The number of pelvic lymph nodes in the quality control and prognosis of radical hysterectomy for the treatment of cervical cancer

Tumor-to-stroma cd8+ t cells ratio combined with cancer-associated fibroblasts: an innovative approach to predicting lymph node metastases of cervical cancer

PURPOSE

Precise identification of lymph node metastases is vital for the management of cervical cancer. However, the existing diagnostic methods for lymph node metastases have certain drawbacks. In this study, we aim to explore the expression of cancer-associated fibroblasts (CAFs) and tumor-to-stroma CD8+ T cells ratio (CD8+ T cells T:S ratio) and its association with lymph node metastases of cervical cancer.

METHODS

Hundred and ten cervical cancer tissues and 39 biopsy tissues from patients were investigated immunocytochemically for the expression of CAFs and CD8+ T cells. The statistical correlation analysis was carried out using the SPSS system.

RESULTS

A strong and statistically significant negative correlation (r= - 0.690; P < 0.001) was observed between CAF density and CD8+ T cells T:S ratio. Not only were CAFs density and CD8+ T cells T:S ratio correlated with lymph node metastases respectively (P < 0.001), but the combination of them also significantly correlated with lymph node metastases (P < 0.001). Then, we constructed the combined diagnosis model (Logit (P) = - 4.446 + 0.300 × CAFs + 0.752 × CD8+ T cells T:S Ratio) of cervical cancer lymph node metastases. ROC curves analysis showed that the ROC curves areas for CAFs, CD8+ T cells T:S ratio, and a combination of both are 0.879, 0.747, and 0.951. Then, the prediction model was verified by biopsy specimens and consistent results were obtained.

CONCLUSIONS

The combination of CAF density and CD8+ T cells T:S ratio has a significant predictive value for lymph node metastases in patients with cervical cancer.

Primary Treatment for Clinically Early Cervical Cancer with Lymph Node Metastasis: Radical Surgery or Radiation?

OBJECTIVE

To compare survival outcomes between primary radical surgery and primary radiation in early cervical cancer.

METHODS

Patient information was extracted from the Surveillance, Epidemiology, and Results database. Patients diagnosed with early cervical cancer of stage T1a, T1b, and T2a (American Joint Committee on Cancer, 7th edition) from 1998 to 2015 were included in this study after propensity score matching. Overall survival (OS) was analyzed using the Kaplan-Meier method.

RESULTS

Among the 4964 patients included in the study, 1080 patients were identified as having positive lymph nodes (N1), and 3884 patients were identified as having negative lymph nodes (N0). Patients with primary surgery had significantly longer 5-year OS than those with primary radiotherapy in both the N1 group (P<0.001) and N0 group (P<0.001). In the subgroup analysis, similar results were found in patients with positive lymph nodes of stage T1a (100.0% vs. 61.1%), T1b (84.1% vs. 64.3%), and T2a (74.4% vs. 63.8%). In patients with T1b1 and T2a1, primary surgery resulted in longer OS than primary radiation, but not in patients with T1b2 and T2a2. In multivariate analysis, the primary treatment was identified as an independent prognostic factor in both N1 and N0 patients (HR_N1=2.522, 95% CI=1.919-3.054, P_N1<0.001; HR_N0=1.895, 95% CI=1.689-2.126, P_N0<0.001).

CONCLUSION

In early cervical cancer stage T1a, T1b1, and T2a1, primary surgery may result in longer OS than primary radiation for patients with and without lymph node metastasis.

Impact of examined lymph node number on lymph node status and prognosis in FIGO stage IB-IIA cervical squamous cell carcinoma: A population-based study

Objective

We aimed to investigate the association of examined lymph node (ELN) number with lymph node status and long-term survival in FIGO stage IB-IIA cervical squamous cell carcinoma(CSCC) and to determine the minimum number of ELN associated with survival improvement.

Method

Data from the Surveillance, Epidemiology, and End Results Program (SEER) database of FIGO stage IB-IIA CSCC patients undergoing hysterectomy and pelvic lymphadenectomy in 2004-2016 were analyzed to explore the relationship between ELN number and lymph node status and overall survival (OS) by using the multivariable approach. The estimated probability of falsely identifying a patient as node-negative and the hazard ratios (HRs) for each ELN was fitted with a LOWESS smoother, and the structural breakpoints were determined. X-tile software was used to determine the optimal cutoff value for ELNs.

Results

A total of 2627 patients were analyzed. The optimal cutoff value of the ELN number was identified as 7 based on the results of X-tile software. The structural breakpoints according to the associations between the number of ELNs and the estimated risk of false-negative lymph node dissection and HRs for overall survival were 9 and 8, respectively. The multivariate analysis indicated that ELN number was an independent prognostic factor for OS, both as a continuous or categorical variable. To further explore the effect of more ELNs on survival, another cutoff value of 17 was chosen to compare the survival curves of patients. The multivariate-adjusted COX model showed that patients with ELN<8 had a significantly higher risk of death than those with ELN8-17 (HR=1.447, 95% CI =1.075-1.947, p=0.015), but there was no significant difference in overall survival between patients with ELN>17 and patients with ELN8-17 (HR=0.822, 95%CI =0.665-1.016, p=0.070).

Conclusion

A sufficient number of ELNs was associated with better long-term survival in FIGO stage IB-IIA CSCC. At least 8 ELNs need to be examined for prognostic stratification. Excessive lymph node dissection (ELN>17) may not confer additional survival benefits.

Treatment Strategies and Prognostic Factors of 2018 FIGO Stage IIIC Cervical Cancer: A Review

Cervical cancer is the fourth most common malignant tumor globally in terms of morbidity and mortality. The presence of lymph node metastasis (LNM) is an independent prognostic factor for progression-free survival (PFS) and overall survival (OS) in cervical cancer patients. The International Federation of Gynecology and Obstetrics (FIGO) staging system was revised in 2018. An important revision designates patients with regional LNM as stage IIIC, pelvic LNM only as stage IIIC1, and para-aortic LNM as stage IIIC2. However, the current staging system is only based on the anatomical location of metastatic lymph nodes (LNs). It does not consider other LN status parameters, which may limit its prognostic significance to a certain extent and needs further exploration and confirmation in the future. The purpose of this review is to summarize the choice of treatment for stage IIIC cervical cancer and the effect of different LN status parameters on prognosis.

Effect of Number of Retrieved Lymph Nodes on Prognosis in FIGO Stage IA1-IIA2 Cervical Cancer Patients Treated With Primary Radical Surgery

Background:

The influence of the number of removed lymph nodes (RLNs) on patients with early-stage cervical cancer (ESCC) is still questionable. The objective of this study was to explore the prognostic value of RLNs on ESCC patients.

Methods:

A retrospective study was performed including all ESCC patients who underwent radical surgery from January 2016 to December 2018. Cox regression analysis was performed to verify the correlation between the number of RLNs and the prognosis (recurrence-free survival [RFS], disease-specific survival [DSS]) of ESCC. According to the guidelines, all the patients were divided into high-risk and non-high-risk groups. The optimal cut-off values of RLNs were determined by receiver operating characteristic curve analysis and Youden index and further the prognostic value of them was explored.

Results:

A total 1101 patients were enrolled. The number of RLNs was an independent prognostic influence factor of the prognosis of ESCC ( P < .001 for RFS, P < .001 for DSS). The optimal cut-off values of RLNs (40 in the high-risk group and 23 in the non-high-risk group) were significantly associated with the prognosis of ESCC, in the high-risk group ( P < .001 for RFS, P = .002 for DSS) and non-high-risk group ( P < .001 for RFS, P < .001 for DSS), respectively.

Conclusions:

More extensive lymph node dissection (RLNs ⩾ 40) could benefit the high-risk ESCC patients. However, in the non-high-risk group, moderate lymph node dissection (RLNs ≈23) could also benefit them and may reduce the incidence of related complications. Those findings may help to determine the scope of lymph node dissection in ESCC patients before operation.

Prognostic Value of Lymph Node Characteristics in Patients with Cervical Cancer Treated with Radical Hysterectomy

Objective

This study evaluated the prognostic value of various lymph node (LN) characteristics, including the lymph node ratio (LNR), in patients with cervical cancer treated with radical hysterectomy.

Methods

In this retrospective study, 260 patients with cervical cancer who had undergone radical hysterectomy with pelvic or paraaortic lymphadenectomies were included. LN characteristics related to several LN statuses included total LN counts, LN metastasis, total positive LN counts, LNR, and levels of lymphadenectomy. LNR was defined as the number of metastatic LNs divided by the total number of LNs harvested. Univariate and multivariate analyses for disease-free survival (DFS) and overall survival (OS) were performed using the clinicopathological and LN characteristics.

