Risk of micrometastases in non-sentinel pelvic lymph nodes in cervical cancer

DMGM: deformable-mechanism based cervical cancer staging via MRI multi-sequence. Phys Med Biol 2024;69:115044. [PMID: 38749463 DOI: 10.1088/1361-6560/ad4c50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Objective.This study aims to leverage a deep learning approach, specifically a deformable convolutional layer, for staging cervical cancer using multi-sequence MRI images. This is in response to the challenges doctors face in simultaneously identifying multiple sequences, a task that computer-aided diagnosis systems can potentially improve due to their vast information storage capabilities.Approach.To address the challenge of limited sample sizes, we introduce a sequence enhancement strategy to diversify samples and mitigate overfitting. We propose a novel deformable ConvLSTM module that integrates a deformable mechanism with ConvLSTM, enabling the model to adapt to data with varying structures. Furthermore, we introduce the deformable multi-sequence guidance model (DMGM) as an auxiliary diagnostic tool for cervical cancer staging.Main results.Through extensive testing, including comparative and ablation studies, we validate the effectiveness of the deformable ConvLSTM module and the DMGM. Our findings highlight the model's ability to adapt to the deformation mechanism and address the challenges in cervical cancer tumor staging, thereby overcoming the overfitting issue and ensuring the synchronization of asynchronous scan sequences. The research also utilized the multi-modal data from BraTS 2019 as an external test dataset to validate the effectiveness of the proposed methodology presented in this study.Significance.The DMGM represents the first deep learning model to analyze multiple MRI sequences for cervical cancer, demonstrating strong generalization capabilities and effective staging in small dataset scenarios. This has significant implications for both deep learning applications and medical diagnostics. The source code will be made available subsequently.

Feasibility and Diagnostic Accuracy of Ultrastaging in the Detection of Micrometastases in Sentinel and Non-sentinel Lymph Nodes in Cervical Cancer: A Single-Center Retrospective Study With a Five-Year Follow-Up Period

BACKGROUND

Cervical cancer is the fourth most common cause of malignant tumor-related deaths among women in developing nations. Cervical cancer has been estimated to cause 527.600 new cases and 265.700 deaths globally per year.

OBJECTIVES

This study aimed to evaluate patients with cervical cancer by ultrastaging all the lymph nodes (LN), sentinel LN (SLN) and non-SLN, to increase the sensitivity of the detection of LN metastases and the diagnostic accuracy in cervical cancer with a five-year follow-up.

MATERIALS AND METHODS

This is a retrospective study of 14 cervical cancer cases from 2017 to 2019 at the Municipal Emergency Clinical Hospital of Timisoara, Romania. The cases were selected based on their high risk of LN involvement but negative intraoperative pathologic LN. After re-evaluating all paraffin block biopsy samples from 29 cases, 14 cases were included in the study, which met all criteria for ultrastaging on surgical biopsy samples.

RESULTS

Patients' ages included in the study ranged from 43 to 70 years (median: 57.14 years). According to the International Federation of Gynecology and Obstetrics (FIGO) staging, the majority of the patients were in stage IB: seven cases (50%). The study revealed a positive correlation between patient age and FIGO staging, with Pearson's correlation coefficient of 0.707 and a p-value of less than 0.05, indicating that older patients were more likely to be diagnosed with a higher FIGO stage. The mean follow-up was 34.5 months, and the median follow-up was 36 months (range: 6-60 months). We obtained 167 nodes, with a mean of 11.92 nodes/case. Twenty-one LN were found to be positive with the ultrastaging method. We detected 11 LN with macrometastases (MAC) (52.38%), seven with micrometastasis (MIC) (33.3%), and three with tumor cell islets (14.4%). That would be 13% of newly diagnosed ultrastaging cases as positive nodes. This ultrastaging method detected nodal MIC in eight (57.1%) out of the 14 patients, who initially tested negative for LN involvement using the routine Hematoxylin and Eosin (HE) method. The detection of micrometastases in these patients underscored the superior sensitivity of ultrastaging, which was further highlighted by the subsequent relapse of four (28.57%) out of these eight patients. The study also found no correlation between the FIGO standardization and the number of MIC found in these patients.

CONCLUSIONS

Predicting cervical LN metastasis (LNM) is crucial for improving survival rates and reducing recurrence. Very few small cohort studies used an ultrastaging method to assess non-SLNs; most of them only assessed SLNs. We showed in our study that the ultrastaging method, both in the case of SLN and non-SLN, is superior compared with H&E analysis, with a 13% rate of new positive nodule diagnosis. Metastatic involvement of non-SLN was found in over 50% of all cases (8/14) according to the ultrastaging method. Additionally, our study confirms that the sensitivity of SLN ultrastaging is high for the presence of both MIC and MAC in SLN pelvic LN. As a result, we feel that ultrastaging is the most effective method for SLN analysis in patients with early-stage cervical cancer, and bilateral detection is preferable, significantly reducing false-negative results. The routine use of SLN along with ultrastaging would lead to more accurate surgical staging and better oncological follow-up of cases.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Intra- and peri-tumoral MRI radiomics features for preoperative lymph node metastasis prediction in early-stage cervical cancer

BACKGROUND

Noninvasive and accurate prediction of lymph node metastasis (LNM) is very important for patients with early-stage cervical cancer (ECC). Our study aimed to investigate the accuracy and sensitivity of radiomics models with features extracted from both intra- and peritumoral regions in magnetic resonance imaging (MRI) with T2 weighted imaging (T2WI) and diffusion weighted imaging (DWI) for predicting LNM.

METHODS

A total of 247 ECC patients with confirmed lymph node status were enrolled retrospectively and randomly divided into training (n = 172) and testing sets (n = 75). Radiomics features were extracted from both intra- and peritumoral regions with different expansion dimensions (3, 5, and 7 mm) in T2WI and DWI. Radiomics signature and combined radiomics models were constructed with selected features. A nomogram was also constructed by combining radiomics model with clinical factors for predicting LNM.

