Adenosquamous carcinoma of the cervix: prognosis in early stage disease treated by radical hysterectomy

Impact of histological subtype on the response to chemoradiation in locally advanced cervical cancer and the possible role of surgery

Cervical cancer is one of the most common cancers in women in developing countries, second only to breast cancer, with more than 450.000 new cases every year. Romania has the highest incidence of cervical cancer in Europe; more than four times the incidence found in Western Europe. Radiotherapy with or without chemotherapy is considered in most countries the gold standard for locally advanced cervical cancer. In Romania, if downstaging occurs after radiotherapy, adjuvant surgery is routinely performed. Thus, in the present study, we investigated the rate of residual cancer in patients with locally advanced cervical cancer who underwent surgery after concurrent chemoradiotherapy and to determine the impact of tumor histological subtype on the chemoradiotherapy response. Of a total of 461 patients with locally advanced cervical cancer that underwent chemoradiotherapy and adjuvant surgery, 254 had a partial response defined as the presence of residual tumor at pathology examination. Depending on the histological subtype of the cervical cancer, partial response was obtained in 50.6% of squamous cell carcinoma cases and in 77.6% of adenocarcinoma or adenosquamous carcinoma cases. The present study demonstrated that cervical cancer patients with adenocarcinomas and adenosquamous carcinomas had a significantly poorer treatment response to chemoradiotherapy than those with squamous cell carcinomas. We consider that in such cases where residual tumor is present, adjuvant surgery is mandatory for improving the survival rates.

Adenocarcinoma of the uterine cervix: Pathologic features, treatment options, clinical outcome and prognostic variables

Adenocarcinoma accounts for 10-25% of all cervical cancers, and its relative and absolute rate has raised over the past decades. Most, but not all the authors, reported that adenocarcinoma has a greater propensity to lymph node, ovarian and distant metastases and a worse prognosis compared with squamous cell carcinoma. However, whether histologic type is an independent prognostic factor is still a debated issue. Moreover, adenocarcinoma is a very heterogenous disease, including different histological subtypes. Whereas radical hysterectomy and definitive radiotherapy achieve the same clinical outcome in early stage squamous cell carcinoma, surgery seems to obtain better survival compared with definitive radiotherapy in early stage adenocarcinoma. Chemoradiation is the standard treatment for locally advanced cervical cancer regardless of histologic type, although several retrospective studies showed that patients with adenocarcinoma were more likely to die than those with squamous cell carcinoma both before and after concurrent chemoradiation era. The prognostic relevance of biological variables, such as cyclin-dependent kinase inhibitors, p53, cyclooxygenase-2 [COX-2], cell surface tyrosine-kinases and programmed death-ligand [PD-L1], is still under investigation. Palliative chemotherapy is the only treatment option for persistent or recurrent cervical adenocarcinoma not amenable with surgery and radiotherapy. The use of immune checkpoint inhibitors as well as a therapeutic strategy targeting cell surface tyrosine kinases should be adequately explored in this clinical setting.

Comparison of clinical outcomes of squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinoma of the uterine cervix after definitive radiotherapy: a population-based analysis

PURPOSE

To evaluate the clinical outcomes in patients with International Federation of Gynecology and Obstetrics (FIGO) stage I to IVA squamous cell carcinoma (SCC), adenocarcinoma (AC), and adenosquamous carcinoma (ASC) of the uterine cervix after definitive radiotherapy.

METHODS

Patients with a primary diagnosis of FIGO stage I-IVA SCC, AC, and ASC of the uterine cervix who had undergone definitive beam radiation with implants or isotopes between 1988 and 2013 were identified using the Surveillance, Epidemiology, and End Results database. Univariate and multivariate Cox regression analyses were performed to analyze the effect of histologic subtype on cause-specific survival (CSS) and overall survival (OS).

RESULTS

A total of 8751 were identified, and 86.0, 10.6, and 3.4 % of patients were SCC, AC, and ASC, respectively. AC patients were more often well differentiated, while more patients were poorly/undifferentiated in ASC subtype. A higher percentage of AC and ASC patients were stage I, and fewer had stage III compared to SCC. Univariate and multivariate Cox analyses showed that histologic subtype was an independent prognostic factor for CSS and OS. SCC subtype had a better CSS and OS compared to AC and ASC subtype. The survival between AC and ASC had no significant difference. The impact of the histologic subtype on CSS and OS was not affected by FIGO stage and the year of diagnosis.

