Recurrence and survival analyses of 1,115 cervical cancer patients treated with radical hysterectomy

Impact of different post-operative treatment modalities on long-term outcomes in International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IIICp cervical cancer

Objective

This retrospective study aimed to evaluate the survival outcomes in International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IIICp cervical cancer patients receiving different adjuvant treatment modalities after radical hysterectomy.

Methods

From January 2008 to December 2012, patients diagnosed with cervical cancer who underwent radical hysterectomy plus retroperitoneal lymphadenectomy with pathologically confirmed positive lymph nodes, and received either radiotherapy, concurrent chemoradiation, or sequential chemoradiation, were included in this study. Survival analysis was performed according to different adjuvant treatment modalities and after adjustment using propensity score matching.

Results

A total of 192 stage IIICp cervical cancer patients were eligible. In multivariate analysis, only sequential chemoradiation versus radiotherapy was associated with both overall survival (HR 0.44, 95% CI 0.21 to 0.94, p=0.035) and disease-free survival (HR 0.26, 95% CI 0.11 to 0.57, p<0.001). The 5-year overall survival for radiotherapy, concurrent chemoradiation, and sequential chemoradiation was 71.6%, 81.7%, and 81.5%, respectively. No significant difference in overall survival was noted between the three groups (radiotherapy vs concurrent chemoradiation, p=0.15; radiotherapy vs sequential chemoradiation, p=0.09; concurrent chemoradiation vs sequential chemoradiation, p=0.95). However, sequential chemoradiation significantly increased disease-free survival compared with radiotherapy alone (79.2% vs 63.1%, p=0.028). After propensity score matching in the baseline characteristics, both overall survival (88.0% vs 71.6%, p=0.028) and disease-free survival (88.0% vs 63.1%, p=0.021) were improved in the sequential chemoradiation group compared with radiotherapy alone; no significant differences were noted between sequential chemoradiation and concurrent chemoradiation (overall survival 88.0% vs 83.8%, p=0.50; disease-free survival 88.0% vs 75.8%, p=0.28).

Conclusion

In this cohort of FIGO 2018 IIICp cervical cancer patients, post-operative sequential chemoradiation was associated with higher survival compared with radiotherapy alone after propensity matching. Future prospective studies are required to further elucidate the optimal modality in node-positive cervical cancer.

Prognostic factors influencing pelvic, extra-pelvic, and intraperitoneal recurrences in lymph node-negative early-stage cervical cancer patients following radical hysterectomy

OBJECTIVE

The aim of this study was to evaluate the clinicopathologic factors influencing pelvic, extra-pelvic, and intraperitonal recurrences and survival in patients with lymph node-negative early-stage cervical cancer treated with abdominal/laparoscopic/robotic radical hysterectomy (ARH/LRH/RRH).

STUDY DESIGN

We retrospectively reviewed clinicopathologic data of 342 patients with FIGO stage IB-IIA cervical cancer (2018 FIGO staging) treated with RH and retroperitonal lymphadenectomy between February 2000 and November 2018. Several clinicopathologic factors such as surgical methods including LRH/RRH-vaginal colpotomy (VC) and LRH/RRH-intracorporeal colpotomy (IC), surgical resection margin, and parametrial/endomyometrial infiltration were selected. Univariate and multivariate Cox proportional hazard regression and logistic regression models were used to determine prognostic factors.

RESULTS

The median follow-up time was 54 months (range, 6-202 months). In multivariate analysis, positive endomyometrial infiltration (HR, 13.576; 95 % CI, 2.917-63.179; P = 0.001), positive parametrial resection margin (HR, 32.648; 95 % CI, 2.774-384.181; P = 0.006), and LRH/RRH-IC (HR, 4.752; 95 % CI, 1.154-19.578; P = 0.031) were significantly related to overall survival. Six (26.3 %) out of 21 patients with endomyometrial infiltration showed extra-pelvic recurrences associated with lung, liver, and brain. Three (50.0 %) out of 6 patients with positive parametrial margin showed both pelvic and extra-pelvic metastases, such as pelvis and supraclavicular/paratracheal lymph nodes. Five (62.5 %) out of the eight relapsed patients who received LRH/RRH-IC showed intraperitoneal recurrences including omentum, liver surface, colon serosa, and splenic hilum.

CONCLUSIONS

Three risk factors including parametrial margin, endomyometrial infiltration, and laparoscopic IC appear to be involved in pelvic, extra-pelvic, and intraperitoneal recurrences in node-negative early-stage cervical cancer patients following RH. In particular, endomyometrial infiltration may be one of the strongest independent prognostic factors for extra-pelvic recurrence. Adjuvant systemic therapy may be indicated for lymph node-negative early-stage cervical cancer patients with endomyometrial infiltration.

Integrated pre-surgical diagnostic algorithm to define extent of disease in cervical cancer

OBJECTIVES

Survival of patients with cervical cancer is strongly associated with the local extent of the primary disease. The aim of the study was to develop an integrated diagnostic algorithm, including ultrasonography (USG), magnetic resonance imaging (MRI), and examination under anesthesia, to define the local extent of disease in patients with newly diagnosed cervical cancer.

METHODS

Patients with biopsy proven cervical cancer who underwent primary surgery from January 2013 to December 2018 in four participating centers were recruited. Patients who underwent USG, MRI, and examination under anesthesia prior to surgery were included in the study. Those for whom complete data were not available were excluded. Data regarding tumor size, parametrial invasion, and vaginal involvement obtained by USG, MRI, and examination under anesthesia were retrieved and compared with final histology. Specificity and sensitivity of the three methods were calculated for each parameter and the methods were compared with each other. An integrated pre-surgical algorithm was constructed considering the accuracy of each diagnostic method for each parameter.