RESULTS

The area under curves (AUCs) of radiomics signature with features from tumors in T2WI and DWI were 0.841 vs. 0.791 and 0.820 vs. 0.771 in the training and testing sets, respectively. Combining radiomics features from tumors in the T2WI, DWI and peritumoral 3 mm expansion in T2WI achieved the best performance with an AUC of 0.868 and 0.846 in the training and testing sets, respectively. A nomogram combining age and maximum tumor diameter (MTD) with radiomics signature achieved a C-index of 0.884 in the prediction of LNM for ECC.

CONCLUSIONS

 Radiomics features extracted from both intra- and peritumoral regions in T2WI and DWI are feasible and promising for the preoperative prediction of LNM for patients with ECC.

Fertility-Sparing Treatment for Early-Stage Cervical Cancer ≥ 2 cm: A Problem with a Thousand Nuances-A Systematic Review of Oncological Outcomes

BACKGROUND

Fertility-sparing treatments (FSTs) have played a crucial role in the management of early-stage cervical cancer (ECC). The guidelines have recognized various approaches, depending on the tumor stage and other risk factors such as histotype and lymphovascular positivity. Much more debate has centered around the boundary within which these treatments should be considered. Indeed, these are methods to be reserved for ECC, but tumor size may represent the most significant limitation. In particular, there is no consensus on the strategy to be adopted in the case of ECC ≥ 2 cm. Therefore, this systematic review was to collect the literature evidence regarding the management of these patients.

METHODS

Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, we systematically searched the Pubmed and Scopus databases was conducted in April 2022, from the date of the first publication. We made no limitation on the country. We included all studies containing data on disease-free survival, overall survival, recurrence rate (RR), or complete response rate (CRR) to chemotherapy.

RESULTS

Twenty-six studies fulfilled the inclusion criteria, and 691 patients were analyzed regarding FST. Surgery-based FST showed an RR of between 0 and 42.9%, which drops to 12.9% after excluding the vaginal or minimally invasive approaches. Furthermore, papers regarding FST based on the neoadjuvant chemotherapy (NACT) approach showed a CRR of between 21.4 and 84.5%, and an RR of between 0 and 22.2% CONCLUSION: This paper focused on the significant heterogeneity present in the clinical management of FST of ECC ≥ 2 cm. Nevertheless, from an oncological point of view, approaches limited to the minimally invasive or vaginal techniques showed the highest RR. Vice versa, the lack of standardization of NACT schemes and the wealth of confounders to be attributed to the histological features of the tumor make it difficult, if not impossible, to set a standard of treatment.

Radiomics Based on Nomogram Predict Pelvic Lymphnode Metastasis in Early-Stage Cervical Cancer

The accurate prediction of the status of PLNM preoperatively plays a key role in treatment strategy decisions in early-stage cervical cancer. The aim of this study was to develop and validate a radiomics-based nomogram for the preoperative prediction of pelvic lymph node metastatic status in early-stage cervical cancer. One hundred fifty patients were enrolled in this study. Radiomics features were extracted from T2-weighted MRI imaging (T2WI). Based on the selected features, a support vector machine (SVM) algorithm was used to build the radiomics signature. The radiomics-based nomogram was developed incorporating radiomics signature and clinical risk factors. In the training cohort (AUC = 0.925, accuracy = 81.6%, sensitivity = 70.3%, and specificity = 92.0%) and the testing cohort (AUC = 0.839, accuracy = 74.2%, sensitivity = 65.7%, and specificity = 82.8%), clinical models that combine stromal invasion depth, FIGO stage, and MTD perform poorly. The combined model had the highest AUC in the training cohort (AUC = 0.988, accuracy = 95.9%, sensitivity = 92.0%, and specificity = 100.0%) and the testing cohort (AUC = 0.922, accuracy = 87.1%, sensitivity = 85.7%, and specificity = 88.6%) when compared to the radiomics and clinical models. The study may provide valuable guidance for clinical physicians regarding the treatment strategies for early-stage cervical cancer patients.

Development and validation of a nomogram for predicting pelvic lymph node metastasis and prognosis in patients with cervical cancer

Objective

Cervical cancer (CC) is one of the main causes of death among gynecological malignancies. Patients with CC with lymph node metastasis (LNM) have poor prognoses. We investigated the risk factors and prognosis of LNM in patients with CC patients using data from the SEER database.

Methods

We collected the information of cervical cancer patients registered in SEER database from 2010 to 2015. The dataset was divided into a training set and a validation set at a 7:3 ratio. LASSO regression analysis was used to evaluate risk factors for LNM in patients with CC. Using the results, we established a nomogram prediction model. C-index, ROC curves, calibration curves, decision curve analysis, and clinical impact curves were used to evaluate the prediction performance of the model.

Results

We included 14,356 patients with CC in the analysis. Among these, 3997 patients were diagnosed with LNM. A training set (10,050 cases) and a validation set (4306 cases) were used for the following analysis. We established nomogram LNM prediction models for the patients with T_1-2-stage CC. The C-indices for the internal and external validations of the prediction models were 0.758 and 0.744, respectively. In addition, we established a prognostic nomogram for all CC patients with LNM, and the internal and external validation C-indices were 0.763 and 0.737.

Conclusion

We constructed a quantitative and visual predictive nomogram that predicted prognosis of patients with LNM in CC to provide clinicians with a reference for diagnosis and treatment.

Management of Early-Stage Cervical Cancer: A Literature Review

Simple Summary

Despite being a preventable disease, cervical cancer still causes morbidity and deaths worldwide. In the early stages (FIGO IA1 with lymph-vascular space invasion-IIA1), the disease is highly curable. The primary treatment for early-stage cervical cancer is radical hysterectomy with pelvic lymphadenectomy. This surgical treatment has changed during the past decades, and we aimed to review and discuss the advances in the literature. We performed a literature review through PubMed focusing on English articles about the topic of surgical management of early-stage cervical cancer. The emergent topics considered here are the FIGO 2018 staging system update, conservative management for selected patients, sentinel lymph node mapping, fertility preservation, surgical approach, and management of tumors up to 2 cm. These topics show an evolvement to a more tailored treatment to prevent morbidity and assure oncologic safety.

