Clear Cell Carcinoma of the Uterine Cervix: A Clinical and Pathological Analysis of 47 Patients Without Intrauterine Diethylstilbestrol Exposure

Clinical and pathological characteristics of cervical clear cell carcinoma in patients not exposed to diethylstilbestrol: a comprehensive analysis of 49 cases

Purpose

This study aimed to investigate the clinical and pathological characteristics, treatment strategies, and prognosis of cervical clear cell carcinoma (CCCC) in patients not exposed to diethylstilbestrol in utero.

Methods

The patients diagnosed with CCCC at West China Second University Hospital of Sichuan University between January 2011 and Jun 2023 were enrolled for this retrospective study. The clinical characteristics and information on treatment and follow-up were collected. The Kaplan-Meier method and Cox regression analysis were performed to identify the relative variables for predicting progression-free survival (PFS) and overall survival (OS).

Results

Of the 49 patients included, the Federation International of Gynecology and Obstetrics (FIGO) (2018) stage distribution was 37 (75.5%) stage I, 6 (12.2%) stage II, and 6 (12.2%) stage III. The median follow-up interval was 24.1 months. Six (12.2%) patients had a recurrence, and five (10.2%) patients died. The 5-year PFS rate was 86.8%, and the 5-year OS rate was 88.2%. No recurrence or death was detected in two patients who successfully completed fertility-preserving treatment and seven patients who underwent surgery to preserve ovaries. Two patients became pregnant, giving birth to two babies. The univariate analysis showed that FIGO stage, Pelvic lymph node (PLN) metastasis, lymph vascular space invasion, and depth of stromal invasion (P < 0.05) were significantly associated with PFS and OS. However, no significant prognostic factors were identified in the multivariate analysis.

Conclusion

Ovary-preserving treatment and fertility-preserving surgery are safe and feasible in early-stage CCCC. Surveillance other than adjuvant treatment may be a better choice for early-stage CCCC without any pathological risk factors. More targeted therapies and immunotherapy should be pursued in future studies.

Window of opportunity with PD1 blockade before chemoradiotherapy for an advanced stage clear cell carcinoma of the cervix

Clear cell carcinoma is a rare and very aggressive subset of cervical cancer, with poor outcome if diagnosed at advanced stage. There are few data available on the optimal management of this histotype, and treatment recommendations that include surgery and chemoradiotherapy, are essentially based on those for squamous cell carcinoma. Here we report the case of a young patient newly diagnosed with advanced stage (FIGO IIB) clear cell carcinoma of the uterine cervix who received a window of opportunity one injection of nivolumab followed by standard chemoradiotherapy. She showed a persistent complete remission after 28 months of follow-up, but developed hypothyroidism, as a consequence of immunotherapy, and required lifelong thyroid hormone replacement.

Clinical Features and Prognostic Factors of Cervical Clear Cell Adenocarcinoma: A Retrospective Analysis of 74 Cases from a Tertiary Hospital

The retrospective study aimed to analyze the clinical characteristics, primary treatment, and prognosis of cervical clear cell adenocarcinoma in a tertiary referral center. The medical data of cervical clear cell adenocarcinoma patients treated in our institution between 1993 and 2020 were reviewed. Their clinical characteristics and information on treatment and follow-up were collected. Seventy-four cases were included. Six early-stage patients successfully preserved their fertility. Forty-five patients underwent a radical hysterectomy. Patients with pathological risk factors all received adjuvant treatment including chemotherapy, radiotherapy, and chemoradiation. Fifteen patients without risk factors underwent surveillance and five patients received adjuvant chemotherapy for poorly differentiated disease. Twenty cases had radiation for primary treatment. Six of them underwent surgery after chemoradiotherapy, and five had pathological residual disease, including three who had pathological risk factors. The median follow-up interval was 36 months, with a 3-year OS and PFS rate of 82.4% and 81.4%, respectively. No recurrence or death was observed in patients with fertility-sparing treatment. FIGO stage was prognostic factors of PFS (P = .001) and OS(P = .006) and lymph node status was that of PFS (P = .023). FIGO stage and lymph node status were prognostic factors for survival. Fertility-sparing treatment is a safe option for young patients in early stage. Early-stage patients without risk factors may benefit from postoperative surveillance. Occult tumor after chemoradiotherapy is common, and surgical resection is recommended when operable residual disease is detected.

