Tertiary prevention strategies for micrometastatic lymph node cervical cancer: A systematic review and a prototype of an adapted model of care

PURPOSE

We found a need for balancing the application of clinical guidelines and tailored approaches to follow-up of cervical cancer (CC) patients in the lymph node micrometastatic (MICs) setting. This review aimed to determine the current knowledge of management of MIC-positive CC cases.

METHODOLOGY

We addressed prognostic and risk of recurrence monitoring impacts associated with MIC+ cases. The electronic databases for literature and relevant articles were analysed.

RESULTS

Fifteen studies, (4882 patients), were included in our systematic review. While the results show that MICs significantly worsen prognosis in early CC. A tertiary prevention algorithm for low volume lymph node disease may stratify follow-up according to the burden of nodal disease and provide data that helps improve follow-up performance.

CONCLUSION

MICs worsen prognosis and should be managed as suggested by the algorithm. However, this algorithm must be externally validated. The clinical impact of isolated tumor cells (ITC) remains unclear.

Protocol of Breast Cancer Prevention Model with Addition of Breast Ultrasound to Routine Gynecological Visits as a Chance for an Early Diagnosis and Treatment in 25 to 49-Year-Old Polish Females

The low attendance rate for cancer screening tests in Poland is a major healthcare concern that requires specific analysis and the development of implementation recommendations for prevention, and both actions are likely to benefit culturally similar countries. Four female cancers account for approximately 20% of all cancer cases-breast cancer, cervical cancer, endometrial cancer, and ovarian cancer-suggesting that gynecologists have a significant preventative role. Of the four, breast cancer and cervical cancer are among the 10 most common malignant neoplasms globally, regardless of gender, occur only in women and are known to have effective screening measures. Our research aims to create a screening model that combines cervical cancer and breast cancer to maximize health outcomes for women at risk of both cancers. In the study protocol, we have created a model that maximizes benefits for patients with minimal additional costs to the health care system. To achieve the set goal, instead of regular clinical breast exams as recommended by the gynecological societies, we proposed an ultrasound examination, during which palpation may also be performed (in the absence of elastography). We present a scheme for such a protocol that takes into consideration all types of prevention in both cancers, and that emphasizes breast ultrasound as the most frequently missing element. Our study includes a discussion of the strengths and weaknesses of our strategy, and the crucial need for infrastructure and education for the successful implementation of the program. We conclude that our model merits consideration and discussion among health-care decision makers, as the screening changes we propose have significant potential benefits for the female population.

Factors limiting the detection of sentinel lymph nodes in early-stage cervical cancer

OBJECTIVES

Sentinel lymph node detection (SLND) has not yet displaced lymphadenectomy, but it is a desired supplementary technique in cervical cancer surgery. The aim of our study was to identify the sources of SLND failure while performing the procedure by injecting blue dye (BD) into the cervix in cases of early-stage cervical cancer (ECC).

MATERIAL AND METHODS

We analyzed 27 consecutive ECC patients (FIGO IA2-IB1) who underwent hysterectomy with SLND and systematic lymphadenectomy between October 2011 and June 2014. The main inclusion criterion was at least unilateral SLND by BD. Predictors of either unilateral or bilateral staining were identified using multinomial logit models and a decision tree.

RESULTS

Overall, bilateral staining was achieved in nine patients (33%). Among the factors analyzed, BMI > 23.5 kg/m2 was the only factor negatively affecting the quality of SLND using BD (p < 0.02) in the univariable multinomial logit model. All patients with BMI < 23.5 kg/m2 and depth of invasion ≥ 15 mm had unilateral mapping.

CONCLUSIONS

Both obese and overweight patients are unlikely to achieve optimal SLN staining with BD alone. Although some possible reasons are discussed, we believe that further studies are needed to clarify the specific limitations of other dyes currently in use.

