Ovarian preservation in adenocarcinoma of the uterine cervix

Low doses of alkylating agents do not harm human ovarian tissue destined for cryopreservation

OBJECTIVE

To investigate the impact of nongonadotoxic doses of alkylating agents on human ovarian cortex.

DESIGN

Retrospective study.

SETTING

Academic research center.

PATIENTS

Biopsies from 78 patients who had undergone ovarian tissue cryopreservation were retrieved and analyzed. Among them, 42 had previously been treated with chemotherapy (alkylating agents, dose <3,400 mg/m2), making up the chemotherapy group, whereas 36 had not been given any chemotherapy, constituting the control group.

MEAN OUTCOME MEASURES

Follicle count and classification, morphology study, immunostaining for apoptosis (cleaved caspase-3), immunostaining for activation (phospho-Akt), fibrosis (Masson's trichrome), and vascularization (von Willebrand factor and smooth muscle actin).

RESULTS

In the prepubertal group, 271 follicles/mm3 were detected in control patients and 501 follicles/mm3 in chemotherapy-exposed subjects. In the adult group, 4,916 follicles/mm3 were found in control patients and 6,570 follicles/mm3 in chemotherapy-exposed patients. No difference in follicle density was observed between the 2 groups in any age category. Neither did we encounter any significant difference in follicle viability according to chemotherapy exposure or age. Proportions of nongrowing follicles were >76% in all age groups, irrespective of chemotherapy exposure, and higher, although not significantly, in the chemotherapy group compared with the control group. There were significantly fewer secondary follicles in the adult chemotherapy group than in the adult control group. Concerning apoptosis, no significant difference was observed between control and chemotherapy subjects in any age groups. Numbers of activated follicles were systematically higher in all age categories in the chemotherapy group than the control group. Areas of atypical follicles were noted in 4 out of 14 prepubertal patients in the chemotherapy group. In these areas, follicle density was 84,570 ± 8,837 follicles/mm3 and all follicles appeared nonviable but showed no sign of apoptosis.

CONCLUSION

Low-dose chemotherapy had no major impact on ovarian tissue, suggesting that ovarian tissue exposed to some chemotherapy before cryopreservation is comparable with ovarian tissue free of any chemotherapy, as clinically demonstrated by high pregnancy rates after ovarian tissue transplantation in women exposed to chemotherapy. Previous chemotherapy should therefore no longer be a contraindication to ovarian tissue cryopreservation.

How do we safely preserve ovaries in patients with cervical adenocarcinoma: risk factors and predictive models

Objective

To study and predict the risk of ovarian metastasis (OM) in patients with cervical adenocarcinoma (ADC).

Methods

Patients with ADC who received surgical treatment from January 2015 to December 2022 in the Obstetrics and Gynecology Hospital of Fudan University were included in the study. Patients were further divided into OP (ovaries were preserved in surgery) and BSO (bilateral salpingo-oophorectomy) groups. For the patients who accepted BSO, 60% of the patients were randomly grouped into a training cohort, and predictive prognostic models were constructed with 10-fold cross-validation through random forest, LASSO, stepwise, and optimum subset analysis. The model with the highest area under receiver operator curve (AUC) was screened out in the testing cohort. The nomogram and its calibration curve presented the possibility of OM in future patients. The prognoses between the different populations were compared using Kaplan-Meier analysis. All data processing was carried out in R 4.2.0 software.

Results

A total of 934 patients were enrolled in our cohort; 266 patients had their ovaries preserved and 668 patients had BSO according to the previous criteria reported The clinical safety with these criteria was secured, while the 5-year overall survival had no significant difference between the BSO and OP groups (p = 0.069), which suggested that the current criteria could be extended and are more precise. Four predictive models for ovarian metastasis by machine learning were constructed in our study, and the random forest model that obtained the highest AUC in both training and testing sets (0.971 for training and 0.962 for testing set) was taken as the best model. The optimal cut-off point of the ROC curve (specificity 99.5% and 90% sensitivity) was utilized to stratify the patients into high- and low-risk OM. Further comparing the survival curves of the high and low-OM risk groups, it was found that both DFS and OS were significantly prolonged in the low-risk group (p < 0.01). On the basis of this random forest model, a nomogram was used to calculate the OM risk, and the results were validated with calibration. The predictive model was further applied to the whole cohort (934 patients), and we identified the OM low-risk population (n = 822) and the patients with high risk who should be recommended for BSO (n = 112). No significant difference was found in the 5-year survival between the low-risk group with our model and the patients who already had ovaries preserved according to the previous criteria (n = 266).

