Radical hysterectomy for stage IIB cervical cancer: a review

Oncological Outcomes After Okabayashi-Kobayashi Radical Hysterectomy for Early and Locally Advanced Cervical Cancer

Importance

The role of surgery in early-stage cervical cancer has been established, but it is controversial in locally advanced cervical cancer.

Objective

To determine whether a radical hysterectomy method with extended removal of paracervical tissue for locally advanced cervical cancer is associated with satisfactory oncological outcomes.

Design, Setting, and Participants

This retrospective cohort study was conducted from January 1, 2002, to December 31, 2011, and participants were patients with cervical cancer at a single tertiary center in Northern Japan. The median follow-up period was 106 months, and none of the patients were lost to follow-up at less than 60 months. Data analyses were performed from July 1, 2017, to December 31, 2018.

Exposures

Patients underwent radical hysterectomy using the Okabayashi-Kobayashi method. Bilateral nerve preservation was used for stage IB1/IB2 disease and unilateral nerve preservation for stage IIA/IIB if disease extension outside the uterine cervix was 1-sided. Chemotherapy was used as the choice of adjuvant treatment for patients with an intermediate or high risk of recurrence, while some patients chose or were assigned to radiotherapy.

Main Outcomes and Measures

Primary outcomes were the 5-year local control rate and 5-year overall survival rate along with risk factor analysis.

Results

Of 121 consecutive patients, 76 (62.8%) had early-stage cervical cancer in 2008 International Federation of Gynecology and Obstetrics stages IB1 and IIA1 and 45 (37.2%) had locally advanced cervical cancer in stages IB2, IIA2, and IIB. The median (range) age was 42 (26-68) years. Adjuvant radiotherapy was used in 2 patients (3%) with early-stage cervical cancer and 3 (7%) of those with locally advanced cervical cancer. The 5-year local control rates for early-stage cervical cancer and locally advanced cervical cancer were 99% and 87%, respectively. The 5-year overall survival rates for early-stage cervical cancer and locally advanced cervical cancer were 95% and 82%, respectively. Cox regression analysis showed that lymph node metastasis and histology of adeno(squamous)carcinoma were independent risk factors for the overall survival of patients with cervical cancer treated with radical hysterectomy.

Conclusions and Relevance

The nerve-sparing Okabayashi-Kobayashi radical hysterectomy for locally advanced cervical cancer may provide survival not inferior to radical hysterectomy or radiotherapy in published literature. The applicability of radical hysterectomy with adjuvant chemotherapy for locally advanced cervical cancer needs to be validated by prospective comparative trials.

Management of Stage IIB Cervical Cancer: an Overview of the Current Evidence

PURPOSE OF REVIEW

To review and discuss the present evidence of surgery- and radiation-based treatment strategies for stage IIB cervical cancer.

RECENT FINDINGS

Recently, two randomized controlled trials compared the efficacy of neoadjuvant chemotherapy followed by radical hysterectomy (NACT + RH) with that of concurrent chemoradiotherapy (CCRT) for stage IB3-IIB cervical cancer. When these studies were combined (N = 1259), NACT + RH was associated with a shorter disease-free survival [hazard ratio (HR) 1.36, 95% confidence interval (CI) 1.13-1.64], but with a similar overall survival (HR 1.11, 95% CI 0.90-1.36) when compared with the findings for CCRT. Stage-specific analysis for stage IIB cervical cancer demonstrated that disease-free survival was significantly worse with NACT + RH than with CCRT (HR 1.90, 95% CI 1.25-2.89); however, no significant difference was observed for stage IB3-IIA cervical cancer. Based on the results of recent level I evidence, the standard treatment for stage IIB cervical cancer remains CCRT.

A case of cervical adenocarcinoma arising from endometriosis in the absence of human papilloma virus infection

Endometriosis-related cervical neoplasms are rare, and their clinicopathological features and association with human papilloma virus infection are unclear. A postmenopausal woman with recently diagnosed cervical adenocarcinoma was referred to our hospital. After further investigation, we suspected a stage IIB neoplasm that originated from endometriosis of the cervix or left parametrium. A radical hysterectomy was performed, and pathological examination confirmed a stage IIB cervical endometrioid carcinoma arising from the endometriosis in the cervix to the left parametrium that invaded the cervix; human papilloma virus infection of tumor cells was not detected. Endometriosis-related neoplasms can occur in the cervix or parametrium and present as cervical cancer. The neoplasm described here was not associated with human papilloma virus infection.

Suspensory Ligaments of the Female Genital Organs: MRI Evaluation with Intraoperative Correlation

The uterus, which plays an important role in the reproductive process, provides a home for the developing fetus and so must be in a stable, though flexible, location. Various structures with suspensory ligaments help provide this berth. MRI with high spatial resolution allows us to detect and evaluate these relatively fine structures. Under physiologic conditions, MRI can be used to depict uterine and ovarian ligaments (ie, the uterosacral, cardinal, and round ligaments, as well as the suspensory ligament of the ovary). In the presence of pathologic conditions (inflammation, endometriosis, tumors), the suspensory ligaments may appear thickened or invaded, which makes their delineation easier. Understanding the normal anatomy of the suspensory ligaments of the female genital organs and using a standardized nomenclature are essential for identifying and reporting related pathologic conditions. The female pelvic anatomy and the suspensory ligaments of the female genital organs are described as depicted with MRI. Also, the compartmental anatomy of the female pelvis is explained, including the extraperitoneal pelvic spaces. Finally, a checklist is provided for structured reporting of the MRI findings in the female pelvis. Online supplemental material is available for this article. ^©RSNA, 2018.

