Laparoscopic assisted radical vaginal hysterectomy for cervical carcinoma: morbidity and long-term follow-up

Effect of laparoscopic-assisted transvaginal hysterectomy on wound complications in patients with early stage cervical cancer: A meta-analysis

Laparoscopic-assisted vaginal radical hysterectomy (LARVH) and abdominal radical hysterectomy (ARH) have been widely applied to treat cervical carcinoma. But LARVH and ARH have not been fully investigated in treating cervical carcinoma after injury associated with injury. This research is intended to provide an up-to-date basis for comparing LARVH with ARH in early stage cervical carcinoma. Comparison between LARVH and ARH in cervical carcinoma was carried out through a combination of related research. Eligible articles from databases such as PubMed and Embase were screened using an established search strategy. This report covered the results of LARVH versus ARH in cervical carcinoma. The average difference and the 95% confidence interval (CI) were used for the combination of consecutive variables. The combination of categorical variables was performed with the odds ratio (OR) 95% confidence interval. Through the identification of 1137 publications, eight of them were chosen to be analysed. Among them, 363 were treated with LARVH and 326 were treated with ARH. Eight trials showed that LARVH was associated with a reduced risk of postoperative wound infection than ARH (OR, 0.23; 95% CI, 0.1-0.55, p = 0.0009). Five trials showed that there was no difference in the risk of postoperative bleeding after surgery (OR, 1.17; 95% CI, 0.42-3.29, p = 0.76). We also did not differ significantly in the duration of the surgery (OR, 1.79; 95% CI, -6.58 to 10.15, p = 0.68). So, the two surgical methods differ significantly only in the risk of postoperative wound infection.

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.

Clinicopathological features and immunophenotype of Silva pattern system in endocervical adenocarcinoma

The aim of this study was to investigate the correlation between Silva pattern system and clinicopathological features of endocervical adenocarcinoma. Moreover, it was to find molecular markers helpful for Silva classification, and thus we also explored the expression levels of invasion, adhesion and proliferation biomarkers in cases of Silva non-invasive and invasive types. The survival based on Silva pattern system was analysed by Kaplan-Meier survival analysis, Log-rank test and  a COX risk proportionality model. Sixty samples were chosen to detect the MMP-2, MMP-9, u-PA, E-cadherin, β-catenin, EGF, TGF-α, HDGF, c-Met and RGN expression by immunohistochemistry. Multivariate analysis showed that pattern A/pattern B/pattern C Silva pattern system provided independent risk factors for prognosis. Our results found the levels of MMP-2, MMP-9 and u-PA were significantly higher in endocervical adenocarcinoma with destructive growth than in the  nondestructive group. The levels of E-cadherin and β-catenin were significantly lower in endocervical adenocarcinoma with destructive growth than in the nondestructive group. The levels of EGF, TGF-α and HDGF were significantly higher in endocervical adenocarcinoma with destructive growth than in the nondestructive group. Compared with 'non-invasive/invasive Silva pattern', this study suggests 'pattern A/pattern B/pattern C Silva pattern' could be a better criteria for predicting the prognosis. Furthermore, the dual-marker combination of 'MMP-2 and u-PA' and 'E-cadherin and β-catenin' is very important in the diagnosis of Silva pattern classification.

Using Silva pattern system to predict prognosis and plan treatment of invasive endocervical adenocarcinoma: a single-center retrospective analysis

BACKGROUND

This study evaluated the prognostic value of the Silva pattern system for invasive endocervical adenocarcinoma (EAC) by analysing its association with clinical and pathological features to provide more appropriate clinical management.

METHODS

A retrospective analysis including 63 patients with pathological diagnosis of invasive EAC was performed from March 2011 to December 2016 at our hospital. All pathological slides were reviewed by three senior pathologists, and cases were stratified into patterns A, B, or C by consensus according to the Silva pattern system criteria. Clinicopathological characteristics and follow-up of the three Silva subgroups were analysed.