RESULTS

A total of 79 consecutive patients were included in the study. Median age was 53 years (range 28-87) and median body mass index was 24.6 kg/m² (range 16-43). Fifty-five (69.6%) patients had squamous carcinoma, 18 (22.8%) patients had adenocarcinoma, and six (7.6%) patients had other histological subtypes. A statistically significant difference among the three methods was found for detecting tumor size (p=0.002 for tumors >2 cm and p=0.006 for tumors >4 cm) and vaginal involvement (p=0.01). There was no difference in detection of parametrial invasion between USG, MRI, and examination under anesthesia (p=0.26). Furthermore, regarding tumor size assessment, USG was found to be the significantly better method (p<0.01 for tumors >2 cm and p=0.02 for tumors >4 cm). Examination under anesthesia was the most accurate method for detection of vaginal involvement (p=0.01). Examination under anesthesia and MRI had higher accuracy than USG for identification of parametrial invasion. Application of the algorithm provided the correct definition of local extent of disease in 77.2% of patients (p=0.04). USG was the most accurate method to determine tumor size, while examination under anesthesia was found to be more accurate in prediction of vaginal involvement.

CONCLUSION

Our integrated diagnostic algorithm allows a higher accuracy in defining the local extent of disease and may be used as a tool to determine the therapeutic approach in women with cervical cancer.

Radiomic signature as a predictive factor for lymph node metastasis in early-stage cervical cancer

BACKGROUND

Lymph node metastasis (LNM) is the principal risk factor for poor outcomes in early-stage cervical cancer. Radiomics may offer a noninvasive way for predicting the stage of LNM.

PURPOSE

To evaluate a radiomic signature of LN involvement based on sagittal T₁ contrast-enhanced (CE) and T₂ MRI sequences.

STUDY TYPE

Retrospective.

POPULATION

In all, 143 patients were randomly divided into two primary and validation cohorts with 100 patients in the primary cohort and 43 patients in the validation cohort.

FIELD STRENGTH/SEQUENCE

T₁ CE and T₂ MRI sequences at 3T.

ASSESSMENT

The gold standard of LN status was based on histologic results. A radiologist with 10 years of experience used the ITK-SNAP software for 3D manual segmentation. A senior radiologist with 15 years of experience validated all segmentations. The area under the receiver operating characteristics curve (ROC AUC), classification accuracy, sensitivity, and specificity were used between LNM and non-LNM groups.

STATISTICAL TESTS

A total of 970 radiomic features and seven clinical characteristics were extracted. Minimum redundancy / maximum relevance and support vector machine algorithms were applied to select features and construct a radiomic signature. The Mann-Whitney U-test and the chi-square test were used to test the performance of clinical characteristics and potential prognostic outcomes. The results were used to assess the quantitative discrimination performance of the SVM-based radiomic signature.

RESULTS

The radiomic signatures allowed good discrimination between LNM and non-LNM groups. The ROC AUC was 0.753 (95% confidence interval [CI], 0.656-0.850) in the primary cohort and 0.754 (95% CI, 0584-0.924) in the validation cohort.

DATA CONCLUSIONS

A multiple-sequence MRI radiomic signature can be used as a noninvasive biomarker for preoperative assessment of LN status and potentially influence the therapeutic decision-making in early-stage cervical cancer patients.

LEVEL OF EVIDENCE

3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:304-310.

Which is better for predicting pelvic lymph node metastases in patients with cervical cancer: Fluorodeoxyglucose-positron emission tomography/computed tomography or a sentinel node biopsy? A retrospective observational study

Systematic pelvic lymph node resection may not be needed for patients with cervical cancer, especially in the early stage, if the pre- or intraoperative diagnosis of lymph node status is correct. The aim of this study was to evaluate the diagnostic accuracy of pelvic lymph node metastasis for fluorodeoxyglucose-positron emission tomography/computed tomography (FDG PET/CT) and sentinel node biopsy (SNB) of cervical cancer patients.Forty-eight patients with cervical cancer were imaged with FDG PET/CT before radical hysterectomy and underwent an SNB followed by systematic pelvic lymph node dissection. The diagnostic accuracy for predicting pelvic node metastases for FDG PET/CT and SNB compared with the ultimate histologic status was analyzed.Among 96 hemi-pelvises (HPs) in 48 patients, pelvic lymph node metastases were obtained in 12 HPs. The sensitivity of pelvic node metastases for FDG PET/CT and SNB was 8.3% and 75.0%, respectively. The specificity for FDG PET/CT and SNB was 97.6% and 94.0%, respectively. The negative predictive value for FDG-PET/CT and SNB was 88.2% and 100%, respectively.SNB is more suitable for detecting pelvic node metastases than FDG PET/CT. The omission of systematic pelvic lymphadenectomy should be considered based on the findings of SNB, not FDG PET/CT.

The detection of sentinel lymph nodes in laparoscopic surgery for uterine cervical cancer using 99m-technetium-tin colloid, indocyanine green, and blue dye

OBJECTIVE

Our objective was to determine the feasibility and detection rates and clarify the most effective combination of injected tracer types for sentinel lymph node (SLN) mapping in uterine cervical cancer in patients who have undergone laparoscopic surgery or neoadjuvant chemotherapy (NAC).

METHODS

A total of 119 patients with cervical cancer underwent SLN biopsy at radical hysterectomy using three types of tracers. The various factors related to side-specific detection rate, sensitivity, and false negative (FN) rate were analyzed.

RESULTS

The SLN detection rates using 99m-technetium ((99m)Tc)-tin colloid, indigo carmine, and indocyanine green (ICG) were 85.8%, 20.2%, and 61.6%, respectively. The patients with ≥2-cm-diameter tumors and those who received NAC had lower detection rates than those with <2-cm-diameter tumors (75.7% vs. 91.5%, p<0.01) and those who did not receive NAC (67.9% vs. 86.3%, p<0.01), respectively. Laparoscopic procedures had a higher detection rate than laparotomy (100.0% vs. 77.1%, p<0.01). No factors significantly affected the sensitivity; however, the patients with ≥2-cm-diameter tumors (86.0% vs. 1.4%, p<0.01), NAC (19.4% vs. 2.2%, p<0.01), and those who underwent laparotomy (7.4% vs. 0%, p<0.01) had an unfavorable FN rate.

CONCLUSION

Among the examined tracers, (99m)Tc had the highest detection of SLN mapping in patients with uterine cervical cancer. Patients with local advanced cervical cancer with/without NAC treatment might be unsuited for SLN mapping. SLN mapping is feasible and results in an excellent detection rate in patients with <2-cm-diameter cervical cancer. Laparoscopic surgery is the best procedure for SLN detection in patients with early-stage disease.