Abstract

Cervical cancer (CC) remains a public health issue worldwide despite preventive measures. Surgical treatment in the early-stage CC has evolved during the last decades. Our aim was to review the advances in the literature and summarize the ongoing studies on this topic. To this end, we conducted a literature review through PubMed focusing on English-language articles on the surgical management of early-stage CC. The emergent topics considered here are the FIGO 2018 staging system update, conservative management with less radical procedures for selected patients, lymph node staging, fertility preservation, preferred surgical approach, management of tumors up to 2 cm, and prognosis. In terms of updating FIGO, we highlight the inclusion of lymph node status on staging and the possibility of imaging. Regarding the preferred surgical approach, we emphasize the LACC trial impact worldwide in favor of open surgery; however, we discuss the controversial application of this for tumors < 2 cm. In summary, all topics show a tendency to provide patients with tailored treatment that avoids morbidity while maintaining oncologic safety, which is already possible in high-income countries. We believe that efforts should focus on making this a reality for low-income countries as well.

Lymph Node Involvement in Early-Stage Cervical Cancer: Is Lymphangiogenesis a Risk Factor? Results from the MICROCOL Study

Simple Summary

The prognosis of cervical cancer is significantly influenced by lymph node involvement. The lymphatic system is the primary way of metastasis for cervical carcinoma, and lymph-vascular space invasion (LVSI) is considered the most important risk factor for pelvic lymph node metastasis (PLNM). Previous studies have not clarified the correlation between lymphangiogenesis and an increased risk of metastasis and tumor recurrence. The evaluation and identification of several markers of lymphangiogenesis may identify patients with high risk of PLNM. Our findings suggest that the lymphatic spread does not required the proliferation of new lymphatic endothelial cells. These results emphasize the importance of pre-existing peritumoral lymphatic vessels in the metastatic process in early cervical cancer.

Abstract

Background: In patients with cervical cancer, the presence of tumoral lymph-vascular space invasion (LVSI) is the main risk factor for pelvic lymph node metastasis (PLNM). The objective of this study was to evaluate the presence of several markers of lymphangiogenesis in early-stage cervical cancer and their correlation with PLNM and tumoral recurrence. Materials and Methods: Seventy-five patients with early-stage cervical carcinoma underwent sentinel lymph node (SLN) sampling in association with complete pelvic lymph node dissection. Primary tumors were stained with the following markers: Ki67, D2-40, CD31 and VEGF-C. A 3-year follow-up was performed to evaluate the disease-free survival. Results: Overall, 14 patients (18.6%) had PLNM. Positive LVSI was seen in 29 patients (38.6%). There was a significant correlation between LVSI evidenced by H/E staining and PLNM (p < 0.001). There was no correlation between high Ki67, CD31, D2-40, and VEGF-C staining with PLNM or tumor recurrence. Conclusions: Our data support that lymphatic spread does not require the proliferation of new lymphatic endothelial cells in early-stage cervical cancer. These results emphasize the importance of pre-existing peritumoral lymphatic vessels in the metastatic process in early cervical cancer. None of the markers of lymphangiogenesis and proliferation assessed in this study were predictive of PLNM or recurrence.

MRI-based radiomics analysis to evaluate the clinicopathological characteristics of cervical carcinoma: a multicenter study

BACKGROUND

Preoperative prediction of clinical pathological indicators of cervical cancer (CC) is of great significance to the formulation of personalized treatment plans for CC.

PURPOSE

To investigate magnetic resonance imaging (MRI) radiomics analysis for the evaluation of pathological types, tumor grade, FIGO stage, and lymph node metastasis (LNM) of CC.

MATERIAL AND METHODS

A total of 235 patients with CC from three institutes were enrolled in the study. All patients underwent T2/SPAIR and contrast-enhanced T1-weighted (CE-T1WI) imaging scans before radical hysterectomy by pelvic lymph node dissection surgery. Radiomics features extracted from T2/SPAIR and CE-T1WI imaging were selected by the least absolute shrinkage and selection operator (LASSO) methods for further radiomics signature calculation. These radiomic features were used to construct regression and decision tree models to evaluate the performance of radiomic features in distinguishing clinicopathological indicators.

RESULTS

The area under the curve (AUC) of T2/SPAIR and CE-T1WI imaging were 0.777 and 0.750, respectively, for differentiating between adenocarcinoma and squamous cell carcinoma. From the two sequences, the AUC of the verification group that distinguished low FIGO stage from high FIGO stage was 0.716 and 0.676, respectively. The AUC for moderately well and poorly differentiated tumors were 0.729 on T2/SPAIR and 0.749 on CE-T1WI imaging. The AUC of the verification groups for LNM was 0.730 and 0.618 on T2/SPAIR and CE-T1WI imaging, respectively.

CONCLUSION

MRI radiomics features can be used as a non-invasive method to evaluate the clinicopathological indexes of CC and provide an important auxiliary examination method for patients to determine individualized treatment plans before operation.

Evidence for disseminated tumor cells in lymphatic vessels afferent to sentinel lymph nodes in patients diagnosed with cervical cancer

BACKGROUND

In patients diagnosed with cervical cancer, the purpose of lymphadenectomy is the removal of lymph nodes for diagnosis and potential treatment of metastasized tumor cells. It is unclear if afferent lymphatic vessels harbor tumor cells and, thus, may pose additional risk for recurrence or progression if not removed.

AIM

In this feasibility study, we analyzed the lymphatic vessels afferent to sentinel lymph node (SLN) using a highly sensitive and specific molecular marker for cervical cancer cells.

METHODS AND RESULTS

Twenty patients diagnosed with cervical cancer of FIGO stage IA1 to IIB2 underwent laparoscopic SLN removal. Labeling was done using patent blue and the afferent lymphatic vessels were harvested from the parametric tissue and frozen at -80°C. HPV DNA type was evaluated in the primary tumor. Lymphatic vessels afferent to the sentinel lymph nodes were analyzed for the presence of viral oncogene transcripts of the respective HPV type. In one of 18 patients, all with tumor stage ≤IBI and pN0 by conventional histopathology, HPV mRNA could be detected in two of four lymphatic vessels, whereas at least one of the lymphatic vessel biopsies of both patients with tumors ˃4 cm and pN1 status was HPV mRNA positive. No clinical correlation with recurrence after a median follow-up of 9 years was noticed.

CONCLUSION

HPV mRNA indicative of disseminated tumor cells could be detected in lymphatic vessels. The relevance of harvesting lymphatic vessels afferent to SLN in order to increase oncologic safety will have to be investigated in a future prospective study.