Predictors for pathological parametrial invasion in clinical stage IIB cervical cancer

OBJECTIVE

To examine predictors of pathological parametrial invasion in clinical stage IIB cervical cancer, and to examine prognostic factors in pathological stage IIB disease.

METHODS

This study is an ancillary analysis of a nation-wide retrospective cohort examining 6,003 clinical stage IB-IIB cervical cancers. Women with clinical stage IIB disease who underwent primary radical hysterectomy with lymphadenectomy were examined (n = 714). Multivariate analysis was performed to identify independent clinico-pathological factors for pathological parametrial invasion and to identify independent prognostic factors in pathological stage IIB disease.

RESULTS

Parametrial invasion was identified on the surgical specimen in 400 cases (56.0%, 95% confidence interval 52.4-59.7). On multivariate analysis, deep stromal invasion (DSI, adjusted-OR 3.922), multiple pelvic nodal metastases (adjusted-OR 3.266), lympho-vascular space invasion (adjusted-OR 2.333), and uterine corpus invasion (adjusted-OR 1.656) remained independent tumor factors for pathological parametrial invasion. In classification-tree models, tumors with DSI and multiple pelvic nodal metastases had the highest incidence of pathological parametrial invasion (75.0-87.7%); contrary, tumors without DSI had the lowest incidence (21.9%). Among patients with pathological stage IIB disease, the absolute difference in 5-year disease-free survival rates was 57.2%, ranging between 80.9% in those with squamous histology with none/single pelvic nodal metastasis and 23.7% in those with non-squamous histology with multiple pelvic nodal metastases.

CONCLUSION

In clinical stage IIB cervical cancer, accuracy for pathological parametrial invasion is low-modest. With absence of DSI, only one in five clinical stage IIB diseases has pathological stage IIB disease. Survival of pathological stage IIB varies widely and is largely dependent on nodal factors.

Feasibility of radical hysterectomy in women with FIGO stage IIB cervical cancer: an observation study of 10-year experience in a tertiary center

Purpose

Although definitive chemoradiotherapy is considered as a standard of care for FIGO stage IIB cervical cancer in many countries, the role of surgery remains controversial. We aimed to evaluate the feasibility and outcomes of patients with FIGO stage IIB cervical cancer who received radical surgery in China.

Patients and methods

A total of 74 women with FIGO stage IIB cervical cancer were treated with radical hysterectomy, with or without adjuvant radio/chemoradiotherapy, at the Obstetrics and Gynecology Hospital of Fudan University between 2004 and 2015. Medical charts and clinical data were retrospectively reviewed. The Kaplan–Meier method and Cox regression models were used for survival analyses. In addition, prognostic nomograms predicting overall survival (OS) and progression-free survival (PFS) were constructed.

Results

Pathological parametrial involvement (PMI) was only identified in 28.3% (21/74) of all patients and 47.3% (9/19) of patients without neoadjuvant treatment. Major surgical complications, including bladder fistula, intestinal obstruction and ureteral injury, were found in 6.8% (5/74) of patients. Although the use of imaging technologies including magnetic resonance imaging (MRI)/positron emission tomography–computed tomography (PET–CT) has increased after 2010 compared to that prior to 2010, the accuracy of MRI/PET–CT in detecting pathological PMI was lower than that of physical examination under anesthesia (P<0.05). Neoadjuvant treatment was the only risk factor affecting the accuracy of pre- and postoperative accordance of PMI (OR: 3.283 [95% CI: 1.363–7.908], P=0.008). The 2- and 5-year OS rates were 84.1% and 68.9%, respectively, while the 2- and 5-year cumulative recurrence rates were 26.9% and 39.9%, respectively. Cox regression analyses indicated that pre- and postoperative accordance of PMI, common iliac lymph node metastasis and major surgical complications were significant prognostic factors for both OS and PFS.

Conclusion

Radical hysterectomy might be a feasible alternative for FIGO stage IIB cervical cancer. As pre- and postoperative accordance of PMI is relatively low, strategies to appropriately select patients who will benefit from surgery via pretreatment evaluation need to be further investigated.

Progress in the Study of Lymph Node Metastasis in Early-stage Cervical Cancer

Spread into regional lymph node is the major route of metastasis in cervical cancer. Although lymph node status is not involved in the International Federation of Gynecology and Obstetrics staging system of uterine cervical cancer, the presence or absence of lymph node metastasis provides important information for prognosis and treatment. In this review, we have attempted to focus on the incidence and patterns of lymph node metastasis, and the issues surrounding surgical assessment of lymph nodes. In addition, the preoperative prediction of lymph node status, as well as the intraoperative assessment by sentinel nodes will be reviewed. Finally, lymph node micrometastasis also will be discussed.

Identification of a microRNA signature associated with survivability in cervical squamous cell carcinoma

Background

The aim of this study is to find the potential miRNA expression signature capable of predicting survival time for cervical squamous cell carcinoma (CSCC) patients.