Conclusion

The predictive model constructed in our study could identify the low-risk population of OM in patients with ADC, which remarkably extended the number with the previous criteria, for whom we could potentially preserve ovaries to help improve their life quality.

Ovarian Metastasis from Human Papillomavirus-associated Usual-type Endocervical Adenocarcinoma: Clinicopathological Characteristics for Distinguishing from Primary Ovarian Mucinous or Endometrioid Tumor

BACKGROUND/AIM

Distinguishing ovarian metastasis of usual-type endocervical adenocarcinoma (UEA) from primary ovarian tumors is often challenging because of several overlapping features. This study aimed to investigate the clinicopathological characteristics and outcomes of patients with metastatic ovarian UEA.

PATIENTS AND METHODS

Clinicopathological information was collected from eight patients with metastatic ovarian UEA. Immunostaining was also performed.

RESULTS

Most patients presented with adnexal masses that were suspected to be primary ovarian tumors. All examined cases showed block p16 positivity in paired primary and metastatic tumors. Five patients who completed post-operative chemotherapy or concurrent chemoradiotherapy (CCRT) did not experience recurrence. In contrast, one patient who refused further treatment after the first CCRT cycle experienced ovarian and peritoneal metastases. One patient with isolated ovarian metastasis left untreated and developed peritoneal metastasis during follow-up.

CONCLUSION

Patients with UEA who received proper management for ovarian metastases showed favorable outcomes. Given that ovarian metastatic UEA can mimic primary ovarian borderline tumor or carcinoma of the mucinous or endometrioid type, pathologists should be aware of this unusual but distinctive morphology to avoid misdiagnosis and inappropriate treatment.

Factors Associated with Patient Survival in Clear Cell Adenocarcinoma of the Cervix: A Single-Center Experience in China

Purpose

Clear cell adenocarcinoma of the cervix (CCAC) is a rare pathological type of cervical cancer. This study aimed to report our clinical experience with CCAC treatment and analyze the factors associated with patient survival.

Patients and Methods

This single-center study included patients diagnosed with CCAC and treated between 01/2003 and 12/2017 at the Obstetrics and Gynecology Hospital of Fudan University. The patients diagnosed with CCAC that underwent radical resection were included. The Kaplan–Meier method and multivariable Cox regression analysis were performed to determine factors associated with patient survival.

Results

Fifty-four patients were included. None were exposed to diethylstilbestrol. The median follow-up was 96 (13.0, 120.0) months. The median recurrence-free survival (RFS) and overall survival (OS) were 68 and 78 months, respectively. Positive pelvic lymph nodes (HR=2.87, 95% confidence interval [CI] 1.14–7.22, P=0.03), tumor size >4 cm (HR=3.31, 95% CI 1.35–8.12, P=0.01), International Federation of Gynecology and Obstetrics (FIGO) IB2-IIA2 stage (HR=2.49, 95% CI 1.56–3.99, P=0.02), and postoperative therapy (HR=1.73, 95% CI 1.07–2.81, P=0.03) were associated with OS. Multivariable analysis showed that FIGO stage IB2-IIA2 (HR=2.36, 95% CI 1.52–3.68, P<0.01) and lymph node status (HR=3.05, 95% CI 1.12–8.28, P=0.03) were independently associated with OS.

Conclusion

Advanced FIGO stage and positive lymph node status are independently associated with shorter survival in patients with CCAC who were not exposed to diethylstilbestrol. After surgery, chemotherapy and concurrent chemoradiotherapy were not independently associated with the prognosis of patients with CCAC.

Adenosquamous Carcinoma of the Cervix: A Population-Based Analysis

Background

Due to the rarity of adenosquamous carcinoma of the cervix (ASCC), studies on the incidence, prognostic factors, and treatment outcomes of ASCC remain scarce. Therefore, we performed a retrospective population-based study to systematically investigate the characteristics of ASCC patients.

Methods

Patients with a histopathologically confirmed diagnosis of ASCC were enrolled from the Surveillance, Epidemiology, and End Results database between 1975 and 2016. Univariate and multivariate Cox regression analyses were performed to identify the potential predictors of cancer-specific survival (CSS) in patients with ASCC. Selected variables were integrated to establish a predictive nomogram and the predictive performance of the nomogram was estimated using Harrell’s concordance index (C-index), calibration curve, and decision curve analysis (DCA).

