Early Cervical Cancer: Current Dilemmas of Staging and Surgery

Predicting Lymph Node Metastasis From Primary Cervical Squamous Cell Carcinoma Based on Deep Learning in Histopathologic Images

We developed a deep learning framework to accurately predict the lymph node status of patients with cervical cancer based on hematoxylin and eosin-stained pathological sections of the primary tumor. In total, 1524 hematoxylin and eosin-stained whole slide images (WSIs) of primary cervical tumors from 564 patients were used in this retrospective, proof-of-concept study. Primary tumor sections (1161 WSIs) were obtained from 405 patients who underwent radical cervical cancer surgery at the Fudan University Shanghai Cancer Center (FUSCC) between 2008 and 2014; 165 and 240 patients were negative and positive for lymph node metastasis, respectively (including 166 with positive pelvic lymph nodes alone and 74 with positive pelvic and para-aortic lymph nodes). We constructed and trained a multi-instance deep convolutional neural network based on a multiscale attention mechanism, in which an internal independent test set (100 patients, 228 WSIs) from the FUSCC cohort and an external independent test set (159 patients, 363 WSIs) from the Cervical Squamous Cell Carcinoma and Endocervical Adenocarcinoma cohort of the Cancer Genome Atlas program database were used to evaluate the predictive performance of the network. In predicting the occurrence of lymph node metastasis, our network achieved areas under the receiver operating characteristic curve of 0.87 in the cross-validation set, 0.84 in the internal independent test set of the FUSCC cohort, and 0.75 in the external test set of the Cervical Squamous Cell Carcinoma and Endocervical Adenocarcinoma cohort of the Cancer Genome Atlas program. For patients with positive pelvic lymph node metastases, we retrained the network to predict whether they also had para-aortic lymph node metastases. Our network achieved areas under the receiver operating characteristic curve of 0.91 in the cross-validation set and 0.88 in the test set of the FUSCC cohort. Deep learning analysis based on pathological images of primary foci is very likely to provide new ideas for preoperatively assessing cervical cancer lymph node status; its true value must be validated with cervical biopsy specimens and large multicenter datasets.

A preoperative nomogram predicting risk of lymph node metastasis for early-stage cervical cancer

OBJECTIVE

This study aimed to develop a preoperative nomogram based on clinical and pathological characteristics to provide a more individualized and accurate estimation of lymph node metastasis (LNM) in patients with early-stage cervical cancer.

METHODS

A total of 7,349 early-stage cervical cancer patients with pathologically confirmed between 1988 and 2015 were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. All the patients were divided into training (n = 5,500) and validation (n = 1,849) cohorts randomly. A cohort of 455 patients from multicenter was used for the external validation. We established a multivariate logistic regression model based on preoperative clinicopathological data, from which a nomogram was developed and validated. A predicted probability of LNM < 5% was defined as low risk.

RESULTS

From multivariate logistic regression analysis, age at diagnosis, histologic subtype, tumor grade, tumor size and FIGO stage were identified as preoperative independent risk factors of LNM. The nomogram incorporating these factors demonstrated good discrimination and calibration (concordance index = 0.723; 95% confidence interval (CI), 0.707-0.738). In the validation cohort, the discrimination accuracy was 0.745 (95% CI, 0.720-0.770) and 0.747 (95% CI, 0.690-0.804), respectively. The nomogram was well calibrated with a high concordance probability. We also established an R-enabled Internet browser for LNM risk assessment, which tool may be convenient for physicians.

CONCLUSIONS

We developed an effective preoperative nomogram based on clinical and pathological characteristics to predict LNM for early-stage cervical cancer. This model could improve clinical trial design and help physicians to decide whether to perform lymphadenectomy or not.

Characteristics and survival of patients with gynecological cancers who refuse radiotherapy: a retrospective cohort study

BACKGROUND

Radiotherapy improves survival for many cancer patients. However, some patients still refuse radiotherapy despite the recommendations of their physicians. We aimed to investigate the impact of refusing recommended radiotherapy on overall survival in patients with gynecological cancers (GC) and attempted to describe what characteristics are associated with the refusal of radiotherapy.

