Surgical and radiologic staging of cervical cancer

Advances in molecular imaging and targeted therapeutics for lymph node metastasis in cancer: a comprehensive review

Lymph node metastasis is a critical indicator of cancer progression, profoundly affecting diagnosis, staging, and treatment decisions. This review article delves into the recent advancements in molecular imaging techniques for lymph nodes, which are pivotal for the early detection and staging of cancer. It provides detailed insights into how these techniques are used to visualize and quantify metastatic cancer cells, resident immune cells, and other molecular markers within lymph nodes. Furthermore, the review highlights the development of innovative, lymph node-targeted therapeutic strategies, which represent a significant shift towards more precise and effective cancer treatments. By examining cutting-edge research and emerging technologies, this review offers a comprehensive overview of the current and potential impact of lymph node-centric approaches on cancer diagnosis, staging, and therapy. Through its exploration of these topics, the review aims to illuminate the increasingly sophisticated landscape of cancer management strategies focused on lymph node assessment and intervention.

Functional roles of magnetic nanoparticles for the identification of metastatic lymph nodes in cancer patients

Staging lymph nodes (LN) is crucial in diagnosing and treating cancer metastasis. Biotechnologies for the specific localization of metastatic lymph nodes (MLNs) have attracted significant attention to efficiently define tumor metastases. Bioimaging modalities, particularly magnetic nanoparticles (MNPs) such as iron oxide nanoparticles, have emerged as promising tools in cancer bioimaging, with great potential for use in the preoperative and intraoperative tracking of MLNs. As radiation-free magnetic resonance imaging (MRI) probes, MNPs can serve as alternative MRI contrast agents, offering improved accuracy and biological safety for nodal staging in cancer patients. Although MNPs' application is still in its initial stages, exploring their underlying mechanisms can enhance the sensitivity and multifunctionality of lymph node mapping. This review focuses on the feasibility and current application status of MNPs for imaging metastatic nodules in preclinical and clinical development. Furthermore, exploring novel and promising MNP-based strategies with controllable characteristics could lead to a more precise treatment of metastatic cancer patients.

Correlation between Neutrophil-to-Lymphocyte Ratio and Pretreatment Magnetic Resonance Imaging and Their Predictive Significance in Cervical Carcinoma Patients Referred for Radiotherapy

OBJECTIVE

The aim of this study was to determine the correlation between neutrophil-to-lymphocyte ratio (NLR) and various tumor parameters assessed by pretreatment magnetic resonance imaging (MRI) and to evaluate their prognostic significance for cervical carcinoma treated with radiotherapy (RT).

METHODS

The study enrolled 78 patients with biopsy-proven squamous cell carcinoma (SCC) of primary cervical cancer (clinically staged IB2 to IVA) who were treated in the Department of Clinical Oncology of the University of Hong Kong-Shenzhen Hospital between August 2015 and May 2019. A retrospective analysis of patients with SCC was performed. Firstly, we investigated the correlations between NLR and MRI parameters. Then, univariate and multivariate analyses were performed to identify the prognostic factors for overall survival (OS) and progression-free survival (PFS). Kaplan-Meier curves were constructed for OS and PFS.

RESULTS

Higher NLR showed significant association with larger tumor diameter and parametrial invasion assessed by pretreatment MRI. Univariate analysis indicated that uterine body invasion, parametrial invasion, and NLR were associated with prognosis of cervical cancer. Multivariable analyses demonstrated that parametrial invasion and NLR higher than the cutoff were independently associated with shorter OS and PFS, whereas uterine body invasion showed a significantly unfavorable influence on OS but showed no significant effect on PFS. Using the three risk factors of NLR above cutoff, parametrial invasion, and uterine body invasion, patients were divided into three subgroups. The three-year OS rates of patients with zero risk factors, one risk factor, and two or three of these factors were 96%, 91%, and 42%, respectively (P < 0.001), showing a downward trend.

