The prognostic significance of vascular channel involvement and deep stromal penetration in early cervical carcinoma

Analysis of Prognostic Variables, Development of Predictive Models, and Stratification of Risk Groups in Surgically Treated FIGO Early-Stage (IA–IIA) Carcinoma Cervix

Objectives

The objectives of the study were to evaluate clinicopathologic prognostic variables in surgically treated International Federation of Obstetrics and Gynecology early-stage (IA–IIA) cervical cancer, develop prognostic models, and note the role of adjuvant treatment, patterns of failure, and salvage survival (SS) in each group.

Methods

Records of 542 patients who received primary surgical treatment for International Federation of Obstetrics and Gynecology (IA–IIA) cervical cancer were reviewed. Ninety-eight patients who relapsed after primary treatment were identified and matched for stage and age with a control group. Clinicopathologic prognostic variables were identified and used to develop a prognostic model with 3 risk groups for overall survival (OS) and relapse-free survival (RFS). The roles of adjuvant treatment, relapse sites, and SS were also noted in the groups.

Results

The 5-year OS was 70% for the whole group, 97% in the control group, and 44% in the relapse group. There was a statistically significant decrease in survival in patients 70 years or older, those with positive lymphovascular space invasion (LVSI), and in patients with positive LVSI and increasing depth of invasion in both univariate and multivariate analyses (P < 0.001). Positive lymph node status and tumor size of 31 mm or greater showed only a trend toward lower OS and RFS, respectively, in multivariate analysis. An additive model using regression coefficients from multivariate Cox model stratified patients into low-, medium-, and high-risk groups. Relapse-free survival and OS were significantly different in all 3 groups (P < 0.001). Salvage survival was better in low-risk group relative to medium- and high-risk groups, (P = 0.05) as well as between the medium- and high-risk groups (P = 0.03). More distant and locoregional relapses were noted in the medium- and high-risk groups, and SS was better with a local versus locoregional or distant recurrence (P < 0.001).

Conclusions

In this study, age 70 years or older and positive LVSI were found to be statistically significant prognostic factors for both OS and RFS. Positive lymph nodes status showed only a trend toward lower OS. Positive LVSI status had significant adverse prognostic effects on RFS and OS in tumors with increasing depth of invasion. Additive prognostic model helps identify predictors and stratify patients into low-, medium-, and high-risk groups for survival. Many of these factors can be identified preoperatively and may assist in decision to offer primary surgery or alternative therapies in patients with potentially operable cervix cancer. Prognostic model can be used as a tool to design clinical trials and select the group of patients who are the appropriate target for a trial.

Further stratification of risk groups in patients with lymph node metastasis after radical hysterectomy for early-stage cervical cancer

OBJECTIVE

To determine the prognostic factors in node-positive patients with early-stage cervical cancer who underwent radical hysterectomy (RH) and to use these factors to stratify patients into risk groups for individualized adjuvant therapy.

METHODS

Patients with early-stage cervical cancer who had lymph node metastasis after RH were retrospectively analyzed.

RESULTS

Multivariate analysis showed that non-squamous histology, tumor size and parametrial involvement were significantly associated with recurrence-free survival (RFS) and overall survival (OS). Prognostic scores were generated for these factors, and patients were categorized into low- (score 0; n=74), intermediate- (score 1-2; n=100) and high- (score 3-4; n=14) risk groups. Relative to the low-risk group, the probability of cancer recurrence was significantly higher in the high- (OR=10.87, 95% CI=4.22-28.0, P<.001) and intermediate- (OR=3.01, 95% CI=1.37-6.58, P=.006) risk groups. Moreover, the probability of cancer death was significantly higher in the high- (OR=9.88, 95% CI=3.76-25.94, P<.001) and intermediate- (OR=2.49, 95% CI=1.12-5.55, P=.026) risk groups compared with the low-risk group. The rates of pelvic failure and distant recurrence increased with increasing risk.

CONCLUSION(S)

Node-positive patients were heterogeneous, with different prognoses and recurrence patterns according to clinicopathologic risk factors. Further clinical trials are warranted to develop adjuvant treatment strategies individualized to each risk group.

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.

