Management of Early-Stage Cervical Cancer: A Literature Review

Disease trend analysis platform accurately predicts the occurrence of cervical cancer under mixed diseases

Cervical cancer (CC) is one of the most common gynecological malignancies. Cytological screening, while being the most common and accurate method for detecting cervical cancer, is both time-consuming and costly. Predicting CC based on bioinformatics can assist in the rapid early screening of CC in clinical practice. Most recent CC prediction methods require a large amount of detection data or sequencing data and are not ideal for CC detection in complex disease samples. We developed the Disease trend analysis platform (Dtap), which can quickly predict the occurrence of diseases using only blood routine data. Blood routine data was collected from 1,292 cervical cancer patients, 4,860 patients with complex diseases, and 4,980 healthy individuals from various sources. The results show that the Dtap-based trend model maintained good and stable performance in the prediction task of multiple datasets as well as complex disease samples. Finally, we built DTAPCC (http://bioinfor.imu.edu.cn/dtapcc), a Dtap-based CC disease prediction platform, to help users quickly predict CC and visualize trend features.

Signaling pathways in HPV-induced cervical cancer: Exploring the therapeutic promise of RNA modulation

Cervical cancer, originating from the epithelial tissue of the uterine cervix, constitutes the most commonly diagnosed malignancy among women worldwide. The predominant etiological factor underpinning cervical carcinogenesis is persistent infection with high-risk human papillomavirus (HPV) genotypes, notably HPV-16 and HPV-18. Oncoproteins encoded by high-risk HPV interfere with multiple essential cellular signaling cascades. Specifically, E5, E6, and E7 proteins disrupt the signaling pathways like p53, retinoblastoma tumor suppressor protein (pRB), The phosphoinositide 3 kinase (PI3K)/Akt/mammalian target of rapamycin (mTOR), epidermal growth factor receptor (EGFR), mitogen-activated protein kinases (MAPK)/extracellular signal-regulated kinases (ERK), and Wnt/β-catenin, promoting HPV-mediated carcinogenesis. This dysregulation disrupts cell cycle control, apoptosis, and metastasis through modulation of microRNAs (miRNA) and key cellular processes. The novel therapeutic interventions for HPV prevention and detection are fundamental to patient management. RNA-based treatment modalities offer the potential for manipulating critical pathways involved in cervical carcinogenesis. RNA therapeutics offer novel approaches to drug development by targeting intracellular genetic elements inaccessible to conventional modalities. Additional advantages include rapid design, synthesis, and a reduced genotoxic profile compared to DNA-based therapies. Despite beneficial attributes, system stability and efficient delivery remain critical parameters. This study assessed the intricate relationship between HPV, cervical cancer, and various signaling pathways. The study explores miRNAs' diagnostic and therapeutic potential, mall interfering RNAs (siRNAs), and long non-coding RNAs (lncRNAs)in cervical cancer management. The review highlights the prospect of RNA-targeted therapies to modulate specific cancer signaling pathways. This approach offers a novel strategy for cervical cancer treatment through precise regulation of cancer signaling. Future research should concentrate on developing RNA-targeted interventions to improve cervical cancer treatment outcomes through increased therapeutic efficacy and specificity.

Small molecule inhibitors of the VEGF and tyrosine kinase for the treatment of cervical cancer

Cervical cancer accounts for most deaths due to cancer in women, majorly in developing nations. The culprit behind this disease is the human papillomavirus (HPV) which accounts for more than 90% of cervical cancer cases. The viral strains produce proteins that favor the knocking down of the apoptosis process and continuous growth of cells in the cervix leading to tumor growth. Proangiogenic growth factors, such as fibroblast growth factor (FGF), vascular endothelial growth factor (VEGF), angiopoietins, and other endothelial growth factors (EGF), are secreted by tumor cells and the surrounding microenvironment, which further advances the development of cancer. The extracellular domain of receptor tyrosine kinases is employed by ligands (like VEGF and EGF) to engage and activate them by inducing receptor dimerization, which facilitates the cascade impact of these factors. The tyrosine kinase domains of each receptor autophosphorylate each other, activating the receptor and initiating signaling cascades that promote angiogenesis, migration, proliferation, and survival of endothelial cells. Cancer cells benefit from its modified signaling pathways, which cause oncogenic activation. Upon early cervical cancer detection, the second-line therapy strategy involves blocking the signaling pathways with VEGF and small molecule tyrosine kinase inhibitors (TKIs). This review paper highlights the genesis of cervical cancer and combating it using VEGF and tyrosine kinase inhibitors by delving into the details of the currently available inhibitors. Further, we have discussed the inhibitor molecules that are currently in various phases of clinical trials. This paper will surely enhance the understanding of cervical cancer and its treatment approaches and what further interventions can be done to alleviate the disease currently serving as a major health burden in the developing world.

Exploring the prognostic significance of immunogenic cell death-related genes as risk biomarkers in cervical cancer

BACKGROUND

Immunogenic cell death (ICD) is a process in which dying cells stimulate an immune response. It is a regulated form of cell death that can remodel the tumor microenvironment (TME) and activate the immune system, making immunotherapy more effective. This work was designed to identify prognostic gene features associated with ICD in cervical cancer (CC).

