A prospective study of sentinel lymph node status and parametrial involvement in patients with small tumour volume cervical cancer

Predictors of Non-Sentinel Lymph Node Metastasis in Patients with Positive Sentinel Lymph Node in Early-Stage Cervical Cancer: A SENTICOL GROUP Study

BACKGROUND

The goal of this study was to identify the risk factors for metastasis in the remaining non-sentinel lymph nodes (SLN) in the case of positive SLN in early-stage cervical cancer.

METHODS

An ancillary analysis of two prospective multicentric databases on SLN biopsy for cervical cancer (SENTICOL I and II) was performed. Patients with early-stage cervical cancer (FIGO 2018 IA to IIA1), with bilateral SLN detection and at least one positive SLN after ultrastaging, were included.

RESULTS

405 patients were included in SENTICOL I and Il. Fifty-two patients had bilateral SLN detection and were found to have SLN metastasis. After pelvic lymphadenectomy, metastatic involvement of non-SLN was diagnosed in 7 patients (13.5%). Patients with metastatic non-SLN were older (51.9 vs. 40.8 years, p = 0.01), had more often lympho-vascular space invasion (LVSI) (85.7% vs. 35.6%, p = 0.03), and had more often parametrial involvement (42.9% vs. 6.7%, p = 0.003). Multivariate analysis retained age (OR = 1.16, 95% IC = [1.01-1.32], p = 0.03) and LVSI (OR = 25.97, 95% IC = [1.16-582.1], p = 0.04) as independently associated with non-SLN involvement.

CONCLUSIONS

Age and LVSI seemed to be predictive of non-SLN metastasis in patients with SLN metastasis in early-stage cervical cancer. Larger cohorts are needed to confirm the results and clinical usefulness of such findings.

Does the New FIGO 2018 Staging System Allow Better Prognostic Differentiation in Early Stage Cervical Cancer? A Dutch Nationwide Cohort Study

Simple Summary

The introduction of a revised staging system (FIGO 2018 staging system) for cervical cancer has led to a significant change in stage allocation for patients with early stage disease. It remains unclear how this change should be translated into treatment options, including less extensive surgery. With this Dutch national study we evaluated whether the revised staging system resulted in a more accurate prediction of overall and recurrence free survival compared to the previous FIGO 2009 staging system. In addition, we assessed other factors which may help the paradigm of treatment. We concluded that the revised FIGO 2018 staging system gives a more precise indication of survival outcomes of women with early stage cervical cancer. In addition, we believe that aside from stage, tumor characteristics, such as LVSI, and depth of invasion should be considered when offering patients less radical or less extensive treatment.

Abstract

The FIGO 2018 staging system was introduced to allow better prognostic differentiation in cervical cancer, causing considerable stage migration and affecting treatment options. We evaluated the accuracy of the FIGO 2018 staging in predicting recurrence free (RFS) and overall survival (OS) compared to FIGO 2009 staging in clinically early stage cervical cancer. We conducted a nationwide retrospective cohort study, including 2264 patients with preoperative FIGO (2009) IA1, IA2 and IB1 cervical cancer between 2007–2017. Kaplan–Meier analyses were used to assess survival outcomes. Logistic regression was used to assess risk factors for lymph node metastasis and parametrial invasion. Stage migration occurred in 48% (22% down-staged, 26% up-staged). Survival data of patients down-staged from IB to IA1/2 disease were comparable with FIGO 2009 IA1/2 and better than patients remaining stage IB1. LVSI, invasion depth and parametrial invasion were risk factors for lymph node metastases. LVSI, grade and age were associated with parametrial invasion. In conclusion, the FIGO 2018 staging system accurately reflects prognosis in early stage cervical cancer and is therefore more suitable than the FIGO 2009 staging. However subdivision in IA1 or IA2 based on presence or absence of LVSI instead of depth of invasion would have improved accuracy. For patients down-staged to IA1/2, less radical surgery seems appropriate, although LVSI and histology should be considered when determining the treatment plan.

Nomogram Predicting Parametrial Involvement Based on the Radical Hysterectomy Specimens in the Early-Stage Cervical Cancer

Objective: Radical hysterectomy (RH) is the surgical standard for the treatment of the early-stage cervical cancer (CC). However, this procedure is associated with a high rate of adverse impact on the quality of the life of the patient. Since the rate of parametrial involvement (PI) is low for the patients with the early-stage CC, some authors believe that the patients with the early-stage CC may benefit from the less radical surgery. This study aims to estimate the incidence of the PI in the patients with the early-stage CC and establish a simple nomogram to identify a cohort of the patients with low risk of the PI who may benefit from the less radical surgery.

Methods: All the patients who underwent the RH and pelvic lymphadenectomy were included from 2013 to 2018. The significant independent predictors were identified through the Cox regression analysis and then incorporated into a nomogram to predicate the PI. The calibration plots and receiver operating characteristic (ROC) curves were used to assess the predictive accuracy of the nomogram.