New therapeutic approaches in the treatment of node-positive cervical cancer patients based on molecular targets: a systematic review

Cervical uterine cancer is the second most frequent female cancer worldwide and a substantial burden for low-income societies and the patients themselves. Understanding the molecular mechanisms of metastasis permits the development of therapies that limit tumor progression, as well as providing health and social benefits. Pathomorphology is still the basis of research and a reference standard for molecular analysis. The aim of our study was to research and critically evaluate clinical trials that use new oncological approaches for node-positive cervical cancer to gain an insight into the molecular mechanisms of tumor metastasis.

INCLUSION CRITERIA

node-positive disease at baseline; at least a first phase clinical study comprising adult female patients; novel clinical approach (e.g., radiotherapy, immunotherapy, targeted therapy, vaccines, radiosurgery); histologic measurement of treatment efficacy (preferably lymph node ultrastaging); and publications in English language only.

INFORMATION SOURCES

US Clinical trials registry, EU Clinical trials register, ISRCTN registry, and Ovid, EBSCO and Cochrane Collaboration databases. Access dates: from January 2010 to April 2018.

EXCLUSIONS

Abstracts that did not meet the inclusion criteria or with unreliable data. We collected complete data (e.g., the entire publication associated with included abstracts, heterogeneity examination of individual studies, and validity measurement of the statistical methods used). Results were analyzed in relation to the most recent understanding of the pathogenesis of cervical cancer metastasis. We proposed a possible direction for drug treatment of epithelial tumors based on the mechanisms of metastasis.

Ultrasound and Clinical Preoperative Characteristics for Discrimination Between Ovarian Metastatic Colorectal Cancer and Primary Ovarian Cancer: A Case-Control Study

The aim of this study was to describe the clinical and sonographic features of ovarian metastases originating from colorectal cancer (mCRC), and to discriminate mCRC from primary ovarian cancer (OC). We conducted a multi-institutional, retrospective study of consecutive patients with ovarian mCRC who had undergone ultrasound examination using the International Ovarian Tumor Analysis (IOTA) terminology, with the addition of evaluating signs of necrosis and abdominal staging. A control group included patients with primary OC. Clinical and ultrasound data, subjective assessment (SA), and an assessment of different neoplasias in the adnexa (ADNEX) model were evaluated. Fisher's exact and Student's t-tests, the area under the receiver-operating characteristic curve (AUC), and classification and regression trees (CART) were used to conduct statistical analyses. In total, 162 patients (81 with OC and 81 with ovarian mCRC) were included. None of the patients with OC had undergone chemotherapy for CRC in the past, compared with 40% of patients with ovarian mCRC (p < 0.001). The ovarian mCRC tumors were significantly larger, a necrosis sign was more frequently present, and tumors had an irregular wall or were fixed less frequently; ascites, omental cake, and carcinomatosis were less common in mCRC than in primary OC. In a subgroup of patients with ovarian mCRC who had not undergone treatment for CRC in anamnesis, tumors were larger, and had fewer papillations and more locules compared with primary OC. The highest AUC for the discrimination of ovarian mCRC from primary OC was for CART (0.768), followed by SA (0.735) and ADNEX calculated with CA-125 (0.680). Ovarian mCRC and primary OC can be distinguished based on patient anamnesis, ultrasound pattern recognition, a proposed decision tree model, and an ADNEX model with CA-125 levels.

Preoperative measurement of serum CA-125 levels: is it useful in the risk assessment of low volume lymph node disease in cervical cancer?

BACKGROUND: Elevated serum cancer antigen 125 (CA-125) is observed in some cervical cancers (CCs). Is the correlation of CA-125 with the presence of nodal events useful in predicting early metastasis to the lymph nodes?

METHODS: The study included 45 patients with CC FIGO (2009) stages IA1-IIA1 and known preoperative CA-125 concentration, surgery treated (05.2011-05.2014). Investigated pretreatment: age (pre-, postmenopausal), histological type, grade, confounding factors - prior cone biopsy, ovarian cyst, endometriosis, liver or colon pathology, concomitant malignancy. LN metastases (LNM) were defined as macro (MAC, >2mm) and/or micrometastases (mic, 0.2 - 2 mm), and LVLND as mic or/and ITC (single CC cells clusters) in LNs. Ultrastaging of all LNs (sentinel and non-sentinel, 4 μm thick slices/150 μm intervals) was performed with hematoxylin and eosin staining and with immunohistochemistry (IHC - AE1/AE3 cytokeratin antibodies). Non-parametrical analysis and receiver operating curve analysis were used to determine correlation between CA-125 and LNM including LVLND.

