Advances in the surgical management of invasive cervical cancer

miR-197 is downregulated in cervical carcinogenesis and suppresses cell proliferation and invasion through targeting forkhead box M1

Cervical cancer is the second most common type of cancer in females worldwide. It has been demonstrated that microRNAs (miRs) serve important roles in the occurrence and development of various types of cancer, including cervical cancer. The results of the present study revealed that miR-197 was downregulated in cervical cancer tissues and cell lines. Restoration of miR-197 expression significantly inhibited cell viability and invasion of cervical cancer. Additionally, forkhead box M1 (FOXM1) was identified as a direct target gene of miR-197. Bioinformatic analysis revealed that FOXM1 was a potential target gene of miR-197. Luciferase reporter assay, reverse transcription-quantitative polymerase chain reaction and western blot analysis demonstrated that miR-197 decreased FOXM1 expression through direct binding to its 3'-untranslated region. Furthermore, the effects of FOXM1 underexpression were comparable with the effects induced by miR-197 overexpression in cervical cancer cells, suggesting that FOXM1 acted as a downstream effector in miR-197-mediated proliferation and invasion of cervical cancer cells. The results of the present study suggested that miR-197 inhibited growth and metastasis of cervical cancer by directly targeting FOXM1.

Laparoscopic Suturing as a Barrier to Broader Adoption of Laparoscopic Surgery

BACKGROUND

Laparoscopic surgery is increasingly replacing the open procedure because of its many patient-related benefits that are well aligned with policies and programs that seek to optimize health system performance. However, widespread adoption of laparoscopic surgery has been slow, in part, because of the complexity of laparoscopic suturing. The objective of this study was to review the clinical and economic impacts of laparoscopic suturing in key procedures and to assess its role as a barrier to the broader adoption of laparoscopic surgery.

DATABASE

A medical literature search of MEDLINE, EMBASE, and BIOSIS from January 2010 through June 2016 identified 47 relevant articles.

CONCLUSION

Laparoscopic suturing and intracorporeal knot tying may result in extended surgical time, complications, and surgeon errors, while improving patient quality of life through improved cosmesis, diet toleration, and better bowel movements. Despite advancement in surgical techniques and the availability of newer surgical tools, the complexity of laparoscopic suturing continues to be a barrier to greater adoption of MIS. The results of the study underscore the need for development of proficiency in laparoscopic suturing, which may help improve patient outcomes and reduce healthcare costs.

Does parents' socio-economic status matter in intentions of vaccinating against human papillomavirus for adolescent daughters?

BACKGROUND

The Human Papilloma Virus (HPV) vaccination provides substantial protection, and it is best to be taken before the age of twelve. Taiwan approved HPV vaccines since 2006. However, very few female adolescent have been vaccinated until now.

OBJECTIVES

To examine whether the parents' socio-economic status matters in deciding to purchase HPV vaccination for their daughters based on the theory of planned behavior.

METHOD

A structured questionnaire to collect 394 responses from parents of adolescent girls in Taiwan. Data was coded to categorize relevant socio-economic classes, and was analyzed with SPSS.

RESULTS

The behavior intentions of parents with low (mean= 5.28) and high (5.01) socio-economic status are significantly stronger than the moderate (4.56) in deciding to purchase the HPV vaccination. Socio-economic factor has a slightly negative impact (B= -0.08), and attitude (0.68), subjective norms (0.16), and behavior control (0.32) have positive impacts on the parents' intention.

CONCLUSION

Major impacts on the decision to purchase an HPV vaccination for their adolescent was not due to the parents' socio-economic status but the parent's attitude. As the major predictor of a less complicated decision, attitudes toward the HPV vaccination should be reinforced through continuous communications between service providers and patient-advocate groups.

Anatomical basis of female pelvic cavity for nerve sparing radical hysterectomy

PURPOSE

The separation and sparing of the vesical branch of the inferior hypogastric plexus (IHP), to preserve the pelvic autonomic nerve, is critical and difficult in nerve sparing radical hysterectomy. Pelvic local anatomy was performed to provide the necessary anatomical information.

METHODS

Precise pelvic anatomy was performed in 15 adult corpses, and immunohistochemical analysis was carried out on the parametrial tissues of three fresh cadavers to analyze the nerve fiber type and content of the vesical branch of the IHP.

