Post-irradiation cytology of cervical cancer patients

Cervical cytology: Radiation and other therapy effects

The different treatment options for carcinoma cervix include radiation, chemotherapy, and surgical treatments. Cytological analysis of smears is crucial for patient follow-up to determine response to therapy and to diagnose the persistence or recurrence of malignancy. Anatomical alterations and changes in cell morphology following radiation or chemotherapy make collecting and interpreting cervical cytology samples difficult. These issues can be mitigated by liquid-based cytology. Ionizing radiation is used in radiotherapy (RT) to kill cells. It is important that cytologists are aware of alterations in morphology of the cells. Radiation can cause cytoplasmic and nuclear changes. Cellular enlargement, vacuolation, granularity loss, and other changes linked with cell death are examples of cytoplasmic alterations. Nuclear enlargement and multinucleation are the most frequent nuclear alterations. These changes are determined by the amount of time that has passed since radiation. It should be emphasized that no one characteristic is pathognomonic. Post-irradiation dysplasia is a condition described as abnormal cellular changes in non-neoplastic epithelial cells after RT. Chemotherapy causes comparable alterations as radiation but impacts fewer cells. Busulfan and other chemotherapeutic treatments may produce morphological alterations, which cytologists must be aware of and able to identify. Immunosuppressive treatments, hormonal therapy, and tamoxifen are some of the other drugs that might cause changes in cervical morphology. Surgical methods used in the detection and treatment of cervical cancer may potentially cause alterations as a result of thermal damage and healing. For the treatment of cervical lesions, electrocautery and the loop electrosurgical excisional procedure are available. These procedures employ electric current ablation leading to ischemic changes in the cervical smear. Cytological analysis of smears following treatment with these modalities necessitates a comprehensive history, kind of therapy, and duration of treatment.

Follow-up for cervical cancer: a Program in Evidence-Based Care systematic review and clinical practice guideline update

BACKGROUND

In 2009, the Program in Evidence-based Care (pebc) of Cancer Care Ontario published a guideline on the follow-up of cervical cancer. In 2014, the pebc undertook an update of the systematic review and clinical practice guideline for women in this target population.

METHODS

The literature from 2007 to August 2014 was searched using medline and embase [extended to 2000 for studies of human papillomavirus (hpv) dna testing]. Outcomes of interest were measures of survival, diagnostic accuracy, and quality of life. A working group evaluated the need for changes to the earlier guidelines and incorporated comments and feedback from internal and external reviewers.

RESULTS

One systematic review and six individual studies were included. The working group concluded that the new evidence did not warrant changes to the 2009 recommendations, although hpv dna testing was added as a potentially more sensitive method of detecting recurrence in patients treated with radiotherapy. Comments from internal and external reviewers were incorporated.

RECOMMENDATIONS SUMMARY

Follow-up care after primary treatment should be conducted and coordinated by a physician experienced in the surveillance of cancer patients. A reasonable follow-up strategy involves visits every 3-4 months within the first 2 years, and every 6-12 months during years 3-5. Visits should include a patient history and complete physical examination, with elicitation of relevant symptoms. Vaginal vault cytology examination should not be performed more frequently than annually. Combined positron-emission tomography and computed tomography, other imaging, and biomarker evaluation are not advocated; hpv dna testing could be useful as a method of detection of recurrence after radiotherapy. General recommendations for follow-up after 5 years are also provided.

Prognostic value of fluorine-18-fluorodeoxyglucose positron emission tomography or PET-computed tomography in cervical cancer: a meta-analysis

OBJECTIVE

We pooled the data from published studies to estimate the prognostic value of fluorine-18-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) or PET/computed tomography (CT) in cervical cancer patients.

METHODS

We searched MEDLINE, EMBASE, and PUBMED to identify studies investigating the association of 18F-FDG PET or PET/CT with clinical survival outcomes of patients with cervical cancer. The summarized hazard ratio (HR) was estimated by using fixed- or random-effect model according to heterogeneity between trails.

RESULTS

We analyzed a total number of 1854 patients from 16 studies and found that positive pretreatment FDG-PET images were significantly associated with poorer event-free survival (hazard ratio [HR], 2.681; 95% confidence interval [CI], 2.059-3.490) and overall survival (HR, 2.063; 95% CI, 1.023-4.158). Furthermore, metabolic response of therapy as shown on posttreatment PET images was also capable of predicting event-free survival and overall survival with statistical significance, and the HR was 2.030 (95% CI, 1.537-2.681) and 2.322 (95% CI, 1.485-3.630), respectively.