RESULTS: The median age was 55 (23-71). 806 LNs were extracted. LNM was found in 12, LVLND in 6 patients. LNM but not LVLND was correlated with higher grade (G2-G3, p<0.05). LVLND was positively correlated with premenopausal age (p<0.05) but not with tumor histology or grade. Liver disease only was found to influence CA-125 levels (p=0.064). There were no differences within CA-125 concentration among LVLND, LNM, and node-negative patients groups, however a trend was found between higher CA-125 and lower LVLND risk.

CONCLUSIONS: Elevated levels of CA-125 may be less likely due to LVLND than to LN positivity. Grade is an important feature in prediction of LNM but not LVLND. CA-125 level was found to be not predictive of LNM nor LVLND, as confirmed by ultrastaging.

Mucinous borderline ovarian tumor: a case report with diagnostic insights on ultrasound findings

Borderline ovarian tumors represent about 10% of all epithelial ovarian cancers, but in contrast to epithelial ovarian cancers, they constitute a group of tumors with a much better prognosis. An assessment of clinical presentation, physical examination, radiological and biochemical findings is necessary to tailor management strategies for patients with ovarian tumors. The article, which is based on a case report, describes different approaches for preoperative diagnosis as well as discusses approaches that might bring some insights on tumor histology. Furthermore, it raises a question about which imaging techniques should be proposed for a reliable diagnosis of borderline ovarian tumors to ensure safe surgery planning.

[Micrometastases in sentinel lymph node in endometrial cancer patients]

BACKGROUND

Detection of micrometastases in sentinel lymph nodes (SLN) extends our knowledge of lymphatic spread in endometrial cancer, although its clinical significance has not yet been confirmed.

OBJECTIVES

The aim of study was to determine the incidence of SLN micrometastases and to analyze the association between micrometastases and disease relapse.

MATERIAL AND METHODS

Fifty-four patients with endometrioid endometrial cancer underwent routine surgical therapy and sentinel lymph node biopsy (SLNB). SLNB was performed using two techniques: cervical injection of 99mTc-labelled albumin or blue dye and fundal injection of blue dye. SLNs were subjected to ultrastaging with immunohistochemistry (AE1/AE3, 150µm).

RESULTS

At least one SLN was detected in 51 patients (94.4%) and bilateral SLN detection was achieved in 80.4%. Nodal macrometastases were found in 3 patients (6.3%). SLNB enabled us to detect nodal macrometastases in 2 out of those 3 patients. In the third case, detection of SLN micrometastasis allowed to correctly determine the nodal status, thus avoiding the false negative result of SLNB. In 48 patients with detected 184 SLNs, there were 4 patients (8.3%) with micrometastases and 4 (8.3%) with ITC foci. No significant associations between the presence of risk factors (grade, myometrial invasion, cervical invasion, lymphovascular space invasion) and incidence of micrometastases and/or ITC foci in SLNs were found.

CONCLUSIONS

Detection of micrometastases may result in lower false-negative rate, thus increasing SLNB safety.

Clinical feasibility and diagnostic accuracy of detecting micrometastatic lymph node disease in sentinel and non-sentinel lyph nodes in cervical cancer: outcomes and implications

BACKGROUND

Lymph node (LN) micrometastatic disease has come to prominence since ultrastaging was shown to improve the quality of LN procedures in epithelial cancers. The aim of the study was to evaluate the feasibility and diagnostic usefulness of detecting micrometastases in sentinel (SLN) and non-sentinel LNs (nSLN) in cervical cancer

MATERIAL AND METHODS

Twelve consecutive patients with cervical cancer stages IA to IIA, classified according to the Union for International Cancer Control (UICC) and divided into two groups: A (7) and B (5), with and without SLN procedure with methylene blue dye, who underwent radical hysterectomy and lymph nodes removal, were recruited for the study. All LNs were evaluated in hematoxylin-eosin (HE) staining and immunohistochemically (IHC) in ultrastaging with anti-cytokeratin AE1/AE3 antibodies. A detailed analysis was performed with regard to the technical and histopathological aspects of the procedure.