Pathological factors associated with non-sentinel lymph node metastasis in early stage cervical cancer

OBJECTIVE

To analyze the predictive factors for non-sentinel lymph node (non-SLN) metastasis in early-stage cervical cancer.

METHODS

We analyzed a series of 113 patients who underwent sentinel lymph node (SLN) mapping for cervical cancer. The SLNs were examined by immunohistochemistry (IHC) when the hematoxylin-eosin stain was negative.

RESULTS

The overall bilateral detection rate was 81.5%, with a median of two SLNs resected. The study ultimately included 92 patients with SLNs that were mapped who had also undergone systematic pelvic lymph node dissection. Thirteen (14.1%) patients had positive SLNs, with a median of one positive SLN. Regarding the size of SLN metastasis, one (1.1%) had isolated tumor cells (ITC), seven (7.6%) had micrometastases, and five (5.4%) had macrometastases. Notably, 46.1% (6/13) had lymph node metastases detected only after IHC. Five (38.5%) cases had positive non-SLNs, with a median count of one positive lymph node. Parametrial invasion was the only risk factor for positive non-SLN (p = .045). Regarding the size of SLN metastasis, non-SLN involvement was present in the only case with ITC (1/1), 42.9% (3/7) of cases with micrometastases, and in 20% (1/5) with macrometastases.

CONCLUSIONS

Our data suggest that parametrial invasion correlates with the risk of non-SLN metastasis in cervical cancer.

Status of Sentinel Lymph Node Biopsy in Vulvar and Cervical Cancer

Assessment of lymphatic metastasis is an essential component of solid tumour staging. Sentinel lymph node (SLN) biopsy is a minimally invasive procedure that allows regional lymph node involvement by tumour to be estimated by selectively examining the sentinel lymph node while minimising the morbidity of systematic lymph node dissection. Within the group of genital cancers, the diagnostic value of SLN biopsy is rated differently. For selected patients with early-stage vulvar cancer (unifocal primary tumour < 4 cm, clinically negative inguinal lymph nodes) the SLN technique is already an established procedure in the guidelines of the German Society for Gynaecology and Obstetrics (DGGG)/German Cancer Society (DKG) and the recommendations of the European Society of Gynaecological Oncology (ESGO). For cervical cancer, SLN biopsy has not yet been sufficiently standardised but can be considered for patients without risk factors with a primary tumour size < 2 cm. The SLN is identified by combined use of radioactive ^99m technetium nanocolloid and patent blue. The use of indocyanine green offers an alternative for SLN identification with few side effects. Recent studies aim to increase the diagnostic reliability of intraoperative frozen section analysis as this continues to show limited sensitivity in both vulvar and cervical cancer. The rate of detection of micrometastases can be increased by additional ultrastaging, the prognostic significance of which for both diseases is still unclear. The prognostic value of SLN biopsy compared with systematic lymph node dissection is being investigated in current studies (GROINSS-V-II for vulvar cancer and SENTIX-, SENTICOL-3 for cervical cancer). For this review article, a guideline-based literature search was performed in the National Library of Medicine (PubMed/MEDLINE) database with a particular focus on recent cohort studies and conference contributions.

Histopathologic Validation of the Sentinel Node Technique for Early-Stage Cervical Cancer Patients

BACKGROUND

The sentinel lymph node (SLN) biopsy may be an alternative to systematic lymphadenectomy in early cervical cancer. The SLN biopsy is less morbid and has been shown to have high sensitivity for metastasis detection. However, the sensitivity of the SLN technique might be overevaluated because SLNs are examined with ultra-staging, and non-sentinel nodes usually are examined only with routine techniques. This study aimed to validate the negative predictive value (NPV) of the SLN technique by the ultra-staging of SLNs and non-sentinel nodes (NSLNs).

METHODS

The SENTICOL 1 study data published in 2011 were used. All nodes (i.e., SLNs and NSLNs) were secondarily subjected to ultra-staging. The ultra-staging consisted of sectioning every 200 µm, in addition to immunohistochemistry. Moreover, the positive slides and 10% of the negative slides were reviewed.

RESULTS

The study enrolled 139 patients, and SLNs were detected in 136 (97.8%) of these patiets. Bilateral SLNs were detected in 104 (76.5%) of the 136 patients. A total of 2056 NSLNs were identified (median, 13 NSLNs per patient; range 1-54). Of the 136 patients with SLNs, 23 were shown to have positive SLNs after serial sectioning and immunohistochemical staining. The NSLNs were metastatic in six patients. In the case of bilateral SLN detection, the NPV was 100%, with no false-negatives (FNs).

CONCLUSIONS

The pelvic SLN technique is safe and trustworthy for determining the nodal status of patients with early-stage cervical cancer. In the case of optimal mapping with bilateral detection, the NPV was found to be 100%.

The impact of low-volume metastasis on disease-free survival of women with early-stage cervical cancer

PURPOSE

We aimed to assess the impact of low-volume metastasis (micrometastasis and isolated tumor cells) on disease-free survival (DFS) of women with early-stage cervical cancer.

METHODS

Women with clinically suspected stage 1A-IB2 (FIGO 2018 classification) disease who underwent retroperitoneal nodal staging between October 2010 and April 2018, were retrospectively analyzed. The group of women who had undergone lymphadenectomy and standard node pathologic analysis (H&E group), were compared to the group undergoing sentinel node mapping (SLN) and ultrastaging with or without lymphadenectomy (ultrastaging group). At a median follow-up of 45 months, the DFS curves were analyzed.

RESULTS

Overall, 573 patients were revised (272 in the H&E group and 302 in the ultrastaging group). Eighty-five patients presented lymph node metastasis (32 in H&E, 53 in ultrastaging). Ultrastaging protocol increased the rate of low-volume metastasis by 5.6%. Twenty patients showed exclusive micrometastasis or ITC's. Seventy-three recurrences occurred (35 in H&E, 38 in ultrastaging). Only 1 out of 53 patients in the ultrastaging group (1.9%) presented with micrometastasis recurred. The 3-year disease-free survival was 89% for the H&E group, and 88% for the ultrastaging group, respectively (p = 0.175).

