Importance of addition of HPV DNA testing to the cytology based cervical cancer screening and triage of findings with p16/Ki67 immunocytochemistry staining in 35 and 45 years old women LIBUSE trial data analysis

OBJECTIVE

The study evaluates results of 2-years follow-up of patients in ages 35-36 and 45-46, who are participating in the project LIBUSE, that deals with efficacy of HPV DNA and Pap smear co-testing and p16/Ki67 dual staining in the Czech national cervical screening.

DESIGN

Prospective observational study.

SETTING

Department of Obstetrics and Gynecology, General University Hospital and 1st Medical Faculty, Charles University, Prague.

MATERIALS AND METHODS

Out of all women enrolled in the project LIBUSE only those who were at the beginning of the study 35-36 and 45-46 years old were sellected. Conventional Pap smear and HPV DNA test (Cobas 4800, Roche Diagnostics) had been collected at the baseline. Women were stratified according to their results in the three risk groups: 1. low-risk, 2. high-risk and 3. intermediate risk, who subsequently underwent p16/Ki67 dual staining. All high-risk patients and those with positive result of dual staing were refered to the expert colposcopy. The cases with biopsy proven precancers or cancers were considered as „positive findings“.

RESULTS

Altogether 352 women meet the age requirements. In 26 (7.6%) women had been proven HPV DNA positivity and out of the them 9 cases were HPV 16/18 positive. Severe cytological abnormality was found only in one patient (0.3%), who was simultaneously HPV positive. Ten women (2.8%) were classified as high-risk and directly refered to colposcopy. Another 18 patients underwent p16/Ki67 dual staining and 4 positive cases were refered to colposcopy too. After one year further 9 patients were classified as intermediate risk and 6 more were identified after two years of follow-up. Within two years 9 more patient were refered to colposcopy. After the entire period of follow-up in 10 patients biopsy confirmed precancer lesions, none of them had invasive cancer.

CONCLUSIONS

Addition of HPV DNA testing with selective HPV 16/18 genotyping to the cytology based screening significantly increases sensitivity and safety of our cervical screening program.

Systemic hormone therapy after breast and gynecological cancers: an Italian expert group consensus opinion

The specific Italian Group of Study of the Menopause formulated a consensus opinion on the use of estrogen therapy (ET) or combined estro-progestin hormone therapy (HT) after breast and gynecological cancers. This consensus is based on the risk of recurrence of the specific cancer during ET/HT, the presence of steroid receptors in cancer cells, the use of adjuvant hormone therapies and data on the use of ET/HT after cancer. The following positions were reached. ET/HT can be used after vulvar cancers and melanoma, but with great caution after the rare adenocarcinomas. ET/HT can be used after cervical cancer, but ET should be used with caution after adenocarcinomas. ET/HT can be used after International Federation of Obstetrics and Gynecology (FIGO) stage I-II estrogen-dependent endometrial cancers, except in Black women, and can probably be used after estrogen-independent endometrial cancers. ET/HT cannot be administered or should be used with great caution after most uterine sarcomas. ET/HT can probably be used after ovarian neoplasms except for granulosa cell tumors, and with great caution after low-grade serous ovarian carcinoma and serous borderline ovarian tumors. ET/HT can be used with great caution in women after estrogen receptor (ER)/progesterone receptor (PR)-positive breast cancer and is probably allowed after ER/PR-negative breast cancer.

High-dose-rate intracavitary brachytherapy for recurrent cervical cancer in the vaginal stump after hysterectomy

This study aimed to evaluate the treatment outcomes of patients who received high-dose-rate intracavitary brachytherapy (HDR-BT) using Iridium-192 with or without external beam radiotherapy as definitive treatment for recurrent cervical cancer after hysterectomy. Thirty-six patients with local recurrence after hysterectomy received radiotherapy including HDR-BT from 2005 to 2013. Overall survival, local control rate, and progression-free survival were estimated retrospectively via the Kaplan-Meier method. Late adverse events were also scored using the Common Terminology Criteria for Adverse Events (version 3.0). Median follow-up time was 38 (range, 7.4–101.3) months. The 3-year estimates of overall survival, local control rate, and progression-free survival were 100.0%, 82.8%, and 76.8%, respectively. Two patients (5.6%) had grade 2 lymphedema, but no other adverse events greater than grade 2 were reported. In conclusion, HDR-BT was an effective treatment modality for patients with cervical cancer recurrence in the vaginal stump.

What next in cervical cancer screening?

INTRODUCTION

The main aim of organized national cervical cancer screening programs is to decrease incidence and mortality of this malignancy. A total of 770 cases of cervical cancer and 354 deaths from the disease were noticed in the Czech Republic in 2017 which means the incidence 14,5 new cases per 100 000 women. The Czech national cervical cancer screening program is based on cytology (Pap smear) testing in asymptomatic women once a year.

OBJECTIVE

To provide an overview of new possibilities and potential tools in cervical cancer screening worldwide and in the Czech Republic.