RESULTS

Silva A, B, and C EAC patients were compared based on tumour size, clinical stage, lymphovascular invasion (LVI), and depth of invasion (DOI). The differences were found to be statistically significant (p < 0.01). There was no statistically significant difference in the proportion of lymph node metastasis among the three groups (p > 0.05) or in the recurrence and mortality rates of patients with Silva A, B, and C EAC (p > 0.05). Single factor analysis showed that tumour size, clinical stage, lymph node metastasis, LVI, and DOI were related to postoperative recurrence, whereas age, Silva classification, and postoperative recurrence were not correlated.

CONCLUSION

The Silva classification system can predict lymph node status and prognosis of invasive EAC, but it cannot be used as an independent indicator. Individualized treatment plans should be adopted for patients with EAC.

Use of Nomogram to Predict the Risk of Lymph Node Metastasis among Patients with Cervical Adenocarcinoma

Background

The objective of this study was to develop a nomogram that can predict lymph node metastasis (LNM) in patients with cervical adenocarcinoma (cervical AC).

Methods

A total of 219 patients with cervical AC who had undergone radical hysterectomy and lymphadenopathy between 2005 and 2021 were selected for this study. Both univariate and multivariate logistic regression analyses were performed to analyze the selected key clinicopathologic features and develop a nomogram and underwent internal validation to predict the probability of LNM.

Results

Lymphovascular invasion (LVI), tumor size ≥ 4 cm, and depth of cervical stromal infiltration were independent predictors of LNM in cervical AC. However, the Silva pattern was not found to be a significant predictor in the multivariate model. The Silva pattern was still included in the model based on the improved predictive performance of the model observed in the previous studies. The concordance index (C-index) of the model increased from 0.786 to 0.794 after the inclusion of the Silva pattern. The Silva pattern was found to be the strongest predictor of LNM among all the pathological factors investigated, with an OR of 4.37 in the nomogram model. The nomogram developed by incorporation of these four predictors performed well in terms of discrimination and calibration capabilities (C − index = 0.794; 95% confidence interval (CI), 0.727–0.862; Brier score = 0.127). Decision curve analysis demonstrated that the nomogram was clinically effective in the prediction of LNM.

Conclusion

In this study, a nomogram was developed based on the pathologic features, which helped to screen individuals with a higher risk of occult LNM. As a result, this tool may be specifically useful in the management of individuals with cervical AC and help gynecologists to guide clinical individualized treatment plan.

Radical Hysterectomy After the LACC Trial: Back to Radical Vaginal Surgery

OPINION STATEMENT

Classical radical vaginal hysterectomy first performed by Anton Pawlik in Prague in 1888 and popularized by Frederic Schauta is now a historical technique virtually abandoned due to painful perineal incision, a high rate of urinary dysfunction, and the inability to perform lymph node assessment. However, the heritage of this approach has been still used and taught in a few centers outside their Austrian birthplace. A combined vaginal and laparoscopic approach was developed in the 1990s by French and German surgeons who designed diverse surgical techniques for which a novel classification is proposed. All these techniques are different from the so-called laparoscopically assisted radical vaginal hysterectomy (LARVH), a term widely used for laparoscopic radical hysterectomies with vaginal extraction of the specimen. Interestingly, after the publication of the LACC trial (Laparoscopic Approach to Cervical Cancer), the radical vaginal approach has found a very timely application. The creation of a vaginal cuff before performing radical laparoscopic hysterectomy described in 2007 by Leblanc as "Schautheim" operation can be used as a protective maneuver to avoid tumor spillage and potentially overturn the negative outcome of minimally invasive surgery in early-stage cervical cancer. As a result, the combination of radical vaginal and laparoscopic steps of surgery is one possible evolution after the LACC trial that needs further investigation. The forgotten vaginal surgical technique needs a specific learning curve. The creation of a vaginal cuff should be mastered by every gynecological oncologist.

Clinical significance of the pattern-based classification in endocervical adenocarcinoma, usual and variants

BACKGROUND

The Silva system is a pattern-based classification system that stratifies endocervical adenocarcinomas (AC) into 3 categories to assess the risk of lymph node (LN) metastasis. This study aimed to evaluate whether this novel risk stratification system is applicable to all endocervical AC, including usual and variant, and to suggest a suitable management plan for cervical AC.

