Risk factors for recurrence in patients with stage IB, IIA, and IIB cervical carcinoma after radical hysterectomy and postoperative pelvic irradiation

Cervical cancer prognosis and related risk factors for patients with cervical cancer: a long-term retrospective cohort study

This study aims to explore the recurrence rate and overall survival for patients with cervical cancer after the first treatment and the related risk factors. A retrospective cohort study was conducted on cervical cancer patients enrolled in a cancer specialist hospital in Hunan Province, China from January 1992 to December 2005 and followed up until December 2010. Kaplan–Meier survival analysis was used to estimate the cumulative recurrence rate, and Cox proportional hazards model was utilized to identify risk factors associated with prognosis. A total of 4358 patients were enrolled with a median follow-up of 7.4 years (range 5–19 years), and 372 (8.5%) patients had cancer recurrence. The cumulative recurrence rate showed a rapid increase from 3.8% in the first year after discharge to 8.0% in the fifth year, and the recurrence rate remained relatively stable afterward reaching 9.7% and 10.8% in the 10th and the 15th year, respectively. The median time to recurrence was 15.5 months with an IQR of 5.5–40.0 months. The Cox regression showed that miscarriage, clinical stage, and treatment received were significantly associated with cervical cancer recurrence after adjustment for confounders. Patients with recurrence showed a significantly higher risk for mortality than those without recurrence (HR 2.79, 95% CI 2.42–3.22). This study depicted the long-term recurrence rate and survival after recurrence for patients with cervical cancer after the first treatment, and reported time to recurrence and risk factors related to recurrence. These findings may provide important evidence for designing targeted interventions for the treatment of cervical cancer.

Prognostic Value of Log Odds of Positive Lymph Nodes after Radical Surgery Followed by Adjuvant Treatment in High-Risk Cervical Cancer

PURPOSE

The purpose of this study is to compare the prognostic efficacy of the number and location of positive lymph nodes (LN), LN ratio (LNR), and log odds of positive LNs (LODDs) in high-risk cervical cancer treated with radical surgery and adjuvant treatment.

MATERIALS AND METHODS

Fifty high-risk patients who underwent radical hysterectomy and pelvic node dissection followed by adjuvant treatment were analyzed retrospectively. The patients had International Federation of Gynecology and Obstetrics (FIGO) stage IA2-IIB. Upper LN is defined as common iliac or higher LN, and LNR is the ratio of positive LNs to harvested LNs. LODDs is log odds between positive LNs and negative LNs. Radiotherapy was delivered to the whole pelvis with median 50.4 Gy/28 Fx± to the para-aortic regions. Platinum-based chemotherapy was used in most patients (93%). The median follow-up duration was 80 months.

RESULTS

The 5-year disease-free survival (DFS) rate was 76.1%, and the overall survival (OS) rate was 86.4%. Treatment failure occurred in 11 patients, and distant failure (DF) was the dominant pattern (90.9%). In univariate analysis, significantly lower DFSwas observed in patients with perineural invasion, ≥ 2 LN metastases, LNR ≥ 10%, upper LN metastasis, and ≥ -1.05 LODDs. In multivariate analysis, ≥ -1.05 LODDs was the only significant factor for DFS (p=0.011). Of patients with LODDs ≥ -1.05, 40.9% experienced DF. LODDs was the only significant prognostic factor for OS as well (p=0.006).

CONCLUSION

LODDs ≥ -1.05 was the only significant prognostic factor for both DFS and OS. In patients with LODDs ≥ -1.05, intensified chemotherapy might be required, considering the high rate of DF.

The efficacy and safety of neoadjuvant chemotherapy in the treatment of locally advanced cervical cancer: A randomized multicenter study

OBJECTIVE

This study sought to evaluate the toxicity and curative effect of irinotecan plus cisplatin neoadjuvant chemotherapy (NACT) for stage Ib2, IIa2, and IIb cervical cancer patients.

METHODS

A total of 219 patients were randomly assigned to two groups: 109 patients were treated with 1-2 cycles of chemotherapy (NACT group), and 110 patients in the control group were treated directly with surgery (DS group). Patients in the NACT group were randomly assigned to two groups: 50 patients were treated with irinotecan plus cisplatin followed by surgery (IP group), and 59 patients were treated with paclitaxel plus cisplatin followed by surgery (TP group). Patients with pathological recurrence risk factors received post-operative radiotherapy.

RESULTS

Survival analysis revealed no significant difference in disease-free survival (DFS) or overall survival (OS) between the NACT and DS groups. Analysis of clinicopathologic factors showed that the lymphovascular space invasion (LVSI) and deep stromal invasion rates were significantly lower in the NACT group. Grade 3/4 neutropenia and grade 3/4 diarrhea were both higher in the IP group than in the TP group. DFS and OS were similar in the IP and TP groups. Univariate analysis showed that LVSI was the only factor associated with DFS.