CONCLUSIONS

Uterine body invasion, parametrial invasion, and NLR were significant prognostic factors for patients with cervical carcinoma treated with RT. These results may supplement FIGO staging to improve prognostic assessment of patients.

Nomogram Predicting Parametrial Involvement Based on the Radical Hysterectomy Specimens in the Early-Stage Cervical Cancer

Objective: Radical hysterectomy (RH) is the surgical standard for the treatment of the early-stage cervical cancer (CC). However, this procedure is associated with a high rate of adverse impact on the quality of the life of the patient. Since the rate of parametrial involvement (PI) is low for the patients with the early-stage CC, some authors believe that the patients with the early-stage CC may benefit from the less radical surgery. This study aims to estimate the incidence of the PI in the patients with the early-stage CC and establish a simple nomogram to identify a cohort of the patients with low risk of the PI who may benefit from the less radical surgery.

Methods: All the patients who underwent the RH and pelvic lymphadenectomy were included from 2013 to 2018. The significant independent predictors were identified through the Cox regression analysis and then incorporated into a nomogram to predicate the PI. The calibration plots and receiver operating characteristic (ROC) curves were used to assess the predictive accuracy of the nomogram.

Results: A total of 4,533 patients met the inclusion criteria and 441 women (9.7%) had the PI. The positive PI rate in the ≤2 cm group (1.2%) was significantly lower compared to >2– ≤4 cm (6.2%) or >4 cm (22.4%) groups. The multivariate analyses revealed that tumor size (p = 0.002), lymphovascular space invasion (LVSI) (p = 0.001), vaginal involvement (VI) (p < 0.001), status of the pelvic lymph nodes (PLNs) (p = 0.001), and depth of stromal invasion (DSI) (p < 0.001) were the independent prognostic factors of the PI. Finally, the five variables were combined to construct the nomogram model. The concordance indexes (C-indexes) of the PI were 0.756 (95% CI 0.726–0.786) for the internal validation and 0.729 (95% CI 0.678–0.780) for the external validation. The calibration plots further showed good consistency between the nomogram prediction and the actual observation.

Conclusion: This study confirmed that the patients with tumor size 2 cm or smaller were at very low risk for the PI. If other variables such as negative LVSI, DSI <50%, no VI, and negative PLN were limited, the risk would reduce significantly. Meanwhile, a simple nomogram based on the significant clinicopathological characteristics could be used as a tool for the clinicians to predict the PI among the patients with the early-stage CC, who might benefit from a less radical surgery.

Pretreatment Lymph Node Metastasis as a Prognostic Significance in Cervical Cancer: Comparison between Disease Status

PURPOSE

Lymph node metastasis (LNM) is the most significant prognostic factor in cervical cancer that was recently incorporated into the International Federation of Gynecology and Obstetrics (FIGO) staging system. This study was performed to evaluate whether the prognostic significance of LNM differs according to disease status.

MATERIALS AND METHODS

Patients with FIGO stage IB or higher cervical cancer who had pretreatment computed tomography and/or magnetic resonance imaging studies as well as long-term follow-up were enrolled in this retrospective study. The hazard ratio (HR) of Cox regression was used to determine the prognostic significance of LNM. The HRs were compared between the different tumor groups (based on stage, histology, tumor size, primary treatment, age, parametrium involvement, and lymphovascular space invasion).

RESULTS

A total of 970 patients treated between January 1999 and December 2007 were included. The pretreatment LNM had prognostic significance in patients with stage IB1/IIA (HR for progression-free survival 2.10, p=0.001; HR for overall survival 1.99, p=0.005). However, the significance gradually decreased or disappeared with advancing stages. Similarly, the prognostic significance of the pretreatment LNM decreased with advancing disease status, including old age, parametrial involvement or lymphovascular space involvement. In contrast, the tumor size was associated with the prognostic significance of LNM with advancing status. The significance of the clinical LNM did not reflect the significance of the clinical stage. In contrast, the tumor size, parametrial involvement, and significance of the pathologic LNM reflected the clinical stage.