METHODS

Based on CC datasets and a set of ICD-related genes obtained from public databases, we first filtered out ICD-related genes unrelated to CC survival using univariate analysis. Subsequently, LASSO regression and multivariate Cox regression analysis were employed to develop prognostic feature genes based on ICD. For the construction and validation of the model, eight genes (CXCL1, IL1B, TNF, YKT6, PDIA3, ROCK1, CXCR3, and CLEC9A) were chosen. A nomogram was created to forecast the prognosis of CC individuals, and Kaplan-Meier curves were utilized to explore the survival disparities among different risk groups of CC individuals.

RESULTS

ssGSEA analysis was employed to investigate immune differences between two risk groups, revealing that the low-risk group exhibited elevated levels of immune cell infiltration, enhanced activation of immune function, and a higher immunophenoscore compared with the other group, which highlighted the relevance of ICD to TME.

CONCLUSION

We constructed a prognostic model based on genetic biomarkers of ICD for prognostic prediction of CC patients. Our model demonstrated excellent discriminative and calibration capabilities, providing a valuable tool for prognostic prediction and assessing the potential efficacy of immunotherapy in CC.

Design and synthesis of novel imidazole-chalcone derivatives as microtubule protein polymerization inhibitors to treat cervical cancer and reverse cisplatin resistance

Using the licochalcone moiety as a lead compound scaffold, 16 novel imidazole-chalcone derivatives were designed and synthesized as microtubule protein polymerization inhibitors. The proliferation inhibitory activities of the derivatives against SiHa (human cervical squamous cell carcinoma), C-33A (human cervical cancer), HeLa (human cervical cancer), HeLa/DDP (cisplatin-resistant human cervical cancer), and H8 (human cervical epithelial immortalized) cells were evaluated. Compound 5a exhibited significant anticancer activity with IC50 values ranging from 2.28 to 7.77 μM and a resistance index (RI) of 1.63, while showing minimal toxicity to normal H8 cells. When compound 5a was coadministered with cisplatin, the RI of cisplatin to HeLa/DDP cells decreased from 6.04 to 2.01, while compound 5a enhanced the fluorescence intensity of rhodamine 123 in HeLa/DDP cells. Further studies demonstrated that compound 5a arrested cells at the G2/M phase, induced apoptosis, reduced colony formation, inhibited cell migration, and inhibited cell invasion. Preliminary mechanistic studies revealed that compound 5a decreased the immunofluorescence intensity of α-/β-tubulin in cancer cells, reduced the expression of polymerized α-/β-tubulin, and increased the expression of depolymerized α-/β-tubulin. Additionally, the molecular docking results demonstrate that compound 5a can interact with the tubulin colchicine binding site and generate multiple types of interactions. These results suggested that compound 5a has anticancer effects and significantly reverses cervical cancer resistance to cisplatin, which may be related to its inhibition of microtubule and P-glycoprotein (P-gp) activity.

Integrated In-Silico and In Vitro analysis to Decipher the contribution of bisphenol-A in cervical cancer

Bisphenol A (BPA) is a synthetic chemical widely used as a monomer for producing polycarbonate plastics. The present investigation employed an in-silico approach to identify BPA-responsive genes and comprehend the biological functions affected using in vitro studies. A Comparative Toxicogenomics Database search identified 29 BPA-responsive genes in cervical cancer (CC). Twenty-nine genes were screened using published datasets, and thirteen of those showed differential expression between normal and CC samples. Protein-Protein Interaction Networks (PPIN) analysis identified BIRC5, CASP8, CCND1, EGFR, FGFR3, MTOR, VEGFA, DOC2B, WNT5A, and YY1 as hub genes. KM-based survival analysis identified that CCND, EGFR, VEGFA, FGFR3, DOC2B, and YY1 might affect CC patient survival. SiHa and CaSki cell proliferation, migration, and invasion were all considerably accelerated by BPA exposure. Changes in cell morphology, remodeling of the actin cytoskeleton, increased number and length of filopodia, elevated intracellular reactive oxygen species and calcium, and lipid droplet accumulation were noted upon BPA exposure. BPA treatment upregulated the expression of epithelial to mesenchymal transition pathway members and enhanced the nuclear translocation of CTNNB1. We showed that the enhanced migration and nuclear translocation of CTNNB1 upon BPA exposure is a calcium-dependent process. The present study identified potential BPA-responsive genes and provided novel insights into the biological effects and mechanisms affected by BPA in CC. Our study raises concern over the use of BPA.

Recent advances in photodynamic therapy combined with chemotherapy for cervical cancer: a systematic review

INTRODUCTION

Despite the evidence that photodynamic therapy (PDT) associated with chemotherapy presents great potential to overcome the limitations of monotherapy, little is known about the current status of this combination against cervical cancer. This systematic review aimed to address the currently available advances in combining PDT and chemotherapy in different research models and clinical trials of cervical cancer.

METHODS

We conducted a systematic review based on PRISMA Statement and Open Science Framework review protocol using PubMed, Web of Science, Embase, Scopus, LILACS, and Cochrane databases. We selected original articles focusing on 'Uterine Cervical Neoplasms' and 'Photochemotherapy and Chemotherapy' published in the last 10 years. The risk of bias in the studies was assessed using the CONSORT and SYRCLE tools.