CONCLUSION

NACT did not improve overall survival but did reduce the number of patients who received post-operative radiotherapy. NACT consisting of irinotecan plus cisplatin for cervical cancer showed similar efficacy and higher toxicity compared with the use of paclitaxel plus cisplatin, although the toxicity was tolerable.

Phase II trial on neoadjuvant intravenous and trans-uterine arterial chemotherapy for locally advanced bulky cervical adenocarcinoma

OBJECTIVE

A phase II trial on neoadjuvant trans-uterine arterial chemotherapy (TUAC) followed by type III radical hysterectomy (RH) was conducted for patients with bulky cervical adenocarcinoma (AC).

METHODS

Tumors of >4 cm were eligible. The neoadjuvant regimen comprised paclitaxel (60 mg/m(2) intravenously on days 1, 8, and 15) and cisplatin (70 mg/m(2) TUAC followed by transcatheter embolization with gelatin sponge particles on day 2) repeated every 3 weeks for 3 cycles. The primary endpoints were clinical and pathological responses.

RESULTS

Twenty-two patients (median age, 51 years; range, 33-75 years) were enrolled. The International Federation of Gynecology and Obstetrics stages were IB2 (9 patients), IIA-IIB (8), IIIB (3), and IVA (2). The adeno/adenosquamous ratio was 16/6. The overall clinical response rate was 95.4% (95% confidence interval [CI], 86.7-100%). RH was completed in 19 patients (86%), including 2 stage IVA patients who underwent anterior or posterior pelvic exenteration. Of the 19 patients, no residual malignant cells were found pathologically in 4; thus, the pathological complete response rate was 18% (4/22). No patients experienced grade 4 thrombocytopenia or febrile neutropenia or required platelet transfusions. The 5-year progression-free survival and overall survival rates in stages IB2-IIB were 70.0% (95%CI, 48.1-92.1%) and 69.5% (95%CI, 47.0-92.0%), respectively. The 2 patients with stage IVA tumors were alive without recurrence for 72 and 84 months after enrollment.

CONCLUSIONS

TUAC showed high clinical and pathological response rates. TUAC is promising for stage IB2-IIB and IVA bulky AC.

Adjuvant radiochemotherapy in patients with locally advanced high-risk cervical cancer

BACKGROUND AND PURPOSE

The aim of this retrospective study was to analyze the outcome of patients with locally advanced cervical carcinoma treated by adjuvant radiochemotherapy and to determine risk factors for local and distant relapse. Furthermore, acute and late effects of treatment were recorded.

PATIENTS AND METHODS

A total of 72 patients with FIGO stages I-III cervical carcinoma were treated by radical hysterectomy, pelvic lymphadenectomy, and postoperative radiochemotherapy. Only patients with positive pelvic lymph nodes, parametrial involvement, positive margins, or tumor bulk were eligible. Patients were irradiated with a standard pelvic field (50.4 Gy in 28 fractions). The majority of patients received platinum-based chemotherapy.

RESULTS

After a median follow-up of 37 months, estimated 1-, 2-, and 4-year disease-free survival (DFS) and overall survival (OS) rates were 89%, 80%, 68% and 95%, 88%, 76%, respectively. Nine of the 72 patients had pelvic recurrences including only 1 isolated local failure; 23 of the 72 patients presented with distant relapse. The majority of relapses occurred within the first 3 years after adjuvant treatment. The number of positive pelvic lymph nodes (> 1) was the strongest prognostic factor for DFS. Treatment was well tolerated with transient acute hematologic (~30%) and gastrointestinal (~30%) grade 3 toxicity. Small bowel obstruction (~6%) was the only important late sequelae.

CONCLUSION

Adjuvant radiochemotherapy in patients with advanced cervical cancer and several risk factors is highly effective to prevent local relapse. Future efforts to improve outcome should be placed on improvement of systemic control especially in subgroups with high-risk features for distant relapse. Combined treatment was well tolerated with moderate acute and late toxicity.

Identification of a gene-expression signature for predicting lymph node metastasis in patients with early stage cervical carcinoma

BACKGROUND

Pelvic lymph node metastasis (PLNM) is an important prognostic factor for patients with cervical carcinoma. The objective of this study was to identify a gene-expression signature that could predict PLNM in cervical carcinoma.

METHODS

Eighty-eight women with cervical carcinoma with PLNM (n = 23) and without PLNM (n = 65) were divided randomly into a training group and a test group. An oligonucleotide microarray that contained probes for 1440 human cancer-related genes was fabricated in-house and was used to detect the gene expression profile of cervical carcinoma. The gene expression levels detected in the microarray were verified by quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR).