Results

Based on receiver-operating characteristics curve analysis, the cut-off value of LNR was 0.0625. Multivariate analysis revealed that high LNR was significantly related to tumor recurrence (hazard ratio [HR], 5.182; 95% confidence interval [CI], 2.424–11.075; p < 0.0001). After adjusting for clinicopathological factors, LNR was also independent prognostic factor for predicting tumor recurrence (HR, 5.930; 95% CI, 2.114–16.634; p = 0.0007). However, total retrieved LN counts and level of lymphadenectomy were not associated with survival outcomes.

Conclusion

LNR may be a prognostic biomarker for predicting disease recurrence in cervical cancer treated with radical hysterectomy.

Lymph Node Staging with a Combined Protocol of 18F-FDG PET/MRI and Sentinel Node SPECT/CT: A Prospective Study in Patients with FIGO I/II Cervical Carcinoma

Lymph node metastasis (LNM) is present in a minority of patients with early stages of cervical carcinomas. As conventional imaging including PET/CT has shown limited sensitivity, systematic lymphadenectomies are often conducted for staging purposes. Therefore, the aim of this prospective study was to analyze the impact of ¹⁸F-FDG PET/MRI in addition to sentinel lymph node (SLN) biopsy on lymph node (LN) status. Methods: Forty-two women with an initial diagnosis of Fédération Internationale de Gynécologie et d'Obstétrique (FIGO) IA-IIB cervical carcinoma were included between March 2016 and April 2019. Each patient underwent preoperative whole-body ¹⁸F-FDG PET/MRI and SLN imaging with SPECT/CT after intracervical injection of ^99mTc-labeled nanocolloid. Systematic lymphadenectomy and SLN biopsy served as the reference standard. Staging using PET/MRI was performed by nuclear medicine and radiology experts working in consensus. Results: One patient was excluded from surgical staging because of liver metastases newly diagnosed on PET/MRI. The overall prevalence of LNM in the remaining 41 patients was 29.3% (12/41). Five of 12 patients with LNM had solely small metastases with a maximum diameter of 5 mm. The consensus interpretation showed PET/MRI to have a specificity of 100% (29/29; 95% CI, 88.3%-100%) for LNM staging but a low sensitivity, 33.3% (4/12; 95% CI, 12.8%-60.9%). LN size was the most important factor for the detectability of metastases, since only LNMs larger than 5 mm could be identified by PET/MRI (sensitivity, 57.1% for >5 mm and 0% for ≤5 mm). Paraaortic LNM was evaluated accurately in 3 of the 4 patients with paraaortic LN metastasis. SLNs were detectable by SPECT/CT in 82.9% of the patients or 69.0% of the hemipelves. In cases with an undetectable SLN on SPECT/CT, the malignancy rate was considerably higher (31.2% vs. 19.3%). The combination of PET/MRI and SLN SPECT/CT improved the detection of pelvic LNM from 33.3% to 75%. Conclusion: ¹⁸F-FDG PET/MRI is a highly specific N-staging method and improves LNM detection. Because of the limited sensitivity in frequently occurring small LNMs, PET/MRI should be combined with SLN mapping. The proposed combined protocol helps to decide whether extensive surgical staging is necessary in patients with FIGO I/II cervical cancer.

Laparoscopic and Robotic Surgery for Endometrial and Cervical Cancer

Minimally invasive surgery (MIS) has many benefits, in the form of reduced postoperative morbidity, improved recovery and reduced inpatient stay. It is imperative, however, when new techniques are adopted, in the context of treating oncology patients, that the oncological efficacy and safety are established rigorously rather than assumed based on first principles. Here we have attempted to provide a comprehensive review of all the contentious and topical themes surrounding the use of MIS in the treatment of endometrial and cervix cancer following a thorough review of the literature. On the topic of endometrial cancer, we cover the role of laparoscopy in both early and advanced disease, together with the role and unique benefits of robotic surgery. The surgical challenge of patients with a raised body mass index and the frail and elderly are discussed and finally the role of sentinel lymph node assessment. For cervical cancer, the role of MIS for staging and primary treatment is covered, together with the interesting and highly specialist topics of fertility-sparing treatment, ovarian transposition and the live birth rate associated with this. We end with a discussion on the evidence surrounding the role of adjuvant hysterectomy following radical chemoradiation and pelvic exenteration for recurrent cervical cancer. MIS is the standard of care for endometrial cancer. The future of MIS for cervix cancer, however, remains uncertain. Current recommendations, based on the available evidence, are that the open approach should be considered the gold standard for the surgical management of early cervical cancer and that MIS should only be adopted in the context of research. Careful counselling of patients on the current evidence, discussing in detail the risks and benefits to enable them to make an informed choice, remains paramount.

Potential prognostic factors in progression-free survival for patients with cervical cancer

Background

Cervical cancer continues to be one of the leading causes of cancer deaths among females in low and middle-income countries. In this study, we aimed to assess the independent prognostic value of clinical and potential prognostic factors in progression-free survival (PFS) in cervical cancer.

Methods

We conducted a retrospective study on 92 cervical cancer patients treated from 2017 to 2019 at the Zhuhai Hospital of Traditional Chinese and Western Medicine. Tumor characteristics, treatment options, progression-free survival and follow-up information were collected. Kaplan–Meier method was used to assess the PFS.

Results

Results showed that the number of retrieved lymph nodes had a statistically significant effect on PFS of cervical cancer patients (P = 0.002). Kaplan-Meier survival curve analysis showed that cervical cancer patients with initial symptoms age 25–39 had worse survival prognoses (P = 0.020). And the using of uterine manipulator in laparoscopic treatment showed a better prognosis (P < 0.001). A novel discovery of our study was to verify the prognostic values of retrieved lymph nodes count combining with FIGO staging system, which had never been investigated in cervical cancer before. According to the Kaplan-Meier survival curve analysis and receiver operating characteristic (ROC) curve analysis, significant improvements were found after the combination of retrieved lymph nodes count and FIGO stage in predicting PFS for cervical cancer patients (P < 0.001, AUC = 0.826, 95% CI: 0.689–0.962).

Conclusion

Number of retrieved lymph nodes, initial symptoms age, uterine manipulator, and retrieved lymph nodes count combining with FIGO staging system could be potential prognostic factors for cervical cancer patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08243-3.

Effect of the Number of Removed Lymph Nodes on Survival in Patients with FIGO Stage IB-IIA Cervical Squamous Cell Carcinoma following Open Radical Hysterectomy with Pelvic Lymphadenectomy: A Retrospective Cohort Study

Objective

To determine whether the number of removed lymph nodes (RLN) is associated with survival in patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB-IIA cervical squamous cell carcinoma (CSCC).

Methods

We reviewed the medical records of FIGO stage IB-IIA CSCC patients who underwent standardized radical hysterectomy with pelvic lymphadenectomy (RHPL) in our center between 2006 and 2014. The X-tile software was performed to calculate the optimal grouping of cutoff points for RLN. The impact of RLN on progression-free survival (PFS) and overall survival (OS) was analyzed using Cox regression analysis.

Results

Among 3,127 patients, the mean number of RLN was 22, and positive lymph node (LN) was found in 668 (21.4%) patients. X-tile plots identified “21” and “16” as the optimal cutoff value of RLN to divide the patients into two groups in terms of PFS and OS separately. In all patients, the number of RLN was not associated with PFS (P=0.182) or OS (P=0.193). Moreover, in both LN positive and negative patients, the number of RLN was not associated with either PFS (P=0.212 and P=0.540, respectively) or OS (P=0.173 and P=0.497, respectively). Cox regression analysis showed that the number of RLN was not an independent prognostic factor for PFS or OS.

Conclusion

If standardized RHPL was performed, the number of RLN was not an independent prognostic factor for survival of patients with FIGO stage IB-IIA CSCC.

Prognostic value of the number of the metastatic lymph nodes in locally early-stage cervical cancer: squamous cell carcinoma versus non-squamous cell carcinoma

PURPOSE

To clarify the prognostic value of the number of metastatic lymph nodes (mLNs) in squamous and non-squamous histologies among women with node-positive cervical cancer.

METHODS

One hundred ninety-one node-positive cervical cancer patients who had undergone radical hysterectomy plus systematic pelvic and para-aortic lymphadenectomy followed by concurrent radiochemotherapy were retrospectively reviewed. The prognostic value of the number of mLNs was investigated in squamous cell carcinoma (SCC) v (n = 148) and non-SCC (n = 43) histologies separately with univariate log-rank test and multivariate Cox regression analyses.