CONCLUSION

AC and ASC subtypes are independent prognostic factors for cervical cancer patients treated with definitive radiotherapy. AC and ASC subtypes are associated with poor survival outcomes than those with SCC.

Comparison of adenocarcinoma and adenosquamous carcinoma in patients with early-stage cervical cancer after radical surgery

OBJECTIVE

To compare outcomes after radical hysterectomy in patients with stage IB1 adenocarcinoma (AdCa) and adenosquamous carcinoma (AdSCCa) of the uterine cervix.

METHODS

We performed a retrospective analysis of 265 patients with AdCa and 72 patients with AdSCCa. Demographic, clinicopathologic, surgical, and follow-up data were compared.

RESULTS

There were no differences in demographic and clinicopathologic characteristics between the two histologic types (AdCa vs. AdSCCa). Only mean size of tumor and lymphovascular space invasion was larger and more frequent in AdSCCa (2.7 cm vs 2.3 cm, P=0.019 & 29.2% vs 14.7%, P=0.008). After a median follow-up time of 68 months, 39 (14.7%) and 13 (18.1%) AdCa and AdSCCa patients, respectively, had recurrent disease (P=0.467), and 33 (12.5%) and 11 (15.3%) patients, respectively, died of their disease (P=0.555). 5-year RFS rates were 89% and 85% (P=0.582), respectively, and 5-year OS rates were 93% and 89% (P=0.787). Histologic type had no clinical impact on RFS and OS in multivariate analysis adjusting for significant prognostic factors. There were no differences in pattern of recurrence and time to recurrence between the two histologic types. When patients were stratified into three risk groups according to the criteria of GOG protocols 92 and 109, histologic type had no clinical impact on RFS and OS in any of the risk groups.

CONCLUSION

There are no differences in clinicopathologic factors, patterns of recurrence, time to recurrence, RFS and OS between patients with AdCa and AdSCCa.

Comparison of outcomes between squamous cell carcinoma and adenocarcinoma in patients with surgically treated stage I-II cervical cancer

To improve our understanding of cervical adenocarcinoma (AD) and evaluate the clinical and pathological variables affecting its prognosis, we retrospectively reviewed the medical records of 455 patients with cervical cancer [International Federation of Gynecology and Obstetrics stage I/II; 91 cases with AD and 364 with squamous cell carcinoma (SCC)] who underwent surgery at our hospital between January, 1995 and August, 2012 and compared the characteristics and prognoses between AD and SCC cases, including age, clinical stage, histological type, lymph node metastasis, lymphovascular space invasion (LVSI), cervical stromal invasion, parametrial invasion, vaginal invasion, corpus invasion, ovarian metastasis and tumor diameter. We used Cox regression analysis to determine independent prognostic factors. AD was found to have a significantly poorer prognosis in all the patients (P=0.001), stage I patients (P=0.001) and stage IB patients (P<0.05). The prognosis did not differ in patients who did not require postoperative treatment; however, patients who received postoperative treatment exhibited a significantly poorer prognosis (P<0.05). Patients with AD who received postoperative irradiation alone had a significantly poorer prognosis (P<0.05). The multivariate analysis identified LVSI (P=0.008), stromal invasion (P=0.024) and ovarian metastasis (P=0.032) as independent predictors of shorter survival. AD was associated with a worse prognosis compared to SCC in patients with stage IB disease, particularly in those who required postoperative treatment. Such patients may benefit from individualized postoperative treatments that differ from those applied for SCC.

Prognosis of Adenosquamous Carcinoma Compared With Adenocarcinoma in Uterine Cervical Cancer: A Systematic Review and Meta-Analysis of Observational Studies

Objective

The aim of this study was to compare the survival outcomes of adenosquamous carcinoma (ASC) and adenocarcinoma (AC) of the cervix.

Methods

We searched PubMed and Embase for observational studies that compared the outcomes of 2 histologic subtypes. Hazards ratios (HRs) with 95% confidence intervals (CIs) were calculated with a fixed effects model.

Results

A total of 17 studies were included in the analyses. Patients with ASC were associated significantly with poorer overall survival (death HR, 1.27; 95% CI, 1.12–1.43; I2= 0%) and recurrence-free survival (recurrence HR, 1.43; 95% CI, 1.05–1.95; I2= 19.4%) than those with AC. For clinical stages I and II in particular, ASC predicted significantly poorer outcomes compared with AC (death HR, 1.41; 95% CI, 1.17–1.70; I2= 0%).

Conclusions

This meta-analysis suggests that ASC may have poorer outcomes compared with AC of the cervix.

