Preoperative MRI criteria for trials on less radical surgery in Stage IB1 cervical cancer

Retrospective analysis of the incidence and predictive factors of parametrial involvement in FIGO IB1 cervical cancer

BACKGROUND AND OBJECTIVES

Radical surgery is the standard primary treatment for patients with stage IB1 (FIGO 2009 staging) cervical cancer due to latent parametrial involvement. Recent studies suggested that less radical surgery was applicable for patients with no or low risk of parametrial involvement. In this study, we aimed to determine the incidence and possible predictive factors of parametrial involvement in patients with stage IB1 cervical cancer so as to evaluate whether less radical surgery was suitable for selected patients.

METHODS

Clinical data of patients who underwent type C radical hysterectomy with pelvic lymphadenectomy and diagnosed as stage IB1 cervical cancer at Union Hospital, Wuhan, China from October 2014 to December 2017 were collected and analysed retrospectively. The incidence of parametrial involvement was calculated and the risk factors for parametrial involvement were evaluated by univariate and multivariate logistic regression.

RESULTS

Among 282 eligible patients, 33 (11.7%) had parametrial involvement. Postmenopause, lymphovascular space invasion (LVSI), lymph node metastasis (LNM), deep stromal invasion (outer 1/3) and tumor size larger than 2 cm were statistically associated with parametrial involvement. Multivariate analysis showed that LNM (OR = 11.431; 95%CI: 3.455 - 37.821), deep stromal invasion (OR = 6.080; 95%CI: 1.814 - 20.382) and LVSI (OR = 7.147; 95%CI: 1.863-27.411) remained as independent risk factors for parametrial involvement in patients with stage IB1 cervical cancer.

CONCLUSIONS

The incidence of parametrial involvement in stage IB1 cervical cancer is non-negligible. Only LNM, LVSI and deep stromal invasion were independent predictors, which were not easy to evaluate accurately before surgery. Less radical surgery requires modified pre-treatment evaluation methods and prospective data support.

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.

Preoperative prediction of parametrial invasion in early-stage cervical cancer with MRI-based radiomics nomogram

PURPOSE

To develop and identify a MRI-based radiomics nomogram for the preoperative prediction of parametrial invasion (PMI) in patients with early-stage cervical cancer (ECC).

MATERIALS AND METHODS

All 137 patients with ECC (FIGO stages IB-IIA) underwent T2WI and DWI scans before radical hysterectomy surgery. The radiomics signatures were calculated with the radiomics features which were extracted from T2WI and DWI and selected by the least absolute shrinkage and selection operation regression. The support vector machine (SVM) models were built using radiomics signatures derived from T2WI and joint T2WI and DWI respectively to evaluate the performance of radiomics signatures for distinguishing patients with PMI. A radiomics nomogram was drawn based on the radiomics signatures with a better performance, patient's age, and pathological grade; its discrimination and calibration performances were estimated.

RESULTS

For T2WI and joint T2WI and DWI, the radiomics signatures yielded an AUC of 0.797 (95% CI, 0.682-0.911) vs 0.946 (95% CI, 0.899-0.994), and 0.780 (95% CI, 0.641-0.920) vs 0.921 (95% CI, 0.832-1) respectively in the primary and validation cohorts. The radiomics nomogram, integrating the radiomics signatures from joint T2WI and DWI, patient's age, and pathological grade, showed excellent discrimination, with C-index values of 0.969 (95% CI, 0.933-1) and 0.941 (95% CI, 0.868-1) in the primary and validation cohorts, respectively. The calibration curve showed a good agreement.

CONCLUSIONS

The radiomics nomogram performed well for the preoperative prediction of PMI in patients with ECC and may be used as a supplementary tool to provide individualized treatment plans for patients with ECC.

KEY POINTS

• No previously reported study that has utilized radiomics nomogram to preoperatively predict PMI for patients with ECC. • Radiomics model involves radiomics features extracted from joint T2WI and DWI which characterize the heterogeneity between tumors in patients with ECC. • Radiomics nomogram can assist clinicians with individualized treatment decision-making for patients with ECC.