METHODS

Data were extracted from the Surveillance, Epidemiology and End Result (SEER) database for patients who were diagnosed with GC and recommended for radiotherapy between 1988 and 2016. Kaplan-Meier and multivariate Cox regression analyses were utilized to analyze the impact of refusal of radiotherapy on overall survival. Univariate and multivariate logistic regression analyses were used to identify characteristics associated with refusal of radiotherapy.

RESULTS

In total, 1,226 of 208,093 patients (0.6%) refused radiotherapy. Multivariate Cox regression analysis showed that refusal of radiotherapy was associated with poorer overall survival in GC patients with stage I/II [hazard ratio (HR) = 1.64; 95% confidence interval (CI), 1.50-1.79], but may not affect overall survival in patients with stage III/IV (HR = 1.03; 95%CI, 0.84-1.25). Multivariate logistic regression analysis demonstrated that factors such as older age (40-65 years, > 65 years), unmarried status (divorced, single, widowed), higher foreign-born rate (1.87-2.82%, 1.51-2.19), refusal of surgery (recommended but not performed), and higher grade (poorly differentiated, undifferentiated/anaplastic) may increase the likelihood of refusing radiotherapy (all P < 0.05). Factors that may reduce the likelihood of refusing radiotherapy include higher income (> 42,810$), lower grade (well-differentiated), primary site of ovarian cancer, and no/unknown chemotherapy (all P < 0.05).

CONCLUSION

Refusal of radiotherapy is related to worse overall survival in GC patients with stage I/II, and many characteristics may affect a patient's choice of refusal of radiotherapy.

Current Update on PET/MRI in Gynecological Malignancies-A Review of the Literature

Early detection of gynecological malignancies is vital for patient management and prolonging the patient's survival. Molecular imaging, such as positron emission tomography (PET)/computed tomography, has been increasingly utilized in gynecological malignancies. PET/magnetic resonance imaging (MRI) enables the assessment of gynecological malignancies by combining the metabolic information of PET with the anatomical and functional information from MRI. This article will review the updated applications of PET/MRI in gynecological malignancies.

HDAC10 Inhibits Cervical Cancer Progression through Downregulating the HDAC10-microRNA-223-EPB41L3 Axis

Background

Although the tumorigenesis of cervical cancer (CC) has been widely investigated and recognized, the study of the systematic impact of histone deacetylase 10 (HDAC10), microRNA, and downstream molecular mechanisms in CC is still limited. Herein, cervical cancer, precancer lesions, and normal cervical tissues were collected to test the expression level of HDAC10, miR-223, and EPB41L3. The mechanism of HDAC10, miR-223, and EPB41L3 was interpreted in cervical cancer cells after HDAC10, miR-223, or EPB41L3 expression was altered.

Results

HDAC10 was poorly expressed in cervical cancer and precancer lesions, while miR-223 was highly expressed in cervical cancer. HDAC10 bound to miR-223, and miR-223 targeted EPB41L3. HDAC10 depressed the invasion property and tumorigenesis of cervical cancer via downregulating miR-223 and subsequently targeting EPB41L3.

Conclusion

The study clarifies that HDAC10 inhibits cervical cancer by downregulating miR-223 and subsequently targeting EPB41L3 expression, which might provide a new insight for management upon cervical cancer and precancer lesions.

miR-92a promotes cervical cancer cell proliferation, invasion, and migration by directly targeting PIK3R1

OBJECTIVE

To clarify the role of miR-92a in regulating the malignant progression of cervical cancer and its specific molecular mechanism.

METHODS

qRT-PCR was used to detect the differential expression of miR-92a in cervical cancer and adjacent tissues. The effects of overexpression of miR-92a on the proliferation, migration, and invasion of HeLa and SiHa cells were tested. Luciferase assays and rescue experiments were used to investigate the regulatory mechanism of miR-92a on its downstream gene PIK3R1 and their interaction in the progression of cervical cancer.

RESULTS

miR-92a was significantly up-regulated in cervical cancer tissues. Overexpression of miR-92a significantly increased the ability of cervical cancer cells to proliferate, migrate, and invade. PIK3R1 was identified as a downstream gene of miR-92a. In cervical cancer tissues, PIK3R1 was found to be down-regulated and negatively correlated with the level of miR-92a. Overexpression of PIK3R1 reversed the promotional effect of overexpressed miR-92a on the proliferation, migration, and invasion of cervical cancer.

