Prognostic factors in microinvasive cervical squamous cell cancer: long-term results

Multiparametric MRI radiomics nomogram for predicting lymph-vascular space invasion in early-stage cervical cancer

OBJECTIVE

To develop a radiomics nomogram based on multiparametric MRI (mpMRI) to pre-operatively predict lymph-vascular space invasion (LVSI) in patients with early-stage cervical cancer.

METHODS

This retrospective study included 233 consecutive patients with Stage IB-IIB cervical cancer. According to the ratio of 2:1, 154 patients and 79 patients were randomly assigned to the primary and validation cohorts, respectively. Features with intraclass and interclass correlation coefficient (ICCs) greater than 0.75 were selected for radiomics features. The significant features for predicting LVSI were selected using the least absolute shrinkage and selection operator (LASSO) algorithm based on the primary cohort. The rad-score for each patient was constructed via a linear combination of selected features that were weighted by their respective coefficients. The radiomics nomogram was developed using multivariable logistic regression analysis by incorporating the rad-score and clinical risk factors.

RESULTS

A total of 19 radiomics features and 3 clinical risk factors were selected. The rad-score exhibited a good performance in discriminating LVSI with a C-index of 0.76 and 0.81 in the primary and validation cohorts, respectively. The radiomics nomogram also exhibited a good discriminating performance in two cohorts (C-index of 0.78 and 0.82). The calibration curve of the radiomics nomogram demonstrated no significant differences was found between prediction and observation outcomes for the probability of LVSI in two cohorts (p = 0.86 and 0.98, respectively). The decision curve analysis indicated that clinician and patients could benefit from the use of radiomics nomogram and rad-score.

CONCLUSION

The nomogram and rad-score could be used conveniently and individually to predict LVSI in patients with early-stage cervical cancer and facilitate the treatment decision for clinician and patients.

ADVANCES IN KNOWLEDGE

The nomogram could pre-operatively predict LVSI in early-stage cervical cancer.

Conservative treatment of microinvasive squamous cell carcinoma of the cervix stage IA1: Defining conization height to an optimal oncological outcome

OBJECTIVE

This paper searches an ideal cone height for stage definition and safe treatment of cervical microinvasive squamous carcinoma stage IA1 (MIC IA1), avoiding excessive cervix resection, favoring a future pregnancy.

METHODS

A retrospective study was performed involving 562 women with MIC IA1, from 1985 to 2013, evaluating cone margin involvement, depth of stromal invasion, lymph vascular invasion, conization height, and residual uterine disease (RD). High-grade squamous lesions or worse detection was considered recurrence. Univariate and multivariate regression analyses were performed, including age, conization technique (CKC, cold-knife, or ETZ, excision of transformation zone), and pathological results. Conization height to provide negative margins and the risk of residual disease were analyzed.

RESULTS

Conization was indicated by biopsy CIN2/3 in 293 cases. Definitive treatments were hysterectomy (69.8%), CKC (20.5%), and ETZ (9.7%). Recurrence rate was 5.5%, more frequent in older women (p = 0.030), and less frequent in the hysterectomy group (p = 0.023). Age ≥40 years, ETZ and conization height are independent risk factors for margin involvement. For ages <40 years, 10 mm cone height was associated with 68.6% Negative Predictive Value (NPV) for positive margins, while for 15 mm and 25 mm, the NPV was 75.8% and 96.2%, respectively. With negative margins, the NPV for RD varied from 85.7-92.3% for up to 24 mm cone height and 100% from 25 mm.

CONCLUSION

Conization 10 mm height for women <40 years provided adequate staging for almost 70%, with 10% of RD and few recurrences. A personalized cone height and staging associated with conservative treatment are recommended.

Pathologic Determination of Multifocality in pT1a1 Squamous Cell Carcinoma of the Cervix: A Retrospective Analysis

When more than one focus of stromal invasion is present in a superficially invasive cervical squamous cell carcinoma (SCC), determination of the tumoral lateral extent/horizontal extension, and hence tumor-nodes-metastases (TNM) staging, can be problematic. In recent years, a diagnostic approach to distinguish multifocal pT1a1 from pT1b cases has gained increased attention. These criteria call for classifying SCC as multifocal when invasive foci are separated by blocks of uninvolved cervical tissues, and/or are located on separated cervical lips in a tumor that is discontinuous, and/or are situated far apart (≥2 mm) from each other. In this study, we assess our experience with multifocal stage pT1a1 cervical SCC that was retrospectively classified as such using these criteria. Slides from the loop electrosurgical excision or conization specimens, comprising 212 pT1a1, 173 pT1a2, and 206 pT1b cases, were reviewed. Twenty-four (11%) of the 212 pT1a1 cases were classified as multifocal after review. The 24 multifocal pT1a1 cases were compared with the 188 unifocal pT1a1 cases regarding a variety of clinicopathologic parameters. Notably, these 2 groups showed no significant differences regarding all parameters that were evaluated, including patient age, recurrence rate, primary tumoral features in the primary excision specimen (rate of positive margins, median depth of stromal invasion, frequency of lymphovascular invasion), and frequency of residual disease in additional excisions. In summary, we demonstrate comparably favorable patient outcomes in both unifocal and multifocal cases of pT1a1 SCC of the cervix, and, accordingly, we conclusively affirm the validity of the aforementioned criteria for establishing multifocality.