RESULTS

More LNs could be extracted and studied in group A as compared to group B (210 vs. 70, mean 30 vs. 14, respectively p < 0.0005). A total of 13 SLNs were extracted, and the identification rate was 71% (5/7 in group A). One micrometastatic LN was found in each of the groups (16% cases), but the preliminary classification of the advancement stage was changed only in 1 case from the labeled nodes group (group A--from pN0 with HE to pN1 with IHC).

CONCLUSIONS

Presence or absence of metastases in SLN(s) should not be sufficient amount of information for a surgeon or an oncologist, who ought to have data about all of the removed lymph nodes (sent to ultrastaging). In order for the surgery to be performed properly it is vital to ensure that SLNs were removed. Assessment of the N status ought to be taken into consideration in the classification according to the International Federation of Gynecology and Obstetrics (FIGO).

[Clinical significance of lymph node micrometastases in cervical cancer]

In most cancers of epithelial origin, metastases to the lymph nodes constitute the most important prognostic factor and are predictive of the results of the surgical and adjuvant therapies. Data on the lymph node status allows to design an appropriate treatment plan. Despite advances in gynecologic oncology the importance of lymph node micrometastases in cervical cancer especially in nonsentinel lymph nodes which are detected by ultrastaging, has not been fully elucidated. The purpose of the article is to familiarize the reader with the state of current knowledge on cervical cancer micrometastases. The authors attempt to answer the question about the benefits of lymph node assessment in the search for micrometastases in cervical cancer as well as to address emerging doubts.

Twenty-four-hour and conventional blood pressure components and risk of preterm delivery or neonatal complications in gestational hypertension

Gestational hypertension is a recognized risk factor for the development of complications during pregnancy. The present study retrospectively assessed the respective values of blood pressure components derived from conventional and 24-h recordings (ABPM) as predictors of premature delivery in women with gestational hypertension based on office readings from 26th week of gestation onwards. Blood pressures were measured conventionally and over 24 h. Standard medical and obstetric history, and standard laboratory work-up were taken into account. The mean (+/- standard deviation, SD) age of 123 women was 29 +/- 6 years. Current pregnancy was, on average, the second. The conventional systolic (SBP)/diastolic (DBP) blood pressure averaged 140 +/- 19/92 +/- 14 mmHg, and pulse pressure (PP) and mean arterial pressure (MBP) averaged 48 +/- 10 and 108 +/- 15 mmHg. The corresponding values derived from ABPM were 135 +/- 16/90 +/- 11, 47 +/- 9 and 105 +/- 12 mmHg. The 24-h blood pressures had better prognostic value than the conventional blood pressures. The 24-h SBP predicted risk of premature delivery and was inversely related to the duration of pregnancy and birth weight. After the exclusion of 41 women with white-coat hypertension, the highest predictive value was associated with PP. PP wider by 1SD was associated with 66% higher risk of premature delivery, and was associated with shortening of pregnancy by 2 weeks and 400 g lower birth weight, even after adjustment for SBP. In conclusion, ABPM is superior to conventional blood pressure measurements in predicting adverse outcome of pregnancy. Twenty-four-hour PP, of all classic indices, seems to be most closely related to increase of that risk.

