Impact of peritoneal vaginoplasty combined with radical hysterectomy on the quality of sexual life for patients with early-stage cervical cancer: trial protocol for a multi-center superiority randomized controlled trial

BACKGROUND

Radical hysterectomy (RH) is commonly used to treat early-stage cervical cancer in women of childbearing age and sexual dysfunction due to postoperative vaginal shortening is a major concern. The impact of intraoperative vaginoplasty on prognosis and quality of sexual life in patients with early-stage cervical cancer remains controversial and lacks high-level evidence. However, there are few reports on vaginoplasty after RH to lengthen vagina in patients. This prospective, multi-center, randomized controlled trial aims to explore the impact of peritoneal vaginoplasty with or without ovarian transposition after laparoscopic RH on sexual dysfunction in patients with early-stage cervical cancer.

METHODS

Eligible patients will be randomly assigned (1:1) to receive peritoneal vaginoplasty or not. The primary evaluation indicators are female sexual function index (FSFI) and male sexual satisfaction scale. The secondary evaluation indicators include EORTC QLQ-CX24, 2-year overall survival (OS), 5-year OS, 2-year progression-free survival (PFS), 5-year PFS and surgery-related complications. The trial will enroll 368 patients from 6 hospitals in China over a 3-year period and follow up for 5 years.

TRIAL REGISTRATION

Chinese Clinical Trial Registry Identifier: ChiCTR2000040610.

Tumor Volume Predicts High-Risk Patients and Guides Initial Chemoradiotherapy for Early Cervical Cancer

We evaluated the relationship between the minimum tumor-free margin, tumor volume, and adverse pathological risk factors in early cervical cancer and explored the predictive value of these parameters for different types of risk patients to guide individualized therapeutic strategies. Patients who received the initial treatment of radical operation of cervical cancer and their postoperative pathological reports in our hospital from July 1, 2017, to June 30, 2019, were reviewed. Their minimum tumor-free margin and tumor volume were measured on preoperative magnetic resonance imaging. Student's t-test and the receiver operating characteristic curve analysis were used for data analysis. A total of 240 patients were included. Adverse pathological risk factors were as follows: deep cervical infiltration, 95 (39.6%) cases; lymph vascular space invasion, 91 (37.9%); lymph node metastasis, 20 (8.3%); parametrial infiltration, 8 (3.3%); tumor diameter ≥4 cm, 7 (2.9%); and positive surgical margin, 1 (0.4%). According to the adverse pathological factors, there were 20 (8.3%) high-risk patients, 50 (20.8%) medium-risk patients, and 170 (70.8%) low-risk patients. The ranges of the minimum tumor-free margin and tumor volume were 0.01-13.5 mm and 105-27,990 mm³, respectively. The minimum tumor-free margin with lymph node metastasis was significantly smaller than that without (P <0.05). The tumor volume with parametrial infiltration, deep cervical infiltration, or lymph vascular space invasion was significantly greater than that without (P < 0.05). The tumor volume was significantly different among low-, medium-, and high-risk patients (P <0.05). Tumor volume was of predictive value for high-risk patients (P < 0.05). With 3,505 mm³ as the cutoff value, the sensitivity and specificity for the prediction of high-risk patients were 88.9% and 84.8%, respectively. Tumor volume can be used as a great predictor of high-risk patients (cutoff value, 3,505 mm³), which could be an indication of initial chemoradiotherapy for early cervical cancer.

Early removal of indwelling urinary catheter after radical surgery for early-stage cervical cancer-A cohort study

OBJECTIVE

To evaluate the difference between early and delayed removal of indwelling urinary catheter after radical hysterectomy (RH) or radical trachelectomy (RT).

METHODS

An ambispective study was conducted in early-stage cervical cancer patients who underwent RH or RT. Delayed indwelling urinary catheter removal occurred on a postoperative day (POD) 7 in the retrospective group (January 2012-November 2013), and early removal occurred on POD 1 in the prospective group (May 2014-June 2017). The postvoid residual (PVR) test was performed after indwelling catheter removal in both groups.

RESULTS

Our sample included 47 patients in the delayed group and 48 in the early one. There was no difference in age, body mass index, tumor size, histology, stage, surgical approach, and intraoperative and postoperative complications. Indwelling urinary catheter reinsertion was needed in 16 (34%) patients in the delayed group and 12 (25%) in the early group (P = .37), with no statistical difference between the median PVR volumes -82.5 and 45 mL (P = .06), respectively. Seven (14.9%) patients in the delayed group presented with 30-day urinary tract infection vs two (4.2%) in the early group (P = .09).