RESULTS

Twenty-three original articles were included, focusing on HeLa cells, derived from endocervical adenocarcinoma and on combinations of several chemotherapeutics. Most of the combinations used modern drug delivery systems for improved simultaneous delivery and presented promising results with increased cytotoxicity compared to monotherapy.

CONCLUSION

Despite the scarcity of animal studies and the absence of clinical studies, the combination of chemotherapy with PDT presents a potential option for cervical cancer therapy requiring additional studies.

OSF REGISTRATION

https://doi.org/10.17605/OSF.IO/WPHN5 [Figure: see text].

A machine learning-based prediction model of pelvic lymph node metastasis in women with early-stage cervical cancer

OBJECTIVE

To develop a novel machine learning-based preoperative prediction model for pelvic lymph node metastasis (PLNM) in early-stage cervical cancer by combining the clinical findings and preoperative computerized tomography (CT) of the whole abdomen and pelvis.

METHODS

Patients diagnosed with International Federation of Gynecology and Obstetrics stage IA2-IIA1 squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinoma of the cervix who had primary radical surgery with bilateral pelvic lymphadenectomy from January 1, 2003 to December 31, 2020, were included. Seven supervised machine learning algorithms, including logistic regression, random forest, support vector machine, adaptive boosting, gradient boosting, extreme gradient boosting, and category boosting, were used to evaluate the risk of PLNM.

RESULTS

PLNM was found in 199 (23.9%) of 832 patients included. Younger age, larger tumor size, higher stage, no prior conization, tumor appearance, adenosquamous histology, and vaginal metastasis as well as the CT findings of larger tumor size, parametrial metastasis, pelvic lymph node enlargement, and vaginal metastasis, were significantly associated with PLNM. The models' predictive performance, including accuracy (89.1%-90.6%), area under the receiver operating characteristics curve (86.9%-91.0%), sensitivity (77.4%-82.4%), specificity (92.1%-94.3%), positive predictive value (77.0%-81.7%), and negative predictive value (93.0%-94.4%), appeared satisfactory and comparable among all the algorithms. After optimizing the model's decision threshold to enhance the sensitivity to at least 95%, the 'highly sensitive' model was obtained with a 2.5%-4.4% false-negative rate of PLNM prediction.

CONCLUSION

We developed prediction models for PLNM in early-stage cervical cancer with promising prediction performance in our setting. Further external validation in other populations is needed with potential clinical applications.

Hsa-miR-194-5p and hsa-miR-195-5p are down-regulated expressed in high dysplasia HPV-positive Pap smear samples compared to normal cytology HPV-positive Pap smear samples

BACKGROUND

The human papillomavirus (HPV) infection may affect the miRNA expression pattern during cervical cancer (CC) development. To demonstrate the association between high-risk HPVs and the development of cervix dysplasia, we examined the expression patterns of hsa-miR-194-5p and hsa-miR-195-5p in Pap smear samples from southeast Iranian women. We compared samples that were HPV-positive but showed no abnormality in the cytological examination to samples that were HPV-positive and had severe dysplasia.

METHODS

Pap smear samples were obtained from 60 HPV-positive (HPV-16/18) patients with histologically confirmed severe dysplasia (cervical intra-epithelial neoplasia (CIN 3) or carcinoma in situ) and the normal cytology group. The expression of hsa-miR-194-5p and hsa-miR-195-5p was analyzed by real-time quantitative PCR, using specific stem-loop primers and U6 snRNA as the internal reference gene. Clinicopathological features were associated with miRNA expression levels. Furthermore, functional enrichment analysis was conducted using in silico tools. The Kaplan-Meier survival method was also obtained to discriminate survival-significant candidate miRNAs in CC, and receiver operating characteristic (ROC) curves were constructed to assess the diagnostic value.

RESULTS

Compared to HPV-positive cytologically normal Pap smear samples, hsa-miR-194-5p and hsa-miR-195-5p relative expression decreased significantly in HPV-positive patients with a severe dysplasia Pap smear. Kaplan-Meier analysis indicated a significant association between the miR-194 decrease and poor CC survival. In essence, ROC curve analysis showed that miR-194-5p and miR-195-5p could serve as valuable markers for the development of cervix dysplasia in individuals who are positive for high-risk HPVs.

CONCLUSIONS

This study revealed that hsa-miR-194-5p and hsa-miR-195-5p may possess tumor suppressor capabilities in the context of cervical dysplasia progression. However, it remains uncertain whether these microRNAs are implicated in the transition of patients with high dysplasia to cervical cancer. We also showed the potential capability of candidate miRNAs as novel diagnostic biomarkers related to cervical dysplasia progression.

An Overview of Cervical Cancer Prevention and Control in Latin America and the Caribbean Countries

Cervical cancer is a health crisis affecting women and their families across the world. It is known that developed countries have comprehensive protocols with recommendations regarding workforce, expertise, and medical resources to address this common cancer among women. In contrast, disparities in addressing cervical cancer remain present in Latin America and Caribbean countries. Here, we reviewed the current strategies of cervical cancer prevention and control in the region.

