The prognosis and treatment of stage I adenocarcinoma of the cervix

Ovarian conservation is associated with better survival in young patients with T1N0M0 cervical adenocarcinoma: a population-based study

PURPOSE

Ovarian conservation is controversial in patients with cervical adenocarcinoma due to the risk of ovarian metastasis. The aim of this study is to evaluate the association of ovarian conservation with survival outcomes in young patients with T1N0M0 cervical adenocarcinoma.

METHODS

Women who were 45 years of age or younger with T1N0M0 cervical adenocarcinoma from 1988 to 2013 recorded in the Surveillance, Epidemiology, and End Results (SEER) database were included. Propensity score weighting was used to balance the intragroup differences. Cause-specific survival (CSS) and overall survival (OS) were compared using Kaplan-Meier estimates. A multivariate Cox model was used to adjust for covariates including propensity score. A stratified analysis was then conducted.

RESULTS

Totally, 1090 (79.7%) patients underwent oophorectomy and 278 (20.3%) patients whose ovaries were preserved were identified. Patients with preserved ovaries were younger, with a lower T classification and less likely to undergo pelvic lymphadenectomy (all p < 0.05). After propensity weighting, ovarian conservation group had better cause-specific survival (CSS) (5-year 98.8 versus 97.1%, 10-year 98.0 versus 95.2%, p = 0.0370) and overall survival (OS) (5-year 98.8 versus 97.1%, 10-year 96.5 versus 93.5%, p = 0.0025). After adjustment, the CSS benefit of ovarian conservation was marginally significant (p = 0.051) and OS benefit was still significant (p = 0.006). Stratified analysis showed that the CSS benefit was found in T1b classification (HR, 0.23; 95% CI 0.06-0.89, p = 0.033) and histological grade > 1 (HR 0.12; 95% CI 0.02-0.87; p = 0.035).

CONCLUSION

Among young women with T1N0M0 cervical adenocarcinoma, ovarian conservation is associated with better survival.

The Safety of Ovarian Preservation in Early-Stage Adenocarcinoma Compared With Squamous Cell Carcinoma of Uterine Cervix: A Systematic Review and Meta-Analysis of Observational Studies

Objective

The aim of this study was to compare the incidence of ovarian metastasis (OM) in adenocarcinoma (ADC) and squamous cell carcinoma (SCC) in early-stage cervical cancer and evaluate the safety of ovarian preservation in early-stage ADC.

Methods

To perform a meta-analysis to compare the incidence of OM between early-stage ADC and SCC, we searched PubMed, EMBASE, and Cochrane for observational studies that compared it with pathological evidence after radical hysterectomy and oophorectomy. Odds ratios with 95% confidence intervals were calculated with a fixed effects model. We also found a few articles evaluating the oncological prognosis of patients with ovarian preservation to perform a systematic review.

Results

A total of 5 studies were included in the meta-analyses. The incidence of OM of patients with early-stage ADC and SCC were 2% and 0.4%, respectively (odds ratio, 5.27; 95% confidence interval, 2.14–13.45). In 1427 patients with ADC or SCC of the cervix FIGO stage (CIS-IIA) who underwent hysterectomy, no ovarian recurrences were observed after unilateral or bilateral ovarian preservation in ADC patients in the follow-up (30–68 months); however, 15 patients with SCC developed pelvic recurrence.

Conclusions

Although the incidence of OM was higher in early-stage ADC than SCC according to ovarian pathology, it might be relatively safe to perform ovarian preservation with early-stage ADC because of low ovarian recurrence rate in short-term follow-ups.

Uterine Glandular Carcinoma

This study correlated the histologic and immunohistochemical features of cervical and endometrial glandular carcinomas (adenosquamous carcinoma [ADENSQ] and ade nocarcinoma [AC] ) with clinical outcome. A series of 87 uterine glandular carcinomas (53 cervical, 33 endometrial, and 1 arising in both cervix and endometrium) were histologically classified into mullerian subtypes: 28 ADENSQ, 19 serous AC, 19 mu cinous AC, 15 endometrioid AC, and 6 clear cell AC. Utilizing both nuclear and archi tectural features, 66 glandular carcinomas were high histologic grade (3) and 21 were low histologic grade (1 or 2). Immunohistochemical studies performed on 83 of the cases showed: 33 + for monoclonal carcinoembryonic antigen (CEA-M); 38 + for polyclonal CEA (CEA-P); 26 + for placental alkaline phosphatase; 18 + for CA 125; 29 + for CA 19-9; 24 + for vimentin; 60 + for cytokeratin CAM 5.2; and 81 + for cytokeratin AE 1 : 3. The following significant correlations were identified. ADENSQ histology was associated with CEA-M staining (P < .025), and mucinous histology was associated with CA 19-9 staining (P < .025). Cervical primary site was associated with ADENSQ histology (P < .001) and staining with CEA-M (P < .025) and CEA-P (P < .05). Endometrial primary site was associated with endometrioid histology (P < .001). Forty-five patients had recurrent disease, 30 patients were disease-free for more than 1 year, and 12 patients had insufficient follow-up evaluation. Recurrent disease was associated with stage III or IV tumors (P < .001), grade 3 histology (P < .001), serous differentiation (P < .001), invasion to at least the middle third of the myometrium (P < .001) and large size of residual tumor at hysterectomy (mean 3.9 cm versus 1.3 cm, P < .005). Disease-free survival was associated with endometrioid differentiation (P < .05), strong CEA-M staining (P < .001), CEA-P staining (P < .025), and CA 19-9 staining (P < .05). Considering only stage 1 and 2 patients, grade 3 histology ( P < .025), deep myometrial invasion (P < .01), and size (P < .05) were still associated with recurrence and strong CEA-M staining (P < .025) was still associ ated with disease-free survival. However, strong CEA-M staining, deep myometrial invasion, and size of tumor after hysterectomy were all associated with histologic grade. Considering just histologic grade 3 carcinomas in stage 1 and 2 patients, absence of strong CEA-M staining, deep myometrial invasion, and size of tumor was no longer associated with recurrent disease. Histologic grade was the only independent predictor of prognosis in stage I and II patients. Int J Surg Pathol 1 (1): 13-24, 1993

Adenocarcinoma and Adenosquamous Carcinoma of the Uterine Cervix

A series of 53 carcinomas of the uterine cervix with a component of glandular differen tiation were identified and included 29 pure adenocarcinomas and 24 adenosquamous carcinomas. Cervical adenosquamous carcinomas were defined as glandular carcino mas mixed with a squamous carcinoma component. Cervical pure adenocarcinomas were classified into various Mullerian subtypes analogous to other portions of the female genital tract yielding 14 mucinous/endocervical, 11 serous, 2 clear cell, and 2 endometrioid adenocarcinomas. A panel of immunostains including monoclonal carcinoembryonic antigen (CEA-M), polyclonal carcinoembryonic antigen (CEA-P), CA 125, CA 19-9, placental alkaline phosphatase, and vimentin showed no association with histologic differentiation except for mucinous/endocervical subtype (7 of 11 CEA- M or CEA-P positive and 7 of 11 CA 19-9 positive). Recurrent disease in adenocarci noma and adenosquamous carcinoma was associated with stage III or IV disease at presentation (P < .001), serous histology (P < .05), absence of strong CEA-M staining (P < .025), absence of strong CEA-P staining (P < 05), and presence of vimentin staining (P < .05). No association was found between survival and other histologic subtypes of adenocarcinoma (mucinous/endocervical, endometrioid, or clear cell), ad enosquamous carcinoma, histologic grade, lymphatic invasion, age, or immunohisto chemical staining for CA 125, CA 19-9, or placental alkaline phosphatase. When only stage I and II disease was considered, there was no correlation between histology or immunohistochemistry and outcome. Int J Surg Pathol 1(3):181-190, 1994

