Effect of number of retrieved lymph nodes on prognosis in FIGO stage IB-IIA cervical cancer patients treated with primary radical surgery

Primary Treatment for Clinically Early Cervical Cancer with Lymph Node Metastasis: Radical Surgery or Radiation?

OBJECTIVE

To compare survival outcomes between primary radical surgery and primary radiation in early cervical cancer.

METHODS

Patient information was extracted from the Surveillance, Epidemiology, and Results database. Patients diagnosed with early cervical cancer of stage T1a, T1b, and T2a (American Joint Committee on Cancer, 7th edition) from 1998 to 2015 were included in this study after propensity score matching. Overall survival (OS) was analyzed using the Kaplan-Meier method.

RESULTS

Among the 4964 patients included in the study, 1080 patients were identified as having positive lymph nodes (N1), and 3884 patients were identified as having negative lymph nodes (N0). Patients with primary surgery had significantly longer 5-year OS than those with primary radiotherapy in both the N1 group (P<0.001) and N0 group (P<0.001). In the subgroup analysis, similar results were found in patients with positive lymph nodes of stage T1a (100.0% vs. 61.1%), T1b (84.1% vs. 64.3%), and T2a (74.4% vs. 63.8%). In patients with T1b1 and T2a1, primary surgery resulted in longer OS than primary radiation, but not in patients with T1b2 and T2a2. In multivariate analysis, the primary treatment was identified as an independent prognostic factor in both N1 and N0 patients (HR_N1=2.522, 95% CI=1.919-3.054, P_N1<0.001; HR_N0=1.895, 95% CI=1.689-2.126, P_N0<0.001).

CONCLUSION

In early cervical cancer stage T1a, T1b1, and T2a1, primary surgery may result in longer OS than primary radiation for patients with and without lymph node metastasis.

Effect of Number of Retrieved Lymph Nodes on Prognosis in FIGO Stage IA1-IIA2 Cervical Cancer Patients Treated With Primary Radical Surgery

Background:

The influence of the number of removed lymph nodes (RLNs) on patients with early-stage cervical cancer (ESCC) is still questionable. The objective of this study was to explore the prognostic value of RLNs on ESCC patients.

Methods:

A retrospective study was performed including all ESCC patients who underwent radical surgery from January 2016 to December 2018. Cox regression analysis was performed to verify the correlation between the number of RLNs and the prognosis (recurrence-free survival [RFS], disease-specific survival [DSS]) of ESCC. According to the guidelines, all the patients were divided into high-risk and non-high-risk groups. The optimal cut-off values of RLNs were determined by receiver operating characteristic curve analysis and Youden index and further the prognostic value of them was explored.

Results:

A total 1101 patients were enrolled. The number of RLNs was an independent prognostic influence factor of the prognosis of ESCC ( P < .001 for RFS, P < .001 for DSS). The optimal cut-off values of RLNs (40 in the high-risk group and 23 in the non-high-risk group) were significantly associated with the prognosis of ESCC, in the high-risk group ( P < .001 for RFS, P = .002 for DSS) and non-high-risk group ( P < .001 for RFS, P < .001 for DSS), respectively.

Conclusions:

More extensive lymph node dissection (RLNs ⩾ 40) could benefit the high-risk ESCC patients. However, in the non-high-risk group, moderate lymph node dissection (RLNs ≈23) could also benefit them and may reduce the incidence of related complications. Those findings may help to determine the scope of lymph node dissection in ESCC patients before operation.

Prognostic Value of Lymph Node Characteristics in Patients with Cervical Cancer Treated with Radical Hysterectomy

Objective

This study evaluated the prognostic value of various lymph node (LN) characteristics, including the lymph node ratio (LNR), in patients with cervical cancer treated with radical hysterectomy.

Methods

In this retrospective study, 260 patients with cervical cancer who had undergone radical hysterectomy with pelvic or paraaortic lymphadenectomies were included. LN characteristics related to several LN statuses included total LN counts, LN metastasis, total positive LN counts, LNR, and levels of lymphadenectomy. LNR was defined as the number of metastatic LNs divided by the total number of LNs harvested. Univariate and multivariate analyses for disease-free survival (DFS) and overall survival (OS) were performed using the clinicopathological and LN characteristics.