RESULTS

In SCC cohort, mLNs > 2 was significantly associated with decreased 5-year disease-free survival (DFS) [hazard ratio (HR) = 2.06; 95% confidence interval (CI) 1.03-4.09; p = 0.03) and overall survival (OS) (HR = 2.35, 95% CI 1.11-4.99; p = 0.02). However mLNs > 2 had no significant impact on 5-year DFS and 5-year OS rates in non-SCC cohort (p = 0.94 and p = 0.94, respectively). We stratified the entire study population as SCC with mLNs ≤ 2, SCC with mLNs > 2, and non-SCC groups. Thereafter, we compared survival outcomes. The non-SCC group had worse 5-year OS (46.8% vs. 85.3%, respectively; p < 0.001) and 5-year DFS rates (31.6% vs. 82.2%, respectively; p < 0.001) when compared to those of the SCC group with mLNs ≤ 2. However, the non-SCC group and the SCC group with mLNs > 2 had similar 5-year OS (46.8% vs. 65.5%, respectively; p = 0.16) and 5-year DFS rates (31.6% vs. 57.5%, respectively; p = 0.06).

CONCLUSION

Node-positive cervical cancer patients who have non-SCC histology as well as those who have SCC histology with mLNs > 2 seem to have worse survival outcomes when compared to women who have SCC histology with mLNs ≤ 2.

Laparo-endoscopic single-site surgery vs conventional laparoscopic surgery for endometrial cancer: A systematic review and meta-analysis

OBJECTIVE

To systematically review and evaluate the safety, advantages and clinical application value of laparo-endoscopic single-site surgery (LESS) for endometrial cancer by comparing it with conventional laparoscopic surgery (CLS).

METHODS

We conducted a systematic review of the published literature comparing LESS with CLS in the treatment of endometrial cancer. English databases including PubMed, Embase, Ovid, and the Cochrane Library and Chinese databases including Chinese National Knowledge Infrastructure, Wanfang and China Biology Medicine were searched for eligible observational studies up to July 10, 2019. We then evaluated the quality of the selected comparative studies before performing a meta-analysis using the RevMan 5.3 software. The complications, surgical time, blood loss during surgery, postoperative length of hospital stay and number of lymph nodes removed during surgery were compared between the 2 surgical approaches.

RESULTS

Four studies with 234 patients were finally included in this meta-analysis. We found that there was no statistically significant difference in complications between the 2 surgical approaches [odds ratio (OR): 0.63, 95% confidence interval (CI): 0.18-2.21, P = .47, I2 = 0%]. There was no statistically significant difference in blood loss between the 2 surgical approaches [mean difference (MD): -61.81, 95% CI: -130.87 to -7.25, P = .08, I2 = 74%]. There was no statistically significant difference in surgical time between the 2 surgical approaches (MD: -11.51, 95% CI: -40.19 to 17.16, P = .43, I2 = 81%). There was also no statistically significant difference in postoperative length of hospital stay between the 2 surgical approaches (MD: -0.56, 95% CI: -1.25 to -0.13, P = .11, I2 = 72%). Both pelvic and paraaortic lymph nodes can be removed with either of the 2 procedures. There were no statistically significant differences in the number of paraaortic lymph nodes and total lymph nodes removed during surgery between the 2 surgical approaches [(MD: -0.11, 95% CI: -3.12 to 2.91, P = .29, I2 = 11%) and (MD: -0.53, 95% CI (-3.22 to 2.16), P = .70, I2 = 83%)]. However, patients treated with LESS had more pelvic lymph nodes removed during surgery than those treated with CLS (MD: 3.33, 95% CI: 1.05-5.62, P = .004, I2 = 32%).

CONCLUSION

Compared with CLS, LESS did not reduce the incidence of complications or shorten postoperative hospital stay. Nor did it increase surgical time or the amount of bleeding during surgery. LESS can remove lymph nodes and ease postoperative pain in the same way as CLS. However, LESS improves cosmesis by leaving a single small scar.

Recurrence pattern and prognostic factors for survival in cervical cancer with lymph node metastasis

AIM

The aim of this study is to evaluate the recurrence pattern and oncological outcomes in cervical cancer (CC) patients with lymph node metastasis.

METHODS

This study included 224 International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB1-IIIB CC patients with pathologically proven lymph node metastasis. Surgical intervention was grouped as hysterectomy performed/not performed. Adjuvant therapy decision was made by the tumor board. Radiotherapy was applied to all patients with lymph node metastasis.

RESULTS

Only paraaortic lymph node metastasis was determined as an independent prognostic factor for recurrence. Presence of paraaortic lymph node metastasis increased the risk of recurrence more than two times (odds ratio: 2.129; 95% confidence interval: 1.011-4.485; p = 0.047). An independent prognostic factor for death because of disease was age only. Risk of death was nearly doubled with younger age (odds ratio: 2.693; 95% confidence interval: 1.064-6.184; p = 0.037).

CONCLUSION

The most of recurrences were located at distant sites and multiple regions. Paraaortic lymph node metastasis was the only independent prognostic factor for recurrence, in spite of that age was an independent predictor for risk of death in patients with early stage or locally advanced CC and also with surgically proven metastatic lymph nodes. Furthermore, the presence of the paraaortic lymph node metastasis was significantly associated with distant recurrence. Therefore, more appropriate and individualized therapy strategy focusing on intenser systemic chemotherapy options in addition to radiotherapy should be taken into consideration according to paraaortic lymph node metastasis and age.

Impact of different therapies on the survival of patients with stage I-IIA cervical cancer with intermediate risk factors

Background

The aim of this study was to determine the effects of different therapies on patients with cervical cancer (CC) with intermediate risk factors.

Methods

Clinicopathological data of 596 patients diagnosed with stage I–IIA CC at the Obstetrics and Gynecology Hospital of Fudan University between January 2013 and November 2015 were retrospectively reviewed. Of the patients, 500 patients received adjuvant therapy including chemotherapy (CT), radiotherapy (RT), and sequential chemotherapy and radiotherapy (CT + RT). Patients who displayed at least one intermediate risk factor number were screened.

Results

The median follow-up was 62 months. The 5-year progression-free survival (PFS) and overall survival (OS) of the entire cohort were 90.4% and 90.9%, respectively. Univariate analysis showed that tumor stage, tumor size, pathological type, lymphovascular space invasion, and numbers of medium risk factors were not risk factors for early-stage CC. Compared with the control group, patients who received CT, RT, or CT + RT showed improved PFS and OS (P<0.05). The RT group had lower PFS and OS than the CT and CT + RT groups (P<0.05). Among the 318 patients with a single intermediate risk factor, 297 patients received CT, RT, and CT + RT benefit from adjuvant therapy (P<0.05). Of the 253 patients with high-risk factors, 220 patients received CT, RT and CT + RT get improved PFS and OS (P<0.05).

Conclusions

Patients who received adjuvant therapy had better postoperative outcomes than those who did not receive adjuvant therapy. Patients had CT alone or CT combined with RT had better efficacy than those had RT alone.

Clinical features that affect the number of pelvic lymph nodes harvested in patients with cervical cancer stage IB1 to IIA2

Objective

To investigate clinical features that affect the number of pelvic lymph nodes (PLNs) harvested and prognostic significance of the number of PLNs removed in patients with stage IB1 to IIA2 cervical cancer.

Methods

Data from patients with cervical cancer whom underwent hysterectomy with PLN dissection between June 2004 and July 2015 were reviewed retrospectively. Data on clinicopathologic factors including age, height, and weight were collected. Data on the presence of PLN metastasis on imaging studies prior to surgery, number of PLNs harvested, and presence of metastasis in the harvested PLNs were retrieved from medical records. Clinical features associated with the number of PLNs harvested were analyzed. Disease-free survival (DFS) and overall survival (OS) according to the number of PLNs harvested were analyzed.

Results

During the study period, 210 patients were included. The height and weight of patients and preoperative positive positron emission tomography findings were significantly associated with a higher number of PLNs harvested. As a pathologic factor, larger tumor size was associated with a higher number of PLNs harvested. Furthermore, a higher number of PLNs harvested was associated with a higher number of metastatic PLNs and patients undergoing postoperative concurrent chemoradiation therapy. Patient height and tumor size were independent factors affecting the number of PLNs harvested in multivariate analysis. However, the number of PLNs harvested was not associated with DFS or OS.

Conclusion

The number of PLNs harvested during surgery was associated with patient height; however, this was not related to the prognosis of the disease.