Methods

The expression of 332 miRNAs was measured in 131 (Training cohort) and 130 (Validation cohort) patients with CSCC in the Cancer Genome Atlas (TCGA) data portal. The miRNA expression signature was identified by Cox Proportion Hazard regression model to the Training data set, and subsequently validated in an independent Validation set. Kaplan-Meier curves and the receiver operating characteristic analyses of 5 years were used to access the overall survival of miRNA signature. MiRNA signature-gene target analysis was performed, followed by the construction of the regulatory network. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway analysis were used to explore the function of target genes of miRNA signature.

Results

A 2-miRNA expression signature of hsa-mir-642a and hsa-mir-378c associated with survivability was identified in CSCC. Both of them had a significant diagnostic and prognostic value of patients with CSCC. A total of 345 miRNA signature-target pairs were obtained in the miRNA signature-gene target regulatory network, in which 316 genes were targets of has-mir-378c and has-mir-642a. Functional analysis of target genes showed that MAPK signaling pathway, VEGF signaling pathway and endocytosis were the significantly enriched signal pathways that covered most genes.

Conclusions

The 2-miRNA signature adds to the prognostic value of CSCC. In-depth interrogation of the 2-miRNAs will provide important biological insights that finding and developing novel molecularly prediction to improve prognosis for CSCC patients.

Incorporation of the number of positive lymph nodes leads to better prognostic discrimination of node-positive early stage cervical cancer

To determine the prognostic value of the number of positive lymph nodes (LNs) in cervical cancer and further stratify patients with positive LNs into multiple risk groups based on analysis of Surveillance Epidemiology and End Results (SEER) program. Patients with cervical cancer who undergo hysterectomy and had pathologically-confirmed positive LNs after lymphadenectomy were identified using the SEER database (1988-2012). Kaplan–Meier survival methods and Cox proportional hazards regression were performed. We included 2,222 patients with the median number of removed LNs and positive LNs was 22 and 2, respectively. Multivariable Cox analysis showed patients with > 2 positive LNs had poorer cause-specific survival (CSS) (hazard ratio [HR] 1.631, 95% confidence interval [CI] 1.382–1.926, P < 0.001) and overall survival (OS) (HR 1.570, 95% CI 1.346–1.832, P < 0.001) than patients with 1–2 positive LNs. Five-year CSS and OS were 78.9% vs. 65.5% (P < 0.001) and 76.7% vs. 62.7% (P < 0.001) for 1–2 positive LNs and > 2 positive LNs, respectively. The number of positive LNs had prognostic value in cervical squamous cell carcinoma or adenosquamous carcinoma, but not in cervical adenocarcinoma. The number of positive LNs is an independent risk factor for CSS and OS in cervical cancer. This new category might be helpful in better prognostic discrimination of node-positive early stage cervical cancer after hysterectomy.

A postoperative scoring system for distant recurrence in node-positive cervical cancer patients after radical hysterectomy and pelvic lymph node dissection with para-aortic lymph node sampling or dissection

OBJECTIVE

To identify risk factors for distant recurrence in node-positive cervical cancer patients who underwent radical hysterectomy and pelvic lymph node dissection (PLND) with para-aortic lymph node sampling (PALNS) or para-aortic lymph node dissection (PALND).

METHODS

A total of 299 patients in whom lymph node metastasis was confirmed after radical surgery at Asan Medical Center for stage IA2 to IIB cervical cancer from February 2001 to December 2012 were identified. In all, 72 (24.1%) patients underwent PLND only and 227 (75.9%) underwent PLND with PALNS or PALND. Four patients were excluded due to diagnosed with small cell carcinoma. The clinicopathologic data of 223 patients were retrospectively analyzed. Distant recurrence was defined as recurrence at a site over the pelvic radiation field.

RESULTS

Among all 223 study patients, the mean number of positive lymph nodes was 4.46. There were 54 (24.2%) patients with distant metastasis. Multivariate analyses using the Cox proportional hazards model showed that histologic types (HR=3.031, P≤0.001 for adenocarcinoma, HR=2.302, P=0.066 for adenosquamous carcinoma), number of positive lymph nodes (HR=1.077, P≤0.001), and surgical stage (HR=1.264, P=0.022) were independent risk factors for distant recurrence of cervical cancer. A scoring system for the prediction of distant recurrence was generated by incorporating these factors and showed good discrimination and calibration (concordance index of 0.753). In an internal validation set, this scoring system showed good discrimination with a C-statistics of 0.777. According to the Hosmer-Lemeshow test, the chi-square was 0.650 and the P-value was 0.723.

CONCLUSIONS

We have developed a robust scoring system that can predict the risk of distant recurrence in node-positive cervical cancer patients after radical operation. This scoring system was used to identify a group of patients who required systemic control of distant micrometastasis. This group of patients is an appropriate target for consolidation chemotherapy after concurrent chemoradiation therapy.