CONCLUSION

miR-92a is up-regulated in cervical cancer tissues. miR-92a promotes the malignant development of cervical cancer by negatively regulating PIK3R1.

Tumor Volume Predicts High-Risk Patients and Guides Initial Chemoradiotherapy for Early Cervical Cancer

We evaluated the relationship between the minimum tumor-free margin, tumor volume, and adverse pathological risk factors in early cervical cancer and explored the predictive value of these parameters for different types of risk patients to guide individualized therapeutic strategies. Patients who received the initial treatment of radical operation of cervical cancer and their postoperative pathological reports in our hospital from July 1, 2017, to June 30, 2019, were reviewed. Their minimum tumor-free margin and tumor volume were measured on preoperative magnetic resonance imaging. Student's t-test and the receiver operating characteristic curve analysis were used for data analysis. A total of 240 patients were included. Adverse pathological risk factors were as follows: deep cervical infiltration, 95 (39.6%) cases; lymph vascular space invasion, 91 (37.9%); lymph node metastasis, 20 (8.3%); parametrial infiltration, 8 (3.3%); tumor diameter ≥4 cm, 7 (2.9%); and positive surgical margin, 1 (0.4%). According to the adverse pathological factors, there were 20 (8.3%) high-risk patients, 50 (20.8%) medium-risk patients, and 170 (70.8%) low-risk patients. The ranges of the minimum tumor-free margin and tumor volume were 0.01-13.5 mm and 105-27,990 mm³, respectively. The minimum tumor-free margin with lymph node metastasis was significantly smaller than that without (P <0.05). The tumor volume with parametrial infiltration, deep cervical infiltration, or lymph vascular space invasion was significantly greater than that without (P < 0.05). The tumor volume was significantly different among low-, medium-, and high-risk patients (P <0.05). Tumor volume was of predictive value for high-risk patients (P < 0.05). With 3,505 mm³ as the cutoff value, the sensitivity and specificity for the prediction of high-risk patients were 88.9% and 84.8%, respectively. Tumor volume can be used as a great predictor of high-risk patients (cutoff value, 3,505 mm³), which could be an indication of initial chemoradiotherapy for early cervical cancer.

A comparative analysis of high-flux and low-flux dialysis in cervical cancer patients with obstructive renal failure showing no significantly improved renal function after catheterisation

Objective:

This study aims to compare the clinical application value of high-flux dialysis with low-flux dialysis in patients without significantly improved renal function after cervical cancer and obstructive renal failure catheterisation.

Methods:

This prospective randomised study was conducted from January 2018 to December 2019. Eighty cervical cancer patients with obstructive renal failure who showed no significant renal function improvement after catheterisation were randomised into two groups (n = 40 in each group) in the Second People’s Hospital of Yibin City. High-flux and low-flux dialysis were employed in the experimental group and the control group, respectively. Treatments in both groups were provided every other day, with the whole course lasting one week. Data were recorded before and after dialysis included inflammatory factors such as IL-6, CRP and TNF-a, large and moderate molecular toxins (e.g., β2 micro-globulin, parathyrin (PTH) and cysteine protease inhibitor). Renal function changes during the dialysis were also recorded. Afterwards, the two groups were compared regarding the overall efficacy.

Results:

Both the experimental group and the control group experienced a significant decrease in IL-6, CRP, TNF-a, β2 micro-globulin, PTH and cysteine protease inhibitor, with the decrease in the experimental group being more evident (p < 0.05). After dialysis was completed, the experimental group restored renal function indicators such as Cre, CysC and serum K+ levels more quickly than the control group (p < 0.05). The effective rate was 100% for the experimental group and 87.5% for the control group. The intragroup difference in the efficacy.was significant.

Conclusions:

High-flux dialysis appears to be more beneficial for cervical cancer patients with obstructive renal failure, showing no significant improvement in renal function after catheterisation. It restored renal function more quickly, had more radical draining of inflammatory factors and large and moderate molecular toxins, and had a higher overall effective rate.