Beyond sentinel node algorithm. Toward a more tailored surgery for cervical cancer patients

Nowadays cervical cancer is frequently diagnosed at early stage. For these patients lymph node metastasis (LNM) is considered the most important prognostic factor. During the last decade many efforts have been made to reduce rate of complications associated with lymphadenectomy (LND). A great interest has arisen in sentinel lymph node (SLN) biopsy as a technique able to decrease number of LND performed and, at the same time, to assess lymph nodal status. High diagnostic performances have been reached thanks to SLN surgical algorithm. However, despite the efforts, about 25% of these patients undergo at least unilateral LND to meet NCCN recommendations. Data of women with International Federation of Gynecology and Obstetrics stage IA1‐IB1/IIA1 cervical carcinoma were retrospectively collected by six Italian institutions. All patients underwent complete preoperative staging workup and were primarily treated by radical hysterectomy and pelvic bilateral LND. A total of 368 patients with early‐stage cervical cancer were identified. Among them 333 (90.5%) showed no suspicious enlarged nodes at the preoperative magnetic resonance imaging (MRI). In this subset, tumor diameter ≥20 mm was the only independent predictor of LN status (P = 0.003). None of the 106 patients with negative MRI nodal assessment, with squamous and adenosquamous histotype and a tumor diameter less than 2 cm had LNM. Based on these results we propose a new modified SLN surgical algorithm that could safely reduce LND performed in patients with very low‐risk early‐stage cervical cancer.

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.

Outcome of cervical cancer patients with single-node compared with no nodal involvement treated with radical hysterectomy and pelvic lymphadenectomy

OBJECTIVE

To evaluate disease-free survival (DFS) after radical hysterectomy and pelvic lymphadenectomy (RHPL) among early-stage cervical cancer patients with single-node involvement versus patients with no nodal involvement.

METHODS

A retrospective review was conducted of the medical records of 843 patients undergoing RHPL at Chiang Mai University Hospital, Thailand, between January 1, 2002, and December 31, 2008. Neoadjuvant chemotherapy was administered when the operative schedule was more than 1 month after diagnosis and adjuvant chemoradiation was administered to high-risk patients. Five subgroups were defined on the basis of pelvic node involvement: group A (0 nodes; n=706), group B (1 node; n=65), group C (2 nodes; n=38), group D (3 nodes; n=13), and group E (≥4 nodes; n=21).

RESULTS

The 5-year DFS was comparable for groups A and B (94.3% versus 92.1%; P=0.454). In groups C, D, and E, the 5-year DFS was 85.9%, 75.0%, and 61.8%, respectively. The survival outcomes for groups A and B were significantly different from those of the other 3 groups (P<0.001).

CONCLUSION

Cervical cancer patients with single-node involvement had comparable survival outcomes to those without nodal metastases; however, patients with multiple node involvement had reduced DFS.

Pelvic node removal and disease-free survival in cervical cancer patients treated with radical hysterectomy and pelvic lymphadenectomy

OBJECTIVE

To examine the relationship between the number of pelvic nodes removed and 5-year disease-free survival in early-stage cervical cancer patients who underwent radical hysterectomy and pelvic lymphadenectomy (RHPL).

METHODS

The medical records of 826 cervical cancer patients who underwent RHPL and who had at least 11 pelvic nodes removed at Chiang Mai University Hospital between January 2002 and December 2008 were reviewed. The patients were divided into 4 groups according to the number of nodes removed: 11-20 nodes (n=243); 21-30 nodes (n=344); 31-40 nodes (n=171); and ≥ 41 nodes (n=68). The 5-year disease-free survival of patients in each group was compared. The clinicopathological factors were analyzed using Cox regression to identify independent prognostic factors.

RESULT

Five-year disease-free survival was not significantly different among the 4 groups. When patients with and without nodal involvement were considered separately, the 5-year disease-free survival in all groups was not significantly different. At multivariate analysis, the number of pelvic nodes removed was not an independent prognostic factor.

CONCLUSION

The number of pelvic nodes removed was not associated with 5-year disease-free survival or number of positive pelvic nodes.

Establishing a sentinel lymph node mapping algorithm for the treatment of early cervical cancer

OBJECTIVE

To establish an algorithm that incorporates sentinel lymph node (SLN) mapping to the surgical treatment of early cervical cancer, ensuring that lymph node (LN) metastases are accurately detected but minimizing the need for complete lymphadenectomy (LND).

METHODS

A prospectively maintained database of all patients who underwent SLN procedure followed by a complete bilateral pelvic LND for cervical cancer (FIGO stages IA1 with LVI to IIA) from 03/2003 to 09/2010 was analyzed. The surgical algorithm we evaluated included the following: 1. SLNs are removed and submitted to ultrastaging; 2. any suspicious LN is removed regardless of mapping; 3. if only unilateral mapping is noted, a contralateral side-specific pelvic LND is performed (including inter-iliac nodes); and 4. parametrectomy en bloc with primary tumor resection is done in all cases. We retrospectively applied the algorithm to determine how it would have performed.

RESULTS

One hundred twenty-two patients were included. Median SLN count was 3 and median total LN count was 20. At least one SLN was identified in 93% of cases (114/122), while optimal (bilateral) mapping was achieved in 75% of cases (91/122). SLN correctly diagnosed 21 of 25 patients with nodal spread. When the algorithm was applied, all patients with LN metastasis were detected; with optimal mapping, bilateral pelvic LND could have been avoided in 75% of cases.

CONCLUSIONS

In the surgical treatment of early cervical cancer, the algorithm we propose allows for comprehensive detection of all patients with nodal disease and spares complete LND in the majority of cases.

Extralesional detection and load of human papillomavirus DNA: a possible marker of preclinical tumor spread in cervical cancer

OBJECTIVE

Because the interaction between viral DNA products and cellular regulatory mechanisms is the first step leading to cancerous transformation, the detection of its presence in histologically negative lymph nodes may represent a very early biological step in cancer spread. The quantitative estimate may represent and an indirect sign of active cellular replication.

MATERIALS AND METHODS

Cervical and lymph nodes tissues of 13 cases of invasive cervical cancer were analyzed for human papillomavirus (HPV)-DNA presence and viral load by HPV typing and quantification by real-time polymerase chain reaction.