RESULTS

A gene-expression signature for predicting PLNM was developed in patients from the training group, including 11 genes: ribosomal protein L35 (RPL35); thymosin β 10 (TMSB10); tyrosine 3-mono-oxytenase/tryptophan 5-mono-oxygenase activation protein, ζ polypeptide (YWHAZ); biotinidase (BTD); lactate dehydrogenase A (LDHA); glucuronidase β (GUSB); superoxide dismutase 2 (SOD2); nuclear receptor subfamily 3, group C, member 2 (NR3C2); fructosamine 3 kinase (FN3K); x-ray repair cross-complementing 4 (XRCC4); and wingless-type mouse mammary tumor virus integration site family member 2 (WNT2). In the test group, the signature's accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were 91%, 90.9%, 93.9%, 83.3%, and 96.9%, respectively, for predicting PLNM. The expression levels of 5 genes in the signature were confirmed by qRT-PCR. A multivariate analysis demonstrated that patients with 11-gene high-risk scores were had a 33-fold increased risk for PLNM compared with patients who had low-risk scores. The 5-year overall and disease-free survival rates for patients who had 11-gene high-risk scores were marginally significantly lower than the rates for patients who had 11-gene low-risk scores (P = .087 and P = .174, respectively).

CONCLUSIONS

In this study, 11-gene signature for predicting PLNM in cervical carcinoma was identified that may help clinicians in planning therapy for patients with cervical carcinoma.

Differing prognosis of cervical cancer patients with high risk of treatment failure after radical hysterectomy warrants trial treatment modification

OBJECTIVE

The aim of this study was to ascertain whether all cervical cancer patients who received adjuvant concurrent chemoradiation (CCRT) for high risk of treatment failure after radical hysterectomy are at the same risk of treatment failure, and if not, to propose trial treatment modification.

METHODS

Between January 1999 and December 2007, 58 patients with FIGO stage Ib-IIa cervical cancer received adjuvant CCRT due to high risk factors such as positive lymph nodes or positive parametrium, or positive vaginal resection margins. Patients were divided into two Groups. Group A were patients with negative parametrium, negative vaginal resection margins, and only unilateral lymph node metastasis (involved L/N</=2). Group B were those with either bilateral pelvic lymph node involvement, or more than 2 lymph node involvement, or positive parametrium with lymph node involvement.

RESULTS

During a median follow-up period of 34 months (range, 6 to 102 months), 9 patients (15.5%) experienced recurrence; among whom 2 patients (2/28, 7.1%) were Group A, and 7 patients (7/30, 23.3%) were Group B. At 3 years, the estimated progression-free survival rate of all 58 patients was 78.3%, and the overall survival rate was 89.7%. Patients in Group A had significantly better progression-free survival (88.2% vs. 68.2%, p=0.042) and overall survival rate (100% vs. 78.8%, p=0.034) than Group B.

CONCLUSION

Treatment modifications such as consolidation chemotherapy after CCRT may be considered based on the poor prognosis of very high risk patients such as those patients in Group B.

Connective tissue growth factor linked to the E7 tumor antigen generates potent antitumor immune responses mediated by an antiapoptotic mechanism

A novel method for generating an antigen-specific cancer vaccine and immunotherapy has emerged using a DNA vaccine. However, antigen-presenting cells (APCs) have a limited life span, which hinders their long-term ability to prime antigen-specific T cells. Connective tissue growth factor (CTGF) has a role in cell survival. This study explored the intradermal administration of DNA encoding CTGF with a model tumor antigen, human papilloma virus type 16 E7. Mice vaccinated with CTGF/E7 DNA exhibited a dramatic increase in E7-specific CD4(+) and CD8(+) T-cell precursors. They also showed an impressive antitumor effect against E7-expressing tumors compared with mice vaccinated with the wild-type E7 DNA. The delivery of DNA encoding CTGF and E7 or CTGF alone could prolong the survival of transduced dendritic cells (DCs) in vivo. In addition, CTGF/E7-transduced DCs could enhance a higher number of E7-specific CD8(+) T cells than E7-transduced DCs. By prolonging the survival of APCs, DNA vaccine encoding CTGF linked to a tumor antigen represents an innovative approach to enhance DNA vaccine potency and holds promise for cancer prophylaxis and immunotherapy.

Assessment of pelvic lymph node micrometastatic disease in stages IB and IIA of carcinoma of the uterine cervix

The objective of this study was to assess the frequency of micrometastatic disease (MID) in pelvic lymph nodes (PLNs) in carcinoma of the uterine cervix (CUC) and to determine the risk of recurrence. The PLNs from 289 patients with CUC (IB and IIA) were studied. Each PLN was assessed via immunohistochemistry using a single histologic section (AE1/AE3). Metastatic deposits were measured and the disease status was classified into three groups: 1) absence of metastatic disease (MOD); 2) MID, one or more metastatic PLN with only isolated tumor cells and/or micrometastases (up to 2 mm); and 3) macrometastatic disease (MAD), presence of one or more metastatic PLN with macrometastases (more than 2 mm). Eleven patients (3.8%) were classified as having MID and 37 (12.8%) as having MAD. The 5-year disease-free survival (DFS) rates for MOD, MAD, and MID were 88.7%, 80.4%, and 50.0%, respectively (P < 0.001). The Cox proportional hazards model showed that MID was an independent variable for recurrence when adjusted for MAD, depth of tumor invasion, severity of inflammatory reaction, and use of adjuvant radiotherapy. We conclude that the frequency of MID in PLN was low. However, patients with MID presented a high risk of recurrence and reduced DFS.