Results: A total of 4,533 patients met the inclusion criteria and 441 women (9.7%) had the PI. The positive PI rate in the ≤2 cm group (1.2%) was significantly lower compared to >2– ≤4 cm (6.2%) or >4 cm (22.4%) groups. The multivariate analyses revealed that tumor size (p = 0.002), lymphovascular space invasion (LVSI) (p = 0.001), vaginal involvement (VI) (p < 0.001), status of the pelvic lymph nodes (PLNs) (p = 0.001), and depth of stromal invasion (DSI) (p < 0.001) were the independent prognostic factors of the PI. Finally, the five variables were combined to construct the nomogram model. The concordance indexes (C-indexes) of the PI were 0.756 (95% CI 0.726–0.786) for the internal validation and 0.729 (95% CI 0.678–0.780) for the external validation. The calibration plots further showed good consistency between the nomogram prediction and the actual observation.

Conclusion: This study confirmed that the patients with tumor size 2 cm or smaller were at very low risk for the PI. If other variables such as negative LVSI, DSI <50%, no VI, and negative PLN were limited, the risk would reduce significantly. Meanwhile, a simple nomogram based on the significant clinicopathological characteristics could be used as a tool for the clinicians to predict the PI among the patients with the early-stage CC, who might benefit from a less radical surgery.

Twenty years of experience with less radical fertility-sparing surgery in early-stage cervical cancer: Oncological outcomes

INTRODUCTION

The standard procedure in cervical cancer is radical hysterectomy (RH) and pelvic lymphadenectomy (PLND). Because of the increasing age of women at childbirth, fertility becomes a major challenge. We present 20 years of experience with two-step less radical fertility-sparing surgery in women with IA1, LVSI positive, IA2 and IB1 (<2 cm, infiltration less than half of stromal invasions.

MATERIALS AND METHOD

Preoperative workout consisted of histopathological diagnosis and magnetic resonance imaging along with ultrasonographic volumetry. We then performed laparoscopic sentinel lymph node mapping (SLNM) with frozen section (FS) followed by PLND and "selective parametrectomy" (removal of afferent lymphatic channels from the paracervix) in case of a negative result. If verified by definitive histopathology, patients were treated by simple trachelectomy (IB1) or large cone (IA1/IA2) biopsy 1 week after primary surgery.

RESULTS

From 1999 to 2018, 91 women were enrolled in the study (median age 29.1 years, range 21-40). Of these 91 women, 51 (56.0%) were nulliparous. The detection rate of SLNs was 100% per patient and the specific side detection rate 96.7%. Positive lymph nodes were diagnosed in nine cases (9.8%). These women then underwent RH. Fertility was spared in 80 women but 4 recurred locally (5.0%). The mortality rate was 0.0%. The median follow-up was 149 months.

CONCLUSION

Less radical fertility-sparing surgery with SLNM is safe in cervical cancers <2 cm at the largest diameter and infiltrating less than half of the cervical stroma. The recurrence rate is acceptable with no mortality. Morbidity with this procedure is low. Extended and accurate follow-up is necessary and human papillomavirus - high risk (HPV-HR tests seem to be useful in such follow-up assessment.

Management of Cervical Cancer in Pregnant Women: A Multi-Center Retrospective Study in China

Background: This retrospective multi-center study aimed to describe the epidemiological characteristics, clinical features, and management of patients with cervical cancer in pregnancy (CCIP) and evaluate maternal and infant outcomes. Methods: The data of patients with CCIP were retrospectively collected from those diagnosed and treated in 17 hospitals in 12 provinces in China between January 2009 and November 2017. The information retrieved included patients' age, clinical features of the tumor, medical management (during pregnancy or postpartum), obstetrical indicators (i.e., gestational age at diagnosis, delivery mode, and birth weight), and maternal and neonatal outcomes. Survival analyses were performed using Kaplan-Meier survival curves and log-rank tests that estimated the overall survival of patients. Results: One-hundred and five women diagnosed with CCIP (median age = 35 years) were identified from ~45,600 cervical cancer patients (0.23%) and 525,000 pregnant women (0.020%). The median gestational age at cancer diagnosis was 20.0 weeks. The clinical-stage of 93.3% of the patients with CCIP was IB1, 81.9% visited the clinic because of vaginal bleeding during pregnancy, and 72.4% had not been screened for cervical cancer in more than 5 years. To analyze cancer treatments during pregnancy, patients were grouped into two groups, termination of pregnancy (TOP, n = 67) and continuation of pregnancy (COP, n = 38). Analyses suggested that the TOP group was more likely to be diagnosed at an earlier gestational stage than the COP group (14.8 vs. 30.8 weeks, p < 0.001). The unadjusted hazard ratio for the COP group's overall survival was 1.063 times that of the TOP group (95% confidence interval = 0.24, 4.71). There were no significant differences between the TOP and COP groups in maternal survival (p = 0.964). Thirty-three of the infants of patients with CCIP were healthy at the end of the follow-up period, with a median age of 18 ± 2.8 months. Conclusions: Most patients with CCIP had not been screened for cervical cancer in over 5 years. The oncologic outcomes of the TOP and COP groups were similar. A platinum-based neoadjuvant chemotherapy regimen could be a favorable choice for the management of CCIP during the second and third trimesters of pregnancy.