RESULTS

HPV-DNA was demonstrated in all tissue samples (primary tumor, positive lymph nodes, negative lymph nodes) with the most prevalence of HPV 16 (61.5%) and single-type infection (69.3%), whereas viral load (mean quantity of DNA copies) is statistically different in negative versus positive lymph nodes (p =.005).

CONCLUSIONS

Concordance of viral type and lymph nodes viral load may represent as a useful tool in identifying early metastatic risk of tumor spread.

Detection of micrometastases in pelvic lymph nodes in patients with carcinoma of the cervix uteri using step sectioning: Frequency, topographic distribution and prognostic impact

OBJECTIVES

Limited information exist about the frequency of micrometastases, their topographic distribution and prognostic impact in patients with cervical carcinoma (CX).

METHODS

Lymph nodes of patients with surgically treated CX, FIGO IB to IIB, with pelvic lymph node involvement, were re-examined regarding the size of metastatic deposits, their topographic distribution within the pelvis. Lymph node status (pN0 vs. pN1mic=metastasis<0.2 cm vs. pN1=metastasis>0.2 cm) was correlated to recurrence free (RFS) and overall survival (OS).

RESULTS

31.4% of all patients (281/894) represented pelvic lymph node involvement. 22.2.% of the node positive ones showed micrometastases (pN1mic). Most commonly, obturator and internal nodes were affected by pN1mic, without any side differences. Patients with macrometastases (pN1) and micrometastases (pN1mic) represented significant reduced RFS-rate at 5-years (62% [95% CI: 54.2 to 69.8] for pN1 and 68.9% [95% CI: 55.5 to 82.4] for pN1mic) when compared to patients without metastatic disease (91.4% [95% CI: 89.0 to 93.8]; p<0.001) The 5-years OS-rate was decreased in patients with metastatic disease (pN0: 86.6% [95% CI: 83.7 to 89.5], pN1mic: 63.8% [95% CI: 50.9 to 76.7], pN1: 48.2% [95% CI: 40.4 to 56.0]; p<0.0001). These differences persisted in detailed analysis within these subgroups. In multivariate analysis, tumor stage, pelvic lymph node involvement and micrometastases were independent prognostic factors.

CONCLUSIONS

A remarkable number of patients with CX show micrometastases within pelvic nodes. Micrometastatic disease represents an independent prognostic factor. So, all patients with pelvic lymph node involvement, including micrometastatic deposits, might be candidates for adjuvant treatment.

Efficacy of Hsp90 inhibition for induction of apoptosis and inhibition of growth in cervical carcinoma cells in vitro and in vivo

PURPOSE

Heat shock protein 90 (Hsp90) is a conserved chaperone involved in crucial signaling events in normal and malignant cells. Previous research suggests that tumor cells are particularly dependent on Hsp90 for survival as well as malignant progression. Hsp90 inhibitors which are derivates of the natural compound geldanamycin, such as the orally bioavailable 17-(dimethylaminoethylamino)-17-demethoxygeldanamycin (17-DMAG), are currently being tested in clinical trials and small molecule inhibitors are in development. In this study we investigated the response of a panel of cervical carcinoma cell lines in vitro and in vivo to determine potential factors that might influence the sensitivity towards Hsp90 inhibition.

METHODS

Cell viability, proliferation and drug-induced changes on Hsp90 chaperoned "client" factors were examined with focus on G2/M cell cycle regulators, and a comparison with immortalized and normal keratinocytes was performed. ME180 and CaSki cells were grown as subcutaneous xenografts in mice treated with 6-10 mg/kg 17-DMAG by oral gavage 2x/day on a chronic schedule. Tissue concentrations of 17-DMAG were measured by high performance liquid chromatography.

RESULTS

Cell death during abnormal mitosis was observed within 48 h after treatment start. ME180 and CaSki showed more cell death at this time point than SiHa and HeLa, and higher levels of pre-treatment Akt activity. IC(50) values ranged between 17 and 37 nanoM geldanamycin (MTS). Keratinocytes were at least as sensitive as carcinoma cells. All cell lines responded with an increase of the G2/M fraction. Despite in vitro effectiveness and tissue concentrations of 1 microM, only a limited tumor growth reduction was observed with 17-DMAG given close to the maximum tolerated dose level. Lower levels of Hsp90 protein, a lower Akt activity and signs of tissue hypoxia were observed in xenografts compared to cell cultures.

CONCLUSIONS

We show here that Hsp90 inhibition effectively induces apoptosis and growth arrest in cervical carcinoma cells in vitro. Mitotic catastrophe was identified as one mechanism of cell death. In contrast, a limited efficacy of 17-DMAG was observed in subcutaneous xenograft models. Induction of a heat shock response has previously been implicated in resistance towards Hsp90 inhibition. Additional factors might be (1) an altered abundance and/or activity of primary (Hsp90) and secondary (e.g., Akt) target(s), (2) a narrow therapeutic range of 17-DMAG by oral application and (3) response-modifying factors within the tumor environment. The further development of synthetic Hsp90 inhibitors with increased therapeutic window is warranted.

HPV16-E6 mRNA is superior to cytokeratin 19 mRNA as a molecular marker for the detection of disseminated tumour cells in sentinel lymph nodes of patients with cervical cancer by quantitative reverse-transcription PCR

About 10-15% of patients with cervical cancer suffer from recurrence despite histologically negative lymph nodes (pN0). Occult micrometastases or small tumour cell clusters may contribute to disease outcome. The aim of this study was to compare at the RNA level 2 known tumour-associated genes, HPV16-E6 and cytokeratin 19 (CK19), as molecular markers for the detection of disseminated tumour cells. Real-time reverse transcription PCR technology was used to quantify gene expression in histologically positive and negative sentinel lymph nodes (SLN) from 70 patients with cervical cancer. Lymph nodes from noncancer patients were used as controls. Calculated copy numbers were normalised to the geometric average of the most stable housekeeping genes. We observed a good correlation (R = 0.915) between the expression of both markers in SLN with histologically confirmed metastases. However, marker gene expression differed considerably in histologically negative nodes: CK19 transcripts were detected in 90 of 112 SLN (80.4%), whereas only 38 nodes (33.9%) were positive for HPV16 E6 mRNA. In particular, 62 of 74 SLN, which were negative by histology, and HPV16 E6 mRNA expressed CK19 mRNA. Moreover, 8 of 10 lymph nodes from noncancer patients expressed CK19 mRNA. Systematic errors due to RNA degradation or incomplete cDNA could be ruled out. It is concluded that HPV16 E6 mRNA is more specific and more sensitive for the detection of tumour cells in SLN than CK19 mRNA. The specificity of CK19 is limited because of low level expression in uninvolved pelvic lymph nodes.