MN Protein Immunolocalization in Uterine Cervix Carcinoma With Glandular Differentiation: A Clinicopathologic Study of a New Cancer-specific Biomarker

MN protein is the product of the newly described endogenous MN gene that is expressed in the tumorigenic phenotype of HeLa X fibroblast somatic cell hybrids. MN protein has carbonic anhydrase and putative DNA binding activity. With the exception of gastric mucosa, MN protein is expressed in neoplasia, particularly uterine cervix carcinoma, but not in benign tissue. This investigation examined the pathogenetic and prognostic significance of MN-protein immunoreactivity in uterine cervix carcinoma with glandular differentiation. Paraffin sections from 77 cervix carcinomas with glandular differentiations including 36 pure adenocarcinomas and 41 adenosquamous carcinomas were immunostained with anti-MN-protein (M-75 monoclonal proprietary; Ciba Corning Diagnostics, Alameda, CA). A total of 64.9% of cervix carcinomas with glandular differentiation exhibit MN-protein immunoreactivity localized to plasma membranes, cytoplasm, and some nuclei of neoplastic cells only, but not in adjacent benign tissue. The MN-protein staining intensity and distribution was as follows: 37.7% strong diffuse (≥ 50% cells positive), 19.5% strong focal (< 50% cells positive), and weak (7.8%). Immunoreactivity occurred in both squamous and glandular areas of adenosquamous carcinomas and was unrelated to histopathologic features. Follow-up information was available on 67 patients: 31 exhibited recurrent disease (7 pelvic, 14 distant, and 10 both) at 1–144 months (mean 37, median 14), and 36 were disease-free at 12–216 months (mean 67, median 44.5). MN-protein immunoreactivity (all positives, both standard diffuse and strong focal, or standard diffuse only) exhibited no association with clinical outcome. Recurrent disease was associated with nuclear grade ( P < .001), lymphatic invasion ( P < .005), size on clinical examination or pathologic evaluation ( P < .005), pelvic lymph node involvement ( P < .05), and clinical stage ( P < .05). MN-protein immunoreactivity did not correlate with these features and did not help predict which patients would develop recurrence in the good prognosis groups. Our data show that expression of MN-protein is associated with cervix carcinoma with glandular differentiation carcinogenesis. MN-protein immunolocalization may have a diagnostic role in confirming cervix carcinoma with glandular differentiation in histologically challenging cases.

Gynecologic Cancer InterGroup (GCIG) consensus review for cervical adenocarcinoma

Cervical adenocarcinoma is known to be less common than squamous cell carcinoma of the cervix comprising approximately 25% of all cervical carcinomas. Differences in associated human papillomavirus types, patterns of spread, and prognosis call for treatments that are not always like those for squamous cancers. In this review, we report a consensus developed by the Gynecologic Cancer InterGroup surrounding cervical adenocarcinoma for epidemiology, pathology, treatment, and unanswered questions. Prospective clinical trials are needed to help develop treatment guidelines.

Ovarian Preservation in Young Patients With Stage I Cervical Adenocarcinoma: A Surveillance, Epidemiology, and End Results Study

Objectives

Although a large part of patients with cervical adenocarcinoma are young, oophorectomy is commonly performed in those who receive hysterectomy for fear of ovarian metastasis. The purpose of this study was to examine the safety of ovarian preservation in young women with cervical adenocarcinoma.

Methods

Patients 45 years or younger with stage I cervical adenocarcinoma and adenosquamous carcinoma were identified in the Surveillance, Epidemiology, and End Results program (1988–2007). The characteristics of the patients with ovarian preservation were compared with those of the women with oophorectomy. Univariate Kaplan-Meier analysis and multivariate Cox proportional hazards model were used to explore the effects of ovarian preservation on survival.

Results

The study sample consisted of 1639 women, including 1062 women (64.8%) who underwent oophorectomy and 577 women (35.2%) who had ovarian preservation at the time of hysterectomy. Younger age (P< 0.001), recent diagnosis (P< 0.001), low-grade (P< 0.001) and smaller tumor (P< 0.001), white population (P= 0.015), as well as less chance to undergo lymphadenectomy (P< 0.001) and adjuvant radiotherapy (P= 0.041) were associated with ovarian preservation. Ovarian preservation had no effect on either cancer-specific (hazard ratio [HR], 0.90; 95% confidence interval [CI], 0.50–1.61) or overall (HR, 0.81; 95% CI, 0.49–1.33) survival in the Cox proportional hazards model. When the patients without radiotherapy were separately analyzed, the effect on either cancer-specific (HR, 1.24; 95% CI, 0.44–3.54) or overall (HR, 0.77; 95% CI, 0.35–1.73) survival were not statistically significant.

Conclusions

Ovarian preservation may have oncological safety for young women with stage I cervical adenocarcinoma.

Daily low-dose cisplatin-based concurrent chemoradiotherapy in patients with uterine cervical cancer with emphasis on elderly patients: a phase 2 trial

OBJECTIVE

We evaluated the usefulness of daily low-dose cisplatin-based concurrent chemoradiotherapy (daily CCRT) in patients with cervical cancer with an emphasis on elderly patients.

METHODS

Between January 2003 and December 2008, a total of 65 patients with untreated stage IIA to IIIB cervical cancer were enrolled and 54 were selected for this nonrandomized prospective study. The daily CCRT comprised pelvic external beam radiotherapy (2 Gy/d × 25) with daily low-dose cisplatin (8.0 mg/m(2) per day) and either low- or high-dose rate intracavitary brachytherapy.

RESULTS

The median age of the patients was 62 years (range, 29-85 years), and 21 patients (39%) were 70 years or older. The median follow-up period was 47 months (range, 4-107 months). Daily CCRT was successfully completed in 91% (49/54) of the patients. The mean total cisplatin dose was 191 mg/m (range, 128-224 mg/m(2)), and a neutropenia grade higher than 3 was observed in 24% of the patients. Of the 21 patients 70 years or older, 17 (81%) completed daily CCRT with acceptable toxicity. The 3-year overall survival (OS) rate for all the patients was 82.9%. No statistically significant differences in the OS rate and toxicity were observed between patients 70 years or older and those younger than 70 years.

CONCLUSIONS

Daily CCRT showed acceptable toxicity and compliance, leading to the use of a high total dosage of cisplatin. The OS rate for daily CCRT was comparable to that for previously reported weekly CCRT. Daily CCRT could be an alternate choice for the CCRT treatment in elderly patients with cervical cancer.

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.

Primary surgery versus primary radiotherapy with or without chemotherapy for early adenocarcinoma of the uterine cervix

BACKGROUND

For early squamous cell carcinoma of the uterine cervix, the outcome is similar after either primary surgery or primary radiotherapy. There are reports that this is not the case for early adenocarcinoma (AC) of the uterine cervix: some studies have reported that the outcome is better after primary surgery. There are no systematic reviews about surgery versus chemoradiation in the treatment of cervical cancer. This is an updated version of the original Cochrane review published in Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD006248. DOI: 10.1002/14651858.CD006248.

