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Balaya V, Bresset A, Guani B, Benoit L, Magaud L, Bonsang-Kitzis H, Ngo C, Mathevet P, Lécuru F. Pre-operative surgical algorithm: sentinel lymph node biopsy as predictor of parametrial involvement in early-stage cervical cancer. Int J Gynecol Cancer 2020; 30:1317-1325. [DOI: 10.1136/ijgc-2020-001586] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/09/2020] [Accepted: 06/11/2020] [Indexed: 11/04/2022] Open
Abstract
IntroductionRadical 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.MethodsWe 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.ResultsOf 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.ConclusionsLess 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.
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Benoit L, Balaya V, Guani B, Bresset A, Magaud L, Bonsang-Kitzis H, Ngô C, Mathevet P, Lécuru F. Nomogram Predicting the Likelihood of Parametrial Involvement in Early-Stage Cervical Cancer: Avoiding Unjustified Radical Hysterectomies. J Clin Med 2020; 9:jcm9072121. [PMID: 32635657 PMCID: PMC7408823 DOI: 10.3390/jcm9072121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 06/28/2020] [Accepted: 07/01/2020] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Louise Benoit
- Faculty of Medicine, Paris University, 75006 Paris, France; (V.B.); (F.L.)
- Correspondence: ; Tel.: +33-(0)6-79-16-99-71
| | - Vincent Balaya
- Faculty of Medicine, Paris University, 75006 Paris, France; (V.B.); (F.L.)
- Gynecology Department, Centre Hospitalo-Universitaire Vaudois, 1011 Lausanne, Switzerland; (B.G.); (P.M.)
| | - Benedetta Guani
- Gynecology Department, Centre Hospitalo-Universitaire Vaudois, 1011 Lausanne, Switzerland; (B.G.); (P.M.)
- University of Lausanne, Department of Gynecology and Obstetrics, 1011 Lausanne, Switzerland
| | - Arnaud Bresset
- Gynecology and Obstetrics Department, Beaujon Hospital, 92110 Clichy, France;
| | - Laurent Magaud
- Public Health Department, Hospices Civils de Lyon, 69002 Lyon, France;
| | - Helene Bonsang-Kitzis
- Gynecological and Breast Surgery and Cancerology Center, RAMSAY-Générale de Santé, Hôpital Privé des Peupliers, 75013 Paris, France; (H.B.-K.); (C.N.)
| | - Charlotte Ngô
- Gynecological and Breast Surgery and Cancerology Center, RAMSAY-Générale de Santé, Hôpital Privé des Peupliers, 75013 Paris, France; (H.B.-K.); (C.N.)
| | - Patrice Mathevet
- Gynecology Department, Centre Hospitalo-Universitaire Vaudois, 1011 Lausanne, Switzerland; (B.G.); (P.M.)
- University of Lausanne, Department of Gynecology and Obstetrics, 1011 Lausanne, Switzerland
| | - Fabrice Lécuru
- Faculty of Medicine, Paris University, 75006 Paris, France; (V.B.); (F.L.)
- Breast, Gynecology and Reconstructive Surgery Unit, Curie Institute, 75005 Paris, France
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Song J, Hu Q, Ma Z, Zhang J, Chen T. Value of diffusion-weighted and dynamic contrast-enhanced MR in predicting parametrial invasion in cervical stromal ring focally disrupted stage IB-IIA cervical cancers. Abdom Radiol (NY) 2019; 44:3166-3174. [PMID: 31377834 DOI: 10.1007/s00261-019-02107-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES To compare the effectiveness of diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) imaging in detecting parametrial invasion (PMI) in cervical stromal ring focally disrupted stage IB-IIA cervical cancers. METHODS Eighty-one patients with cervical stromal ring focally disrupted stage IB-IIA cervical cancers (PMI positive, n = 35; PMI negative, n = 46) who underwent preoperative MRI and radical hysterectomy were included in this study. Preoperative clinical variables and MRI variables were analyzed and compared. RESULTS The Ktrans (min, mean, 10%, 25%, 50%, 75%, 90%), Kep (min, 10%, 25%, 50%, 75%, 90%), and Ve (min, 10%, 25%, 50%, 75%, 90%) values of patients with PMI were significantly higher than patients without PMI. The apparent diffusion coefficient (ADC) value did not show statistical difference between the two groups (1.01 ± 0.21 vs. 0.97 ± 0.20 10-3 mm2/s, p = 0.360). Tumor craniocaudal planes were higher in PMI-positive group than PMI-negative group (35.84 ± 15.39 vs. 29.70 ± 11.78 mm, p = 0.048). Tumor craniocaudal planes combined with Kepmin value showed the highest area under the curve (AUCs) of 0.775, with a sensitivity of 72.7% and a specificity of 71.1% (p = 0.000). CONCLUSIONS DCE parameters combined tumor craniocaudal planes may represent a prognostic indicator for PMI in cervical stromal ring focally disrupted IB-IIA cervical cancers.