Pre-operative surgical algorithm: sentinel lymph node biopsy as predictor of parametrial involvement in early-stage cervical cancer

Introduction

Radical hysterectomy is the gold standard in the management of early-stage cervical cancer. Parametrectomy aims to remove occult disease but is associated with significant surgical morbidity. Avoiding unnecessary parametrectomy in a subset of patients at low risk of parametrial involvement may decrease the incidence of such morbidity. The purpose of this study was to identify patients at low risk of parametrial involvement in early-stage cervical cancer potentially eligible for less radical surgery based on pre-operative criteria and sentinel lymph node (SLN) status.

Methods

We performed an ancillary analysis of data from two prospective trials on sentinel node biopsy for cervical cancer (SENTICOL I and II). Patients with International Federation of Gynecology and Obstetrics (FIGO) IA–IIA cervical cancer who underwent primary radical surgery and bilateral SLN mapping were identified between 2005 and 2012 from 25 French oncologic centers. Patients who underwent pre-operative brachytherapy or did not undergo radical surgery (simple trachelectomy, simple hysterectomy, or lymph node staging only) were excluded.

Results

Of 174 patients who fullfiled the inclusion criteria, 9 patients (5.2%) had parametrial involvement and 24 patients (13.8%) had positive SLN. Most patients had 2018 FIGO stage IB1 disease (86.1%) and squamous cell carcinomas (68.9%). Parametrial involvement was significantly associated with tumor size ≥20 mm on pelvic magnetic resonance imaging (MRI) (adjusted odds ratio (ORa) 9.30, 95% CI 1.71 to 50.57, p=0.01) and micrometastic or macrometastatic SLN (ORa 8.98, 95% CI 1.59 to 50.84, p=0.01). Of 114 patients with tumors <20 mm on pre-operative MRI and negative SLN after ultrastaging, only one patient had parametrial involvement (0.9%). By triaging patients with both of these criteria in a two-step surgical procedure, unjustified and contra-indicated radical hysterectomy would have been avoided in 65.5% and 8.6% of cases, respectively.

Conclusions

Less radical surgery may be an option for patients with bilateral negative SLN after ultrastaging and tumors <20 mm. SLN status should be integrated into the decision-making process for tailored surgery in early-stage cervical cancer.

Nomogram Predicting the Likelihood of Parametrial Involvement in Early-Stage Cervical Cancer: Avoiding Unjustified Radical Hysterectomies

BACKGROUND

We aimed to establish a tool predicting parametrial involvement (PI) in patients with early-stage cervical cancer and select a sub-group of patients who would most benefit from a less radical surgery.

METHODS

We retrospectively reviewed patients from two prospective multicentric databases-SENTICOL I and II-from 2005 to 2012. Patients with early-stage cervical cancer (FIGO 2018 IA with lympho-vascular involvement to IIA1), undergoing radical surgery (hysterectomy or trachelectomy) with bilateral sentinel lymph node (SLN) mapping with no metastatic node or PI on pre-operative imaging, were included.

RESULTS

In total, 5.2% patients (11/211) presented a histologic PI. After univariate analysis, SLN status, lympho-vascular space invasion, deep stromal invasion and tumor size were significantly associated with PI and were included in our nomogram. Our predictive model had an AUC of 0.92 (IC95% = 0.86-0.98) and presented a good calibration. A low risk group, defined according to the optimal sensitivity and specificity, presented a predicted probability of PI of 2%.

CONCLUSION

Patients could benefit from a two-step approach. Final surgery (i.e. radical surgery and/or lymphadenectomy) would depend on the SLN status and the probability PI calculated after an initial conization with bilateral SLN mapping.

Nerve-sparing radical hysterectomy in the precision surgery for cervical cancer

Precision cancer surgery is a system that integrates the accurate evaluation of tumor extension and aggressiveness, precise surgical maneuvers, prognosis evaluation, and prevention of the deterioration of quality of life (QoL). In this regard, nerve-sparing radical hysterectomy has a pivotal role in the personalized treatment of cervical cancer. Various types of radical hysterectomy can be combined with the nerve-sparing procedure. The extent of parametrium and vagina/paracolpium excision and the nerve-sparing procedure are tailored to the tumor status. Advanced magnetic resonance imaging technology will improve the assessment of the local tumor extension. Validated risk factors for perineural invasion might guide selecting treatment for cervical cancer. Type IV Kobayashi (modified Okabayashi) radical hysterectomy combined with the systematic nerve-sparing procedure aims to both maximize the therapeutic effect and minimize the QoL impairment. Regarding the technical aspect, the preservation of vesical nerve fibers is essential. Selective transection of uterine nerve fibers conserves the vesical nerve fibers as an essential piece of the pelvic nervous system comprising the hypogastric nerve, pelvic splanchnic nerves, and inferior hypogastric plexus. This method is anatomically and surgically valid for adequate removal of the parametrial and vagina/paracolpium tissues while preserving the total pelvic nervous system. Local recurrence after nerve-sparing surgery might occur due to perineural invasion or inadequate separation of pelvic nerves cutting through the wrong tissue plane between the pelvic nerves and parametrium/paracolpium. Postoperative management for long-term maintenance of bladder function is as critical as preserving the pelvic nerves.

Pathologic Protocols for Sentinel Lymph Nodes Ultrastaging in Cervical Cancer

CONTEXT.—

Ultrastaging of sentinel lymph nodes (SLNs) is a crucial aspect in the approach to SLN processing. No consensual protocol for pathologic ultrastaging has been approved by international societies to date.

