Table 2 - uploaded by Yukiharu Todo
Content may be subject to copyright.
Clinical characteristics of 115 patients with cervical cancer treated with radical hysterectomy/trachelectomy with pelvic lymphadenectomy
Source publication
All patients with stage IB1 cervical cancer do not need to undergo parametrectomy. Some low-risk criteria for parametrial involvement (PI) have been proposed based on pathological findings. The aim of this study was to determine pretreatment risk factors for PI in stage IB1 cervical cancer.
We retrospectively reviewed 115 patients with stage IB1 ce...
Citations
... Currently, MRI is more available for women with cervical cancer because it is more precise for measuring tumor size than a physical examination (16)(17)(18). These MR images can be scanned in the axial, sagittal, and coronal planes. ...
... Gynecologists inspect the outer tumor surface alone, but not the inner margin, which is well-depicted on MRI. This imaging modality provides precise tumor staging, and thus, it is more sensitive to detecting parametrial invasion or endocervical cancer than visual assessment (16)(17)(18). MRI also has the potential to avoid intravenous urography, cystoscopy, and sigmoidoscopy if cervical cancer is in the early stages (19)(20)(21)(22). Moreover, current FIGO staging requires metastatic work-up in iliac or paraaortic LNs, which are not palpable (22). ...
Background
Invisible cervical cancers on MRI can indicate less invasive surgery. Cervical cancers consist of squamous cell carcinoma (SCC) and non-SCC, each with different long-term outcomes. It is still unclear if surgical planning should be changed according to the histologic type of cervical cancer when it is not visible on MRI.
Purpose
The purpose of the study was to determine if surgical planning for cervical cancer that is not visible on MRI is influenced by the histologic type.
Materials and methods
Between January 2007 and December 2016, 155 women had Federation of Gynecology and Obstetrics (FIGO) stage 1B1 cervical cancer that was not visible on preoperative MRI. They underwent radical hysterectomies and pelvic lymph node dissections. Among them, 88 and 67 were histologically diagnosed with SCC and non-SCC, respectively. The size of the residual tumor, depth of stromal invasion, parametrial invasion, vaginal invasion, lymphovascular invasion, and lymph node metastasis were compared between these patients using the t-test, Mann–Whitney U test, Chi-squared test, or Fisher’s exact test. The recurrence-free and overall 10-year survival rates were compared between the groups by Kaplan–Meier analysis.
Results
The mean sizes of residual tumors were 8.4 ± 10.4 mm in the SCC group and 12.5 ± 11.9 mm in the non-SCC group (p = 0.024). The mean depth of stromal invasion in the SCC group was 12.4 ± 21.2% (0%–100%), whereas that in the non-SCC group was 22.4 ± 24.4 (0%–93%) (p = 0.016). However, there was no difference in parametrial or vaginal invasion, lymphovascular invasion, or lymph node metastasis (p = 0.504–1.000). The recurrence-free and overall 10-year survival rates were 98.9% (87/88) and 95.5% (64/67) (p = 0.246), and 96.6% (85/88) and 95.5% (64/67) (p = 0.872), respectively.
Conclusions
The non-SCC group tends to have larger residual tumors and a greater depth of stromal invasion than the SCC group, even though neither is visible on MRI. Therefore, meticulous care is necessary for performing parametrectomy in patients with non-SCC cervical cancer.
... 48 reported that patients with FIGO stage IB1, tumour size ≥2 cm, deep cervical stromal invasion and distance ≤5 cm between tumour and internal cervical os (ICO) were associated with increased possibility of radical hysterectomy. In contrast, Yamazaki et al. 49 suggest that patients with FIGO stage IB1, MRI-based tumour diameter <2.5 cm, MRI-based volume index <5 cm³ and negative serum tumour markers (SCC-Ag or CA-125) should require less invasive surgery as an alternative therapy. Stage II of FIGO classification is characterized by tumour invasion beyond the cervix but with no extension onto the lower third of the vagina or the pelvic wall ( Figure 2). ...