Imaging in cervical cancer

Cervical cancer traditionally has been staged clinically. Advances in imaging could improve the staging of cervical cancer by facilitating the detection of lymph node metastases and micrometastases in distant organs. Such progress could lead to improvements in treatment selection and therefore increase overall survival rates. At the Second International Conference on Clinical Cancer (Houston, TX, April 11-14, 2002), a panel composed of gynecologic oncologists, radiation oncologists, and diagnostic radiologists reviewed relevant technologies. Advances in lymphangiography, ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and lymphatic mapping were reviewed, along with the impact of these advances on the diagnosis, treatment, and survival of patients with cervical cancer. Few cancer centers still use lymphangiography, but the sensitivity of this method ranges from 28% to 83%, with specificity ranging from 47% to 100%. The roles of transabdominal and transvaginal ultrasonography in evaluating cervical cancer are expected to expand when new contrast agents increase the sensitivity of these techniques to parametrial invasion and lymph node metastases; meanwhile, ultrasonography's most significant contributions may involve the identification of uterine and cervical leiomyomas and the evaluation of urinary tract obstruction. Advances in CT have made it a rival technique to MRI, but limitations prevent CT from providing definitive information on certain parameters. MRI, which is valuable because of its superior soft tissue contrast resolution, multiplanar capabilities, and cost-effectiveness, is used to determine the size of the cervix and to detect certain types of invasion, characteristics of lymph nodes, and the presence of disease in the ureter, lung, and liver. PET with 2-[fluorine-18]fluoro-2-deoxy-D-glucose has been found to detect abnormal lymph node regions better than CT does but PET can also be used in conjunction with CT to measure tumor dimensions. PET also has become a method for identifying tumors that are unresponsive to chemoradiation. When used together with immunohistochemical and molecular techniques as well as conventional stains, sentinel lymph node mapping, an important development in the surgical management of solid tumors, is expected to improve gynecologic cancer management. Advances in imaging methods and in contrast agents, along with advances in the combined use of the two, are expected to make imaging technologies more valuable in cervical cancer assessment.

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.

Race and clinical outcome in patients with carcinoma of the uterine cervix treated with radiation therapy

OBJECTIVES

The aim of this study was to examine factors underlying differences in outcome between African-American (AA) and Caucasian (C) patients undergoing radiation therapy (RT).

METHODS

Patient, tumor, treatment characteristics, and the outcome of 316 AA and 94 C cervical cancer patients who underwent RT were compared. Median follow-up was 72.4 months.

RESULTS

AA patients had a trend to a poorer 8-year cause-specific survival (47.9 vs 60.6%) (P = 0.10) compared to C patients with a significant difference seen in stage IIB-IVA disease (34.3 vs 59.5%) (P = 0.04). Several factors correlated with poor outcome were present in the AA group including lower mean hemoglobin levels during RT (P = 0.001), lower median income (P = 0.001), and less frequent intracavitary RT (P = 0.09). In addition, while uncommon in C patients, health problems were major reasons for treatment protraction and inability to undergo intracavitary RT in the AA patients. Multivariate analysis demonstrated that race was not an independent prognostic factor after controlling for difference in patient, tumor, and treatment factors.

CONCLUSIONS

AA cervical cancer patients possess multiple factors that adversely impact upon the efficacy of RT. These findings may add further insight into the observed differences in outcome of cervical cancer patients based on race.

Flow cytometric DNA content analysis of paraffin-embedded tissue derived from cervical carcinoma

PURPOSE

Flow cytometric deoxyribonucleic acid (DNA) content analysis has been shown to be of prognostic importance in some cancers. There have been recent reports of a prognostic importance for DNA content analysis in cervical carcinoma.

METHODS AND MATERIALS

We retrospectively reviewed the hospital and radiation oncology records of cervical carcinoma patients who presented between 1984-1990.

RESULTS

A total of 101 archival paraffin-embedded blocks were processed, of which 77 were of technical quality for analysis. Thirty-five percent were found to be DNA content aneuploid (DNA-A) and 65% DNA content diploid (DNA-D). No statistical difference was found between the two groups in age at diagnosis, % S-phase, coefficient of variation (CV), or proliferative index (PI). A statistical difference was noted in the G2M phase between the two groups (p = 0.004). The median % S-phase was 8.4% in the DNA-D group. A statistical difference (p = 0.017) in survival was noted between the low and high % S-phase DNA-D groups. In patients who received radiation alone, high-PI patients had improved survival compared to low-PI patients. No statistical difference in survival was noted in the high % S-phase DNA-D group and DNA-A group (p = 0.28). Proportional Hazard (Cox) Regression found clinical stage the only independent prognostic indicator for survival.

CONCLUSION

Flow cytometric DNA content analysis is being used more frequently in the management of different malignant tumors. Our study shows that DNA content analysis is useful in determining the prognosis and survival outcomes in cervical carcinomas and may aid in predicting outcome to certain types of treatment regimens.

Prediction of lymph node metastases in patients with early squamous cell carcinoma of the cervix uteri by histopathological grading and flow cytometry

The present study comprises a retrospective investigation of 126 patients with stage IB squamous cell carcinoma of the cervix, and a similar prospective investigation of 53 patients with stage IB and 6 patients with stage IIA disease. Tumour biopsies from these patients were analysed by means of flow cytometry and a semiquantitative histological grading system. The study showed that a combination of a low tumour cell DNA index and a low score value of the grading system indicated a very low risk of regional lymph node metastases (0% lymph node metastases in patients with low scores vs. 24-46% metastases in patients with high scores, P < 0.001). In order to study the reproducibility of the histological grading 20 randomly selected cases were studied blindly by three of the participating pathologists and after discussion of the grading criteria. A kappa coefficient of 722 demonstrated a substantial agreement between the observers. These results suggest that by combining flow cytometry with semiquantitative histological grading, a subgroup of patients with early squamous cell cancer of the cervix uteri may be selected that could be sufficiently treated with simple hysterectomy instead of radical hysterectomy including lymphadenectomy, which, in many oncology centres, is the standard treatment of this patient category.