SETTING

Gynecologic Oncology Center, Department of Gynecology and Obstetrics, Hospital Na Bulovce and 1st Medical School of Charles University, Prague; Gynecologic Oncology Center, Department of Gynecology and Obstetrics, General Faculty Hospital and 1st Medical School of Charles University, Prague.

METHODS

For this review, we have used the results of studies, review articles, and guidelines of national cervical cancer screening programs published in English. We summarize the current knowledge of molecular genetic methods being applied in the screening of cervical carcinoma.

CONCLUSION

The knowledge that persistent human papillomavirus (HPV) infection is the main cause of cervical cancer has resulted in the development of new possibilities of cervical cancer screening worldwide. HPV testing use for cervical cancer screening is now a reality with a quite lot of countries. Nevertheless, HPV testing is mainly used in the stratification of patients with unclear results of a cytological (PAP smear) result in the Czech Republic. While there is a wide and growing consensus that HPV molecular testing is the most accurate and cost-effective method of primary screening, there is a comparative lack of consensus regarding the optimal stratification of patients with proven HPV infections. Biomarkers, such a p16/Ki67 dual immunostaining, a methylation of viral DNA, a detection of E6/E7 mRNA, and others have been proposed for triage of HPV positive women. New possibilities and approaches in strategy of cervical cancer screening are discussed.

Individualization of surgical management of cervical cancer stages IA1, IA2

OBJECTIVE

To evaluate the risk of involvement of sentinel lymph nodes in cervical cancer stage IA1 with lymphovascular space invasion and IA2 using the detection of sentinel lymph nodes.

DESIGN

Original article.

SETTINGS

Department of Gynecology and Obstetrics 3rd Faculty of Medicine, Charles University, Faculty Hospital Královské Vinohrady, Prague; Oncogynecological centrum; Department of Pathology 3rd Faculty of Medicine, Charles University, Faculty Hospital Kralovské Vinohrady, Prague.

METHODS

The study included women from prospective protocols LAP I and LAP II with cervical cancer stage IA1 with lymphovascular space invasion and stage IA2 from 2002 to 2018 classified according to FIGO 2014 staging, TNM 8. Detection of sentinel lymph nodes throughout this period was performed using ultra-short protocol with Tc and patent blau and also by histopathological examination.

RESULTS

In the first group (28 women) with stage IA1 and lymphovascular space invasion diagnosed from cone biopsy there were two women with positive lymph nodes (7.1%). In the group stage IA2 (34 women) there were 13 women (38.2%) with positive lymphovascular space invasion and two women had positive lymph nodes (5.9%). The risk of positive lymph nodes for stage IA1 with lymphovascular space invasion and for stage IA2 is not statistically significant OR = 0.8125 (95% CI 0.1070-6.172).

CONCLUSION

The detection of sentinel lymph nodes aids to individualize the therapy of early stage cervical cancer and helps to reduce the radicalization of surgery. The risk of positive lymph nodes in stage IA1 with lymphovascular space invasion and stage IA2 with/without lymphovascular space invasion is the same. The results confirm, that the detection of sentinel lymph nodes in stage IA1 with lymphovascular space invasion is fully indicated.

Current data on the efficacy of prophylactic HPV vaccination in the primary prevention of cervical lesions

OBJECTIVE

A review of current knowledge on the efficacy of HPV (human papillomavirus) HPV vaccination against pre-cancers and cervical cancer.

METHODS AND RESULTS

HPV infection is probably the most common sexually transmitted disease and the cause of approximately 5% of all human cancers. Currently, three prophylactic vaccines against HPV infection are on the market: bivalent Cervarix, quadrivalent Gardasil (formerly Silgard) and nonavalent Gardasil9. The Czech Republic is one of the countries with a national vaccination program where HPV vaccination is covered by health insurance for girls and boys aged 13-14 years. Extensive scientific data on the efficacy of the vaccines clearly demonstrate significant efficacy against the development of cervical pre-cancers for all three vaccines. According to a high-certainty evidence of the Cochrane database, the efficacy of HPV vaccines against cervical intraepithelial neoplasia grade 2 or 3 associated with HPV 16, 18 compared with placebo in girls and women aged 15-26 is 99%. There is also moderate-certainty evidence that HPV vaccines reduce the risk of adenocarcinoma in situ for approximately 90% for the same population. Initial data also demonstrate a direct impact on reducing the incidence of invasive cervical cancer in vaccinated individuals. In addition, quadrivalent and nonavalent vaccines are highly effective in preventing genital warts.

CONCLUSION

All three available prophylactic vaccines show high efficacy in preventing the development of cervical lesions. Efficacy is highest against lesions caused by vaccine genotypes and the highest efficacy is achieved in the HPV naive population.

Chemoradiotherapy in the treatment of cervical cancer - a single institution retrospective review

BACKGROUND

The aim of this study is a retrospective analysis of treatment outcomes and toxicity in a group of patients with cervical cancer who underwent (chemo) radiotherapy at the Institute of Radiation Oncology in Bulovka University Hospital in Prague in the period 2014-2017.