Magnetic resonance imaging (MRI) is a widely used imaging modality that depicts detailed information regarding morphological and functional characteristics of the human body. It is routinely used in gynaecologic oncology for female pelvis imaging because of the high spatial and soft-tissue contrast resolution. Furthermore, MRI is an important diagnostic tool for the assessment of common gynaecological malignancies - endometrial carcinoma, cervical carcinoma and malignant ovarian tumours. Novel technical developments enabled the multiparametric MRI approach in the diagnosis of respective tumours combining T1-weighted (T1W) sequences, T2-weighted (T2W) sequences, diffusion-weighted (DW) sequences with apparent diffusion coefficient (ADC) values and dynamic contrast-enhanced (DCE) sequences. With highlighted novelties, MRI importance ranges from tumour detection to treatment response monitoring and early recurrent disease evaluation. This review discusses the value of MRI in the diagnostic assessment of the common gynaecological malignancies with an emphasis on tumour staging.
... Magnetic resonance imaging (MRI) is more precise in estimating tumor volume than is physical examination because MRI enables accurate measurement of three-dimensional tumor axes [11][12][13]. Only a few investigations have reported on the usefulness of such MRI findings, showing that early cervical or endometrial cancer can be treated with less invasive surgery if the tumor is invisible on MRI [14][15][16]. ...
... Parametrectomy is performed for radical hysterectomy in women with early cervical cancer to reduce recurrent cervical cancer [4][5][6][7]. However, several investigations have reported that a small tumor size, small depth of invasion, or no LVS invasion are good prognostic factors for no parametrial involvement [8][9][10][11][12][13]. The risk factor that they predict parametrial invasion most commonly is the tumor size [8][9][10][11][12][13]. ...
... However, several investigations have reported that a small tumor size, small depth of invasion, or no LVS invasion are good prognostic factors for no parametrial involvement [8][9][10][11][12][13]. The risk factor that they predict parametrial invasion most commonly is the tumor size [8][9][10][11][12][13]. If it is 2 cm or less, parametrial invasion is rare so that less invasive surgery is recommended in this small cervical cancer [8][9][10][11]13]. ...
Purpose:
Cervical cancer that is invisible on magnetic resonance imaging (MRI) may suggest lower tumor burden than physical examination. Recently, 3 tesla (3T) MRI has been widely used prior to surgery because of its higher resolution than 1.5T MRI. The aim was to retrospectively evaluate the utility of 3T MRI in women with early cervical cancer in determining the necessity of less invasive surgery.
Materials and methods:
Between January 2010 and December 2015, a total of 342 women with FIGO stage IB1 cervical cancer underwent 3T MRI prior to radical hysterectomy, vaginectomy, and lymph node dissection. These patients were classified into cancer-invisible (n = 105) and cancer-visible (n = 237) groups based on the 3T MRI findings. These groups were compared regarding pathologic parameters and long-term survival rates.
Results:
The cancer sizes of the cancer-invisible versus cancer-visible groups were 11.5 ± 12.2 mm versus 30.1 ± 16.2 mm, respectively (p < 0.001). The depths of stromal invasion in these groups were 20.5 ± 23.6% versus 63.5 ± 31.2%, respectively (p < 0.001). Parametrial invasion was 0% (0/105) in the cancer-invisible group and 21.5% (51/237) in the cancer-visible group (odds ratio = 58.3, p < 0.001). Lymph node metastasis and lymphovascular space invasion were 5.9% (6/105) versus 26.6% (63/237) (5.8, p < 0.001) and 11.7% (12/105) versus 40.1% (95/237) (5.1, p < 0.001), respectively. Recurrence-free and overall 5-year survival rates were 99.0% (104/105) versus 76.8% (182/237) (p < 0.001) and 98.1% (103/105) versus 87.8% (208/237) (p = 0.003), respectively.
Conclusions:
3T MRI can play a great role in determining the necessity of parametrectomy in women with IB1 cervical cancer. Therefore, invisible cervical cancer on 3T MRI will be a good indicator for less invasive surgery.