Results

Based on receiver-operating characteristics curve analysis, the cut-off value of LNR was 0.0625. Multivariate analysis revealed that high LNR was significantly related to tumor recurrence (hazard ratio [HR], 5.182; 95% confidence interval [CI], 2.424–11.075; p < 0.0001). After adjusting for clinicopathological factors, LNR was also independent prognostic factor for predicting tumor recurrence (HR, 5.930; 95% CI, 2.114–16.634; p = 0.0007). However, total retrieved LN counts and level of lymphadenectomy were not associated with survival outcomes.

Conclusion

LNR may be a prognostic biomarker for predicting disease recurrence in cervical cancer treated with radical hysterectomy.

Potential prognostic factors in progression-free survival for patients with cervical cancer

Background

Cervical cancer continues to be one of the leading causes of cancer deaths among females in low and middle-income countries. In this study, we aimed to assess the independent prognostic value of clinical and potential prognostic factors in progression-free survival (PFS) in cervical cancer.

Methods

We conducted a retrospective study on 92 cervical cancer patients treated from 2017 to 2019 at the Zhuhai Hospital of Traditional Chinese and Western Medicine. Tumor characteristics, treatment options, progression-free survival and follow-up information were collected. Kaplan–Meier method was used to assess the PFS.

Results

Results showed that the number of retrieved lymph nodes had a statistically significant effect on PFS of cervical cancer patients (P = 0.002). Kaplan-Meier survival curve analysis showed that cervical cancer patients with initial symptoms age 25–39 had worse survival prognoses (P = 0.020). And the using of uterine manipulator in laparoscopic treatment showed a better prognosis (P < 0.001). A novel discovery of our study was to verify the prognostic values of retrieved lymph nodes count combining with FIGO staging system, which had never been investigated in cervical cancer before. According to the Kaplan-Meier survival curve analysis and receiver operating characteristic (ROC) curve analysis, significant improvements were found after the combination of retrieved lymph nodes count and FIGO stage in predicting PFS for cervical cancer patients (P < 0.001, AUC = 0.826, 95% CI: 0.689–0.962).

Conclusion

Number of retrieved lymph nodes, initial symptoms age, uterine manipulator, and retrieved lymph nodes count combining with FIGO staging system could be potential prognostic factors for cervical cancer patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08243-3.

Clinical features that affect the number of pelvic lymph nodes harvested in patients with cervical cancer stage IB1 to IIA2

Objective

To investigate clinical features that affect the number of pelvic lymph nodes (PLNs) harvested and prognostic significance of the number of PLNs removed in patients with stage IB1 to IIA2 cervical cancer.

Methods

Data from patients with cervical cancer whom underwent hysterectomy with PLN dissection between June 2004 and July 2015 were reviewed retrospectively. Data on clinicopathologic factors including age, height, and weight were collected. Data on the presence of PLN metastasis on imaging studies prior to surgery, number of PLNs harvested, and presence of metastasis in the harvested PLNs were retrieved from medical records. Clinical features associated with the number of PLNs harvested were analyzed. Disease-free survival (DFS) and overall survival (OS) according to the number of PLNs harvested were analyzed.

Results

During the study period, 210 patients were included. The height and weight of patients and preoperative positive positron emission tomography findings were significantly associated with a higher number of PLNs harvested. As a pathologic factor, larger tumor size was associated with a higher number of PLNs harvested. Furthermore, a higher number of PLNs harvested was associated with a higher number of metastatic PLNs and patients undergoing postoperative concurrent chemoradiation therapy. Patient height and tumor size were independent factors affecting the number of PLNs harvested in multivariate analysis. However, the number of PLNs harvested was not associated with DFS or OS.

Conclusion

The number of PLNs harvested during surgery was associated with patient height; however, this was not related to the prognosis of the disease.

Prognostic and clinicopathological value of ZIC1 in patients with cervical squamous cell carcinoma