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Affiliation(s)
- Jiacheng Song
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Road, Nanjing, 210029, China
| | - Qiming Hu
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Zhanlong Ma
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Road, Nanjing, 210029, China
| | - Jing Zhang
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Road, Nanjing, 210029, China.
| | - Ting Chen
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Road, Nanjing, 210029, China.
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Assessment of Parametrial Involvement in Early Stages Cervical Cancer With Preoperative Magnetic Resonance Imaging. Int J Gynecol Cancer 2019; 28:1758-1765. [PMID: 30153214 DOI: 10.1097/igc.0000000000001349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The objective of this study was to develop a predictive model for parametrial involvement (PMI) and to identify low-risk group of PMI in early stages of cervical cancer based on preoperative magnetic resonance imaging (MRI) parameters. METHODS We retrospectively analyzed patients with stages IB1 to IIA2 cervical cancer (N = 1347) who underwent type C radical hysterectomy between 2005 and 2012. Clinical records, preoperative MRI, and its association with pathological data were reviewed. A predictive model for PMI was developed using preoperative MRI parameters for the estimation of its performance. RESULTS Of 1347 patients, 138 (10.2%) had pathological PMI (p-PMI). Multivariate analysis identified the maximal tumor diameter (odds ratio, 2.0; 95% confidence interval, 1.23-3.40; P < 0.001) and PMI (odds ratio, 7.0; 95% confidence interval, 4.49-11.02; P < 0.001) on preoperative MRI (m-PMI) as independent predictive factors for p-PMI. The rate of p-PMI was 1.3% for low-risk patients identified by the current model (maximal tumor diameter ≤2.5 cm and no indication of PMI, n = 448). The 5-year progression-free survival rate was significantly greater (96.7%) in low-risk patients than in those with a maximal tumor diameter greater than 2.5 cm and/or indication of m-PMI (90.8%, P = 0.004). CONCLUSIONS A predictive model for p-PMI was developed in which p-PMI exclusion was set as a maximal tumor diameter less than or equal to 2.5 cm and no indication of m-PMI. Patients with a low risk of m-PMI could be identified so that less radical surgery for stages IB1 to IIA2 cervical cancer could be offered.
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Kubota S, Kobayashi E, Kakuda M, Matsuzaki S, Ueda Y, Yoshino K, Kimura T. Retrospective analysis for predictors of parametrial involvement in IB cervical cancer. J Obstet Gynaecol Res 2018; 45:679-685. [PMID: 30565810 DOI: 10.1111/jog.13855] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/14/2018] [Indexed: 11/26/2022]
Abstract
AIM The use of less radical surgery for early stage cervical cancer has often been discussed. To better determine eligible candidates for less radical surgery, we investigated the risk factors for parametrial involvement (PI). METHODS The study included 193 patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB cervical cancer who were treated with radical hysterectomy and pelvic lymphadenectomy between 2008 and 2014. The patients were divided into two groups according to whether or not the parametrium was involved pathologically. The two groups were compared with regards to clinical and histopathological variables. RESULTS Univariate analysis showed that International Federation of Gynecology and Obstetrics stage, clinical tumor size, depth of stromal invasion, lymphovascular space invasion and pelvic lymph node metastasis were significantly associated with PI (P < 0.05 each). Multivariate analysis showed pelvic lymph node metastasis was an independent risk factor for PI (odds ratio, 10.70; [95% confidence interval, 3.02-48.08]; P = 0.0006). All patients with clinical tumor size less than or equal to 2 cm and negative for pelvic lymph node metastasis had no PI. CONCLUSION Cervical cancer with the tumor less than or equal to 2 cm and negative for pelvic lymph node metastasis seldom has PI. These patients are good candidates for less radical surgery.