METHODS

We retrospectively retrieved consecutive pathology cases with a final diagnosis of endocervical AC treated via radical hysterectomy and pelvic lymphadenectomy. Specimens were classified by consensus according to the Silva system based on "pattern of invasion" as A, B, or C, further clinical/pathologic features were assessed according to pattern-based classification.

RESULTS

A total of 76 cases of invasive cervical AC were evaluated. Of these, 63 (82.9%) were categorized as usual-type endocervical AC and 13 (17.1%) as special types. Among those with usual and variants, all patients with pattern A tumor had no LN metastasis and did not develop recurrence. Likewise, multivariate analysis revealed that LN metastasis and pattern C or B tumors are significant independent predictors of disease-free survival (DFS). Although pattern A tumors had no LN metastasis, they also developed complications after surgery, similar to pattern B or C tumors.

CONCLUSION

Regardless of histologic subtypes, pattern A tumors had no LN metastasis and no recurrence. Thus, the Silva classification system can influence the clinical management of all types of endocervical AC. Conservative management is reasonable in all patients with endocervical AC with pattern A tumors.

Impact of hospital care volume on clinical outcomes of laparoscopic radical hysterectomy for cervical cancer: A systematic review and meta-analysis

BACKGROUND

In cervical cancer, the impact of hospital volume of laparoscopic radical hysterectomy (LRH) has not been investigated systematically as in ovarian cancer.The aim of this study was to investigate the impact of hospital care volume of LRH on treatment outcomes of patients with cervical cancer.

METHODS

The PubMed, Embase, and Cochrane Library databases were searched with the terms "cervical cancer," "radical hysterectomy," and "laparoscopy." The selection criteria included studies presenting operative outcomes and/or perioperative complications of LRH from high-volume hospitals (HVHs) (≥15 cases/year) and low-volume hospitals (LVHs) (<15 cases/year). Fifty-nine studies including 4367 cases were selected. Linear regression analysis weighted by the average annual case number in each study was performed to evaluate differences between the groups.

RESULTS

In HVH, a higher number of lymph nodes (24.5 vs 21.1; P = .037) were retrieved by LRH in older women (48.4 vs 44.5 years; P = .010) with tendencies of shorter operation time (224.4 vs 256.4 minutes; P = .096) and less blood loss (253.1 vs 322.2 mL; P = .080). Compared with LVH, HVH had fewer patients with stage IA disease (13.8 vs 24.4%; P = .003) and more patients with stage IIA disease (15.3 vs 7.1%; P = .052) with comparable 5-year overall survival (93.1 vs 88.6%; P = .112).

CONCLUSION

HVH is a prognostic factor for operative outcome and perioperative complications in patients with cervical cancer undergoing LRH. The exact effect of hospital volume on survival outcome needs to be evaluated.

Pattern based classification of endocervical adenocarcinoma: a review

While endocervical adenocarcinoma is comprised of several histological subtypes, the most common subtype is human papillomavirus-associated usual type, and management of these tumours is primarily determined by FIGO (International Federation of Gynecology and Obstetrics) stage, a clinically based staging system. Early stage cervical cancer is determined by the pathological evaluation of tumour microscopic measurement (depth of invasion), which can be particularly challenging because of the lack of a defined point of origin. Yet important treatment decisions, cone versus radical surgery, are based on this imperfect system, resulting in overtreatment and related morbidities in many patients for whom it may not be necessary. There is a growing consensus, however, for a more conservative approach, one that reduces morbidity and prevents loss of fertility in these (often young) patients. This movement has been supported, in part, by the development of a morphology based risk stratification system which was devised in order to recognise those tumours that, while invasive, could potentially be treated more conservatively. In this review, we provide the reader with the background and rationale for a more conservative approach in treating endocervical adenocarcinoma, summarise the risk stratification system, and review the system's utility and reproducibility. In addition, we comment on recent updates that attempt to further refine the system. The application of this morphology based classification could help identify a subset of patients with endocervical adenocarcinoma (who would otherwise undergo radical surgery based on FIGO staging alone) that have good clinical outcomes and could be treated more conservatively.