Novel ensemble learning approach with SVM-imputed ADASYN features for enhanced cervical cancer prediction

Cervical cancer remains a leading cause of female mortality, particularly in developing regions, underscoring the critical need for early detection and intervention guided by skilled medical professionals. While Pap smear images serve as valuable diagnostic tools, many available datasets for automated cervical cancer detection contain missing data, posing challenges for machine learning models' efficacy. To address these hurdles, this study presents an automated system adept at managing missing information using ADASYN characteristics, resulting in exceptional accuracy. The proposed methodology integrates a voting classifier model harnessing the predictive capacity of three distinct machine learning models. It further incorporates SVM Imputer and ADASYN up-sampled features to mitigate missing value concerns, while leveraging CNN-generated features to augment the model's capabilities. Notably, this model achieves remarkable performance metrics, boasting a 99.99% accuracy, precision, recall, and F1 score. A comprehensive comparative analysis evaluates the proposed model against various machine learning algorithms across four scenarios: original dataset usage, SVM imputation, ADASYN feature utilization, and CNN-generated features. Results indicate the superior efficacy of the proposed model over existing state-of-the-art techniques. This research not only introduces a novel approach but also offers actionable suggestions for refining automated cervical cancer detection systems. Its impact extends to benefiting medical practitioners by enabling earlier detection and improved patient care. Furthermore, the study's findings have substantial societal implications, potentially reducing the burden of cervical cancer through enhanced diagnostic accuracy and timely intervention.

Surgical Treatment for Early Cervical Cancer in the HPV Era: State of the Art

Cervical cancer (CC) is the fourth most common cancer among women worldwide. The aim of this study is to focus on the state of the art of CC prevention, early diagnosis, and treatment and, within the latter, the role of surgery in the various stages of the disease with a focus on the impact of the LACC study (Laparoscopic Approach to Cervical Cancer trial) on the scientific debate and clinical practice. We have discussed the controversial application of minimally invasive surgery (MIS) for tumors < 2 cm and the possibility of fertility-sparing surgery on young women desirous of pregnancy. This analysis provides support for surgeons in the choice of better management, including patients with a desire for offspring and the need for sentinel node biopsy (SNB) rather than pelvic lymphadenectomy for tumors < 4 cm, and without suspicious lymph nodes' involvement on imaging. Vaccines and early diagnosis of pre-cancerous lesions are the most effective public health tool to tackle cervical cancer worldwide.

Activatable probes with potential for intraoperative tumor-specific fluorescence-imaging guided surgery

Owing to societal development and aging population, the impact of cancer on human health and quality of life has increased. Early detection and surgical treatment are the most effective approaches for most cancer patients. As the scope of conventional tumor resection is determined by auxiliary examination and surgeon experience, there is often insufficient recognition of tiny tumors. The ability to detect such tumors can be improved by using fluorescent tumor-specific probes for surgical navigation. This review mainly describes the design principles and mechanisms of activatable probes for the fluorescence imaging of tumors. This type of probe is nonfluorescent in normal tissue but exhibits obvious fluorescence emission upon encountering tumor-specific substrates, such as enzymes or bioactive molecules, or changes in the microenvironment, such as a low pH. In some cases, a single-factor response does not guarantee the effective fluorescence labeling of tumors. Therefore, two-factor-activatable fluorescence imaging probes that react with two specific factors in tumor cells have also been developed. Compared with single biomarker testing, the simultaneous monitoring of multiple biomarkers may provide additional insight into the role of these substances in cancer development and aid in improving the accuracy of early cancer diagnosis. Research and progress in this field can provide new methods for precision medicine and targeted therapy. The development of new approaches for early diagnosis and treatment can effectively improve the prognosis of cancer patients and help enhance their quality of life.

Applied anatomy of female pelvic plexus for nerve-sparing radical hysterectomy(NSRH)

BACKGROUND

Nerve-sparing radical hysterectomy(NSRH)has the advantage of reducing postoperative complications and improving postoperative quality of life. The separation and protection of the pelvic plexus in NSRH is extremely important and challenging.

METHODS

24 female cadaveric hemipelves were dissected. Morphologic patterns and compositions of pelvic plexus as well as relationship of pelvic plexus to the surrounding structures were observed and documented.

RESULTS

Two patterns of superior hypogastric plexus were observed, including fenestrated and cord-like shape. The origin of bilateral hypogastric nerves were inferiorly to upper margin of promontory about 1.6 ± 0.1 cm and parallel to the ureter in front of the sacrum. Pelvic splanchnic nerves(PSN)from the second sacral nerve, the third sacral nerve and the forth sacral nerve were observed combing with the hypogastric nerves within the lateral rectal ligament. The sacral sympathetic trunk can be identified anteriorly or medially to the anterior sacral foramen. We identified the boundaries of pelvic plexus as following: the upper margin is formed by the PSNs from the third sacral nerve, posterior margin by inferior rectal artery, and anteriorly by vesical venous plexus. The uterine branches from pelvic plexus were observed accompanying with uterine artery, while other branches were inferiorly to the artery. The PSNs were located beneath the deep uterine veins within the cardinal ligament. The upper margin of pelvic plexus was observed directly approach to urinary bladder within the vesico-vaginal ligament as a single trunk accompanying with ureter, between the middle and inferior vesical veins.

CONCLUSIONS

Our study clarified the intricate arrangement, distribution and relationship of female pelvic plexus and the related structures to provide reference index for NSRH application. The innervation patterns of bladder and uterine were clarified, and by tracing these visceral branches of pelvic plexus, we suggest several new important land markers for NSRH.