CONCLUSIONS

Early indwelling urinary catheter removal, in regard to the rate of catheter reinsertion and PVR volume, does not differ from delayed removal.

Pre-operative surgical algorithm: sentinel lymph node biopsy as predictor of parametrial involvement in early-stage cervical cancer

Introduction

Radical hysterectomy is the gold standard in the management of early-stage cervical cancer. Parametrectomy aims to remove occult disease but is associated with significant surgical morbidity. Avoiding unnecessary parametrectomy in a subset of patients at low risk of parametrial involvement may decrease the incidence of such morbidity. The purpose of this study was to identify patients at low risk of parametrial involvement in early-stage cervical cancer potentially eligible for less radical surgery based on pre-operative criteria and sentinel lymph node (SLN) status.

Methods

We performed an ancillary analysis of data from two prospective trials on sentinel node biopsy for cervical cancer (SENTICOL I and II). Patients with International Federation of Gynecology and Obstetrics (FIGO) IA–IIA cervical cancer who underwent primary radical surgery and bilateral SLN mapping were identified between 2005 and 2012 from 25 French oncologic centers. Patients who underwent pre-operative brachytherapy or did not undergo radical surgery (simple trachelectomy, simple hysterectomy, or lymph node staging only) were excluded.

Results

Of 174 patients who fullfiled the inclusion criteria, 9 patients (5.2%) had parametrial involvement and 24 patients (13.8%) had positive SLN. Most patients had 2018 FIGO stage IB1 disease (86.1%) and squamous cell carcinomas (68.9%). Parametrial involvement was significantly associated with tumor size ≥20 mm on pelvic magnetic resonance imaging (MRI) (adjusted odds ratio (ORa) 9.30, 95% CI 1.71 to 50.57, p=0.01) and micrometastic or macrometastatic SLN (ORa 8.98, 95% CI 1.59 to 50.84, p=0.01). Of 114 patients with tumors <20 mm on pre-operative MRI and negative SLN after ultrastaging, only one patient had parametrial involvement (0.9%). By triaging patients with both of these criteria in a two-step surgical procedure, unjustified and contra-indicated radical hysterectomy would have been avoided in 65.5% and 8.6% of cases, respectively.

Conclusions

Less radical surgery may be an option for patients with bilateral negative SLN after ultrastaging and tumors <20 mm. SLN status should be integrated into the decision-making process for tailored surgery in early-stage cervical cancer.

Clinical analysis of HPV58-positive cervical cancer

Objective

To study the clinical features of HPV58-positive cervical cancer.

Methods

A retrospective analysis of 347 patients with HPV58- or HPV16 positive cervical cancer from the Department of Gynecology Tumor of Guangxi Medical University Affiliated Cancer Hospital was performed. Molecular hybridization was used to detect HPV genotypes. The clinical features, including age, pathology, and invasion, were compared between the HPV58 positive and HPV16 positive cervical cancer groups.

Results

A total of 347 patients were eligible for this study, and the proportion of patients who were with poorly differentiated cancer (P = 0.015) was significantly higher in the HPV58 positive group. HPV58 positivity was an independent risk factor for poorly differentiated cancer [HR 2.156, 95% confidence interval: 1.167–3.984, P = 0.014]. The percentage of uterus corps invasion is significantly lower in HPV58 (p = 0.041), but HPV58 positivity is the independent risk factor for uterus corps invasion [HR = 3.985, 95% confidence interval: 1.066–14.893, P = 0.040]. The overall survival of HPV58-positive cervical cancer patients with uterine corpus invasion was significantly lower (P = 0.000). The age of patients in the HPV58-positive cervical cancer at advanced stage was significantly older (P = 0.045).

Conclusions

HPV58-positive cervical cancer patients are at higher risk of poorly differentiated cancer and uterus corps invasion. The patients with HPV58 positive cervical cancer with uterus corps invasion may result a worse prognosis.

Early Cervical Cancer: Current Dilemmas of Staging and Surgery

PURPOSE OF REVIEW

Advances in cervical cancer screening and treatment have resulted in high cure rates in developed countries for early-stage disease. Current research focuses on minimizing morbidity and maximizing quality of life.

