High false negative rate of frozen section examination of sentinel lymph nodes in patients with cervical cancer

Abdominal radical trachelectomy guided by sentinel lymph node biopsy for stage IB1 cervical cancer with tumors >2 cm

Accuracy of prediction of pelvic lymph node status using sentinel lymph node biopsy (SLNB), and outcomes of SLNB-guided abdominal radical trachelectomy (ART) were assessed. Patients with stage IB1 (Figure 2009) cervical cancer and with tumors >2 cm were enrolled. Prior to fertility-sparing surgery 99mTc-labeled phytate was administered. SLNs were intraoperatively identified, excised, and assessed using fast-frozen sections. Systematic bilateral pelvic lymphadenectomy with or without para-aortic lymphadenectomy was subsequently undertaken. The SLN detection rate was 91.8% (45/49 patients); 8.2% (4/49) had radical hysterectomies because of metastatic primary SLNs. All SLNs received routine immunopathological examination to detect micrometastasis. Sensitivity, accuracy, and false negative rates were 100%, 100%, and 0%, respectively. ART was successfully completed in 45 patients (median follow-up, 61 [range, 4-149] months). Three of the 45 (6.7%) were lost to follow-up; two relapsed and one died of tumor progression. Overall 3-year survival and progression-free survival rates were 97.6% and 95.2%, respectively. Of the 19 patients who attempted to conceive after surgery, five achieved pregnancy, and one had a live birth in the third trimester. We concluded that SLNB using 99mTc-labeled phytate can accurately assess pelvic node status. SLNB-guided ART is safe and feasible in patients selected for fertility-sparing procedures.

GINS2 is a novel prognostic biomarker and promotes tumor progression in early-stage cervical cancer

GINS complex subunit 2 (GINS2), a member of the GINS complex, is involved in DNA replication. GINS2 is upregulated in a variety of aggressive tumors. However, its role in cervical cancer carcinogenesis remains to be elucidated. We investigated the clinical significance of GINS2 in patients with early-stage cervical cancer and its biological functions in cervical cancer progression. GINS2 expression was analyzed in cervical cancer cell lines and in 8 matched cervical cancer samples at the mRNA and protein levels using real-time PCR and western blotting, respectively. GINS2 protein expression in 155 paraffin-embedded cervical cancer specimens was validated using immunohistochemistry. Statistical analysis was used to evaluate its clinicopathological significance. Short hairpin RNA interference, anchorage-independent growth ability, colony formation assay, wound healing ability, Transwell assays and western blotting were used to determine the effects of GINS2 on the aggressive phenotype of cervical cancer cells. There was obvious upregulation of GINS2 in the cervical cancer cell lines and tumor specimens compared to that in the normal cervical tissues. Significant correlations were identified between GINS2 expression and squamous cell carcinoma antigen (SCC-Ag; P<0.001), deep stromal invasion (P=0.021), vital status (P<0.001), recurrence (P<0.001) and pelvic lymph node metastasis (PLNM; P<0.001). Moreover, patients with higher GINS2 expression had shorter overall survival (OS) compared to patients with low GINS2 expression. Multivariate analysis revealed that GINS2 may serve as an independent risk factor of poor prognosis in early-stage cervical cancer. In addition, GINS2 downregulation markedly suppressed cell proliferation and tumorigenic ability, as well as cell migration and invasion. Our findings suggest that GINS2 is a novel indicator of PLNM and a valuable prognostic biomarker in early-stage cervical cancer, and subsequently is a valuable molecular target for cervical cancer diagnosis and treatment.

Significance of heparanase in metastatic lymph nodes of cervical squamous cell cancer