Comparison of the Prognoses of FIGO Stage I to Stage II Adenosquamous Carcinoma and Adenocarcinoma of the Uterine Cervix Treated With Radical Hysterectomy

Objectives

To evaluate the significance of adenosquamous carcinoma (ASC) compared with adenocarcinoma (AC) in the survival of surgically treated early-stage cervical cancer.

Methods

We retrospectively reviewed the medical records of 163 patients with International Federation of Gynecology and Obstetrics stage IA2 to stage IIB cervical cancer who had been treated with radical hysterectomy with or without adjuvant radiotherapy between January 1998 and December 2008. The patients were classified according to the following: (1) histological subtype (ASC group or AC group) and (2) pathological risk factors (low-risk or intermediate/high-risk group). Survival was evaluated using the Kaplan-Meier method and compared using the log-rank test. Multivariate analysis of progression-free survival (PFS) was performed using the Cox proportional hazards regression model to investigate the prognostic significance of histological subtype.

Results

Clinicopathological characteristics were similar between the ASC and AC histology groups. Patients with the ASC histology displayed a PFS rate similar to that of the patients with the AC histology in both the low-risk and intermediate/high-risk groups. Neither the recurrence rate nor the pattern of recurrence differed between the ASC group and the AC group. Univariate analysis revealed that patients with pelvic lymph node metastasis and parametrial invasion achieved significantly shorter PFS than those without these risk factors.

Conclusions

Characteristics of the patients and the tumors as well as survival outcomes of ASC were comparable to adenocarcinoma of early-stage uterine cervix treated with radical hysterectomy. Our results in part support that the management of ASC could be the same as the one of AC of the uterine cervix.

Outcome analysis of cervical adenosquamous carcinoma compared with adenocarcinoma

OBJECTIVE

To compare survival between patients with cervical adenocarcinoma (AC) and adenosquamous carcinoma (ASC).

DESIGN

Retrospective study.

SETTING

National Taiwan University Hospital, Taipei, Taiwan.

POPULATION

All patients with cervical AC or ASC who received definitive treatment from January 1995 to December 2009.

METHODS

Medical and histopathological record review.

MAIN OUTCOME MEASURES

Overall and recurrence-free survival.

RESULTS

A total of 170 women received a histological diagnosis of AC and 42 of ASC. The median follow-up was 56.7 months. There were no significant differences in age, International Federation of Gynecology and Obstetrics (FIGO) stage, gravidity or treatment modality between women with AC and ASC. Patients with ASC had a higher percentage of poorly differentiated tumors than those with AC (33.3 vs. 15.3%, respectively; p= 0.014). Five year overall and recurrence-free survival was 66.8 and 58.9%, respectively, for women with AC and 69.5 and 61.9%, respectively, for those with ASC (p= 0.795 and p= 0.892, respectively). Survival outcomes in patients with early or advanced stage disease did not differ between the histological groups. No differences in failure patterns were found between the two groups. The FIGO stage and treatment modality were factors which affected overall and recurrence-free survival.

CONCLUSIONS

We did not find evidence to suggest that ASC subtypes indicate worse outcome. Cervical ASC could be categorized as one subtype of AC. The FIGO stage and treatment modalities have greater influence on outcomes than histological subtype.

HPV-related squamous cell carcinoma variants in the head and neck

The great majority of HPV-related carcinoma of the oropharynx is nonkeratinizing squamous cell carcinoma. More recently, an increasing number of squamous cell carcinoma variants that are HPV positive are being reported in the oropharynx, as well as in other head and neck sites. As a result, several clinical and pathologic questions have emerged. Importantly, questions raised include whether the virus is biologically active and involved in the pathogenesis of these tumors, and whether there are clinical implications with regard to patient outcome and treatment modality changes that may be needed in HPV-related variants. Examples of HPV-related squamous cell carcinoma variants that will be addressed here include: basaloid squamous cell carcinoma, undifferentiated carcinoma, adenosquamous carcinoma, papillary squamous carcinoma, and small cell carcinoma. Some investigations have suggested a favorable prognosis in some variants, analogous to that of the conventional nonkeratinizing (basaloid) carcinoma, while others showed poorer outcome. So far, the number of studies on this subject is limited and the number of cases evaluated in each investigation is few. Because of this, it is prudent at this stage not to alter management protocols as a result of identification of HPV in these variants and to await additional studies.

A comparison of pure adenocarcinoma and squamous cell carcinoma of the cervix after radical hysterectomy in stage IB-IIA

OBJECTIVE

This study was designed to investigate the survival difference between pure adenocarcinoma (AC) and squamous cell carcinoma (SCC) in early cervical cancer (FIGO stage IB-IIA) after radical hysterectomy with or without adjuvant therapy performed at a single institution.