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Affiliation(s)
- Satoshi Kubota
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Eiji Kobayashi
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Mamoru Kakuda
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shinya Matsuzaki
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yutaka Ueda
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kiyoshi Yoshino
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka, Japan.,Department of Obstetrics and Gynecology, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Tadashi Kimura
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka, Japan
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Dabi Y, Willecocq C, Ballester M, Carcopino X, Bendifallah S, Ouldamer L, Lavoue V, Canlorbe G, Raimond E, Coutant C, Graesslin O, Collinet P, Bricou A, Huchon C, Daraï E, Haddad B, Touboul C. Identification of a low risk population for parametrial invasion in patients with early-stage cervical cancer. J Transl Med 2018; 16:163. [PMID: 29898732 PMCID: PMC6001133 DOI: 10.1186/s12967-018-1531-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 05/30/2018] [Indexed: 12/11/2022] Open
Abstract
Background Recent studies have challenged radical procedures for less extensive surgery in selected patients with early-stage cervical cancer at low risk of parametrial invasion. Our objective was to identify a subgroup of patients at low risk of parametrial invasion among women having undergone surgical treatment. Methods Data of 1447 patients with cervical cancer treated between 1996 and 2016 were extracted from maintained databases of 10 French University hospitals. Patients with early-stage (IA2–IIA) disease treated by radical surgery including hysterectomy and trachelectomy, were selected for further analysis. The Kaplan–Meier method was used to estimate the survival distribution. A Cox proportional hazards model including all the parameters statistically significant in univariate analysis, was used to account for the influence of multiple variables. Results Out of the 263 patients included for analysis, on final pathology analysis 28 (10.6%) had parametrial invasion and 235 (89.4%) did not. Factors significantly associated with parametrial invasion on multivariate analysis were: age > 65 years, tumor > 30 mm in diameter measured by MRI, lymphovascular space invasion (LVSI) on pathologic analysis. Among the 235 patients with negative pelvic lymph nodes, parametrial disease was seen in only 7.6% compared with 30.8% of those with positive pelvic nodes (p < 0.001). In a subgroup of patients presenting tumors < 30 mm, negative pelvic status and no LVSI, the risk of parametrial invasion fell to 0.6% (1/173 patients). Conclusion Our analysis suggests that there is a subgroup of patients at very low risk of parametrial invasion, potentially eligible for less radical procedures. Electronic supplementary material The online version of this article (10.1186/s12967-018-1531-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yohann Dabi
- Department of Obstetrics and Gynecology, Centre Hospitalier Intercommunal, Créteil, France.,Faculté de Médecine de Créteil UPEC - Paris XII, Créteil, France
| | - Claire Willecocq
- Department of Obstetrics and Gynecology, Centre Hospitalier Intercommunal, Créteil, France.,Faculté de Médecine de Créteil UPEC - Paris XII, Créteil, France
| | - Marcos Ballester
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), University Pierre and Marie Curie, Paris 6, Institut Universitaire de Cancérologie (IUC), Paris, France
| | - Xavier Carcopino
- Department of Obstetrics and Gynecology, Hopital Nord, APHM, Marseilles, France
| | - Sofiane Bendifallah
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), University Pierre and Marie Curie, Paris 6, Institut Universitaire de Cancérologie (IUC), Paris, France
| | - Lobna Ouldamer
- Department of Obstetrics and Gynaecology, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, Tours, France
| | - Vincent Lavoue
- CRLCC Eugène-Marquis, Service de Gynécologie, CHU de Rennes, Université de Rennes 1, Rennes, France
| | - Geoffroy Canlorbe
- Department of Gynaecology and Obstetrics, Pitié Salpetrière University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), University Pierre and Marie Curie, Paris 6, Institut Universitaire de Cancérologie (IUC), Paris, France
| | - Emilie Raimond
- Department of Obstetrics and Gynaecology, Institute Alix de Champagne University Hospital, Reims, France
| | - Charles Coutant
- Centre de lutte contre le cancer Georges François Leclerc, Dijon, France
| | - Olivier Graesslin
- Department of Obstetrics and Gynaecology, Institute Alix de Champagne University Hospital, Reims, France
| | - Pierre Collinet
- Department of Obstetrics and Gynecology, Centre Hospitalier Régional Universitaire, Lille, France
| | - Alexandre Bricou
- Department of Obstetrics and Gynecology, Jean-Verdier University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - Cyrille Huchon
- EA 7285 Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint-Quentin University (UVSQ), 78180, Montigny-le-Bretonneux, France.,Department of Gynaecology and Obstetrics, Intercommunal Hospital Centre of Poissy-Saint-Germain-en-Laye, 78103, Poissy, France
| | - Emile Daraï
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), University Pierre and Marie Curie, Paris 6, Institut Universitaire de Cancérologie (IUC), Paris, France
| | - Bassam Haddad
- Department of Obstetrics and Gynecology, Centre Hospitalier Intercommunal, Créteil, France.,Faculté de Médecine de Créteil UPEC - Paris XII, Créteil, France
| | - Cyril Touboul
- Department of Obstetrics and Gynecology, Centre Hospitalier Intercommunal, Créteil, France. .,Faculté de Médecine de Créteil UPEC - Paris XII, Créteil, France. .,Inserm U965 Laboratory, Angiogenèse et Recherche Translationnelle, Paris, France.