CONCLUSIONS

Uptake of 18F-FDG on PET or PET/CT either before or after treatment has a promising value of both predicting survival outcomes for patients with cervical cancer and identifying patients for more aggressive treatment.

PET/CT in gynecologic cancer: present applications and future prospects--a clinician's perspective

This article briefly reviews the epidemiology, diagnosis, and treatment of the common gynecologic malignancies, with an emphasis on the shortcomings of current clinical practice. The persistent need to achieve early diagnosis, adjust proper treatment, enhance surveillance, and improve the outcome of these patients has led to the development of new diagnostic modalities. Novel tools such as 18F-fluorodeoxyglucose PET/CT should aim at enhancing the clinician's ability to make critical decisions in treating difficult scenarios.

Follow-up evaluation of radiation-induced DNA damage in CSF disseminated high-grade glioma using phospho-histone H2AX antibody

Cytological examination of cerebrospinal fluid (CSF) is used not only for the diagnosis of spinal disease, but also to assess the postoperative effect of treatment. We experienced a case of high-grade glioma in disseminated CSF, and retrospectively examined the clinical, pathological and cytological features. We further investigated radiation-induced DNA damage in glioma cells using phospho-Histone H2AX antibody. A five-year-old boy received a clinical diagnosis of optic nerve glioma, and was followed-up for three months after chemotherapy. Magnetic resonance imaging was repeated, revealing abnormalities in other brain areas. The pathological diagnosis was anaplastic astrocytoma. CSF dissemination was detected, and increases in the number and mitosis of tumor cells were observed in CSF cytology. After radiotherapy the tumor cells in CSF decreased markedly. On cytomorphologic and immunocytochemical evaluation post-irradiation, tumor cells showed vacuolation of both the nucleus and cytoplasm, degeneration of nuclear chromatin, and alteration of the phospho-Histone H2AX expression, compared with tumor cells before the irradiation. CSF cytology is an effective means of evaluating DNA damage in tumor cells after irradiation, and may be useful in assessing the therapeutic response.

Posttherapy residual disease associates with long-term survival after chemoradiation for bulky stage 1B cervical carcinoma: a Gynecologic Oncology Group study

OBJECTIVE

The objective of the study was to study posttherapy chemoradiation hysterectomy histology with long-term survival in bulky stage 1(B) cervical cancer patients.

STUDY DESIGN

Gynecologic Oncology Group protocols 71 and 123 enrolled 464 patients randomly allocated to pelvic radiation (75 Gy, n = 291) plus hysterectomy (RTH) or to pelvic radiation (75 Gy) and cisplatin (40 mg/m(2), n = 176) plus hysterectomy (RTCH). Risk of progression and death were evaluated by posttherapy hysterectomy response (good: <10% viable; poor: ≥10% viable).

RESULTS

Median survivor follow-up was 112 months. Relative risks of disease progression and death were 0.656 (95% confidence interval, 0.472-0.912) and 0.638 (95% confidence interval, 0.449-0.908), favoring RTCH. Good response patients (345; 74%) had similar 10 year overall survival (OS) and progression-free survival (PFS) after RTH or RTCH (P > .47). Poor response patients after RTCH had superior OS (P = .046) and PFS (P = .084). Extrapelvic recurrences occurred more often in poor response patients.

CONCLUSION

Posttherapy viable residual disease less than 10% was associated with reduced risk of progression and cancer-related death.

PET/CT in Gynecologic Cancer: Present Applications and Future Prospects-A Clinician's Perspective

This article briefly reviews the epidemiology, diagnosis, and treatment of the common gynecologic malignancies, with an emphasis on the shortcomings of current clinical practice. The persistent need to achieve early diagnosis, adjust proper treatment, enhance surveillance, and improve the outcome of these patients has led to the development of new diagnostic modalities. Novel tools such as 18F-fluorodeoxyglucose PET/CT should aim at enhancing the clinician's ability to make critical decisions in treating difficult scenarios.

