Analysis of Prognostic Variables, Development of Predictive Models, and Stratification of Risk Groups in Surgically Treated FIGO Early-Stage (IA–IIA) Carcinoma Cervix

A Multicenter Study on Preoperative Assessment of Lymphovascular Space Invasion in Early-Stage Cervical Cancer Based on Multimodal MR Radiomics

BACKGROUND

As lymphovascular space invasion (LVSI) was closely related to lymph node metastasis and prognosis, the preoperative assessment of LVSI in early-stage cervical cancer is crucial for patients.

PURPOSE

To develop and validate nomogram based on multimodal MR radiomics to assess LVSI status in cervical cancer patients.

STUDY TYPE

Retrospective.

POPULATION

The study included 168 cervical cancer patients, of whom 129 cases (age 51.36 ± 9.99 years) from institution 1 were included as the training cohort and 39 cases (age 52.59 ± 10.23 years) from institution 2 were included as the external test cohort.

FIELD STRENGTH/SEQUENCE

There were 1.5 T and 3.0 T MRI scans (T1-weighted imaging [T1WI], fat-saturated T2-weighted imaging [FS-T2WI], and contrast-enhanced [CE]).

ASSESSMENT

Six machine learning models were built and selected to construct the radiomics signature. The nomogram model was constructed by combining the radiomics signature with the clinical signature, which was then validated for discrimination, calibration, and clinical usefulness.

STATISTICAL TESTS

The clinical characteristics were compared using t-tests, Mann-Whitney U tests, or chi-square tests. The Spearman and LASSO methods were used to select radiomics features. The receiver operating characteristic (ROC) analysis was performed, and the area under the curve (AUC), accuracy, sensitivity, and specificity were calculated.

RESULTS

The logistic regression (LR) model performed best in each sequence. The AUC of CE-T1-T2WI-combined was the highest in the LR model, with an AUC of 0.775 (95% CI: 0.570-0.979) in external test cohort. The nomogram showed high predictive performance in the training (AUC: 0.883 [95% CI: 0.823-0.943]) and test cohort (AUC: 0.830 [95% CI: 0.657-1.000]) for predicting LVSI. Decision curve analysis demonstrated that the nomogram was clinically useful.

DATA CONCLUSION

Our findings suggest that the proposed nomogram model based on multimodal MRI of CE T1WI-T2WI-combined could be used to assess LVSI status in early cervical cancer.

EVIDENCE LEVEL

4.

TECHNICAL EFFICACY

Stage 2.

Recent Advances in Cervical Cancer Management: A Review on Novel Prognostic Factors in Primary and Recurrent Tumors

BACKGROUND

Several pathological parameters, including tumor size, depth of stromal invasion, lympho-vascular space invasion and lymph node status, have been proposed as prognostic predictors in cervical cancer. However, given the high mortality and recurrence rate of cervical cancer, novel parameters that are able to provide additional prognostic information are needed in order to allow a better prognostic stratification of cervical cancer patients.

METHODS

A search was conducted on PubMed to identify relevant literature data regarding prognostic factors in cervical cancer. The key words "cervical cancer", "prognostic factors", "pathology", and "outcome" were used.

RESULTS

The novel pathological grading system based on tumor budding and cell nest size appeared the most relevant prognostic factor in primary neoplasms. Moreover, other potentially useful prognostic factors were tumor size, depth of stromal invasion, lympho-vascular space invasion, perineural invasion, tumor-free distance and tumor-infiltrating lymphocytes. Prognostic factors related to advanced-stage cervical cancer, including lymph-nodes status, endometrial and cervical involvement as well as distant metastases, were also taken into consideration.

CONCLUSIONS

According to our findings, tumor budding and cell nest size grading system, depth of stromal invasion, lympho-vascular space invasion, perineural invasion, tumor-free distance and tumor-infiltrating lymphocytes appeared the most relevant factors included in the pathology report.

Preliminary MRI Study of Extracellular Volume Fraction for Identification of Lymphovascular Space Invasion of Cervical Cancer

BACKGROUND

Lymphovascular space invasion (LVSI) is a risk factor for poor prognosis of cervical cancer. Preoperative identification of LVSI is very difficult.