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Appropriate magnetic resonance imaging techniques for gross tumor volume delineation in external beam radiation therapy of locally advanced cervical cancer. Oncotarget 2018. [PMID: 29515794 PMCID: PMC5839375 DOI: 10.18632/oncotarget.24071] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background Accurate delineation of the gross tumor volumes (GTV) is a prerequisite for precise radiotherapy planning and delivery. Different MRI sequences have different advantages and limitations in their ability to discriminate primary cervical tumor from normal tissue. The purpose of this work is to determine appropriate MRI techniques for GTV delineation for external-beam radiation therapy of locally advanced cervical cancer (LACC). Materials and Methods GTVs were delineated on the MRI, CT, and PET images acquired for 23 LACC patients in treatment positions to obtain GTVs on CT (GTV-CT), on various MRI sequences including T1 (GTV-T1), T2 (GTV-T2), T1 with fat suppression and contrast (GTV-T1F+), DWI-ADC (GTV-ADC) and on PET were generated using the threshold of 40% of maximum SUV (GTV-SUV40%) as well as SUV of 2.5 (GTV-SUV2.5). MRI, CT and PET were registered for comparison. The GTVs defined by MRI were compared using the overlap ratio (OR) and relative volume ratio (RVR). The union of GTV-T2 and GTV-ADC was generated to represent the MRI-based GTV (GTV-MRI). Results The differences between GTV-T2 and other MRI GTVs are significant (P < 0.05). The average ORs for GTV-T1, GTV-T1F+, and GTV-ADC related to GTV-T2 were 86.3%, 81.6%, and 61.6% with the corresponding average RVRs 113.8%, 112.3% and 77.2%, respectively. There is no significant difference between GTV-T1 and GTV-T1F+. GTV-ADC was generally smaller than GTV-T2, however, encompassed suspicious regions that are uncovered in GTV-T2 (up to 16% of GTV-T2) because of different imaging mechanisms. There was significant difference between GTV-MRI, GTV-SUV2.5, GTV-SUV40%, and GTV-CT. On average, GTV-MRI is 18.4% smaller than GTV-CT. Conclusions MRI provides improved visualization of disease over CT or PET for cervical cancer. The GTV from the union of GTV-T2 and GTV-ADC provides a reasonable GTV including tumor region defined anatomically and functionally with MRI and substantially reduces the conventional GTV defined on CT.