CONCLUSION

Ultrastaging analysis allowed increasing the detection of low volume metastasis in women with early-stage cervical cancer. However, the type of nodal staging did not have an impact on patients' 3-year disease-free survival.

Role of carbon nanoparticle suspension in sentinel lymph node biopsy for early-stage cervical cancer: a prospective study

OBJECTIVE

To evaluate the clinical diagnostic validity of carbon nanoparticle suspension (CNS) in sentinel lymph node biopsy (SLNB) for assessing lymphatic spread of early-stage cervical cancer.

DESIGN

A prospective study.

SETTING AND POPULATION

356 cases.

METHODS

We enrolled 356 stage Ia2-IIa2 cervical cancer patients to undergo SLNB using CNS, followed by systematic pelvic lymphadenectomy. All lymph node specimens were assessed using conventional histopathologic ± pathologic ultrastaging analyses.

MAIN OUTCOME MEASURES

Sentinel lymph node detection rate (DR), clinical diagnostic validity and various related factors were analysed.

RESULTS

CNS identified 1456 SLNs in 325 patients. The overall SLN DR was 91.29%. A significantly higher DR was found for patients with tumours <20 mm (97.75% versus 71.91%; P < 0.001). Two patients had false-negative results. SLNB with CNS had sensitivity of 96.65%, false-negative rate (FNR) of 4.35% and negative predictive value (NPV) of 99.29%. Importantly, sensitivity (100%), NPV (100%) and FNR (0%) were improved when testing the subgroup of patients with tumours <20 mm (267 cases). There were no observed differences in DR based on pathological type or grade, stage, depth of stromal invasion, surgical approach, menopausal status or prior treatment with chemotherapy (P > 0.05).

CONCLUSIONS

Sentinel lymph node biopsy with CNS results in favourable DR, sensitivity and NPV for women with early-stage cervical cancer with small tumour sizes. SLNB with CNS is safe, feasible and relatively effective for guiding precise surgical treatment of early-stage cervical cancer.

TWEETABLE ABSTRACT

Sentinel lymph node biopsy with carbon nanoparticle suspension is safe and feasible for early-stage cervical cancer.

Radiomics Analysis of Multiparametric MRI for the Preoperative Prediction of Lymph Node Metastasis in Cervical Cancer

Objective: To develop and validate a radiomics predictive model based on multiparameter MR imaging features and clinical features to predict lymph node metastasis (LNM) in patients with cervical cancer.

Material and Methods: A total of 168 consecutive patients with cervical cancer from two centers were enrolled in our retrospective study. A total of 3,930 imaging features were extracted from T2-weighted (T2W), ADC, and contrast-enhanced T1-weighted (cT1W) images for each patient. Four-step procedures, mainly minimum redundancy maximum relevance (MRMR) and least absolute shrinkage and selection operator (LASSO) regression, were applied for feature selection and radiomics signature building in the training set from center I (n = 115). Combining clinical risk factors, a radiomics nomogram was then constructed. The models were then validated in the external validation set comprising 53 patients from center II. The predictive performance was determined by its calibration, discrimination, and clinical usefulness.

Results: The radiomics signature derived from the combination of T2W, ADC, and cT1W images, composed of six LN-status-related features, was significantly associated with LNM and showed better predictive performance than signatures derived from either of them alone in both sets. Encouragingly, the radiomics signature also showed good discrimination in the MRI-reported LN-negative subgroup, with AUC of 0.825 (95% CI: 0.732–0.919). The radiomics nomogram that incorporated radiomics signature and MRI-reported LN status also showed good calibration and discrimination in both sets, with AUCs of 0.865 (95% CI: 0.794–0.936) and 0.861 (95% CI: 0.733–0.990), respectively. Decision curve analysis confirmed its clinical usefulness.

Conclusion: The proposed MRI-based radiomics nomogram has good performance for predicting LN metastasis in cervical cancer and may be useful for improving clinical decision making.

Detection of sentinel lymph node in laparoscopic surgery for uterine cervical cancer using carbon nanoparticles

BACKGROUND AND OBJECTIVES

Carbon nanoparticles (CNPs) has been widely confirmed the efficiency in sentinel lymph node (SLN) mapping for various solid tumors. This study aims to explore the feasibility and effectiveness of CNPs during laparoscopic surgery for cervical cancer.

METHODS

We analyzed 45 women with stage IB1-IIA1 cervical cancer who underwent SLN mapping using CNPs during laparoscopic surgery. The effectiveness of CNPs was evaluated by the detection rate and accuracy parameters. Factors associated with SLN laterality and SLNs localizations were analyzed.

RESULTS

The overall and bilateral detection rate was 93.3% (42/45) and 60.0% (27/45), respectively. Elevated body mass index was associated with decreased bilateral detection rate (P = .015). A total of 225 SLNs were harvested, with a mean number of 5.0 ± 3.6. A total of 81.3% of SLNs were in expected localizations including external iliac (39.1%), internal iliac (25.8%), and obturator (16.4%) regions, while 18.7% in unusual localizations including common iliac (10.7%), parametrial (7.6%), and presarcal (0.4%) regions. None positive lymph node was found in non-SLNs with a false-negative rate of 0%.

CONCLUSION

Laparoscopic SLN mapping with CNPs appears to be simple and efficient for patients with early-stage cervical cancer.

Two ultrastaging protocols for the detection of lymph node metastases in early-stage cervical and endometrial cancers

OBJECTIVE

To date, there is no universal consensus on which is the optimal ultrastaging protocol for sentinel lymph node (SLN) evaluation in gynecologic malignancies. To estimate the impact of different ultrastaging methods of SLNs on the detection of patients with nodal metastases in early-stage cervical and endometrial cancers and to describe the incidence of low-volume metastases between two ultrastaging protocols.

METHODS

We retrospectively compared two ultrastaging protocols (ultrastaging-A vs ultrastaging-B) in patients with clinical stage I endometrial cancer or FIGO stage IA-IB1 cervical cancer who underwent primary surgery including SLN biopsy from October 2010 to December 2017 in our institution. The histologic subtypes and grades of the tumors were evaluated according to WHO criteria. Only SLNs underwent ultrastaging, while other lymph nodes were sectioned and examined by routine hematoxylin and eosin (H&E).