Downregulation of HOTAIR Expression Mediated Anti-Metastatic Effect of Artesunate on Cervical Cancer by Inhibiting COX-2 Expression

Artesunate (ART) has anti-cancer activities for a variety of solid tumors. The aim of this study was to investigate the anti-metastatic effect of ART on cervical cancer cells. In vivo anti-metastatic effect of ART was investigated in mice with the lung metastasis model by the subcutaneous injection of ART. The interaction of HOTAIR and COX-2 was measured by RNA immunoprecipitation and RNA pull-down assay. The effect of ART on metastasis of CaSki and Hela cells was evaluated by invasion and migration assay. We found that ART inhibited cervical cancer metastasis and HOTAIR expression. HOTAIR overexpression partially abolished the anti-metastatic effect of ART on cervical cancer cells. In addition, HOTAIR can interact with COX-2 to positively regulate COX-2 expression and catalytic activity. Finally, overexpression of COX-2 reversed the effect of HOTAIR knockdown on Hela cell migration and invasion. Taken together, our data revealed that ART may elicit anti-metastatic effect against cervical cancer by inhibition of HOTAIR expression, which resulted in the decrease of COX-2 expression.

Carcinoma of the cervix in elderly patients treated with radiotherapy: patterns of care and treatment outcomes

OBJECTIVE

The aim of this analysis was to examine the management of cervix cancer in elderly patients referred for radiotherapy and the results of treatment in terms of overall survival (OS), relapse-free survival (RFS), and treatment-related toxicities.

METHODS

Patients were eligible if they were aged ≥75 years, newly diagnosed with cervix cancer and referred for radiotherapy as part of their treatment. Patient details were retrieved from the gynaecology service database where clinical, histopathological treatment and follow-up data were prospectively collected.

RESULTS

From 1998 to 2010, 126 patients aged ≥75 years, met selection criteria. Median age was 81.5 years. Eighty-one patients had definitive radiotherapy, 10 received adjuvant radiotherapy and 35 had palliative radiotherapy. Seventy-one percent of patients had the International Federation of Gynecology and Obstetrics stage 1b-2b disease. Median follow-up was 37 months. OS and RFS at 3 years among those treated with curative intent were 66.6% and 75.9% respectively with majority of patients dying without any evidence of cervix cancer. Grade 2 or more late toxicities were: bladder 5%, bowel 11%, and vagina 27%. Eastern Cooperative Oncology Group (ECOG) status was a significant predictor of OS and RFS with each unit increment in ECOG score increased the risk of death by 1.69 times (p<0.001).

CONCLUSION

Following appropriate patient selection, elderly patients treated curatively with radiotherapy for cervix cancer have good disease control. Palliative hypofractionated regimens are well tolerated in patients unsuitable for radical treatment.

Prognostic effect of different PD-L1 expression patterns in squamous cell carcinoma and adenocarcinoma of the cervix

Programmed death-ligand 1 (PD-L1) is expressed in various immune cells and tumor cells, and is able to bind to PD-1 on T lymphocytes, thereby inhibiting their function. At present, the PD-1/PD-L1 axis is a major immunotherapeutic target for checkpoint inhibition in various cancer types, but information on the clinical significance of PD-L1 expression in cervical cancer is largely lacking. Here, we studied PD-L1 expression in paraffin-embedded samples from two cohorts of patients with cervical cancer: primary tumor samples from cohort I (squamous cell carcinoma, n=156 and adenocarcinoma, n=49) and primary and paired metastatic tumor samples from cohort II (squamous cell carcinoma, n=96 and adenocarcinoma, n=31). Squamous cell carcinomas were more frequently positive for PD-L1 and also contained more PD-L1-positive tumor-associated macrophages as compared with adenocarcinomas (both P<0.001). PD-L1-positive tumor-associated macrophages were found to express CD163 and/or CD14 by triple fluorescent immunohistochemistry, demonstrating an M2-like phenotype. Interestingly, disease-free survival (P=0.022) and disease-specific survival (P=0.046) were significantly poorer in squamous cell carcinoma patients with diffuse PD-L1 expression as compared with patients with marginal PD-L1 expression (i.e., on the interface between tumor and stroma) in primary tumors. Disease-specific survival was significantly worse in adenocarcinoma patients with PD-L1-positive tumor-associated macrophages compared with adenocarcinoma patients without PD-L1-positive tumor-associated macrophages (P=0.014). No differences in PD-L1 expression between primary tumors and paired metastatic lymph nodes were detected. However, PD-L1-positive immune cells were found in greater abundance around the metastatic tumors as compared with the paired primary tumors (P=0.001 for squamous cell carcinoma and P=0.041 for adenocarcinoma). These findings point to a key role of PD-L1 in immune escape of cervical cancer, and provide a rationale for therapeutic targeting of the PD-1/PD-L1 pathway.

The influence of number of high risk factors on clinical outcomes in patients with early-stage cervical cancer after radical hysterectomy and adjuvant chemoradiation

Objective

The purpose of this study was to evaluate the prognosis according to the number of high risk factors in patients with high risk factors after radical hysterectomy and adjuvant chemoradiation therapy for early stage cervical cancer.

Methods

Clinicopathological variables and clinical outcomes of patients with FIGO (International Federation of Gynecology and Obstetrics) stage IB1 to IIA cervical cancer who had one or more high risk factors after radical hysterectomy and adjuvant chemoradiation therapy were retrospectively analyzed. Patients were divided into two groups according to the number of high risk factors (group 1, single high risk factor; group 2, two or more high risk factors).