Neoadjuvant chemotherapy and radical surgery compared to radical surgery alone in bulky stage IB-IIA cervical cancer

AIM

The aim of this study was evaluation of the efficacy of neoadjuvant chemotherapy (NACT) and radical hysterectomy on long-term survival in stage IB-IIA locally advanced cervical cancer as compared with radical surgery alone.

METHODS

We reviewed all patients with cervical cancer stage IB-IIA who were treated with two treatment modalities, i.e. NACT followed by radical hysterectomy and lymphadenectomy, and radical hysterectomy alone between March 1996 and March 2004. There were 22 patients in the NACT group (group 1) and 160 patients in the immediate radical surgery group (group 2). All patients in group 1 were followed for more than 108months, and long-term survival and factors affecting recurrence were evaluated.

RESULTS

Nineteen patients in the NACT arm underwent radical surgery. Pelvic lymph node metastasis was found in 8 patients in this group and in 36 in the radical surgery group. Eighteen patients in the NACT group and 96 patients in the radical surgery group were scheduled for adjuvant postoperative chemoradiation. During the 9-year follow-up, recurrence rate was 47.1% and 30.2% in NACT and control groups, respectively. In the NACT group lymph node metastasis was a significant independent risk factor for recurrence. Overall survival in the NACT arm was not statistically significantly lower than the control arm (p=0.06).

CONCLUSION

NACT did not improve long-term overall survival of bulky early-stage cervical cancer patients compared to primary radical surgery.

Occult tumor cells in pelvic lymph nodes and parametrial tissue of small-sized FIGO IB1 squamous cell carcinomas of the uterine cervix – results of a pilot study

Micrometastases (MM) and occult tumor cell deposits (OTCD) in pelvic tissue may cause recurrences, and immunohistochemistry may improve their detection. We used cytokeratine-immunohistochemistry to investigate 263 pelvic lymph nodes and parametrial tissue for MM and OTCD obtained from eight squamous cell carcinomas (maximum tumor size: 2.5 cm). These patients were treated with radical abdominal hysterectomy (Piver type III) with complete tumor resection without receiving any adjuvant therapy. The mean count of resected pelvic lymph nodes was 32.9 (range 24-47). All lymph nodes were completely embedded, and three step sections were performed for routine histopathologic evaluation. Three patients developed pelvic side wall and five central tumor recurrences within a median time of 25.9 (range 8-55) months. On immunohistochemistry, only one case (12.5%) showed OTCD in a venule in the parametrial tissue. In patients with small cervical carcinomas (< 2.5 cm in largest dimension), OTCD can only rarely be detected by immunohistochemistry after careful handling of resected lymph nodes using step sectioning for routine histologic examination and complete processing of parametrial pelvic tissue. Therefore, tumor recurrence in those patients appears to be due to occult residual tumor cells that were not resected during the classical Wertheim-Meigs-procedure or that were disseminated during the surgical procedure and persisted in situ.

Identification of micrometastases in histologically negative lymph nodes of early-stage cervical cancer patients

OBJECTIVE

Despite histologically negative lymph nodes, approximately 15% of patients with early-stage cervical cancer will develop recurrence. Micrometastases have been shown to be important in staging and treatment of breast cancers and melanoma and have been identified by polymerase chain reaction analysis in cervical cancers. This study sought to estimate the frequency of micrometastases identified by immunohistochemistry in histologically negative lymph nodes and compare this to other known risk factors for recurrence of cervical cancer.

METHODS

Early-stage (stages IA2, IB1, and IB2) cervical cancer patients of all histologic subtypes were identified from the surgical logs of the Los Angeles County-University of Southern California Medical Center for the period 1994-2000. One hundred thirty-two patients had histologically negative lymph nodes. Immunohistochemical assay was performed on 3,106 lymph nodes by using antibodies against cytokeratins AE-1 and CAM 5.2 in combination according to standard protocols. The stained nodes were then evaluated for the presence of micrometastases and compared against the respective clinicopathologic information in each case.

RESULTS

Micrometastases were detected in 19 of 132 (15%, 95% confidence interval [CI] 9%, 22%) patients, found in 29 of the 3,106 (0.9%) lymph nodes evaluated. Vascular space invasion was seen in 50 of 132 cases (38%, 95% CI 30%, 47%) and in 8 of 19 (42%, 95% CI 21%, 66%) cases with micrometastases. Surgical margins of the resected specimen were negative in 120 of 132 cases (91%, 95% CI 84%, 95%) and in 16 of 19 (84%, 95%CI 60%, 96%) of those cases with micrometastases. Micrometastases were seen most frequently in pelvic lymph nodes (25 of 29, 86%). Patients with more than 20 lymph nodes removed were more likely to demonstrate metastasis (P <.001). There was no statistically significant association between micrometastasis and vascular space invasion or tumor volume.

CONCLUSION

Micrometastases are identifiable in histologically negative lymph nodes in 15% (95% CI 9%, 22%) of early-stage cancer patients, a frequency which approximates the recurrence rate for patients with negative nodes. In this series, patients with greater numbers of lymph nodes analyzed were more likely to have lymph node micrometastasis identified. There appears to be no relationship between tumor volume and the identification of micrometastases. Although micrometastases can be identified in histologically negative lymph nodes, their presence is not strongly associated with other known factors of cervical cancer recurrence. Further research is needed to determine whether the presence of lymph node micrometastases is associated with an unfavorable prognosis.

LEVEL OF EVIDENCE

II-3

Is lymph vascular space involvement an independent prognostic factor in early cervical cancer?

OBJECTIVE

To determine whether lymph vascular space involvement (LVSI) in women with early cervical carcinoma is an independent prognostic factor.

METHODS

The literature was reviewed using Medline and known literature to determine if LVSI is an independent risk factor as determined by multivariant analysis with survival being the end point in patients undergoing radical hysterectomy and pelvic lymphadenopathy.