OBJECTIVES

The objectives of this review were to compare the effectiveness and safety of primary surgery for early stage AC of the uterine cervix with primary radiotherapy or chemoradiation.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2009, MEDLINE (1950 to July week 5, 2009), EMBASE (1980 to week 32, 2009) and we also searched the related articles feature of PubMed and the Web of Science. We also checked the reference lists of articles. For this update, the searches were re-run in June 2012: MEDLINE 2009 to June week 2, 2012, EMBASE 2009 to 2012 week 24, CENTRAL Issue 6, 2012, Cochrane Gynaecological Specialised Register June 2012.

SELECTION CRITERIA

Studies of treatment of patients with early AC of the uterine cervix were included. Treatment included surgery, surgery followed by radiotherapy, radiotherapy and chemoradiation.

DATA COLLECTION AND ANALYSIS

Forty-three studies were selected by the search strategy and 30 studies were excluded. Twelve studies were considered for inclusion. Except for one randomised controlled trial (RCT), all other studies were retrospective cohort studies with variable methodological quality and had limitations of a retrospective study. Comparing the results from these retrospective studies was not possible due to diverging treatment strategies.

MAIN RESULTS

Analysis of a subgroup of one RCT showed that surgery for early cervical AC was better than radiotherapy. However, the majority of operated patients required adjuvant radiotherapy, which is associated with greater morbidity. Furthermore, the radiotherapy in this study was not optimal, and surgery was not compared to chemoradiation, which is currently recommended in most centres. Finally, modern imaging techniques (i.e. magnetic resonance imaging (MRI) and positive emission tomography - computed tomography (PET-CT) scanning) allow better selection of patients and node-negative patients can now be more easily identified for surgery, thereby reducing the risk of 'double trouble' caused by surgery and adjuvant radiotherapy.  

AUTHORS' CONCLUSIONS

We recommend surgery for early-stage AC of the uterine cervix in carefully staged patients. Primary chemoradiation remains a second best alternative for patients unfit for surgery; chemoradiation is probably first choice in patients with (MRI or PET-CT-suspected) positive lymph nodes. Since the last version of this review no new studies were found.

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.

Roles of intrinsic angiogenesis inhibitor, vasohibin, in cervical carcinomas

The aim of the present study is to clarify the critical roles of vasohibin in cervical carcinomas. We investigated the expression ratios of vasohibin and vascular endothelial growth factor (VEGF) receptor-2 on endothelium and microvessel density, lymphatic vessel density (LVD) by immunohistochemistry. Sixty-one squamous cell carcinoma (SCC), 18 mucinous adenocarcinoma (Adenocarcinoma), 38 carcinoma in situ (CIS), and 35 normal cervical epithelium were collected. We investigated the expression of vasohibin and compared it with the expression of VEGF receptor-2 (VEGFR-2, KDR/flk-1), and CD34 in the stromal endothelium. Expression of VEGF was counted using the histological score (H score). D2-40 was used as a marker for lymphatic endothelial cells to investigate LVD. The microvessel density of the normal cervical epithelium was significantly lower than that of CIS, SCC, and Adenocarcinoma (P < 0.05). The expression ratio of vasohibin in the normal cervical epithelium was significantly lower than that of SCC and Adenocarcinoma (P < 0.05). The expression ratio of VEGFR-2 of the normal cervical epithelium was significantly lower than that of SCC and Adenocarcinoma (P < 0.05). The LVD of the normal cervical epithelium was significantly lower than that of CIS, SCC, and Adenocarcinoma (P < 0.05). For normal cervical epithelium, CIS, and SCC, there was a moderate correlation between the expression percentage of vasohibin and the expression percentage of VEGFR-2 (P < 0.05, r(2) = 0.3018). This is the first study to elucidate the correlation between the expression of vasohibin in the stromal endothelial cells and the expression of VEGFR-2 in human cervical carcinomas.

Primary surgery versus primary radiation therapy with or without chemotherapy for early adenocarcinoma of the uterine cervix

BACKGROUND

For early squamous cell carcinoma of the uterine cervix, the outcome is similar after either primary surgery or primary radiotherapy. There are reports that this is not the case for early adenocarcinoma (AC) of the uterine cervix: some studies have reported that the outcome is better after primary surgery. There are no systematic reviews about surgery versus chemoradiation in the treatment of cervical cancer.

OBJECTIVES

The objectives of this review were to compare the effectiveness and safety of primary surgery for early stage AC of the uterine cervix with primary radiotherapy or chemoradiation.

SEARCH STRATEGY

We searched Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2009, MEDLINE (1950 to July week 5, 2009), EMBASE (1980 to week 32, 2009) and we also searched the related articles feature of PubMed and the Web of Science. We also checked the reference lists of articles.

SELECTION CRITERIA

Studies of treatment of patients with early AC of the uterine cervix were included. Treatment included surgery, surgery followed by radiotherapy, radiotherapy and chemoradiation.

DATA COLLECTION AND ANALYSIS

Forty-three studies were selected by the search strategy and thirty studies were excluded. Twelve studies were considered for inclusion. Except for one randomised controlled trial (RCT), all other studies were retrospective cohort studies with variable methodological quality and had limitations of a retrospective study. Comparing the results from these retrospective studies was not possible due to diverging treatment strategies.

MAIN RESULTS

Analysis of a subgroup of one RCT showed that surgery for early cervical AC was better than RT. However, the majority of operated patients required adjuvant radiotherapy, which is associated with greater morbidity. Furthermore, the radiotherapy in this study was not optimal, and surgery was not compared to chemoradiation, which is currently recommended in most centres. Finally, modern imaging techniques, i.e. MR-imaging and PET-CT-scanning, allow better selection of patients and node negative patients can now be more easily identified for surgery, there by reducing the risk of 'double trouble' caused by surgery and adjuvant radiotherapy.

AUTHORS' CONCLUSIONS

We recommend surgery for early stage AC of the uterine cervix in carefully staged patients. Primary chemoradiation remains a second best alternative for patients unfit for surgery; chemoradiation is probably first choice in patients with (MRI or PET-CT-suspected) positive lymph nodes.

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.

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.

Factors predicting disease outcome in early stage adenocarcinoma of the uterine cervix

CONTEXT

Adenocarcinoma (AC) and adenosquamous carcinoma (ASC) comprise the second principal histological types of cervical carcinoma. As compared with the squamous cell cancer (SCC), these lesions are far less frequent, and their epidemiology, natural history and prognostic determinants are less well understood.

OBJECTIVE

Patients with an early stage AC of the uterine cervix diagnosed in our clinic were subjected to detailed analysis for the prognostic determinants.

STUDY SUBJECTS

A series of 94 women with early stage (adenocarcinoma in situ (AIS) to IIB) cervical ACs or ASCs diagnosed and treated in our department during 1995-1999 and subsequently followed-up for a mean of 43.1 +/- 16.2 (S.D.) months.

MAIN OUTCOME MEASURES

Patients were examined by colposcopy, Papanicolaou (PAP) smear and biopsy. The stage of the disease (FIGO) and tumour histology in operative specimens were recorded, and univariate (Kaplan-Meier) and multivariate survival analysis (Cox) were run to explore the factors predicting disease outcome.