Results

A total of 93 patients were enrolled in the present study. Forty nine out of 93 (52.7%) patients had a single high risk factor, and 44 (47.3%) had two or more high risk factors. Statistically significant differences in stage and stromal invasion were observed between group 1 and group 2. However, age, histology, tumor size, and lymphovascular space invasion did not differ significantly between the groups. Distant recurrence occurred more frequently in group 2, and the probability of recurrence and death was higher in group 2.

Conclusion

Patients with two or more high risk factors had worse prognosis in early stage cervical cancer. For these patients, consideration of new strategies to improve survival may be worthwhile. Conduct of further clinical trials is warranted for development of adjuvant treatment strategies individualized to each risk group.

The Number of Positive Pelvic Lymph Nodes and Multiple Groups of Pelvic Lymph Node Metastasis Influence Prognosis in Stage IA-IIB Cervical Squamous Cell Carcinoma

Background:

Pelvic lymph node metastasis (LNM) is an important prognostic factor in cervical cancer. Cervical squamous cell carcinoma accounts for approximately 75–80% of all cervical cancers. Analyses of the effects of the number of positive lymph nodes (LNs), unilateral versus bilateral pelvic LNM and a single group versus multiple groups of pelvic LNM on survival and recurrence of cervical squamous cell carcinoma are still lacking. The study aimed to analyze the effects of the number of positive pelvic LNs and a single group versus multiple groups of pelvic LNM on survival and recurrence.

Methods:

We performed a retrospective review of 296 patients diagnosed with Stage IA–IIB cervical squamous cell carcinoma who received extensive/sub-extensive hysterectomy with pelvic lymphadenectomy/pelvic LN sampling at Peking University People's Hospital from November 2004 to July 2013. Ten clinicopathological variables were evaluated as risk factors for pelvic LNM: Age at diagnosis, gravidity, clinical stage, histological grade, tumor diameter, lymph-vascular space involvement (LVSI), depth of cervical stromal invasion, uterine invasion, parametrial invasion, and neoadjuvant chemotherapy.

Results:

The incidence of pelvic LNM was 20.27% (60/296 cases). Pelvic LNM (P = 0.00) was significantly correlated with recurrence. Pelvic LNM (P = 0.00), the number of positive pelvic LNs (P = 0.04) and a single group versus multiple groups of pelvic LNM (P = 0.03) had a significant influence on survival. Multivariate analysis revealed that LVSI (P = 0.00), depth of cervical stromal invasion (P = 0.00) and parametrial invasion (P = 0.03) were independently associated with pelvic LNM.

Conclusions:

Patients with pelvic LNM had a higher recurrence rate and poor survival outcomes. Furthermore, more than 2 positive pelvic LNs and multiple groups of pelvic LNM appeared to identify patients with worse survival outcomes in node-positive IA-IIB cervical squamous cell carcinoma. LVSI, parametrial invasion, and depth of cervical stromal invasion were identified as independent clinicopathological risk factors for pelvic LNM.

Surgical principles for managing stage IB2, IIA2, and IIB uterine cervical cancer (Bulky Tumors) in Japan: a survey of the Japanese Gynecologic Oncology Group

OBJECTIVE

The aim of this study was to determine the current operative management of International Federation of Gynecology and Obstetrics (FIGO) stage IB2, IIA2, and IIB uterine cervical cancer (bulky tumors) in Japan by surveying the member institutions of the Japanese Gynecologic Oncology Group.

METHODS

We conducted a survey to assess current operative management, including indications and treatment, at all 199 active member institutions of the Japanese Gynecologic Oncology Group.

RESULTS

A total of 166 institutions (83.4%) responded to the survey. For patients with stage IIB squamous cell carcinoma, 35.5% (59/166) of the institutions performed surgery. For stage IIB nonsquamous cell carcinoma, surgery was performed at 88 (53.7%) of 164 institutions. Neoadjuvant chemotherapy was provided by 75 (45.5%) of 165 institutions (actively in 44 and reluctantly in 31). At 101 (61.2%) of 165 institutions, para-aortic node dissection was performed as part of radical surgery in patients with any indications. At 96 (57.9%) of 166 institutions, high-risk patients underwent chemoradiotherapy after surgery. On the other hand, adjuvant chemotherapy was given to high-risk and intermediate-risk patients at 19.9% and 33.1% institutions, respectively. More than half of the 166 institutions considered the number of metastatic nodes (91/166, 54.8%) and tumor histology (116/166, 69.9%) when selecting adjuvant therapy.

CONCLUSIONS

This survey provided information regarding the current surgical management of uterine cervical cancer (stages IB2, IIA2, and IIA) in Japan.

Radical hysterectomy with adjuvant radiotherapy versus radical radiotherapy for FIGO stage IIB cervical cancer

BACKGROUND

The goal of this study was to compare treatment outcomes for Federation of Gynecology and Obstetrics (FIGO) stage IIB cervical carcinoma patients receiving radical surgery followed by adjuvant postoperative radiotherapy versus radical radiotherapy.

METHODS

Medical records of FIGO stage IIB cervical cancer patients treated between July 2008 and December 2011 were retrospectively reviewed. A total of 148 patients underwent radical hysterectomy with pelvic lymph node dissection followed by adjuvant radiotherapy (surgery-based group). These patients were compared with 290 patients that received radical radiotherapy alone (RT-based group). Recurrence rates, progression-free survival (PFS), overall survival (OS), local control rates, and treatment-related complications were compared for these two groups.