Diagnostic Performance of MRI for Assessing Parametrial Invasion in Cervical Cancer: A Head-to-Head Comparison between Oblique and True Axial T2-Weighted Images

OBJECTIVE

To directly compare the diagnostic performance of true and oblique axial T2-weighted imaging (T2WI) for assessing parametrial invasion (PMI) in cervical cancer.

MATERIALS AND METHODS

This retrospective study included 71 women with treatment-naive cervical cancer who underwent MRI that included both oblique and true axial T2WI, followed by radical hysterectomy. Two blinded radiologists (Radiologist 1 and Radiologist 2) independently assessed the presence of PMI on both sequences using a 5-point Likert scale. Receiver operating characteristic (ROC) curve analysis was performed, with a subgroup analysis for tumors sized > 2.5 cm and ≤ 2.5 cm in diameter. Inter-reader agreement was assessed with kappa (k) statistics.

RESULTS

At hysterectomy, 15 patients (21.1%) had PMI. For Radiologist 1, the area under the ROC curve (AUC) was greater for oblique axial than for true axial T2WI {0.941 (95% confidence interval [CI] = 0.858-0.983) vs. 0.917 (95% CI = 0.827-0.969), p = 0.027}. The difference was not significant for Radiologist 2 (0.879 [95% CI = 0.779-0.944] vs. 0.827 [95% CI = 0.719-0.906], p = 0.153). For tumors > 2.5 cm, AUC was greater with oblique than with true axial T2WI (0.906 vs. 0.860, p = 0.046 for Radiologist 1 and 0.839 vs. 0.765, p = 0.086 for Radiologist 2). Agreement between the radiologists was almost perfect for oblique axial T2WI (k = 0.810) and was substantial for true axial T2WI (k = 0.704).

CONCLUSION

Oblique axial T2WI potentially provides greater diagnostic performance than true axial T2WI for determining PMI, particularly for tumors > 2.5 cm. The inter-reader agreement was greater with oblique axial T2WI.

Predictors for pathological parametrial invasion in clinical stage IIB cervical cancer

OBJECTIVE

To examine predictors of pathological parametrial invasion in clinical stage IIB cervical cancer, and to examine prognostic factors in pathological stage IIB disease.

METHODS

This study is an ancillary analysis of a nation-wide retrospective cohort examining 6,003 clinical stage IB-IIB cervical cancers. Women with clinical stage IIB disease who underwent primary radical hysterectomy with lymphadenectomy were examined (n = 714). Multivariate analysis was performed to identify independent clinico-pathological factors for pathological parametrial invasion and to identify independent prognostic factors in pathological stage IIB disease.

RESULTS

Parametrial invasion was identified on the surgical specimen in 400 cases (56.0%, 95% confidence interval 52.4-59.7). On multivariate analysis, deep stromal invasion (DSI, adjusted-OR 3.922), multiple pelvic nodal metastases (adjusted-OR 3.266), lympho-vascular space invasion (adjusted-OR 2.333), and uterine corpus invasion (adjusted-OR 1.656) remained independent tumor factors for pathological parametrial invasion. In classification-tree models, tumors with DSI and multiple pelvic nodal metastases had the highest incidence of pathological parametrial invasion (75.0-87.7%); contrary, tumors without DSI had the lowest incidence (21.9%). Among patients with pathological stage IIB disease, the absolute difference in 5-year disease-free survival rates was 57.2%, ranging between 80.9% in those with squamous histology with none/single pelvic nodal metastasis and 23.7% in those with non-squamous histology with multiple pelvic nodal metastases.

CONCLUSION

In clinical stage IIB cervical cancer, accuracy for pathological parametrial invasion is low-modest. With absence of DSI, only one in five clinical stage IIB diseases has pathological stage IIB disease. Survival of pathological stage IIB varies widely and is largely dependent on nodal factors.

