Comparison of adenocarcinoma (ACA) and squamous cell carcinoma (SCC) of the uterine cervix in a sub-optimally screened cohort: A population-based epidemiologic study of 51,842 women in Brazil

Cervical Cancer Screening: A Review

Importance

Each year in the US, approximately 100 000 people are treated for cervical precancer, 14 000 people are diagnosed with cervical cancer, and 4000 die of cervical cancer.

Observations

Essentially all cervical cancers worldwide are caused by persistent infections with one of 13 carcinogenic human papillomavirus (HPV) genotypes: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68. HPV vaccination at ages 9 through 12 years will likely prevent more than 90% of cervical precancers and cancers. In people with a cervix aged 21 through 65 years, cervical cancer is prevented by screening for and treating cervical precancer, defined as high-grade squamous intraepithelial lesions of the cervix. High-grade lesions can progress to cervical cancer if not treated. Cervicovaginal HPV testing is 90% sensitive for detecting precancer. In the general population, the risk of precancer is less than 0.15% over 5 years following a negative HPV test result. Among people with a positive HPV test result, a combination of HPV genotyping and cervical cytology (Papanicolaou testing) can identify the risk of precancer. For people with current precancer risks of less than 4%, repeat HPV testing is recommended in 1, 3, or 5 years depending on 5-year precancer risk. For people with current precancer risks of 4% through 24%, such as those with low-grade cytology test results (atypical squamous cells of undetermined significance [ASC-US] or low-grade squamous intraepithelial lesion [LSIL]) and a positive HPV test of unknown duration, colposcopy is recommended. For patients with precancer risks of less than 25% (eg, cervical intraepithelial neoplasia grade 1 [CIN1] or histologic LSIL), treatment-related adverse effects, including possible association with preterm labor, can be reduced by repeating colposcopy to monitor for precancer and avoiding excisional treatment. For patients with current precancer risks of 25% through 59% (eg, high-grade cytology results of ASC cannot exclude high-grade lesion [ASC-H] or high-grade squamous intraepithelial lesion [HSIL] with positive HPV test results), management consists of colposcopy with biopsy or excisional treatment. For those with current precancer risks of 60% or more, such as patients with HPV-16-positive HSIL, proceeding directly to excisional treatment is preferred, but performing a colposcopy first to confirm the need for excisional treatment is acceptable. Clinical decision support tools can facilitate correct management.

Conclusions and Relevance

Approximately 100 000 people are treated for cervical precancer each year in the US to prevent cervical cancer. People with a cervix should be screened with HPV testing, and if HPV-positive, genotyping and cytology testing should be performed to assess the risk of cervical precancer and determine the need for colposcopy or treatment. HPV vaccination in adolescence will likely prevent more than 90% of cervical precancers and cancers.

Comprehensive analysis of novel prognosis-related proteomic signature effectively improve risk stratification and precision treatment for patients with cervical cancer

OBJECTIVE

Cervical cancer (CC) is one of the most common types of malignant female cancer, and its incidence and mortality are not optimistic. Protein panels can be a powerful prognostic factor for many types of cancer. The purpose of our study was to investigate a proteomic panel to predict the survival of patients with common CC.

METHODS AND RESULTS

The protein expression and clinicopathological data of CC were downloaded from The Cancer Proteome Atlas and The Cancer Genome Atlas database, respectively. We selected the prognosis-related proteins (PRPs) by univariate Cox regression analysis and found that the results of functional enrichment analysis were mainly related to apoptosis. We used Kaplan-Meier analysis and multivariable Cox regression analysis further to screen PRPs to establish a prognostic model, including BCL2, SMAD3, and 4EBP1-pT70. The signature was verified to be independent predictors of OS by Cox regression analysis and the area under curves. Nomogram and subgroup classification were established based on the signature to verify its clinical application. Furthermore, we looked for the co-expressed proteins of three-protein panel as potential prognostic proteins.

CONCLUSION

A proteomic signature independently predicted OS of CC patients, and the predictive ability was better than the clinicopathological characteristics. This signature can help improve prediction for clinical outcome and provides new targets for CC treatment.