Clinical Effect of Intrauterine 3-Dimensional Ultrasound on the Function of the Intrauterine Cavity of Puerpera With Intrauterine Adhesions and Safety of Pregnancy

ABSTRACT

This study aimed to analyze the diagnostic value of intrauterine 3-dimensional ultrasound and the functional characteristics of the intrauterine cavity for puerpera with intrauterine adhesions, and to explore the safety of pregnancy after treatment. A total of 102 puerperas with intrauterine adhesions were randomly selected, and intrauterine 3-dimensional ultrasound and 2-dimensional ultrasound were performed, respectively. Patients were followed up for 3 years to observe the pregnancy outcome and safety. The overall accuracy of diagnosing intrauterine adhesions through intrauterine 3-dimensional ultrasound was significantly higher than that through 2-dimensional ultrasound, and the accuracy of detecting mild intrauterine adhesions was significantly higher than that through 2-dimensional ultrasound, with statistically significant difference ( P < 0.05). There was no significant difference in the accuracy between intrauterine 3-dimensional and 2-dimensional ultrasound in detecting moderate and severe intrauterine adhesions ( P > 0.05). The difference in missed diagnosis and misdiagnosis rates between the 2 methods was statistically significant ( P < 0.05). All patients received hysteroscopic surgery, and 78 cases (76.47%) were naturally fertilized during postoperative follow-up, including 24 cases of mature delivery, 45 cases of cesarean delivery, and 9 cases of spontaneous abortion. The intrauterine 3-dimensional ultrasound examination of the intrauterine cavity will provide intuitive and comprehensive diagnostic information for a parturient with intrauterine adhesion. Its detection accuracy is higher, and the clinical application is noninvasive and safe, which has certain guiding significance for treatment.

Prognostic analysis of pT1-T2aN0M0 cervical adenocarcinoma based on random survival forest analysis and the generation of a predictive nomogram

Background

The efficacy of adjuvant radiotherapy for postoperative patients with early-stage cervical adenocarcinoma who are lymph node-negative is still inconclusive. Establishing a nomogram to predict the prognosis of such patients could facilitate clinical decision-making.

Methods

We recruited 4636 eligible patients with pT1-T2aN0M0 cervical adenocarcinoma between 2004 and 2016 from the Surveillance, Epidemiology and End Results (SEER) database. Random survival forest (RSF) and conditional survival forest (CSF) model was used to assess the prognostic importance of each clinical characteristic variable. We identified independent prognostic factors associated with overall survival (OS) by univariate and multivariate Cox regression risk methods and then constructed a nomogram. We stratified patients based on nomogram risk scores and evaluated the survival benefit of different adjuvant therapies. To reduce confounding bias, we also used propensity score matching (PSM) to match the cohorts before performing survival analyses.

Results

The RSF and CSF model identified several important variables that are associated with prognosis, including grade, age, radiotherapy and tumor size. Patients were randomly divided into training and validation groups at a ratio of 7:3. Multivariate cox analysis revealed that age, grade, tumor size, race, radiotherapy and histology were independent prognostic factors for overall survival. Using these variables, we then constructed a predictive nomogram. The C-index value for evaluating the prognostic nomogram fluctuated between 0.75 and 0.91. Patients were divided into three subgroups based on risk scores, and Kaplan-Meier (K-M) survival analysis revealed that in the low-risk group, postoperative chemotherapy alone was associated with a significantly worse OS than surgery alone. Following PSM, survival analysis showed that compared with surgery alone, radiotherapy was associated with a worse OS in the training group although there was no significant difference in the validation group.