RESULTS

Similar rates of recurrence (16.89% vs. 12.41%, p = 0.200), PFS (log-rank, p = 0.211), OS (log-rank, p = 0.347), and local control rates (log-rank, p = 0.668) were observed for the surgery-based group and the RT-based group, respectively. Moreover, the incidence of acute grade 3-4 gastrointestinal reactions and late grade 3-4 lower limb lymphedema were significantly higher for the surgery-based group versus the RT-based group. Cox multivariate analyses found no significant difference in survival outcome between the two groups, and tumor diameter and histopathology were identified as significant prognostic factors for OS.

CONCLUSIONS

Radical radiotherapy was associated with fewer treatment-related complications and achieved comparable survival outcomes for patients with FIGO stage IIB cervical cancer compared to radical hysterectomy followed by postoperative radiotherapy.

Surgical-pathologic risk factors of pelvic lymph node metastasis in stage Ib1-IIb cervical cancer

OBJECTIVE

To study the distribution characteristics and risk factors of cervical cancer lymph node metastasis (LNM).

DESIGN

Retrospective study.

SETTING

Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology and Affiliated Hospital to Zunyi Medical College.

POPULATION

404 women diagnosed with cervical cancer FIGO stage Ib1-IIa who underwent primary radical surgery and 104 women with Ib2-IIb tumors treated with neoadjuvant chemotherapy (NACT) before surgery.

METHODS

Clinicopathological data were collected and analyzed.

MAIN OUTCOME MEASURES

Incidence of infiltration, metastasis and pelvic LNM.

RESULTS

In women without NACT, the incidence of infiltration, metastasis and LNM was 7.2, 17.6 and 15.8%, respectively. Metastasis and LNM were significantly associated with advanced FIGO stage and poorer histological grade. The incidence of multiple metastatic lymph nodes (MLNs), bilateral LNM, skip LNM, LNM in primary group and LNM in secondary group was 6.2, 3.0, 6.2%, 11.4 and 4.5%, respectively. Of the 111 MLNs, 13 (11.7%) were common iliac lymph nodes. In the NACT group, infiltration, metastasis and LNM were observed in 10 (9.6%), 24 (23.1%) and 21 (20.1%) of 104 women, respectively. Metastasis and LNM were significantly correlated with moderate cell differentiation.

CONCLUSION

High LNM risk is expected in tumors of IIa stage or higher and in moderately differentiated tumors. Skip metastasis and common iliac LNM are relatively common and therefore should not be neglected. Our results suggest that standardized and complete pelvic lymph node dissection under surgery is an important measure to ensure a therapeutic effect.

Radical hysterectomy with adjuvant radiotherapy versus definitive radiotherapy alone for FIGO stage IIB cervical cancer

OBJECTIVES

The aim of this study was to compare the treatment outcomes and adverse effects of radical hysterectomy followed by adjuvant radiotherapy with definitive radiotherapy alone in patients with FIGO stage IIB cervical cancer.

METHODS

We retrospectively reviewed the medical records of FIGO stage IIB cervical cancer patients who were treated between April 1996 and December 2009. During the study period, 95 patients were treated with radical hysterectomy, all of which received adjuvant radiotherapy (surgery-based group). In addition, 94 patients received definitive radiotherapy alone (RT-based group). The recurrence rate, progression-free survival (PFS), overall survival (OS), and treatment-related complications were compared between the two groups.

RESULTS

Radical hysterectomy followed by adjuvant radiotherapy resulted in comparable recurrence (44.2% versus 41.5%, p=0.77), PFS (log-rank, p=0.57), and OS rates (log-rank, p=0.41) to definitive radiotherapy alone. The frequencies of acute grade 3-4 toxicities were similar between the two groups (24.2% versus 24.5%, p=1.0), whereas the frequencies of grade 3-4 late toxicities were significantly higher in the surgery-based group than in the RT-based group (24.1% versus 10.6%, p=0.048). Cox multivariate analyses demonstrated that treatment with surgery followed by adjuvant radiotherapy was associated with an increased risk of grade 3-4 late toxicities, although the statistical significance of the difference was marginal (odds ratio 2.41, 95%CI 0.97-5.99, p=0.059).

CONCLUSIONS

Definitive radiotherapy was found to be a safer approach than radical hysterectomy followed by postoperative radiotherapy with less treatment-related complications and comparable survival outcomes in patients with FIGO stage IIB cervical cancer.

Local Control After Tailored Surgical Treatment of Early Cervical Cancer

Background:

It was the aim of our study to analyze oncological outcome and prognostic parameters in patients with early stages cervical cancer after tailored and well-standardized surgical treatment with an adequate follow-up.

Methods:

Oncological outcome and prognostic parameters were evaluated in a group of 192 patients with cervical cancer stages IA2 to 2B who had undergone radical hysterectomy (n = 171), radical parametrectomy (n = 12), or radical trachelectomy (n = 9). Procedures were classified as type B (n = 72), type C1 nerve sparing (n = 103), or type C2 (n = 17).