PURPOSE

To evaluate the potential of extracellular volume (ECV) fraction based on T1 mapping in preoperative identification of LVSI in cervical cancer compared with dynamic contrast-enhanced MRI (DCE-MRI).

STUDY TYPE

Retrospective.

SUBJECTS

A total of 79 patients (median age 54 years) with cervical cancer were classified into LVSI group (n = 29) and without LVSI group (n = 50) according to postoperative pathology.

FIELD STRENGTH/SEQUENCE

A 3-T, noncontrast and contrast-enhanced T1 mapping performed with volume interpolated breath hold examination (VIBE) sequence, DCE-MRI applied with 3D T1-weighted VIBE sequence.

ASSESSMENT

Regions of interest along the medial edge of the lesion were drawn on slices depicting the maximum cross-section of the tumor. The noncontrast and contrast-enhanced T1 value of the tumor and arteries in the same slice were measured, and ECV was calculated from T1 values. The parametric maps (K^trans , k_ep , and v_e ) derived from DCE-MRI standard Toft's model were evaluated.

STATISTICAL TESTS

ECV, K^trans , k_ep , and v_e between groups with and without LVSI were compared using Student's t-test. The receiver operating characteristic (ROC) curve and DeLong test were used to evaluate and compare the diagnostic performance of ECV, K^trans , k_ep , and v_e for differentiating LVSI. P < 0.05 was considered statistically significant.

RESULTS

The ECV and K^trans of the LVSI group were significantly higher than that of non-LVSI group (52.86% vs. 36.77%, 0.239 vs. 0.176, respectively), and no significant differences in K_ep or v_e values were observed (P = 0.071 and P = 0.168, respectively). The ECV fraction showed significantly higher area under ROC curve than K^trans for differentiating LVSI (0.874 vs. 0.655, respectively).

DATA CONCLUSION

ECV measurements based on T1 mapping might improve the discrimination between patients with and without LVSI in cervical cancer, showing better performance for this purpose than DCE-MRI.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 2.

Oncologic outcomes of patients with FIGO 2014 stage IB-IIA cervical adenocarcinoma who underwent radical surgery

PURPOSE

To identify prognostic factors of early-stage cervical adenocarcinoma in patients with FIGO IB-IIA, who were treated with radical surgery.

MATERIALS AND METHODS

Clinical data of 64 patients with stage IB-IIA cervical adenocarcinoma who underwent radical hysterectomy and lymphadenectomy with or without adjuvant therapy between 1993 and 2019 were retrospectively reviewed. The clinicopathologic factors that affect the oncological outcomes were evaluated. The Kaplan-Meier method was used for the assessment of survival outcomes. Survival curves were compared using the log-rank test.

RESULTS

The 5-year recurrence-free survival and 5-year disease-specific survivals were 83% and 98%, respectively. Tumor size, stage of disease and uterine spread were significantly related prognostic factors for shorter recurrence-free survival. During the follow-up, nine (14.1%) patients recurred. Five of them were extrapelvic recurrence. No correlation was identified between histopathologic subtype and extrapelvic recurrence (p = 0.265). There was no difference between adjuvant only radiotherapy and concurrent chemoradiotherapy on recurrence-free survival in a univariate analysis adjusting for prognostic factors.

CONCLUSION

It is important to determine the prognostic factors that predict disease outcome in surgically treated cervical adenocarcinoma for tailored adjuvant treatment. Tumor size, stage and uterine spread are determinant factors for recurrence. Risk stratifications, including uterine spread may especially be useful for patients with AC.

Adjuvant treatment in cervical, vaginal and vulvar cancer

Primary surgical management is successful as the sole therapeutic modality in the majority of women with early-stage cervical, vaginal and vulvar cancer, but the presence of certain risk factors in the surgico-pathological specimen indicates a poorer prognosis. Adjuvant treatment can improve overall survival in such cases. Important risk factors in cervical cancer include intermediate-risk factors (large tumor size, deep cervical stromal invasion, lymph-vascular space invasion) and high-risk factors (positive or close margins, lymph nodes, or parametrial involvement). In vulvar cancer, positive margins and lymph nodes are the two most important factors for adjuvant therapy. Radiation therapy has been the mainstay of adjuvant therapy in these cancers, supplemented by chemotherapy. Recent advances have witnessed the inclusion of newer therapeutic modalities such as immunotherapy. This review addresses the current status of various adjuvant therapeutic modalities for these gynecological cancers.