Pretreatment neutrophil-lymphocyte and platelet-lymphocyte ratio predict clinical outcome and prognosis for cervical Cancer

Variations in systemic inflammatory response biomarker levels have been associated with adverse clinical outcome in various malignancies. In this study, we aimed to evaluate the predictive and prognostic role of the pretreatment neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in cervical cancer. We retrospectively investigated 616 patients who underwent initial radical hysterectomy with pelvic lymphadenectomy for cervical cancer between July 2012 and December 2014 in China. Their clinical and histopathological markers and complete blood counts were obtained and analyzed. Then we chose the group of 339 of the total 616 patients who were not combined preoperative radiotherapy or chemotherapy for the survival analysis. Prognostic factors were assessed by univariate and multivariate analyses. The ROC curve revealed NLR and PLR had significant ability to predict parametrial involvement, and the cutoff values for NLR and PLR were 2.5 and 138.8 respectively. Clinicopathologic analysis showed that NLR was linked to age, parametrial involvement, tumor-invasion depth and histologic grade, and PLR was related to age, parametrial involvement, tumor-invasion depth and FIGO stage. Univariate analysis identified high PLR as a significant poor predictor for progression-free survival (PFS) and overall survival (OS), and NLR exhibited no predict power on OS or PFS. Multivariable analysis showed that PLR was an independent predictor of PFS, but not OS. NLR and PLR were associated with the clinical characteristics of cervical cancer. Additionally, PLR had independence prognostic value for PFS in patients with cervical cancer receiving radical hysterectomy with pelvic lymphadenectomy.

Preoperatively Assessable Clinical and Pathological Risk Factors for Parametrial Involvement in Surgically Treated FIGO Stage IB-IIA Cervical Cancer

OBJECTIVE

Determining the risk factors associated with parametrial involvement (PMI) is of paramount importance to decrease the multimodality treatment in early-stage cervical cancer. We investigated the preoperatively assessable clinical and pathological risk factors associated with PMI in surgically treated stage IB1-IIA2 cervical cancer.

METHODS

A retrospective cohort study of women underwent Querleu-Morrow type C hysterectomy for cervical cancer stage IB1-IIA2 from 2001 to 2015. All patients underwent clinical staging examination under anesthesia by the same gynecological oncologists during the study period. Evaluated variables were age, menopausal status, body mass index, smoking status, FIGO (International Federation of Obstetrics and Gynecology) stage, clinically measured maximal tumor diameter, clinical presentation (exophytic or endophytic tumor), histological type, tumor grade, lymphovascular space invasion, clinical and pathological vaginal invasion, and uterine body involvement. Endophytic clinical presentation was defined for ulcerative tumors and barrel-shaped morphology. Two-dimensional transvaginal ultrasonography was used to measure tumor dimensions.

RESULTS

Of 127 eligible women, 37 (29.1%) had PMI. On univariate analysis, endophytic clinical presentation (P = 0.01), larger tumor size (P < 0.001), lymphovascular space invasion (P < 0.001), pathological vaginal invasion (P = 0.001), and uterine body involvement (P < 0.001) were significantly different among the groups with and without PMI. In multivariate analysis endophytic clinical presentation (odds ratio, 11.34; 95% confidence interval, 1.34-95.85; P = 0.02) and larger tumor size (odds ratio, 32.31; 95% confidence interval, 2.46-423.83; P = 0.008) were the independent risk factors for PMI. Threshold of 31 mm in tumor size predicted PMI with 71% sensitivity and 75% specificity. We identified 18 patients with tumor size of more than 30 mm and endophytic presentation; 14 (77.7%) of these had PMI.

CONCLUSIONS

Endophytic clinical presentation and larger clinical tumor size (>3 cm) are independent risk factors for PMI in stage IB-IIA cervical cancer. Approximately 78% of the patients with a tumor size of more than 3 cm and endophytic presentation will require adjuvant chemoradiation for PMI following radical surgery. Considering clinical tumor presentation along with tumor size can enhance the physician's prediction of PMI in early-stage cervical cancer.