Improving Prediction of Cervical Cancer Using KNN Imputed SMOTE Features and Multi-Model Ensemble Learning Approach

Objective: Cervical cancer ranks among the top causes of death among females in developing countries. The most important procedures that should be followed to guarantee the minimizing of cervical cancer's aftereffects are early identification and treatment under the finest medical guidance. One of the best methods to find this sort of malignancy is by looking at a Pap smear image. For automated detection of cervical cancer, the available datasets often have missing values, which can significantly affect the performance of machine learning models. Methods: To address these challenges, this study proposes an automated system for predicting cervical cancer that efficiently handles missing values with SMOTE features to achieve high accuracy. The proposed system employs a stacked ensemble voting classifier model that combines three machine learning models, along with KNN Imputer and SMOTE up-sampled features for handling missing values. Results: The proposed model achieves 99.99% accuracy, 99.99% precision, 99.99% recall, and 99.99% F1 score when using KNN imputed SMOTE features. The study compares the performance of the proposed model with multiple other machine learning algorithms under four scenarios: with missing values removed, with KNN imputation, with SMOTE features, and with KNN imputed SMOTE features. The study validates the efficacy of the proposed model against existing state-of-the-art approaches. Conclusions: This study investigates the issue of missing values and class imbalance in the data collected for cervical cancer detection and might aid medical practitioners in timely detection and providing cervical cancer patients with better care.

The role of microRNA-185 in the pathogenesis of human diseases: A focus on cancer

MicroRNAs (miRNAs) are a widely-studied class of non-coding RNAs characterized by their short length (18-25 nucleotides). The precise functions of miRNAs are not well-elucidated; however, an increasing number of studies suggest their involvement in various physiologic processes and deregulation in pathologic conditions. miRNA-185 (miR-185) is among the mostly-studied miRNAs in human diseases, which is found to play putative roles in conditions like metabolic disorders, asthma, frailty, schizophrenia, and hepatitis. Notably, many cancer studies report the downregulation of miR-185 in cell lines, tumor tissues, and plasma specimens of patients, while it demonstrates a suppressing role on the malignant properties of cancer cells in vitro and in vivo. Accordingly, miR-185 can be considered a tumor suppressor miRNA in human malignancies, while a few studies also report inconsistent findings. Being suggested as a prognostic/diagnostic biomarker, mi-185 is also found to offer clinical potentials, particularly for early diagnosis and prediction of the prognosis of cancer patients. In this review, we have outlined the studies that have evaluated the functions and clinical significance of miR-185 in different human diseases with a particular focus on cancer.

High- or Intermediate-Risk Histologic Features in Patients with Clinical Early-Stage Cervical Cancer Planned for Fertility-Sparing Surgery: A Systematic Review

BACKGROUND

Fertility-sparing surgery (FSS) is a viable option for young women with early-stage cervical cancer (ECC); however, certain risk factors may necessitate additional treatments and impact fertility. This review examines the prevalence of these risk factors and available treatment options.

METHODS

A systematic search was conducted of studies including patients with ECC (IA1 with LVSI, IA2, IB1 (FIGO 2009)) who underwent FSS.

RESULTS

Sixty-four articles, comprising a total of 4118 women planned for FSS, were included. High- or intermediate-risk histologic features were found in 638 (15.5%) women: 5.1% had positive lymph node(s), 4.1% had positive resection margins, 0.3% had parametrial involvement, 1.0% had unspecified high-risk features, and 5.1% had intermediate-risk histology (primarily based on the Sedlis criteria). Adjuvant treatment impaired fertility in all women with adjuvant hysterectomy and/or (chemo)radiation (58.7%). Adjuvant chemotherapy was given to 1351 (32.8%) patients, which may reduce fertility.

CONCLUSIONS

Fertility preservation could be achieved in most women; but high- or intermediate-risk factors necessitate more extensive surgery or radiotherapy leading to infertility. Adjuvant chemotherapy could be an alternative treatment option considering its effectiveness, safety and higher change in fertility preservation. The low incidence of parametrial involvement justifies waiving parametrectomy in tumors < 2 cm.

Analysis of WSI Images by Hybrid Systems with Fusion Features for Early Diagnosis of Cervical Cancer

Cervical cancer is one of the most common types of malignant tumors in women. In addition, it causes death in the latter stages. Squamous cell carcinoma is the most common and aggressive form of cervical cancer and must be diagnosed early before it progresses to a dangerous stage. Liquid-based cytology (LBC) swabs are best and most commonly used for cervical cancer screening and are converted from glass slides to whole-slide images (WSIs) for computer-assisted analysis. Manual diagnosis by microscopes is limited and prone to manual errors, and tracking all cells is difficult. Therefore, the development of computational techniques is important as diagnosing many samples can be done automatically, quickly, and efficiently, which is beneficial for medical laboratories and medical professionals. This study aims to develop automated WSI image analysis models for early diagnosis of a cervical squamous cell dataset. Several systems have been designed to analyze WSI images and accurately distinguish cervical cancer progression. For all proposed systems, the WSI images were optimized to show the contrast of edges of the low-contrast cells. Then, the cells to be analyzed were segmented and isolated from the rest of the image using the Active Contour Algorithm (ACA). WSI images were diagnosed by a hybrid method between deep learning (ResNet50, VGG19 and GoogLeNet), Random Forest (RF), and Support Vector Machine (SVM) algorithms based on the ACA algorithm. Another hybrid method for diagnosing WSI images by RF and SVM algorithms is based on fused features of deep-learning (DL) models (ResNet50-VGG19, VGG19-GoogLeNet, and ResNet50-GoogLeNet). It is concluded from the systems' performance that the DL models' combined features help significantly improve the performance of the RF and SVM networks. The novelty of this research is the hybrid method that combines the features extracted from deep-learning models (ResNet50-VGG19, VGG19-GoogLeNet, and ResNet50-GoogLeNet) with RF and SVM algorithms for diagnosing WSI images. The results demonstrate that the combined features from deep-learning models significantly improve the performance of RF and SVM. The RF network with fused features of ResNet50-VGG19 achieved an AUC of 98.75%, a sensitivity of 97.4%, an accuracy of 99%, a precision of 99.6%, and a specificity of 99.2%.