OBJECTIVE.—

To provide a review of the ultrastaging protocol and all its aspects related to the processing of SLNs in patients with cervical cancer.

DATA SOURCES.—

In total, 127 publications reporting data from 9085 cases were identified in the literature. In 24% of studies, the information about SLN processing is entirely missing. No ultrastaging protocol was used in 7% of publications. When described, the differences in all aspects of SLN processing among the studies and institutions are substantial. This includes grossing of the SLN, which is not completely sliced and processed in almost 20% of studies. The reported protocols varied in all aspects of SLN processing, including the thickness of slices (range, 1-5 mm), the number of levels (range, 0-cut out until no tissue left), distance between the levels (range, 40-1000 μm), and number of sections per level (range, 1-5).

CONCLUSIONS.—

We found substantial differences in protocols used for SLN pathologic ultrastaging, which can impact sensitivity for detection of micrometastases and even small macrometastases. Since the involvement of pelvic lymph nodes is the most important negative prognostic factor, such profound discrepancies influence the referral of patients to adjuvant radiotherapy and could potentially cause treatment failure. It is urgent that international societies agree on a consensual protocol before SLN biopsy without pelvic lymphadenectomy is introduced into routine clinical practice.

Gynecologic cancers in pregnancy: guidelines based on a third international consensus meeting

We aimed to provide comprehensive protocols and promote effective management of pregnant women with gynecological cancers. New insights and more experience have been gained since the previous guidelines were published in 2014. Members of the International Network on Cancer, Infertility and Pregnancy (INCIP), in collaboration with other international experts, reviewed existing literature on their respective areas of expertise. Summaries were subsequently merged into a manuscript that served as a basis for discussion during the consensus meeting. Treatment of gynecological cancers during pregnancy is attainable if management is achieved by collaboration of a multidisciplinary team of health care providers. This allows further optimization of maternal treatment, while considering fetal development and providing psychological support and long-term follow-up of the infants. Nonionizing imaging procedures are preferred diagnostic procedures, but limited ionizing imaging methods can be allowed if indispensable for treatment plans. In contrast to other cancers, standard surgery for gynecological cancers often needs to be adapted according to cancer type and gestational age. Most standard regimens of chemotherapy can be administered after 14 weeks gestational age but are not recommended beyond 35 weeks. C-section is recommended for most cervical and vulvar cancers, whereas vaginal delivery is allowed in most ovarian cancers. Breast-feeding should be avoided with ongoing chemotherapeutic, endocrine or targeted treatment. More studies that focus on the long-term toxic effects of gynecologic cancer treatments are needed to provide a full understanding of their fetal impact. In particular, data on targeted therapies that are becoming standard of care in certain gynecological malignancies is still limited. Furthermore, more studies aimed at the definition of the exact prognosis of patients after antenatal cancer treatment are warranted. Participation in existing registries (www.cancerinpregnancy.org) and the creation of national tumor boards with multidisciplinary teams of care providers (supplementary Box S1, available at Annals of Oncology online) is encouraged.

Characteristics of patients with cervical cancer during pregnancy: a multicenter matched cohort study. An initiative from the International Network on Cancer, Infertility and Pregnancy

BACKGROUND

Treatment of cervical cancer during pregnancy is often complex and challenging. This study aimed to analyze current patterns of practice in the management of pregnant patients diagnosed with cervical cancer.

METHODS

This was a matched cohort study comprising patients managed for cervical cancer during pregnancy from six European centers. Patient information was retrieved from the dataset of the International Network for Cancer, Infertility and Pregnancy from 1990 to 2012. Each center matched its patients with two non-pregnant controls for age (±5 years) and International Federation of Gynecology and Obstetrics (FIGO) 2009 stage. Information on age, histological type, grade, lymphovascular space invasion, stage, tumor size, method of diagnosis, site of recurrence, delivery, date of recurrence, and date of death was recorded. Progression-free survival was compared using multivariable Cox proportional hazards regression.

RESULTS

A total of 132 pregnant patients and 256 controls were analyzed. The pregnant patients (median age 34 years, range 21-43) were diagnosed at a median gestational age of 18.4 weeks of pregnancy (range 7-39). Stage distribution during pregnancy was 14.4% for stage IA, 47.0% for IB1, 18.9% for IB2, and 19.7% for II-IV. For treatment during pregnancy, 17.4% of the patients underwent surgery, 16.7% received neoadjuvant chemotherapy, 26.5% delayed their treatment, 12.9% had a premature delivery, and 26.5% had their pregnancy terminated. Median follow-up was 84 months (67 months for pregnant and 95 months for non-pregnant patients). The unadjusted hazard ratio of pregnancy for progression-free survival was 1.18 (95% confidence interval 0.74 to 1.88).

CONCLUSION

Surgery and chemotherapy is increasingly used in the management of pregnant patients with cervical cancer and prognosis is similar to that of non-pregnant patients.

Class I hysterectomy in stage Ia2-Ib1 cervical cancer

Introduction

During the last 3 decades, the standard treatment for stage Ia2-Ib1 cervical cancer has been Piver-Rutledge class II or III radical hysterectomy. However, this surgery is associated with a high rate of urologic morbidity.