Horizons in Veterinary Precision Oncology: Fundamentals of Cancer Genomics and Applications of Liquid Biopsy for the Detection, Characterization, and Management of Cancer in Dogs

Cancer is the leading cause of death in dogs, in part because many cases are identified at an advanced stage when clinical signs have developed, and prognosis is poor. Increased understanding of cancer as a disease of the genome has led to the introduction of liquid biopsy testing, allowing for detection of genomic alterations in cell-free DNA fragments in blood to facilitate earlier detection, characterization, and management of cancer through non-invasive means. Recent discoveries in the areas of genomics and oncology have provided a deeper understanding of the molecular origins and evolution of cancer, and of the "one health" similarities between humans and dogs that underlie the field of comparative oncology. These discoveries, combined with technological advances in DNA profiling, are shifting the paradigm for cancer diagnosis toward earlier detection with the goal of improving outcomes. Liquid biopsy testing has already revolutionized the way cancer is managed in human medicine - and it is poised to make a similar impact in veterinary medicine. Multiple clinical use cases for liquid biopsy are emerging, including screening, aid in diagnosis, targeted treatment selection, treatment response monitoring, minimal residual disease detection, and recurrence monitoring. This review article highlights key scientific advances in genomics and their relevance for veterinary oncology, with the goal of providing a foundational introduction to this important topic for veterinarians. As these technologies migrate from human medicine into veterinary medicine, improved awareness and understanding will facilitate their rapid adoption, for the benefit of veterinary patients.

A novel prognostic nomogram utilizing the 2018 FIGO staging system for cervical cancer: A large multicenter study

OBJECTIVE

To evaluate the prognostic performance of the revised 2018 FIGO staging system for cervical cancer.

METHODS

This retrospective multicenter study enrolled cervical cancer patients with 2009 FIGO Stage IA1-IIA2 who underwent surgeries between January 2006 and December 2017 in four tertiary hospitals. Patients were restaged according to the 2018 FIGO staging system by reviewing their medical data.

RESULTS

Of 3238 cervical cancer patients included, 1841 (56.9%) patients were restaged: 641 (34.9%) due to tumor size, 544 (29.5%) due to lymph node metastasis, 614 (33.4%) due to the inconsistency between pre- and postoperative assessments, and 42 due to the cancellation of invasion width in Stage IA. After restaging, a clear tendency of decreased recurrence-free survival (RFS) and overall survival (OS) with increasing stage was observed. Multivariate Cox analysis showed that 2018 FIGO stage, parametrial involvement, and histology were independent prognostic factors for both OS and RFS (P < 0.05). Based on these factors, we established predictive nomograms with c-indexes of 0.735 and 0.721, showing good predictive ability for cervical cancer.

CONCLUSION

The revised 2018 FIGO staging system can better reflect the survival of cervical cancer patients. Based on it, we established a nomogram that can predict the prognosis of cervical cancer patients more precisely.

Ultrasound targeting of microbubble-bound anti PD-L1 mAb to enhance anti-tumor effect of cisplatin in cervical cancer xenografts treatment

AIMS

Anti-PD-L1 monoclonal antibody (mAb)-conjugated ultrasound (US) lipid-shelled microbubbles (PD-L1-MBs) were successfully synthesized to investigate whether that PD-L1-MBs could enhance anti-tumor effect in combination therapy with cisplatin (CDDP) under ultrasound mediation.

MAIN METHODS

Based on affinity between biotin and streptavidin, we prepared microbubbles conjugated with anti-PD-L1 mAb by membrane hydration and mechanical oscillation. A subcutaneous tumor model was established to test the anti-tumor effect and immunological activity of this combination therapy. Bax and Bcl-2 expression were detected by RT-qPCR and Immunohistochemistry. Cells undergoing apoptosis in tissue section were determined by TUNEL. Proliferation of splenocytes was analyzed by Flow cytometry. A cytotoxic T lymphocyte assay was performed by CTL. Expression of PD-L1 and CD8 in tissue section was examined by immunologfluorescence. Expression of IFN-γ, TNF-α, CD86 and CD80 was also detected by RT-qPCR.