The role of semiquantitative evaluation of lympho-vascular space invasion in early stage cervical cancer patients

OBJECTIVE

Lymph vascular space involvement (LVSI) is one of the most important prognostic factors in early stage cervical cancer. Its qualitative evaluation represents a milestone for patient risk stratification and treatment choice, but a semi-quantitative analysis of LVSI may offer a more truthful risk model, as already demonstrated for endometrial cancer. The present study aims to investigate the performances of a semi-quantitative evaluation of LVSI in terms of patient risk assessment.

METHODS

In this retrospective study were enrolled patients underwent surgical treatment for early cervical cancer from January 2009 to October 2018. A semi-quantitative evaluation such as the "three-tiered approach" was used to classify the LVSI pathway: negative vs. focal vs. diffuse.

RESULTS

Diffuse LVSI was found to be a risk factor for lymph node metastasis (OR: 9.844, p < 0.001), and parametrial involvement (OR: 5.566, p < 0.001). Lymph nodal recurrences were more frequent in diffuse LVSI group (LVSI negative vs. focal LVSI p = 0.369; LVSI negative vs. diffuse LVSI p = 0.002; Focal LVSI vs. diffuse LVSI p = 0.214); and so distant recurrences (LVSI negative vs. focal LVSI p = 0.623; LVSI negative vs. diffuse LVSI p = 0.002; Focal LVSI vs. diffuse LVSI p = 0.026). Patients with diffuse LVSI showed a worse disease-free survival (DFS) than patients with focal or absent involvement (DFS LVSI negative vs. focal LVSI p = 0.938; LVSI negative vs. diffuse LVSI p < 0.001; focal LVSI vs. diffuse LVSI p = 0.036).

CONCLUSION

Semi-quantitative evaluation of LVSI may be useful to identify risk patients for shorter disease-free survival and lymphatic and distant recurrences in patients with early stage.

Surgical Approach and Use of Uterine Manipulator Are Not Associated with LVSI in Surgery for Early-stage Cervical Cancer

STUDY OBJECTIVE

In 2018, the Laparoscopic Approach to Cervical Cancer trial reported that patients undergoing minimally invasive surgery for cervical cancer (CC) had poorer outcomes than patients undergoing open surgery. Several hypotheses have been made to explain the results. We aimed to investigate whether laparoscopic procedures and use of a uterine manipulator increase the risk of lymphovascular space invasion (LVSI) in early-stage CC.

DESIGN

A retrospective study.

SETTING

A Chinese women's and children's hospital.

PATIENTS

Patients with early-stage CC who underwent radical hysterectomy in West China Second University Hospital between April 2019 and May 2020.

INTERVENTIONS

Laparoscopic surgery (with uterine manipulator and uterine manipulator-free) and open surgery.

MEASUREMENTS AND MAIN RESULTS

A total of 979 patients diagnosed with CC were registered in West China Second University Hospital for surgical treatment. Of these, 525 patients underwent laparoscopic surgery and 454 patients underwent open surgery. In total, 735 patients with early-stage cancer underwent radical hysterectomy and pelvic lymphadenectomy, including 357 by laparoscopic surgery and 378 by open surgery. For those who underwent radical hysterectomy and pelvic lymphadenectomy, the incidence of LVSI was 48.41% and 47.34% in laparoscopic and open groups, respectively (p = .771). After 1:1 propensity score matching with age, International Federation of Gynecology and Obstetrics stage, pathology, and tumor size, the incidence of LVSI was 45.54% and 51.79% in laparoscopic and open groups, respectively (p = .186). Subdividing the laparoscopic group into uterine manipulator and uterine manipulator-free groups, the incidence of LVSI was 45.22% and 48.35%, respectively (p = .580). After propensity score matching with age, International Federation of Gynecology and Obstetrics stage, pathology, and tumor size, the incidence of LVSI was 45.78% and 55.42% in these 2 groups, respectively (p = .214). Multiple factor analysis revealed that lymph node metastasis and deep stromal invasion were associated with LVSI (p value <.05 in both groups).