METHODS

Patients with AC or SCC between November 1994 and September 2007 at the Samsung Medical Center, Sungkyunkwan University School of Medicine in Seoul, Korea were evaluated.

RESULTS

Among the 775 patients, 636 patients had SCC, and 139 patients had pure AC. In basal characteristics, preoperative FIGO stage, adjuvant therapy after surgery, as well as chemotherapeutic regimens, were not different between the two groups. However, the median age was about 5 years younger in pure AC patients than in SCC patients (44 years vs. 49 years, P=.001). In the comparison of pathological findings after surgery between the two groups, there were no differences between the two groups, except for LVSI status. The recurrence rate was higher in the pure AC group than in the SCC group (SCC; 36/636; 5.7%, AC; 20/139; 14.4%, P=<0.001, respectively). The pure AC group had a higher recurrence rate in hematogenous/distant areas than the SCC group (SCC: 8/36; 22.2%, AC; 9/20; 45.0%, P=.076, respectively). In multivariable analysis, positive for pelvic LN and the pure AC cell type were independent factors in both DFS and OS.

CONCLUSION

We observed that pure AC of the cervix might entail a worse survival outcome than SCC in patients with early cervical cancer (IB-IIA).

Adenocarcinoma: a unique cervical cancer

Adenocarcinoma of the cervix constitutes only approximately 20% of all cervical carcinomas; therefore, specific Level 1 evidence to guide patient management is lacking. Most trials have included this histologic subtype but in insufficient numbers to do more than generate hypotheses from subset analyses. As a consequence, our understanding of the natural history and optimal management of adenocarcinoma of the cervix is limited. The optimal management of adenocarcinoma of the cervix continues to be a subject of debate among practitioners as to whether or not it should be different from squamous cell carcinoma and what would constitute this management. The purpose of this review was to give an overview of the current knowledge on adenocarcinoma of the cervix and its differences from squamous cell carcinoma with regard to risk factors, prognosis, survival rates, patterns of recurrence, and response to treatment. This article will focus on possible specific therapeutic directions to explore in the management of locally advanced adenocarcinomas.

Adenosquamous carcinoma versus adenocarcinoma in early-stage cervical cancer patients undergoing radical hysterectomy: An outcomes analysis

OBJECTIVE

To evaluate whether histology (adenocarcinoma versus adenosquamous carcinoma) is an independent prognostic indicator in patients with stage IB1 cervical cancer after radical hysterectomy.

METHODS

All patients with adenocarcinoma or adenosquamous carcinoma who underwent radical hysterectomy between October 1990 and December 2006 at The University of Texas M. D. Anderson Cancer Center were evaluated. Clinico-pathological data collected included age, disease stage, tumor grade, lymph node status, parametrial involvement, depth of invasion, evidence of lymph-vascular space invasion (LVSI), and adjuvant therapy. Patients were categorized as having "low-risk" or "high-risk" disease depending on the final pathologic findings.

RESULTS

We identified 126 patients with stage IB1 adenosquamous (n=29) or adenocarcinoma (n=97) cervical cancer. The median follow-up was 79 months (range 1.7-184.6). The median age was 40.3 years for patients with adenocarcinoma and 35.2 years for patients with adenosquamous carcinoma (P=0.88). Grade III histology and LVSI were more common in patients with adenosquamous tumors than in patients with adenocarcinoma (85% versus 16%; P<0.01 and 56.5% versus 32.8; P=0.04). Histology was not associated with lymph node or parametrial involvement. There was no difference in recurrence rates between the two histologic groups, but the time to recurrence was shorter for patients with adenosquamous carcinoma (7.9 months versus 15 months; P=0.01). There was no difference between cell types with regards to recurrence and recurrence-free survival rates in the low- and high-risk groups.

CONCLUSION

We found no evidence that histologic subtype affects outcome; however, the median time to recurrence was shorter in patients with adenosquamous carcinoma. Our study suggests that in patients with stage IB1 adenosquamous carcinoma or adenocarcinoma, the presence of high-risk features is more important than histologic subtype.

Pathological characteristics of cervical adenocarcinoma in a multi-center U.S.-based study

OBJECTIVE

Difficulties in detecting cervical adenocarcinoma early are well known. We report a detailed pathology review of cervical adenocarcinoma subtypes, comparing growth patterns and appearance of non-neoplastic epithelium to inform possible clues for disease progression and early detection.