Results:

Event-free and overall 5-year survivals probabilities reached 92.7% (confidence interval, 89.5%-95.9 %) and 94.1% (confidence interval, 90.9%-97.3 %). There was only 1 isolated pelvic recurrence found of the total of 10 recurrences. Adjuvant radiotherapy was given to only 22% of patients. The most significant independent prognostic parameters in stage IB tumors were lymph node status, histological type, and tumor volume, whereas in stage II, the parameters included histological type and tumor volume, the latter being inversely related to the prognosis.

Conclusions:

We have shown an excellent prognosis, especially local control, after tailored surgical treatment of stages IA2 to IIB of cervical cancer, with low prevalence of adjuvant treatment. Different prognostic parameters were observed for stages IB1/IB2 and IIA/B.

Clinical significance of tumor volume and lymph node involvement assessed by MRI in stage IIB cervical cancer patients treated with concurrent chemoradiation therapy

OBJECTIVE

The purpose of this study was to evaluate the prognostic significance of tumor volume assessed by pretreatment MRI in stage IIB cervical cancer patients with concurrent chemoradiation therapy.

METHODS

A retrospective chart review was performed on seventy five patients with cervical cancer who were treated with concurrent weekly cisplatin (40 mg/m(2)) and radiotherapy between January 2000 and April 2007. Potential prognostic factors were age, chemotherapy numbers, histology, tumor diameter and volume, lymph node (LN) involvement and pretreatment squamous cell carcinoma antigen (SCC-Ag) levels.

RESULTS

The median follow-up time was 55 months (range, 8 to 104 months). The median tumor size and volume (range) were 4.5 cm (2 to 10) and 33.1 mL (4.2 to 392.7), respectively. Pelvic LN enlargement rate was 58.7%. Para-aortic LN enlargement rate was 14.7%. Using multivariate analysis, a tumor volume (>33 mL, p=0.025), pelvic LN enlargement (p=0.044) revealed a significantly unfavorable outcome on overall survival. PFS was influenced by tumor histology (p<0.001), pelvic LN enlargement (p=0.015) and pretreatment SCC-Ag levels (p=0.018). We found that 22 (29.3%) patients had recurrences and 14 (18.7%) patients died of disease. The 5-year overall survival rate was 80.6% (standard error, 4.9%) and 5-year PFS rate was 71.3% (standard error, 5.3%).

CONCLUSION

Tumor volume and pelvic LN involvement showed possibility to predict overall survival in patient with stage IIB cervical cancer. Optimal tumor volume and pelvic LN assessment by pretreatment MRI might be helpful to predict treatment outcome.

Sentinel node (SLN) biopsy in the management of locally advanced cervical cancer

OBJECTIVES

Sentinel lymph node (SLN) biopsy can significantly contribute to the management of locally advanced cervical cancers with high risk of lymph node (LN) positivity. However, low detection rate and sensitivity were reported in larger tumors, albeit on a small number of cases. It was the aim of our study to verify the SLN reliability in large tumors, with modified dye application technique and a careful identification of side-specific lymphatic drainage.

METHODS

The study involved 44 patients with tumors 3 cm in diameter or larger, stages IB1 to IIA, or selected IIB. In cases where SLN could not be detected, systematic pelvic lymphadenectomy was performed on the respective side. Systematic pelvic lymphadenectomy was performed during the second step radical procedure if not already done.

RESULTS

Detection rate in the whole cohort reached 77% per patient and 59% bilaterally. No significant difference was found whether a blue dye or a combined method was used (75% vs 80%, and 55% vs 67%). Systematic pelvic lymphadenectomy was performed in cases with undetected SLN unilaterally in 8 and bilaterally in 10 women. A systematic pelvic lymphadenectomy was included in the second step radical procedure in 19 cases and no positive LN were found. There was no case of false-negative SLN result in patients who underwent surgical treatment.

CONCLUSION

Detection rate in locally advanced cervical cancer could be improved by a careful dye application technique. Low false-negative SLN rate could be achieved if pelvic lymphatic drainage is evaluated on a side-specific principle by performing systematic lymphadenectomy if SLN is not detected.

Radical hysterectomy for FIGO stage I-IIB adenocarcinoma of the uterine cervix

A retrospective analysis was carried out to identify risk factors for survival and relapse in patients with FIGO stage I–IIB cervical adenocarcinoma (AC), who underwent radical hysterectomy, and to compare outcome and spread pattern with those of squamous cell carcinoma (SCC). One hundred and twenty-three FIGO stage I–IIB patients with AC and 455 patients with SCC, who all underwent primary radical hysterectomy, were reviewed. Among the patients with AC, Cox model identified tumour size (95% CI: 1.35–30.71) and node metastasis (95% CI: 5.09–53.44) as independent prognostic factors for survival, and infiltration to vagina (95% CI: 1.15–5.76) and node metastasis (95% CI: 6.39–58.87) as independent prognostic factors for relapse. No significant difference was found in survival or relapse between the AC and SCC groups, after adjusting for other clinicopathological characteristics using Cox model. No significant difference was found in the positive rates of lymph nodes or location of initial failure sites between the two groups, but ovarian metastatic rate was significantly higher in patients with pathologic stage IIB AC (P=0.02). Positive node is a common independent prognostic factor for survival and relapse of patients with AC. FIGO stage I–IIB patients with AC or SCC, who underwent radical hysterectomy, have similar prognosis and spread pattern, but different ovarian metastasis rates.