Postoperative radiation therapy improves prognosis in patients with adverse risk factors in localized, early-stage cervical cancer: a retrospective comparative study

The objective of this study was to assess the role of postoperative radiotherapy (RT) in early-stage cervical carcinoma with risk factors other than positive nodes, parametrial invasion, or positive margins and to compare outcomes using the Leiden University Medical Center (LUMC) modification of the Gynecologic Oncology Group (GOG) system with the GOG prognostic scoring system itself. Between January 1984 and April 2005, 402 patients with early-stage cervical cancer underwent radical hysterectomy. A total of 51 patients (13%) had two of the three risk factors and had pathologic tumor size (> or =40 mm), invasion (> or =15 mm), and capillary lymphatic space involvement, and were identified as the so-called high-risk (HR). We compared 34 patients who received RT based on the LUMC risk profile (67%) with 17 who did not (33%). The GOG score was calculated as well. We compared the GOG scores within the LUMC risk groups: HR+ (two out of three risk factors) and HR- (less than two out of three risk factors). Differences in 5-year cancer-specific survival (CSS) and 5-year disease-free survival (DFS) between the HR group treated with RT (86%, 85%) and without RT (57%; 43%) were statistically significant. The LUMC criteria did not significantly differ from the GOG risk profile, concerning recurrence, CSS, and DFS. HR patients benefit from adjuvant RT. The LUMC modification of the GOG system seems to be simpler and has a slightly higher threshold for the indication for RT but without a difference in outcome.

Preliminary results of consolidation chemotherapy following concurrent chemoradiation after radical surgery in high-risk early-stage carcinoma of the uterine cervix

AIMS

To evaluate the efficacy and toxicity of consolidation chemotherapy after concurrent chemoradiation (CCRT) with 5-fluorouracil (5-FU) and cisplatin in the treatment of high-risk, early stage cervical carcinoma after radical surgery.

MATERIALS AND METHODS

Women with clinical stage IB and IIA cervical carcinoma, initially treated with radical hysterectomy and pelvic lymphadenectomy, and who had positive pelvic lymph nodes, positive margins, parametrial involvement, or all three, were divided into either a CCRT alone group or a consolidation chemotherapy after CCRT group. Three cycles of chemotherapy were given to the CCRT alone group, and six cycles to the consolidation chemotherapy group. Women in each group received 50.4 Gy external radiation in 28 fractions to a standard pelvic field. Chemotherapy consisted of cisplatin 60 mg/m2 (X 1) and 5-FU 1000 mg/m2/d (X 5) every 3 weeks, with the first and second cycles given concurrent with radiation. Survival and toxicity were compared between the two groups.

RESULTS

Forty women were evaluable (25 in the CCRT alone group and 15 in the consolidation chemotherapy group). The estimated 2-year progression-free survival was 87.7% in the CCRT alone group and 67.0% in the consolidation chemotherapy group. The estimated 2-year overall survival was 95.8% in the CCRT alone group and 100% in the consolidation chemotherapy group. However, no significant differences were found in progression-free and overall survival in the two groups (P = 0.17 and P = 0.29, respectively). Grade 2 or higher leukopenia and neutropenia were significantly more frequent in the consolidation chemotherapy group than in the CCRT alone group (P = 0.02 and P < 0.01, respectively).

CONCLUSIONS

Although the sample size was small, and this study was not randomised, these results suggest that consolidation chemotherapy may not improve survival. Rather, it may increase haematologic toxicities for women with high-risk, early stage cervical carcinoma who undergo radical surgery followed by CCRT.

Impact of radical hysterectomy for cervical cancer on urodynamic findings

To elucidate the impact of radical hysterectomy upon the urodynamic findings of patients with cervical cancer, 20 patients with cervical cancer at stage IB to IIA who underwent radical hysterectomy were recruited. Each patient underwent a 20-min pad test and urodynamic study prior to and 3 months after radical hysterectomy. ANOVA, Bonferroni test and paired t -test were utilized for analysis. The mean age of the 20 patients was 50.2+/-8.7 years with a mean parity of 3.5+/-1.5. Four (20%) of the 20 cases revealed normal urodynamic findings preoperatively, and the urodynamic findings became abnormal after surgery. Comparing the urodynamic parameters of both bladder voiding and storage functions pre- and post-surgery, we found significant impairments postoperatively in all 20 cases. Our data demonstrate that abnormal urodynamic findings may pre-exist for some patients with cervical cancer prior to surgical treatment. These findings may worsen, and/or additional abnormal states may arise subsequent to radical hysterectomy.