The role of 18F-FDG PET in assessing therapy response in cancer of the cervix and ovaries

For locally advanced cervical cancer, the current literature supports the use of (18)F-FDG PET for assessing treatment response 3 mo after the completion of concurrent chemoradiation. (18)F-FDG PET can provide reliable long-term prognostic information for these patients and, in the future, may be used to guide additional therapy. Investigational areas include the use of (18)F-FDG PET for monitoring response during radiotherapy and chemotherapy in the metastatic and neoadjuvant settings. For ovarian masses, the performance of (18)F-FDG PET in the detection of borderline tumors is limited, and the presence of physiologic (18)F-FDG uptake in normal ovaries of premenopausal women poses another limitation. Preliminary data suggest that the performance of (18)F-FDG PET and (18)F-FDG PET/CT is superior to that of CT alone in initial staging, but the sensitivity of both in the detection of carcinomatosis is limited. Preliminary data also suggest that (18)F-FDG PET may be promising for early prediction of response to chemotherapy and for prediction of response after the completion of chemotherapy. (18)F-FDG PET and (18)F-FDG PET/CT are most helpful in the evaluation of patients with suspected recurrent ovarian carcinoma, especially when CA-125 levels are rising and CT findings are normal or equivocal. PET and CT are complementary, and PET/CT should be used when available. Preliminary data suggest that the addition of (18)F-FDG PET/CT to the evaluation of these patients changes management in approximately a third and reduces overall treatment costs by accurately identifying patients who will or will not benefit from surgery.

Is early postradiation dysplasia almost associated with poor prognosis? A case report and review of the literature

Following radiotherapy for cervical carcinoma, abnormal cytologic changes have been reported in a number of publications. These reactions occur at varying periods of time following irradiation and do not necessarily reflect the presence of invasive cancer. On the basis of cytologic and histopathologic features, these reactions were determined as postradiation dysplasia (PRD). PRD has been reported to occur in 18.7-26% of patients treated by radiotherapy for cervical cancer. In the literature, it was reported that patients diagnosed with PRD less than 3 years after the initial diagnosis of cervical cancer had a mean survival rate of 33.8% as compared with a 100% 5-year survival rate in patients with a delayed (>3 years) onset of period. We present a case of stage IIIB cervical squamous cell carcinoma with PRD detected 6 months after radiotherapy. The patient is still tumor free 8 years after radiotherapy. In the light of this patient, we review the literature and discuss the relationship of PRD with survival in the cervical carcinomas.

Liquid-based cytology for the postirradiation surveillance of women with gynecologic malignancies

OBJECTIVE

To determine the performance of liquid-based cytology using ThinPrep in the postirradiation surveillance of women with gynecologic malignancies.

METHODS

Patients with endometrial and cervical cancer treated with primary or adjuvant radiotherapy between 2000 and 2002 were identified. Details regarding tumor characteristics, treatment, and cytologic and histologic results were abstracted. Binomial variables were compared with the chi-square test. The performance characteristics of liquid-based cytology were evaluated.

RESULTS

A total of 302 liquid-based cytologic samples from 121 women were evaluated. Overall, 294 (97.4%) of the specimens were adequate for interpretation and 132 (44.9%) were within normal limits. Benign cellular changes, including benign radiation changes, were identified in 141 (47.6%). Atypical squamous cells (ASCUS) were found in 15 (5.1%), recurrent dysplasia in 4 (1.3%), and recurrent carcinoma in 2 (0.7%). Follow-up of the 15 ASCUS smears revealed 13 (86.7%) normal smears and 2 cases of squamous intraepithelial lesions. Benign findings were noted in three of the four smears with SIL. The sensitivity for the detection of SIL was 33%, the specificity 99%, and the positive predictive value (PPV) 25%. Of the 4 patients with local recurrences, 2 were detected by cytology. The sensitivity for the detection of recurrent carcinoma was 50%, with a specificity and PPV of 100%.

CONCLUSIONS

ThinPrep for the surveillance of women with gynecologic malignancies treated with radiotherapy is associated with a high rate of satisfactory samples and a low rate of equivocal and ASCUS cytology.

Chronic radiation effects: a correlative study of smears and biopsies from the cervix and vagina

Cervicovaginal smears and biopsies from patients treated with radiotherapy for cervical carcinoma were examined morphologically and immunochemically to provide information on the tissue derivation of cells characteristic of chronic radiation effect in postirradiation smears. In biopsies, stromal changes, such as fibrosis, vessel changes, and atypical fibroblasts were most common. Ulceration, leucocytic infiltration, multinucleated giant cells, regenerative epithelium, and atypical glandular epithelial cells were also present in some specimens. These changes were reflected in smears collected from the same patients, where multinucleated giant cells, repair cells, and large atypical cells were often present. Correlation of smears and biopsies suggest that repair cells are collected from areas of epithelial regeneration and glandular radiation atypia. Sampling of ulcerative or eroded tissue may produce smears with multinucleated giant cells, atypical stromal cells, endothelial cells, and numerous macrophages. Correct recognition of these cell types and smear patterns may assist in avoiding false positive diagnoses.

Radiation and chemotherapy injury: pathophysiology, diagnosis, and treatment

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