The aim of this study was to explore the expression of heparanase (HPA) in metastatic lymph nodes (LNs) of cervical cancer and to evaluate HPA as a marker of micro-metastasis of LNs. Immunohistochemistry was performed to detect the expression of HPA in 53 cases with metastasis of LNs (group A) and 49 cases without (group B). Scoring was determined based on the intensity of immunostaining and the size of the staining area. Three points or higher score was considered as positive. Among all cases, the positive rate of HPA was 76.5% in primary lesions and 84.9% in both primary lesions and metastatic LNs in group A. In group B, the rates were 67.3% in primary lesions and 8.2% in metastatic LNs. The expression of HPA in group A was significantly higher than that in group B (P<0.05). Compared with stage IA-IB and well-differentiated and non-metastatic LNs, the LNs of stage IIA and moderately/poorly differentiated and metastatic LNs expressed higher HPA (P<0.05). The overall 5-year survival rate was 73.3% and the median overall survival time (MOS) was 49.0 months. The MOS of the two groups was 36.0 and 58.5 months, respectively (P=0.023); the MOS of patients with positive HPA expression was distinctly lower than that of negative patients (P=0.040). Clinical staging, degree of differentiation, lymph node metastasis and expression of HPA notably affected patient prognosis; lymph node metastasis and expression of HPA were independent risk factors affecting patient prognosis (P<0.05). Our study demonstrated that high-level expression of HPA in cervical cancer was involved in LN metastasis, further impacting on patients' long-term survival. The clinical value of HPA requires further in-depth study.

Fertility-sparing surgery for uterine cervical cancer

The standard treatment for early cervical cancer of the uterus (CC) is radical hysterectomy with resection of the parametrium and pelvic lymphadenectomy. At least 40% of patients develop early-stage CC during child-bearing age, therefore preserving the uterus to maintain fertility has been an important consideration. Several surgical procedures including conization and vaginal or abdominal radical trachelectomy have been reported. These procedures are safe for removing lymph node negative CC tumors with <2 cm diameter. Recently, less radical surgical procedures that maintain fertility, such as conization, simple trachelectomy, minimally invasive surgery and neoadjuvant chemotherapy, have been indicated for tumors greater than 2 cm in diameter. In this review, we discuss the currently accepted surgical approaches for treating CC while maintaining fertility.

Can pelvic lymphadenectomy be omitted in patients with stage IA2, IB1, and IIA1 squamous cell cervical cancer?

Purpose

This study aimed to identify the surgical-pathologic risk factors of lymph node metastasis (LNM) in patients with early stage squamous cell cervical cancer and to evaluate the potential efficacy of omitting pelvic lymphadenectomy.

Methods

A total of 276 patients with stage IA2, IB1, and IIA1 squamous cell cervical cancer receiving primary radical hysterectomy with pelvic lymphadenectomy were included in this study.

Results

The incidences of LNM in patients with stage IA2, IB1, and IIA1 squamous cell cervical cancer were 0 % (0/8), 17.4 % (36/207), and 29.5 % (18/61), respectively. The most common location of LNM was the obturator lymph node. Human papilloma virus 16 subtype was the most common infection in early stage squamous cell cervical cancer. Univariate analysis revealed that squamous cell carcinoma antigen (SCCAg) greater than 1.5 μg/L (p < 0.001), tumor size greater than 2 cm (p < 0.001), tumor size greater than 3 cm (p < 0.001), depth of stromal invasion (p < 0.001) and lymphovascular invasion (p < 0.001) were associated with LNM. Logistic regression analysis revealed that depth of stromal invasion {model 1 [p = 0.006; odds ratio (OR) 2.161; 95 % confidence interval (CI) 1.251–3.734], model 2 [p = 0.002; OR 2.344; 95 % CI 1.337–3.989]}, lymphovascular invasion [model 1 (p = 0.004; OR 2.967; 95 % CI 1.411–6.237), model 2 (p = 0.004; OR 2.978; 95 % CI 1.421–6.243)], and SCCAg greater than 1.5 μg/L [model 1 (p = 0.023; OR 2.431; 95 % CI 1.129–5.235), model 2 (p = 0.024; OR 2.418; 95 % CI 1.125–5.194)] were independently associated with LNM.

Conclusions

Pelvic lymphadenectomy may be omitted in patients with SCCAg lower than 1.5 μg/L, superficial stromal invasion and without lymphovascular invasion in stage IA2, IB1, IIA1 squamous cell cervical cancer.

Routine Intraoperative Frozen Section Examination to Minimize Bimodal Treatment in Early-Stage Cervical Cancer

OBJECTIVE

In early-stage cervical cancer, single modality therapy is the main objective, to minimize patient morbidity while offering equivalent cure rates. Intraoperative frozen section examination (FSE) of lymph nodes (LNs) can facilitate this aim, ensuring that radical surgery is avoided in patients requiring adjuvant therapy for metastatic LN involvement. We aimed to evaluate the accuracy of routine intraoperative FSE of pelvic LNs during the surgical staging of early-stage cervical cancers and identify a group at low risk for nodal metastases.