KEY FINDINGS

We observed that the growth of the subcutaneous tumor was significantly slower in combined group than that in the group treated with either drug or microbubbles. Moreover, higher antitumor activity was observed in the combined group than that in cisplatin alone, which could be reflected by the number of apoptotic cells in tumor tissues and over expression of bax in the combined group. This combination treatment also exhibited a better immunological activity, increasing the infiltration of CD8⁺ T cells and the expression of several revelant cytokines.

SIGNIFICANCE

The ultrasound lipid-shelled PD-L1-MBs may enhance anti-tumor effects of cisplatin by blocking the PD-L1 site and improving immune function.

Coix lacryma-jobi var. ma-yuen Stapf sprout extract induces cell cycle arrest and apoptosis in human cervical carcinoma cells

Background

Cervical cancer is the second-leading cause of cancer-related mortality in females. Coix lacryma-jobi L. var. ma-yuen (Rom.Caill.) Stapf ex Hook. f. is the most widely recognized medicinal herb for its remedial effects against inflammation, endocrine system dysfunctions, warts, chapped skin, rheumatism, and neuralgia and is also a nourishing food.

Methods

To investigate the activity of Coix lacryma-jobi sprout extract (CLSE) on cell proliferation in human cervical cancer HeLa cells, we conducted a Cell Counting Kit-8 (CCK-8) assay. Flow-cytometric analysis and western blot analysis were performed to verify the effect of CLSE on the regulation of the cell cycle and apoptosis in HeLa cells.

Results

We observed that CLSE significantly inhibited cell proliferation. Furthermore, CLSE dose-dependently promoted cell cycle arrest at the sub-G1/ S phase in HeLa cells, as detected by bromodeoxyuridine (BrdU) staining. The cell-cycle-arrest effects of CLSE in HeLa cells were associated with downregulation of cyclin D1 and cyclin-dependent kinases (CDKs) 2, 4, and 6. Moreover, CLSE induced apoptosis, as determined by flow-cytometric analysis and nuclear DNA fragmentation with Annexin V/propidium iodide (PI) and 4′6′-diamidino-2-phenylindole (DAPI) staining. Induction of apoptosis by CLSE was involved in inhibition of the antiapoptotic protein B-cell lymphoma 2 (Bcl-2) and upregulation of the apoptotic proteins p53, cleaved poly (ADP-ribose) polymerase (PARP), cleaved caspase-3, and cleaved caspase-8. Finally, we observed that CLSE inactivated the phosphoinositide 3-kinase (PI3K) and protein kinase B (AKT) pathways.

Conclusions

CLSE causes cell cycle arrest and apoptotic cell death through inactivation of the PI3K/AKT pathway in HeLa cells, suggesting it is a viable therapeutic agent for cervical cancer owing to its anticancer effects.

Prognostic factors for and pattern of lymph-node involvement in patients with operable cervical cancer

PURPOSE

Lymph node metastases significantly worsen the prognosis in cervical carcinoma. Risk factors-pathological and patient related-could select patients at high risk for lymph node involvement.

METHODS

This retrospective analysis was performed by analyzing data from patients with cervical carcinoma treated between 2000 and 2017 at the Department of Obstetrics and Gynecology of the University Hospital Ulm.

RESULTS

In total, 261 patients with cervical carcinoma (International Federation of Gynecology and Obstetrics (FIGO) stage IA-IIB) and lymphadenectomy with at least 10 removed lymph nodes were available for analysis. Overall, 86 (33.0%) patients had lymph node metastases; 73 patients had pelvic lymph node metastases only and 13 patients had both pelvic and paraaortic lymph node metastases. Lymph node metastases were found most often in the region of the external iliac artery and obturator fossa, with 57.0% and 54.7% of all 86 node-positive patients, respectively. Univariable analyses showed that presence of lymph node metastases was significantly associated with both preoperative FIGO stage (p = 0.001) and final pathological tumor stage (p < 0.001), status of resection margin (p = 0.002), lymphovascular space invasion (LVSI), (p < 0.001) and vascular space invasion, (p < 0.001). In a multivariable logistic regression model with presence of lymph node metastases (yes/no) as binary response variable, only LVSI (p < 0.001) and body mass index (BMI), (p = 0.035) remained as significant independent predictors of lymph node involvement. Subgroup analyses showed that LVSI was a significant predictive factor for lymph node involvement in patients with a preoperatively assessed FIGO stage < IIB (p < 0.001), but not for patients with a preoperatively assessed FIGO stage ≥ IIB (p = 0.122).