Aim

To determine the efficacy of class I radical hysterectomy compared with class III radical hysterectomy in terms of morbidity, overall survival, and patterns of relapse in patients with Ia2-Ib1 cervical cancer undergoing primary surgery.

Material and methods

A total of 101 patients with stage Ia2-Ib1 cervical cancer < 2 cm were randomized to class I and class III hysterectomy groups. Clinical, pathologic, and follow-up data were prospectively collected. Univariate analysis was carried out. Of the total patients, 45 were randomized to class I surgery and 56 to class III surgery. No significant differences were observed in terms of pathologic findings or adjuvant treatment (p > 0.05). The morbidity rates were higher after class III surgery.

Results

The difference in recurrence rate between the class I and class III groups was not statistically significant (p > 0.05). The 5-year overall survival rate was 93% and 91%, respectively (p > 0.05). There were no significant differences in terms of recurrence rate or overall survival among patients with stage Ia2-Ib1 cervical cancer < 2 cm who underwent class I or radical (class III) hysterectomy. Morbidity was proportional to the extent of radicality.

Conclusions

These data confirm the need for reducing surgical radicality in the treatment of patients with early cervical cancer, by tailoring the extent of resection according to the extent of disease.

Factors predicting parametrial invasion in patients with early-stage cervical carcinomas

We aimed to identify factors predicting parametrial invasion in early-stage cervical cancer patients undergoing radical hysterectomy. We recruited women with invasive cervical cancer who underwent radical hysterectomy at a single medical institute from 2000–2011. The clinical and pathological characteristics and outcomes were retrospectively recorded, and the risk factors for parametrial invasion were analyzed. We enrolled 339 patients, including 7 with stage IA1 carcinomas, 10 with stage IA2, 266 with stage IB1, 39 with stage IB2, 14 with stage IIA1, and 3 with stage IIA2. The majority (237/339, 69.9%) had squamous cell carcinoma, while 32 (12.4%) had parametrial invasion. The 16 patients with stage IB1 tumors and parametrial invasion were older (55.9±9.5vs. 49.0±9.9 years, p = 0.005, Mann-Whitney U test), and had deeper cervical stromal invasion (9.59±4.87 vs. 7.47±5.48 mm, p = 0.048, Mann-Whitney U test), larger tumor size (2.32±1.15 vs. 1.74±1.14cm, p = 0.043, Mann-Whitney U test), higher incidences of lymphovascular space invasion (87.5% vs. 28.8%, p<0.001, chi-square test), and greater lymph node metastasis (68.8% vs. 10.8%, p<0.001, chi-square test) than the 260 patients without parametrial invasion. Among the patients with stage IB1 tumor size >2 cm,10% had parametrial invasion and 24.2% had lymph node metastasis compared with only 4% and 9.4% of stage IB1 patients with a tumor size <2 cm, respectively. Only one (0.9%) of the 109 patients aged less than 50 years had parametrial invasion compared with 6 (9.7%) of the 62 patients aged over 50 years. Patients with stage IA2 and IB1 tumors <2 cm may not need radical hysterectomy owing to the low incidence of parametrial invasion.

A Prognostic Nomogram for Cervical Cancer after Surgery from SEER Database

Background: To develop and validate a nomogram based on the conventional measurements and log of odds between the number of positive lymph node and the number of negative lymph node (LODDS) in predicting prognosis for cervical cancer patients after surgery. Methods: A total of 8202 cervical cancer patients with pathologically confirmed between 2004 and 2014 were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. All the patients were divided into training (n=3603) and validation (n=4599) cohorts based on consecutive age of diagnosis. Demographic and clinical pathological factors were evaluated the association with overall survival (OS). Parameters significantly correlating with OS were used to create a nomogram. An independent external validation cohort was subsequently used to assess the predictive performance of the model. Results: In the training set, age at diagnosis, race, marital status, tumor grade, FIGO stage, histology, size and LODDS were correlated significantly with outcome and used to develop a nomogram. The calibration curve for probability of survival showed excellent agreement between prediction by nomogram and actual observation in the training cohort, with a bootstrap-corrected concordance index of 0.749(95% CI, 0.731-0.767). Importantly, our nomogram performed favorably compared to the currently utilized FIGO model, with concordance indices of 0.786 (95% CI, 0.764 to 0.808) vs 0.685 (95%CI, 0.660 to 0.710) for OS in the validation cohort, respectively. Conclusions: By incorporating LODDS, our nomogram may be superior to the currently utilized FIGO staging system in predicting OS in cervical cancer patients after surgery.

Can simple trachelectomy or conization show comparable survival rate compared with radical trachelectomy in IA1 cervical cancer patients with lymphovascular space invasion who wish to save fertility? A systematic review and guideline recommendation

OBJECTIVE

This study aims to analyze the published literatures on the effect of less radical fertility-preserving procedures, such as conization or simple trachelectomy, on oncological outcomes in IA1 cervical cancer patients with lymphovascular space invasion (LVSI) through a systematic-review.

METHODS

The EMBASE and MEDLINE databases and Cochrane Library were searched for published studies reporting the oncological outcomes of conization/simple trachelectomy in these patients, through April 2017. The endpoints were recurrence and mortality rates. Data were presented as per the Meta-analysis Of Observational Studies in Epidemiology checklist. Practice guidelines were generated via the Grading of Recommendation, Assessment, Development and Evaluation system.