New pattern-based personalized risk stratification system for endocervical adenocarcinoma with important clinical implications and surgical outcome

We present a recently introduced three tier pattern-based histopathologic system to stratify endocervical adenocarcinoma (EAC) that better correlates with lymph node (LN) metastases than FIGO staging alone, and has the advantage of safely predicting node-negative disease in a large proportion of EAC patients. The system consists of stratifying EAC into one of three patterns: pattern A tumors characterized by well-demarcated glands frequently forming clusters or groups with relative lobular architecture and lacking destructive stromal invasion or lymphovascular invasion (LVI), pattern B tumors demonstrating localized destructive invasion (small clusters or individual tumor cells within desmoplastic stroma often arising from pattern A glands), and pattern C tumors with diffusely infiltrative glands and associated desmoplastic response. Three hundred and fifty-two cases were included; mean follow-up 52.8 months. Seventy-three patients (21%) had pattern A tumors; all were stage I and there were no LN metastases or recurrences. Pattern B was seen in 90 tumors (26%); all were stage I and LVI was seen in 24 cases (26.6%). Nodal disease was found in only 4 (4.4%) pattern B tumors (one IA2, two IB1, one IB not further specified (NOS)), each of which showed LVI. Pattern C was found in 189 cases (54%), 117 had LVI (61.9%) and 17% were stage II or greater. Forty-five (23.8%) patients showed LN metastases (one IA1, 14 IB1, 5 IB2, 5 IB NOS, 11 II, 5 III and 4 IV) and recurrences were recorded in 41 (21.7%) patients. This new risk stratification system identifies a subset of stage I patients with essentially no risk of nodal disease, suggesting that patients with pattern A tumors can be spared lymphadenectomy. Patients with pattern B tumors rarely present with LN metastases, and sentinel LN examination could potentially identify these patients. Surgical treatment with nodal resection is justified in patients with pattern C tumors.

New Options in Constipation Management

Constipation is common in the general population and for those on opioids and/or who are suffering from advanced cancer. Self-management consists of dietary changes, exercise, and laxatives. However, responses to self-management efforts are often inadequate to relieve the subjective and objective experience of constipation. Multiple new anti-constipating medications have recently been tested in randomized trials and the following are available commercially: probiotics, prucalopride, lubiprostone, linaclotide, elobixibat, antidepressants, methylnaltrexone, alvimopan, and naloxegol. This review will discuss the evidence-based benefits of these medications and outline an approach to managing constipation.

Patterns of Invasion of Cervical Adenocarcinoma as Predicators of Outcome

In this review, a recently published pattern-based risk stratification system of endocervical adenocarcinoma (EAC) is presented. This novel system evaluates the morphologic features of the tumor and establishes patterns that are associated with a particular tumor behavior. Patients with pattern A EAC do not develop lymph node metastasis, and therefore avoiding lymph node resection in these patients should be considered. These patients also have stage I tumors and conservative surgery would be beneficial to decrease morbidity. Patients with pattern B tumors rarely show metastases to lymph nodes, only if there is lymphovascular invasion, whereas those with pattern C tumors would require aggressive treatment as most lymph node or distant metastases and recurrences were noted in patients with this tumor pattern. Combining this new risk stratification system with an algorithm that surgeons and oncologists could complement to other actionable data would result in a more conservative treatment plan in patients with a new diagnosis of invasive usual-type EAC, as opposed to the current more radical treatment plan. This risk stratification model significantly improves on conventionally used factors such as histologic type, grade, and stage to help manage patients with EAC and identify those in need for aggressive surgical management versus a more conservative approach.