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Less radical surgery for early-stage cervical cancer: Can conization specimens help identify patients at low risk for parametrial involvement? Gynecol Oncol 2017; 144:290-293. [DOI: 10.1016/j.ygyno.2016.11.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 11/14/2016] [Accepted: 11/16/2016] [Indexed: 11/21/2022]
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Magnetic Resonance Imaging as a Valuable Tool for Predicting Parametrial Invasion in Stage IB1 to IIA2 Cervical Cancer. Int J Gynecol Cancer 2017; 27:332-338. [DOI: 10.1097/igc.0000000000000878] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
ObjectivesThe aims of study were to determine the predictive value of preoperative magnetic resonance imaging (MRI) for parametrial invasion (PMI) and to develop a predictive model for PMI in patients with stage IB1 to IIA2 cervical cancer.MethodsWe retrospectively analyzed patients with stage IB1 to IIA2 cervical cancer (n = 215) who underwent radical hysterectomy between 2003 and 2014. The presence of PMI from postoperative pathological reports and its association with preoperative MRI findings were evaluated. We developed a predictive model for PMI using independent predictive factors identified by logistic regression and estimated its predictive performance.ResultsThirty patients (14.0%) had PMI from postoperative pathological reports. Among the preoperative MRI findings, a greater tumor diameter (4.2 vs 2.0 cm;P <0.001), a larger tumor volume (92.6 vs 12.7 cm3;P< 0.001), the presence of PMI (53.3% vs 8.6%;P< 0.001), and upper vaginal involvement (73.3% vs 22.7%;P< 0.001) were significantly associated with PMI. Multivariate analysis identified tumor volume (odds ratio, 7.0; 95% confidence interval, 2.63–18.53;P< 0.001) and PMI (odds ratio, 6.1; 95% confidence interval, 2.31–15.97;P< 0.001) from preoperative MRI findings as independent predictive factors for PMI. Our predictive model demonstrates that the presence of PMI or a tumor volume of greater than 18.0 cm3has a higher sensitivity (86.7% vs 53.3%) and lower specificity (74.6% vs 91.4%) than the presence of PMI alone. Specifically, the model's negative predictive value was superior to that of PMI only (97.2% vs 92.3%). In the low-risk group, defined as preoperative MRI findings suggesting no PMI and a tumor volume of 18.0 cm3or less, the proportion of false negative cases was just 2.8%.ConclusionsWhen tumor volume with findings suggesting that PMI is considered, preoperative MRI is useful in excluding PMI. A predictive model based on preoperative MRI findings seems to be valuable in identifying potential candidates for less radical surgery in stage IB1 to IIA2 cervical cancer.
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Kong TW, Kim J, Son JH, Kang SW, Paek J, Chun M, Chang SJ, Ryu HS. Preoperative nomogram for prediction of microscopic parametrial infiltration in patients with FIGO stage IB cervical cancer treated with radical hysterectomy. Gynecol Oncol 2016; 142:109-114. [DOI: 10.1016/j.ygyno.2016.05.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 05/02/2016] [Accepted: 05/06/2016] [Indexed: 11/28/2022]
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Bai H, Cao D, Yuan F, Wang H, Xiao M, Chen J, Cui Q, Shen K, Zhang Z. Accuracy of conization procedure for predicting pathological parameters of radical hysterectomy in stage Ia2-Ib1 (≤2 cm) cervical cancer. Sci Rep 2016; 6:25992. [PMID: 27181832 PMCID: PMC4867621 DOI: 10.1038/srep25992] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 04/26/2016] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Huimin Bai
- Department of Obstetrics and Gynecology, Beijing Chao-Yang Hospital affiliated with China Capital Medical University, Beijing, China.,Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences &Peking Union Medical College, Beijing, China
| | - Dongyan Cao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences &Peking Union Medical College, Beijing, China
| | - Fang Yuan
- Department of Obstetrics and Gynecology, the Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| | - Huilan Wang
- Department of Obstetrics and Gynecology, the Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Meizhu Xiao
- Department of Obstetrics and Gynecology, Beijing Chao-Yang Hospital affiliated with China Capital Medical University, Beijing, China
| | - Jie Chen
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences &Peking Union Medical College, Beijing, China
| | - Quancai Cui
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences &Peking Union Medical College, Beijing, China
| | - Keng Shen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences &Peking Union Medical College, Beijing, China
| | - Zhenyu Zhang
- Department of Obstetrics and Gynecology, Beijing Chao-Yang Hospital affiliated with China Capital Medical University, Beijing, China
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Bai H, Yuan F, Wang H, Chen J, Cui Q, Shen K. The potential for less radical surgery in women with stage IA2-IB1 cervical cancer. Int J Gynaecol Obstet 2015; 130:235-40. [PMID: 26070225 DOI: 10.1016/j.ijgo.2015.03.042] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 03/18/2015] [Accepted: 05/20/2015] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Huimin Bai
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Obstetrics and Gynecology, Beijing Chao-Yang Hospital, China Capital Medical University, Beijing, China
| | - Fang Yuan
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Qingdao University Medical College, Qingdao, China