Long-term clinical outcomes of postoperative pelvic radiotherapy with or without prophylactic paraaortic irradiation for stage I-II cervical carcinoma with positive lymph nodes: retrospective analysis of predictive variables regarding survival and failure patterns

We performed retrospective analysis to classify the risk hazard of patients with stage I-II cervical cancer with lymph node metastases treated with postoperative radiotherapy. From 1981 to 1995, 106 patients with early stage cervical carcinoma who received adjuvant pelvic radiation were entered in the analysis. The median patient age was 53.0 years (range 21-73). The median dose of 45.3 Gy (range, 32.1-56.4 Gy) was delivered over the whole pelvis. Seventy patients also received prophylactic paraaortic radiation (median 44 Gy; range 22-46 Gy). The 5/10-year overall survival (OAS), disease-free survival (DFS), pelvic control, and distant metastasis-free survival rates were 69.1/63.5%, 62.4/58.1%, 85.7/84.3%, and 74.1/71.6%, respectively. In the uni-/multivariate analyses, the significant prognostic factors of OAS and DFS proved to be disease stage, duration period between operation and radiotherapy, histology, and presence or absence of common iliac lymph node metastasis. Using the results of these analyses, we devised a predictive model for DFS. In this model, the 5-year DFS rates of patients with low (N = 35), intermediate (N = 59), and high-risk factors (N = 12) were 88.1%, 56.7%, and 16.7%, respectively (p < 0.0001). The majority of analyzed patients did not have adequate DFS estimates in this series. High-risk patients should receive a more intensive strategy, such as concurrent chemoradiotherapy. On the other hand, the effort to reduce toxicity should be considered carefully.

Usefulness of Preoperative Chemoradiation in Locally Advanced Cervical Carcinoma

This study investigated response rate, toxicity, and influence on intra- and postoperative complications of neoadjuvant concurrent chemoradiation in locally advanced (Figo IB2-IIIB) cervical carcinomas. Twenty-eight patients (median age 46.5 years, age range 29-73 years), diagnosed as having squamous cell carcinomas (n=21), adenocarcinomas (n=6), and undifferentiated carcinoma (n=1), entered this study. The chemoradiation protocol included external radiotherapy to the pelvis (39.6 Gy), intra-arterial or intravenous infusion of cisplatin (70 mg/m2 on days 1 and 22), and 24-hour continuous intravenous infusion of 5-fluorouracil (700 mg/m2 on days 1-4 and 22-25). Two weeks after the end of chemoradiotherapy, the patients underwent restaging followed by suitable operation including pelvic lymphadenectomy. The median follow-up period in the surviving patients was 13.1 months. The response rate for chemoradiation was 93% (26/28). The 2-year disease free survival was 85.2%. Grade 3-4 neutropenia was observed in 14 patients (50%), 4 patients (14%) showed grade 3 anemia, and 5 patients (17.8%) showed grade 3-4 thrombocytopenia. Nineteen patients (67.8%) could undergo surgery after concurrent chemoradiation. Pathological examination revealed a complete response (pT0) in 7 patients, and 5 patients showed only microscopic residual disease (pTmic). In 4 patients, there were intraoperative complications: vesical lesions in 2 (10%) and small intestine lesions in 2 (10%). Neoadjuvant therapy with concurrent chemoradiation for locally advanced cervical carcinoma is effective, safe, and useful for increasing operability rates as well as decreasing intra- and postoperative complications. Therefore, neoadjuvant concurrent chemoradiation should be considered for treatment in patients with locally advanced cervical carcinomas who could not undergo primary operation.

Use of small pelvic field instead of whole pelvic field in postoperative radiotherapy for node-negative, high-risk stages I and II cervical squamous cell carcinoma

We investigated whether a small pelvic (SP) field that covers primarily the pericervical regions in postoperative radiotherapy for cervical squamous cell carcinoma is adequate for a subgroup of node-negative patients. Of 84 patients with stage I-II disease treated with postoperative radiotherapy due to pathologic risk factors, 42 node-negative patients received SP-field radiotherapy, whereas remaining 42 node-positive patients were treated with a conventional whole pelvic (WP) field that also covered pelvic lymph nodes, both with 50.0-50.4 Gy/25-28 fractions. The pathologic risk factors included positive nodes, deep stromal invasion (>/=2 /3 thickness), parametrial extension, and positive or close surgical margin. Recurrence was identified for 20 patients: three in the SP group and 17 in the WP group. Intrapelvic recurrence accounted for all three recurrences in the SP group and for four in the WP group; 5-year pelvic-control rate did not differ significantly between the SP (93%) and WP (90%) groups. Extrapelvic recurrence (n = 11) was identified exclusively in the WP group. Patterns of recurrence indicate that use of an SP field instead of a WP field may be adequate in postoperative radiotherapy for a subgroup of node-negative, high-risk patients.

The significance of rapid intraoperative cytology in the evaluation of intraperitoneal and retroperitoneal spread of cervical cancer

OBJECTIVE

To evaluate the contribution of the rapid intraoperative cytology (peritoneal washing [PW] cytology together with imprint cytology performed on lymph node samples) in the assessment of peritoneal and retroperitoneal dissemination of cervical cancer.