[Spontaneous rupture of common iliac artery after hysterectomy for malignant gynecologic tumor]

Authors described a serious, iatrogenic, vessel complications after hysterectomy for uterus sarcoma. After successful abdominal hysterectomy spontaneous rupture of right common iliac artery occurred causing massive exsanguination into intraperitoneal space. During secondary laparotomy procedure large, partial loss of arterial wall was recognized and provided with non-absorbable Prolene 4-0 suture. Subsequently, the injury was replaced by arterial artificial prosthesis gore-tec 8. Intraoperatively, ventricular fibrillation and cardiac arrest took place with subsequent acute respiratory and circulatory distress syndrome. Throughout next several days after reoperation patient was deep unconscious and hospitalized on Intensive Care Unit. She manifested symptoms of damaged extrapyramidal tracts. In spite of further unfavourable prognosis, after almost a month of respiratory therapy, she fully recovered without symptoms of brain damage and visual sequelae.

[Burkitt lymphoma involving the ovaries]

Burkitt lymphoma is a very rare type of lymphoma with a predilection for the ovary. We report a case of 18-years old woman with dramatic course of the Burkitt lymphoma involving ovaries. Immunohistochemistry techniques allowed for the diagnosis and the successful chemotherapy. The case demonstrates the importance of an appropriate pathology evaluation and interdisciplinary collaboration.

[Assessment of high blood pressure in 24-hours Holter records in hypertensive pregnant patients]

DESIGN

The aim of our study was to established possible a correlation between Holter blood pressure measurements and BP levels measured incidentally by the medical personnel. We also tried to evaluate usefulness of ABPM in monitoring intensification of the hypertension.

MATERIALS AND METHODS

The research was performed on 57 pregnant women where pregnancies were complicated by hypertension (PIH or chronic hypertension). All patients were divided into four groups conforming with JNC VI protocol according to BP level measured in the time of the admission to hospital. Therefore circadian blood pressure profile was done by using ABPM SpaceLab device. After that BP load indicator was estimated in each group to assess intensification of the disease. However, we compared those results between groups by using t-Student test (p < 0.05).

RESULTS

We qualified 22 patients to group 0 with SBP = 129,45 + 6.31 mmHg and DBP = 80.59 + 5.45 mmHg in the time of admission. There were 21 pregnant women with mild hypertension (group I SBP = 144,14 + 7.32 mmHg, DBP = 93.14 + 4.52 mmHg), moderate (group II, N = 8 with SBP = 153,88 + 5.54 mmHg and DBP = 101,34 + 3.78 mmHg) and severe hypertension (group III, N = 6 with SBP = 175,83 + 33.23 mmHg, DBP = 121 + 11.92 mmHg). BP load value measured in group 0 was 14.57 + 21.3% of SBP and 13.92 + 22.99% of DBP inappropriate results. In group I was found SBP 24.91 + 30.3%, DBP 23.12 + 26.01%, group II SBP 38.11 + 33.66%, DBP 26.31 + 22.75% and in group III SBP 59.3 + 38.76% and DBP 61.37 + 35.72%, respectively.

CONCLUSIONS

Only between the group with normal blood pressure and the group with severe hypertension the obtained results were statistically significant (p < 0.05). We've also found a statistical correlation between BP values measured in the time of admission to the hospital and BP load indices in each group.

[New techniques with biodegradable Valtrac-Bar rings for intestinal anastomosis management of advanced cancer]

AIM

In the study we tried to demonstrate usefulness of the biofragmentable Valtrac-Bar rings in treatment of intestinal obstruction caused by advanced ovarian carcinoma.

MATERIALS AND METHODS

Intestinal anastomosis with biofragmentable Valtrac-Bar rings were performed in 26 patients with advanced ovarian cancer with symptoms of intestinal obstruction. In nine patients manifestation of acute or subacute intestinal obstruction symptoms, cachexia and ascites necessitated the use of Valtrac rings during primary surgical operation. In the other 17 women we observed recidive of the disease causing obstruction mainly in the lower part of the digestive tract. Eight sigmoid, six sigmo-rectal and three ileo-ileal Valtrac-Bar rings anastomosis were done after secondary cytoreductive surgery.

RESULTS

In 25 treated women we achieved improvement of their general condition, so we were able to continue treatment by chemio- or radiotherapy. Only in one treated patient further relaparotomy with colostomy was needed due to of anastomosis leak.