METHODS

This analysis includes 154 women aged 18-69 years and diagnosed with incident in situ or invasive adenocarcinoma (AC), adenosquamous (AS), or other rare cervical glandular tumors from 1992-1996 in six U.S. medical centers. A pathology review panel evaluated histological features from original diagnostic slides.

RESULTS

Higher tumor grade (P < 0.001) and vascular invasion (P = 0.002) were more common in AS compared to AC. Adenocarcinoma in situ (AIS) was also more common among AC than AS (P = 0.002). Among AC with cervical intraepithelial carcinoma (CIN), AIS and cribriform patterns were more common than AC without CIN (P = 0.01). Further, non-endometrioid AC had higher tumor grade (P = 0.01) and stromal responses (P = 0.02) than endometrioid AC. Finally, although microglandular hyperplasia is historically thought to be related to oral contraceptive (OC) use, our data do not support this notion.

CONCLUSION(S)

AS appears to be either diagnosed later or histologically more aggressive than AC, and among AC subtypes, there are distinct histologic characteristics. Further research is needed to identify precursor lesions for early detection of AC and particularly for AS where AIS may not be a common precursor.

What is the difference between squamous cell carcinoma and adenocarcinoma of the cervix? A matched case–control study

The objective of this study was to investigate the efficacy of treatment strategies in patients with adenocarcinoma (AC) of the cervix and compare it with those with squamous cell carcinoma (SCC) of the cervix. Women with FIGO (1994) stage IB1 AC, especially pathologic tumor size of 2-4 cm, treated with class III hysterectomy, were compared with those with SCC treated with comparable strategy in a case-controlled study. Eighty patients (20 cases, 60 controls) were analyzed. Lymphvascular space invasion (P = 0.01) and lymph node metastasis (P = 0.07) were more frequent in patients with SCC than in those with AC. However, there was no significant difference in depth of stromal invasion (P = 0.51) and invasion of the parametrium (P = 0.44) between two groups. And there was also no statistically significant difference in disease-free survival (P = 0.86) and overall survival (P = 0.89) between two groups. Primary radical surgery followed by adjuvant therapy, same as for SCC, would be acceptable for AC with pathologic tumor size of 2-4 cm. Although it was difficult to determine whether AC recurred more systemically, more effective treatment strategies than those currently available for AC should be considered to reduce the systemic recurrence.

A comparison of prognoses of FIGO stage IB adenocarcinoma and squamous cell carcinoma

OBJECTIVES

The objective of this study was to compare clinical and pathologic variables and prognosis of FIGO stage IB adenocarcinoma and squamous cell carcinoma of uterine cervix.

METHODS

A retrospective review was performed of 521 patients with stage IB squamous cell carcinoma and adenocarcinoma of cervix who treated primarily by type 3 hysterectomy and pelvic and/or para-aortic lymphadenectomy at Hacettepe University Hospitals between 1980 and 1997.

RESULTS

Age, tumor size, grade, depth of invasion, lymph node metastasis, parametrial, vaginal, and lymphvascular space involvement (LVSI) were not different between two cell types except number of the lymph nodes involved. Metastasis to three or more lymph nodes was significantly higher in adenocarcinoma. Overall and disease-free survival were 87.7%, 84.0% versus 86.4%, 83.1% for squamous cell carcinoma and adenocarcinoma, respectively (P > 0.05). The rate and site of recurrence were not different between two cell types. Multivariate analysis of disease-free and overall survival revealed independent prognostic factors as tumor size, LVSI, number of involved lymph node, and vaginal involvement.

CONCLUSION

Prognosis of FIGO stage IB cervical cancer patients who were treated by primarily radical surgery was found to be same for those with adenocarcinoma and squamous cell carcinoma.

Les adénocarcinomes du col utérin ont-ils un plus mauvais pronostic que les carcinomes épidermoïdes ?

OBJECTIVE

The objective of this study was to examine the influence of histology on the outcome of patients with cervix carcinoma, treated with radiotherapy and radical surgery.

PATIENTS AND METHODS

Clinical, histological, therapeutical and outcome data of 360 patients with stage IB-II cervix carcinoma patients (45 adenocarcinomas and 315 squamous cell carcinoma) managed between 1985 and 1998 were collected from the database of the Institut Gustave-Roussy.