RESULTS

The deep uterine vein is located in the upper region of the cardinal ligament (CL), with three to six multiple branches and anatomical variation, including one or two cervical branches, and two to four vesical branches. Three branches were found to be most common (63.3 %). The major distribution of the vesical branch of the IHP is dorsomedial to the middle and inferior vesical veins, with less ventral and lateral distribution. There are more sympathetic fibers than parasympathetic fibers in the vesical branch. There is a region rare of vasculature and nerve between the vaginal lateral margin and the vesical branch.

CONCLUSION

The deep uterine vein is suggested as an anatomical landmark during surgery, to process the CL and preserve the pelvic splanchnic nerves. The middle and inferior vesical veins can be used as the landmark to preserve the vesical branch of the IHP.

Effects of music relaxation video on pain and anxiety for women with gynaecological cancer receiving intracavitary brachytherapy: a randomised controlled trial

The purpose of this study was to explore the effects of music relaxation video on pain severity, opioid utilisation, and anxiety experienced by women with gynaecological cancer undergoing intracavitary brachytherapy. A two-group randomised controlled trial was conducted in an academic comprehensive cancer centre. Sixty women were randomly assigned to either an experimental group ( n = 31) that watched a 30-minute music relaxation video four times (total 120 minutes) or a control group ( n = 29) that received standard nursing care during the first 44 hours of the intracavitary brachytherapy. Data were collected to evaluate the effects on pain severity, opioid utilisation and anxiety between groups. Pain scores were measured before and after patients watched the 30-minute music relaxation video and anxiety scores were measured following the video. The amount of opioid consumption was recorded during the 44-hour treatment. Data were tested using ANOVA and t-test. Perceived pain reduction was statistically significant in the experimental group ( p = 0.027), but this did not translate into lower total consumption of opioids between the two study groups. Anxiety level reduction was statistically significant in the experimental group ( p = 0.001). Music relaxation videos hold promise to be used in conjunction with standard pharmacologic therapy to reduce perceived pain and anxiety levels during the treatments.

Vaginal laparoscopically assisted radical trachelectomy in cervical clear cell adenocarcinoma

Adenocarcinoma of the cervix is a rare condition that has shown an increase in incidence, especially in the 20- to 34-year-old group. Adenocarcinoma represents about 5–10% of all tumours in this area, and, among these, the clear cell type accounts for 4–9%. This type of tumour affects mainly postmenopausal women but also occurs in young women with a history of prenatal exposure to diethylstilbestrol (DES). The prognosis for adenocarcinoma of the cervix is poor overall and worse for the clear cell variety. This article discusses a case of clear cell adenocarcinoma of the cervix, unrelated to intrauterine exposure to DES, in a woman of childbearing age who wished to preserve her fertility and was therefore treated by radical vaginal trachelectomy and pelvic lymphadenectomy.

miR-99 inhibits cervical carcinoma cell proliferation by targeting TRIB2

MicroRNAs (miRNAs) have significant roles in cell processes, including proliferation, apoptosis and stress responses. To investigate the involvement of miR-99 in the inhibition of HeLa cell proliferation, an miR-99 gene expression vector (pU6.1/miR-99), which overexpressed miR-99 in HeLa cells after transient transfection, was constructed. The expression of miR-99 was detected by qPCR. Cell proliferation and apoptosis were analyzed by cell viability, proliferation and apoptosis assays, as well as by electron microscopy. The results showed that overexpression of miR-99 in HeLa cells increased the HeLa cell mortality rate. Moreover, miR-99 overexpression was able to markedly inhibit HeLa cell proliferation according to the 3-(4, 5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay. The cell apoptosis rate was significantly higher in pU6.1/miR-99-treated cells compared with that in the control cultures. Increases in intracellular electron density, as well as the proportion of nuclear plasma, blebbing phenomena and apoptotic bodies were observed in pU6.1/miR-99-treated cells compared with control cultures according to electron microscopy analysis. The Tribbles 2 (TRIB2) 3′-untranslated region was also observed to be targeted by miR-99 and the results further demonstrated that miR-99 was able to negatively regulate TRIB2 expression in HeLa cells The results indicate that miR-99 acts as a tumor suppressor gene in HeLa cells, establishing a theoretical basis for its application in cancer therapeutics.

Contribution of pelvic and para-aortic lymphadenectomy with sentinel node biopsy in patients with IB2-IIB cervical cancer

Objective:

Detection of lymph node involvement in women with IB2–IIB cervical cancer could have a positive effect on survival. We set out to evaluate the incidence of pelvic and/or para-aortic lymph node involvement using the sentinel node (SN) biopsy and its impact on survival.