Comparison of different lymph node staging systems in patients with node-positive cervical squamous cell carcinoma following radical surgery

Objective: We compared the prognostic accuracy of four lymph node (LN) staging systems - the 2018 International Federation of Gynecology and Obstetrics (FIGO) stage, number of positive lymph node (PLN), metastatic lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS) systems - in patients with node-positive cervical squamous cell carcinoma (CSCC) following radical surgery and explored the optimal choice for clinical applications. Materials and methods: Data were retrospectively collected from 928 node-positive CSCC patients who underwent radical surgery between 2006 and 2014 in our center. Tree-based recursive partitioning was applied to split variables (PLN, LNR, and LODDS) into low-risk and high-risk groups. The log-rank test was used to compare survival curves, and Cox regression analysis was performed to identify prognostic factors. The relative discriminative abilities of the different staging systems were assessed using Harrell's concordance index (C index) and the Akaike information criterion (AIC). Results: The mean number of PLNs was 3.8 (range: 1-44 nodes). According to the 2018 FIGO staging system, 831 patients had stage IIIC1, and 97 had stage IIIC2. For the PLN system, 761 patients were included in the low-risk group, and 167 were included in the high-risk group. For the LNR system, 658 patients were included in the low-risk group, and 270 were included in the high-risk group. The low-risk LODDS group included 694 patients, while the high-risk LODDS group included 234 patients. All four staging systems had a significant influence on patients' progression-free survival (PFS, P < 0.001) and overall survival (OS, P < 0.001). Univariate analysis and multivariate Cox analysis adjusted for significant factors indicated that the four staging systems were significant prognostic factors for PFS and OS. Among them, the PLN system was noted to have the best prognostic performance for both PFS (C index: 0.582; AIC: 8213.33) and OS (C index: 0.624; AIC: 8433.80). Conclusion: The PLN system seemed to be the most accurate LN staging method for predicting node-positive CSCC following radical surgery.

Risk Stratification Based on Metastatic Pelvic Lymph Node Status in Stage IIIC1p Cervical Cancer

Purpose

Stage IIIC1 cervical cancer showed heterogeneous in oncologic outcomes with highly variable survival rates. Our objective was to determine the prognostic significance of removed and metastatic pelvic lymph node status and further perform risk stratification in patients with stage IIIC1p cervical cancer.

Patients and Methods

Patients with stage IIIC1p cervical cancer and undergoing radical hysterectomy with lymphadenectomy in 2008–2018 were retrospectively analyzed. Patients’ stage was classified using the revised 2018 International Federation of Gynecology and Obstetrics (FIGO) staging schema. Univariate and multivariable models were used to examine the association between removed and metastatic lymph node status and recurrence-free survival/overall survival.

Results

During a median follow-up of 34 months, 73 relapses and 44 deaths were observed among 273 patients with stage IIIC1p cervical cancer. Parametrial involvement and metastatic lymph node ratio (mLNR) were identified as independent predictors for recurrence-free survival. Parametrial involvement and mLNR were independent predictors for overall survival. A stratification system was then created based on parametrial involvement and mLNR. A total of 123 (45.1%), 127 (46.5%) and 23 (8.4%) patients were classified into the low-risk, intermediate-risk, and high-risk groups, with as a 5-year recurrence-free survival of 81.7%, 51.1%, 38%, respectively. Compared to the low-risk group, the intermediate- and high-risk groups had a significantly greater risk of recurrence and death.

Conclusion

The prognosis of stage IIIC1p patients varied significantly. A risk stratification system based on parametrial involvement and mLNR successfully separated patients into low, intermediate, and high-risk group. Our findings could facilitate the practical use of further stratification in Stage IIIC1p cervical cancer.

Prognostic factors affecting survival and recurrence in patients with early cervical squamous cell cancer following radical hysterectomy

OBJECTIVE

This study aimed to investigate the clinical and histological features affecting the survival of patients with early cervical squamous cell cancer treated with radical hysterectomy.

METHODS

We retrospectively analyzed clinical and histological data for patients with stage IB-IIA cervical cancer treated by radical hysterectomy at Zhejiang Cancer Hospital from August 2008 to January 2013.

RESULTS

A total of 1435 patients were included in the study. Cox regression analysis identified tumor size >4 cm, lymphovascular space involvement (LVSI), lymph node ratio (LNR), and squamous cell carcinoma antigen (SCC-Ag) >2.65 ng/mL as independent prognostic risk factors. Among 1096 patients without high pathological risk factors, the 5-year local recurrence rates for SCC-Ag ≤2.65 and >2.65 ng/mL were 6.6% and 25.7%, respectively. Among 332 patients with lymph node positivity, the overall survival rates for LNR ≤0.19 and >0.19 were 87.8% and 55.6%, respectively.

CONCLUSIONS

LVSI, tumor size >4 cm, LNR >0.19, and SCC-Ag >2.65 ng/mL may predict a poor prognosis in patients with early cervical squamous cell cancer treated with radical hysterectomy. SCC-Ag >2.65 ng/mL may be a useful prognostic factor guiding the use of postoperative radiotherapy in patients without pathologic risk factors.

Progress in the Study of Lymph Node Metastasis in Early-stage Cervical Cancer

Spread into regional lymph node is the major route of metastasis in cervical cancer. Although lymph node status is not involved in the International Federation of Gynecology and Obstetrics staging system of uterine cervical cancer, the presence or absence of lymph node metastasis provides important information for prognosis and treatment. In this review, we have attempted to focus on the incidence and patterns of lymph node metastasis, and the issues surrounding surgical assessment of lymph nodes. In addition, the preoperative prediction of lymph node status, as well as the intraoperative assessment by sentinel nodes will be reviewed. Finally, lymph node micrometastasis also will be discussed.

Predictive Factors of Pelvic Lymph Node Metastasis in Early-Stage Cervical Cancer

BACKGROUND

Pelvic lymphadenectomy, which is the routine surgical treatment for early-stage cervical cancer, causes serious morbidity. The goal of the current retrospective study was to identify predictive factors of lymph node metastasis (LNM) in patients with early-stage cervical cancer.

PATIENTS AND METHODS

The study included 496 patients diagnosed with stages IA2-IB1cervical cancer who underwent a radical hysterectomy with pelvic lymphadenectomy. The predictive factors of LNM were evaluated.

RESULTS

The incidence of LNM in this study was 4.6%. LNM was more common in patients with deep stromal invasion (DSI), tumor size > 2 cm, lymph vascular invasion and parametrial involvement (PI). Multivariate analysis showed DSI (p = 0.010) and PI (p = 0.005) were independently associated with LNM. The median follow-up time was 56.9 months. The patients with LNM had poorer 5-year overall survival (77.8%; 95% confidence interval (CI) 44.2-92.6) than the patients without LNM (98.2%; 95% CI 95.6-99.2; p = 0.002) and also poorer 5-year recurrence-free survival (65.5%; 95% CI 38.6-82.8) than the patients without LNM (90.2%; 95% CI 86.5-92.9; p < 0.001).

CONCLUSION

The predictive factors of pelvic lymph node metastasis in stage IA2-IB1 cervical cancer patients were DSI and PI. LNM was associated with poorer oncological outcomes.

Completing or Abandoning Radical Hysterectomy in Early-Stage Lymph Node-Positive Cervical Cancer: Impact on Disease-Free Survival and Treatment-Related Toxicity

INTRODUCTION

Management regarding completing hysterectomy in case of intraoperative finding of positive lymph nodes in early-stage cervical cancer differs between institutions. The aim of this study was to compare survival and toxicity after completed hysterectomy followed by adjuvant (chemo-)radiotherapy versus abandoned hysterectomy and primary treatment with chemoradiotherapy (CRT).

METHODS

A retrospective multicenter cohort study was performed. All patients were scheduled for radical hysterectomy with pelvic lymphadenectomy (RHL). In the RHL group, hysterectomy was completed followed by adjuvant (chemo-)radiotherapy. In the second group, hysterectomy was abandoned, and CRT was conducted. Primary outcomes were disease-free survival (DFS) and overall survival. A multivariable analysis on DFS was performed. Toxicity was scored according to the National Cancer Institute CTCAE (Common Terminology Criteria for Adverse Events) v4.03.

RESULTS

A total of 121 patients were included (RHL, n = 89; CRT, n = 32). There was no difference in overall survival (84% vs 77%). Five-year DFS was in favor of completing RHL (81% vs 67%). Multivariable analysis showed that, corrected for lymph node variables, treatment regimen was not associated with DFS. After RHL, pelvic recurrence rate was significantly lower compared with CRT (2% vs 16%). CTCAE grade 3-4 toxicity rates were higher in the CRT compared with the RHL group (59% vs 30%), mainly because of differences in chemotherapy-related hematologic toxicity.

CONCLUSIONS

In patients with clinically N0 early-stage cervical cancer with intraoperative detection of positive nodes, completing RHL followed by adjuvant (chemo-)radiotherapy may result in a better pelvic control compared with abandoning hysterectomy and treatment with chemoradiotherapy. However, if corrected for lymph node variables, treatment (RHL or CRT) was not associated with DFS.