The aim of the present study was to analyze the differences in zinc finger of the cerebellum 1 (ZIC1) expression between cervical cancer tissue, precancer tissue and normal cervical tissue to determine its clinicopathological and prognostic value in cervical squamous cell carcinoma (CSCC). Reverse transcription-quantitative PCR was used to determine the mRNA expression levels of ZIC1 in 569 fresh-frozen biopsy tissues, and immunohistochemistry was performed to detect ZIC1 protein expression in 80 CSCC tissues and 320 cervical intraepithelial neoplasia (CIN) grade III samples. The association of ZIC1 expression with the clinicopathological characteristics of CSCC was then analyzed using Cox regression analysis, and Kaplan-Meier curves were used to analyze the prognostic value. The level of ZIC1 mRNA expression in CSCC was significantly lower compared with normal cervical tissues and CIN I–III tissues (P<0.001). There was a negative correlation between ZIC1 immunoreactivity score (IRS) in CSCC tissue and adjacent noncancerous tissue (R=−0.279; P=0.012); the mean IRS of ZIC1 in CSCC tissue was 5.36±3.48, which was significantly lower compared with the corresponding adjacent noncancerous tissues (11.31±5.68; P<0.001) and CIN III samples (10.42±1.54; P<0.001). In addition, expression of ZIC1 was negatively associated with International Federation of Gynecology and Obstetrics (FIGO) stage (P=0.027) and lymph node metastasis (P<0.001). In Cox regression analysis, ZIC1 expression [hazard ratio (HR), 0.61; 95% confidence interval (CI), 0.40–0.92; P=0.018), FIGO staging (HR, 3.55; 95% CI, 2.35–5.37; P<0.001) and lymph node metastasis (HR, 2.50; 95% CI, 1.62–3.86; P<0.001) were three independent prognostic factors of overall survival. Furthermore, ZIC1 expression was also associated with disease-free survival (P=0.003). These results suggest that ZIC1 expression in CSCC may be lower than in normal cervical tissues or CIN tissues, and high expression of ZIC1 may be negatively associated with FIGO stage and lymph node metastasis. Therefore, ZIC1 may be a promising biomarker for the prognosis of CSCC.

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

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

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

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

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

The prognostic value of negative lymph node count for patients with cervical cancer after radical surgery

Negative lymph node (NLN) count has been recognized as a prognostic indicator in various cancers. However, the relationship between NLN count and the prognosis of cervical cancer is still unknown. In this study, 10, 500 cervical cancer patients after radical surgery were selected from Epidemiology and End Results Program (SEER) data. Clinicopathological characteristics were collected for analysis, including year of diagnosis, age, race, grade, primary site, FIGO stage and cause specific survival (CSS). Univariate and multivariate Cox proportional hazards model was used to assess risk factors for survival of patients. X-tile plots identified 6 as the optimal cutoff value of NLN count to divide patients into high and low risk subsets in terms of CSS (χ² = 183.95, P < 0.001). The rate of 5-year CCS of cervical cancer patients was improved with an increase in NLN count from 0 to 23 (all P < 0.001). NLN count was validated as an independently prognostic factor by the multivariate Cox analysis (HR: 1.571, 95% CI: 1.370~1.801, P < 0.001). Subgroup analysis showed that NLN count was a prognosis factor in FIGO stage I (χ²=35.023, P < 0.001), stage II (χ² = 12.910, P < 0.001), stage III + IV (χ² = 9.732, P = 0.002) and unknown stage (χ² = 16.654, P < 0.001). Conclusively, this study demonstrated the NLN count was an independent prognostic factor for cervical cancer patients.

The impact of examined lymph node count on survival in squamous cell carcinoma and adenocarcinoma of the uterine cervix

Introduction

The prognostic impact of the number of examined lymph nodes (ELNs) in different histological subtypes of cervical cancer remains unclear. We aimed to assess the impact of the number of ELNs in stage IA2–IIA cervical cancer with different histological subtypes.

Methods

Data of patients with stage IA2–IIA squamous cell carcinoma (SCC) and adenocarcinoma (AC) of the uterine cervix between 1988 and 2013 were retrieved from the Surveillance, Epidemiology, and End Results program. Univariate and multivariate Cox regression analyses were performed to analyze the effect of number of ELNs on cause-specific survival (CSS) and overall survival (OS).

Results

The final data set identified 11,830 patients including 7,920 (66.9%) women with SCC and 3,910 (33.1%) with AC. The median number of ELNs was 19. The multivariate analysis indicated that the number of ELNs was an independent prognostic factor influencing CSS and OS, both as a continuous or a categorical variable. Patients with a higher number of ELNs had better survival outcomes. In SCC subtype, the number of ELNs was also the independent prognostic factor of CSS and OS in node-positive patients, but not in patients with node-negative disease. In AC patients, ELN count was not an independent predictor of CSS and OS regardless of lymph node status.

Conclusion

The number of ELNs is an independent prognostic factor in patients with stage IA2–IIB cervical cancer. A higher number of ELNs is associated with better survival outcomes, especially in the node-positive SCC subtype.