Prognosis determination of endocervical adenocarcinomas morphologically reclassified as HPV associated or HPV independent

OBJECTIVE

To evaluate the prognosis of endocervical adenocarcinomas after reclassification according to the morphologic type based on the 2020 World Health Organization Classification.

METHODS

A retrospective longitudinal study with cases admitted at the University of Campinas, Brazil, from 2013 to 2020. The sample included 140 cases morphologically reclassified: 100 cases as adenocarcinoma HPV-associated (HPVA), 17 as HPV-independent (HPVI), and 23 non-HPVA/HPVI. Clinic and pathologic variables were evaluated. Analyses were performed by χ² , Fisher exact, and Mann-Whitney U tests, Kaplan-Meier curves, Log-rank test, and Cox regression.

RESULTS

Compared with the HPVA group, advanced stage (FIGO Stage II+) was more frequent in the HPVI group (P = 0.009), which also showed older patients (P = 0.032), and a higher proportion of deaths (P = 0.006). The median overall survival (OS) differed between groups: 73.3 months in HPVA and 42.4 months in HPVI (P = 0.005). At the multivariate analysis, the risk of death was 6.7 (95% confidence interval 1.9-23.0) times higher in patients diagnosed in advanced stages.

CONCLUSION

HPVI cases were more frequent in older patients, presenting at more advanced stages and with worse OS. The morphology-based approach of the new WHO classification appears to be prognostically valuable and applicable in lower- and middle-income settings.

The value of HPV genotypes combined with clinical indicators in the classification of cervical squamous cell carcinoma and adenocarcinoma

Background

To investigate the differences in HPV genotypes and clinical indicators between cervical squamous cell carcinoma and adenocarcinoma and to identify independent predictors for differentiating cervical squamous cell carcinoma and adenocarcinoma.

Methods

A total of 319 patients with cervical cancer, including 238 patients with squamous cell carcinoma and 81 patients with adenocarcinoma, were retrospectively analysed. The clinical characteristics and laboratory indicators, including HPV genotypes, SCCAg, CA125, CA19-9, CYFRA 21–1 and parity, were analysed by univariate and multivariate analyses, and a classification model for cervical squamous cell carcinoma and adenocarcinoma was established. The model was validated in 96 patients with cervical cancer.

Results

There were significant differences in SCCAg, CA125, CA19-9, CYFRA 21–1, HPV genotypes and clinical symptoms between cervical squamous cell carcinoma and adenocarcinoma (P < 0.05). Logistic regression analysis showed that SCCAg and HPV genotypes (high risk) were independent predictors for differentiating cervical squamous cell carcinoma from adenocarcinoma. The AUC value of the established classification model was 0.854 (95% CI: 0.804–0.904). The accuracy, sensitivity and specificity of the model were 0.846, 0.691 and 0.899, respectively. The classification accuracy was 0.823 when the model was verified.

Conclusion

The histological type of cervical cancer patients with persistent infection of high-risk HPV subtypes and low serum SCCAg levels was more prone to being adenocarcinoma. When the above independent predictors occur, the occurrence and development of cervical adenocarcinoma should be anticipated, and early active intervention treatment should be used to improve the prognosis and survival of patients.

Incidence and risk factors for the development of cerebral metastasis in cervical cancer patients

OBJECTIVE

Cerebral metastasis (CM) in cervical cancer (CC) cases, although rare, results in high lethality rates. The present study aimed to assess CM incidence in a Brazilian reference CC center and evaluate the risk factors for CM development. Retrospective observational study of patients diagnosed with CC between 2010 and 2017.

METHODS

Cumulative CM incidence and incidence density were evaluated. Characteristics associated to CM development risks were identified using crude (cOR) or adjusted (aOR) odds ratios.