RESULTS

From 6,755 records, 94 full-texts articles were reviewed for eligibility, and five studies were included in this systematic review. All included studies were nonrandomized studies: two case-control studies comparing conization (n = 14) with hysterectomy (n = 24), and the other three were interrupted time series including conization (n = 20) and simple vaginal trachelectomy (n = 59). During the median follow-up duration of 43 months, no recurrence was reported in both conization and simple trachelectomy groups in IA1 patients with LVSI. From three studies reporting the fertility outcomes, the rates of pregnancy, live birth, preterm delivery, and second-trimester miscarriage were 73% (35/48), 64% (32/50), 10% (5/48), and 6% (3/48), respectively.

CONCLUSION

Results suggest that simple trachelectomy or conization could be performed for IA1 cervical cancer patients with LVSI who want to preserve fertility, although these results are only based on a small number of nonrandomized studies (recommendation grade 2 = weak; evidence level D = very low). Further randomized trials with long-term study period are needed to address this issue.

Treatment of gynecological cancers diagnosed during pregnancy

Because of a notable increase in age at delivery, the incidence of malignancy diagnosed during pregnancy has substantially increased. This review aims to summarize the literature and expert knowledge on gynecologic cancers diagnosed in pregnancy regarding epidemiology, examination and staging procedures, description of treatment modalities and management of gynecological malignancies with special interest in cervical and ovarian cancer. Thorough attention is paid to the surgery and chemotherapy administration for early-stage cervical cancer diagnosed during pregnancy.

Occult invasive cervical cancer after simple hysterectomy: a multi-center retrospective study of 89 cases

Background

Occult invasive cervical cancer (OICC) is sometimes incidentally found in surgical specimens after a simple hysterectomy (SH). This study was aimed at identifying a subset of patients with OICC who have a favorable prognosis. This patient group may not require adjuvant radiotherapy and other procedures.

Methods

The medical records of women in whom OICC was detected after an inadvertent SH were retrospectively reviewed. The relevant data, including clinicopathological characteristics, treatment and clinical outcome were evaluated. The primary and secondary endpoints were overall survival (OS) and relapse-free survival (RFS), respectively.

Results

Eighty-nine patients who met the inclusion criteria were included for analysis, and the risk of OICC was found to be 1.9 %. Finding an invasive cancer in a hysterectomy specimen after a conization procedure that shows positive margins was the most common reason (41.6 %) for the performance of inadvertent SH. In the univariate analysis, a tumor width > 20 mm, deep stromal invasion, and lymph node metastasis (LNM) were adversely associated with relapse (P < 0.001, < 0.001, and = 0.001, respectively) and survival (P = 0.003, 0.004, and 0.027, respectively), although these parameters were not independently associated with patient prognoses in the multivariate analysis. In patients with a tumor width ≤ 20 mm and superficial stromal invasion in the observation subgroup, the 5-year RFS and 5-year OS were both 100 %, whereas they were 57.1 % and 66.7 %, respectively, in patients with a tumor size > 20 mm and deep stromal invasion in the radiotherapy or chemotherapy subgroup (P < 0.001, and = 0.008, respectively).

Conclusions

Simple observation after a lymphadenectomy procedure may be feasible in OICC patients with a tumor width ≤ 20 mm, superficial stromal invasion, a negative section margin in hysterectomy specimens, and no LNM.

Significance of the Factors Associated With Parametrial Involvement in Stage IB to IIA Cervical Cancer

Objective

The aim was to explore the factors associated with parametrial involvement (PI) in patients with stage IB to IIA cervical cancer.

Materials and Methods

Medical records of 507 patients were reviewed. Nine factors were analyzed by univariate analysis using χ2 test and multivariate analysis using logistic regression analysis to screen for factors associated with PI.

Results

There were 46 patients with PI. Result of univariate analysis suggested depth of stromal invasion, lymphovascular space invasion (LVSI), and lymph node metastasis, and uterine involvement was associated with PI (P < 0.05 for all). The multivariate analysis model included factors that could be diagnosed by a cone biopsy, and the result suggested nonsquamous histological type and LVSI was the independent factor of PI. The incidence of PI in the patients with no LVSI and squamous cancer was 6.97%. When the patients with inner 1/3 stromal invasion were stratified into those with squamous cancer and no LVSI, the incidence of PI was 1.17%. The incidence of PI in the patients with LVSI and nonsquamous cancer was 33.33%.

Conclusions

The patients with inner 1/3 stromal invasion, no LVSI, and squamous histological type may be considered for less radical surgery. The patients with nonsquamous histological type and LVSI may be considered for radical hysterectomy including a complete resection of parametrium.