... It has been shown that a subpopulation of patients presents a low risk of PI. Several studies have described variables associated with PI: age, tumor size, body-mass index, menopausal status, lymph-vascular space involvement (LVSI) and deep stromal invasion (DSI) [1][2][3][4][17][18][19][20][21]. As an alternative to nerve-sparing radical hysterectomy, another strategy would be to accurately select these patients who would not benefit from a parametrectomy. ...
... Even if the negative predictive value of LVSI on conization sample is still debated, data are still lacking concerning its predictive power [31]. [1,18,19,32]. All found a low risk groups with a probability of PI of 0-1.94%. ...
... The retrospective analysis of two prospective databases may suffer from some bias. The small number of patients may limit the power of our work, yet studies evaluating PI are often relatively small, since PI is rare [2][3][4]18,19]. Likewise, the small number of events may result in the overfitting of our tool. ...
Background:
We aimed to establish a tool predicting parametrial involvement (PI) in patients with early-stage cervical cancer and select a sub-group of patients who would most benefit from a less radical surgery.
Methods:
We retrospectively reviewed patients from two prospective multicentric databases-SENTICOL I and II-from 2005 to 2012. Patients with early-stage cervical cancer (FIGO 2018 IA with lympho-vascular involvement to IIA1), undergoing radical surgery (hysterectomy or trachelectomy) with bilateral sentinel lymph node (SLN) mapping with no metastatic node or PI on pre-operative imaging, were included.
Results:
In total, 5.2% patients (11/211) presented a histologic PI. After univariate analysis, SLN status, lympho-vascular space invasion, deep stromal invasion and tumor size were significantly associated with PI and were included in our nomogram. Our predictive model had an AUC of 0.92 (IC95% = 0.86-0.98) and presented a good calibration. A low risk group, defined according to the optimal sensitivity and specificity, presented a predicted probability of PI of 2%.
Conclusion:
Patients could benefit from a two-step approach. Final surgery (i.e. radical surgery and/or lymphadenectomy) would depend on the SLN status and the probability PI calculated after an initial conization with bilateral SLN mapping.
... Furthermore, Kong et al. 10 reported the utility of the SCC-Ag and Cyfra levels for predicting PMI in stage IB, while Chang et al. 11 reported the utility of the SCC-Ag level for stage IB1 disease. Yamazaki et al. 12 suggested the possibility of less radical surgery for stage IB1 cases that were negative for SCC-Ag and cancer antigen 125. In our study, however, we did not find a correlation between PMI and tumor markers, possibly because our subjects included higher risky patients with stage IB2, IIA and IIB cervical cancer. ...
Aim:
This study aimed to assess adequate conditions for omitting parametrectomy for stage IB1-IIA2 cervical cancer with the aim of reducing postoperative complications during Type III radical hysterectomy (RH).
Methods:
We investigated factors associated with parametrial invasion (PMI) in patients who underwent Type III RH for stage IB1, IB2, IIA1, IIA2 and IIB cervical cancer at two tertiary institutions from November 2006 to February 2018. Both clinicopathological and preoperatively estimated factors were assessed.
Results:
One hundred fifty-six patients were preoperatively diagnosed with stage IB1 to IIB disease. Thirty-four patients (21.8%) showed PMI on histological analyses. In the multivariate analysis, an age older than 50 years, tumor size larger than 40 mm, common iliac lymph node metastasis and lymphovascular space invasion were identified as significant risk factors for PMI (P-values = 0.008, 0.003, 0.004 and 0.004, respectively). The preoperatively estimated risk factors for PMI were an older age, larger tumor size, and common iliac lymph node metastasis (P-values = 0.007, 0.002 and 0.001, respectively). A combination of these three factors was sufficient to estimate PMI with a high specificity (100%) and positive predictive value (100%) in patients with stage IB1 to IIA2 disease.
Conclusion:
During RH, resecting the posterior layer of the vesicouterine ligament and the paracolpium without removing the cardinal ligament (avoiding parametrectomy) might be feasible for stage IB1-IIA2 cervical cancer in patients younger than 50 years presenting with smaller tumors (<40 mm) and no common iliac lymph node metastasis.