RESULTS

A total of 3,397 patients were included in this study. Patient age ranged from 18 to 101 years, with a mean age of 48.8±14.0. After a mean follow-up time of 3.2±2.1 years, 51 CM cases were identified, resulting in a cumulative incidence of 1.5% (95% confidence intervals [CI]=1.12-1.97) and an incidence density at the end of the 6th year of 27.4 per 1,000 women/year. Advanced clinical stage (aOR=3.15; 95% CI=1.16-8.58; p=0.025), the presence of previous lung metastasis (aOR=4.04; 95% CI=1.82-8.94; p=0.001) and the adenocarcinoma (aOR=2.90; 95% CI=1.46-5.76; p=0.002), adenosquamous carcinoma (aOR=7.33; 95% CI=2.87-18.73; p<0.001), undifferentiated carcinoma (aOR=14.37; 95% CI=3.77-54.76; p<0.001) and neuroendocrine carcinoma (aOR=21.31; 95% CI=6.65-68.37, p<0.001) histological types were associated with a higher risk for CM development. CM risk was higher in the first years of follow-up, with no cases observed after the 6th year.

CONCLUSION

CC patients in advanced clinical stages, displaying previous lung metastasis and non-squamous histological types are at high risk of developing CM.

Cervical Cancer Screening with HPV Testing: Updates on the Recommendation

The present update is a reassessment of the 2018 'Guidelines for HPV-DNA Testing for Cervical Cancer Screening in Brazil' (Zeferino et al.)9, according to the changes observed in new international guidelines and knowledge updates. The most relevant and recent guidelines were assessed. Questions regarding the clinical practice were formulated, and the answers considered the perspective of the public and private sectors of the Brazilian health system. The review addressed risk-based strategies regarding age to start and stop screening, the use of cytology and colposcopy to support management decisions, treatment, follow-up strategies, and screening in specific groups, including vaccinated women. The update aims to improve the prevention of cervical cancer and to reduce overtreatment and the misuse of HPV testing.

Clinical and MRI Characteristics of Uterine Cervical Adenocarcinoma: Its Variants and Mimics

Adenocarcinoma currently accounts for 10–25% of all uterine cervical carcinomas and has a variety of histopathological subtypes. Among them, mucinous carcinoma gastric type is not associated with high-risk human papillomavirus (HPV) infection and a poor prognosis, while villoglandular carcinoma has an association with high-risk HPV infection and a good prognosis. They show relatively characteristic imaging findings which can be suggested by magnetic resonance imaging (MRI), though the former is sometimes difficult to be distinguished from lobular endocervical glandular hyperplasia. Various kinds of other tumors including squamous cell carcinoma should be also differentiated on MRI, while it is currently difficult to distinguish them on MRI, and HPV screening and pathological confirmation are usually necessary for definite diagnosis and further patient management.

Characterization of women with cervical cancer assisted at Inca by histological type

OBJECTIVE

To determine the distribution of sociodemographic, reproductive, clinical and lifestyle habits in the cohort of women diagnosed with cervical cancer, assisted at Inca between 2012 and 2014, according to the histological type.

METHODS

Retrospective observational study of a hospital cohort of 1,004 women diagnosed with cervical cancer. Data were obtained from the Inca hospital cancer registry, physical and electronic records.

RESULTS

The most frequent histological type was squamous cell carcinoma (83.9%). Approximately 70% of the women aged more than 40 years. The study includes non-white women (67.4%), with less than 8 years of education (51.9%), with onset of sexual activity up to 16 years of age (40.7%), who were pregnant before (95.5%), with more than one pregnancy (82.9%), and more than two children (52.7%); 45.8% of the women were smokers or former smokers. Cervical adenocarcinoma was positively associated with earlier staging (IA-IIA) (OR = 1.79; 95%CI 1.03–3.13), as well as women with ≥ 12 years of education (OR = 6.30; 95%CI 1.97–20,13), who had no children (OR = 3.81; 95%CI 1.20 – 12,08) or who had up to two children (OR = 1.74; 95%CI 1.05 – 2,87).

CONCLUSIONS

The difference between histological types is highlighted, suggesting that women with cervical adenocarcinoma may represent a distinct clinical entity of cervical neoplasia, which may require different approaches from those used in squamous cell carcinoma.

Distinctive clinicopathologic characteristics and prognosis for different histologic subtypes of early cervical cancer

OBJECTIVES

To compare clinicopathologic characteristics and prognosis for different histologic subtypes in early cervical cancer.