CONCLUSION

The surgical approach and use of a uterine manipulator are not associated with LVSI in surgery for early-stage CC. Lymph node metastasis and deep stromal invasion are associated with LVSI.

Survival outcomes of low-risk and intermediate-risk stage IB1 cervical cancer patients

Background

Survival for patients with early stage cervical cancer without any high-risk factors treated with radical hysterectomy is excellent. However, there are few data on the survival outcomes for low-risk and intermediate-risk early stage cervical cancer patients.

Objective

To determine survival outcomes and prognostic factors of low-risk and intermediate-risk stage IB1 cervical cancer patients.

Methods

Stage IB1 cervical cancer patients with radical hysterectomy and pelvic lymphadenectomy were retrospectively reviewed. Patients with positive pelvic nodes, parametrial involvement, and positive margin who are classified as high-risk patients were excluded. Patients with squamous cell carcinoma or grade 1–2 adenocarcinoma, tumor size less than 2 cm, no lymphovascular space invasion (LVSI), and depth of stromal invasion (DSI) less than 10 mm were defined as low-risk patients. Survival was evaluated using the Kaplan–Meier method and compared by the log-rank test. Multivariate analysis was performed using Cox proportional-hazards regression.

Results

There were 82 (42.3%) low-risk patients and 112 (57.7%) intermediate-risk patients. More patients in intermediate risk received adjuvant treatment (3.6% and 14.3%, P = 0.07). Three (3.6%) low-risk patients and 18 (16.1%) intermediate-risk patients had recurrent disease (P = 0.004). At median follow-up of 86 months, 1.2% of low-risk patients and 8.9% of intermediate-risk had cancer-related deaths (P = 0.02). Low-risk patients had significantly better 5-year disease-free survival (98.2% vs 91.1%, P = 0.01) and estimated 5-year overall survival (98.5% vs 91.1%, P = 0.01). DSI more than 10 mm and presence of LVSI were significantly associated with recurrence. However, LVSI was an independent prognostic factor.

Conclusion

Stage IB1 cervical cancer patients had excellent survival. Low-risk patients had significantly better survival. Presence of LVSI was an independent prognostic factor.

Prognostic value of lymphovascular space invasion in patients with early stage cervical cancer in Jilin, China: A retrospective study

The metastasis of cervical carcinoma is associated with the lymphovascular spread. The primary objective of the present study was to determine the prognostic value of lymphovascular space invasion (LVSI) in patients with early-stage cervical cancer in Jilin, China.In this retrospective cohort study, patients with early-stage cervical cancer (stage IB-IIA) at the Second Hospital of Jilin University from February 2014 to December 2016 were included in the analysis. All included participants underwent radical hysterectomy with pelvic lymphadenectomy. LVSI was identified by hematoxylin and eosin (H&E) staining. The primary outcomes are overall survival (OS) and progression-free survival (PFS). Kaplan-Meier curves were used to calculate the patient's survival. Survival was compared using the log-rank test, while risk factors for the prognosis were assessed by Cox regression analysis.The incidence of LVSI was positively associated with the depth of stromal invasion (P = .009) and lymph node metastasis (LNM, P < .001). LVSI is an independent factor that affects OS (P = .009) and PFS (P = .006) in patients with early stage cervical cancer. LNM status is an independent factor that affects postoperative OS (P = .005).The incidence of lymphatic vessel infiltration is positively associated with the depth of stromal invasion and LNM. LVSI is an independent risk factor for the prognosis of early cervical cancer. The results suggest that further large-scale studies are needed to improve the treatment for patients with LVSI.

Surgical Treatment of Early-Stage Cervical Cancer: A Multi-Institution Experience in 2124 Cases in The Netherlands Over a 30-Year Period

OBJECTIVE

This study aimed to describe the pattern of recurrence and survival related to prognostic variables, including type of surgery as a clinical variable, in patients surgically treated for early cervix cancer.

METHODS

Records of 2124 patients who underwent a radical hysterectomy for International Federation of Gynaecology and Obstetrics stage I/IIA cervical cancer between 1982 and 2011 were reviewed. Clinical-pathologic prognostic variables, also including extent of parametrectomy, were identified and used in a multivariable Cox proportional hazard model to explore associations between disease-free survival (DFS) and prognostic variables.