METHODS

A retrospective cohort study of 94 women aged 23 to 80 years who underwent primary surgery and planned intraoperative FSE of the pelvic LNs at the gynecological cancer center in Oxford was performed. The diagnostic value of FSE and the prediction of metastatic nodal disease were assessed by use of preoperative and intraoperative variables.

RESULTS

A total of 1825 LNs were submitted for FSE. Of 94 women (13.8%), 13 had positive LNs at FSE. Two false-negative cases were reported with micrometastases but no false-positive cases. Frozen section examination as a diagnostic test reached a sensitivity of 86.7% and a specificity of 100%. A regression model including grade I to II and tumor size of less than 20 mm identified a low-risk group for LN involvement.

CONCLUSIONS

In light of diverse practice patterns, FSE should be routinely offered to women with early-stage cervical cancer in a 1-step protocol. We equally devised a model to predict those patients at least risk of nodal disease, who may be spared of FSE.

Role of short-term follow-up magnetic resonance imaging in the detection of post-operative residual breast cancer

The aim of the present study was to evaluate the role of short-term follow-up magnetic resonance imaging (MRI) in the detection of postoperative residual breast cancer. A retrospective analysis was performed on 10 patients who were diagnosed with non-malignant breast lesions by preoperative clinical, ultrasound and mammography examinations and intraoperative frozen-section pathology. These patients were finally confirmed as having malignant breast lesions by paraffin-embedded tissue histology and corresponding received second surgeries. Routine MRI, enhancement MRI and echo-planar imaging-diffusion-weighted imaging were performed on the 10 patients within 1 month after the first surgery. All the cases showed a local distortion of mammary architecture revealed by routine MRI and enhancement MRI images. The enhancement characteristics of the 10 cases were as follows: 3 cases featured stippled enhancement, 2 had small nodular enhancement, 1 showed dendritic enhancement, 1 had a ring-shaped enhancement of the cystic wall and 3 had no abnormal enhancement. The lesions of 7 cases had a type-I enhancement curve (progressive enhancement pattern) and 3 cases had a type-II curve (plateau pattern). The lesions of 4 cases had a decreased apparent diffusion coefficient. In total, 4 cases of tumor residue were diagnosed by MRI and the second pathological examination, while in 1 case the tumor residue was misdiagnosed by MRI but confirmed by the second pathological examination. In conclusion, the present study suggested that short-term follow-up MRI may be of value in the diagnosis of postoperative residual breast tumors and may be helpful for surgeons to develop an accurate surgical plan.

Detection of human papillomavirus DNA in peri-tumor tissues and pelvic lymph nodes as potential molecular marker of micrometastasis in cervical cancer

BACKGROUND

The association between high risk human papillomaviruses (HPV) and cervical cancer has been firmly established. HPV genome is present in nearly all cases of cervical cancer and detection of viral DNA could therefore be used as a surrogate marker of micrometastasis in peri-tumor tissues and lymph nodes.

METHODS

We analyzed primary cervical carcinomas, peri-tumor biopsies and pelvic lymph nodes in 20 women with invasive cancer (FIGO stage I-II) who underwent radical pelvic surgery and lymphadenectomy. HPV DNA was searched by broad spectrum PCR in 142 DNA samples extracted from paraffin embedded tissues. Viral genotypes were identified by direct sequencing analysis.

RESULTS

HPV DNA sequences were identified in all available primary cervical tumors (n = 15). The most common genotype was HPV16 (60 %), followed by HPV18 (20 %), HPV35 (7 %), HPV45 (7 %) and HPV66 (7 %). Seven out of 20 (35 %) women had metastatic spread in peri-tumor tissues and/or lymph nodes, as determined by histology. HPV DNA was detected in all histological positive samples as well as in 16 and 25 % of histological negative peri-tumor tissues and lymph nodes, respectively. Three out of 20 (15 %) women without histological evidence of metastatic spread had HPV-positive lymph nodes. HPV genotype was found always concordant between primary tumor and metastatic lesions. The remaining 10 women (50 %) were histology and HPV-negative in all peri-tumor biopsies and lymph nodes analyzed.

CONCLUSIONS

Evaluation of HPV DNA in peri-tumor tissues as well as pelvic lymph nodes could be a sensitive marker to identify micrometastasis or isolated tumor cells and to monitor the risk of disease recurrence in women with cervical cancer.