Radical hysterectomy for FIGO stage IIB cervical cancer: clinicopathological characteristics and prognostic evaluation

OBJECTIVE

To clarify the clinicopathological features and prognostic factors of patients with FIGO stage IIB cervical cancer who were treated with radical hysterectomy.

METHODS

One hundred thirty-nine FIGO stage IIB patients with squamous or adenosquamous cell carcinoma (median age, 51 years) who were treated with primary radical hysterectomy were examined retrospectively. Sixty-six FIGO stage IIB patients who were treated with primary radiotherapy (median age, 70 years) were included for comparison of survival.

RESULTS

Fifty percent (70/139) of the patients had pathological parametrial involvement. Among them, the positive rate of pelvic lymph nodes was 71% (50/70). Ninety-nine percent (138/139) of the tumors were completely removed, and the pelvic control rate was 88%. Major complications requiring surgery were found in 2.9% (4/139). Significant differences in survival were found among patients in subgroups according to pathological parametrial involvement, pelvic lymph node status, tumor size, lymph-vascular space invasion, and depth of myometrial invasion (log-rank test, P<0.05). Of these, the Cox proportional-hazard model revealed that parametrial involvement (P=0.001, 95% CI 1.992-6.297) and lymph node metastasis (P=0.042, 95% CI 1.023-3.298) were independent prognostic factors. The 5-year survival rate and relapse-free survival at 36 months were 69% and 72% among the radical hysterectomy group, and 69% and 75% among the radiotherapy group. The Cox model adjusted for age showed no significant differences in survival and relapse-free survival between these two groups.

CONCLUSION

Pathological parametrial involvement and positive nodes were prognostic factors for surgically treated patients with FIGO stage IIB cervical cancer.

Prognostic factors in pathologic parametrium-positive patients with stage IB-IIB cervical cancer treated by radical surgery and adjuvant therapy

OBJECTIVE

The purpose of the present study was to identify prognostic factors and recurrent patterns in pathologic parametrium-positive patients with stage IB-IIB cervical cancers treated by radical surgery and adjuvant therapy.

METHODS

The patient population consisted of 84 individuals presenting with stage IB-IIB cervical cancers and histologically proven parametrial invasion. All these patients were treated postoperatively with adjuvant external whole pelvic irradiation, combination chemotherapy, or chemoradiotherapy.

RESULTS

The 5-year disease-free survival rate was found to be 67.2% and 5-year overall survival rate, 75.4%. Multivariate analysis revealed that vaginal invasion (p=0.0008), lymph node metastasis (p=0.002), and non-squamous histology (p=0.010) were independent indicators of the disease-free survival rates and that the vaginal invasion (p=0.009) and lymph node metastasis (p=0.011) were independent prognostic factors for the overall survival rates. The 5-year overall survival rate was approximately 90% for patients without these risk factors. Disease recurrence was observed in 26 patients (31.0%) with a median time of 16.5 months (range, 5-59 months) from the surgery. Hematogenous recurrences, including those in the lung, liver, and bone, were significantly higher in patients with non-squamous cell carcinomas (p=0.008). Distant lymph node recurrences were significantly higher in patients with positive pelvic lymph node and vaginal invasion (p=0.004 and p=0.023, respectively). Pelvic recurrences were significantly higher in patients with vaginal invasion (p=0.026).

CONCLUSIONS

Vaginal invasion and lymph node metastasis are independent indicators for disease-free and overall survival rates in pathologic parametrium-positive patients with stage IB-IIB cervical cancer treated by radical surgery and adjuvant therapy. The survival rate is excellent in the patients without these risk factors. Hematogenous recurrence may be evident in patients with non-squamous cell carcinomas.

Radiation-sparing managements for cervical cancer: a developing countries perspective

Cervical cancer is the seventh most frequent cancer worldwide but more than 80% of cases occur in developing countries. Till date, radiation therapy with external beam and brachytherapy remains as the core treatment for most stages of cervical cancer. However, radiation treatment protocols and equipment modelled on the best developed countries can be seldom applied directly to developing countries owing to financial constraints and lack of qualified personnel, thus, a substantial proportion of patients do not have access to even palliative radiation therapy. Treatment options when the standard therapy is either not available or difficult to reproduce in particular settings is highly desirable with the potential to save lives that otherwise could be lost by the lack of adequate treatment. These options of treatment ideally had to have show, 1) that these are not inferior to the "standard" in terms of either survival or quality of life; 2) that these can be delivered in settings were the "standard" is not available or if available its quality is poor; and 3) that the treatment option be accepted by the population to be treated.

Based on these considerations, it is obvious that cervical cancer patients, particularly those who live in countries with limited resources and therefore may not have sufficient radiation therapy resources are in need of newer therapeutical options. There is now a considerable amount of information emanating from clinical studies where surgery has a major role in treating this disease. These forms of "radiation-sparing" treatments include total mesometrial resection that could make unnecessary the use of adjuvant radiation; neoadjuvant chemotherapy that could avoid the use of adjuvant radiation in around 85% of patients and preoperative chemoradiation that could make brachytherapy dispensable. The feasibility and therapeutical value of these potential forms of management need to be prospectively evaluated.