RESULTS

The incidence of adenocarcinomas slightly increased during the study period (P =0.07). Histological grade was higher for squamous cell carcinoma than for adenocarcinoma (P =0.08). Adenocarcinomas were smaller than squamous cell carcinoma (P =0.06). With only 38% of sterilized hysterectomy specimen vs 52% for squamous cell carcinomas (P =0.07), adenocarcinoma seemed to be less radiosensitive. With a median follow-up of 67 months, histological type did not influence survival.

DISCUSSION AND CONCLUSIONS

Our study demonstrates that radiosensitivity is different between adenocarcinoma and squamous cell carcinoma of the cervix and that surgery may compensate the low radiosensitivity of adenocarcinoma.

Adenosquamous histology predicts a poor outcome for patients with advanced-stage, but not early-stage, cervical carcinoma

BACKGROUND

The objective of this study was to compare survival between patients with adenocarcinoma and patients with adenosquamous carcinoma of the cervix.

METHODS

Patients who were diagnosed with invasive cervical carcinoma from 1988 to 1999 were identified from the Automated Central Tumor Registry for the United States Military Health Care System. Clinical data, including race, age at diagnosis, histology, tumor grade, disease stage, lymph node status, treatment modality, and survival, were collected. Survival analysis was performed with Kaplan-Meier survival curves and compared using the log-rank test.

RESULTS

A total of 273 women were identified, 185 women with a histologic diagnosis of adenocarcinoma (AC) and 88 women with a diagnosis of adenosquamous carcinoma (ASC). Among the women with ASC, only 5% had Grade 1 tumors, and 66% had Grade 3 tumors. By comparison, among the women with AC, 37% had Grade 1 tumors, and 26% had Grade 3 tumors (P < 0.001). There was no difference in the incidence of positive lymph nodes or in the number of patients who underwent radical hysterectomy as primary treatment between patients with ASC and patients with AC. More patients with ASC received radiation therapy (51% vs. 28%) or chemotherapy (29% vs. 12%) as treatment (P < 0.001). Patients who had tumors with ASC histology had a significantly decreased 5-year survival rate compared with patients who had tumors with AC histology (65% vs. 83%; P < 0.002). When patients with early-stage cervical carcinoma (International Federation of Gynecology and Obstetrics [FIGO] Stage I) were examined separately, there was no statistically significant difference in the 5-year survival rate (AC, 89%; ASC, 86%; P = 0.644). However, when patients with advanced-stage disease (FIGO Stages II-IV) were analyzed, ASC was associated with a significant decrease in median and overall survival (P = 0.01). When the results were analyzed by grade, patients who had tumors with ASC histology had a shorter survival compared with patients who had AC histology of any grade; however, this was a significant difference only for patients with Grade 1 tumors: The 5-year survival rate for patients with Grade 1 AC was 93%, compared with 50% for patients with Grade 1 ASC (P < 0.01).

CONCLUSIONS

ASC histology appears to be an independent predictor of poor outcome in women with cervical carcinoma compared with their counterparts who have pure AC. The significant decrease in survival was observed only in patients with advanced-stage cervical carcinoma. This decreased survival may be related mainly to the grade of ASC.

Does histology influence prognosis in patients with early-stage cervical carcinoma?

BACKGROUND

The objective of this study was to examine the influence of histology on the outcome of patients with surgically treated, Stage IA-IB carcinoma of the uterine cervix.

METHODS

All patient information was collected prospectively and was extracted subsequently from the University of Toronto cervical carcinoma surgery data base. Selection criteria for surgery were based on tumor size and were independent of histology. Patients with adenocarcinoma were separated into two groups: those with mucinous/endometrioid adenocarcinoma (M/E AC) and those with adenosquamous/clear cell adenocarcinoma (AS/CC AC). Statistical analysis used Wilcoxon rank tests, Mantel-Hanzel tests, chi-square tests, and Cox regression analyses.

RESULTS

Between July 1984 and January 2000, 880 patients with Stage IA-IB cervical carcinoma underwent radical surgery, including pelvic lymphadenectomy, as the primary treatment. Two hundred fifty-five patients had M/E AC (29%), 81 patients had AS/CC AC (9%), and 544 patients had squamous cell carcinoma (SCC; 62%). Compared with patients who had SCC, patients with M/E AC had significantly more favorable prognostic characteristics: age (median, 39 years vs. 41 years; P < 0.03), depth of invasion (3.7 mm vs. 5.5 mm; P < 0.001), vascular space involvement (24% vs. 57%; P < 0.0001), Grade 2-3 tumor (40% vs. 78%; P < 0.0001), and pelvic lymph node metastases (4% vs. 8%; P < 0.04), respectively. Characteristics among patients with AS/CC AC tended have values similar to the median values for patients with SCC (or intermediate between the values for patients with M/E AC and the values for patients with SCC): age (38 years), depth of invasion (6 mm), vascular space involvement (40%), Grades 2-3 (70%), and pelvic lymph node metastases (6%). The 2-year and 5-year recurrence free survival rate was similar between patients with M/E AC and patients with SCC (95% vs. 94% and 90% vs. 90%, respectively); however, both were significantly superior to the rates for patients with AS/CC AC (2-year recurrence free survival rate: 86%, P < 0.03; 5-year recurrence free survival rate: 81%, P % 0.03). There were no differences in the pattern of first recurrence by histology.