Factors influencing the prevalence of cervical cancer screening in Malaysia: a nationwide survey

BACKGROUND

In 2020, cervical cancer ranked fourth in terms of both frequency of diagnosis and the leading cause of cancer-related deaths among women globally. Among Malaysian women, it was the third most prevalent form of cancer. Published data on nationally representative cervical cancer screening in Malaysia have been limited. Therefore, this study aimed to determine the prevalence of receiving a Pap smear test in the past three years, its relationship with socio-demographic factors and physical activity.

METHODS

Using a subset of survey data from the National Health and Morbidity Survey (NHMS) 2019, a secondary data analysis was performed. Trained research assistants collected data through face-to-face method using a mobile tablet questionnaire system application. Logistic regression analysis was performed to examine the relationship between sociodemographic factors, physical activity, and cervical cancer screening. The analyses were conducted using STATA version 14 (Stata Corp, College Station, Texas, USA), accounting for sample weighs and complex sampling design.

RESULTS

The analysis included 5,650 female respondents, representing an estimated 10.3 million Malaysian female adults aged 18 and above. Overall, 35.2% (95%CI 33.2, 37.4) respondents had a Pap smear test within the past three years. Respondents who were physically active were 1.41 times more likely to have a Pap smear test. Similarly, respondents aged 35-59 (OR 1.84; 95%CI 1.46, 2.34) and those living in rural localities (OR 1.38; 95%CI 1.13, 1.70) had higher odds of receiving a Pap smear test. Compared to married respondents, single respondents (OR 0.04; 95%CI 0.02, 0.07) and widowed/divorcee respondents (OR 0.72; 95%CI 0.56, 0.82) were less likely to receive a Pap smear test. Educated respondents were more likely to have had a Pap smear test.

CONCLUSIONS

The overall prevalence of cervical cancer screening in Malaysia remains low (35.2%). Efforts should be made to strengthen health promotion programs and policies in increasing awareness on the significance of cervical cancer screening. These initiatives should specifically target younger women, single women, and widowed/divorced individuals. The higher cervical screening uptake among rural women should be studied further, and the enabling factors in the rural setup should be emulated in urban areas whenever possible.

Construction and Assessment of a Prognostic Risk Model for Cervical Cancer Based on Lactate Metabolism-Related lncRNAs

Purpose

Cervical cancer (CC) has the fourth highest incidence and mortality rate among female cancers. Lactate is a key regulator promoting tumor progression. Long non-coding RNAs (lncRNAs) are closely associated with cervical cancer (CC). The study was aimed to develop a prognostic risk model for cervical cancer based on lactate metabolism-associated lncRNAs and to determine their clinical prognostic value.

Patients and Methods

In this study, CESC transcriptome data were obtained from the TCGA database. 262 lactate metabolism-associated genes were extracted from MsigDB (Molecular Characterization Database). Then, correlation analysis was used to identify LRLs. Univariate Cox regression analysis was performed afterwards, followed by least absolute shrinkage and selection operator (LASSO) regression analysis and multiple Cox regression analysis. 10 lncRNAs were finally identified to construct a risk score model. They were divided into two groups of high risk and low risk according to the median of risk scores. The predictive performance of the models was assessed by Kaplan-Meier (K-M) analysis, subject work characteristics (ROC) analysis, and univariate and multivariate Cox analyses. To assess the clinical utility of the prognostic model, we performed functional enrichment analysis, immune microenvironment analysis, mutation analysis, and column line graph generation.

Results

We constructed a prognostic model consisting of 10 LRLs at CC. We observed that high-risk populations were strongly associated with poor survival outcomes. Risk score was an independent risk factor for CC prognosis and was strongly associated with immune microenvironment analysis and tumor mutational load.

Conclusion

We developed a risk model of lncRNAs associated with lactate metabolism and used it to predict prognosis of CC, which could guide and facilitate the progress of new treatment strategies and disease monitoring in CC patients.