RESULTS

Mean age of the women was 44.2 +/- 2.5 (S.D.) years (range 24-81 years), which is significantly (P=0.000) lower than that (49.9 +/- 14.2) of 464 SCC patients in our material. Minority of the women (38.2%) reported any clinical symptoms, but these correlated with the stage (P=0.041). Screening history was acceptable (i.e. screening interval 3 to 4 years) in 56 women, whereas 28 (29.8%) had no previous PAP smear taken. Interpretation errors were established in 17 (23.6%) and sampling errors in 6 (8.3%) of the 72 smears available for re-screening. No colposcopic lesions were found in 29 (30.9%) women. Follow-up data were available from 72 patients, of whom the disease progressed in four (one died), whereas 68 patients are alive and well at the moment. Patient's age (P=0.000), screening history (P=0.0127), FIGO stage (P=0.001), mode of therapy (P=0.0187), and presence of co-existent squamous cell lesions (P=0.0184) were significant prognostic indicators in univariate survival analysis. Cox's multivariate survival analysis disclosed FIGO stage (P=0.001) and screening history (P=0.006) as the only significant independent predictors of the disease outcome.

CONCLUSIONS

The present data emphasise the importance of early cervical AC as a disease of younger women, making early detection of its precursors (AIS) by regular PAP smear screening mandatory in prevention of disease progression. This can only be achieved by increasing the sensitivity of the PAP smear in detecting abnormal glandular cells in asymptomatic women.

Histologic subtype has minor importance for overall survival in patients with adenocarcinoma of the uterine cervix: a population-based study of prognostic factors in 505 patients with nonsquamous cell carcinomas of the cervix

BACKGROUND

The incidence of adenocarcinoma of the uterine cervix is increasing. For better prognostic information, the authors studied all nonsquamous cell carcinomas (non-SCCs) in the Norwegian population over a total of 15 years.

METHODS

All non-SCCs from three 5-year periods (1966-1970, 1976-1980, and 1986-1990) were reviewed and classified according to the World Health Organization classification system, and histopathologic and clinical parameters were registered. Tissue blocks were available from all patients.

RESULTS

Of 505 patients, 417 had tumors classified as adenocarcinoma, and 88 had tumors classified as other non-SCC. The mean ages were 53 years and 52 years for patients with adenocarcinoma and non-SCC, respectively. Sixty-two percent of the staged patients had clinical Stage I disease according to the classification system of the International Federation of Gynecology and Obstetrics (FIGO). In univariate analyses, histology, architectural and nuclear grade, extension to the vagina or corpus uteri, tumor length (> 20 mm) or tumor volume (> 3000 mm(3)), infiltration depth (in thirds of the cervical wall), thickness of the remaining wall (< 3 mm), vascular invasion, lymph node metastases, treatment, and patient age were significant variables in patients with FIGO Stage I disease. Variables with no significance in patients with Stage I disease were number of mitoses, state of resection margins, infiltration to ectocervix, tumor thickness, lymphoid reaction, earlier or concomitant cervical intraepithelial neoplasia, stump carcinoma, DNA ploidy or DNA index, or time period. Multivariate analyses of patients with FIGO Stage I disease identified small cell carcinoma, corpus infiltration, vascular invasion, and positive lymph nodes as independent prognostic factors.

CONCLUSIONS

Small cell carcinoma was the only histologic subgroup of independent importance for prognosis in patients with non-SCC of the uterine cervix. No significant difference between major subtypes of adenocarcinoma favored a simplified classification. Extension to the corpus in patients with early-stage disease was of independent significance and should be acknowledged in planning treatment.

A comparison of prognoses of pathologic stage Ib adenocarcinoma and squamous cell carcinoma of the uterine cervix

OBJECTIVES

The influence of the histology of adenocarcinoma on recurrence and survival for patients treated with radical hysterectomy and diagnosed as having pathologic stage Ib cervical cancer was investigated.

METHODS

Five hundred and nine patients (405 squamous cell carcinomas, 104 adenocarcinomas) with pathologic stage Ib cervical cancer treated initially at the Aichi Cancer Center between 1976 and 1995 were studied.

RESULTS

Multivariate analysis identified the prognostic variables as histology of adenocarcinoma, number of lymph nodes involved, and tumor size beyond 4 cm. Five-year overall survival and disease-free survival of patients with adenocarcinoma in the presence of lymph node metastasis were 63.2 and 47.4%, respectively, significantly poorer than for squamous cell carcinoma (83.6 and 80.6%; P < 0.001 and P = 0.002, respectively). These were not different in the absence of lymph node metastasis (adenocarcinoma, 93.9 and 92.7%; squamous cell carcinoma, 97.9% and 96.1%; P = 0.067 and P = 0.250, respectively).

CONCLUSIONS

The independent significant risk factors for the recurrence and survival of pathologic stage Ib cervical cancer were the presence of lymph node metastasis, large tumor size beyond 4 cm, and histology of adenocarcinoma. The prognosis of patients with adenocarcinoma was poorer than of patients with squamous cell carcinoma in the presence of lymph node metastasis, while the prognosis of pathologic stage Ib cervical cancer was equivalent when there was no metastasis.

Microinvasive adenocarcinoma of the cervix

We evaluated the management of patients with microinvasive adenocarcinoma of the cervix (MIAC), in particular, to determine the place of conservative surgery, and determine if the FIGO classification for MIAC is valid and equivalent to the classification as it applies to microinvasive squamous cancer. A review was undertaken of the database of the Queensland Centre for Gynaecological Cancer (QCGC) from January, 1986 to October, 1998. The records of all patients recorded as having MIAC were retrieved. Microinvasion was defined according to the 1995 FIGO classification as a depth of invasion of no greater than 5 mm and a horizontal dimension of no greater than 7 mm 30 patients were found to have been treated for MIAC. The vast majority (29) were asymptomatic, disease being discovered at the time of routine Papanicolaou smear. There was a 43% incidence of coexisting squamous intraepithelial neoplasia. Multifocal disease was found in 17% of patients and lymph-vascular positivity in 7%. Eighteen patients were treated with radical surgery and 13 with conservative surgery. There were no recurrences over a follow-up interval of 3-116 months. Of the 18 patients treated with radical surgery, none was found to have occult microscopic disease in the parametria or nodal metastases. A total of 27 ovaries were removed, all of which were free of disease. In this small study, MIAC appears to behave in a manner similar to the squamous equivalent. The results provide some justification for the FIGO classification of a microinvasive glandular neoplasm of the cervix. There is some support for a role for conservative surgery in managing this condition, but there is insufficient worldwide experience to make definitive recommendations.