... LVSI involvement [8,9], DOI > 1/2 [8,10], parametrial microinvasion [1,8,[11][12][13], LN metastasis [8,10,12], and vaginal margin involvement [12] are significantly more frequent in stage IB1 CC patients with a tumor diameter ≥ 2 cm than in those with smaller tumors. Although parametrial invasion [10] and positive vaginal margin involvement [5,8,10] were more frequently associated with tumors ≥ 2 cm in diameter, some studies indicated no significant differences according to tumor size. ...
Objectives: This study was performed to investigate prognostic factors status at smaller tumors in patients with stage IB1 cervical cancer (CC) who underwent modified radical or radical hysterectomy. Matherial and metods: Data from patients diagnosed with CC between January 1995 and January 2017 at the Gynecological Oncology Department, Tepecik Training and Research Hospital and Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey, were investigated. A total of 182 stage IB1 CC cases were evaluated retrospectively. Results: Patients were divided into two groups according to tumor size ( < 2 cm and ≥ 2 cm). There were no complications associated with the operation in patients with a tumor size < 2 cm. Among patients with a tumor size ≥ 2 cm, however, 0.9% (n = 1) developed bladder laceration, 0.9% (n = 1) rectum laceration, and 0.9% (n = 1) pulmonary emboli (P = 0.583). The rates of intermediate risk factors (depth of stromal invasion and lymphovascular space invasion) were significantly higher and lymph node involvement significantly more frequent in patients with a tumor size ≥ 2 cm. However, there were no significant differences in parametrial invasion or vaginal margin involvement between the two groups. Conclusions: Intermediate risk factors and lymph node metastasis were significantly less frequent in patients with small tumors measuring < 2 cm. However, although parametrial involvement and vaginal margin involvement were less common in patients with small tumors compared with large tumors (≥ 2 cm), the differences were not significant.
... 5 As suggested in the published article, tumor diameter was correlated with FIGO stage, LNM, and tumor recurrence rate. 23,24 It is mostly reported that the larger the tumor diameter, the broader the surrounding invasion and the 26 Our study confirmed the previously mentioned results that the maximum diameter of resectable cervical cancer correlated with regional LNM and LVSI. ...
Objective:
To determine whether gross tumor volume (GTV) and the maximum diameter of resectable cervical cancer at magnetic resonance imaging (MRI) could predict lymph node metastasis (LNM) and lymphovascular space invasion (LVSI).
Materials and methods:
A total of 315 consecutive patients with cervical cancer were retrospectively identified. Gross tumor volume and the maximum diameter of tumor were evaluated on MRI. Univariate and multivariate logistic regression analyses were performed to determine whether tumor size could predict LNM and LVSI. Cutoffs of GTV, maximum diameter, and the International Federation of Gynecology and Obstetrics (FIGO) classification of tumor were first investigated in 255 patients (group A) and then validated in an independent cohort of 60 patients (group B) using area under the receiver operating characteristic curve (AUC) analysis for predicting the presence of LNM and LVSI.
Results:
Univariate analysis showed that GTV and the maximum diameter of tumor could predict LNM and LVSI (all P < 0.0001). Multivariate analyses indicated GTV as an independent risk factor of LNM and LVSI (all P < 0.0001). In group A, GTV, the maximum diameter, and the FIGO stage could identify LNM (AUC, 0.813, 0.741, and 0.69, respectively) and LVSI (AUC, 0.806, 0.751, and 0.684, respectively). In group B, GTV, the maximum diameter, and the FIGO stage could help identify LNM (AUC, 0.902, 0.825, and 0.759, respectively) and LVSI (AUC, 0.771, 0.748, and 0.700, respectively).
Conclusions:
Gross tumor volume and the maximum diameter of resectable cervical cancer at MRI demonstrated capability in predicting LNM and LVSI, which were more accurate than FIGO stage.