CONCLUSIONS

Patients with surgically treated Stage IA-IB cervical carcinoma with M/E AC and SCC histology have a similar prognosis. For patients with disease with AS/CC AC histology, the current results and the literature indicate that patients with uncommon histologies have an inferior recurrence free survival rate. Although the optimal therapy for these patients remains undefined, there is no obvious rationale for altering the treatment strategies from those currently employed for patients with M/E AC and SCC.

Overall 5-year survival rate and prognostic factors in patients with stage IB and IIA cervical cancer treated by radical hysterectomy and pelvic lymph node dissection

The objective of this paper was to analyze the 5-year survival rate and prognostic factors for stage Ib and IIa cervical cancer treated by radical hysterectomy. A total of 366 patients with invasive cervical cancer treated by radical hysterectomy from June 1985 to June 1994 at Chonnam National University Hospital, Kwangju, Korea were retrospectively analyzed. Survival analysis was performed using the Kaplan-Meier estimator. Multivariate analysis was performed using the Cox proportional hazards regression model. The overall 5-year survival rate was 92% in stage Ib and 87% in stage IIa. Factors assessed for prognostic value included age, FIGO stage, cell type, tumor size, depth of invasion, lymphovascular space invasion (LVSI), and pelvic lymph node metastases (LNM). In the multivariate analysis, age, cell type, and lymph node metastases were independent predictors of survival. Lower survival was associated with age greater than 50 years, adenocarcinoma, and presence of lymph node metastases. The higher survival rates in patients with single lymph node involvement or lymph node metastases below the level of the common iliac nodes (85 and 84.6%, respectively) versus multiple or extrapelvic lymph node metastases (50 and 20%, respectively) were statistically significant (P < 0.01). In conclusion, patients who had lymph node metastases, adenocarcinoma, and were older than 50 years had a poorer survival rate. Such patients require more intense postoperative treatment and closer surveillance. Low-risk patients with a single lymph node metastasis below the level of the common iliac nodes may benefit from thorough lymphadenectomy without adjuvant therapy to prevent unpleasant complications.

Prognostic factors of the uterine cervix adenocarcinoma

BACKGROUND

Prognosis factors for adenocarcinoma of the uterine cervix after primary treatment are poorly established.

METHODS

A retrospective study of 45 cases of adenocarcinoma of the cervix with a follow-up of 96 months on average was performed. The primary treatment consisted in combined radical surgery and radiotherapy for stage I-II patients while patients with advanced disease were treated by radiotherapy. In case of poor prognosis factors, they were given chemotherapy. Survival rates were established and prognosis factors influencing survival and recurrences were studied.

RESULTS

Fifteen women remained alive without evolutive disease. FIGO stage and pelvic node involvement were the most important parameters influencing overall survival. Local failures (27%, average period of 30 months) were unpredictable and led to a dramatic outcome. Histological grade and pelvic node status were significant predictive factors for metastatic recurrence (40%, average period of 29 months).

CONCLUSIONS

Local recurrence and metastatic dissemination of cervical adenocarcinoma after primary treatment prove to be rapidly fatal although life expectancy can be prolonged with adjuvant treatment of the recurrence. In the event of aggressive tumors with high histological grade and pelvic node involvement, an attempt to assess adjuvant systemic chemotherapy could be useful.