RESULTS

A total of 25 articles were identified that satisfied the evaluation criteria. Only three (12%) identified LVSI as an independent risk factor while 88% and 61% of those evaluated, noted lymph node metastasis and tumor size/depth of invasion to be significant risk factors for survival.

CONCLUSIONS

Using LVSI as the sole determining factor for consideration of post radical hysterectomy radiotherapy appears questionable.

Prognostic factors in FIGO stage IB cervical cancer without lymph node metastasis and the role of adjuvant radiotherapy after radical hysterectomy

OBJECTIVES

The aim of this study was to evaluate the clinical and pathologic prognostic variables for disease free survival, overall survival and the role of adjuvant radiotherapy in FIGO stage IB cervical carcinoma without lymph node metastasis.

METHODS

A retrospective review was performed of 393 patients with lymph node negative stage IB cervical cancer treated by type 3 hysterectomy and pelvic lymphadenectomy at the Hacettepe University Hospitals between 1980 and 1997.

RESULTS

The disease free survival and overall survival were 87.6 and 91.0%, respectively. In univariate analysis, tumor size, depth of invasion, vaginal involvement, lympho-vascular space involvement (LVSI) and adjuvant radiotherapy were found significant in disease free survival. Overall survival was affected by tumor size, LVSI, vaginal involvement and adjuvant radiotherapy. Tumor size, LVSI and vaginal involvement were found as independent prognostic factors for overall and disease free survival in multivariate analysis. Disease free survival, recurrence rate and site did not differ between patients underwent radical surgery and radical surgery plus radiotherapy.

CONCLUSION

Tumor size, LVSI and vaginal involvement were independent prognostic factors in lymph node negative FIGO stage IB cervical cancer. Adjuvant radiotherapy in stage IB cervical cancer patients with negative nodes provides no survival advantage or better local tumoral control.

High cyclooxygenase-2 expression in cervical adenocarcinomas

OBJECTIVE

The purpose of this study was to examine the relationships between cyclooxygenase-2 (COX-2) expression and prognostic factors in cervical carcinomas.

METHODS

We studied COX-2 expression in 53 women with cervical cancers, including 35 squamous cell carcinomas (SCCs), 1 adenosquamous cell carcinoma (ASCC), and 17 adenocarcinomas (ACs), using commercially available polyclonal antibodies on Formalin-fixed, paraffin-embedded tissues. Normal cervical tissues were obtained as from other patients with uterine myomas treated with a total hysterectomy (n = 16). The immunoreactivity was quantified using an immunohistochemical scoring system that approximates the use of an image analysis-based system.

RESULTS

Twenty-two cervical cancer tissues (41.5%), including 10 SCCs and 12 ACs, expressed COX-2 at a moderate to strong level, which significantly, differed from the negligible expression found in the control group of 16 normal cervical tissues (P = 0.001). Different cell types showed significantly different expression levels of COX-2 (SCC at 28.6% vs AC at 70.6%, P = 0.004). The presence of deep stromal invasion (n = 40) showed a significant inverse relationship to COX-2 expression (32.5% vs 69.2%, P = 0.02). The expression of COX-2 in well-differentiated carcinomas was significantly increased compared to that in moderately and poorly differentiated carcinomas (72.7% vs 33.3%, respectively, P = 0.018).

CONCLUSIONS

Overexpression of COX-2 was found in both SCC and AC, but SCCs showed infrequent and low expression. These findings suggest that increased COX-2 expression may play an important role in cervical adenocarcinomas.

Nonoperative assessment of nodal status for locally advanced cervical squamous cell carcinoma treated by radiotherapy with regard to patterns of treatment failure

PURPOSE

Lymph node metastasis is a major prognostic factor in the treatment of cervical cancer, but its nonsurgical assessment is not necessarily accurate, particularly in small nodes. We evaluated whether node-negative status could be accurately assessed using a low cutoff measure.

METHODS AND MATERIALS

The subjects were 84 patients with Stage IIB-IVA cervical squamous cell carcinoma treated by definitive radiotherapy. Nodal status was assessed by CT as negative (<5 mm), possibly positive (5-10 mm), or probably positive (>10 mm). Cause-specific survival and the disease-free rate, including the pelvic recurrence-free and distant metastasis-free rates, were estimated.

RESULTS

The cause-specific survival, disease-free rate, and pelvic recurrence-free rate at 5 years were significantly higher for the 32 patients with node-negative disease (83.5%, 86.1%, and 86.1%) and the 17 patients with possibly node-positive disease (59.2%, 93.8%, and 93.8%) than for the 35 patients with probably node-positive disease (32.6%, 22.0%, and 46.8%), respectively. No significant difference was found between negative and possibly node-positive status. In contrast, the distant metastasis-free rate differed significantly among node-negative (96.4%), possibly node-positive (59.3%), and probably node-positive (35.1%) status.

CONCLUSION

Node-negative status assessed using a strict cutoff measure may be useful as a strong predictor of cervical cancer being confined to the pelvis.

Multivariate analysis of histopathologic prognostic factors for invasive cervical cancer treated with radical hysterectomy and systematic retroperitoneal lymphadenectomy

BACKGROUND

The aim of this study was to identify the independent histopathologic prognostic factors for patients with cervical carcinoma treated with radical hysterectomy including paraaortic lymphadenectomy.

METHODS

A total of 187 patients with stage IB to IIB cervical carcinomas treated with radical hysterectomy and systematic retroperitoneal lymphadenectomy were retrospectively analyzed. The median follow-up period was 83 months. Cox regression analysis was used to select independent prognostic factors.