RECENT FINDINGS

Imaging has been disappointing in identifying small volume metastases. Sentinel lymph node biopsy represents a significant advantage with high sensitivity, low false negative rates, reduced morbidity, and equivalent survival in recent studies compared to pelvic lymphadenectomy. Non-radical surgical options are currently being investigated for early cervical cancer in a number of large prospective studies in patients at low risk for metastases. Evidence suggests that sentinel lymph node biopsy and non-radical surgery are safe approaches for the staging and management of early cervical cancer in appropriately selected patients with the potential to significantly reduce treatment-related morbidity.

Transvaginal Sonography Versus Cystoscopy for Detecting Urinary Bladder Invasion in Early Stage Cervical Cancer

INTRODUCTION

Cervical cancer is a major cause of mortality from cancer among women. In it's early stage pre operative staging with cystoscopy is a standard procedure for the detection of urinary bladder involvement.

AIM

The present study was conducted with the aim to compare the efficacy of Transvaginal Sonography (TVS) and cystoscopy in diagnosing bladder involvement in early stage cervical cancer patients by confirming it intraoperatively and further by histopathologic examination.

MATERIALS AND METHODS

A prospective partially blinded study was conducted between March 2006 and September 2008 on 30 patients with early stage cervical cancer (Stage I and IIa) who were planned to undergo radical hysterectomy. Pre operatively, these patients underwent both TVS and cystoscopy to diagnose bladder involvement. Presence or absence of bladder involvement was then confirmed intra operatively and by histopathologic examination.

RESULTS

In all the 30 patients studied, no bladder involvement was seen on cystoscopy where as TVS showed bladder involvement in three patients. Involvement of the bladder in these three patients was confirmed intra operatively and by histopathologic examination. Thus, in our study, TVS was 100% sensitive in detecting bladder involvement.

CONCLUSION

TVS is highly sensitive in diagnosing bladder involvement in early stage cervical cancer and could potentially detect cases missed with a cystoscopy.

Accuracy of conization procedure for predicting pathological parameters of radical hysterectomy in stage Ia2-Ib1 (≤2 cm) cervical cancer

The accuracy of conization for the prediction of radical hysterectomy (RH) pathological variables in patients with stage Ia2 to Ib1 (≤2 cm) cervical cancer was retrospectively evaluated in the present study. Endocervical or deep resection margin (RM) involvement in the conization specimens was found to be independently associated with residual disease in the hysterectomy specimens (P < 0.001, = 0.003, respectively). When a tumor width of >20 mm in the final RH pathology analysis was predicted by a tumor width of >2 mm or involvement of endocervical or deep RMs in the conization specimens, the sensitivity and negative predictive value (NPV) of conization were 98.2% and 95.2%, respectively. In addition, when deep stromal invasion in the final RH pathology analysis was predicted by deep stromal invasion or involvement of the endocervical or deep RMs in the conization specimens, the sensitivity and NPV of conization were 98.4% and 95.8%, respectively. The sensitivity and NPV of this prediction model for identifying LVSI in the final RH pathology analysis were both 100%. These findings suggest that conization variables and endocervical and deep resection margin statuses can be analyzed to effectively predict RH pathological parameters.

Is It Possible to Perform Less Radical Surgery for Invasive Uterine Cervical Cancer?

BACKGROUND/AIMS

A retrospective analysis was performed to evaluate the possibility of less radical surgery for early-stage invasive uterine cervical cancer without compromising the oncological outcome.

METHODS

The analysis was performed on 175 patients with invasive uterine cervical cancer in FIGO stage IA2-IIB, all of whom underwent primary radical hysterectomy. Relationship of tumor size with the incidence of pathologic parametrial involvement and the pelvic lymph node metastasis were investigated.

RESULTS

Fifty-one patients had tumor size ≤2 cm and 124 had tumor size >2 cm. Patients with tumor size ≤2 cm had a significantly lower incidence of parametrial invasion (p < 0.0001), lymph node metastasis (p < 0.0001), lymph vascular space involvement (p < 0.0001) and recurrence (p = 0.0002) than patients with tumor size >2 cm. Five-year relapse-free survival rate was 98 and 73%, respectively (p = 0.0004).

CONCLUSION

It is suggested that less radical surgery may be appropriate for some cases with tumor size <2 cm.

Standardized Uptake Value on F-FDG PET/CT as a Prognostic Factor for Survival of Women with Malignant Uterine Tumors: A Meta-Analysis

BACKGROUND

Malignant uterine tumors are crucial in the evaluation of prognosis and the determination of therapeutic strategy.