Accuracy of conization procedure for predicting pathological parameters of radical hysterectomy in stage Ia2-Ib1 (≤2 cm) cervical cancer

The accuracy of conization for the prediction of radical hysterectomy (RH) pathological variables in patients with stage Ia2 to Ib1 (≤2 cm) cervical cancer was retrospectively evaluated in the present study. Endocervical or deep resection margin (RM) involvement in the conization specimens was found to be independently associated with residual disease in the hysterectomy specimens (P < 0.001, = 0.003, respectively). When a tumor width of >20 mm in the final RH pathology analysis was predicted by a tumor width of >2 mm or involvement of endocervical or deep RMs in the conization specimens, the sensitivity and negative predictive value (NPV) of conization were 98.2% and 95.2%, respectively. In addition, when deep stromal invasion in the final RH pathology analysis was predicted by deep stromal invasion or involvement of the endocervical or deep RMs in the conization specimens, the sensitivity and NPV of conization were 98.4% and 95.8%, respectively. The sensitivity and NPV of this prediction model for identifying LVSI in the final RH pathology analysis were both 100%. These findings suggest that conization variables and endocervical and deep resection margin statuses can be analyzed to effectively predict RH pathological parameters.

Can radical parametrectomy be omitted in occult cervical cancer after extrafascial hysterectomy?

BACKGROUND

Occult invasive cervical cancer discovered after simple hysterectomy is not common, radical parametrectomy (RP) is a preferred option for young women. However, the morbidity of RP was high. The aim of our study is to assess the incidence of parametrial involvement in patients who underwent radical parametrectomy for occult cervical cancer or radical hysterectomy for early-stage cervical cancer and to suggest an algorithm for the triage of patients with occult cervical cancer to avoid RP.

METHODS

A total of 13 patients with occult cervical cancer who had undergone RP with an upper vaginectomy and pelvic lymphadenectomy were included in this retrospective study. Data on the clinicopathologic characteristics of the cases were collected. The published literature was also reviewed, and low risk factors for parametrial involvement in early-stage cervical cancer were analyzed.

RESULTS

Of the 13 patients, 9 had a stage IB1 lesion, and 4 had a stage IA2 lesion. There were four patients with grade 1 disease, seven with grade 2 disease, and two with grade 3 disease. The median age of the entire patients was 41 years. The most common indication for extrafascial hysterectomy was cervical intraepithelial neoplasia 3. Three patients had visible lesions measuring 10-30 mm, in diameter and ten patients had cervical stromal invasions with depths ranging from 4 to 9 mm; only one patient had more than 50% stromal invasion, and four patients had lymph-vascular space invasion (LVSI). Perioperative complications included intraoperative bowel injury, blood transfusion, vesico-vaginal fistula, and ileus (1 case for each). Postoperative pathologic examination results did not show residual disease or parametrial involvement. One patient with positive lymph nodes received concurrent radiation therapy. Only one patient experienced recurrence.

CONCLUSIONS

Perioperative complications following RP were common, whereas the incidence of parametrial involvement was very low among selected early-stage cervical cancer patients. Based on these results, we thought that patients with very low-risk parametrial involvement(tumor size ≤ 2 cm, no LVSI, less than 50% stromal invasion, negative lymph nodes) may benefit from omitting RP. Further prospective data are warranted.

The potential for less radical surgery in women with stage IA2-IB1 cervical cancer

OBJECTIVE

To identify a subset of patients with stage IA2-IB1 cervical cancer and small tumors (≤2cm) who could be suitable for less radical surgery.

METHODS

In a retrospective study, the medical records of women treated at nine hospitals in China were reviewed. Included women had undergone radical hysterectomy and pelvic lymph node dissection. The clinicopathologic factors associated with uterine isthmus invasion (UII), vaginal invasion (VI), parametrial invasion (PI), lymph node metastasis (LNM), and prognosis were analyzed.

RESULTS

Overall, 1632 women were included. Tumor size greater than 2cm (measured postoperatively) was an independent predictor of VI (P=0.002), PI (P=0.001), and UII (P=0.021). Squamous cell carcinoma and superficial stromal invasion were associated with a low frequency of UII (P<0.001 for both). Among patients with adenocarcinoma, deep stromal invasion and lymphovascular space involvement (LVSI) were independently associated with UII (P=0.006 and P=0.004, respectively). Grade 2/3 disease (P=0.009), deep stromal invasion (P=0.015), and LVSI (P<0.001) were independently associated with LNM. LNM was the only independent adverse factor for survival (P<0.001).

CONCLUSION

Women with stage IA2-IB1 cervical cancer with low-risk factors could be candidates for large-scale prospective clinical trials of less radical surgery and lymphadenectomy omission.

Sentinel node biopsy for lymph nodal staging of uterine cervix cancer: a systematic review and meta-analysis of the pertinent literature

BACKGROUND

We reviewed the available literature on the accuracy of sentinel node mapping in the lymph nodal staging of uterine cervical cancers.

METHODS

MEDLINE and Scopus were searched by using "sentinel AND (cervix OR cervical)" as key words. Studies evaluating the accuracy of sentinel node mapping in the lymph nodal staging of uterine cervical cancers were included if enough data could be extracted for calculation of detection rate and/or sensitivity.

RESULTS

Sixty-seven studies were included in the systematic review. Pooled detection rate was 89.2% [95% CI: 86.3-91.6]. Pooled sensitivity was 90% [95% CI: 88-92]. Sentinel node detection rate and sensitivity were related to mapping method (blue dye, radiotracer, or both) and history of pre-operative neoadjuvant chemotherapy. Sensitivity was higher in patients with bilaterally detected pelvic sentinel nodes compared to those with unilateral sentinel nodes. Lymphatic mapping could identify sentinel nodes outside the routine lymphadenectomy limits.