Pathological Risk Factors and Outcomes in Women With Stage IB2 Cervical Cancer Treated With Primary Radical Surgery Versus Chemoradiotherapy

OBJECTIVE

Both radical hysterectomy with pelvic lymphadenectomy and primary chemoradiotherapy have been shown to be effective in the management of women with stage IB2 cervical cancer. This study aims to review the outcomes related to each treatment modality and the effects of pathological risk factors on overall survival (OS) and disease-free survival.

METHODS

We performed a retrospective study of 92 women with stage IB2 cervical cancer who were treated at the Northern Gynecological Oncology Center (Gateshead, United Kingdom) across a 22-year period between January 1991 and July 2013. Women were divided into those undergoing primary surgery and those undergoing primary radiotherapy/chemoradiotherapy. The main outcome measures were OS and progression-free survival (PFS). Pathological risk factors of survival were assessed using multivariate analysis.

RESULTS

Sixty-seven women (72.8%) underwent primary surgery, and 25 women (27.2%) had primary radiotherapy/chemoradiotherapy. Thirty-one of 67 women (46.3%) required adjuvant radiotherapy/chemoradiotherapy after surgery because of positive lymph nodes in 77.4% of cases. The median follow-up was 57.5 months (range, 3-137 months). Thirty-two women (34.8%) had disease recurrence: 6 women (16.7%) in the group undergoing surgery alone, 15 women (48.4%) in the group requiring adjuvant treatment after surgery, and 11 women (44%) in the group having primary radiotherapy/chemoradiotherapy. Overall survival and PFS were higher for women undergoing surgery alone (91.7% and 83.3%) compared with women requiring adjuvant treatment after surgery (54.8% and 51.4%) and those having primary radiotherapy/chemoradiotherapy (60% and 56%) (P = 0.0004 and P = 0.005, respectively). Lymph node metastasis was a significant pathological risk factor of OS and PFS in multivariate analysis.

CONCLUSIONS

Most women require adjuvant treatment after surgery because of positive lymph nodes. Because survival outcomes for women requiring dual treatment are similar to those for women undergoing primary chemoradiotherapy, nodal assessment before definitive treatment should guide the management of these women and identify a low-risk group that can be treated with surgery alone.

Sentinel node biopsy for lymph nodal staging of uterine cervix cancer: a systematic review and meta-analysis of the pertinent literature

BACKGROUND

We reviewed the available literature on the accuracy of sentinel node mapping in the lymph nodal staging of uterine cervical cancers.

METHODS

MEDLINE and Scopus were searched by using "sentinel AND (cervix OR cervical)" as key words. Studies evaluating the accuracy of sentinel node mapping in the lymph nodal staging of uterine cervical cancers were included if enough data could be extracted for calculation of detection rate and/or sensitivity.

RESULTS

Sixty-seven studies were included in the systematic review. Pooled detection rate was 89.2% [95% CI: 86.3-91.6]. Pooled sensitivity was 90% [95% CI: 88-92]. Sentinel node detection rate and sensitivity were related to mapping method (blue dye, radiotracer, or both) and history of pre-operative neoadjuvant chemotherapy. Sensitivity was higher in patients with bilaterally detected pelvic sentinel nodes compared to those with unilateral sentinel nodes. Lymphatic mapping could identify sentinel nodes outside the routine lymphadenectomy limits.

CONCLUSION

Sentinel node mapping is an accurate method for the assessment of lymph nodal involvement in uterine cervical cancers. Selection of a population with small tumor size and lower stage will ensure the lowest false negative rate. Lymphatic mapping can also detect sentinel nodes outside of routine lymphadenectomy areas providing additional histological information which can improve the staging. Further studies are needed to explore the impact of sentinel node mapping in fertility sparing surgery and in patients with history of neoadjuvant chemotherapy.