METHODS

Seventy-nine patients with clinical Stage IA2-IIA cervical cancer underwent PW cytology and imprint cytology performed on retroperitoneal lymph node samples during primary surgical treatment. Cytologic specimens were stained with the May-Grünwald-Giemsa (MGG) and hematoxylin-eosin (HE) techniques. Pertinent histologic sections of the cervical lesions, of the cell blocks prepared from PW sediments, and of the lymph node sampling were studied and compared with the cytologic findings.

RESULTS

PW cytology was positive in 2.5% of the patients, and lymph node imprints revealed metastases in 19% of the patients. Cervical adenocarcinomas presented increased rates of metastatic disease in both the peritoneal cavity and retroperitoneum. HE presented higher sensitivity in detecting malignant cells in the peritoneal fluids, while MGG gave more accurate results in the diagnosis of lymph node metastases.

CONCLUSIONS

Cytologic evaluation of intraperitoneal and retroperitoneal spread of cervical cancer by use of PW cytology and imprint cytology performed on lymph node samples contributes to the assessment of the extent of disease and therefore could be useful in further treatment of the patient.

High-risk group in node-positive patients with stage IB, IIA, and IIB cervical carcinoma after radical hysterectomy and postoperative pelvic irradiation

OBJECTIVE

The goal of this study was to identify risk factors in patients with node-positive stage IB, IIA, and IIB cervical carcinoma after radical hysterectomy with pelvic lymph node dissection and postoperative irradiation.

METHODS

Two hundred forty-two patients with FIGO stage IB, IIA, and IIB cervical carcinoma underwent radical hysterectomy with pelvic lymph node dissection; pathological analysis of the surgical specimen showed positive lymph nodes in 59 patients. These 59 patients were further treated with postoperative radiotherapy. Eighteen patients were in stage IB, 4 in stage IIA, and 37 in stage IIB. Histological tumor type, tumor size, lymph-vascular space invasion, parametrium infiltration, number of positive nodes, and involvement of common iliac nodes were assessed for correlation with cancer recurrence.

RESULTS

When all these variables were assessed in the Cox proportional regression analysis, parametrium infiltration (P = 0. 0199) and number of positive nodes (two or more nodes) (P = 0.0483) revealed the factor correlating significantly with disease-specific survival. Based on these two factors, node-positive patients could be divided into low-risk (n = 11), intermediate-risk (n = 29), and high-risk (n = 19) groups. The 5-year disease-specific survival for the low-risk group was 100% which was significantly better than the 39.1% for the high-risk group (P = 0.0012).

CONCLUSION

For patients in the high-risk group, it may be worthwhile to consider new strategies to improve survival.

Concurrent chemotherapy and pelvic radiation therapy compared with pelvic radiation therapy alone as adjuvant therapy after radical surgery in high-risk early-stage cancer of the cervix

PURPOSE

To determine whether the addition of cisplatin-based chemotherapy (CT) to pelvic radiation therapy (RT) will improve the survival of early-stage, high-risk patients with cervical carcinoma.

PATIENTS AND METHODS

Patients with clinical stage IA(2), IB, and IIA carcinoma of the cervix, initially treated with radical hysterectomy and pelvic lymphadenectomy, and who had positive pelvic lymph nodes and/or positive margins and/or microscopic involvement of the parametrium were eligible for this study. Patients were randomized to receive RT or RT + CT. Patients in each group received 49.3 GY RT in 29 fractions to a standard pelvic field. Chemotherapy consisted of bolus cisplatin 70 mg/m(2) and a 96-hour infusion of fluorouracil 1,000 mg/m(2)/d every 3 weeks for four cycles, with the first and second cycles given concurrent to RT.

RESULTS

Between 1991 and 1996, 268 patients were entered onto the study. Two hundred forty-three patients were assessable (127 RT + CT patients and 116 RT patients). Progression-free and overall survival are significantly improved in the patients receiving CT. The hazard ratios for progression-free survival and overall survival in the RT only arm versus the RT + CT arm are 2.01 (P =.003) and 1.96 (P =. 007), respectively. The projected progression-free survivals at 4 years is 63% with RT and 80% with RT + CT. The projected overall survival rate at 4 years is 71% with RT and 81% with RT + CT. Grades 3 and 4 hematologic and gastrointestinal toxicity were more frequent in the RT + CT group.

CONCLUSION

The addition of concurrent cisplatin-based CT to RT significantly improves progression-free and overall survival for high-risk, early-stage patients who undergo radical hysterectomy and pelvic lymphadenectomy for carcinoma of the cervix.

The prognostic factors for patients with early cervical cancer treated by radical hysterectomy and postoperative radiotherapy

PURPOSE

This study was undertaken to evaluate the efficacy of postoperative radiotherapy (post-OP RT) and to investigate the prognostic factors for early-stage cervical cancer patients who were treated by radical surgery, and the pathological findings suggested a relatively high risk of relapse with surgery alone.