CONCLUSIONS

We conclude that biofragmentable valtrac-Bar rings are very useful, safe and effective tools enabling fast intestinal anastomosis even in patients with inappropriate healing, for instance treated previously by chemio- et radiotherapy.

[Isolated metastases of cervical cancer to the abdominal wall--a case report]

We described an unusual case of skin metastases of the uterine cervix in 63 year old woman. Previously, she was found having a Stage IIa squamous carcinoma of the cervix. She underwent bilateral salpingo-oophorectomy, total abdominal hysterectomy and pelvic node dissection. Then the patient was treated by external and intracavitary radiation. Within the next six months she was readmitted to the hospital because of abdominal pain and urinary stress incontinence after irradiation. The examination revealed three firm, freely-movable, solid subcutaneous nodules on the abdominal wall, umbilical site and urinary fistula. No other significant physical phenomena were noted. Radical excision of all the lesions was conducted and followed by four courses of adjuvant chemotherapy. Histopathological examination of the excised nodules revealed nests of squamous cell carcinoma, which were histologically identical to the previous carcinoma of the cervix. After successful treatment, the patient was continued for three months now, without any clinical evidence of recrudescence, and with good results from the urinary fistula treatment. Moreover, in these case-report we presented a review of current literature about new techniques and treatment methods of the cervical carcinomas.

[An advanced cervical carcinoma coexisting with pregnancy in 19-years old primipara--a case report and review of current literature]

In our case report we described an fatal outcome of very young, nineteen years old primipara with advanced, aggressive squamous cervical cancer associated with 20 weeks gestation. Despite of our intentions to abort the pregnancy and started immediate therapy, she decided to delay treatment to allow fetal maturity. After 12 weeks interval, she was readmitted to the hospital with symptoms of intestinal occlusions caused by fast progression of disease. In 33 week of gestation we performed classical caesarean section with Pivercs type III radical hysterectomy. She was delivered of viable female infant weighing 1800 g. Simultaneously, we extended operation of possible cytoreductive surgery. After that, patient received two courses of adjuvant chemotherapy (MIC-scheme) and supplemental external beam radiation. Unfortunately, despite of multidisciplinary, aggressive treatment, she experienced recurrence in pelvic side walls within 6 months of surgery. At last follow-up, she was receiving salvage therapy.

[Evaluation of risk factors after intraperitoneal chemotherapy in patients with ovarian cancer]

DESIGN

The authors sought to evaluate risk factors of patients with ovarian cancer treated with intraperitoneal cisplatin based chemotherapy (IPC).

MATERIAL AND METHODS

From January 1996 to December 1998, 24 patients with recurrent or persistent ovarian cancer were treated. We divide them in two groups first beneath 65 year old (19 patients), second above 65 year (5 patients), and in three groups with residual microscopic diseases, residual below 0.5 cm, and between 0.5 and 2 cm in the time of the beginning of treatment with IPC. We also estimate stage (FIGO) as a risk factor.

RESULTS

In the first group the study showed (CRP) among 9 patients (SD) among 2 patients PD in among patients. In the second group CRP were observed among 2 patients PD among 2 patients, and SD 1 patient.

CONCLUSION

IPC is the valuable method of second line chemotherapy for ovarian cancer. Age is not a risk factor in IPC. IPC prolongs survival in ovarian cancer patients, progression free survival, and gives only slightly adverse effects.

[A rare case of non-Hodgkin's lymphoma of the uterine cervix]

We report a rare case of primary extranodal non-Hodgkin lymphoma of the uterine cervix. A 58-year old, postmenopausal multipara was admitted to the hospital with metrorrhagia and vaginal discharge. After diagnostic biopsy, the patient underwent radical abdominal hysterectomy, bilateral salpigo-oophorectomy and pelvic lymph node dissection. histologically, the lymphoma was classified as non-Hodgkin lymphoma of intermediate malignancy. Immunohistochemical studies revealed that the atypical lymphoid cells were B-cells (CD 20+), indicating that the lymphoma was of B-lineage. Postoperatively, she received adjuvant chemiotherapy. Our experience and a review of current literature are presented.