CONCLUSION

Sentinel node mapping is an accurate method for the assessment of lymph nodal involvement in uterine cervical cancers. Selection of a population with small tumor size and lower stage will ensure the lowest false negative rate. Lymphatic mapping can also detect sentinel nodes outside of routine lymphadenectomy areas providing additional histological information which can improve the staging. Further studies are needed to explore the impact of sentinel node mapping in fertility sparing surgery and in patients with history of neoadjuvant chemotherapy.

[Sentinel lymph node in low stage cervical cancers. Current data. Quality assurance. Prospects]

Sentinel node biopsy appears as a promising technique for the assessment of nodal disease in early cervical cancers. Selection of a population with a low risk of nodal metastasis, a minimal training, and simple rules allow a low false negative rate. Sentinel node biopsy provides supplementary information, such as anatomical information (nodes outside of routine lymphadenectomy areas) and histological information (isolated tumors cells and micrometastases).

Surgical treatment of stage IA2 cervical cancer

BACKGROUND

Cervical cancer is the second most common cancer among women up to 65 years of age and is the most frequent cause of death from gynaecological cancers worldwide. Women with International Federation of Gynecology and Obstetrics (FIGO) stage IA2 cervical cancer have measured stromal invasion (when the cancer breaks through the basement membrane of the epithelium) of greater than 3 mm and no greater than 5 mm in depth with a horizontal surface extension of no more than 7 mm. For stage IA2 disease, radical hysterectomy with pelvic lymphadenectomy or radiotherapy is the standard treatment. In order to avoid complications of more radical surgical methods, less invasive options, such as simple hysterectomy, simple trachelectomy or conisation, with or without pelvic lymphadenectomy, may be feasible for stage IA2 disease, considering the relative low risk of local or distant metastatic disease. The evidence for less radical tumour excision and for the role of systematic lymphadenectomy in stage IA2 cervical cancer is not clear.

OBJECTIVES

To evaluate the effectiveness and safety of less radical surgery in stage IA2 cervical cancer.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group trials register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE up to September 2013. We also searched registers of clinical trials and abstracts of scientific meetings.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs) that compared surgical techniques in women with stage IA2 cervical cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. We found no trials and, therefore, no data were analysed.

MAIN RESULTS

The search strategy identified 982 unique references, which were all excluded on the basis of title and abstract because it was clear that they did not meet the inclusion criteria. We identified one relevant large ongoing trial, so it is anticipated that we will be able to add this evidence to this review in the future.

AUTHORS' CONCLUSIONS

We found no evidence to inform decisions about different surgical techniques in women with stage IA2 cervical cancer. In the future, the results of one large ongoing RCT should allow comparison of different types of surgery.

Current status of sentinel lymph node mapping in the management of cervical cancer

The status of regional lymph nodes is the most important prognostic factor in early cervical cancer patients. Pelvic lymph node dissections are routinely performed as a part of standard surgical treatment. Systematic pelvic lymphadenectomy is associated with short- and long-term morbidities. This review discusses single components of the sentinel lymph node mapping (SLNM) technique and results of the detection of sentinel lymph nodes. SLNM biopsy performed by an experienced team for small volume tumors (<2 cm) has high specific side detection rate, excellent negative-predictive value and high sensitivity. Uncommon lymphatic drainage has been reported in 15% of cervical cancer patients. There is sufficient data now to suggest that SLNM with 99mTc plus blue dye in the hands of a surgeon with extensive experience should prove to be an important part of individualized cervical cancer surgery and increase the safety of less radical or fertility-sparing surgery.

Fertility-sparing surgery for early-stage cervical cancer

Nowadays cervical cancer is diagnosed in many women who still want to have children. This led to the need to provide fertility-sparing treatments. The main goal is to maintain reproductive ability without decreasing overall and recurrence-free survival. In this article, we review data on procedures for fertility preservation, namely, vaginal and abdominal trachelectomy, less invasive surgery and neoadjuvant chemotherapy. For each one, oncological and obstetrical outcomes are analyzed. Comparing to traditionally offered radical hysterectomy, the overall oncologic safety is good, with promising obstetrical outcomes.

Unusual localizations of sentinel lymph nodes in early stage cervical cancer: a review

OBJECTIVE

The aim of this study was to systematically determine the frequency of unusual localizations of sentinel lymph node in patients with early stage cervical cancer.

METHODS

We performed a comprehensive computer literature search of English and French language studies in human subjects on sentinel node procedures in PUBMED database up to December 2010. For each article two reviewers independently performed data extraction using a standard form to determine the route of unusual lymphatic spread of sentinel procedures in cervical cancer.

RESULTS

According to our search, 83.7% of detected sentinel lymph nodes in patients with cervical cancer were in expected localizations (i.e., external iliac, obturator, internal iliac or interiliac). The unusual localizations were: 6.6% in the common iliac chain, 4.31% parametrial, 1.26% sacral, 2% in the lower para-aortic area and 0.07% in the inguinal chain.

CONCLUSION

The unusual localizations of sentinel lymph nodes impose to the gynecologic surgeons to be able to perform lymph node dissection in all the territories potentially affected.