CONCLUSIONS

The risk factor LVSI should play an important role in deciding whether an individualized therapy concept is based on escalating or deescalating treatment. In future, the sentinel concept could reduce morbidity and at the same time provide an important prognostic assessment for a subset of cervical cancer patients.

TMTP1-modified Indocyanine Green-loaded Polymeric Micelles for Targeted Imaging of Cervical Cancer and Metastasis Sentinel Lymph Node in vivo

Metastasis is one of the most threatening aspects of cervical cancer. We developed a method to intraoperatively map the primary tumor, metastasis and metastatic sentinel lymph nodes (SLNs), providing real-time intraoperative guidance in cervical cancer.

Methods: TMTP1, a tumor metastasis targeting peptide, was employed to modify the indocyanine green (ICG)-loaded poly (ethylene glycol)- poly (lactic-co-glycolic acid) (PEG-PLGA) micelles. The cervical cancer subcutaneous tumor model and lung metastasis model were established to determine the active targeting of ICG-loaded TMTP1-PEG-PLGA micelles (ITM) for the primary tumor and occult metastasis of cervical cancer. Human cervical cancer HeLa cells engineered by firefly luciferase were injected into the right hocks of BALB/c nude mice to develop the SLN metastasis model. The ITM and control ICG-loaded PEG-PLGA micelles (IM) were injected into the right hind footpads in the SLN metastasis model, and the migration and retention of micelles were recorded under near-infrared fluorescence. K14-HPV16 transgenic mice were also used to detect the image capability of ITM to target cancerous lesions.

Results: ITM could actively target imaging of the primary tumor and cervical cancer metastasis. ITM quickly diffused from the injection site to SLNs along lymphatic capillaries and remained in the SLNs for 12 h. Moreover, ITM specifically accumulated in the tumor metastatic SLNs (T-SLNs), which could be successfully distinguished from normal SLNs (N-SLNs).

Conclusion: ITM could achieve active targeting of the primary tumor, metastasis and T-SLNs, providing precise and real-time intraoperative guidance for cervical cancer.

Risk Factors of Regional Lymph Node Metastasis in Patients with Cervical Cancer

Objectives

To explore the risk factors related to regional lymph node metastasis in cervical cancer and analyze the value of independent risk factors in predicting regional lymph node metastasis.

Methods

We retrospectively analyzed the clinical data of 699 patients who underwent surgery for stage IB1–IIA2 cervical cancer in Quanzhou First Hospital affiliated to Fujian Medical University from 2010 to 2016. The patients were divided into metastasis (n = 92) and non-metastasis (n = 607) groups based on the postoperative pathology of regional lymph node status. The relevant clinicopathological features of the metastasis and non-metastasis groups were compared through variance analysis and chi-square tests. Logistic regression was adopted to screen relevant independent risk factors of regional lymph node metastasis.

Results

In univariate analysis, International Federation of Gynecology and Obstetrics (FIGO) stages, serum squamous cell carcinoma antigen (SCC-Ag), histological type of squamous carcinoma and maximal tumor diameter were related factors for lymphatic metastasis in patients with cervical cancer. In multivariate analysis, SCC-Ag and histological type of squamous carcinoma were independent prognostic factors for lymphatic metastasis in patients with cervical cancer. Pre-treatment SCC-Ag serum levels, as a predictor of lymph node metastasis of cervical cancer, revealed a sensitivity of 62.07% (95% confidence interval (CI): 51.03–72.62%), specificity of 65.15% (59.07–70.89%), and area under the receiver operating characteristic (ROC) curve of 0.69 (95% CI: 0.61–0.76).

Conclusions

Cervical cancer patients whose pathological type is squamous carcinoma with high levels of SSC-Ag pre-operation are more likely to be diagnosed with regional lymph node metastasis. Standardized lymph node dissection should be implemented during operation.

Staging early cervical cancer in China: data from a multicenter collaborative

BACKGROUND

In 2018 the International Federation of Gynecology and Obstetrics (FIGO) revised the staging system of cervical cancer. This study aimed to assess the quality of staging early cervical cancer in China before the revision.