Aspects of Therapy for Cervical Cancer in Germany 2012 - Results from a Survey of German Gynaecological Hospitals

Introduction: In spite of the existence of guidelines and international recommendations, many aspects in the diagnosis, therapy and follow-up of patients with cervical cancer are not based on validated data. A broad spectrum of different opinions and procedures concerning the therapy for patients with cervical cancer is under controversial discussion by the responsible gynaecologists in German hospitals. Methods: The present study is intended to picture the current treatment situation for cervical cancer in Germany. For this purpose a specially developed questionnaire with questions divided into 19 subsections was sent to all 688 gynaecological hospitals in Germany. Results: The response rate to the questionnaire was 34 %. 91 % of the hospitals treated between 0 and 25 patients with cervical cancer per year. 7.5 % treated between 26 and 50 and 1.4 % of the hospitals more than 50 patients per year. The bimanual examination was the most frequently used staging method (98 %); PET-CT was the least used staging method (2.3 %). Interestingly 48 % of the hospitals used surgical staging. The great majority of the hospitals (71 %) used abdominal radical hysterectomy (Wertheim-Meigs operation) to treat their patients. TMMR via laparotomy was used by 13 %. 16 % of the hospitals performed laparoscopic or robot-assisted radical hysterectomies. The sentinel concept was hardly used even in the early stages. It must be emphasised that in 74 % of the hospitals radical hysterectomies were performed even in cases with positive pelvic lymph nodes and in 43 % also in cases with positive paraaortic lymph nodes. The therapy of choice for FIGO IIB cancers is primary radiochemotherapy (RCTX) in 21 % of the hospitals; operative staging followed by radiochemotherapy in 24 % and treatment by radical hysterectomy followed by adjuvant RCTX was employed in this situation by 46 % of the hospitals. In 15-97 % of the hospitals for node-negative and in sano resected patients in stage pT1B1/1B2 after radical hysterectomy, an adjuvant RCTX is recommended when further risk factors exist (LVSI, tumour > 4 cm, age < 40 years, adenocarcinoma, S3). Conclusion: A broad spectrum of differing staging and therapy concepts is in use for patients with cervical cancer in Germany. A standardisation of therapy is needed. An update of national guidelines could help to achieve more transparency and a standardisation of treatment for patients with cervical cancer.

Consensus statement AIGO/SICCR: Diagnosis and treatment of chronic constipation and obstructed defecation (part I: Diagnosis)

Chronic constipation is a common and extremely trou-blesome disorder that significantly reduces the quality of life, and this fact is consistent with the high rate at which health care is sought for this condition. The aim of this project was to develop a consensus for the diagnosis and treatment of chronic constipation and obstructed defecation. The commission presents its results in a “Question-Answer” format, including a set of graded recommendations based on a systematic review of the literature and evidence-based medicine. This section represents the consensus for the diagnosis. The history includes information relating to the onset and duration of symptoms and may reveal secondary causes of constipation. The presence of alarm symptoms and risk factors requires investigation. The physical examination should assess the presence of lesions in the anal and perianal region. The evidence does not support the routine use of blood testing and colonoscopy or barium enema for constipation. Various scoring systems are available to quantify the severity of constipation; the Constipation Severity Instrument for constipation and the obstructed defecation syndrome score for obstructed defecation are the most reliable. The Constipation-Related Quality of Life is an excellent tool for evaluating the patient‘s quality of life. No single test provides a pathophysiological basis for constipation. Colonic transit and anorectal manometry define the pathophysiologic subtypes. Balloon expulsion is a simple screening test for defecatory disorders, but it does not define the mechanisms. Defecography detects structural abnormalities and assesses functional parameters. Magnetic resonance imaging and/or pelvic floor sonography can further complement defecography by providing information on the movement of the pelvic floor and the organs that it supports. All these investigations are indicated to differentiate between slow transit constipation and obstructed defecation because the treatments differ between these conditions.

From laparoscopic assisted radical vaginal hysterectomy to vaginal assisted laparoscopic radical hysterectomy

Radical hysterectomy with pelvic lymphadenectomy is the standard surgical treatment for patients with early stage cervical cancer. The majority of radical hysterectomies are performed with the open technique. However, laparoscopic, combined laparoscopic and vaginal, and robotic-assisted approaches may also be used. Compared with the abdominal radical hysterectomy (ARH), laparoscopic techniques are associated with less blood loss, shorter hospital stay, better cosmesis, and faster recovery. A further breakthrough in laparoscopic technique can only be made if safety and oncological clearance are comparable with ARH. We describe the technique and results of laparoscopic assisted radical vaginal hysterectomy and the transition to vaginal assisted laparoscopic radical hysterectomy.