MATERIALS AND METHODS

From January 1990 to December 1995, 222 patients with stage IB-IIA cervical cancer, treated by radical surgery and a full course of post-OP RT, were included in this study. The indications for post-OP RT were based on pathological findings, including lymph node metastasis, positive surgical margins, parametrial extension, lymphovascular permeation, and invasion of more than two-thirds of the cervical wall thickness. The radiation dose of external beam was 44-45 Gy to the whole pelvis and 50-54 Gy to the true pelvis. One hundred seventy-two patients also received intravaginal brachytherapy as a local boost. The minimal follow-up period was 2 years.

RESULTS

The actuarial 5-year overall and disease-specific survival rates for all patients were 76 and 82%, respectively. The tumor control rate within the pelvis reached 94%, and distant metastasis was the major cause of treatment failure. Univariate analysis of clinical and pathological parameters revealed that clinical stage, bulky tumor size, positive lymph nodes, parametrial extension, and histologic type were significant prognostic factors. After multivariate analysis, only positive lymph nodes (P = 0.01), bulky tumor size (P = 0.02), and parametrial extension (P = 0.05) independently influenced the disease-specific survival (DSS). For patients with lymph node metastasis, the number and location of the nodal involvement significantly affected the prognosis. The 5-year DSS for patients with no, one, and more than one lymph node metastasis were 87, 84, and 61% (P = 0.0001), respectively. Patients with upper pelvic lymph node metastasis had a higher incidence of distant metastasis (50% vs 16% in lower pelvic node group, P = 0.03). In the subgroup of single lower pelvic nodal metastasis, the prognosis was similar to that of patients without lymph node involvement (5-year DSS 85% vs 87%, P = 0.71).

CONCLUSION

Our results indicate that post-OP RT can achieve very good local control in stage IB-IIA cervical cancer patients whose pathological findings show risk features for relapse after radical surgery. The prognostic factors for treatment failure identified in this study can be used as selection criteria for clinical trials to test the effects of other adjuvant treatments, such as chemotherapy. Patients with a single lower pelvic lymph node metastasis have a relatively good prognosis and may not need adjuvant treatment beyond radiation therapy.

The possible use of colour flow Doppler in planning treatment in early invasive carcinoma of the cervix

OBJECTIVE

To investigate the pathological significance of intra-tumoural blood flow signals detected by colour Doppler ultrasound and their association with angiogenesis in cervical carcinoma.

DESIGN

A prospective cross-sectional study.

SETTING

University hospital.

POPULATION

One hundred and four women with Stage IB-IIA cervical carcinoma.

METHODS

All women underwent radical hysterectomy and pelvic lymph node dissection. Transvaginal colour Doppler ultrasound was performed before surgery to search for arterial blood flow signals within the tumours. Tumours with a measurable intra-tumoural resistance index were defined as tumour with detectable blood flow and the others as tumour with undetectable blood flow. The microvessel density of the excised tumour was assessed immunohistochemically. The women's clinical and pathologic data were recorded.

RESULTS

There were 60 tumours (58%) exhibiting detectable intra-tumoural blood flow signals. Tumours with detectable blood flow were larger, had deeper cervical stromal invasion, a higher incidence of parametrial invasion and pelvic lymph node metastases, and a higher microvessel density, when compared with those without detectable blood flow. Cervical cancers with deep cervical stromal invasion, parametrial invasion, and pelvic lymph node metastasis had higher microvessel density than those with superficial stromal invasion, no parametrial invasion, or no lymph node metastasis. Microvessel density correlated well with lymph node metastases and parametrial invasion by multiple regression analysis, while intra-tumoural blood signals only showed correlation with parametrial invasion. In the prediction of pelvic lymph node metastases and parametrial invasion, colour flow Doppler had a sensitivity of 0.80 and specificity of 0.48 in predicting lymph node metastases, and sensitivity of 0.91 and specificity of 0.57 in predicting parametrial invasion.

CONCLUSIONS

The characteristics of blood flow signals in cervical carcinoma detected by colour Doppler ultrasound are associated with tumour angiogenesis and could reflect the likelihood of parametrial invasion and lymph node metastases in cervical carcinoma. The intra-tumoural blood flow signals might be used as a screening test in predicting parametrial invasion and pelvic lymph node metastases. These findings may be helpful in planning treatment for women with Stage I and II cervical carcinoma.

A clinicopathological study of postoperative pulmonary metastasis of uterine cervical carcinomas

OBJECTIVE

To investigate the clinicopathological backgrounds and prognostic factors of uterine cervical carcinomas metastatic to the lung.

METHODS

A total of 519 patients with invasive cervical carcinoma (Stage pTIb-IIb) treated by abdominal radical hysterectomy at the Saitama Cancer Center from January 1, 1976 to December 31, 1989 were analyzed clinicopathologically.