Parametrial Involvement on Magnetic Resonance Imaging Has No Effect on the Survival of Early-Stage Cervical Cancer Patients

OBJECTIVES

Parametrial involvement (PMI) in patients with cervical cancer is known to be an unfavourable prognostic factor. The purpose of this study was to investigate the prognostic significance of PMI on magnetic resonance imaging (MRI) in patients with early-stage cervical cancer.

METHODS

Three hundred three patients with stage IB or IIA cervical cancer treated by adjuvant radiotherapy or concurrent chemoradiotherapy following primary surgery from 2001 to 2011 were enrolled in this study. We reviewed preoperative MRI and pathologic findings and compared recurrence and survival of group defined according to PMI status.

RESULTS

There were 73 patients (24.1%) with PMI based on MRI and 52 patients (17.2%) with PMI based on surgical pathology. The accuracy of MRI for detecting PMI was 77.2% (sensitivity, 53.8%; specificity, 82.1%). In all patients, pathology-based evidence of PMI had a negative effect on both 5-year disease-free survival (73.2% vs 85.3%, P = 0.048) and 5-year overall survival (76.6% vs 91.4%, P = 0.009), but PMI on MRI did not have a significant effect on survival. In subgroups defined according to PMI status on MRI and surgical pathology, subgroups with pathology-based evidence of PMI showed a trend of a lower survival rate, regardless of PMI on MRI, but without statistical significance.

CONCLUSIONS

Unlike pathologic results, PMI on MRI was not associated with recurrence or survival in patients with early-stage cervical cancer.

Role of Imaging in Fertility-sparing Treatment of Gynecologic Malignancies

Treatments for gynecologic cancer usually result in loss of fertility due to surgery or radical radiation therapy in the pelvis. In countries with an established screening program for cervical cancer, the majority of gynecologic malignancies occur in postmenopausal women. However, a substantial number of affected women are of childbearing age and have not completed their families. In these younger women, consideration of fertility preservation may be important. This article describes the fertility-sparing treatment options that are currently available and outlines the role of imaging in the selection of eligible patients on the basis of a review of the literature. In the setting of cervical cancer, magnetic resonance (MR) imaging is used to delineate the size, position, and stage of the tumor for selection of patients who are suitable for radical trachelectomy. In patients with solitary complex adnexal masses, diffusion- and perfusion-weighted MR imaging sequences are used to categorize the likelihood of invasive or borderline malignancy for consideration of unilateral ovarian resection, with fertility preservation when possible. In patients with endometrial cancer, MR imaging is used to rule out signs of invasive disease before hormone therapy is considered. Imaging is also used at patient follow-up to detect recurrent disease; however, evidence to support this application is limited. In conclusion, imaging is an essential tool in the care of patients with gynecologic malignancies who are considering fertility-preserving treatment options. ^©RSNA, 2016.

Magnetic resonance imaging for detection of parametrial invasion in cervical cancer: An updated systematic review and meta-analysis of the literature between 2012 and 2016

OBJECTIVE

To review the diagnostic performance of MRI for detection of parametrial invasion (PMI) in cervical cancer patients.

METHODS

MEDLINE and EMBASE databases were searched for studies providing diagnostic performance of MRI for detecting PMI in patients with cervical cancer. Studies published between 2012 and 2016 using surgico-pathological results as reference standard were included. Study quality was evaluated using QUADAS-2. Sensitivity and specificity of all studies were calculated. Results were pooled and plotted in a hierarchical summary receiver operating characteristic plot. Meta-regression and subgroup analyses were performed.