RESULTS

Overall 224 patients were reviewed (159 endometrial cancer and 65 cervical cancer). Lymph node involvement was noted in 15% of patients with endometrial cancer (24/159): 24% of patients (9/38) with the ultrastaging protocol A and 12% (15/121) with the ultrastaging protocol B (p=0.08); while for cervical cancer, SLN metastasis was detected in 14% of patients (9/65): 22% (4/18) in ultrastaging-A and 11% (5/47) in ultrastaging-B (p=0.20). Overall, macrometastasis and low-volume metastases were 50% and 50% for endometrial cancer and 78% and 22% for cervical cancer. Median size of nodal metastasis was 2 (range 0.9-8.5) mm for the ultrastaging-A and 1.2 (range 0.4-2.6) mm for the ultrastaging-B protocol in endometrial cancer (p=0.25); 4 (range 2.5-9.8) mm for ultrastaging-A and 4.4 (range 0.3-7.8) mm for ultrastaging-B protocol in cervical cancer (p=0.64).

CONCLUSION

In endometrial or cervical cancer patients, the incidence of SLN metastasis was not different between the two different types of ultrastaging protocol.

Detection of high-risk human papillomavirus DNA in sentinel lymph nodes of patients with cervical cancer

The aim of the present study was to investigate the expression of human papillomavirus (HPV) DNA in sentinel lymph nodes (SLN) in patients with early-stage cervical cancer (CC). In addition, the present study compared the positive rate of SLNs metastasis detected by routine pathological examination, and investigated the value of HPV-DNA in the detection of early CC lymph node micrometastasis. Reverse transcription-quantitative PCR (RT-qPCR) was used in order to evaluate the HPV DNA detection in all CC samples [International Federation of Gynecology and Obstetrics (FIGO) stage IA2-IIA2]. The consistency of HPV-DNA was compared between primary lesions and SLNs. The positive rates of HPV-DNA were compared with pathological diagnosis of SLN metastasis, and the association between the positive expression of HPV-DNA in SLNs and the clinical and pathological parameters of patients with cervical cancer were analyzed. A total of 345 sentinel lymph nodes were detected in 100 patients with IA2-IIA2 CC. The positive rates of RT-qPCR and conventional histopathological detection of SLNs metastasis were 31.6% (109/345) and 12.8% (44/345), respectively (P<0.001). The positive expression of HPV-DNA in SLNs was associated with the clinical stage and tumor diameter (P<0.05), but not with patients' age, depth of cervical invasion, histological grade, lymphatic and vascular space invasion (LVSI), squamous cell carcinoma antigen (SCCAg) (P>0.05). The detection of HPV-DNA expression in pelvic lymph nodes of early CC may be used to improve the detection rate of micrometastasis, guide the postoperative adjuvant therapy more accurately and improve prognosis. Patients with positive HPV-DNA would require closer surveillance than those with negative HPV-DNA.

Noninvasive prediction of lymph node status for patients with early-stage cervical cancer based on radiomics features from ultrasound images

OBJECTIVE

To investigate the feasibility of a noninvasive detection of lymph node metastasis (LNM) for early-stage cervical cancer (ECC) patients with radiomics methods based on the textural features from ultrasound images.

METHODS

One hundred seventy-two ECC patients between January 2014 and September 2018 with pathologically confirmed lymph node status (LNS) and preoperative ultrasound images were retrospectively reviewed. Regions of interest (ROIs) were delineated by a senior radiologist in the ultrasound images. LIFEx was applied to extract textural features for radiomics study. Least absolute shrinkage and selection operator (LASSO) regression was applied for dimension reduction and for selection of key features. A multivariable logistic regression analysis was adopted to build the radiomics signature. The Mann-Whitney U test was applied to investigate the correlation between radiomics and LNS for both training and validation cohorts. Receiver operating characteristic (ROC) curves were applied to evaluate the accuracy of the radiomics prediction models.

RESULTS

A total of 152 radiomics features were extracted from ultrasound images, in which 6 features were significantly associated with LNS (p < 0.05). The radiomics signatures demonstrated a good discrimination between patients with LNM and non-LNM groups. The best radiomics performance model achieved an area under the curve (AUC) of 0.79 (95% confidence interval (CI), 0.71-0.88) in the training cohort and 0.77 (95% CI, 0.65-0.88) in the validation cohort.

CONCLUSIONS

The feasibility of radiomics features from ultrasound images for the prediction of LNM in ECC was investigated. This noninvasive prediction method may be used to facilitate preoperative identification of LNS in patients with ECC.

KEY POINTS

• Few studied had investigated the feasibility of radiomics based on ultrasound images for cervical cancer, even though it is the most common practice for gynecological cancer diagnosis and treatment. • The radiomics signatures based on ultrasound images demonstrated a good discrimination between patients with and without lymph node metastasis with an area under the curve (AUC) of 0.79 and 0.77 in the training and validation cohorts, respectively. • The radiomics model based on preoperative ultrasound images has the potential ability to predict lymph node status noninvasively in patients with early-state cervical cancer, so as to reduce the impact of invasive examination and to optimize the treatment choices.

Pathology of sentinel lymph nodes: historical perspective and current applications in gynecologic cancer

Efforts to reduce surgical morbidity related to en bloc lymph node removal associated with cancer surgery led to the development of targeted lymph node sampling to identify the lymph node(s) most likely to harbor a metastasis. Through identification of one or only a few lymph nodes at highest risk, the overall number of lymph nodes removed could be markedly reduced. Submission of fewer lymph nodes affords more detailed pathologic examination than would otherwise be practical with a standard lymph node dissection. Such enhanced pathologic examination techniques (ie, ultra-staging) have contributed to increased detection of lymph node metastases, primarily by detection of low volume metastatic disease. Based on the success of sentinel lymph node mapping and ultra-staging in breast cancer and melanoma, such techniques are increasingly used for other organ systems including the gynecologic tract. This review addresses the historical aspects of sentinel lymph node evaluation and reviews current ultra-staging protocols as well as the implications associated with increased detection of low volume metastases.