The prognostic value of negative lymph node count for patients with cervical cancer after radical surgery

Negative lymph node (NLN) count has been recognized as a prognostic indicator in various cancers. However, the relationship between NLN count and the prognosis of cervical cancer is still unknown. In this study, 10, 500 cervical cancer patients after radical surgery were selected from Epidemiology and End Results Program (SEER) data. Clinicopathological characteristics were collected for analysis, including year of diagnosis, age, race, grade, primary site, FIGO stage and cause specific survival (CSS). Univariate and multivariate Cox proportional hazards model was used to assess risk factors for survival of patients. X-tile plots identified 6 as the optimal cutoff value of NLN count to divide patients into high and low risk subsets in terms of CSS (χ² = 183.95, P < 0.001). The rate of 5-year CCS of cervical cancer patients was improved with an increase in NLN count from 0 to 23 (all P < 0.001). NLN count was validated as an independently prognostic factor by the multivariate Cox analysis (HR: 1.571, 95% CI: 1.370~1.801, P < 0.001). Subgroup analysis showed that NLN count was a prognosis factor in FIGO stage I (χ²=35.023, P < 0.001), stage II (χ² = 12.910, P < 0.001), stage III + IV (χ² = 9.732, P = 0.002) and unknown stage (χ² = 16.654, P < 0.001). Conclusively, this study demonstrated the NLN count was an independent prognostic factor for cervical cancer patients.

Lymph node ratio may predict the benefit of postoperative radiotherapy in node-positive cervical cancer

The standard treatment for node-positive cervical cancer after radical hysterectomy is pelvic radiotherapy and concurrent chemotherapy. Given the potential toxicity of postoperative radiotherapy, we used the lymph node ratio (LNR) to assess the benefit of postoperative radiotherapy in lymph node-positive cervical cancer patients. Data from the Surveillance Epidemiology and End Results database (1988-2010) were analyzed using Kaplan-Meier and Cox regression proportional hazard analysis. A total of 2,269 eligible patients were identified (median follow-up, 78.0 months); 1,863 (82.1%) patients received postoperative radiotherapy. In both univariate and multivariate analysis multivariate analysis, a higher LNR was significantly associated with a poorer outcome. A LNR > 0.16 was associated with poorer cervical cancer-related survival (CCSS) (hazard Ratio [HR] 1.376, confidence interval [CI] 1.082-1.750; P < 0.001) and overall survival (OS) (HR 1.287, CI 1.056-1.569; P = 0.012). Postoperative radiotherapy was only associated with survival benefits in patients with a LNR > 0.16 (CCSS, P < 0.001; OS, P < 0.001) and not in patients with a LNR ≤ 0.16 (CCSS, P = 0.620; OS, P = 0.167); these trends were not affected by number of removed lymph nodes. A higher LNR is associated with a poorer survival in lymph node-positive cervical cancer. The survival benefits of postoperative radiotherapy appear to be limited to patients with a LNR > 0.16.

The impact of examined lymph node count on survival in squamous cell carcinoma and adenocarcinoma of the uterine cervix

Introduction

The prognostic impact of the number of examined lymph nodes (ELNs) in different histological subtypes of cervical cancer remains unclear. We aimed to assess the impact of the number of ELNs in stage IA2–IIA cervical cancer with different histological subtypes.

Methods

Data of patients with stage IA2–IIA squamous cell carcinoma (SCC) and adenocarcinoma (AC) of the uterine cervix between 1988 and 2013 were retrieved from the Surveillance, Epidemiology, and End Results program. Univariate and multivariate Cox regression analyses were performed to analyze the effect of number of ELNs on cause-specific survival (CSS) and overall survival (OS).

Results

The final data set identified 11,830 patients including 7,920 (66.9%) women with SCC and 3,910 (33.1%) with AC. The median number of ELNs was 19. The multivariate analysis indicated that the number of ELNs was an independent prognostic factor influencing CSS and OS, both as a continuous or a categorical variable. Patients with a higher number of ELNs had better survival outcomes. In SCC subtype, the number of ELNs was also the independent prognostic factor of CSS and OS in node-positive patients, but not in patients with node-negative disease. In AC patients, ELN count was not an independent predictor of CSS and OS regardless of lymph node status.

Conclusion

The number of ELNs is an independent prognostic factor in patients with stage IA2–IIB cervical cancer. A higher number of ELNs is associated with better survival outcomes, especially in the node-positive SCC subtype.

Effect of number of retrieved lymph nodes on prognosis in FIGO stage IB-IIA cervical cancer patients treated with primary radical surgery

AIM

In the treatment of cervical cancer, the extent of lymphadenectomy is a matter of debate. The goal of the current study was to examine the question of whether the number of retrieved lymph nodes (RLN) can influence survival of patients with early stage cervical cancer.

METHODS

The medical records of 180 FIGO stage IB-IIA cervical cancer patients treated with primary radical surgery were reviewed. Patients were divided into two groups: those with ≤ 40 RLN and those with > 40 RLN. Patients were also assigned to either the bulky (tumor size > 4 cm) cervical cancer group or the non-bulky (tumor size ≤ 4 cm) cervical cancer group.

RESULTS

The number of RLN had a statistically significant effect on both disease-free survival (P = 0.04) and overall survival (P = 0.02) of all patients. Patients with > 40 RLN had better prognoses than those with ≤ 40 RLN. In the bulky cervical cancer group, the number of RLN was an independent prognostic factor. In multivariate analysis for the bulky cervical cancer group, > 40 RLN had a significant positive effect on disease-free survival (adjusted hazard ratio, 0.36; 95% confidence interval, 0.13-0.97) and overall survival (adjusted hazard ratio, 0.23; 95% confidence interval, 0.06-0.90). However, number of RLN was not an independent prognostic factor in the non-bulky cervical cancer group.

CONCLUSIONS

A more extensive lymphadenectomy increased the survival of bulky cervical cancer patients. This finding may be helpful in determining surgical extent before surgery for cervical cancer.

Potential use of lymph node-derived HPV-specific T cells for adoptive cell therapy of cervical cancer

Adoptive transfer of tumor-specific T cells, expanded from tumor-infiltrating lymphocytes or from peripheral blood, is a promising immunotherapeutic approach for the treatment of cancer. Here, we studied whether the tumor-draining lymph nodes (TDLN) of patients with human papillomavirus (HPV)-induced cervical cancer can be used as a source for ACT. The objectives were to isolate lymph node mononuclear cells (LNMC) from TDLN and optimally expand HPV-specific CD4+ and CD8+ T cells under clinical grade conditions. TDLN were isolated from 11 patients with early-stage cervical cancer during radical surgery. Isolated lymphocytes were expanded in the presence of HPV16 E6 and E7 clinical grade synthetic long peptides and IL-2 for 22 days and then analyzed for HPV16 specificity by proliferation assay, multiparameter flow cytometry and cytokine analysis as well as for CD25 and FoxP3 expression. Stimulation of LNMC resulted in expansion of polyclonal HPV-specific T cells in all patients. On average a 36-fold expansion of a CD4+ and/or CD8+ HPV16-specific T cell population was observed, which maintained its capacity for secondary expansion. The T helper type 1 cytokine IFNγ was produced in all cell cultures and in some cases also the Th2 cytokines IL-10 and IL-5. The procedure was highly reproducible, as evidenced by complete repeats of the stimulation procedures under research and under full good manufacturing practice conditions. In conclusion, TDLN represent a rich source of polyclonal HPV16 E6- and E7-specific T cells, which can be expanded under clinical grade conditions for adoptive immunotherapy in patients with cervical cancer.

Surgical Treatment of Early-Stage Cervical Cancer

Surgical treatment of cervical cancer has been a cornerstone in the management of this malignancy for more than 100 years. Today, for early-stage and low-risk cervical cancer, surgery is still considered the gold standard. If the preoperative assessment of the tumor reveals a situation prompting postoperative adjuvant radiochemotherapy, the latter should be planned as the primary treatment option, being preceded by staging laparoscopy including pelvic and paraaortic lymph node dissection. As an alternative to the open approach, the definitive surgical treatment should be either performed laparoscopically, or be laparoscopic-assisted, or laparoscopically robotic-assisted.

Can pelvic lymphadenectomy be omitted in patients with stage IA2, IB1, and IIA1 squamous cell cervical cancer?

Purpose

This study aimed to identify the surgical-pathologic risk factors of lymph node metastasis (LNM) in patients with early stage squamous cell cervical cancer and to evaluate the potential efficacy of omitting pelvic lymphadenectomy.

Methods

A total of 276 patients with stage IA2, IB1, and IIA1 squamous cell cervical cancer receiving primary radical hysterectomy with pelvic lymphadenectomy were included in this study.