| | - Huilan Wang
- Department of Obstetrics and Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jie Chen
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Quancai Cui
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Keng Shen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Lee JY, Youm J, Kim JW, Cho JY, Kim MA, Kim TH, Suh DH, Lim MC, Park NH, Song YS. Identifying a low-risk group for parametrial involvement in microscopic Stage IB1 cervical cancer using criteria from ongoing studies and a new MRI criterion. BMC Cancer 2015; 15:167. [PMID: 25885786 PMCID: PMC4374417 DOI: 10.1186/s12885-015-1184-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 03/12/2015] [Indexed: 11/10/2022] Open
Abstract
Background There are currently three ongoing studies on less radical surgery in cervical cancer: ConCerv, GOG-278, and SHAPE. The aim of this study was to evaluate the performance of the criteria used in ongoing studies retrospectively and suggest a new, simplified criterion in microscopic Stage IB1 cervical cancer. Methods A retrospective analysis was performed in 125 Stage IB1 cervical cancer patients who had no clinically visible lesions and were allotted based on microscopic findings after conization. All patients had magnetic resonance imaging (MRI) after conization and underwent type C2 radical hysterectomy. We suggested an MRI criterion for less radical surgery candidates as patients who had no demonstrable lesions on MRI. The rates of parametrial involvement (PMI) were estimated for patients that satisfied the inclusion criteria for ongoing studies and the MRI criterion. Results The rate of pathologic PMI was 5.6% (7/125) in the study population. ConCerv and GOG-278 identified 11 (8.8%) and 14 (11.2%) patients, respectively, as less radical surgery candidates, and there were no false negative cases. SHAPE and MRI criteria identified 78 (62.4%) and 74 (59.2%) patients, respectively, as less radical surgery candidates; 67 patients were identified as less radical surgery candidates by both sets of criteria. Of these 67 patients, only one had pathologic PMI with tumor emboli. Conclusions This study suggests that the criteria used in three ongoing studies and a new, simplified criterion using MRI can identify candidates for less radical surgery with acceptable false negativity in microscopic Stage IB1 disease.
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Affiliation(s)
- Jung-Yun Lee
- Department of Obstetrics and Gynecology, Institute of Women's Medical Life Science, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 120-752, Seoul, Korea.
| | - Jina Youm
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 110-744, Seoul, Korea.
| | - Jae-Weon Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 110-744, Seoul, Korea.
| | - Jeong Yeon Cho
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.
| | - Min A Kim
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea.
| | - Tae Hun Kim
- Department of Obstetrics and Gynecology, Korea Cancer Center, Seoul, Korea.
| | - Dong Hoon Suh
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Gyeonggi-di, Korea.
| | - Myong Cheol Lim
- Center for Uterine Cancer and Gynecologic Cancer Branch, National Cancer Center, Goyang, Gyeonggi-do, Korea.
| | - Noh Hyun Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 110-744, Seoul, Korea.
| | - Yong-Sang Song
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 110-744, Seoul, Korea.
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14
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Lee JY, Youm J, Kim JW, Kim K, Kim HJ, Cho JY, Kim MA, Park NH, Song YS. An Alternative Triage Strategy Based on Preoperative MRI for Avoiding Trimodality Therapy in Stage IB Cervical Cancer. Cancer Res Treat 2015; 48:259-65. [PMID: 25797571 PMCID: PMC4720075 DOI: 10.4143/crt.2014.370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 02/24/2015] [Indexed: 01/03/2023] Open
Abstract
Purpose Adjuvant chemoradiation following primary surgery is frequently indicated in patients with stage IB cervical cancer. The aim of this study is to evaluate the role of a magnetic resonance imaging (MRI)-based strategy in avoiding trimodality therapy. Materials and Methods We retrospectively reviewed all patients with stage IB cervical cancer treated initially with primary surgery at Seoul National University Hospital. We suggest an alternative triage strategy in which the primary treatment modality is determined based on preoperative MRI findings. Using this strategy, primary surgery is only indicated when there is no evidence of parametrial involvement (PMI) and lymph node metastasis (LNM) in the MRI results; when there is evidence of either or both of these factors, primary chemoradiation is selected. Assuming that this strategy is applied to our cohort, we evaluate how the rate of trimodality therapy is affected. Results Of the 254 patients in our sample, 77 (30.3%) had at least one category 1 risk factor (PMI, LNM, positive resection margin) upon pathologic examination. If the MRI-based strategy had been applied to our cohort, 168 patients would have undergone primary surgery and 86 would have undergone primary chemoradiation. Only 25 patients (9.8%) would have required trimodality therapy based on an indication of at least one category 1 pathologic risk factor following radical hysterectomy. Conclusion The inclusion of MRI in the decision-making process for primary treatment modality could have reduced the number of patients requiring trimodality therapy based on the indication of a category 1 risk factor from 30.3% to 9.8% in our cohort.