Close vaginal margins as a prognostic factor after radical hysterectomy

From 1965 to 1995, at the University of Miami/Jackson Memorial Medical Center, 1223 patients with stage IA2, IB, or IIA cervical cancer have undergone a radical hysterectomy. The charts of these patients were reviewed retrospectively for pathology reports showing positive or close surgical margins. Fifty-one of these cases had final pathology results interpreted as close vaginal margins (CVM), which we define as tumor less than or equal to 0.5 cm from the vaginal margins of resection. All slides of blocks with close vaginal margins were found and reviewed by a single pathologist. Twenty-eight (54.9%) had parametrial involvement or positive lymph nodes and received adjuvant radiation therapy (RT). Of the remaining 23 cases, only 6 had other high risk factors, tumor greater than 4 cm, poorly differentiated, greater than 50% invasion, or lymphovascular space involvement. Sixteen of 23 received radiation. The 5-year survival was significantly greater with RT, 81.3%, than without RT, 28.6% (P < 0.05). The recurrence rate was also decreased from 85.7 to 12.5% (P < 0.01). Although present in less than 2% of radical hysterectomy specimens, CVM without other high risk factors may be an important prognostic variable that should be considered when making adjuvant therapy decisions.

Surgically defined prognostic parameters in patients with early cervical carcinoma. A multivariate survival tree analysis

BACKGROUND

This study was performed to identify a statistical combination of independent pathologic and clinical features that best predict 5-year disease free survival (DFS) in patients with early stage cervical carcinoma treated by radical hysterectomy. The main goal of the study was to identify subsets of patients based on risk factors with maximal differences in DFS.

METHODS

Three hundred and seventy patients were found for whom complete clinical and pathologic material, including cone and cervical biopsies, were available for analysis. Variables studied included age, weight, race, marital status, economic status, tumor size (TS), depth of invasion (DI), lymph-vascular space involvement (LVSI), cell type, tumor grade, lymph node metastasis (LNM), and number of lymph nodes removed. Patients with LNM, parametrial involvement, and positive or close surgical margins were offered postoperative radiation. After excluding patients with microinvasive and small cell carcinoma, data from the remaining 301 patients were submitted to univariate and multivariate analyses to define those variables that best predict DFS.

RESULTS

Univariate analysis showed that, ranked by degree of significance, DI, TS, LVSI, LNM, tumor volume (TV) and clinical stage were significant in predicting survival. Significant (P < 0.05) single parameters and other variables considered important were chosen for multivariate analysis, including the creation of a survival tree. With this method, DI (< or = 6 mm and > 2 cm), LVSI, age (> or = 40 yrs), and LNM were found to be the best combination of risk factors to define prognosis.

CONCLUSIONS

The multivariate survival tree analysis maximally separates patients with early stage invasive carcinoma of the cervix into 3 subgroups with 5-year DFS of 91%, 68%, and 43%, respectively. The authors excluded patients with microinvasive carcinoma (SGO, Society of Gynecologic Oncologists), who have an excellent DFS of 100%, and patients with small carcinoma, who have a poor DFS of 36.4% based on cell type alone, to define independent risk factors that maximally separate the remaining patients by DSF. The survival tree prognostic scoring system is easy to apply, and only requires DI (mm), LVSI (+, -), LNM, and age to assign an individual patient to one of three risk groups.

Prognostic factors of early stage cervical cancer treated by radical hysterectomy

BACKGROUND

This study was performed to identify pathologic and clinical features that best correlate with lymph node metastasis and disease free survival among patients with Stage I and II cervical cancer treated by radical hysterectomy.

METHODS

Three hundred-seventy patients with complete clinical information and pathologic material, including cone and cervical biopsies, were selected for analysis. Of these patients, 301 with clinical stages I and II disease were the subject of this paper. The results of patients with microinvasive carcinoma of the cervix, as defined by the Society of Gynecologic Oncologists (depth of invasion < or = 3 mm and no lymph node vascular space invasion), were reported previously and excluded from this analysis. Patients with small cell carcinoma of the cervix were found to have a very poor prognosis (disease free 5-year survival of 36%) and were also excluded from this analysis (Sevin BU, Nadji M, Metkoch MW, Lu Y, Averette HE. Unpublished data, 1995). Variables studied were patient age, weight, race, marital status, and economic status; tumor size; depth of invasion; lymph node-vascular space involvement; cell type; tumor grade; lymph node metastasis; and number of lymph nodes removed. The influence of these variables on survival was examined by univariate analysis with use of Cox's regression model and the log rank test for comparison of survival curves.

RESULTS

Factors that predict disease free survival, ranked by degree of significance, were depth of invasion, tumor size, lymph node-vascular space invasion, number of positive nodes, tumor volume, clinical stage, and tumor extension to the vagina or surgical margins.

CONCLUSIONS

Radical hysterectomy and bilateral lymphadenectomy is standard therapy for patients with Stage IB and IIA carcinoma of the cervix. A variety of surgically defined risk factors predict 5-year disease free survival, and many of these factors are related. Identification of independent risk factors requires a multivariate analysis of data.