Methods:

From 2002 to 2010, 66 women with IB2–IIB cervical cancer underwent a pelvic and paraaortic lymphadenectomy with SN biopsy. Survival between groups according to lymph node status was evaluated.

Results:

Mean tumour size was 43.5 mm. At least one SN was detected in 69% of the 45 SN procedures performed. Sixteen of these patients had metastatic SN and the false negative rate was 20%. Metastatic pelvic SNs or non-SNs were detected in 33 patients (50%), including pelvic-positive nodes in 26 (40%), pelvic- and paraaortic-positive lymph nodes in seven (11%), and paraaortic skip metastases in two (6%). Positive paraaortic node was the sole determinant for disease-free survival (DFS) and overall survival (OS; P<0.001). Differences in DFS and OS between groups according to the nodal status were observed (P<0.001).

Conclusion:

SN procedure gave a higher rate of metastasis detection. Further studies are required to evaluate whether pre-therapeutic node staging, including paraaortic and pelvic lymphanedectomy, should be performed.

Effect of nerve-sparing radical hysterectomy on bladder function recovery and quality of life in patients with cervical carcinoma

OBJECTIVE

To investigate the bladder function recovery and quality of life (QOL) using nerve-sparing radical hysterectomy (NSRH) in treating early invasive cervical carcinoma.

METHODS

Subjects included patients who underwent radical hysterectomy by laparotomy for early-stage cervical carcinoma. Thirty-one patients were randomly assigned to 2 groups: group A, 15 patients who underwent NSRH; and group B, 16 patients who underwent classical radical hysterectomy. We observed the patients' general clinical information, surgical characteristics, postoperative vital signs, pathological findings, adjuvant therapies, and adverse effects. A urodynamic study was used to assess the bladder function. The patients' QOL was evaluated by Functional Assessment of Cervical Cancer Therapy (FACT-Cx).

RESULTS

Twenty-nine patients completed the study. No significant differences were found in age, body mass index, surgery characteristics, pathological findings, adjuvant therapies, and main adverse effects between the 2 groups (P > 0.05). The postoperative time of bladder function recovery in group A was obviously earlier than that in group B (P < 0.05). The urodynamic study showed that the extent of bladder function recovery in group A was better than that in group B (P < 0.05). The QOL in group A evaluated 1 year after operation was improved compared with that in group B (P < 0.05). The QOL analysis showed that group A did much better than group B in social and family life, emotional well-being, working status, and the symptom correlated with the operation (P < 0.05). No significant differences were found in basic bodily functions (P > 0.05).

CONCLUSIONS

Nerve-sparing radical hysterectomy is a safe and reliable technique for early invasive cervical carcinoma. The postoperative bladder function recovery and the patients' QOL were improved after NSRH compared with the control group. Therefore, NSRH could be an alternative management to modify the classical surgery for cervical carcinoma with International Federation of Gynecology and Obstetrics stages IB1 to IIA.

Radical vaginal trachelectomy (Dargent's operation): A critical review of the literature

AIMS

To present a review of the most recent articles about radical vaginal trachelectomy (RVT).

METHODS

Recent literature has been reviewed, concentrating on surgical, oncological and obstetrical outcome of RVT. Data for this review were identified by searches of PubMed, and references from relevant articles using the search terms "trachelectomy" and "radical vaginal trachelectomy", "cervical carcinoma", and "fertility saving".

FINDINGS

Although a considerable number of women in their reproductive years have been diagnosed with cervical carcinoma, conservative management of early-stage cervical carcinoma did not come into practice until the beginning of the new millennium. To date, 7 gynecologic oncologic centers worldwide have reported oncological and pregnancy outcomes since Dargent made his first announcement of radical vaginal trachelectomy (RVT) in 1994. Recurrence and death rates (4.2% and 2.8%, respectively) of RVT seem to be comparable to classical radical abdominal hysterectomy. It appears that RVT's overall recurrence and death rates were similar to early-stage cervical cancer treated by radical hysterectomy (RH) or radiotherapy. Furthermore fertility results of RVT seem to be promising. A 70% pregnancy rate was reported in the women who wanted to conceive following RVT, though such patients should be informed about the risk of second trimester loss and preterm delivery. On the other hand, there is a lack of satisfactory information about the follow-up of post-RVT patients, both after the operation and during subsequent pregnancy.