Role of one-step nucleic acid amplification (OSNA) to detect sentinel lymph node low-volume metastasis in early-stage cervical cancer

INTRODUCTION

Growing evidence in the literature supports the accuracy of sentinel lymph node (SLN) biopsy in early-stage cervical cancer. One-step nucleic acid amplification (OSNA) is a rapid assay able to detect cytokeratin 19-mRNA in SLNs, and it can be used for intra-operative detection of low-volume metastases. The aim of this study was to evaluate the rate of low-volume metastasis in SLNs detected by OSNA in patients with early-stage cervical cancer. Secondary aims were to define the sensitivity and the negative predictive value of SLN biopsy assessed with OSNA.

METHODS

After IRB approval, consecutive patients who underwent surgery for International Federation of Gynecology and Obstetrics stage IA1 with lymph-vascular space involvement to IB1 between November 2017 and July 2019 and had SLN biopsy and pelvic lymphadenectomy were included. SLNs were detected with indocyanine-green cervical injection and sent intra-operatively for OSNA.

RESULTS

Eighteen patients underwent SLN assessment with OSNA and systematic pelvic lymphadenectomy in the study period. Four (22.2%) patients had unilateral and 14 (77.8%) had bilateral mapping. OSNA detected micro-metastasis in 6/18 (33.3%) patients. All micro-metastases were detected in patients with bilateral SLN mapping. The sensitivity and negative predictive value of SLN in detecting lymph node metastasis with OSNA calculated per pelvic sidewall were 85.7% and 96.1%, respectively. The false negative rate in mapped sidewalls was 14.3%.

DISCUSSION

This is the first series entirely processing SLNs for OSNA in early-stage cervical cancer. OSNA is able to intra-operatively detect low-volume metastases in SLNs. Further studies are necessary to confirm the accuracy of this technique and to assess survival implications of low-volume metastases detected by OSNA.

Pathologic Protocols for Sentinel Lymph Nodes Ultrastaging in Cervical Cancer

CONTEXT.—

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

OBJECTIVE.—

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

DATA SOURCES.—

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

CONCLUSIONS.—

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

Oncologic impact of micrometastases or isolated tumor cells in sentinel lymph nodes of patients with endometrial cancer: a meta-analysis

PURPOSE

There is a gap in knowledge regarding the impact of micrometastases (MIC) and isolated tumor cells (ITCs) found in the sentinel lymph nodes of patients with endometrial cancer. Here, we present a meta-analysis of the published literature on the rate of MIC and ITCs after lymphatic mapping and determine trends in postoperative management.

METHODS

Literature search of Medline and PubMed was done using the terms: micrometastases, isolated tumor cells, endometrial cancer, and sentinel lymph node. Inclusion criteria were: English-language manuscripts, retrospectives, or prospective studies published between January 1999 and June 2019. We removed manuscripts on sentinel node mapping that did not specify information on micrometastases or isolated tumor cells, non-English-language articles, no data about oncologic outcomes, and articles limited to ten cases or less.

RESULTS

A total of 45 manuscripts were reviewed, and 8 studies met inclusion criteria. We found that the total number of patients with MIC/ITCs was 286 (187 and 99, respectively). The 72% of patients detected with MIC/ITCs in sentinel nodes received adjuvant therapies. The MIC/ITCs group has a higher relative risk of recurrence of 1.34 (1.07, 1.67) than the negative group, even if the adjuvant therapy was given.

CONCLUSION

We noted that there is an increased relative risk of recurrence in patients with low-volume metastases, even after receiving adjuvant therapy. Whether adjuvant therapy is indicated remains a topic of debate because there are other uterine factors implicated in the prognosis. Multi-institutional tumor registries may help shed light on this important question.

Clinical management of early-stage cervical cancer: The role of sentinel lymph node biopsy in tumors ≤2 cm

OBJECTIVE

To evaluate the experience with sentinel lymph node (SLN) biopsy in patients with early-stage cervical cancer at our hospital, and to analyze factors influencing the rate of false negatives.

STUDY DESIGN

This study was carried out at the Vall d'Hebron Hospital (Barcelona, Spain) between September 2000 and October 2016. All patients underwent SLN biopsy and systematic and bilateral pelvic lymphadenectomy, followed by radical hysterectomy. SLNs were analyzed by the pathologist by staining with hematoxylin-eosin and immunohistochemistry.

RESULTS

Patients (N = 128) had been diagnosed with early-stage cervical cancer (FIGO-2009 stages 1A2, IB1, and IIA1). The combined SLN detection rate (99-technecium and a blue dye) was 98.4%, bilateral in 76% of the patients. Positive SLNs were found in 19 patients (14.8%). Sensitivity of detection was 79.2% (CI95, 57.9-92.9), false negative rate 20.8% (CI95, 7.1-42.2), and negative predictive value 95.4% (CI95, 89.6-98.5). False negative cases were observed in 5 patients with tumors >2 cm and presenting lymphovascular space invasion. Micrometastases were detected during SLN ultrastaging in 3 patients (2.3%). The median follow-up was 8.24 years and the 5-year overall survival (OS) was 88.4% (CI95, 80.9-93.1).

CONCLUSION

SLN mapping and biopsy in early-stage cervical cancer is feasible and has high sensitivity to detect patients with initial metastases. The risk of false negatives could be lower in certain groups of patients, such as those with tumors ≤2 cm and no lymphovascular space invasion, but future studies will be required to test this hypothesis.

Feasibility of an ADC-based radiomics model for predicting pelvic lymph node metastases in patients with stage IB-IIA cervical squamous cell carcinoma

OBJECTIVES

To investigate the prediction value of a radiomics model based on apparent diffusion coefficient (ADC) maps for pelvic lymph node metastasis (PLNM) in patients with stage IB-IIA cervical squamous cell carcinoma (CSCC).

METHODS

A total of 153 stage IB-IIA CSCC patients who underwent preoperative MRI including DWI from January 2015 to October 2017 were retrospectively studied and divided into a training cohort ( n = 102) and a validation cohort ( n = 51). Radiomics features were extracted from the ADC maps. The one-way ANOVA method, Mann-Whitney U test and Pearson's correlation analysis were used for selecting radiomics features. Logistic regression analyses were used to develop the model. ROC analyses were used to evaluate the prediction performance of the model.