Results

The incidences of LNM in patients with stage IA2, IB1, and IIA1 squamous cell cervical cancer were 0 % (0/8), 17.4 % (36/207), and 29.5 % (18/61), respectively. The most common location of LNM was the obturator lymph node. Human papilloma virus 16 subtype was the most common infection in early stage squamous cell cervical cancer. Univariate analysis revealed that squamous cell carcinoma antigen (SCCAg) greater than 1.5 μg/L (p < 0.001), tumor size greater than 2 cm (p < 0.001), tumor size greater than 3 cm (p < 0.001), depth of stromal invasion (p < 0.001) and lymphovascular invasion (p < 0.001) were associated with LNM. Logistic regression analysis revealed that depth of stromal invasion {model 1 [p = 0.006; odds ratio (OR) 2.161; 95 % confidence interval (CI) 1.251–3.734], model 2 [p = 0.002; OR 2.344; 95 % CI 1.337–3.989]}, lymphovascular invasion [model 1 (p = 0.004; OR 2.967; 95 % CI 1.411–6.237), model 2 (p = 0.004; OR 2.978; 95 % CI 1.421–6.243)], and SCCAg greater than 1.5 μg/L [model 1 (p = 0.023; OR 2.431; 95 % CI 1.129–5.235), model 2 (p = 0.024; OR 2.418; 95 % CI 1.125–5.194)] were independently associated with LNM.

Conclusions

Pelvic lymphadenectomy may be omitted in patients with SCCAg lower than 1.5 μg/L, superficial stromal invasion and without lymphovascular invasion in stage IA2, IB1, IIA1 squamous cell cervical cancer.

Prognostic significance of number of nodes removed in patients with node-negative early cervical cancer

AIM

The aim of this study was to investigate whether the number of removed lymph nodes was associated with survival of patients with node-negative early cervical cancer and to analyze the prognostic significance of clinical and pathologic features in these patients.

METHODS

Patients with FIGO stage IA-IIB cervical cancer who underwent radical hysterectomy with lymphadenectomy without receiving preoperative therapy were reviewed retrospectively. Patients were all proved to have lymph-node-negative disease and classified into five groups based on the number of nodes removed. The Kaplan-Meier method and Cox's proportional hazards regression model were used in prognostic analysis.

RESULTS

The final dataset included 359 patients: 45 (12.5%) patients had ≤10 nodes removed, 93 (25.9%) had 11-15, 98 (27.3%) had 16-20, 64 (17.8%) had 21-25, and 59 (16.4%) had >25 nodes removed. There was no association between the number of nodes removed and survival of patients with node-negative early cervical cancer (χ²  = 6.19, P = 0.185). Similarly, subgroup analyses for FIGO stage IB1-IIB also showed that the number of lymph nodes was not significantly related to survival in each stage. Multivariate analyses showed that histology and depth of invasion were independent prognostic factors for survival in these patients.

CONCLUSION

If a standardized lymphadenectomy is performed, the number of lymph nodes removed is not an independent prognostic factor for patients with node-negative early cervical cancer. Our study suggests that there is inconclusive evidence to support survival benefit of complete lymphadenectomy among these patients.

Deep obturator lymph node dissection in gynaecological cancer patients: Is it feasible and useful?

Our aim was to investigate the feasibility and outcomes of deep obturator lymph node (DOLN) dissection in gynaecological cancer patients. A prospective study included 62 patients with a diagnosis of ovarian, endometrial or cervical cancer who underwent surgery. In the study group, 36 patients underwent obturator lymph node dissection above and under the obturator nerve, while 26 control group patients underwent routine obturator lymph node dissection above the obturator nerve. Groups were compared with respect to dissected lymph node count, intraoperative characteristics and early postoperative complications. Total lymph node count in the DOLN dissected group was greater than that in the control group, and the difference was statistically significant. No statistically significant difference was found between the groups, regarding postoperative complications and intraoperative characteristics. The total number of lymph nodes dissected by using DOLN dissection increased without an increase in intra- and postoperative complications in gynaecological cancer patients.

Impact of the care provided by gynecologic oncologists on outcomes of cervical cancer patients treated with radical hysterectomy

For many malignant diseases, specialized care has been reported to be associated with better outcomes. The purpose of this study is to investigate the influence of gynecologic oncologists on treatment outcomes for cervical cancer patients treated by radical hysterectomy. Records of patients who received radical hysterectomy between January 2005 and June 2010 were reviewed. Perioperative morbidity, recurrence-free survival, and cancer-specific survival were assessed. Cox regression model was used to evaluate gynecologic oncologists as an independent predictor of survival. A total of 839 patients were included. Of these patients, 553 were treated by gynecologic oncologists, while 286 were treated by other subspecialties. With regard to operative outcomes, significant differences in favor of operation by gynecologic oncologists were found in number of patients receiving para-aortic node sampling and dissection (P=0.038), compliance with surgical guidelines (P=0.003), operative time (P<0.0001), estimated blood loss (P<0.0001), transfusion rate (P=0.046), number of removed nodes (P=0.033), and incidences of ureteric injury (P=0.027), cystotomy (P=0.038), and fistula formation (P=0.002). Patients who were operated on by gynecologic oncologists had longer recurrence-free survival (P=0.001; hazard ratio [HR] =0.64; 95% confidence interval [CI] [0.48, 0.84]) and cancer-specific survival (P=0.005; HR=0.64; 95% CI [0.47, 0.87]), and this association remained significant in patients with locally advanced disease. Care by gynecologic oncologists was an independent predictor for improved recurrence-free survival (P<0.0001; HR=0.57; 95% CI [0.42, 0.76]) and cancer-specific survival (P=0.001; HR=0.58; 95% CI [0.42, 0.81]), which was still significant among patients with locally advanced cancer. Given the results, we believe for cervical cancer patients receiving radical hysterectomy, operation by gynecologic oncologists results in significantly improved surgical and survival outcomes. The importance of the subspecialty of a gynecologist for cervical cancer patients should be addressed in clinical practice, especially for those in developing countries.

Pathways of lymphatic spread in gynecologic malignancies

Precise radiologic evaluation of regional adenopathic involvement in pelvic gynecologic tumors is fundamental to clinical practice because of its prognostic and therapeutic significance. Likewise, the identification of metastatic adenopathies at posttreatment imaging is essential for assessing response and detecting recurrence. Similar to urologic neoplasms, gynecologic neoplasms most often spread regionally to the pelvic and retroperitoneal lymph nodes, following the normal drainage pathways of the pelvic organs. Familiarity with routes of dissemination, treatment options, and means of analyzing lymph node characteristics is crucial to determine the extent of disease. Two staging systems can be used in characterizing gynecologic malignancies: the FIGO (International Federation of Gynecology and Obstetrics) system, which is the most commonly and universally used, and the TNM (tumor, node, metastasis) system, which is based on clinical and/or pathologic classification. Anatomic assessment with multidetector computed tomography (CT) and magnetic resonance (MR) imaging is still the most commonly used technique for the detection of lymph node spread, which is mainly based on morphologic criteria, the most important of which is nodal size. However, size has limited diagnostic specificity. Consequently, functional imaging techniques such as diffusion-weighted MR imaging, positron emission tomography combined with CT, lymphoscintigraphy, and sentinel lymph node mapping, which are based on molecular and physiologic activity and allow more precise evaluation, are often incorporated into diagnostic imaging protocols for staging of gynecologic malignancies.

Adjuvant chemotherapy versus concurrent chemoradiotherapy for high-risk cervical cancer after radical hysterectomy and systematic lymphadenectomy

BACKGROUND

The aims of this study were to evaluate the efficacy and toxicity of chemotherapy (CT) compared with concurrent chemoradiotherapy (CCRT) after radical hysterectomy and lymphadenectomy in high-risk patients with early-stage cervical cancer and to evaluate whether the radicality of the lymphadenectomy would affect the outcome and toxicity of postoperative adjuvant therapy.

METHODS

The cases of all patients (n = 393) with FIGO IB1-IIB cervical cancer who were treated by radical surgery at Shizuoka Cancer Center between January 2002 and December 2013 were reviewed. Of these, 111 patients met the inclusion criteria for this retrospective study: (1) high risk for occurrence due to pathologically confirmed parametrial invasion and/or pelvic lymph node metastasis; (2) postoperative treatment with adjuvant CT or CCRT. The clinical data of these patients were reviewed.

RESULTS

Of the 111 patients, 37 and 74 patients underwent CT and CCRT, respectively. The 4-year progression-free survival rate [PFS; 71.7 (CT) vs. 68.3 % (CCRT)] and overall survival rate [76.0 (CT) vs. 82.7 % (CCRT)] did not differ significantly between the two groups. The CT group contained significantly more patients with severe neutropenia than the CCRT group (66.7 vs. 23.0 %, respectively; p < 0.001), and the CCRT group contained significantly more patients with diarrhea than the CT group (10.8 vs. 0 %, respectively; p = 0.04). The patients who had ≥40 lymph nodes dissected (≥40 group) had higher PFS than the patients who had <40 lymph nodes dissected (<40 group) (73.2 vs. 64.2 %, respectively), although the difference was not significant. In the CT group, there was no significant association between the number of dissected lymph nodes and severe toxicities. However, in the CCRT group, significantly more vomiting (p = 0.046) and edema (p = 0.046) occurred in the ≥40 group than in the <40 group.