Ovarian metastasis in stage IB and II cervical adenocarcinoma

We performed the present study to identify those patients with adenocarcinoma of the cervix in whom ovarian preservation might be acceptable. Between January 1971 and December 1996, 82 patients with International Federation of Gynecology and Obstetrics stage IB and II cervical adenocarcinoma and adenosquamous carcinoma, treated by radical hysterectomy, bilateral salpingo-oophorectomy, and pelvic node dissection, were identified. The mean age of the patients was 44.6 years (range 27-72). The incidence of ovarian metastasis was more frequent in stage II (19.0%) than in stage IB disease (2.5%), in which only 1 patient with apparent extrauterine disease at laparotomy had an ovarian metastasis. No patients with up to inner two-thirds of stromal invasion had ovarian metastasis; however, 5 of 24 patients with outer one-third stromal invasion (20.8%) and 4 of 20 with parametrial invasion (20.0%) had ovarian metastasis. A significantly higher incidence of ovarian metastasis was also observed in 5 of 20 cases with lymph node metastasis (25.0%) than in 4 of 62 patients without lymph node metastasis (6.5%). Multivariate analysis, however, found only deep stromal invasion to be an independent risk factor for ovarian metastasis. Although it would be reasonable to conserve normal-appearing ovaries in young women undergoing radical hysterectomy for treatment of stage IB cervical adenocarcinoma and adenosquamous carcinoma, gross intraoperative inspection of the radical hysterectomy specimen may identify deep cervical invasion or extrauterine spread in those who are at increased risk of ovarian metastases.

Are adenocarcinomas and adenosquamous carcinomas different from squamous carcinomas in stage IB and II cervical cancer patients undergoing primary radical surgery?

The aim of this study was to define clinicopathologic features and to investigate prognostic factors in early-stage cervical adenocarcinomas and adenosquamous carcinomas in patients undergoing primary radical surgery. One hundred thirty-four patients with stage IB or II cervical adenocarcinoma or adenosquamous carcinomas treated at a single institution were reviewed and compared to squamous carcinomas (N = 757) treated in the same period. Among adeno-adenosquamous carcinomas, stage II disease, parametrial extension, and deep cervical stromal invasion (>2/3) were associated with increased risk of pelvic lymph node metastases, while only clinical stage II, DNA index >1.3 (by flow cytometry), and pelvic node metastases were significantly associated with decreased survival by multivariate analyses. The five-year recurrence-free and overall survival rates of patients with adeno-adenosquamous vs squamous carcinoma were 72.2% vs 81.2% (P = 0.0109), and 74.1% vs 82.8% (P = 0.0136), respectively by Mantel-Cox test. After controlling confounding factors, histologic type (adeno-adenosquamous vs squamous) was confirmed as an independent prognostic factor for recurrence-free survival [relative risk (RR): 1.2792; 95% confidence interval (CI): 1.0628-1.5399, P = 0.0092) and overall survival (RR: 1.2594, 95% CI: 1.0467-1.5155, P = 0.0146) in the whole series (N = 891). Although pattern of relapse by histologic type was not significantly different, patients with recurrent adeno-adenosquamous carcinoma did significantly worse than those with recurrent squamous carcinoma. In conclusion, the prognosis of adeno-adenosquamous carcinoma of the cervix is slightly worse than squamous tumors. Since salvage of recurrent adeno-adenosquamous carcinoma after primary radical surgery is generally ineffective using conventional treatment, innovative strategies are necessary for the high-risk group after primary surgery and all recurrent adeno-adenosquamous carcinomas regardless of size or site.

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.

Stage I adenocarcinoma of the cervix: does lesion size affect treatment options and prognosis?

A retrospective analysis of 93 patients with International Federation of Gynecology and Obstetrics stage I adenocarcinoma of the cervix was performed to determine the significance of tumor size, patient age, tumor grade, lymph node status, and primary treatment modality as prognostic variables of 5-year survival and 5-year progression-free survival (PFS). Multivariate analysis demonstrated that patient age and tumor grade were significant variables prognostic of survival (p < 0.01 and p = 0.01, respectively). Tumor size was a significant (p < 0.01) prognostic variable of PFS in a multivariate model that included tumor size and patient age. An important advantage in survival and PFS for patients with lesions smaller than 3 cm compared with those patients with lesions 3 cm or more was observed (92% vs. 76% and 89% vs. 67%, respectively). Among surgically treated patients, survival and PFS among patients with lesions smaller than 3 cm were significantly improved compared with patients with tumors 3 cm or more (97% vs. 77% [p = 0.03] and 90% vs. 69% [p = 0.03], respectively). Significant improvement in survival and PFS was observed among patients with lesions smaller than 3 cm who were treated with surgery compared with those who received radiation therapy (97% vs. 77% [p = 0.03] and 90% vs. 77% [p = 0.048], respectively).

Angiogenesis in adenocarcinoma of the uterine cervix

BACKGROUND

Angiogenesis is essential for tumor growth, progression, and metastases. Microvessel density (MVD), a measure of tumor angiogenesis, has been found to have prognostic significance in many tumor types for predicting metastasis and survival.

METHODS

Between 1979-1989, 56 cases of FIGO Clinical Stage I and II adenocarcinoma of the uterine cervix treated by hysterectomy were reviewed histologically. All hysterectomy specimens were stained immunohistologically for factor VIII-related antigen. MVD was counted in a x200 field (0.785 mm2 per field) in the most active area of neovascularization. Results were expressed as the highest number of microvessels identified within any single x200 field. MVD and several other prognostic parameters were examined for correlation with progression free survival (PFS) and overall survival (OS) by a multivariate analysis according to the Cox proportional hazards model.

RESULTS

In early adenocarcinoma of the uterine cervix, MVD was increased significantly in invasive areas compared with adjacent nonneoplastic areas (median: 62.5 [range, 30-105] vs. median: 36.5 [range, 23-47]; P=0.0003). MVD also was significantly correlated with ascites cytology (P=0.0377). There was no correlation between microvessel count and lymph node status, depth of invasion, disease stage, lymph-vascular space invasion, grade, or parametrial involvement. Patients with high MVD (> or=75) had significantly worse PFS and OS than those with low MVD (< 75) (log rank test, P=0.0180 and 0.0199, respectively). Multivariate analysis showed that MVD correlated significantly and independently with PFS and OS.

CONCLUSIONS

In adenocarcinoma of the cervix, MVD is an independent prognostic factor for PFS and OS.

Evaluation of immunostaining for MIB1 and nm23 products in uterine cervical adenocarcinoma

In this study, we evaluated whether proliferative activity and metastatic potential are prognostic factors in adenocarcinoma of the cervix. Formalin-fixed, paraffin-embedded sections from 34 patients with cervical adenocarcinoma or adenosquamous carcinoma were immunostained with monoclonal antibody MIB1, expressed in proliferating cells, and anti-nm23 antibody, reacts with metastasis suppression gene products. MIB1 positivity ranged from 0.2 approximately 54.7% with a mean of 21.4%. The level did not differ significantly between various clinicopathological categories. Although patient survival of high or low MIB1 expressing tumor was not significantly different, the disease-free interval of high (> or =25%) expressing tumor was significantly lower than that of low (<25%) expressing tumor. Strong and medium expression for nm23 were detected in 7 (21%) and 3 (9%) of patients. Tumor with strong nm23 expression tended to have a higher relapse rate. Although the survival of strong and weakly nm23 expressing tumor was not significantly different, the disease-free survival of strong nm23 expressing tumor was lower than that of weakly nm23 expressing tumor. MIB1 and nm23 immunostaining might be some of prognostic indicators of recurrence in cervical adenocarcinoma. In cervical adenocarcinoma, the nm23 gene products may not function as metastatic suppression but reflect proliferative activity.