RESULTS

Fourteen studies (1,028 patients) were included. Study quality was generally moderate. Pooled sensitivity was 0.76 (95% CI 0.67-0.84) and specificity was 0.94 (95% CI 0.91-0.95). The possibility of heterogeneity was considered low: Cochran's Q-test (p = 0.471), Tau² (0.240), Higgins I² (0%). With meta-regression analysis, magnet strength, use of DWI, and antispasmodic drugs were significant factors affecting heterogeneity (p < 0.01). Subgroup analysis for studies solely using radical hysterectomy as reference standard yielded pooled sensitivity and specificity of 0.73 (95% CI 0.60-0.83) and 0.93 (95% CI 0.90-0.95), respectively.

CONCLUSIONS

MRI shows good performance for detection of PMI in cervical cancer. Using 3-T scanners and DWI may improve diagnostic performance.

KEY POINTS

• MRI shows good performance for detection of parametrial invasion in cervical cancer. • Subgroup of studies using only radical hysterectomy showed consistent results. • Using 3-Tesla scanners and diffusion-weighted imaging may improve diagnostic performance.

Practice guidelines for management of cervical cancer in Korea: a Korean Society of Gynecologic Oncology Consensus Statement

Clinical practice guidelines for gynecologic cancers have been developed by academic society from several countries. Each guideline reflected their own insurance system and unique medical environment, based on the published evidence. The Korean Society of Gynecologic Oncology (KSGO) published the first edition of practice guidelines for gynecologic cancer treatment in late 2006; the second edition was released in July 2010 as an evidence-based recommendation. The Guidelines Revision Committee was established in 2015 and decided to develop the third edition of the guidelines in an advanced format based on evidence-based medicine, embracing up-to-date clinical trials and qualified Korean data. These guidelines cover strategies for diagnosis and treatment of primary and recurrent cervical cancer. The committee members and many gynecologic oncologists derived key questions through discussions, and a number of relevant scientific literature were reviewed in advance. Recommendations for each specific question were developed by the consensus conference, and they are summarized here, along with the details. The objective of these practice guidelines is to establish standard policies on issues in clinical practice related to the management in cervical cancer based on the results in published papers to date and the consensus of experts as a KSGO Consensus Statement.

A Predictive Model for Parametrial Invasion in Patients With FIGO Stage IB Cervical Cancer: Individualized Approach for Primary Treatment

OBJECTIVE

The aim of this study was to preoperatively identify high- and low-risk subgroups of patients with parametrial involvement in those with FIGO (International Federation of Gynecology and Obstetrics) stage IB cervical cancer treated with radical hysterectomy according to menopause.

MATERIALS AND METHODS

We retrospectively reviewed data of 197 patients with FIGO stage IB cervical cancer. None of the patients had definite evidence of parametrial invasion in a preoperative examination and underwent type III radical hysterectomy between February 2006 and March 2015. Preoperative risk criteria predicting parametrial involvement were identified in premenopausal and postmenopausal women, respectively.

RESULTS

Tumor size on magnetic resonance imaging (MRI) more than 4 cm (odds ratio [OR], 10.029; 95% confidence interval [95% CI], 2.300-43.741; P = 0.002) and serum squamous cell carcinoma-antigen level of 3.60 ng/mL or more (OR, 4.132; 95% CI, 1.086-5.723; P = 0.037) were independent factors for parametrial invasion in premenopausal women. Significant factors associated with parametrial involvement in postmenopausal women were tumor size on MRI more than 3 cm (OR, 11.353; 95% CI, 2.614-49.306; P = 0.001) and Cyfra 21-1 level of 2.40 ng/mL or more (OR, 8.048; 95% CI, 1.240-52.221; P = 0.029). Patients were categorized into low- and high-risk groups according to risk criteria. Significant differences in the rates of parametrial invasion were observed between the groups (2.3% vs 38.6% in the premenopausal group, P < 0.001; 11.1% vs 77.3% in the postmenopausal group, P < 0.001).