CONCLUSION

RVT looks as if it is a valid uterus-conserving surgery for women of reproductive age who have early-stage cervical carcinoma. However, in order to reach a final conclusion about the oncological and obstetrical results, further studies are needed with larger sample sizes and longer follow-up periods.

New surgical approaches for the management of cervical carcinoma

Cervical carcinoma remains an important health problem in both developed and developing countries even though population-based screening programs are widely available. The classical surgical management of early-stage cervical carcinoma, known as radical hysterectomy (RH), was first described by Wertheim more than one hundred years ago and was then modified and re-popularized by Meigs in 1950s. The surgical principles of this operation have undergone only minor modifications and remain the basis for the surgical approach utilized by gynecologic oncologists today. However, some recent studies have questioned the role of RH due to a high rate of postoperative complications involving the pelvic autonomic nerve system and poor oncological outcomes despite postoperative adjuvant chemoradiation. During the last 2 decades, new surgical operations (radical vaginal trachelectomy, nerve-sparing hysterectomy, total mesometrial resection, laterally extended endopelvic resection, laparoscopic assisted radical vaginal hysterectomy, laparoscopic lumbo-aortic lymph node dissection, and laparoscopic pelvic exenteration) have been proposed for the management of both early- and late-stage cervical carcinoma. In this manuscript, some technical details and oncological outcomes of these new surgical approaches are summarized.

Oncological safety of laparoscopic-assisted vaginal radical trachelectomy (LARVT or Dargent’s operation): A comparative study with laparoscopic-assisted vaginal radical hysterectomy (LARVH)

OBJECTIVE

The aim of our study was to compare the results of radical trachelectomy (LARVT or Dargent's operation) to radical vaginal hysterectomy (LARVH) in terms of intraoperative and postoperative morbidity and mainly in terms of risk of tumor recurrence. Each technique is associated with laparoscopic pelvic lymph node dissection. Our objective was to know if performing radical trachelectomy in order to preserve the fertility of a young patient with an early cervical cancer is associated or not with an increased risk of operative morbidity or tumor recurrence.

METHODS

Patient affected by early invasive cervical cancer who has been submitted to LARVT (n=118) in our Institute between December 1986 and December 2003 has been compared to patients treated by LARVH (n=139) in the same period. All patient's information, surgical and pathological data and oncological results have been prospectively collected. The associations between the discrete variables were assessed using chi(2) test with Yate's correction when appropriate. Fisher's exact test was used when it was necessary. Continuous variables were compared by Student's t test. p values less than 0.05 were considered statistically significant. Statistical analysis used the Kaplan-Meier method to calculate disease-free and overall survival.

RESULTS

Between December 1986 and December 2003, 118 and 139 patients have undergone LARVT and LARVH, respectively, for FIGO stage I-IIA carcinoma of the cervix. The two populations (LARVT and LARVH) are comparable in terms of the main prognostic factors of cervical cancer. The rate of intraoperative complications has been similar in the two groups (2.5% for LAVRT and 5.8% for LAVRH, p=NS). Also the rate of postoperative complications has been similar in the two groups (21.2% for LAVRT and 19.4% for LAVRH, p=NS). When considering the risk of recurrence, the results in the two groups are also identical: 7 cases (5.2%) in patients treated with LAVRT and 9 cases (8.5%) in patients treated with LAVRH (p=NS).

CONCLUSION

Our data demonstrate that early cervical cancer (less than 2 cm diameter) can be treated successfully with LARVT with similar efficacy and recurrence rates to LARVH. In our experience radical trachelectomy is a safe treatment for young women affected by early cervical cancer who want to conserve their fertility.

Magnetic resonance imaging of the cervix

Due to deficiencies of clinical staging, magnetic resonance (MR) imaging is being increasingly used in the pre-treatment work-up of cervical cancer. Lymph node status, as evaluated by advanced imaging modalities, is also being incorporated into management algorithms. Familiarity with MR imaging features will lead to more accurate staging of cervical cancer. Awareness of impact of staging on management will enable the radiologists to tailor the report to clinically and surgically relevant information. This article emphasizes the guidelines on the MR staging criteria, dependence of newer treatments on imaging staging and lymph node involvement, and MR imaging in post-treatment surveillance of cervical cancer.