Age as a prognostic factor in patients with squamous cell carcinoma of the uterine cervix

Correlations between age and several prognostic factors, such as histologic cell type, depth of invasion, intravascular invasion, and lymph node metastases (LNM), were analyzed in squamous cell carcinoma of the cervix (SCC). A total of 380 patients with Stage IB or more advanced SCC underwent radical hysterectomy at the authors' institution from 1971 to 1987. The cases were divided into four age groups: 30 to 39 years, 40 to 49 years, 50 to 59 years, and 60 to 69 years. The depth of invasion was classified in four categories according to pathologic examination of surgical specimens. The only significant factor was the frequency of LNM with deeper invasion, which was less in the 60-to-69-year age group than in the younger age groups. The 5-year survival rates of the patients with LNM also were higher in the 60-to-69-year group. Thus, age 60 or older can be considered a prognostic factor correlating to LNM in squamous cell carcinoma of the cervix.

Early stage I adenocarcinoma of the uterine cervix: treatment results in patients with tumors less than or equal to 4 cm in diameter

Between 1965 and 1985, 160 patients had initial treatment at the M. D. Anderson Cancer Center for Stage I adenocarcinoma of the uterine cervix less than or equal to 4 cm in diameter. Of these patients, 84 were treated with radiation therapy (RT) alone, 20 were treated with external and intracavitary radiation followed by total hysterectomy (R + S), and 56 were treated with radical hysterectomy (RH). Survival rate was strongly correlated with tumor volume (P = 0.0008), lymphangiogram findings (P = 0.01), and tumor grade (P = 0.0018). Patients with a normal-appearing cervix or a small visible or palpable tumor that did not expand the cervix more than 3 cm had survival and pelvic-control rates of more than 90% after treatment with RH or RT. However, after 5 years, 45% of patients treated with RH for tumors 3-4 cm in diameter had disease recurrence in the pelvis, compared with 11% of patients treated with either RT or R + S (P = 0.025). For patients treated with RH, recurrence was also strongly correlated with findings of lymph/vascular space invasion (P = 0.0004) and poorly differentiated tumor (P = 0.018). Major complication rates were comparable for the three treatment groups. The high rate of pelvic recurrence following treatment with radical hysterectomy alone for patients with tumors greater than 3 cm in diameter, particularly in the presence of lymph/vascular space invasion, poorly differentiated features, and/or positive nodes, should be considered in planning the primary management of patients with Stage I adenocarcinoma of the cervix.

Adjuvant radiotherapy following radical hysterectomy for patients with stage IB and IIA cervical cancer

From 1971 through 1984, 320 women underwent radical hysterectomy as primary therapy of stage IB and IIA cervical cancer. Two hundred forty-eight patients (78%) were treated with surgery alone and 72 patients (22%) received adjuvant postoperative external-beam radiotherapy. Presence of lymph node metastasis, large lesion (greater than 4 cm in diameter), histologic grade, race (noncaucasian), and age (greater than 40 years) were significant poor prognostic factors for the entire group of patients. Patients treated with surgery alone had a better disease-free survival than those who received combination therapy (P less than 0.001). However, patients receiving adjuvant radiation therapy had a higher incidence of lymphatic metastases, tumor involvement of the surgical margin, and large cervical lesions. Adjuvant pelvic radiation therapy did not improve the survival of patients with unilateral nodal metastases or those who had a large cervical lesion with free surgical margins and the absence of nodal involvement. Radiation therapy appears to reduce the incidence of pelvic recurrences. Unfortunately, 84% of patients who developed recurrent tumor after combination therapy had a component of distant failure. The incidence of severe gastrointestinal or genitourinary tract complications was not different in the two treatment groups. However, the incidence of lymphedema was increased in patients who received adjuvant radiation therapy. Although adjuvant radiation therapy appears to be tolerated without a significant increase in serious complications, the extent to which it may improve local control rates and survival in high-risk patients appears to be limited. In view of the high incidence of distant metastases in high-risk patients, consideration should be given to adjuvant systemic chemotherapy in addition to radiation therapy.

Presurgical prognostic factors in carcinoma of the cervix, stages IB and IIA

Possible prognostic factors in early stage cervical cancer include patient age, tumor size, cell type, differentiation, and channel invasion. In this study each of these factors was evaluated based only on the findings available before surgery, and the observations are compared with patient survival and incidence of node metastases. One hundred consecutive patients with stage IB or IIA cervical cancer treated by primary radical surgery and followed at least 2 years are reported. Disease-free survival was 90% at 2 years and 85% at 5 years; 19% had node metastases. Of the factors studied, only age greater than 50 years was associated with poor prognosis (p less than 0.02 versus age less than 50 years). Only large tumor size was associated with increased node metastases (p less than 0.001 versus medium and small size). Tumor cell type, differentiation, and channel involvement had no bearing on survival or node metastases. Because older age and large tumors appear to be factors of poor prognosis for surgery, and yet it is not clear that these patients fare better with radiotherapy, we suggest a prospective trial of radiotherapy versus surgery for this group.