AIM

This meta-analysis of the available literature aimed to investigate the prognostic value of standardized uptake value (SUV) on fluorine-18-fluorodeoxyglucose positron emission tomography with computed tomography (18F-FDG PET/CT) in uterine malignancies before treatment.

METHODS

The PubMed, MEDLINE and EMBASE databases (1990 to February 2014) were searched to identify studies evaluating SUV on 18F-FDG PET/CT as a prognostic tool for predicting long-term survival in patients with carcinomas of the uterus. The χ2 test and the I2 index were used to estimate heterogeneity among the trials selected in the meta-analysis. The combined hazard ratio was calculated by using a fixed- or random-effects model according to heterogeneity.

RESULTS

Thirteen studies with a total of 1,196 patients were eligible for analysis. High pretreatment SUVmax was significantly associated with poorer event-free survival and overall survival, and the summarized hazard ratio was 3.33 (95% confidence interval 2.34-4.74) and 1.31 (95% confidence interval 1.03-1.67), respectively.

CONCLUSION

The present evidence indicates that SUV on 18F-FDG PET/CT seems to be a valuable prognostic indicator for survival of patients with malignant uterine tumors. Given that 18F-FDG PET/CT can provide both morphologic and functional information, we suggest utilizing PET/CT and its quantitative marker in uterine malignancies before treatment. © 2015 S. Karger AG, Basel.

Total laparoscopic nerve-sparing radical parametrectomy for occult early-stage cervical cancer: surgical technique and postoperative bladder function

Surgery and radiotherapy are both regarded as standard treatments for occult cervical cancers. Surgery has several theoretical advantages over radiotherapy; therefore, such cancers, especially in their early stages, are commonly treated with radical parametrectomy. However, postoperative bladder dysfunction is an important potential complication of this type of surgery. This is a case report of total laparoscopic nerve-sparing radical parametrectomy for an occult cervical cancer using our original surgical concept based on detailed anatomical investigation of pelvic nerve networks in a fresh cadaver. We evaluated the validity of our nerve-sparing technique by assessing postoperative bladder function using urodynamic studies.

A Comparison of Adenosquamous Carcinoma and Adenocarcinoma of the Cervix after Radical Hysterectomy

BACKGROUND/AIMS

The aim of this study was to compare the survival outcomes of adenocarcinoma and adenosquamous carcinoma in early-stage cervical cancer patients after radical hysterectomy.

METHODS

A retrospective analysis was performed of stage IB-IIA cervical cancer patients with adenocarcinoma or adenosquamous carcinoma who underwent radical hysterectomy at Seoul National University Hospital between 1998 and 2008.

RESULTS

A total of 166 patients with adenosquamous carcinoma (ASC) (n = 38) and adenocarcinoma (AC) (n = 128) were identified. In terms of baseline characteristics, the ASC group had higher rates of lymph node metastasis, deep stromal invasion, and lymphovascular space invasion than the AC group. However, there was no significant difference between the two histological subtypes in terms of recurrence-free survival (p = 0.396) and overall survival (p = 0.223). Patients with ASC showed similar outcomes to those with AC when limiting to either an intermediate/high-risk group or patients who underwent adjuvant concurrent chemoradiotherapy.

CONCLUSION

Although the ASC group presented poorer pathologic findings after radical hysterectomy compared with the AC group, there was no significant difference in survival outcomes. This suggests that intermediate/high-risk patients with ASC may be successfully treated with postoperative concurrent chemoradiotherapy.

A multicenter study of the importance of systemic chemotherapy for patients with small-cell neuroendocrine carcinoma of the uterine cervix

AIMS

We investigated the prognosis of patients with small-cell neuroendocrine carcinoma of the uterine cervix (SCNEC) in relation to treatment modalities.

METHODS

We retrospectively reviewed the medical records and pathological reports of 102 patients who were histologically diagnosed with SCNEC at 5 different institutes. Time to progression (TTP) and overall survival (OS) were analyzed for each treatment modality.