PSME3 induces radioresistance and enhances aerobic glycolysis in cervical cancer by regulating PARP1

Cervical cancer (CC) ranks the fourth in gynecologic cancers. The incidence and mortality of CC has been decreased due to the cancer screening and early treatments in recent years, but the prognosis of CC patients at advanced stage is still sorrowful. Whether PSME3 exerted a role in the radioresistance of CC cells remains to be investigated. In this study, the expression of PSME3 in mRNA and protein levels was measured by RT-qPCR and western blot analysis, and increased expression of PSME3 in CC tissues and cells was observed. CCK-8 and colony formation assay revealed that the cell viability and proliferation of Hela and CaSki cells treated with different doses of X-ray was reduced due to the depletion of PSME3, indicating that silencing of PSME3 enhanced the radiosensitivity of CC cells. In addition, repair on DNA damage in CC cells was enhanced by PSME3 and the damage was attenuated by PSME3. Besides, the expression of glycolysis-related proteins (GLUT1, PGC-1α, LDHA and HK2) were enhanced by PSME3 but reduced by silencing PSME3 in CC cells. PSME3 restraint attenuated the levels of glucose consumption and lactate production, suggesting PSME3 depletion suppressed abnormal glycolysis of CC cells. Mechanically, PSME3 increased the PARP1 expression via elevating c-myc. Finally, we observed PSME3 attenuation inhibited CC growth in vivo. In conclusion, PSME3 enhanced radioresistance and aerobic glycolysis in CC by regulating PARP1, which might shed a light into the function of PSME3 in CC treatment.

Special Issue: "Management of Early Stage Cervical Cancer"

Cervical carcinoma is a common gynecological malignancy that remains a challenge for oncologic gynecologists around the world [...].

Economic burden of cervical cancer and premalignant lesions associated with human papilloma virus: a societal perspective

BACKGROUND

Cervical cancer is one of the most common cancers in women, the cause of which is mostly human papilloma virus (HPV). The aim of this study was to determine the economic burden of cervical cancer and premalignant lesions associated with HPV infection from a societal perspective.

METHODS

The study is a partial economic evaluation (cost of illness), which was conducted cross-sectionally in the referral university clinic in Fars province in 2021. The prevalence-based and bottom-up approaches used to calculate the costs, the indirect costs were calculated by human capital approach.

RESULTS

The mean cost of premalignant lesions associated with HPV infection was USD 2,853 per patient, which 68.57% was direct medical costs. In addition, the mean cost of cervical cancer was USD 39,327 per patient, the largest share of which (57.9%) was related to indirect costs. The mean annual cost of cervical cancer patients in the country was estimated at USD 40,884,609 as well.

CONCLUSION

Cervical cancer and premalignant lesions associated with HPV infection imposed a significant economic burden on the health system and patients. The results of the present study can help health policymakers with efficient and equitable prioritization and allocation of resources.

Integrating network pharmacology approaches for the investigation of multi-target pharmacological mechanism of 6-shogaol against cervical cancer

Traditional treatment of cancer has been plagued by a number of obstacles, such as multiple drug resistance, toxicity and financial constraints. In contrast, phytochemicals that modulate a variety of molecular mechanisms are garnering increasing interest in complementary and alternative medicine. Therefore, an approach based on network pharmacology was used in the present study to explore possible regulatory mechanisms of 6-shogaol as a potential treatment for cervical cancer (CC). A number of public databases were screened to collect information on the target genes of 6-shogaol (SuperPred, Targetnet, Swiss target prediction and PharmMapper), while targets pertaining to CC were taken from disease databases (DisGeNet and Genecards) and gene expression omnibus (GEO) provided expression datasets. With STRING and Cytoscape, protein-protein interactions (PPI) were generated and topology analysis along with CytoNCA were used to identify the Hub genes. The Gene Ontology (GO) database Enrichr was used to annotate the target proteins, while, using the Kyoto Encyclopedia of Genes and Genomes (KEGG) database, signaling pathway enrichment analysis was conducted. Molecular docking and survival analysis for the Hub genes revealed four genes (HSP90AA1, HRAS, ESR1 and EGFR) with lowest binding energy and majority of the Hub genes (EGFR, SRC, CASP-3, HSP90AA1, MTOR, MAPK-1, MDM2 and ESR1) were linked with the overall survival of CC patients. In conclusion, the present study provides the scientific evidence which strongly supports the use of 6-shogoal as an inhibitor of cellular proliferation, growth, migration as well as inducer of apoptosis via targeting the hub genes involved in the growth of CC.Communicated by Ramaswamy H. Sarma.

Immune checkpoint inhibitors in cervical cancer: Current status and research progress

Cervical cancer is the second most common gynecological malignant tumor endangering the health of women worldwide. Despite advances in the therapeutic strategies available to treat cervical cancer, the long-term prognosis of patients with recurrent and metastatic cervical cancer remains unsatisfactory. In recent years, immune checkpoint inhibitors (ICIs) have shown encouraging efficacy in the treatment of cervical cancer. ICIs have been approved for use in both first- and second-line cervical cancer therapies. This review summarizes the current knowledge of ICIs and the application of ICIs in clinical trials for the treatment of cervical cancer.