CONCLUSIONS

A model using preoperative tumor size on MRI, serum squamous cell carcinoma-antigen, and Cyfra 21-1 level was highly predictive of parametrial invasion in patients with FIGO stage IB cervical cancer. In particular, postmenopausal women were likely to have microscopic parametrial invasion, even among tumors 3 cm or less. Therefore, individualized approaches considering several preoperative factors are needed.

Pretreatment risk factors for parametrial involvement in FIGO stage IB1 cervical cancer

Objective

All patients with stage IB1 cervical cancer do not need to undergo parametrectomy. Some low-risk criteria for parametrial involvement (PI) have been proposed based on pathological findings. The aim of this study was to determine pretreatment risk factors for PI in stage IB1 cervical cancer.

Methods

We retrospectively reviewed 115 patients with stage IB1 cervical cancer who underwent radical hysterectomy or radical trachelectomy. Magnetic resonance imaging (MRI) was performed and serum concentrations of squamous cell carcinoma antigen (SCC-Ag) and cancer antigen 125 (CA-125) were determined in all patients before initial treatment. The following pretreatment factors were investigated: histological variant, maximum tumor diameter, tumor volume (volume index), pelvic lymph node enlargement, and serum tumor markers. Logistic regression analysis was used to select the independent risk factors for PI.

Results

Eighteen of the 115 patients (15.7%) were pathologically diagnosed with PI. Multivariate analysis confirmed the following independent risk factors for PI: MRI-based tumor diameter ≥25 mm (odds ratio [OR], 9.9; 95% confidence interval [CI], 2.1 to 48.1), MRI-based volume index ≥5,000 mm³ (OR, 13.3; 95% CI, 1.4 to 125.0), and positive serum tumor markers SCC-Ag ≥1.5 ng/mL or CA-125 ≥35 U/mL (OR, 5.7; 95% CI, 1.3 to 25.1). Of 53 patients with no risk factors for PI, none had PI.

Conclusion

Less radical surgery may become one of the treatment options for stage IB1 cervical cancer patients with MRI-based tumor diameter <25 mm, MRI-based volume index <5,000 mm³, and negativity for SCC-Ag and CA-125.

Identifying a low-risk group for parametrial involvement in microscopic Stage IB1 cervical cancer using criteria from ongoing studies and a new MRI criterion

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.

An Alternative Triage Strategy Based on Preoperative MRI for Avoiding Trimodality Therapy in Stage IB Cervical Cancer

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.

Implementation of laparoscopic approach for type B radical hysterectomy: a comparison with open surgical operations

OBJECTIVE

To investigate the safety, feasibility and effectiveness of laparoscopic approach in the management patients undergoing modified radical hysterectomy for early stage cervical cancer.

METHODS

Consecutive data of 157 women who had class II radical hysterectomy, for stage IA2 and stage IB1 <2 cm cervical cancer, were prospectively collected. Data of patients undergoing surgery via laparoscopy (LRH) were compared with those undergoing open surgical operations (RAH). A propensity-matched comparison (1:1) was carried out to minimize as possible selection biases. Post-operative complications were graded per the Clavien-Dindo classification. Five-year survival outcomes were assessed using Kaplan-Meier model.

RESULTS

After the exclusion of 37 (23.5%) patients on the basis of propensity-matching, 60 patients undergoing LRH were compared with 60 patients undergoing RAH. No between-group differences in baseline, disease and pathological variables were observed (p > 0.05). Patients undergoing surgery via laparoscopy experienced longer operative time than patients undergoing RAH; while LRH correlated whit shorter length of hospitalization and lower blood loss in comparison to RAH. Intra- and post-operative complication rate was similar between groups (p = 1.00). The execution of LRH or RAH did not influence site of recurrence (p > 0.2) as well as survival outcomes, in term of 5-year disease-free (p = 0.29, log-rank test) and overall survivals (p = 0.50, log-rank test).

CONCLUSION

Laparoscopic approach is a safe procedure, upholds the results of RAH, reducing invasiveness of open surgical operations. Further large prospective investigations are warranted.