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Affiliation(s)
- Jung-Yun Lee
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Jina Youm
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Weon Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Kidong Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hak Jae Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Yeon Cho
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Min A Kim
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Noh Hyun Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Yong-Sang Song
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
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Kato T, Takashima A, Kasamatsu T, Nakamura K, Mizusawa J, Nakanishi T, Takeshima N, Kamiura S, Onda T, Sumi T, Takano M, Nakai H, Saito T, Fujiwara K, Yokoyama M, Itamochi H, Takehara K, Yokota H, Mizunoe T, Takeda S, Sonoda K, Shiozawa T, Kawabata T, Honma S, Fukuda H, Yaegashi N, Yoshikawa H, Konishi I, Kamura T. Clinical tumor diameter and prognosis of patients with FIGO stage IB1 cervical cancer (JCOG0806-A). Gynecol Oncol 2015; 137:34-9. [PMID: 25662625 DOI: 10.1016/j.ygyno.2015.01.548] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 01/29/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVE In order to determine indications for less radical surgery such as modified radical hysterectomy, the risk of pathological parametrial involvement and prognosis of FIGO stage IB1 cervical cancer patients undergoing standard radical hysterectomy with pre-operatively assessed tumor diameter≤2 cm were investigated. METHODS We conducted a retrospective multi-institutional chart review of patients with FIGO stage IB1 cervical cancer who underwent primary surgical treatment between 1998 and 2002. The eligibility criteria for the analyses were (i) histologically-proven squamous cell carcinoma, adenocarcinoma or, adenosquamous cell carcinoma, (ii) radical hysterectomy performed, (iii) clinical tumor diameter data available by MR imaging or specimens by cone biopsy, and (iv) age between 20 and 70. Based on the clinical tumor diameter, patients were stratified into those with the following tumors: i) 2 cm or less (cT≤2 cm) and ii) greater than 2 cm (cT>2 cm). We expected 5-year OS of ≥95% and parametrial involvement<2-3% for patients with cT≤2 cm who underwent radical hysterectomy. RESULTS Of the 1269 patients enrolled, 604 were eligible for the planned analyses. Among these, 571 underwent radical hysterectomy (323 with cT≤2 cm and 248 with cT>2 cm). Parametrial involvement was present in 1.9% (6/323) with cT≤2 cm and 12.9% (32/248) with cT>2 cm. Five-year overall survivals were 95.8% (95% CI 92.9-97.6%) in cT≤2 cm and 91.9% (95% CI 87.6-94.8%) in cT>2 cm patients. CONCLUSION Patients with cT≤2 cm had lower risk of parametrial involvement and more favorable 5-year overall survival. They could therefore be good candidates for receiving less radical surgery.
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Affiliation(s)
- Tomoyasu Kato
- Department of Gynecologic Oncology, National Cancer Center Hospital, Japan.
| | - Atsuo Takashima
- Japan Clinical Oncology Group Data Center, Multi-institutional Clinical Trial Support Center, National Cancer Center, Japan
| | - Takahiro Kasamatsu
- Department of Gynecologic Oncology, National Cancer Center Hospital, Japan
| | - Kenichi Nakamura
- Japan Clinical Oncology Group Data Center, Multi-institutional Clinical Trial Support Center, National Cancer Center, Japan
| | - Junki Mizusawa
- Japan Clinical Oncology Group Data Center, Multi-institutional Clinical Trial Support Center, National Cancer Center, Japan
| | - Toru Nakanishi
- Department of Gynecologic Oncology, Aichi Cancer Center, Japan
| | | | - Shoji Kamiura
- Department of Gynecology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Japan
| | - Takashi Onda
- Department of Obstetrics and Gynecology, Kitasato University, Japan
| | - Toshiyuki Sumi
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, Japan
| | - Masashi Takano
- Department of Obstetrics and Gynecology, National Defense Medical College, Japan
| | | | - Toshiaki Saito
- Gynecologic Service, National Kyushu Cancer Center, Japan
| | | | | | - Hiroaki Itamochi
- Department of Obstetrics and Gynecology, Tottori University, Japan
| | | | - Harushige Yokota
- Department of Gynecologic Oncology, Saitama Cancer Center, Japan
| | - Tomoya Mizunoe
- Department of Gynecologic Oncology, Kure Medical Center, Japan
| | - Satoru Takeda
- Department of Obstetrics and Gynecology, Juntendo University School of Medicine, Japan