RESULTS

Using multivariate Cox regression analysis, lymph node (LN) status (negative vs. metastasis to pelvic nodes except for common iliac nodes vs. common iliac/paraaortic node metastasis), histopathologic parametrial invasion, lymph-vascular space invasion (LVSI), and histology of pure adenocarcinoma were found to be independently related to patients' poor survival. For patients who had a tumor histologically confined to the uterus and have neither parametrial invasion nor lymph node metastasis, LVSI was the most important prognostic factor, and histologic type, depth of cervical stromal invasion, and tumor size were not related to survival. The survival of patients with a tumor extending to parametrium or pelvic lymph node(s) was adversely affected by histology of pure adenocarcinoma. When the tumor extended to common iliac or paraaortic nodes, patients' survival became quite poor irrespective of LVSI or histologic type of pure adenocarcinoma. Patients' prognosis could be stratified into low risk (patients with a tumor confined to the uterus not associated with LVSI: n = 80), intermediate risk (patients with a tumor confined to the uterus associated with positive LVSI, and patients with squamous/adenosquamous carcinoma associated with pelvic lymph node metastasis or parametrial invasion: n = 86), and high risk (patients with pure adenocarcinoma associated with pelvic lymph node metastasis or parametrial invasion, and patients with common iliac/paraaortic node metastasis: n = 21) with an estimated 5-year survival rate of 100 +/- 0 (mean +/- SE)%, 85.5 +/- 3.9%, and 25.1 +/- 9.7%, respectively.

CONCLUSIONS

LN status, parametrial invasion, LVSI, and histology of pure adenocarcinoma are important histopathologic prognostic factors of cervical carcinoma treated with radical hysterectomy and systematic retroperitoneal lymphadenectomy. Prognosis for patients with cervical carcinoma may be stratified by combined analysis of these histopathologic prognostic factors. Postoperative therapy needs to be individualized according to these prognostic factors and validated for its efficacy using randomized clinical trials.

SCC antigen in the serum as an independent prognostic factor in operable squamous cell carcinoma of the cervix

The aim of this study was to retrospectively examine whether the occurrence of squamous cell carcinoma (SCC) antigen tumour marker in the serum has prognostic significance in operable SCC of the cervix at the International Federation of Gynaecology and Obstetrics (FIGO) stages IA2-IIB. A total of 129 patients who had undergone a radical hysterectomy for SCC of the uterine cervix at the Department of Gynecology of the Martin-Luther University, Halle-Wittenberg in 1991-2000 were included. SCC antigen (Ag) was measured by IMx SCC-Ag microparticle enzyme immunoassay (Abbott Laboratories, Abbott Park, IL, USA). To assess the prognostic value of SCC antigen in the serum, we used a step-by-step multivariate analysis based on the Cox proportional hazard regression model. Using a cut-off value of 3.0 ng/ml, we detected preoperative SCC antigen in the serum as an independent prognostic factor in SCC of the cervix, both for recurrence-free and overall survival (P=0.003 and 0.0078). In this retrospective analysis the value of the SCC antigen tumour marker correlates with prognosis in operable SCC of the cervix, independent of tumour size, pelvic nodal status, cervical stroma infiltration, parametrial spread and tumour grading.

Expression of sialyltransferase family members in cervix squamous cell carcinoma correlates with lymph node metastasis

OBJECTIVE

Altered messenger ribonucleic acid (mRNA) expression of the four sialyltransferases (STs including ST3Gal I, ST3Gal III, ST3Gal IV, and ST6Gal I) is important in squamous cell carcinoma of the cervix. This study further investigates their changes in mRNA expression of the four STs in FIGO stage IB1 squamous cell carcinoma to assess the extent of sialylation associated with lymph node metastases.

METHODS

Alterations in ST mRNA expression in FIGO IB1 cervical squamous cell carcinomas (n = 79) were examined by semiquantitative reverse transcription-polymerase chain reaction.

RESULTS

Both ST6Gal I mRNA and ST3Gal III mRNA expressions were significantly increased in patients with lymph node metastases compared to those without lymph node metastases (P = 0.002 and P = 0.001, respectively, Mann-Whitney U test). Using receiver operating characteristic curves of ST ratio index for accuracy comparison of lymph node metastases, ST3Gal III and ST6Gal I were observed to be fairly interchangeable (area under the curve (AUC) of 3Gal I = 0.810; AUC of 6Gal I = 0.786, significance of difference between AUC = 0.810). High ST6Gal I expression was associated with other invasive properties of cervical cancer, such as deep stromal invasion and presence of lymph-vascular space involvement. ST6Gal I expression seemed to be more enhanced in bigger tumors.

CONCLUSIONS

Our results suggested that ST3Gal III and ST6Gal I were of importance for the lymph node metastases in FIGO IB1 cervical cancer patients; more specifically, overexpression of ST6Gal I was of crucial relevance for the presence of poor prognostic factors, such as deep stromal invasion and lymph-vascular space involvement and lymph node metastases.

Detecting cytokeratin 19 mRNA in the peripheral blood cells of cervical cancer patients and its clinical-pathological correlation

OBJECTIVE

The aim of this study was to study the presence of cytokeratin 19 (CK19)-expressing cancer cells in the blood of preoperative patients with FIGO stage Ib and IIb cervical cancers who received radical hysterectomy and to investigate the cells' clinical significance.

METHODS

CK19 mRNA in the blood cells of the patients was detected preoperatively by a newly designed nested reverse transcriptase-polymerase chain reaction, which excluded pseudogenes a and b, performed on 84 patients with stage Ib and IIb cervical carcinoma. Possible correlations between clinicopathological factors were then analyzed.

RESULTS

The sensitivity of this assay was 1 CK19-mRNA-positive cell per 10(6) peripheral blood mononuclear cells. Results showed that 21.4% of the 84 patients with cervical carcinoma had CK19-mRNA-positive cells in the blood, in comparison with 5.7% of the 35 patients with benign gynecological tumors and 0% of the 28 healthy controls (P = 0.037 and 0.006, respectively). The positive tests in the cervical cancer patients were not associated with prognostic factors including stage, pelvic lymph node metastasis, pathological types, bulky tumor size (> or =4 cm), differentiation, parametrial extension, lymphovascular space involvement, deep stromal invasion, or age.

CONCLUSIONS

This study revealed the presence of circulating CK19-expressing cancer cells in the blood of patients with untreated early-stage cervical carcinomas, indicating that cervical cancer disseminated early. The survival effect of this phenomenon must be clarified. This detection assay provides an early checkpoint in the multistep process for developing metastasis in cervical cancer patients.