METHODS

Patients who underwent radical surgery for stage IA2-IIA2 cervical cancer with squamous cell carcinoma, adenocarcinoma, or adenosquamous carcinoma between March 2006 and February 2014 at our institution were retrospectively evaluated. The two-sample t-test was used to compare the mean values of continuous variables. The Chi-square test was used to assess differences in the distribution of categorical variables. Survival curves were generated by the Kaplan-Meier method using log-rank test. Univariable and multivariable analyses were performed using Cox regression analysis.

RESULTS

Of 5181 patients evaluated, 4510 had squamous cell carcinoma, 488 had adenocarcinoma, and 183 had adenosquamous carcinoma. Compared with squamous cell carcinoma, adenocarcinoma was associated with earlier stage, smaller tumor size, less lymphovascular space invasion (26.7% vs 37.9%), less deep (>2/3 depth) stromal invasion (30.4% vs 36.2%), and more ovarian metastasis (4.2% vs 0.7%) (all p<0.001). Compared with adenosquamous carcinoma, adenocarcinoma was associated with earlier stage (p=0.011), smaller tumor size (p<0.001), less lymphovascular space invasion (26.7% vs 41.5%, p<0.001), and less peripheral nerve infiltration (5.7% vs 15.4%, p<0.001). Except for more peripheral nerve infiltration in adenosquamous carcinoma (15.4% vs 8.4%, p=0.002), no significant differences in other clinicopathologic characteristics were noted between squamous cell carcinoma and adenosquamous carcinoma. Five-year recurrence-free survival was 85.1%, 78.2%, and 72.3% for squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinoma, respectively (p<0.001). Corresponding 5-year overall survival was 89.7%, 83.1%, and 79.6%, respectively (p<0.001). In multivariable analysis, adenocarcinoma and adenosquamous carcinoma were independent prognostic factors for worse recurrence-free survival for adenocarcinoma versus squamous cell carcinoma (HR 2.594 (95% CI 2.030 to 3.316), p<0.001) and for adenosquamous carcinoma versus squamous cell carcinoma (HR 2.105 (95% CI 1.517 to 2.920), p<0.001), and overall survival for adenocarcinoma versus squamous cell carcinoma (HR 2.976 (95% CI 2.226 to 3.977), p<0.001) and for adenosquamous carcinoma versus squamous cell carcinoma (HR 2.295 (95% CI 1.579 to 3.338), p<0.001).

CONCLUSION

Squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinoma carried distinctive patterns of clinicopathologic characteristics. Adenocarcinoma and adenosquamous carcinoma had worse survival outcomes than squamous cell carcinoma.

Stage and histology of cervical cancer in women under 25 years old

Objective

To evaluate the histological and stage characteristics of cervical cancer in women under 25 years old, and to compare them with older women.

Methods

Cross-sectional study of cases from the Hospital Cancer Registry of São Paulo State/Brazil from 2000 to 2015. Variables were age, International Federation of Gynecology and Obstetrics stage and histological type. Prevalence ratio (PR) and its 95% confidence interval (CI) were calculated.

Results

Out of 18,423 cervical cancer cases 204 (1.1%) were in women under 25 years old. The most frequent stage was stage I in women under 25 (36.2%) and between 25 and 34 (43.4%), and stage III in older women (31.8%). No statistically significant difference was observed in stages by age group. Squamous carcinomas were the most frequent in 73.5% of women under 25 and 78.5% of older women. In women under 25 the following histological types were more frequent: neuroendocrine carcinomas (PR=6.10, 95% CI=2.03–18.35), malignant germ cell tumors (PR=54.98, 95% CI=26.53–113.95), mesenchymal tumors (sarcomas) (PR=5.67, 95% CI=2.58–12.45) and hematopoietic/lymphoid tumors (PR=0.72, 95% CI=2.90–36.69).

Conclusion

In women under 25 years old cervical cancer was an uncommon diagnosis and in about one third occurred at early stage. Squamous carcinoma was the most frequent histological type regardless age, but rare histological types were more frequent in young women.