RESULTS

The 5-year DFS for the total group was 86%. Large tumor diameter, nonsquamous histology, lymph node metastases, parametrial involvement, lymph vascular space invasion, deep stromal invasion, and less radical surgery were independent poor prognostic variables for survival. Disease-free survival was independently associated with the type of radical hysterectomy with pelvic lymphadenectomy in favor of more radical parametrectomy (hazard ratio, 2.0; 95% confidence interval, 1.6-2.5). This difference was not found in tumors with a diameter of at least 20 mm.

CONCLUSIONS

This study confirms that variables such as large tumor diameter, nonsquamous histology, lymph vascular space invasion, deep stromal invasion, positive lymph nodes, and parametrial infiltration are poor prognostic variables in early cervix cancer treated by surgery. The extent of parametrectomy had no influence on survival in tumors of 20 mm or less. For larger tumors, a more radical hysterectomy might be associated with better DFS. Taking into account the possible bias in this study as a result of its retrospective design, ideally a prospective cohort study with clear definition of radicality is necessary to answer this important clinical question.

Treatment results of adjuvant pelvic radiotherapy after radical hysterectomy for low-risk Stage IB1-IIA cervical cancer

Objective

The aim of the present retrospective analysis was to determine the effectiveness of pelvic radiotherapy (RT) as postoperative adjuvant therapy for low-risk cervical cancer.

Methods

Between June 2003 and April 2011, the clinical data of 225 International Federation of Gynecology and Obstetrics (FIGO) Stage IB1-IIA cervical cancer patients with low-risk factors were retrospectively reviewed, to analyze the relationship between adjuvant pelvic RT after radical hysterectomy and tumor recurrence or the patients' survival.

Results

The 5-year overall survival (OS) of 225 patients was 91.2% and 5-year disease-free survival (DFS) was 84.5%. The 5-year DFS and local regional disease-free survival was significantly better for patients in the RT group compared with that in the non-RT group (5-year DFS, 91.2% vs. 77.1%, P = 0.006; 5-year local regional disease-free survival 94.6% vs. 79.0%, P = 0.001). There were no statistically significant differences in the 5-year OS (92.9% vs. 89.4%, P = 0.371) and distant metastasis-free survival (96.4% vs. 96.5%, P = 0.887) between the two groups. Grade 3-4 treatment-related acute and late toxicities were not significantly different between the two groups. Subgroup analysis shows the 5-year DFS of RT alone, chemotherapy (CT) alone, non-RT/CT, RT and CT was, respectively, 90.5%, 62.9%, 81.4%, 92.5% separately (P = 0.002). The 5-year OS was not significantly different (91.6% vs. 78.2% vs. 92.9% vs. 96.9%, P = 0.887) between the four groups. Performing univariate analysis, postoperative CT was the only significant risk factor for DFS.

Conclusions

Our results indicate that postoperative adjuvant pelvic RT has a tendency to improve DFS especially local regional disease-free survival for FIGO Stage IB1-IIA cervical cancer patients with low-risk factors, without increased Grade 3-4 treatment-related acute and late toxicities, but non-standard CT is harmful to the prognosis (DFS) of these patients.

Validation of Nomograms for Survival and Metastases after Hysterectomy and Adjuvant Therapy in Uterine Cervical Cancer with Risk Factors