Conclusions

For patients with pT1-T2aN0M0 cervical adenocarcinoma, adjuvant treatments such as postoperative radiotherapy or chemotherapy, compared with surgery alone, are of no benefit with regards to patient survival. Our prognostic nomogram exhibits high accuracy for predicting the survival of patients with early-stage postoperative cervical adenocarcinoma.

Factors Associated with Patient Survival in Clear Cell Adenocarcinoma of the Cervix: A Single-Center Experience in China

Purpose

Clear cell adenocarcinoma of the cervix (CCAC) is a rare pathological type of cervical cancer. This study aimed to report our clinical experience with CCAC treatment and analyze the factors associated with patient survival.

Patients and Methods

This single-center study included patients diagnosed with CCAC and treated between 01/2003 and 12/2017 at the Obstetrics and Gynecology Hospital of Fudan University. The patients diagnosed with CCAC that underwent radical resection were included. The Kaplan–Meier method and multivariable Cox regression analysis were performed to determine factors associated with patient survival.

Results

Fifty-four patients were included. None were exposed to diethylstilbestrol. The median follow-up was 96 (13.0, 120.0) months. The median recurrence-free survival (RFS) and overall survival (OS) were 68 and 78 months, respectively. Positive pelvic lymph nodes (HR=2.87, 95% confidence interval [CI] 1.14–7.22, P=0.03), tumor size >4 cm (HR=3.31, 95% CI 1.35–8.12, P=0.01), International Federation of Gynecology and Obstetrics (FIGO) IB2-IIA2 stage (HR=2.49, 95% CI 1.56–3.99, P=0.02), and postoperative therapy (HR=1.73, 95% CI 1.07–2.81, P=0.03) were associated with OS. Multivariable analysis showed that FIGO stage IB2-IIA2 (HR=2.36, 95% CI 1.52–3.68, P<0.01) and lymph node status (HR=3.05, 95% CI 1.12–8.28, P=0.03) were independently associated with OS.

Conclusion

Advanced FIGO stage and positive lymph node status are independently associated with shorter survival in patients with CCAC who were not exposed to diethylstilbestrol. After surgery, chemotherapy and concurrent chemoradiotherapy were not independently associated with the prognosis of patients with CCAC.

Precursor Lesions of Cervical Clear Cell Carcinoma: Evidence For Origin From Tubo-Endometrial Metaplasia

Cervical clear cell carcinoma (CCC) is an HPV-independent tumor historically associated with in-utero exposure to diethylstilboestrol. With the cessation of diethylstilboestro use, most contemporary cases are sporadic and of uncertain pathogenesis, with no established precursor lesion. Following the detection of 3 incidental "early" (FIGO stage IA1) cervical CCCs, all of which displayed adjacent tubo-endometrial metaplasia, we examined further cases, including resection specimens, of this tumor in an attempt to delineate potential precursors. We identified tubo-endometrial metaplasia in proximity to the tumor in 5 of 5 additional primary cervical CCCs, with some tubo-endometrial glands exhibiting subtle mild cytologic atypia. This observation adds to the sparse existing literature proposing tubo-endometrial metaplasia as a precursor to sporadic cervical CCC, with possible progression via an "atypical" transitional phase to malignancy. We also review the published literature regarding possible precursor lesions of primary cervical CCC.

A Rare Case of Clear Cell Cervical Carcinoma to a Woman, 50 Years After Diethylstilbestrol Exposure for Lactation Suppression

A 73-year-old lady presented with post-menopausal bleeding and a suspicious-looking endocervical polyp. She had a loop biopsy of the cervix that showed clear cell cervical carcinoma, and she was referred to our Gynaecology oncology team for further management. Following imaging for staging and an MDT discussion, she had a total abdominal radical hysterectomy that confirmed the diagnosis. The diagnosis of clear cell adenocarcinoma of the cervix is rare, accounting for 4% of cervical carcinomas. However, it is often correlated with diethylstilbestrol (DES) exposure in utero. It is well documented that daughters of mothers who received DES during pregnancy are at a higher risk of adenocarcinomas in the genital tract. In our case, the patient had been administered DES for lactation suppression 50 years earlier. After reviewing the relevant literature, we present the case of our patient, the management of this uncommon case, and help identify possible correlation/long-term implications to patients who received DES.