Incidence rates and temporal trends of cervical cancer relating to opportunistic screening in two developed metropolitan regions of Brazil: a population-based cohort study

BACKGROUND

Brazilian opportunistic screening programs for cervical cancer have limited impact. In the regions of two cities (Campinas and Curitiba) with high human development indices, consistent information from 96-97% of all cervical cancer cases managed within the public healthcare system is available.

OBJECTIVE

To estimate the incidence rate (IR) and temporal trends in these regions, covering 2001-2012.

DESIGN AND SETTING

A population-based cohort study was conducted under the assumption that all cervical cancer cases were managed in cancer referral center hospitals.

METHODS

3,364 records (1,646 from Campinas; 1,718 from Curitiba) were analyzed to provide estimates of IR, age-standardized IR (ASR) and cervical cancer trends (shown per 100,000 women/year). Longitudinal patterns were analyzed using linear regression and shown as annual percentage change (APC); P < 0.05 for significance.

RESULTS

Annual IR and ASR estimates for cervical cancer ranged from 3.8 to 8.0 over 2001-2012, decreasing over more recent years, and were similar for the two regions. The age-specific IR was about 50% lower among women aged 45 years or older (IR-2001/IR-2012: Campinas = 14.8/8.0; Curitiba = 18.7/8.3; P < 0.001). There was an increasing APC trend in Campinas among women aged 15-24 years, and a decreasing IR trend for squamous-cell histology in both regions (P < 0.05).

CONCLUSION

Cervical cancer incidence estimates showed slowly decreasing trends in both regions, most evidently for women aged 45 years or older and for squamous-cell histology. These findings reflect the opportunistic nature of the population screening program, despite the comparatively high economic development level in the two regions.

Comparison of survival outcomes between radical hysterectomy and definitive radiochemotherapy in stage IB1 and IIA1 cervical cancer

Introduction

There is an ongoing debate regarding the optimal local treatment modalities for stage IB1 and IIA1 cervical cancer. The aim of this study was to determine whether radical hysterectomy or definitive radiochemotherapy is superior in stage IB1 and IIA1 cervical squamous cell carcinoma (SCC).

Methods

From 1990 to 2010, a total of 3,769 patients with stage IB1 and IIA1 cervical SCC were included from the Surveillance, Epidemiology, and End Results database and were stratified according to whether they received radical hysterectomy or primary radiochemotherapy. Propensity score-matching (PSM) methods were used to balance patient baseline characteristics. Cancer-specific survival (CSS) and overall survival (OS) were compared between the two groups.

Results

Of the 3,769 patients, 3,653 (96.9%) and 116 (3.1%) patients received radical hysterectomy and definitive radiochemotherapy, respectively. Radiochemotherapy was rarely used for definitive treatment prior to 2000. Before PSM, patients who were older, of black ethnicity, and with larger tumor size and stage IIA1 disease were more likely to receive definitive radiochemotherapy. A total of 116 pairs were completely matched using PSM. The local treatment modalities had no effect on CSS or OS in either unmatched or matched populations. In the matched population, the 8-year CSS rates were 82.1% and 76.5% in surgery and radiochemotherapy groups, respectively (p=0.382). The 8-year OS rates were 74.6% and 67.8% in surgery and radiochemotherapy groups, respectively (p=0.205).

Conclusion

Our population-based study suggests that there is no clear local treatment of choice on survival outcomes between radical hysterectomy and definitive radiochemotherapy in patients with stage IB1 and IIA1 cervical SCC.

The prognostic value of histologic subtype in node-positive early-stage cervical cancer after hysterectomy and adjuvant radiotherapy

BACKGROUND

To assess the survival outcomes in patients with International Federation of Gynecology and Obstetrics (FIGO) stage I-IIA adenocarcinoma (AC) or squamous cell carcinoma (SCC) of the uterine cervix after hysterectomy and adjuvant radiotherapy (RT).

METHODS

Patients with a primary diagnosis of FIGO stage I-IIA AC or SCC of the uterine cervix after hysterectomy and adjuvant RT between 1988 and 2012 were included using data from the Surveillance, Epidemiology, and End Results database. Univariate and multivariate Cox regression analyses were used to analyze the effect of histologic subtype on cause-specific survival (CSS) and overall survival (OS).