Prognostic factors of primary adenocarcinoma of the uterine cervix

OBJECTIVE

To determine which clinicopathological factors influence the prognosis of cervical adenocarcinoma.

METHODS

Three hundred and two cases of primary adenocarcinoma of the uterine cervix, treated between 1977 and 1994, were studied retrospectively. Clinical data and pathological findings with respect to primary therapy were reviewed and evaluated.

RESULTS

The 5-year survival rates for stages I, II, and III/IV were 75.9, 62.9, and 25.1%, respectively. International Federation of Gynecology and Obstetrics stage (P < 0. 0001), cell type (P = 0.0176), tumor grade (P = 0.023), lymph node status (P = 0.018), and bulky tumor (P = 0.007) were found to be independent factors using the stepwise Cox proportional hazards model. Old age (P = 0.0581), presence of hypertension (P = 0.46), diabetes mellitus (P = 0.18), obesity (P = 0.15), and oral contraceptive use (P = 0.42) were not found to adversely influence survival rates for cervical adenocarcinoma after adjusting for other covariates. Adenosquamous adenocarcinoma had a better prognosis than endocervical columnar cell adenocarcinoma in stages I and II (P = 0. 0235). Also, in cervical adenocarcinoma's early stages, multivariate modeling revealed that chances of survival were significantly better for patients treated by radical surgery than for patients treated by radiation therapy (P < 0.001).

CONCLUSIONS

Survival rates for cervical adenocarcinoma were significantly influenced by stage, histologic subtype, tumor grade, the presence of a positive lymph node, and tumor size. Although a randomized prospective study is needed, our data imply that radical surgery may be considered a better primary modality of treatment than radiation therapy for the early stages of cervical adenocarcinoma. Further, the presence of hypertension, diabetes mellitus, or obesity may not adversely influence survival rates.

Adenocarcinoma of the uterine cervix: a study of 37 cases

In a study of 37 patients diagnosed with cervical adenocarcinoma between 1961 and 1994, clinical and pathologic findings were evaluated. Of the 37 patients, 27 (73%) had a pure adenocarcinoma, five (13.5%) had a collision tumor and five (13.5%) had an adenosquamous carcinoma. Twenty-six patients (70.3%) were diagnosed in Stage I, and 11 (29.7%) patients in Stage II, III, and IV. Two patients (5.4%) were treated with simple hysterectomy alone, nine (24.3%) with simple hysterectomy followed by radiotherapy, eight (21.6%) with radical hysterectomy alone, five (13.5%) with radical hysterectomy followed by radiotherapy, nine (24.3%) with radiotherapy alone, one (2.7%) with radiotherapy followed by simple hysterectomy, and three (8.1%) received no treatment. The actuarial 5-year survival rate was 69%. It is suggested that for patients with small early-stage disease, radical hysterectomy should be primary treatment and postoperative adjuvant radiotherapy would be advocated if high-risk features are histologically demonstrated. For all other patients, radiotherapy should be primary treatment.

Is there really a difference in survival of women with squamous cell carcinoma, adenocarcinoma, and adenosquamous cell carcinoma of the cervix?

BACKGROUND

The authors' aim was to assess whether there is a difference in biologic behavior and survival in comparing adenocarcinoma (AdCA), squamous cell carcinoma (SCC), and adenosquamous carcinoma (Ad/SC) of the cervix.

METHODS

Cancer registrars at 703 hospitals submitted anonymous data on 11,157 patients with cervical cancer diagnosed and/or treated in 1984 and 1990 for a Patient Care Evaluation Study of the American College of Surgeons. Among these patients, 9351 (83.8%) had SCC; 1405 (12.6%), AdCA; and 401 (3.6%), Ad/SC cancers. There were no significant changes in percentages of the different histologic types between the study years 1984 and 1990, nor was the patient distribution different regarding age, race/ethnicity, and socioeconomic background for each histologic group. Furthermore, the distribution of patients who had had a hysterectomy did not change between 1984 and 1990.

RESULTS

A larger percent of patients with SCC (63.8%) than those with Ad/SC (59.8%) or AdCA (50.2%) had tumors larger than 3 cm at greatest dimension. Early stage patients (IA, IB, IIA) often were treated by hysterectomy alone (45.5%) or combined with radiation (21.1%). The remaining patients (21.9%) received radiation alone. Of the patients with clinical stage I disease, 7.6% of Ad/CA patients, 15.5% of Ad/SC patients and 12.6% of SCC patients had positive nodes. Although patients with SCC had higher survival rates for all four clinical stages (I-IV), the differences were only significant for Stage II patients. Patients with clinical stage IB SCC and AdCA treated by surgery alone were found to have significantly better survival rates (93.1% and 94.6% at 5 years, respectively) than women treated by either radiation alone or a combination of surgery and radiation (P < 0.001, both histologic comparisons). For women with Ad/SC tumors, however, the 5-year survival rate was 87.3% for those receiving combined treatment compared with those receiving surgery alone (69.2%) or radiation alone (79.2%). However, these survival curves were not significantly different (P = 0.496). One hundred six patients with positive nodes were available for analysis. The 5-year survival rate of patients with SCC and positive nodes was 76.1%. Surprisingly, patients with Ad/SC and positive nodes had the highest 5-year survival rate (85.7%), whereas, women with AdCA and positive nodes had a sharply reduced 5-year survival rate (33.3%). The curves were significantly different (P < 0.01). For patients with clinical stage I, the risk factors for age, tumor size, nodal status, histologic features, and treatment were analyzed with Cox's multivariate regression. In this analysis, subset IB, greater tumor size, age 80 or older, and positive nodal status were each independently significant for poorer survival. Patients who were treated by surgery alone had a significantly better survival than patients who had other types of treatment or no treatment. Histologic characteristics had no significant effect on survival. In the analysis of patients with pathologic stage I disease, those with SCC had significantly poorer survival and those with Ad/SC had significantly better survival than patients with Ad/CA. Positive nodes had no significant independent effect on survival. In another analysis, tissue type was not found to be an important factor in recurrence time.

CONCLUSIONS

1. Ad/CA and Ad/SC tumors were found to represent 12.6% and 3.6%, respectively, of a large series (N = 11,157) of cervical cancers diagnosed in 1984 and 1990 and reported to the Commission on Cancer of the American College of Surgeons. 2. Two thirds of women with early clinical stage disease (IA, IB, IIA) had hysterectomy as all or part of their primary therapy. 3. No significant differences were found in 5-year survival among the three tissue types in any clinical stage except American Joint Committee on Cancer stage II.

Lymph node metastases, cell type, age, HPV status and type, neoadjuvant chemotherapy and treatment failures in cervical cancer

Conflicting evidence on the prognostic influence of some of the clinical and histopathological variables in cervical cancer of the HPV status and type and chemotherapeutic response prompted a number of reviews from nearly 40 years experience in a tertiary referral centre. The collation and analyses of these data with those from recent literature allow some proposals to be made. The disease is more prevalent in the young women in whom, in many centers, the mortality is also higher; the latter may be related to the reported increase in both small cell types and adeno and adenosquamous carcinoma--a finding more marked in the young. Lymph node metastases, related to increasing grade, size, stage and lymph space invasion, are unequivocally associated with a worse prognosis. Resolution of the exact nature of the intimate association of this disease with the human papilloma virus remains to be resolved as does the influence on prognosis of the tumor HPV status and that of the different oncogenic types. Reports on the efficiency of neoadjuvant platinum based combination chemotherapy are generally promising but vary considerably depending on the regimen used. Its value will not be determined without properly conducted large randomized studies.