Prognosis Analysis and Validation of Fatty Acid Metabolism-Related lncRNAs and Tumor Immune Microenvironment in Cervical Cancer

Cervical cancer (CC) is the third most common carcinoma and the fourth leading cause of cancer-associated mortality in women. The deregulation of fatty acid metabolism plays a crucial role in the progression of various tumors. This study is aimed at exploring the prognostic values of fatty acid metabolism- (FAM-) related long noncoding RNAs (lncRNAs) in CC. FAM-related differentially expressed genes (DEGs) and lncRNAs were screened in CC specimens based on TCGA datasets. Univariate analysis was carried out on differentially expressed lncRNAs to screen the survival-related lncRNAs. Multivariate assays were performed on the resulting lncRNAs to create a novel risk model. Survival assays were applied to examine the prognostic abilities of our model. Receiver operating characteristic (ROC) analysis was used to evaluate the accuracy of the new model. The association between risk model and immune responses was analyzed. In this study, we screened 9 differently expressed lncRNAs associated with the clinical outcome of CC patients. A nine-lncRNA signature comprising SCAT1, AC119427.1, AC009097.2, MIR100HG, AC010996.1, AL583856.2, MIAT, AP003774.2, and AC004540.2 was established to predict overall survival of CC. Survival assays revealed that patients' high risk score showed a shorter overall survival than those with low risk score. Multivariate assays demonstrated that the nine-gene signature was an independent prognostic factor in CC. In addition, we observed that APC_co_stimulation, CCR, and parainflammation were distinctly different between low-risk and high-risk groups. Our group observed a distinct difference in the expressions of CD44, TNFRSF8, CD276, LAG3, TNFRSF14, TMIGD2, VTCN1, TNFRSF25, CD80, NRP1, TNFRSF18, CD70, TNFSF9, and LGALS9 between the two groups of patients. Overall, our findings indicated that the 9 FAM-related lncRNA signature might be a promising prognostic factor for CC and can promote the management of FAM-related therapy in clinical practice.

Comparison of Survival Outcomes between Minimally Invasive Surgery and Open Radical Hysterectomy in Early-Stage Cervical Cancer

OBJECTIVES

To compare the survival outcomes between minimally invasive surgery (MIS) and laparotomy radical hysterectomy in patients with early-stage cervical cancer.

METHODS

We conducted a retrospective study involving women who received a radical hysterectomy for cervical cancer, stage IA1 with lymphovascular invasion, IA2, IB1, IB2, or IIA from 2008 to 2016. Clinicopathologic and perioperative outcomes were compared using appropriate statistical methodologies.

RESULTS

Oncologic survival outcomes were analyzed using the Kaplan-Meier method. Among the 105 cases identified, 58 (55.2%) and 47 (44.8%) women underwent MIS and open radical hysterectomy, respectively. Over a median follow-up period of 62 months, women who underwent MIS and open radical hysterectomy had a 5-year overall survival rate of 87.9% and 89.4% (p = 0.845) and a 5-year disease-free survival rate of 82.5% and 86.7% (p = 0.624), respectively.

CONCLUSIONS

For early-stage cervical cancer, patients who underwent MIS radical hysterectomy had survival outcomes that were comparable to those who underwent open surgery at our institute.

Clinical Epidemiology of Microinvasive Cervical Carcinoma in an Italian Population Targeted by a Screening Programme

Simple Summary

According to this population-based study, 3750 patients living in the Emilia-Romagna Region (northern Italy) were registered with cervical carcinoma between 1995–2016, including 2942 eligible patients. The likelihood of stage IA cervical carcinoma (n = 876, 29.8%) did not change over time, decreased with increasing patient age, and was lower for patients with adenocarcinoma and grade 3–4 disease. Three hundred and fifty (40.0%) patients had a conservative treatment, 317 (36.2%) had hysterectomy, 197 (22.5%) had hysterectomy with lymph node dissection (LND), and 12 (1.4%) had a conservative treatment with LND. The proportion of hysterectomy decreased from 70.6% in 1995–1999 to 46.9% in 2011–2016. The likelihood of hysterectomy increased above the age of 40. Among screening-aged (25–64 years) patients, the likelihood of hysterectomy did not differ between screen-detected and non-screen-detected ones. Hysterectomy was increasingly combined with LND. High tumour grade was the strongest determinant of LND during hysterectomy.

Abstract

(1) Background: This population-based study aimed at identifying the factors associated with the likelihood of detection of stage IA cervical carcinoma—versus the detection of stage IB through IV cervical carcinoma—and the patterns of surgical treatment. (2) Methods: Between 1995–2016, 3750 patients living in the Emilia-Romagna Region (northern Italy) were registered with cervical carcinoma, including 2942 eligible patients (median age, 53). Multivariate analysis was performed using binary logistic regression models. (3) Results: The likelihood of stage IA cervical carcinoma (n = 876, 29.8%) did not change over time, decreased with increasing patient age, and was lower for patients with adenocarcinoma and grade 3–4 disease. Three hundred and fifty (40.0%) patients had a conservative treatment, 317 (36.2%) had hysterectomy, 197 (22.5%) had hysterectomy with lymph node dissection (LND), and 12 (1.4%) had a conservative treatment with LND. The proportion of hysterectomy decreased from 70.6% in 1995–1999 to 46.9% in 2011–2016. The likelihood of hysterectomy increased above the age of 40. Among screening-aged (25–64 years) patients, the likelihood of hysterectomy did not differ between screen-detected and non-screen-detected ones. Hysterectomy was increasingly combined with LND. High tumour grade was the strongest determinant of LND during hysterectomy. (4) Conclusions: This study provided a multifaceted overview of stage IA cervical carcinoma over the last decades.