RESULTS

We included 1171 patients: 919 with cervical SCC and 252 with cervical AC. In multivariate analysis, cervical AC was an independent adverse prognostic factor for survival. Patients with cervical AC had worse CSS (p = 0.001) and OS (p = 0.001) compared to patients with cervical SCC. In the subgroup analysis, patients with cervical SCC in the era of concurrent chemoradiotherapy (CCRT) (2000-2012) had better CSS (p = 0.006) and OS (p = 0.004) compared with the era of RT. However, there was no significant difference in CSS (p = 0.079) and OS (p = 0.053) between the eras of RT (1988-1999) and CCRT for patients with cervical AC.

CONCLUSIONS

Survival of cervical AC is significantly worse than that of cervical SCC. As CCRT usage increases, the survival benefit is derived only in cervical SCC, but not in cervical AC.

The effect of local treatment modalities in patients with early-stage adenocarcinoma of the uterine cervix: A population-based analysis

BACKGROUND

To determine the optimal local treatment modalities in stage IB-IIA adenocarcinoma (AC) of the uterine cervix and assess the impact of tumor size in the clinical outcomes.

METHODS

Patients with a primary diagnosis of stage IB-IIA cervical AC between 1988 and 2013 were identified using the Surveillance, Epidemiology, and End Results database. Cox regression analyses was performed to analyze the effect of local treatment modalities on cause-specific survival (CSS) and overall survival (OS).

RESULTS

A total of 2773 patients were identified. Of these, 1816, 795, and 162 patients received primary surgery, surgery and radiotherapy (RT), and primary RT, respectively. Local treatment modality was the independent prognostic factor for CSS and OS. Patients who received primary surgery had better CSS and OS, especially in patients with tumor size ≤4 cm. However, of those with tumor size >4 cm, patients who underwent primary surgery showed significantly better survival; the survival of patients who underwent surgery and RT was not significantly different from those who underwent primary RT alone. The results were not influenced by the year before (1988-1999) and after (2000-2013) the era of concurrent chemoradiation therapy.

CONCLUSIONS

Surgery remains the optimal local treatment modality in patients with early stage cervical AC.

A phase I study of mTOR inhibitor everolimus in association with cisplatin and radiotherapy for the treatment of locally advanced cervix cancer: PHOENIX I

BACKGROUND

Cervix cancer (CC) represents the fourth most common cancer in women. Treatment involving cisplatin and radiotherapy has been the standard for locally advanced disease. Everolimus inhibits the aberrant activity of mTOR that is part of carcinogenesis in CC. Further everolimus inactivates the HPV E7 oncoprotein and inhibits its proliferation. Preclinical models have suggested that everolimus sensitizes tumoral cells and vasculature to cisplatin and radiotherapy.

METHODS

In a 3 + 3 design, the trial aimed to treat three dose levels of at least three patients with daily doses of everolimus (2.5, 5 and 10 mg/day), cisplatin and radiotherapy delivered in a 9-week interval in CC patients, stage IIB, IIIA or IIIB. Patients received everolimus from day -7 up to the last day of brachytherapy. Primary objective was to evaluate safety, toxicity and the maximum-tolerated dose (MTD) of everolimus in association with cisplatin and radiotherapy. Pharmacokinetic (PK) parameters and response rates were analyzed as secondary objectives.

RESULTS

Thirteen patients were enrolled, 6 at 2.5 mg, 3 at 5 mg and 4 at 10 mg. Four patients did not complete the planned schedule, 1 at 2.5 mg presented grade 4 acute renal failure interpreted as dose-limiting toxicity (DLT) and 3 at 10 mg: 1 with disease progression, and 2 with DLTs-1 grade 3 rash and 1 grade 4 neutropenia. PK results were characterized by dose-dependent increases in AUC and C max.

CONCLUSIONS

The MTD of everolimus in combination with cisplatin and radiotherapy has been defined as 5 mg/day. The data regarding safety and response rates support further studies.