Altered mRNA expression of sialyltransferase in squamous cell carcinomas of the cervix

OBJECTIVE

Increased sialylation has been reported in various kinds of cancers, but to date, sialylation of cervical carcinoma has never been evaluated. This study of the changes in messenger ribonucleic acid (mRNA) expression of the four sialyltransferases (ST3Gal I, ST3Gal III, ST3Gal IV, and ST6Gal I) in a normal cervix and that with FIGO stage IB1 squamous cell carcinoma was undertaken to assess the extent of sialylation associated with establishment of the carcinoma.

METHODS

Alterations in ST mRNA expression in FIGO IB1 cervical cancer (n = 30) and normal cervixes (n = 30) were examined by semiquantitative reverse transcription-polymerase chain reaction (RT-PCR).

RESULTS

ST6Gal I expression was enhanced in squamous cell carcinoma of the cervix (P = 0.026, Mann-Whitney U test), but mRNA expression from the other three STs (ST3Gal I, ST3Gal III, and ST3Gal IV) was significantly down-expressed in squamous cell carcinoma of the cervix compared to the normal cervix (P = 0.003, P < 0.001, and P = 0.001, respectively). High ST6Gal I expression was associated with more invasive properties of cervical cancer, such as deep stromal invasion, lymph or vascular space involvement, and poor differentiation (P = 0.010, P < 0.001, P < 0.001, respectively).

CONCLUSIONS

A combination of enhanced ST6Gal I mRNA expression and decreased mRNA expression from ST3Gal I, ST3Gal III, and ST3Gal IV might be important in cervical cancer. Future studies will investigate whether RT-PCR detection of the expression of these enzymes can be helpful for prognostic purposes.

Prognostic value of p53 expression in stage IB1 cervical carcinoma

The purpose of this retrospective study was to evaluate the patterns of p53 expression in stage IB1 squamous cell carcinoma of the uterine cervix, to compare p53 expression with clinicopathological findings, and to assess its prognostic value. 27 patients with stage IB1 squamous cell carcinoma of the uterine cervix underwent abdominal radical hysterectomy and pelvic lymph node dissection. Expression of p53 was studied immunohistochemically. Overexpression of p53 was detected in 33.3% of the tumors, low expression was seen in 11.1%, and negative expression was found in 55.6%. Deep cervical stromal invasion (> or = 1/2) was found to be associated with the increased risk of lymph node metastases (odds ratio = 17.5). A significantly lower percentage of patients survived when p53 overexpression was observed (p = 0.0315). Univariate analysis revealed that tumor size (2-3.9 cm), lymph node metastasis, tumor invasion into parametria, tumor invasion into blood/lymph vessels, squamous cell carcinoma antigen (> or = 2 ng/ml), and p53 overexpression had a significantly lower recurrence-free survival rate. None of these above factors obtained significance in the multivariate analysis. This study suggests that expression of p53 may be indicative of an unfavorable prognosis in patients with stage IB1 squamous cell carcinoma of the uterine cervix.

Overall 5-year survival rate and prognostic factors in patients with stage IB and IIA cervical cancer treated by radical hysterectomy and pelvic lymph node dissection

The objective of this paper was to analyze the 5-year survival rate and prognostic factors for stage Ib and IIa cervical cancer treated by radical hysterectomy. A total of 366 patients with invasive cervical cancer treated by radical hysterectomy from June 1985 to June 1994 at Chonnam National University Hospital, Kwangju, Korea were retrospectively analyzed. Survival analysis was performed using the Kaplan-Meier estimator. Multivariate analysis was performed using the Cox proportional hazards regression model. The overall 5-year survival rate was 92% in stage Ib and 87% in stage IIa. Factors assessed for prognostic value included age, FIGO stage, cell type, tumor size, depth of invasion, lymphovascular space invasion (LVSI), and pelvic lymph node metastases (LNM). In the multivariate analysis, age, cell type, and lymph node metastases were independent predictors of survival. Lower survival was associated with age greater than 50 years, adenocarcinoma, and presence of lymph node metastases. The higher survival rates in patients with single lymph node involvement or lymph node metastases below the level of the common iliac nodes (85 and 84.6%, respectively) versus multiple or extrapelvic lymph node metastases (50 and 20%, respectively) were statistically significant (P < 0.01). In conclusion, patients who had lymph node metastases, adenocarcinoma, and were older than 50 years had a poorer survival rate. Such patients require more intense postoperative treatment and closer surveillance. Low-risk patients with a single lymph node metastasis below the level of the common iliac nodes may benefit from thorough lymphadenectomy without adjuvant therapy to prevent unpleasant complications.

Application of tumor markers CEA, TPA, and SCC-Ag in patients with low-risk FIGO stage IB and IIA squamous cell carcinoma of the uterine cervix

OBJECTIVE

The aim of this study was to determine the potential clinical utility of tumor markers carcinoembryonic antigen (CEA), tissue polypeptide antigen (TPA), and squamous cell carcinoma antigen (SCC-Ag) in patients with FIGO stage IB and IIA squamous cell carcinoma of the uterine cervix with low-risk clinicopathologic factors (negative lymph node metastasis, no lymphovascular space involvement, no bulky tumor size, no parametrial invasion, no deep stromal invasion, and well-differentiated cellular histology).

METHODS

A retrospective study was performed on 558 patients with FIGO stage IB-IIA and pathology-proven invasive squamous cell carcinoma of the uterine cervix, treated at the Veterans General Hospital, Taipei, between December 1986 and November 1990. Serum specimens were drawn before operation. A total of 140 assessable patients were enrolled into the study (including 109 stage IB patients and 31 stage IIA patients; all patients had no clinicopathologic risk factors and had at least one tumor marker datum). Survival curves were constructed according to the Kaplan-Meier method and survival curves were compared using the log-rank test.

RESULTS

In univariate analysis of survival, CEA, TPA, and SCC-Ag all have roles in the prediction of prognosis. In Cox proportional hazards model using CEA, TPA, and SCC-Ag as covariates, TPA demonstrated the most significant risk factor (P = 0.031).

CONCLUSIONS

We concluded that preoperative evaluation of serum TPA might be of great value in the prediction of survival of patients without any clinicopathologic risk factors and this special group of patients should be paid much attention in the follow-up period. From this study, preoperative elevation of TPA defines a group of otherwise low-risk invasive cervical cancer patients who are at high risk for recurrence. Adjuvant therapy might be necessary for this special subset of patients. A prospective study with a larger sample should be conducted to prove this particular finding.