CONCLUSION

In patients with cervical cancer, pretreatment LNM on imaging has different clinical significance depending on the tumor status.

PET/CT and MRI in the imaging assessment of cervical cancer

Imaging plays a central role in the evaluation of patients with cervical cancer and helps guide treatment decisions. The purpose of this pictorial review is to describe magnetic resonance (MR) imaging and positron emission tomography (PET)/computed tomography (CT) assessment of cervical cancer, including indications for imaging, important findings that may result in management change, as well as limitations of both modalities. The International Federation of Gynecology and Obstetrics cervical cancer staging system does not officially include imaging; however, the organization endorses the use of MR imaging and PET/CT in the management of patients with cervical cancer where these modalities are available. MR imaging provides the best visualization of the primary tumor and extent of soft tissue disease. PET/CT is recommended for assessment of nodal involvement, as well as distant metastases. Both MR imaging and PET/CT are used to follow patients post-treatment to assess for recurrence. This review focuses on the current MR imaging and PET/CT protocols, the utility of these modalities in assessing primary tumors and recurrences, with emphasis on imaging findings which change management and on imaging pitfalls to avoid. It is important to be familiar with the MR imaging and PET/CT appearance of the primary tumor and metastasis, as well as the imaging pitfalls, so that an accurate assessment of disease burden is made prior to treatment.

Prognostic factors associated with radiotherapy for cervical cancer with computed tomography-detected para-aortic lymph node metastasis

Patients with cervical cancer diagnosed with a para-aortic lymph node (PALN) metastasis by computed tomography (CT) scan were analyzed to identify associated prognostic factors. A total of 55 patients were reviewed, and 27 of these patients underwent extended-field radiotherapy (EFRT). The median PALN dose in patients receiving EFRT was 45 Gy (range, 27-57.6 Gy). Of the 55 patients, 28 underwent pelvic radiotherapy (RT); concurrent chemoradiotherapy (CCRT) was administered to 41 patients. The Kaplan-Meier method was used to calculate the actuarial rate. Multivariate analysis was performed using the Cox proportional hazards model. Five-year overall survival (OS) rates were 41% and 17.9% in patients undergoing EFRT and pelvic RT (P = 0.030), respectively. Age < 53 years (P = 0.023), FIGO Stage I-II (P = 0.002), and treatment with EFRT (P = 0.003) were independent predictors of better OS. The use of CCRT (P = 0.014), Stage I-II (P = 0.002), and treatment using EFRT (P = 0.036) were independent predictors of distant metastasis. In patients undergoing EFRT plus CCRT, the 5-year OS was 50%. Three-year PALN disease-free rates were 8.8%, 57.9% and 100% (P < 0.001) in CCRT patients who received PALN doses of 0 Gy, ≤45 Gy and ≥50.4 Gy, respectively. Although PALN metastasis is thought to be distant metastasis in cervical cancer, EFRT plus CCRT shows a good outcome, particularly in younger patients in an early FIGO stage. Cervical cancer with a PALN metastasis should not be considered incurable. Doses ≥50.4 Gy for treating PALN may result in better disease control.

Locally advanced cervical cancer: what is the standard of care?

PURPOSE OF REVIEW

Carcinoma of the cervix remains a significant health problem for women worldwide. Locally advanced cervical cancer (LACC) is a common presentation that has been extensively studied in the last three decades. This article reviews the standard of care and discusses current topics of clinical research.

RECENT FINDINGS

A multidisciplinary approach to the treatment of cervical cancer has led to marked improvement in outcome. Main advances are with neoadjuvant chemotherapy, chemoradiation, and preventive vaccination. Concurrent chemoradiation with a platinum-based agent is the recommended treatment for LACC. Palliation with platinum agent remains the standard of care for inoperable patients who have metastatic or recurrent disease.

SUMMARY

This is a review of published and ongoing studies testing multidisciplinary and medical management of LACC, with a focus on newer chemotherapeutic approaches. Optimal multidisciplinary treatment planning improves the outcome of each patient diagnosed with cervical cancer.