Background. Three nomogram models for early stage uterine cervical cancer have been developed (KROG 13-03 for overall survival [OS], SNUH/AMC for disease-free survival [DFS], and KROG 12-08 for distant metastases-free survival [DMFS]) after radical hysterectomy (RH) and pelvic lymph node dissection (PLND). This study aimed to validate these models using our cohort with adjuvant radiotherapy. Methods. According to the eligibility criteria of nomogram studies, patients were enrolled in Group A (N = 109) for the two KROG models (RH with PLND and whole pelvic irradiation) and Group B (N = 101) for the SNUH/AMC model (RH with PLND and squamous histology). Using Cox-regression hazard models, the prognostic factors of our cohorts were evaluated. The risk probabilities induced from published nomogram scores were calculated and the concordance indices were evaluated. Results. Group A had 88.1% 5-year OS and 86.0% 5-year DMFS. Group B had 83.0% 5-year DFS. In multivariate analyses, large tumor size for OS (HR 8.62, P < 0.001) and DMFS (HR 5.13, P = 0.003), young age (≤40 versus 41-64 years) for OS (HR 4.63, P = 0.097) and DFS (HR 3.44, P = 0.051), and multiple lymph node metastases (0 versus ≥3) for DMFS (HR 4.03, P = 0.031) and DFS (HR 3.90, P = 0.038) were significantly correlated. The concordance indices for OS, DMFS, and DFS were 0.612 (P = 0.002), 0.597 (P = 0.014), and 0.587 (P = 0.020), respectively. Conclusion. The developed nomogram models after RH and PLND are clinically useful in predicting various types of survival with significance.

Satellite lymphovascular space invasion: An independent risk factor in early stage cervical cancer

OBJECTIVE

This study was performed to determine whether satellite LVSI in women with early stage cervical carcinoma is an independent prognostic factor for recurrence and survival.

METHODS

A total of 210 eligible patients with FIGO stages IA2 and IB1 cervical carcinoma, who underwent radical hysterectomy or radical trachelectomy with pelvic lymphadenectomy between January 2000 and December 2012, were included. Variables studied included age, histology type, differentiation grade, tumor size (TS), depth of invasion (DI), lymph node metastasis (LNM), conjoined lymphovascular space invasion (LVSI) and satellite LVSI. Univariate and multivariate analyses were performed to define variables that best predict recurrence and survival.

RESULTS

Univariate analysis showed that differentiation grade, depth of invasion, tumor size, lymph node metastasis, and both conjoined LVSI and satellite LVSI were significantly associated with recurrence and survival. Using multivariate analysis, differentiation grade (HR 3.63, 95%-CI 1.51-8.72), conjoined LVSI (HR 5.95, 95%-CI 1.57-22.53) and satellite LVSI (HR 7.45, 95%-CI 3.03-18.27) were independent prognostic factors for recurrence; LNM (HR 5.55, 95%-CI 1.52-20.26) and satellite LVSI (HR 8.94, 95%-CI 2.43-32.95) were prognostic factors for overall survival. For patients with low-risk cervical cancer without LNM only satellite LVSI correlated significantly with disease-free and overall survival.

CONCLUSION

Differentiation grade, DI, TS, LNM, and conjoined LVSI as well as satellite LVSI were prognostic factors for DFS and OS. Satellite LVSI is the most important factor predicting DFS and OS in early stage cervical cancer, especially when lymph nodes are negative.

Leukemoid reaction in cervical cancer: a case report and review of the literature

Background

The presentation of a leukemoid reaction in cervical cancers is rare. A leukemoid reaction is defined as leukocytosis associated with a cause outside the bone marrow, with the white blood cell count (WBC) exceeding 50*10⁹/L. Two cervical cancers presenting with leukemoid reactions were previously reported. However, the cancers in these cases were mainly in the advanced stages and had a poor outcome.

Case presentation

Here we report a 40-year old patient with clinical stage (FIGO IIA1) cervical squamous carcinoma suffering from vaginal cuff recurrence with a leukemoid reaction two months after laparoscopic radical hysterectomy. The patient suffered from persistent fever and leukocytosis after one month of antibiotic treatment accompanied by rapid growth of the vaginal mass indicated that the leukocytosis could not be caused only by infection. After paclitaxel injection, the WBC count increased to 70.37*10⁹/L. Bone marrow aspirates and biopsy showed left-shift neutrophilia, which confirmed leukemoid reaction. After two courses of paclitaxel and cisplatin treatment, the white blood cell counts decreased to normal, the fever disappeared, and the vaginal mass was reduced dramatically. She achieved completed remission after subsequent chemo-radiation and two additional courses of chemotherapy.

Conclusion

In our case, leukemoid reaction was related to recurrent cervical carcinoma and sensitive to chemotherapy. To our knowledge, this is the third case to be reported in the literature. Furthermore, this is the only case described that shows an unequivocal correlation between tumor response and leukemoid reaction.