FIGO stage, histology, histologic grade, age and race as prognostic factors in determining survival for cancers of the female gynecological system: an analysis of 1973-87 SEER cases of cancers of the endometrium, cervix, ovary, vulva, and vagina

The prognostic impact of FIGO stage, histology, histologic grade, age and race in survival for cancers of the female gynecological (cervix, endometrium, ovary, vulva, vagina) were examined using cases obtained from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program that were diagnosed between 1973 and 1987. Utilizing Cox proportional hazards modeling and relative survival rates analysis of 17,119 cases of cervical cancer indicated that the International Federation of Gynecology and Obstetrics (FIGO) stage, histology, histological grade, lymph node status, and age at diagnosis were all independently prognostic. No evidence was found of survival differences between squamous cell carcinoma and adenocarcinoma. Younger women were not found to have a poorer prognosis, survival declined with increased age. Analysis of 41,120 cases of endometrial cancer indicated that FIGO stage, histology, histologic grade, lymph node status, age at diagnostic, and race were all prognostic factors. Clear cell adenocarcinoma, leiomyosarcoma, and mixed mullerian tumors were all found to have poorer prognosis. Analysis of 21,240 cases of ovarian cancer indicated that FIGO stage, histology, histologic grade, lymph node status, age at diagnosis, presence of ascites, and race were all prognostically significant. Analysis of 2,575 cases of vulvar cancer indicated that FIGO stage, histology, histologic grade, age, and race were all prognostically significant. Analysis of 916 cases of vaginal cancer indicated that FIGO stage, histologic grade, lymph node status, and age are all prognostically significant. Additional analysis of the data by combinations of independent prognostic factors indicates that the interaction of factors may be more predictive of outcome than any one factor separately.

The presentation of adenocarcinoma of the uterine cervix

BACKGROUND

Among malignancies of the uterine cervix, the percentage of adenocarcinomas seems to have increased in recent reports.

METHODS

The clinical presentation of adenocarcinoma of the uterine cervix during the past 25 years was examined by review of charts and pathologic specimens. The data of a total of 124 patients with cervical adenocarcinoma treated between 1964 and 1988 were evaluated.

RESULTS

During the 25-year period, the percentage of adenocarcinoma among all cervical malignancies increased from 9% to 25%. In addition, the average number of new cases per year increased from 3.7 to 10.8. The percentage of women young than 35 years with adenocarcinoma increased from 16% in 1964 to 24% in 1989. Of these younger women, 74% had disease discovered by cytopathology, in comparison with 27% of the patients who were older than 35 years. The overall percentage of patients with disease diagnosed by cytology increased from 24% in the first half to 39% in the second half of the study period. Vaginal bleeding was the most common symptom. In the entire period, 57% of patients had International Federation of Gynecology and Obstetrics (FIGO) Stage I disease, with a median tumor diameter of 1 cm in patients with no symptoms and 3 cm in patients with symptoms. Outcome was inversely related to stage, tumor volume, and the presence of lymph node metastasis but not to histologic tumor type.

CONCLUSION

The frequency of adenocarcinoma of uterine cervix is increasing in patients 35 years or younger. Cytopathology is a good screening tool for these patients, leading to earlier diagnosis and improved outcome.

The prognosis of adenosquamous carcinomas of the uterine cervix

OBJECTIVES

Firstly, to identify a cohort of women with invasive adenosquamous carcinomas of the uterine cervix, including mucin-producing squamous cell carcinomas. Secondly, to compare the biological characteristics and behaviour of a cohort of adenosquamous carcinomas with a cohort of non-mucin-producing squamous cell carcinomas.

DESIGN

Histological review, retrospective survival analysis.

SETTING

Regional multidisciplinary gynaecological oncology service.

SUBJECTS

161 cases of stage 1B and above invasive cervical carcinoma presenting between 1 January 1980 and 31 July 1987. Thirty nine women with adenosquamous carcinomas were compared with 103 women with non-mucin-producing squamous cell tumours.

RESULTS

Inclusion of routine stains for mucin in the assessment of histological material resulted in the reclassification of 38 (24%) of the cases, including the identification of 31 mucin-producing squamous cell carcinomas. The survival with adenosquamous tumours was significantly worse than with squamous cell cancers (P = 0.006), 5-year survival rates being 52% and 75% respectively. Multivariate analysis showed that this effect was explained by differences in clinical stage, pelvic lymph node metastasis and vascular invasion by tumour.

CONCLUSIONS

The application of routine mucin stains to cervical tumours identifies a group of previously unrecognized adenosquamous cancers. Tumours so identified are likely to pursue a more aggressive clinical course associated with a poorer survival when compared to non-mucin-producing squamous carcinomas.

Clinical presentation and management of stage I cervical adenocarcinoma: a 25 year experience

In this study, we review the clinical presentation, treatment, and prognosis of 89 patients with stage I cervical adenocarcinoma treated at Strong Memorial Hospital over the past 25 years. In the past decade, the mean age of patients with stage I cervical adenocarcinoma was 44 years, in contrast to a mean of 58 years in the prior interval (P less than 0.001). Prior to 1980 only 4% of patients were of childbearing age, whereas in the past decade 27% were under 35 years old (P = 0.02). The difference in age at presentation cannot be explained by earlier detection, as the fraction of stage I patients, the mean tumor size, and the percentage of clinically occult tumors have not changed. There were no ovarian metastases in 41 patients who underwent oophorectomy. Adenosquamous tumours did not differ in prognosis from pure adenocarcinoma. Grade and lymph node status were significant predictors of outcome. Treatment results have not improved over the past 25 years, and combined therapy with radiation and surgery offered no advantage over radiation alone. Because this tumor is more frequently seen in younger patients, the management of occult adenocarcinoma with early stromal invasion has become problematic. Ovarian conservation has been questioned, and the lack of generally accepted criteria for microinvasive adenocarcinoma has led to radical therapy in patients who might have been adequately treated with local excision. Further study is necessary to guide our recommendations regarding preservation of ovarian function or even childbearing potential in young women.

Stage IB glassy cell carcinoma of the cervix diagnosed during pregnancy and recurring in a transposed ovary

A case report of glassy cell carcinoma of the cervix occurring during pregnancy is presented. Clinical staging was FIGO IB and treatment consisted of a radical hysterectomy, bilateral ovarian transposition, and postoperative pelvic radiation therapy. The patient had a relapse in one of the transposed ovaries. A review of ovarian conservation in Stage IB carcinoma of the cervix is discussed.