Clear Cell Adenocarcinoma of Uterine Cervix: A Single Institution Retrospective Experience

Purpose

The purpose of the study is to summarize the clinical characteristics and identify the prognosis of clear cell adenocarcinoma of the uterine cervix (CCAUC) in patients without a history of diethylstilbestrol (DES) exposure.

Methods

Forty-two patients with CCAUC, treated initially at Sun Yat-sen University Cancer Center between 1985 and 2017, were studied.

Results

Of all the CCAUC patients, the median age was 47 years old, and the median tumor size was 3 cm. Thirty-four early stage patients (IB = 28, IIA = 6) underwent radical surgery. Eight advanced stage patients (IIB = 8) received concurrent chemoradiotherapy (n = 4) or radical surgery (n = 4). Survival analysis showed that patients with early stage (IB-IIA) had a significantly better 5-year progression-free survival (PFS) and overall survival (OS) than those with advanced stage (IIB) (p < 0.05). The patients with negative pelvic lymph node (PLN) had a significantly better 5-year PFS and OS than those with positive PLN (p < 0.05). Radiotherapy (RT) did not affect PFS or OS in early stage patients with intermediate risk factors (p > 0.05). Adjuvant chemotherapy (CT) did not affect PFS or OS in early stage patients without risk factors (p > 0.05).

Conclusion

The FIGO stage and pelvic node status were important prognostic factors for both PFS and OS. For treatment modality, we recommended that radical surgery alone was used in early stage patients without high risk factors. Ovarian preservation in early stage patients involved some risk.

A Rare Case of Clear Cell Adenocarcinoma of the Cervix with No Intrauterine Diethylstilbestrol Exposure

Cervical cancer is the fourth most common cancer in females. Clear cell adenocarcinoma of the cervix is an uncommon histological variant and is usually seen with intrauterine exposure to diethylstilbestrol. A 28-year-old female with no intrauterine exposure to diethylstilbestrol presented with postcoital bleeding. A pelvic exam revealed a cervical mass. Imaging confirmed the cervical mass and positron emission tomography scan showed an increased uptake in the cervical mass as well as the para-aortic and pelvic lymph nodes. Biopsy showed a clear cell carcinoma of the cervix. She was treated with cisplatin and paclitaxel for eight cycles and concurrent radiation therapy. She had a complete response to therapy and has been in complete remission nine months from the end of therapy. There are no clear guidelines for the treatment of clear cell carcinoma with current therapy based on the treatment of squamous and non-clear cell adenocarcinoma. Cisplatin and paclitaxel could be an option, given the successful treatment of the patient in our case.

Expression and Significance of Immune Checkpoints in Clear Cell Carcinoma of the Uterine Cervix

The purpose of this study was to investigate the expression levels of the immune checkpoint proteins, programmed cell death-ligand 1 (PD-L1), B7-H3, B7-H4, and V-domain Ig suppressor of T cell activation (VISTA), as well as the significance thereof, in clear cell carcinoma (CCC) of the cervix (a rare histological subtype of cervical cancer). We also compared the expression statuses of these biomarkers in cervical CCCs with those in cervical squamous cell carcinomas (SCCs). We evaluated the expression of PD-L1, B7-H3, B7-H4, and VISTA in 50 cervical CCCs and 100 SCCs using immunohistochemical staining and investigated the associations between these markers, clinicopathologic features, and survival in patients with CCCs. Of the cervical CCC samples examined, 22%, 16%, 32%, and 34% were positive for PD-L1, B7-H3, B7-H4, and VISTA, respectively. Nineteen samples (38%) were negative for all 4 of these markers, whereas 31 (62%) expressed at least 1 marker. None of these markers was associated with the investigated clinicopathologic variables or patient survival. PD-L1, B7-H3, and VISTA were observed significantly more frequently in SCCs than in CCCs of the cervix. Our study confirmed the expression of immune checkpoint proteins in cervical CCCs and indicated their nonredundant and complementary roles. As such, our data suggest that monotherapeutic immune checkpoint blockade may not be sufficiently effective in patients with cervical CCC.