RESULTS

Of the patients with early-stage [International Federation of Obstetrics and Gynecology (FIGO) stage IB2 or below] SCNEC, 57.8 and 79.3% underwent radical hysterectomy followed by adjuvant therapy. In advanced-stage SCNEC, concurrent chemoradiation therapy was given to 51.4% of the patients. The overall recurrence rate was 51.6%. In early- and advanced-stage SCNEC, the TTP was not different (22.3 vs. 13.3 months, p = 0.104), but the OS was different (40.7 vs. 21.4 months, p = 0.029). Parametrial involvement and lymph vascular space invasion were found to be associated with an unfavorable prognosis. Interestingly, survival was the most unfavorable in patients with early-stage SCNEC who had never received chemotherapy. FIGO stage and use of chemotherapy were identified as independent prognostic factors in SCNEC patients.

CONCLUSIONS

SCNEC requires systemic chemotherapy as part of the initial treatment, along with surgery or radiation, even in patients with early-stage disease.

Prognostic significance of pretreatment plasma fibrinogen and platelet levels in patients with early-stage cervical cancer

BACKGROUND

Hyperfibrinogenaemia and thrombocytosis, which usually occur in cancer patients, have been shown to contribute to cancer cell growth, progression, and metastasis. The aims of the present study were to assess the prognostic significance of pretreatment plasma fibrinogen and platelet levels in early-stage cervical cancer patients.

METHODS

The present study was a retrospective analysis of 220 cervical cancer patients with stage I-IIA disease. The pretreatment plasma fibrinogen and platelet levels were investigated along with clinicopathological findings and survival data.

RESULTS

The incidences of hyperfibrinogenaemia and thrombocytosis were 11.8 and 25.5%, respectively. Elevated fibrinogen levels were associated with advanced tumour stage, older age, large tumour size, deep stromal invasion, and tumour recurrence, whereas higher platelet levels correlated significantly with advanced tumour stage, large tumour size, and tumour recurrence. Kaplan-Meier analysis showed that hyperfibrinogenaemia and thrombocytosis were significantly associated with shorter disease-free and overall survival. Furthermore, patients with hyperfibrinogenaemia and thrombocytosis may suffer from a higher risk of recurrence. Multivariate survival analyses showed that fibrinogen levels, but not platelet levels, were an independent prognostic factor for poor survival in early-stage patients.

CONCLUSION

Hyperfibrinogenaemia and thrombocytosis may be valuable biomarkers for predicting recurrence in patients with early-stage cervical cancer.

Nonrandom return: lessons from women returning for follow-up results of cervical cancer screening in rural haiti

PURPOSE

Few studies have evaluated approaches to improve patient follow-up in screening programs within resource-limited areas. This study investigated the patterns of return among women presenting for results from a cervical cancer screening program implemented in a resource-poor region to highlight areas for future research and potential interventions.

METHODS

In the development of a cervical cancer screening program in rural Haiti, women aged 18-45 years were recruited from local churches to undergo cervical cancer screening and follow-up for results. A dot plot was used to analyze the distribution of women returning during the results phase compared to the random return rates based on the screening phase.

RESULTS

Of the 250 women tested, 121 (48%) returned for follow-up. On the 2 result days with the most returnees, 46 and 63% of the women had been tested during only 3 of the 11 testing days which themselves accounted for 41% of the total number of women who returned. The highest volume return days, a Monday and a Friday, gave results to women tested on Monday, Wednesday and Friday, and on Monday, Tuesday and Thursday, respectively. The 2 result days with the lowest return numbers had 80% (8/10) of those who returned coming as the only returnee from their day of testing.

CONCLUSION

Result days corresponding with the highest return rates had increased clustering of women from the screening phase, and the result days with fewer women returning had less clustering. These findings are among the first to implicate the importance of defining these patterns of return and the potential for recruitment techniques that exploit such groupings, potentially described by social connections, in limited-resource settings to improve follow-up for screening programs.

Uterine prolapse complicated by vaginal cancer: a case report and literature review

Primary vaginal cancer is not common, representing 1-2% of all female genital malignancies. We present a case of a third-degree uterine prolapse complicated by an isolated primary vaginal cancer and its surgical treatment. The cervix was clinically normal, but on the nearby prolapsed vaginal wall, a large exogenous hard lesion had developed. A biopsy of the lesion revealed a squamous carcinoma. The patient was asymptomatic and had no recurrence during the last 4 years of follow-up after surgical treatment with radiotherapy. The surgical treatment with or without radiotherapy is the optimum treatment for uterine prolapse with early-stage vaginal squamous cell carcinoma, although the majority of vaginal malignancies are treated with radiotherapy. We recommend always performing a biopsy prior to surgery in prolapse-induced ulceration.