Sequelae of lateral ovarian transposition in unirradiated cervical cancer patients

The sequelae of lateral ovarian transposition (LOT) in cervical cancer patients has been examined only in the light of the effect of pelvic radiation therapy on ovarian preservation. Preservation of ovarian function has not been examined in the absence of radiation therapy, and symptomatic ovarian cyst formation in transposed ovaries with the need for subsequent surgery has not been addressed in either radiated or unirradiated cervical cancer patients. We studied 84 premenopausal FIGO stage IA or IB cervical cancer patients treated by primary radical hysterectomy between the years 1978 and 1988. None of these patients received adjuvant radiation therapy. Fifty-nine of eight-four patients had radical hysterectomy (RH) without LOT. These patients were compared to 25 of 84 patients who had LOT in addition to RH. The incidence of symptomatic ovarian cysts, the majority requiring operative intervention, was 24% in the ovarian transposition patients as compared to 7.4% in those who had RH alone. This threefold increase in symptomatic benign ovarian cyst formation in the translocated ovary was significant (P = .048). On the other hand, LOT in these RH patients does not appear to increase the incidence of early menopause (P greater than 0.05). On follow-up of those patients who did not incur additional surgery or radiation, 4.3% became menopausal, as compared to 4.1% of those patients undergoing RH alone, with the mean ages of the two groups being comparable.

Adenocarcinoma of the uterine cervix. Prognosis and patterns of failure in 367 cases

Between 1965 and 1985, 367 patients received initial treatment for adenocarcinoma of the uterine cervix at the M. D. Anderson Cancer Center (MDACC). Of the 334 patients treated with curative intent, 223 had International Federation of Gynecology and Obstetrics (FIGO) Stage I, 60 had Stage II, and 51 had Stage III/IV disease. The 5-year and 10-year relapse-free survival (RFS) rates for all patients treated for Stage I disease were 73% and 70%, respectively. RFS was strongly correlated with initial bulk of disease (P = 0.002), although locoregional control (LRC) was good in all groups: 91 patients with a normal-sized cervix (tumor less than 3 cm) had a 5-year RFS rate of 88% and an actuarial LRC rate of 94%; 102 patients with lesions 3 to 5.9 cm in diameter had an RFS rate of 64% and an LRC rate of 82%; and 22 patients with bulky lesions greater than 6 cm in diameter had a comparable LRC rate of 81%, but an RFS rate of only 45%. Decreased RFS also was strongly correlated with positive lymphangiogram (LAG) results (P = 0.02) and poorly differentiated lesions (P = 0.0014). When initial primary tumor size was taken into account, there was no significant difference in RFS or LRC between patients treated with radiation (RT) alone or RT plus extrafascial hysterectomy (R + S). The 5-year and 10-year RFS rates of 60 patients who received curative therapy for Stage II disease were 32% and 25%, respectively, with an LRC rate of 62% at 5 years. Patients with bulky Stage II disease did particularly poorly, with a 5-year RFS rate of 15%. Decreased RFS was correlated with positive LAG results and poorly differentiated tumors. Most Stage II patients whose disease relapsed died with distant metastases (73%). Forty-eight patients with Stage III/IV disease treated with curative intent had a 5-year survival rate of 31% and a 5-year pelvic disease control rate of 52%. In summary, patients with small volume Stage IB lesions have excellent LRC and survival with RT alone. RT achieves good LRC of bulkier Stage I lesions, but survival decreases with increasing primary tumor size. R + S holds no apparent advantage over RT alone. Patients with more advanced disease have a high rate of relapse with frequent distant metastasis. In particular, the survival of patients with FIGO Stage II disease is much lower than what we have observed after treatment of comparable stage squamous carcinoma.(ABSTRACT TRUNCATED AT 400 WORDS)

Invasive cervical cancer treated initially by standard hysterectomy

Ninety-two patients with invasive cervical cancer initially treated by standard hysterectomy were evaluated for features related to survival. The cell type included squamous cell (64) and adenocarcinoma (28). Posthysterectomy therapy included radiation therapy (78), pelvic lymphadenectomy (3), and radical parametrectomy (1). Hysterectomy was initially performed for the following indications: invasive lesion missed on cone biopsy, 17; hemorrhage at cone biopsy, 2; bleeding, 16; abnormal cytology, 13; presumed endometrial cancer, 9; known cancer, 7; pelvic relaxation, 5; planned therapy, 3; fibroids, 3; adnexal mass, 2; chronic discharge, 1; pyometra, 1; postpartum endometritis, 1. The cumulative 5-year survival for all patients was 68%, for squamous cell 80%, and for adenocarcinoma 41% (P = 0.0001). On postoperative evaluation 84 patients had presumed Stage I and 7 had parametrial involvement (Stage II). Patients with Stage I disease were then examined separately by cell type. Fifty-seven patients with squamous cell disease had cumulative 5-year survival of 85%. Radiation therapy in the immediate postoperative period produced a survival of 88%, compared to observation only with a 69% survival (P = .10). Patients with squamous cell disease and more than 50% cervical invasion had a 75% survival compared to a 96% survival for those with less than 50% (P = .02). The presence of disease at the surgical margins, grade, age, and increase in radiation therapy did not influence survival. Twenty-seven patients with presumed Stage I adenocarcinoma had a cumulative 5-year survival rate of 42%. Survival was significantly influenced by tumor grade (P = .018) and the amount of postoperative radiation therapy (P = .03), while age, amount of residual tumor, and presence of tumor at surgical margins did not influence survival. Patients with invasive squamous cell carcinoma treated by standard hysterectomy and postoperative radiation therapy have a prognosis similar to those treated initially by either radical surgery or radiation therapy. Patients with adenocarcinoma appear to have a significantly decreased survival when compared to patients with squamous cell disease and their prognosis is related to tumor grade and the amount of postoperative pelvic radiation.

Prognosis of the adenocarcinoma of the cervix uteri: a comparative study

The different prognoses for patients with adenocarcinomas and squamous cell carcinomas of the cervix uteri were proved by matched-pair analysis. One hundred forty-four patients with adenocarcinoma treated in 1964-1985 were compared in a ratio of 1:2 with 268 patients with squamous cell carcinoma comparable in age, stage, and treatment modality. In both groups 45% of patients were in stage I, 38% in stage II, 15% in stage III, and 2% in stage IV. Five- and 10-year survivals of patients with adenocarcinoma were significantly lower than for those with squamous cell carcinoma (53% resp. 42% vs 68% vs 58%, P = 0.006). In an analyses of patients' prognosis according to clinical stage there was no significant difference between both groups in stages III and IV treated exclusively by radiotherapy. No significant differences were found in stage I and II patients treated by radical surgery. However, the most significant difference in prognosis was seen in stage I and II patients treated by radiotherapy. Five-year survival was 58.6% in stage I adenocarcinomas compared with 85.0% in squamous cell carcinomas. It can be concluded from these results that a discussion of the problem of FIGO staging is more necessary than a discussion of the different radiosensitivities of these two histological types. Surgical treatment must have the same priority as radical surgery or staging laparotomy for exact histologic staging in adenocarcinomas of the cervix uteri.

Stage I adenocarcinoma of the uterine cervix: tumour size, grade, lymph node metastases and 5-year survival

This study includes 22 cases of Stage I cervical adenocarcinoma. The lymph node metastases and 5-year survival according to the size of lesion and grade of tumour were evaluated. The overall pelvic and para-aortic lymph node metastases were found to be 31.8% and 0% respectively. Metastases in the pelvic lymph nodes were found in 16.6% of patients with lesions less than 2 cm and 50.0% of patients with lesions 2 cm or greater in size. Pelvic lymph node metastases were found to be 0% for Grade 1, 25% for Grade 2 and 46% for Grade 3 tumours. The overall 5-year survival was 68.2%. This figure varied from 60% to 75% according to the size of lesion and from 61.5% to 100% according to the grade of tumour.