A fertility-preserving option in early cervical carcinoma: laparoscopy-assisted vaginal radical trachelectomy and pelvic lymphadenectomy

OBJECTIVE

Laparoscopic vaginal radical trachelectomy is a fertility-preserving alternative to radical hysterectomy or chemoradiation in young women with stage IA2 to IB cervical cancers. The aim of this study is to describe the feasibility and outcome of laparoscopic radical vaginal trachelectomy and pelvic lymphadenectomy in women treated with early cervical cancers who wish to maintain fertility.

STUDY DESIGN

From August 2000 through December 2004, 16 patients were offered this procedure. Patients were selected for this treatment on the basis of favorable cervical tumors and a desire to maintain fertility. Laparoscopic pelvic lymphadenectomies were performed in all patients. Vaginal radical trachelectomy was performed immediately if removed lymph nodes were negative. Obstetrical and oncological outcomes were evaluated.

RESULTS

Sixteen women underwent this procedure. The mean operative time was 142 min (115-178 min), with a mean blood loss of 180 ml (120-230 ml), and the average hospital stay was 6.7 days. No intraoperative or postoperative complications occurred. With an average follow-up of 28.2 months, there have been no recurrences. Five pregnancies have subsequently occurred, with two third-trimester deliveries, two miscarriages at 24 and 26 weeks' gestation, and one patient is currently 18 weeks' pregnant.

CONCLUSIONS

Laparoscopy-assisted radical vaginal trachelectomy is an adequate treatment, with its minimally invasive procedure and shorter recovery time, for early-stage cervical cancer in women who wish to preserve fertility. However, fertility issues remain the largest unanswered problem with this technique.

Is common iliac lymph node dissection necessary in early stage cervical carcinoma?

OBJECTIVES

Nodal metastasis is one of the most important prognostic factors in early stage cervical carcinoma and has an immense impact on the subsequent management. Thus, searching for nodal metastasis by pelvic lymphadenectomy is an integral part in the surgical management of cervical carcinoma. Complete nodal clearance of lymphatic tissue up to 2 cm above the bifurcation of common iliac vessels is therefore performed as a routine in our unit. The aim of this study is to investigate the incidence and pattern of pelvic lymph node metastases in patients with early stage cervical carcinoma to determine the role of common iliac node dissection in the surgery.

METHODS

We retrospectively reviewed 174 operation and histopathology reports of patients who underwent pelvic lymphadenectomy because of stage IA2 to IIA cervical carcinoma. Lymph nodes collected below and above the bifurcation of common iliac vessels were labeled as pelvic nodes and common iliac nodes, respectively. The incidence and distribution of nodal metastases were analyzed.

RESULTS

Complete and selective pelvic lymphadenectomy was performed in 163 and 11 patients, respectively. Nodal metastasis was documented in 35 (20.1%) patients. Pelvic and common iliac nodes were involved in 34 and 8 cases, respectively. All except one patient with common iliac node metastases were also found to have pelvic node metastasis.

CONCLUSIONS

In early stage cervical carcinoma, isolated common iliac lymph node metastasis is rare, especially in cases without associated high risk factors. Less extensive pelvic lymphadenectomy may be considered in these patients in order to reduce operation morbidity and time.

A review of total laparoscopic hysterectomy: role, techniques and complications

PURPOSE OF REVIEW

The following review examines the current role of total laparoscopic hysterectomy, which is a hysterectomy completed entirely laparoscopically. Recent advances in equipment, surgical techniques and training have made total laparoscopic hysterectomy a well tolerated and efficient technique. It is increasingly being adopted around the world because of the benefits to patients and surgeons. This study discusses the role of total laparoscopic hysterectomy, provides some technical suggestions about how to perform a total laparoscopic hysterectomy and how to avoid possible complications.

RECENT FINDINGS

Only a few surgeons performing total laparoscopic hysterectomy have published their techniques and results. The terminology and techniques for total laparoscopic hysterectomy used by different surgeons, such as energy sources, the use of uterine manipulators, vaginal tubes, the method for uterine artery ligation and method of vault closure, vary. This makes objective comparison of the literature, techniques and complication rates difficult.

SUMMARY

As more surgeons become trained in advanced laparoscopic surgery, the role of total laparoscopic hysterectomy will increasingly take over indications for total abdominal hysterectomy. It remains important that surgeons share their experience and publish their techniques, results and complications. Advanced laparoscopic training and supervision are paramount before embarking on total laparoscopic hysterectomy, so that complications are minimized.