PATIENTS AND METHODS

During this period, 141 patients were treated, 105 (74.5%) of them underwent combined (chemo) radiotherapy with radical intent and palliative radiotherapy was performed in 36 (25.5%) cases. According to the International Federation of Gynecology and Obstetrics (FIGO) 2009 classification, the most numerous stages were IIB in 39 (27.7%) and IIIB in 64 (45.4%) cases; according to FIGO 2018, a significant number of newly established stages is evident: IIIC1 in 55 (39.0%) patients and IIIC2 in 22 (15.6%) cases.

RESULTS

The median progression-free survival (PFS) and overall survival (OS) reached 31.3, resp. 40.1 months in the whole group. In the subgroup of patients treated with radical intent, the median PFS was 44.0 months and OS 48.8 months; in the palliative subgroup, the median PFS was 9.4 months and OS 14.8 months. In a radically treated subgroup, 7 (6.7%) patients had gastrointestinal or genitourinary manifestations of G3-4 toxicity, and overall acute toxicity (including skin and haematological reactions) of G3-4 occurred in 18 (17.1%) patients. Late toxicity of G3-4 was reported in 13 (12.4%) cases. Patients who underwent complete brachytherapy (BRT) showed significantly better survival compared to patients with a lower number of BRT fractions. The prognostic potential of PS (performance status) and anemia was confirmed; significantly longer overall survival was observed in patients in good general condition or in those without anemia.

CONCLUSION

Our results confirmed the key role of BRT for the delivery of the curative dose to the target volume. The prognostic role of PS and anemia is evident. The side effects were in acceptable limits but we expect improvements because of the use of modern radiotherapy technologies.

Image guided adaptive brachytherapy of cervical cancer - practical recommendations

Brachytherapy (BT) is an integral part of radical radiotherapy (RT) or radiochemotherapy (RCT) in patients who are not suitable candidates for surgery. These are usually patients with locally advanced cervical cancer. The goal of all BT planning eff orts has been, still is, and certainly will continue to be, to defi ne the anatomical boundaries of the tumor and the relationship of the tumor to organs at risk (OARs) as best as possible, using available modern imaging techniques. Image guided adaptive brachytherapy (IGABT) is currently the most advanced method of uterovaginal BT. Adaptive planning allows dose escalation from BT to newly defi ned target volumes, according to the risk of recurrence, which is mainly determined by the level of tumor burden. This dose adaptation based on the response to external RCT is a major change in practice compared to conventional BT planning based on dose prescription to point A. The main advantage of the IGABT concept is that it allows the assessment of individual dose distributions in target volumes and OARs, which in turn leads to improved dose coverage of target volumes while decreasing the volume irradiated by the prescribed dose compared to conventional 2D planning. Purpose: In this review article, I provide a comprehensive up-to-date perspective on this issue, particularly in terms of practical recommendations regarding the defi nition of target volumes, the use of diff erent types of uterovaginal applicators, intraoperative complications, and potential manifestations of late gastrointestinal, genitourinary, and vaginal toxicity.

Peritumoral stroma and systemic inflammatory response in cervical cancer

OBJECTIVE

To compare cervical stroma in advanced cervical cancer with the control group; to compare, in the pre-treatment period, hemogram parameters in patients with advanced cervical cancer with the same parameters as the control group; and to verify if there is an association of stromal markers with prognostic factors in cervical cancer.

MATERIALS AND METHODS

We prospectively evaluated 16 patients diagnosed with advanced invasive cervical cancer. A control group of 22 patients was used (uterine leiomyoma). Immunohistochemistry was performed to verify the stromal immunostaining of alpha-smooth muscle actin (SMA) and fibroblast activation protein alpha (FAP). Immunostainings and hemogram parameters were compared using Fisher's exact and Mann-Whitney Test, respectively.

RESULTS

Strong FAP immunostaining was more frequent in patients with cervical cancer when compared with patients with leiomyoma (P = 0.0002). Regarding SMA, strong immunostaining was also found more in the group of cancer patients compared to the control group (P < 0.00001). The neutrophil-lymphocyte ratio (NLR) values were higher in the cancer patient group compared to the control group (P = 0.0019). There was no association of the parameters studied with prognostic factors.

CONCLUSIONS

Strong FAP and SMA immunostaining was found more in patients with cervical cancer when compared to the control group. NLR values were also higher in cervical cancer.

Surgical treatment of recurrent gynecological malignancies

OBJECTIVE

A comprehensive overview of surgical treatment of recurrent gynecological malignancies. Recurrent breast malignancies are not included in this review.

METHODOLOGY

A review providing overview of surgical treatment options for recurrent malignancies of adnexa of the uterus (ovary, fallopian tube), uterine corpus, uterine cervix, and carcinoma of the vagina and vulva.

CONCLUSION

Optimal surgical treatment for patients with recurrent cancer is based on multidisciplinary approach with stratification according to individual prognostic markers. These include patient's performance status, outcome of primary surgery, current extent of recurrence, and histopathological, molecular, and biochemical characteristics. Decision about choice of treatment should be individually discussed and evaluated by the multidisciplinary oncogynecological commission board.