Results

A total of 1142 ASCC patients were identified and included in this study and were further randomized into the training and validation cohorts in a 7:3 ratio. The age-adjusted incidence of ASCC declined from 0.19 to 0.09 cases per 100,000 person-years between 2000 and 2017, with an annual percentage change of -4.05% (P<0.05). We identified age, tumor grade, FIGO stage, tumor size, and surgical procedure as independent predictors for CSS in ASCC patients and constructed a nomogram to predict the 3- and 5-year CSS using these prognostic factors. The calibration curve indicated an outstanding consistency between the nomogram prediction and actual observation in both the training and testing cohorts. The C-index was 0.7916 (95% CI: 0.7990-0.8042) and 0.8148 (95% CI: 0.7954-0.8342) for the training and testing cohorts, respectively, indicating an excellent discrimination ability of the nomogram. The DCA showed that the nomogram exhibited more clinical benefits than the FIGO staging system.

Conclusions

We established and validated an accurate predictive nomogram for ASCC patients based on several clinical characteristics. This model might serve as a useful tool for clinicians to estimate the prognosis of ASCC patients.

Tumor Staging of Endocervical Adenocarcinoma: Recommendations From the International Society of Gynecological Pathologists

The International Federation of Gynecology and Obstetrics (FIGO) updated its staging system for cervical cancer in 2018 with changes that affect size criteria for early stage disease, as well as including pathology and radiology in addition to clinical assessment to be used in staging. Lymph node involvement was also included in the staging system. In early stage disease, pathologic findings are crucial in determining stage, which in turn determine treatment and prognosis for the patient. Therefore, it is imperative that there are unified and consistent methods and recommendations for assessing and reporting pathologic parameters for accurate staging. We describe the changes in the revised FIGO staging scheme and discuss controversial issues in cervical cancer staging from a pathologic perspective. We also provide practical recommendations regarding these parameters based on literature review and/or expert opinion/consensus.

[Pregnancy-preserving and maternal-fetal management in a patient with rare large cell neuroendocrine carcinoma of the uterine cervix]

OBJECTIVE

To explore the strategy of pregnancy-preserving and maternal- fetal management in patients with primary gynecologic neuroendocrine tumors (gNETs) during pregnancy.

METHODS

We performed whole genome sequencing (WGS) for analyzing maternal and fetal somatic and germline single nucleotide variations (SNVs) and small insertions and deletions (InDels) for a 29-year-old pregnant woman diagnosed with stage IB2 large cell neuroendocrine carcinoma (LCNEC) and adenocarcinoma in the cervix. A systematic literature review was performed to explore the strategies for treatment of such rare histological type while maintaining pregnancy.

RESULTS

Global case analysis of cervical NETs during pregnancy suggested that negative lymph node metastasis and an early FIGO stage were potentially associated with a good prognosis of the patients. In the case presented herein, a pregnancy-preserving strategy was adopted and favorable maternal-fetal outcomes were achieved after neoadjuvant chemotherapy, radical surgery and postoperative systemic chemotherapy. At 35⁺⁵ weeks, the fetus was delivered by caesarian section, and the patient has by now had a disease-free survival of 19 months postoperatively. WGS analysis revealed 6 missense somatic pathogenic mutations in two cancer tissues of the patient, and among them KARS and VEGFA were related with targeted therapy. Five pathogenic germline variants were detected in the patient and her son, suggesting the necessity of a long-term follow-up schedule including precise genetic counselling for both the mother and the child.

CONCLUSIONS

Although gNETs in pregnancy are rare and highly risky, pregnancy-preserving managements of gNETs can still be considered and favorable maternalfetal outcomes are possible with proper assessment of the clinical indications and implementation of multimodal treatments. Precise treatment and follow-up strategies based on the results of WGS for risk-reducing intervention of cancer recurrence or occurrence can potentially benefit the patient and the neonate.

Clear Cell Adenocarcinoma of Uterine Cervix: A Single Institution Retrospective Experience

Purpose

The purpose of the study is to summarize the clinical characteristics and identify the prognosis of clear cell adenocarcinoma of the uterine cervix (CCAUC) in patients without a history of diethylstilbestrol (DES) exposure.

Methods

Forty-two patients with CCAUC, treated initially at Sun Yat-sen University Cancer Center between 1985 and 2017, were studied.

Results

Of all the CCAUC patients, the median age was 47 years old, and the median tumor size was 3 cm. Thirty-four early stage patients (IB = 28, IIA = 6) underwent radical surgery. Eight advanced stage patients (IIB = 8) received concurrent chemoradiotherapy (n = 4) or radical surgery (n = 4). Survival analysis showed that patients with early stage (IB-IIA) had a significantly better 5-year progression-free survival (PFS) and overall survival (OS) than those with advanced stage (IIB) (p < 0.05). The patients with negative pelvic lymph node (PLN) had a significantly better 5-year PFS and OS than those with positive PLN (p < 0.05). Radiotherapy (RT) did not affect PFS or OS in early stage patients with intermediate risk factors (p > 0.05). Adjuvant chemotherapy (CT) did not affect PFS or OS in early stage patients without risk factors (p > 0.05).