Primary Clear Cell Adenocarcinoma of the Cervix: A Clinical Analysis of 18 Cases without Exposure to Diethylstilbestrol

OBJECTIVES

Cervical clear cell adenocarcinoma (CCAC) is a rare malignant tumor with independent biological behavior in the female reproductive system. In this report, we collect the clinical and histopathological characteristics of 18 CCAC patients without exposure to diethylstilbestrol (DES) and conduct relevant clinical analysis.

METHODS

We retrospectively analyzed the clinical data of 18 patients with CCAC who were diagnosed and treated from January 2009 to August 2017 in the Second Hospital of Jilin University.

RESULTS

A total of 18 patients were enrolled. The age of patients ranged from 37 to 74 years with the peak incidence between 45 and 55 years. The median age was 53 years. The most common symptom was vaginal bleeding (66.7%, 12/18). The most common type of lesion was the endocervical type (66.7%, 12/18). The negative rate of human papillomavirus (HPV) examination was 88.9% (8/9). Based on the staging criteria of the International Federation of Gynecology and Obstetrics (FIGO) cervical cancer clinical stage in 2018, 55.6% patients were stage I (n=10), 16.7% were stage II (n=3), 22.2% were stage III (n=4), and 5.6% were stage IV (n=1). Seventeen patients underwent surgery; 64.7% (11/17) of cases showed infiltration of the entire layer of the cervix, pelvic lymph node (PLN) metastasis was observed in 4 patients (26.7%, 4/15), endometrium metastasis was observed in 4 patients (25%, 4/16), and 13 patients (72.2%, 13/18) were diagnosed at an early stage (stage IB1-IIA2). Fifteen patients' immunohistochemistry indicated that napsin A, CK7, CK (AE1/AE3), and PAX-8 were positive, and p53, p16, ER, and vimentin were expressed to different degrees. Follow-up data were obtained in 13 patients (72.2%, 13/18). One patient died of recurrence 5 months after surgery, and the other patients' progression-free survival (PFS) ranged from 9 to 59 months. Tumor size (>4 cm), tumor stage (FIGO IIA2-IV), PLN, and endometrium metastasis had negative effects on PFS (P < 0.05).

CONCLUSIONS

CCAC is a highly invasive malignant tumor, whose pathogenesis may not be associated with HPV infection. Radical hysterectomy combined with chemotherapy (paclitaxel + platinum) has the ideal short-term curative effect. In the future, larger samples of clinical data are required to confirm these insights.

Tumour growth and immune evasion as targets for a new strategy in advanced cancer

It has become clearer that advanced cancer, especially advanced breast cancer, is an entirely displayed pathological system that is much more complex than previously considered. However, the direct relationship between tumour growth and immune evasion can represent a general rule governing the pathological cancer system from the initial cancer cells to when the system is entirely displayed. Accordingly, a refined pathobiological model and a novel therapeutic strategy are proposed. The novel therapeutic strategy is based on therapeutically induced conditions (undetectable tumour burden and/or a prolonged tumour ‘resting state’), which enable an efficacious immune response in advanced breast and other types of solid cancers.

Cervical clear cell adenocarcinoma with an exceptionally low proliferation index: Report of a case

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A histologically low-grade cervical clear cell lesion was observed.

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Proliferating cells were seen only at the periphery of this lesion.

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Due to its low proliferation index, this may represent a precursor of clear cell carcinoma.

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Further definition of such lesions may allow for more minimal management.