CONCLUSIONS

Chemotherapy after surgery for high-risk patients had similar efficacy and a different toxicity profile compared with CCRT, and a more radical surgical procedure would improve the survival outcome. However, CCRT was associated with worse toxicity than CT. We advocate a prospective randomized study to compare CT with CCRT for patients with high-risk factors for recurrence.

An Audit of 204 Histopathology Reports Over Three Years of Carcinoma of Cervix: Experience from a Tertiary Referral Centre

BACKGROUND

The aim was to see compliance to minimum data set information in carcinoma cervix histopathology reports from a team of 13 pathologists; and also to analyse the distribution of parameters like tumor size, grade, depth of cervical stromal invasion, lymph node yield and pTNM stage.

MATERIALS AND METHODS

All pathology reports of radical hysterectomy for carcinoma cervix operated in house within a three year duration (2010-2012), (n=204) were retrieved from medical records and analyzed for the above parameters.

RESULTS

In 2010- 59 cases, in 2011- 67 cases and in 2012- 78 cases of carcinoma cervix underwent operations in our hospital. The median age was 50.5 years and the maximum T diameter was 2.8 cms in the reports of three years. Squamous carcinoma was the commonest subtype amongst all the tumors. It was noted that 60.8% of cases had cervical stromal involvement more than half the thickness of the cervical stroma. Parametrial involvement was seen in 4.82% of cases. pTNM Staging was not mentioned in 65.06% of the cases. The mean bilateral pelvic lymph node yield count in our study was 16.6 inclusive of all the three years.

CONCLUSIONS

Compliance with provision of a minimum dataset in our team of 13 pathologists was generally good. Lymph node yield in our hands is reasonable, but constant striving for greater numbers should be made. pTNM staging should be more meticulously documented. Use of proformas /checklists is recommended.

Lymph node counts are valid indicators of the quality of surgical care in bladder cancer: a population-based study

OBJECTIVE

To describe lymph node counts in routine clinical practice and evaluate their association with outcomes to explore its utility as a quality indicator.

METHODS AND MATERIALS

Electronic records of treatment and surgical pathology reports were linked with the population-based Ontario Cancer Registry to identify all patients who underwent cystectomy between 1994 and 2008. Temporal trends were described over 3 periods: 1994 to 1998, 1999 to 2000, and 2004 to 2008. Multivariate generalized linear regression analysis was used to determine the factors associated with the use of pelvic lymph node dissection (PLND). A Cox proportional hazards regression model was used to explore the associations between PLND and survival.

RESULTS

The study population included 2,802 patients. Use of PLND (50%, 62%, and 85%, correspondingly), median node yield (5, 6, and 9, correspondingly), and node density (56%, 50%, and 39%, correspondingly) all improved over the study periods, 1994 to 1998, 1999 to 2000, and 2004 to 2008 (P<0.001). In multivariate analysis, factors associated with not having PLND include advanced age, female sex, lower socioeconomic status, low surgeon volume, and partial cystectomy. In adjusted analyses, patients who did not receive a PLND had inferior overall (hazard ratio = 1.26, 95% CI: 1.15-1.38) and cancer-specific (hazard ratio = 1.23, 95% CI: 1.11-1.36) survival. Node yield, as well as density, was also associated with long-term survival.

CONCLUSIONS

There is significant variation in use and quality of PLND at cystectomy in routine practice. Node counts are independently associated with long-term survival, and this association is persistent despite adjustment for provider-related variables. These results suggest that lymph node counts are a valid quality indicator of surgical care of muscle-invasive bladder cancer.

Does debulking of enlarged positive lymph nodes improve survival in different gynaecological cancers?

Lymph-node-positive gynaecological cancers remain a pharmacotherapeutic challenge, and patients with lymph-node-positive gynaecological cancers have poor survival. The purpose of this review is to determine whether a survival advantage arises from surgical debulking of enlarged positive lymph nodes in different types of gynaecological cancers. Information from studies published on the survival benefits from debulking lymph nodes in gynaecological cancers was investigated. Pertaining to therapeutic lymphadenectomy, survival benefit can be analysed in two ways, direct survival benefit following therapeutic lymphadenectomy of bulky positive metastatic lymph nodes and indirect survival benefit, which results after a sequela of systematic lymphadenectomy, proper, accurate staging of disease and stage migration and tailor-made adjuvant treatment. The direct hypothesis of therapeutic lymphadenectomy and survival benefit has been prospected in cervical cancers and vulval cancers and in post-chemotherapy residual paraarotic nodal mass in germ cell ovarian cancer. The indirect survival benefit of therapeutic paraarotic lymphadenectomy in high-risk endometrial cancers and advanced epithelial ovarian cancers needs to be tested in randomized controlled trials. More randomized controlled trials are required to investigate this research question. Further, indirect benefit due to tailor-made adjuvant treatment, secondary to accurate staging achieved as a sequela of systematic lymphadenectomy, needs to be analysed in future trials.

Tailoring Pelvic Lymphadenectomy for Patients with Stage IA2, IB1, and IIA1 Uterine Cervical Cancer

Purpose: The purpose of this study was to assess the risk factors for pelvic lymph node metastasis (PLNM) in patients with early-stage uterine cervical cancer.

Methods: A total of 192 patients with early-stage uterine cervical cancer (FIGO stage IA2, IB1, and IIA1) receiving radical hysterectomy with pelvic lymphadenectomy were included in the statistical analysis.

Results: Thirty-six patients (18.8%) developed PLNM, and the incidences of PLNM in patients with stage IA2, stage IB2, and stage IIA1 were 0% (0/6), 13.9% (20/144), and 38.1% (16/42), respectively. The most common location of PLNM was the obturator lymph node. Univariate analysis showed that stage IIA1 (p < 0.001), tumor size greater than 3 cm (p = 0.019), deep-full thickness stromal invasion (p < 0.001), and lymphovascular invasion (p = 0.001) were associated with PLNM. Multivariate analysis showed that deep or full-thickness stromal invasion and lymphovascular invasion were significantly and independently associated with PLNM (p < 0.05 for both). The incidence of PLNM was 34.9% and 28.7% in patients with deep-full thickness stromal invasion and lymphovascular invasion, respectively, but that was only 5.7% and 9.2% in patients with superficial-middle stromal invasion and absence of lymphovascular invasion, respectively.

Conclusion: Patients with superficial-middle stromal invasion and without lymphovascular invasion may be avoided pelvic lymphadenectomy in stage IA2, IB1, IIA1 uterine cervical cancer.

Anatomical variations of the internal iliac veins in the presacral area: Clinical implications during sacral colpopepxy or extended pelvic lymphadenectomy

The purpose of this study was to classify anatomical variations of the internal iliac vein (IIV) in relation to robotic or laparoscopic extended lymphadenectomy. Between March 2011 and July 2012, 60 consecutive patients underwent robotic or laparoscopic extended lymphadenectomy. We retrospectively reviewed surgical video clips and analyzed the pattern of the IIVs in the presacral area. IIV variations were classified into seven types: Type A, normal (n = 39, 65.0%); Type A with a dilated middle sacral vein (n = 5, 8.3%); Type B, left IIV connecting centrally to the left external iliac vein (n = 5, 8.3%); Type C, a separated trunk of the left IIV draining into the left central common iliac vein (CIV; n = 1, 1.7%); Type D, a separated trunk of the right IIV draining into the left central CIV (n = 8, 13.3%); Type E, a separated trunk of the right IIV draining into the right central CIV (n = 0, 0%); and Type F, separated trunks of the bilateral IIV connecting with each other before draining into the left central CIV (n = 2, 3.3%). The prevalence of IIV anomalies was 26.7%; the incidence of separated IIV trunks was 18.3%. To prevent life-threatening IIV injury during extended lymphadenectomy or sacral colpopexy, the anatomical variations of the IIVs should be known exactly.

Detection of sentinel lymph nodes in minimally invasive surgery using indocyanine green and near-infrared fluorescence imaging for uterine and cervical malignancies

OBJECTIVES

Our primary objective was to assess the detection rate of sentinel lymph nodes (SLNs) using indocyanine green (ICG) and near-infrared (NIR) fluorescence imaging for uterine and cervical malignancies.

METHODS

NIR fluorescence imaging for the robotic platform was obtained at our institution in 12/2011. We identified all cases planned for SLN mapping using fluorescence imaging from 12/2011-4/2013. Intracervical ICG was the fluorophobe in all cases. Four cc (1.25mg/mL) of ICG was injected into the cervix alone divided into the 3- and 9-o'clock positions, with 1 cc deep into the stroma and 1 cc submucosally before initiating laparoscopic entry. Blue dye was concurrently injected in some cases.