METHODS

This multicenter retrospective study included 34 tertiary hospitals in China. Medical records of patients with cervical cancer who underwent primary surgical treatment between January 2010 and December 2015 were reviewed retrospectively. All patients were clinically staged according to the 2009 FIGO staging system. Eligibility criteria included: histopathologically confirmed cervical cancer; 2009 FIGO stage IA-IIA2 based on 2009 FIGO staging system; primary surgical treatment including extrafascial, type II or type III radical hysterectomy; radical trachelectomy; with or without pelvic lymphadenectomy; regardless of surgical route via laparotomy or laparoscopy; and complete clinical and pathological data. Patients who received non-surgical treatment, neoadjuvant treatment, or those with incomplete data were excluded. The accuracy of clinical staging was assessed by comparison between clinical and pathologic stage using the latter as the reference standard.

RESULTS

A total of 23 933 cases of cervical cancer were identified and 12 681 fulfilled the inclusion criteria. Of these patients, 69.6% were staged accurately, 9.4% were clinically understaged, and 21.0% were clinically overstaged. The accuracy of stage IA, IB1, IB2, IIA1, and IIA2 was 90.0%, 87.5%, 57.4%, 20.3%, and 25.5%, respectively. The causes of stage inaccuracy were as follows: vaginal involvement (62.3%), maximal tumor diameter (24.6%), extent of cervical stromal invasion (7.1%), parametrial invasion (5.8%), bladder or rectal infiltration (0.1%), and distant metastases (0.1%).

CONCLUSION

The accuracy of staging early cervical cancer in China was suboptimal before the revision of the staging system, especially for IIA1 and IIA2. The most common reasons for staging inaccuracy were vaginal involvement and tumor diameter.

Detection of high-risk human papillomavirus DNA in tissue from primary cervical cancer tumor, pelvic lymph nodes and recurrent disease

Objectives

The present study investigated Human Papillomavirus (HPV) DNA genotyping in primary tumor, pelvic lymph nodes (PLN) and recurrence in early-stage cervical cancer patients.

Methods

We conducted a hospital-based case-control study. From 2003 to 2015, 282 patients underwent surgery for cervical cancer in the Department of Gynecology, Aarhus University Hospital, Denmark. Twenty-nine recurrent cases were identified. HPV DNA genotyping was performed on formalin-fixed, paraffin-embedded tissue specimens from the primary tumor, PLN, and recurrent disease.

Results

In the primary tumor, HPV DNA was detectable in 18(72%) of 25 tissue specimens from recurrent cases and in 15(83%) of 18 controls. HPV DNA-positive PLN was significantly associated with recurrence, 83%(95%CI: 52–98%), compared to patients with HPV-negative PLN, 38%(95%CI: 18–62%)(p < 0.05). HPV DNA genotyping was positive in eight of 12(67%) patients with recurrent disease. The genotype was identical in all three tissues types.

The positive predictive value for recurrence was the same for detection of HPV-DNA and metastases in the PLN, with reasonable sensitivity. The negative predictive value for recurrence, however, was best for HPV-DNA, 62%(95%CI: 38–98%).

Conclusions

In conclusion, our data suggest that the presence of HPV in pelvic lymph nodes is associated with an increased risk of recurrence.

Radical Trachelectomy for Early Stage Cervical Cancer

OPINION STATEMENT

In patients with early-stage cervical cancer, radical hysterectomy and pelvic lymphadenectomy is the gold standard. However, this disease commonly affects women of childbearing age; thus an option to spare fertility is ideal. This option came to fruition in the early 90s when the Dargent procedure or radical trachelectomy was first reported. The procedure has subsequently been modified as technology has improved and now may be performed via minimally invasive techniques. Additionally, with the advent of the sentinel lymph node procedure, the morbidity in this usually young patient population has continued to improve. There is a multitude of data to show that oncologic outcomes, concerning recurrence and mortality, are comparable to radical hysterectomy, as well as obstetrical outcomes are favorable. Data to support its acceptance within the gynecologic oncology community has led to radical trachelectomy being implemented into governing body guidelines and should be offered to appropriate candidates with early-stage cervical cancer who wish to preserve fertility.