Oncologic and obstetric outcomes after conization for adenocarcinoma in situ or stage IA1 cervical cancer

This study aims to reveal the risk factors associated with recurrence or new-onset high-grade squamous intraepithelial lesions (HSILs) or more severe lesions (HSILs +) and analyze obstetrical outcomes in patients with adenocarcinoma in situ (AIS) or stage IA1 cervical cancer patients after conization. A retrospective cohort study was developed from January 1, 2002, and July 1, 2018, in a single center, where all patients with AIS or stage IA1 cervical cancer who accepted conization for primary surgery were reviewed and followed up until July 1, 2019, for the pathological findings of HSILs + and obstetric outcomes. Two hundred and seventeen patients were identified, including 114 cases of AIS, 76 cases of stage IA1 squamous cell carcinoma (SCC) and 27 cases of stage IA1 adenocarcinoma (ADC). A total of 88 (40.6%) patients had an intact uterus without radiotherapy. Five patients experienced HSIL+ recurrence. The cumulative 3-, 5- and 10-year incidence rates of HSILs + were 1.0%, 1.5% and 2.0%, respectively. No significant risk factors, including primary disease, margin status and hysterectomy, were associated with recurrence. Twenty (66.7%) of 30 patients who attempted pregnancy had 23 successful pregnancies, which result in 7 miscarriages, 16 live births and 5 preterm births. Age at conization was the only independent risk factor associated with pregnancy, live births and preterm births. In conclusion, conization is safe for young women with AIS, stage IA1 SCC and ADC who desire future fertility, and the associated HSIL recurrence rate is low. Increased age significantly lowered the conception or live birth rate.

Fertility-Sparing Surgery for Early-Stage Cervical Cancer: A Systematic Review of the Literature

OBJECTIVE

This systematic review aimed to evaluate oncologic and reproductive outcomes after fertility-sparing surgery (FSS) for early-stage cervical cancer (early CC).

DATA SOURCES

Ovid MEDLINE, Ovid EMBASE, and Cochrane CENTRAL were searched from 1980 to the present using Medical Subject Headings terms; other controlled vocabulary terms; and keywords related to fertility, cervical cancer, and surgical techniques.

METHODS OF STUDY SELECTION

A total of 2415 studies were screened, with 53 studies included. Studies reporting recurrences with a median follow-up of 12 months in early CC (International Federation of Gynecology and Obstetrics 2009 stages IA with lymphovascular space invasion, IB, or IIA) of traditional histologic type undergoing FSS were included.

TABULATION, INTEGRATION, AND RESULTS

The studies were grouped by intervention, including vaginal radical trachelectomy (VRT), abdominal radical trachelectomy (ART), minimally invasive radical trachelectomy (MIS-RT), and conization or simple trachelectomy (ST), and studies involving neoadjuvant chemotherapy (NACT). Combined rates of recurrence (RR), cancer death (CDR), pregnancy (PR), and live birth (LBR) were calculated per procedure on the basis of all included studies that reported outcomes on that procedure. The results were as follows: VRT: RR 4%, CDR 1.7%, PR 49.4%, and LBR 65.0% ART: RR 3.9%, CDR 1.4%, PR 43.2%, and LBR 44.0% MIS-RT: RR 4.2%, CDR 0.7%, PR 36.2%, and LBR 57.1% Cone or ST: RR 4.2%, CDR 0.8%, PR 55.1%, and LBR 71.9% NACT: RR 7.5% and CDR 2.0% CONCLUSION: FSS of early CC with VRT, ART, or MIS-RT have comparable oncologic outcomes in carefully selected patients, with reproductive outcomes favoring VRT. Data on nonradical FSS with cone or ST are less robust but support similar oncologic outcomes to radical trachelectomy with fewer reproductive complications. NACT in this setting requires more investigation before routine implementation into practice.

Management of microinvasive cervical cancer: a British Society for Colposcopy and Cervical Pathology audit

The incidence of microinvasive cervical cancers seems to be increasing as a result of screening. However, there is little national or international guidance on best management or follow-up of women treated with conservation of the cervix.

OBJECTIVE

The study aimed to assess the current management and follow-up of women with stage IA cervical cancer, according to the International Federation of Gynecology and Obstetrics, within the United Kingdom.

DESIGN/SETTING

This study is a multicenter national audit of a clinical practice in the United Kingdom.

MATERIALS AND METHODS

A structured questionnaire was sent and returned electronically to all lead colposcopists in the United Kingdom on the management and follow-up of women with stage IA cervical cancer according to the International Federation of Gynecology and Obstetrics. The study was approved by the British Society for Colposcopy and Cervical Pathology.

RESULTS

Of the 210 lead colposcopists, 110 (52%) responded. All reported that women with stage IA cervical cancer are discussed at a gynecologic multidisciplinary team meeting. Women who managed conservatively with their cervix in situ are followed up for at least 5 years. There is a wide variation in clinical management of cases with lymphovascular space involvement (LVSI) and depth of invasion greater than 3 mm (stage IA2).

CONCLUSIONS

The pattern and practice of follow-up for stage IA cervical cancer is highly variable. The development of national guidance should be considered.

Curative treatment of a pelvic side wall recurrence after conization for microinvasive cervical cancer stage IA1: a case report and review of the literature

BACKGROUND

For patients wishing to preserve fertility conization is regarded as an adequate treatment in cervical cancer stage IA1 without lymphovascular space involvement (LVSI). Reviewing case series with IA1 cervical cancers without LVSI, lymph node metastasis (LNM) is present in 0.5%.

MATERIALS AND METHODS

We pr esent a case of a 34-year-old patient treated with conization for squamous cervical cancer invading 1.2 mm without LVSI and horizontal extension of 6 mm (IA1).

RESULTS

At a routine postpartum examination after an uneventful pregnancy, a 5-cm pelvic mass was noted at the right pelvic wall. Intraoperative evaluation revealed a LNM which was resected, and postoperative pelvic chemoradiotherapy was performed. The patient remains recurrence-free 84 months after conization and 73 months after resection of the recurrence.

CONCLUSIONS

Occurrence of LNM in IA1 cervical cancers is very rare, but if early diagnosed curative treatment is possible.