Conclusion

The FIGO stage and pelvic node status were important prognostic factors for both PFS and OS. For treatment modality, we recommended that radical surgery alone was used in early stage patients without high risk factors. Ovarian preservation in early stage patients involved some risk.

British Gynaecological Cancer Society (BGCS) cervical cancer guidelines: Recommendations for practice

Cervix cancer in many countries is declining and screening programmes and immunisation will reduce the incidence in the next few decades. This guideline attempts to cover management of invasive disease reflecting diagnosis and imaging including new imaging and sentinel lymph node biopsies. Smaller volume disease is usually managed surgically whereas advanced disease is treated with (chemo)- radiation. It also includes discussion of fertility sparing procedures. Practices are changing frequently for all aspects of care usually in attempts to reduce complications and improve quality of life. The management of advanced disease is treated by chemotherapy and the use of newer agents is also discussed. Other sections discuss specialist situations such as cancer in pregnancy, rare cervical tumours, late effects and supportive measures and fertility preserving approaches.

Oncological Outcomes and Safety of Ovarian Preservation for Early Stage Adenocarcinoma of Cervix: A Systematic Review and Meta-Analysis

Objectives: To evaluate the oncological outcomes and safety of ovarian preservation, and to review the prognostic factors for ovarian metastases in early stage cervical adenocarcinoma.

Methods: PubMed, Embase, and Cochrane databases were searched for publications up to January 2019. Two investigators independently screened the studies for eligibility and extracted specific data. The primary outcomes were overall survival (OS) and progression-free survival (PFS). Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using STATA statistical software version 19.0.

Results: A total of 68 unique manuscripts were identified through the search strategy, and 10 studies were included in the meta-analysis of the safety of ovarian preservation. Fixed-effects model was used because of moderate heterogeneity. Pooled results of the included studies showed that ovarian preservation is not associated with a statistically significant OS (OR 1.00, 95% CI 0.64–1.56, I² = 25.7%) or PFS (OR 0.98, 95% CI 0.57–1.66, I² = 0%) in early stage cervical adenocarcinoma. In addition, 19 studies were included in the review of prognostic factors for cervical adenocarcinoma and risk factors for ovarian metastases. The incidence of ovarian metastases was 0% in stage IA, 2.8% in stage IB, 3.4% in stage IIA, and 11.8% in stage IIB cervical adenocarcinoma. International Federation of Gynecology and Obstetrics (FIGO) stage, tumor size, deep stromal invasion (DSI), lymph node metastasis (LNM), and vaginal invasion were significantly related to poor prognosis. Risk factors associated with ovarian metastases included age, FIGO stage, tumor size, DSI, parametrial invasion, corpus uteri invasion, LNM, vaginal invasion, and blood vessel invasion.

Conclusions: Ovarian preservation in young patients with early stage cervical adenocarcinoma is safe and has no significant effect on OS or PFS. Preserving ovaries in patients with FIGO stage IIB seems not reasonable because of the high rate of ovarian metastasis.

Revised FIGO staging for carcinoma of the cervix uteri

OBJECTIVE

To revise FIGO staging of carcinoma of the cervix uteri, allowing incorporation of imaging and/or pathological findings, and clinical assessment of tumor size and disease extent.

METHODS

Review of literature and consensus view of the FIGO Gynecologic Oncology Committee and related societies and organizations.

RESULTS

In stage I, revision of the definition of microinvasion and lesion size as follows. Stage IA: lateral extension measurement is removed; stage IB has three subgroups-stage IB1: invasive carcinomas ≥5 mm and <2 cm in greatest diameter; stage IB2: tumors 2-4 cm; stage IB3: tumors ≥4 cm. Imaging or pathology findings may be used to assess retroperitoneal lymph nodes; if metastatic, the case is assigned stage IIIC; if only pelvic lymph nodes, the case is assigned stage IIIC1; if para-aortic nodes are involved, the case is assigned stage IIIC2. Notations 'r' and 'p' will indicate the method used to derive the stage-i.e., imaging or pathology, respectively-and should be recorded. Routine investigations and other methods (e.g., examination under anesthesia, cystoscopy, proctoscopy, etc.) are not mandatory and are to be recommended based on clinical findings and standard of care.

CONCLUSION

The revised cervical cancer staging is applicable to all resource levels. Data collection and publication will inform future revisions.

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.