RESULTS

Two hundred twenty-seven cases were performed. Median age was 60 years (range, 28-90 years). Median BMI was 30.2 kg/m(2) (range, 18-60 kg/m(2)). The median SLN count was 3 (range, 1-23). An SLN was identified in 216 cases (95%), with bilateral pelvic mapping in 179 (79%). An aortic SLN was identified in 21 (10%) of the 216 mapped cases. When ICG alone was used to map cases, 188/197 patients mapped, for a 95% detection rate compared to 93% (28/30) in cases in which both dyes were used (P=NS). Bilateral mapping was seen in 156/197 (79%) ICG-only cases and 23/30 (77%) ICG and blue dye cases (P=NS).

CONCLUSIONS

NIR fluorescence imaging with intracervical ICG injection using the robotic platform has a high bilateral SLN detection rate and appears favorable to using blue dye alone and/or other modalities. Combined use of ICG and blue dye appears unnecessary.

Robot-assisted total preservation of the pelvic autonomic nerve with extended systematic lymphadenectomy as part of nerve-sparing radical hysterectomy for cervical cancer

OBJECTIVE

To evaluate our short-term clinical outcomes of robot-assisted autonomic nerve-sparing extended systematic lymphadenectomy as part of nerve-sparing radical hysterectomy.

METHODS

Between March 2011 and June 2012, we observed prospectively 28 consecutive patients who underwent robot-assisted autonomic nerve-sparing extended systematic lymphadenectomy, including the superior and inferior gluteal, presacral (subaortic), common iliac, and lower para-aortic nodes.

RESULTS

The predominant International Federation of Gynecology and Obstetrics stage was IB1 (15 patients), followed by IB2 (5 patients), IA2 (3 patients), IIA1 (3 patients), and IIA2 (2 patients). The mean ± SD total operating time was 308.8 ± 54.9 minutes, and the mean ± SD console time was 280.0 ± 46.0 minutes. The mean ± SD blood loss was 102.7 ± 153.8 mL. The mean ± SD acquired pelvic lymph node was 27.1 ± 9.3, the mean ± SD extended lymph node was 19.2 ± 9.6, and the mean ± SD total lymph node was 46.3 ± 14.5. A total of 10 patients (35.7%) had nodal metastasis; among them, 6 patients (21.4%) had single pelvic nodal metastasis, 3 patients (10.7%) had concurrent pelvic and extended nodal metastasis, and one patient (3.6%) had single extended nodal metastasis. No intraoperative complications that required treatment occurred; however, ureterovaginal fistula was identified in 4 patients (14.3%) and ureter stricture in 4 patients (14.3%) after radiotherapy. After a median follow-up of 10 months (range, 1-16 months), there was no pelvic recurrence; however, one patient had recurrence at transposition site of ovary.

CONCLUSIONS

With the advantage of delicate movement of robot instrument, robot-assisted systematic extended lymphadenectomy with total preservation of pelvic autonomic nerves did not compromise the radicality, and its surgical technique was feasible and safe. By using this approach, we could harvest more lymph nodes and have a high rate of metastatic nodes without disturbing voiding function; however, there was increased rate of urological complications. Moreover, long-term survival benefit after an extended systematic lymphadenectomy must be evaluated.

Pelvic Lymphadenectomy Improves Survival in Patients With Cervical Cancer With Low-Volume Disease in the Sentinel Node: A Retrospective Multicenter Cohort Study

Objective

In this study, we aimed to describe the value of pelvic lymph node dissection (LND) after sentinel lymph node (SN) biopsy in early-stage cervical cancer.

Methods

We performed a retrospective multicenter cohort study in 8 gynecological oncology departments. In total, 645 women with International Federation of Gynecology and Obstetrics stage IA to IIB cervical cancer of squamous, adeno, or adenosquamous histologic type who underwent SN biopsy followed by pelvic LND were enrolled in this study. Radioisotope tracers and blue dye were used to localize the sentinel node, and pathologic ultrastaging was performed.

Results

Among the patients with low-volume disease (micrometastases and isolated tumor cells) in the sentinel node, the overall survival was significantly better (P = 0.046) if more than 16 non-SNs were removed. No such significant difference in survival was detected in patients with negative or macrometastatic sentinel nodes.

Conclusions

Our findings indicate that in patients with negative or macrometastatic disease in the sentinel nodes, an additional LND did not alter survival. Conversely, our data suggest that the survival of patients with low-volume disease is improved when more than 16 additional lymph nodes are removed. If in a prospective trial our data are confirmed, we would suggest a 2-stage operation.

Preoperative nomogram for the identification of lymph node metastasis in early cervical cancer

Background:

The objective of this study is to construct a preoperative nomogram predicting lymph node metastasis (LNM) in early-cervical cancer patients.

Methods:

Between 2009 and 2012, 493 early-cervical cancer patients received hysterectomy and pelvic/para-aortic lymphadenectomy. Patients who were diagnosed during 2009–2010 were assigned to a model-development cohort (n=304) and the others were assigned to a validation cohort (n=189). A multivariate logistic model was created from preoperative clinicopathologic data, from which a nomogram was developed and validated. A predicted probability of LNM<5% was defined as low risk.

Results:

Age, tumour size assessed by magnetic resonance imaging, and LNM assessed by positron emission tomography/computed tomography were independent predictors of nodal metastasis. The nomogram incorporating these three predictors demonstrated good discrimination and calibration (concordance index=0.878; 95% confidence interval (CI), 0.833−0.917). In the validation cohort, the discrimination accuracy was 0.825 (95% CI, 0.736−0.895). In the model-development cohort, 34% of them were classified as low risk and negative predictive value (NPV) was 99.0%. In the validation cohort, 38% were identified as low risk and NPV was 95.8%. Integrating the model-development and validation cohorts, negative likelihood ratio was 0.094 (95% CI, 0.036−0.248).

Conclusion:

A robust nomogram predicting LNM in early cervical cancer was developed. This model may improve clinical trial design and help physicians to decide whether lymphadenectomy should be performed.

The role of lymphadenectomy in cervical cancer patients: the significance of the number and the status of lymph nodes removed in 526 cases treated in a single institution

PURPOSE

To investigate whether the total number of removed lymph nodes (LNs) and the number of metastatic LNs would prove to be independent prognostic factors for survival in patients with cervical cancer (CC).

METHODS

Data from patients with CC who underwent radical surgery between March 1980 and September 2009 were reviewed. A total of 526 patients were included in the statistical analysis. Full pathologic evaluation was performed. The total number of examined LNs and their histopathological status were analyzed for their prognostic effect on survival by means of multivariable Cox proportional hazard regression models.

RESULTS

The median number (interquartile range) of total, pelvic, and para-aortic nodes removed was 37 (29-47), 34 (27-42), and 19 (14-24), respectively. Positive pelvic nodes were found in 102 of 526 (19%) patients. All 8 patients with para-aortic metastases had also pelvic node metastases. At multivariable analysis, vaginal involvement, type of lymphadenectomy and LN status all significantly negatively affected disease-free survival and overall survival, whereas the number of total LNs removed did not affect survival.

CONCLUSIONS

LN metastasis and number of LN metastases confer an independent risk for worse survival in patients with CC. Pelvic lymphadenectomy is important for staging and regional disease control when LNs are involved. If a standardized complete lymphadenectomy is performed, the number of LNs is not a significant factor per se.

Combining the negative lymph nodes count with the ratio of positive and removed lymph nodes can better predict the postoperative survival in cervical cancer patients

BACKGROUND

To evaluate the impacts of the negative lymph nodes (NLNs) count on the prognostic prediction of the ratio of positive and removed lymph nodes (RPL) in cervical cancer patients after radical hysterectomy and pelvic lymphadenectomy (RHPL).

METHODS

The positive and negative lymph node counts were calculated for 609 postoperative cervical cancer patients. The 5-year survival rate (5-YSR) was examined according to clinicopathologic variables. Cox regression was used to identify independent prognostic factors.

RESULTS

The NLNs count cutoffs were determined to be 10 and 25 with 5-YSR of 62.8% and 80.5%. The RPL of 13 patients who had the NLNs count of 10 or fewer was >20%. Among 242 patients who had 10 < NLNs count ≤ 25, 194 without positive nodes had the 5-YSR of 77.8%, 31 with 0% < RPL ≤ 5% had the 5-YSR of 3.2%, 15 with RPL > 20% had died when follow-up was completed. Among 354 patients who had NLNs count >25, 185 without positive nodes had the 5-YSR of 87.6%, 6 with 0% < RPL ≤ 5% had the 5-YSR of 25%, 15 with 5% < RPL ≤ 20% had the 5-YSR of 4.5%, and 2 with RPL >20% had died when follow-up was completed. Furthermore, stage, histologic grade and RPL were independently correlated with overall survival of cervical cancer patients after RHPL in the multivariate analysis.

CONCLUSIONS

RPL was an independent prognostic factor. The NLNs count is a key factor for improvement of survival prediction of RPL in cervical cancer.