| | - Kenzo Sonoda
- Department of Obstetrics and Gynecology, Kyushu University, Japan
| | - Tanri Shiozawa
- Department of Obstetrics and Gynecology, Shinshu University, Japan
| | - Takayo Kawabata
- Department of Obstetrics and Gynecology, Kagoshima City Hospital, Japan
| | - Shigeru Honma
- Department of Gynecology, Niigata Cancer Center Hospital, Japan
| | - Haruhiko Fukuda
- Japan Clinical Oncology Group Data Center, Multi-institutional Clinical Trial Support Center, National Cancer Center, Japan
| | - Nobuo Yaegashi
- Department of Obstetrics and Gynecology, Tohoku University, Japan
| | | | - Ikuo Konishi
- Department of Gynecology and Obstetrics, Kyoto University, Japan
| | - Toshiharu Kamura
- Department of Obstetrics and Gynecology, Kurume University, Japan
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Lee JY, Youm J, Kim TH, Cho JY, Kim MA, Suh DH, Lim MC, Kim JW, Park NH, Song YS. Preoperative MRI criteria for trials on less radical surgery in Stage IB1 cervical cancer. Gynecol Oncol 2014; 134:47-51. [DOI: 10.1016/j.ygyno.2014.02.042] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Revised: 01/25/2014] [Accepted: 02/03/2014] [Indexed: 11/24/2022]
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17
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Value of diffusion-weighted imaging in predicting parametrial invasion in stage IA2–IIA cervical cancer. Eur Radiol 2014; 24:1081-8. [DOI: 10.1007/s00330-014-3109-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 12/20/2013] [Accepted: 01/27/2014] [Indexed: 10/25/2022]
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18
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Reade CJ, Eiriksson LR, Covens A. Surgery for early stage cervical cancer: How radical should it be? Gynecol Oncol 2013; 131:222-30. [DOI: 10.1016/j.ygyno.2013.07.078] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Revised: 07/03/2013] [Accepted: 07/07/2013] [Indexed: 11/26/2022]
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19
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Gemer O, Eitan R, Gdalevich M, Mamanov A, Piura B, Rabinovich A, Levavi H, Saar-Ryss B, Halperin R, Finci S, Beller U, Bruchim I, Levy T, Ben Shachar I, Ben Arie A, Lavie O. Can parametrectomy be avoided in early cervical cancer? An algorithm for the identification of patients at low risk for parametrial involvement. Eur J Surg Oncol 2013; 39:76-80. [DOI: 10.1016/j.ejso.2012.10.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 10/07/2012] [Accepted: 10/12/2012] [Indexed: 11/16/2022] Open
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20
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A model for prediction of parametrial involvement and feasibility of less radical resection of parametrium in patients with FIGO stage IB1 cervical cancer. Gynecol Oncol 2012; 126:82-6. [DOI: 10.1016/j.ygyno.2012.04.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Revised: 04/10/2012] [Accepted: 04/11/2012] [Indexed: 11/20/2022]
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21
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A case of parametrial lymph node involvement in stage IA2 squamous cell carcinoma of the cervix treated with radical hysterectomy and a review of the literature: a case report. J Low Genit Tract Dis 2012; 16:145-8. [PMID: 22227838 DOI: 10.1097/lgt.0b013e3182350490] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cervical cancer classified as stage IA2 and IB1 according to the International Federation of Gynecology and Obstetrics has historically been treated with radical hysterectomy and bilateral lymph node dissection, but recent recommendations suggest more conservative treatment modalities. We report a woman with stage IA2 cervical cancer at low risk for parametrial spread including no lymphovascular space invasion, clear conization margins, and tumor size less than 2 cm, who underwent radical hysterectomy and was found to have a single positive metastatic parametrial lymph node. This case report is an important reminder that parametrial involvement occurs in low-risk early-stage cervical cancers.
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Loubeyre P, Navarria I, Undurraga M, Bodmer A, Ratib O, Becker C, Petignat P. Is imaging relevant for treatment choice in early stage cervical uterine cancer? Surg Oncol 2012; 21:e1-6. [DOI: 10.1016/j.suronc.2011.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Accepted: 10/08/2011] [Indexed: 10/15/2022]
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