RESULTS

Clinical stage, tumor diameter, and MR-reported lymph node (LN) status were significantly associated with LN status ( p < 0.05 for both the training and validation cohorts). The radiomics model, which incorporated clinical stage, MR-reported LN status, and grey-level non-uniformity, showed good predictive performance in the training group (AUC 0.864; 95% CI, 0.782 - 0.924) and the validation group (AUC 0.870; 95% CI, 0.747 - 0.948). The performance of the radiomics model was significantly better than that of each predictive factor alone.

CONCLUSION

The presented radiomics model, a non-invasive preoperative prediction tool, has the potential to have more predictive efficacy than clinical and radiological factors for differentiating between metastatic and non-metastatic lymph nodes.

ADVANCES IN KNOWLEDGE

A radiomics model derived from the ADC maps of primary lesions demonstrated good performance for predicting PLNM in stage IB-IIA CSCC patients and may help to improve clinical decision-making.

Impact of micrometastasis or isolated tumor cells on recurrence and survival in patients with early cervical cancer: SENTICOL Trial

Objectives

The aim of this study was to evaluate the impact of micrometastasis and isolated tumor cells on disease recurrence in patients with early-stage cervical cancer.

Methods

We included patients with International Federation of Gynecology and Obstetrics (FIGO) stage IA1 with lymphvascular space invasion, stage IA2, and IB1 who participated in the SENTICOL1 trial. A centralized histologic analysis with re-reading and ultrastaging was performed 3 months after surgery and treatment was not impacted by findings from our study. Patients were followed for 3 years and outcomes were compared according to prognostic factors.

Results

A total of 139 patients were included and 13 recurrences were found. There were two recurrences in patients with positive sentinel lymph node (SLN) (one macrometastases and one micrometastases) and 11 recurrences in patients with negative lymph nodes (sentinel or non-sentinel). Among patients with positive SLN for micrometastases there was only one recurrence. No patient with isolated tumor cells on their lymph nodes experienced a recurrence. There was a significant decrease in disease-free survival in patients aged >50 years (p = 0.01).

Conclusion

Evidence of micrometastasis or isolated tumor cells in the SLN of untreated patients with early cervical cancer in the SENTICOL1 trial did not impact progression-free survival.

Sentinel lymph node (SLN) concept in cervical cancer: Current limitations and unanswered questions

Sentinel lymph node (SLN) biopsy has been increasingly used in the management of early-stages cervical cancer instead of systematic pelvic lymph node dissection (PLND). The aim of this article is to give a critical overview of key aspects related to this concept, such as a necessity for reliable detection of micrometastases (MIC) in SLN and the requirements for SLN pathologic ultrastaging, low accuracy of intraoperative detection of SLN involvement, and still a limited evidence of oncological safety of the replacement of PLND by SLN biopsy only in ≥IB1 tumours due to unknown risk of MIC in non-SLN pelvic lymph nodes in patients with negative SLN, and absence of any prospective evidence.

Preoperative SCC-Ag and thrombocytosis as predictive markers for pelvic lymphatic metastasis of squamous cervical cancer in early FIGO stage

Objectives:To explore the clinical significance of squamous cell carcinoma antigen (SCC-Ag) and thrombocytosis to predict pelvic lymphatic metastasis (PLM) of squamous cervical cancer (SCC) in International Federation of Gynecology and Obstetrics (FIGO) stages IA-IIA.

Methods:A retrospective clinicopathologic review of 782 patients of a primary cohort in three Chinese hospitals from 2010 to 2015, and 407 patients of a validation cohort in another institution from 2015 to 2017. A receiver operating characteristic curve was used to determine the optimal SCC-Ag threshold to predict PLM in the groups. Univariate and multivariate logistic analyses for PLM were performed to assess differences in outcome.

Results:In the primary and validation cohort, 15.6% (122/782) and 25.3% (103/407) patients were classified into the thrombocytosis group (platelet count >300 × 10⁹/L), respectively. Optimal cutoff values of SCC-Ag for predicting PLM of the thrombocytosis group and the normal group were 3.26 ng/mL (AUC 0.754; sensitivity 73.08%; specificity 72.92%; P = 0.000) and 4.58 ng/mL (AUC 0.706; sensitivity 53.26%; specificity 83.98%; P = 0.000), respectively, in the primary cohort, and 1.55 ng/mL (AUC 0.705; sensitivity 79.31%; specificity 55.41%; P = 0.000) and 1.75 ng/mL (AUC 0.655; sensitivity 69.57%; specificity 64.26%; P = 0.000), respectively, in the validation cohort. In multivariate logistic analysis, preoperative SCC-Ag over 3.26 ng/mL and lymphovascular space involvement were the significant predictors of PLM for SCC in FIGO stages IA-IIA.

Conclusions: Preoperative SCC-Ag alone or combined with thrombocytosis might be used as predictive markers for PLM before initial treatment in early stage SCC.

Results from Survey to Assess Current Trends in Surgical Practice in the Management of Women with Early Stage Cervical Cancer within the BGCS Community with an Emphasis on Routine Frozen Section Examination

In the UK, more than 3,200 new cases of cervical cancer are diagnosed each year. Early stage cervical cancer (IA2-IB1) treatment comprises central surgery mainly in the form of radical hysterectomy or fertility sparing surgery including trachelectomy as well as systematic pelvic lymphadenectomy to detect metastases and adjust treatment accordingly. Given the variation in determining the lymph node (LN) status, a major prognosticator, we reviewed the current UK practice of LN assessment in women undergoing surgery for early cervical cancer. A 7-question, web-based survey, screened by the BGCS committee, was circulated amongst BGCS members. The overall response rate was 51%. Only 12.5% of the respondents routinely performed frozen section examination (FSE); the main reasons for not doing FSE were the pressure on theatre time (54.5%) and the lack of available facilities (48.5%). When positive pelvic nodal disease was detected, in 21 out of 50 (42%) the planned radical hysterectomy (RH) was aborted. More than 70% of the respondents routinely performed RH without any prior resort to pelvic lymphadenectomy. Pretreatment surgical para-aortic LN assessment was performed by 20% of the respondents. The survey confirms the diversity of the UK practice patterns in the surgical treatment of early cervical cancer.