based on the differences of tissue integrity and histological heterogeneity between SCC and NSCC.

High levels of soluble MICA are significantly related to increased disease-free and disease-specific survival in patients with cervical adenocarcinoma

Downregulation of major histocompatibility complex class I chain-related molecule A (MICA) and upregulation of human leukocyte antigen G (HLA-G) on the tumor cells are important immune escape mechanisms for different epithelial tumors. In addition, upregulation of the soluble forms of the latter molecules in serum leads to peripheral T-cell and natural killer (NK)-cell tolerance. As for cervical cancer, it remains unknown whether soluble MICA (sMICA) and soluble HLA-G (sHLA-G) concentrations are related to tumor characteristics or patient survival rates. We measured sMICA and sHLA-G in pre-treatment sera of a large cohort of cervical cancer patients (n = 366) by enzyme-linked immunosorbent assay (ELISA). We detected a median sMICA of 174.73 pg/ml and a median sHLA-G of 5.35 U/ml. We did not find an association between sHLA-G levels and clinicopathological characteristics. In adenocarcinoma, low sMICA concentration was positively related to recurrent disease, a higher International Federation of Gynecology and Obstetrics (FIGO) stage and vaginal involvement (Mann-Whitney U-test; P = 0.018, P = 0.042 and P = 0.013, respectively). In the latter patient group, high sMICA levels were associated with better disease-free survival (DFS) and disease-specific survival (DSS) (P = 0.011 and P = 0.047). After adjusting for confounding factors, high sMICA proved to be an independent predictor for a better DFS and DSS [HR 0.16; 95% confidence interval (CI) 0.04-0.64; P = 0.009 and HR 0.12; 95% CI 0.03-0.50; P = 0.004]. sHLA-G did not influence survival in cervical cancer patients, regardless of histology. We conclude that cervical adenocarcinoma patients with high sMICA levels have an increased DFS and DSS. This data warrants a prospective trial to study the functional role of sMICA in cervical adenocarcinoma.