Preoperative SCC-Ag and thrombocytosis as predictive markers for pelvic lymphatic metastasis of squamous cervical cancer in early FIGO stage

Objectives:To explore the clinical significance of squamous cell carcinoma antigen (SCC-Ag) and thrombocytosis to predict pelvic lymphatic metastasis (PLM) of squamous cervical cancer (SCC) in International Federation of Gynecology and Obstetrics (FIGO) stages IA-IIA.

Methods:A retrospective clinicopathologic review of 782 patients of a primary cohort in three Chinese hospitals from 2010 to 2015, and 407 patients of a validation cohort in another institution from 2015 to 2017. A receiver operating characteristic curve was used to determine the optimal SCC-Ag threshold to predict PLM in the groups. Univariate and multivariate logistic analyses for PLM were performed to assess differences in outcome.

Results:In the primary and validation cohort, 15.6% (122/782) and 25.3% (103/407) patients were classified into the thrombocytosis group (platelet count >300 × 10⁹/L), respectively. Optimal cutoff values of SCC-Ag for predicting PLM of the thrombocytosis group and the normal group were 3.26 ng/mL (AUC 0.754; sensitivity 73.08%; specificity 72.92%; P = 0.000) and 4.58 ng/mL (AUC 0.706; sensitivity 53.26%; specificity 83.98%; P = 0.000), respectively, in the primary cohort, and 1.55 ng/mL (AUC 0.705; sensitivity 79.31%; specificity 55.41%; P = 0.000) and 1.75 ng/mL (AUC 0.655; sensitivity 69.57%; specificity 64.26%; P = 0.000), respectively, in the validation cohort. In multivariate logistic analysis, preoperative SCC-Ag over 3.26 ng/mL and lymphovascular space involvement were the significant predictors of PLM for SCC in FIGO stages IA-IIA.

Conclusions: Preoperative SCC-Ag alone or combined with thrombocytosis might be used as predictive markers for PLM before initial treatment in early stage SCC.

Kaempferia parviflora Extract Exhibits Anti-cancer Activity against HeLa Cervical Cancer Cells

Kaempferia parviflora (KP) has been traditionally used as a folk remedy to treat several diseases including cancer, and several studies have reported cytotoxic activities of extracts of KP against a number of different cancer cell lines. However, many aspects of the molecular mechanism of action of KP remain unclear. In particular, the ability of KP to regulate cancer cell growth and survival signaling is still largely unexplored. The current study aimed to investigate the effects of KP on cell viability, cell migration, cell invasion, cell apoptosis, and on signaling pathways related to growth and survival of cervical cancer cells, HeLa. We discovered that KP reduced HeLa cell viability in a concentration-dependent manner. The potent cytotoxicity of KP against HeLa cells was associated with a dose-dependent induction of apoptotic cell death as determined by flow cytometry and observation of nuclear fragmentation. Moreover, KP-induced cell apoptosis was likely to be mediated through the intrinsic apoptosis pathway since caspase 9 and caspase 7, but not BID, were shown to be activated after KP exposure. Based on the observation that KP induced apoptosis in HeLa cell, we further investigated the effects of KP at non-cytotoxic concentrations on suppressing signal transduction pathways relevant to cell growth and survival. We found that KP suppressed the MAPK and PI3K/AKT signaling pathways in cells activated with EGF, as observed by a significant decrease in phosphorylation of ERK1/2, Elk1, PI3K, and AKT. The data suggest that KP interferes with the growth and survival of HeLa cells. Consistent with the inhibitory effect on EGF-stimulated signaling, KP potently suppressed the migration of HeLa cells. Concomitantly, KP was demonstrated to markedly inhibit HeLa cell invasion. The ability of KP in suppressing the migration and invasion of HeLa cells was associated with the suppression of matrix metalloproteinase-2 production. These data strongly suggest that KP may slow tumor progression and metastasis in patients with cervical cancer. Taken together, the present report provides accumulated evidence revealing the potent anti-cancer activities of Kaempferia parviflora against cervical cancer HeLa cells, and suggests its potential use as an alternative way for cervical cancer prevention and therapy.