... Pre-operative MRI and serum markers have been proposed as tools that can be utilized in pre-operative assessment to determine eligibility for less radical surgery. While serum markers are not commonly used in North America, they are being used in some parts of the world to help define low-risk population pre-operatively [68,73]. Lee et al. showed in their retrospective study that of 74 patients with stage IB1 cervical cancer who had non-visible tumor on MRI following a cone biopsy, only 1 (1.4%) had of parametrial involvement [72]. ...
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.
... There is evidence indicating a correlation of CA-125 with both adenocarcinoma and SCC. Previous studies of the latter histological type have focused on finding a correlation of preoperative levels of CA-125 with tumor size, grade, depth of invasion, infiltration of the lymphvascular spaces and extrauterine spread of disease, including invasion of the parametrium [10][11][12][13][14][15][16][17][18]. However, available literature does not discuss CA-125 reference test results regarding low volume lymph node disease (LVLND, consisting of micrometastases, MICs, and isolated tumor cells, ITC) in SCC. ...
... On the other hand, the correlation of CA-125 level with initial stage of disease cannot always be found [18,24], however, it may be taken under consideration in determining the risk of parametrial infiltration [18]. Although the biology of CA-125 did not support the rationale of early detection of MIC to LN by CA-125, it is unknown whether CA-125 may indicate an altered state of health, caused by LVLND. ...
... On the other hand, the correlation of CA-125 level with initial stage of disease cannot always be found [18,24], however, it may be taken under consideration in determining the risk of parametrial infiltration [18]. Although the biology of CA-125 did not support the rationale of early detection of MIC to LN by CA-125, it is unknown whether CA-125 may indicate an altered state of health, caused by LVLND. ...
BACKGROUND: Elevated serum cancer antigen 125 (CA-125) is observed in some cervical cancers (CCs). Is the correlation of CA-125 with the presence of nodal events useful in predicting early metastasis to the lymph nodes?
METHODS: The study included 45 patients with CC FIGO (2009) stages IA1-IIA1 and known preoperative CA-125 concentration, surgery treated (05.2011-05.2014). Investigated pretreatment: age (pre-, postmenopausal), histological type, grade, confounding factors - prior cone biopsy, ovarian cyst, endometriosis, liver or colon pathology, concomitant malignancy. LN metastases (LNM) were defined as macro (MAC, >2mm) and/or micrometastases (mic, 0.2 - 2 mm), and LVLND as mic or/and ITC (single CC cells clusters) in LNs. Ultrastaging of all LNs (sentinel and non-sentinel, 4 μm thick slices/150 μm intervals) was performed with hematoxylin and eosin staining and with immunohistochemistry (IHC - AE1/AE3 cytokeratin antibodies). Non-parametrical analysis and receiver operating curve analysis were used to determine correlation between CA-125 and LNM including LVLND.
RESULTS: The median age was 55 (23-71). 806 LNs were extracted. LNM was found in 12, LVLND in 6 patients. LNM but not LVLND was correlated with higher grade (G2-G3, p<0.05). LVLND was positively correlated with premenopausal age (p<0.05) but not with tumor histology or grade. Liver disease only was found to influence CA-125 levels (p=0.064). There were no differences within CA-125 concentration among LVLND, LNM, and node-negative patients groups, however a trend was found between higher CA-125 and lower LVLND risk.
CONCLUSIONS: Elevated levels of CA-125 may be less likely due to LVLND than to LN positivity. Grade is an important feature in prediction of LNM but not LVLND. CA-125 level was found to be not predictive of LNM nor LVLND, as confirmed by ultrastaging.
... Thus, patients with tumors b2 cm in diameter as assessed by conization or MRI may be optimal candidates for less radical surgery, including simple or modified RH. Recently, MRI-based tumor diameter ≥ 25 mm, volume index ≥ 5000 mm 3 , and serum SCC-Ag N 1.5 ng/mL or cancer antigen 125 (CA-125) N 35 U/mL were suggested as pretreatment risk factors for PMI in FIGO stage IB2 cervical cancer [35]. However, approximately 5% to 10% of all FIGO stage IB1 cervical cancer patients, particularly those with tumors equal to or N2 cm in diameter, showed microscopic PMI [4,[7][8][9]. ...