RESULTS

The frequencies of pulmonary metastasis were 6.4% (24/377) and 11.3% (16/142) in patients with negative and positive pelvic lymph nodes, respectively. Among 24 negative lymph node patients, 15 had pulmonary metastasis only. The overall 5-year survival rate of these 15 patients was 36% after relapse. Of the 15, the prognosis of 12 patients with 1-3 pulmonary metastases only was better, that is, 46% after surgical resection (mean size of resectable tumor = 2.8 cm) and/or chemotherapy. But the other patients died within 3.3 years after relapse.

CONCLUSIONS

The occurrence of pulmonary metastasis only, its number (1-3) and size (mean size = 2.8 cm), and no lymph node metastasis are important prognostic factors. For these patients, active surgical resection of the pulmonary lesion(s) and further chemotherapy are recommended in order to improve their prognosis.

Abnormal urodynamic findings after radical hysterectomy or pelvic irradiation for cervical cancer

OBJECTIVE

To assess urodynamic study results in patients with cervical cancer who had received radical hysterectomy or pelvic irradiation or radical hysterectomy with pelvic irradiation.

METHODS

Forty-two patients with stage IB cervical cancer after radical hysterectomy (group A), 11 patients at stage IB or IIA after pelvic irradiation (group B), 15 patients at stage IB or IIA after both radical hysterectomy and pelvic irradiation (group C) and 17 patients at stage IB before treatment (group D) as control were recruited for urodynamic examination. The evaluations for each case included a 20-min pad test, uroflowmetry, both filling and voiding cystometry, and stress urethral pressure profile. ANOVA method with Bonferroni test and Pearson chi2-test were utilized for statistical analysis.

RESULTS

The mean ages in sequential groups A, B, C and D were 52.9 +/- 10.2, 62.5 +/- 13.5, 49.8 +/- 11.7 and 49.4 +/- 12.5 years (P = 0.02), respectively. The occurring frequency of either detrusor instability or low bladder compliance was 57%, 45%, 80% and 24%, respectively. Each group revealed decreased bladder capacity as 268.4 +/- 102.8, 164.1 +/- 62.9, 233.5 +/- 73.9 and 293.0 +/- 47.2 ml (P < 0.0001). However, the frequency of abdominal strain voiding was 100% in groups A, B and C as compared to 0% in group D (P < 0.01), and the frequency of abnormal residual urine (> 50 ml) was 41%, 27%, 40% and 24%. Although each case showed a poor pressure transmission ratio (< 100%), the frequency of positive pad test in each group was 81%, 46%, 100% and 18% (P < 0.001). The functional urethral length decreased in each group and was 2.6 +/- 0.8, 2.3 +/- 0.8, 2.5 +/- 0.8 and 2.9 +/- 0.6 cm, but there were no significant differences in maximal urethral pressure or urethral closure pressure among the four groups.

CONCLUSIONS

Our data show that abnormal urodynamic findings pre-exist in patients with cervical cancer before treatment especially in bladder storing function, and that these findings may worsen, or that new abnormal findings may happen after radical hysterectomy or pelvic irradiation, or both.

The role of human papillomavirus DNAs in cervical carcinoma and risk of lymph node metastasis: association with 72-kilodalton metalloproteinase immunostaining

BACKGROUND

The role of human papillomavirus (HPV) as a prognostic factor in cervical carcinoma is not understood completely and little is known regarding the intrinsic mechanisms involved in the metastatic process of HPV positive carcinoma. The authors evaluated HPV status with respect to clinical features in early stage cervical carcinoma, with special emphasis on lymph node spread. The authors also analyzed the relation between HPV, lymph node involvement, and 72-kilodalton (kDa) metalloproteinase immunostaining, an enzyme that cleaves Type IV collagen and may play a role in tumor metastasis.

METHODS

Thirty-two patients with International Federation of Gynecology and Obstetrics Stage I and IIA squamous cell cervical carcinoma treated by primary radical surgery were reviewed. Histologic grade of differentiation, tumor size, fractional depth of invasion, and lymph node spread were evaluated with respect to HPV status and 72-kDa metalloproteinase immunostaining. HPV DNA was detected by polymerase chain reaction and the primers potentially recognized at least the following HPV subtypes: 6, 11, 16, 18, 31, 33, 34, 35, 42, 51, 56, and 58. Immunohistochemical staining was performed using the avidin-biotin complex technique. Affinity-purified rabbit anti-72-kDa metalloproteinase antibody was used.

RESULTS

HPV DNA was detected in a total of 69% of cases, and HPV-16 was the most frequent type detected. HPV positive carcinomas showed a significantly higher rate of lymph node metastases than HPV negative carcinomas (45% vs. 10%; P = 0.03); similarly, 72-kDa metalloproteinase index was significantly higher (P = 0.001).

CONCLUSIONS

These findings suggest a relation between HPV and risk of lymph node metastasis, which may be mediated by an increased production of 72-kDa metalloproteinase.