Usefulness, methods and rationale of lymph nodes HPV-DNA investigation in estimating risk of early stage cervical cancer recurrence: a systematic literature review

Metastatic involvement of pelvic lymph-nodes (LNs), generally found in 0-29.3 % of early stages, is the most important prognostic factor in cervical cancer (CC). However, even in non-metastatic LNs, recurrence rate reaches 10-15 %. The role of HPV-DNA presence in pelvic LNs has been a point of debate in the last two decades. The aim of this systematic review is to collect all available data about LNs HPV-DNA detection in patients affected by early-stage CC in order to elucidate its clinical and surgical usefulness to choose the best surgical treatment, the necessity of adjuvant therapy and to estimate the overall oncological prognosis. The available data in this field results very patchy and often conflicting in the results. The high correlation between HPV-DNA genome detected in primary lesion and the one detected in LNs, as well as the high correlation between LNs metastatic involvement and HPV-DNA presence, lead to hypothesize that LNs HPV presence represents a potential risk-factor for recurrence and poor oncological prognosis. The large disparities in recurrence-rate of cases with LNs positive for HPV-DNA test and negative for metastases could be explained by the relative "inappropriateness" of PCR test to discriminate the presence of HPV-genome alone (condition necessary but not sufficient) or in association with squamous cells (condition necessary and sufficient). The use of ISH test for HPV-DNA detection in LNs, particularly if associated to CK19-assay, improve the accuracy of micro-metastasis detection, and the identification of patients with negative histology but potentially at high-risk of recurrence and poor oncological prognosis.

[Sentinel lymph node in low stage cervical cancers. Current data. Quality assurance. Prospects]

Sentinel node biopsy appears as a promising technique for the assessment of nodal disease in early cervical cancers. Selection of a population with a low risk of nodal metastasis, a minimal training, and simple rules allow a low false negative rate. Sentinel node biopsy provides supplementary information, such as anatomical information (nodes outside of routine lymphadenectomy areas) and histological information (isolated tumors cells and micrometastases).

TBLR1 is a novel prognostic marker and promotes epithelial-mesenchymal transition in cervical cancer

BACKGROUND

Invasion and metastasis remain a critical issue in cervical cancer. However, the underlying mechanism of it in cervical cancer remains unclear. The newly discovered protein, TBLR1, plays a crucial role in regulating various key cellular functions.

METHODS

In this study, western blot, real-time RT-PCR, immunohistochemical staining, 3D morphogenesis Matrigel culture, wound healing and Boyden chamber invasion assays, xenografted tumour model, luciferase assays, and chromatin immunoprecipitation assays were used.

RESULTS

The expression of TBLR1 in cervical cancer cell lines and tissues was significantly upregulated at both the RNA and protein levels compared with that in normal cervical cells. Statistical analysis suggested that TBLR1 as an independent prognostic factor was significantly correlated with the clinical stage, survival time and recurrence. Moreover, overexpression of TBLR1 in Hela and Siha cell lines promoted invasion in vitro and in vivo with the increases of the mesenchymal factors vimentin and fibronectin and decreases of the epithelial marker α-catenin. In contrast, RNAi-mediated knockdown of TBLR1 inhibited epithelial-mesenchymal transition in vitro and in vivo. Further study indicated that this might be mediated via the NF-κB and Wnt/β-Catenin signalling pathway, and involve regulation of Snail and Twist.

CONCLUSIONS

The TBLR1 protein may be a prognostic marker in cervical cancer and play an important role in the invasion and metastasis of human cervical cancer.

Could HPV-DNA test solve the dilemma about sentinel node frozen section accuracy in early stage cervical cancer? Hypothesis and rationale

In order to reduce the surgical invasiveness in early-stage cervical-cancer treatment, the sentinel lymph-node (SLN) technique could be considered as a possible intraoperative-guidance to lymphadenectomy decision making. Unfortunately its accuracy ranges between 33.3% and 100% in different studies. Recent manuscripts suggest that HPV-DNA presence in pelvic-lymph-nodes may represent a molecular marker of micrometastases. According to this hypothesis, the rationale in proposing the HPV-DNA-test when negative frozen-section occurs is due to the expected improvement of its diagnostic-accuracy. HPV-DNA test may represent a marker able to discriminate at frozen section the false-negative from the truth-negative tests filling the gap between optimal and real frozen-section accuracy.

Sentinel lymph node evaluation in women with cervical cancer

Lymph node status is the most important prognosticator of survival in women with early stage cervical cancer. Thus many patients with cervical cancer will undergo pelvic lymphadenectomy as part of the treatment. This procedure is associated with substantial morbidity. Use of the sentinel lymph node technique in women with cervical cancer has the potential to decrease this morbidity. Multiple studies have suggested that sentinel lymph node mapping in these patients is feasible, with excellent detection rates and sensitivity. This review examines the current body of literature about sentinel lymph node biopsy in women with cervical cancer.