The significance of microscopic involvement of the parametrium and/or pelvic lymph nodes in cervical cancer stages IB and IIA

doi:10.1016/0090-8258(83)90009-4

Gynecologic Oncology

Volume 16, Issue 1, August 1983, Pages 56-62

https://doi.org/10.1016/0090-8258(83)90009-4 Get rights and content

Abstract

From 1961 through 1980, 388 patients with cervical carcinoma stage IB (272) and stage IIA (116) were treated by radical hysterectomy and pelvic lymphadenectomy. The operation specimens were divided into four groups: no involvement of the parametrium and pelvic lymph nodes (71.4%), involvement of the parametrium alone (7.2%), involvement of the pelvic lymph nodes alone (11.9%), and involvement of both the parametrium and pelvic lymph nodes (9.5%). Two hundred thirty-eight patients were followed for at least 5 years. The corrected 5-year survival figures for these four groups (stages IB and IIA together) were 90.3, 75.0, 62.1, and 50.0%, respectively. The differences are of statistical significance (P < 0.005). Not only the stage of disease and involvement of the lymph nodes, but clearly also the involvement of the parametrium is of significance for the results of treatment in cervical cancer.

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Twenty-first century cervical cancer management: A historical perspective of the gynecologic oncology group/NRG oncology over the past twenty years
2018, Gynecologic Oncology
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Similarly, GOG 109 which was performed in conjunction with both the Southwest Oncology Group and Radiation Therapy Oncology Group, evaluated the role of chemotherapy added to post-operative external beam radiation therapy to the pelvis [4]. While GOG 49 was able to predict the impact of intermediate risk factors on recurrence and positive nodal status, much of the data available on higher risk features was retrospective [18, 19]. Nonetheless, based on the relatively consistent information that noted not only a higher risk of recurrence but also inferior survival, a prospective trial was developed which randomly assigned patients to either 49.3 Gy alone or in combination with cisplatin 70 mg/m2 and 5-fluorouracil (5FU) 1000 mg/m2/d over 96 h every 3 weeks.
Since 1970, the Gynecologic Oncology Group (GOG) has been at the forefront of evaluating and helping to implement ground breaking and paradigm changing research in the management of cervical cancer. While the most dramatic example of this impact was a series of clinical trials published in 1999 that evaluated chemoradiation therapy versus radiation therapy alone for patients with various clinical scenarios, including both locally advanced as well as post radical hysterectomy patients, investigation has continued to further refine and improve therapy. In 2014, based on the results of GOG protocol 240, bevacizumab became the first approved targeted therapy in a gynecologic cancer in the United States. Most recently, clinical trial work from the GOG is changing the standard of care for all clinical scenarios. Finally, an emphasis on survivorship and special populations are now top priorities.
Post-operative radiotherapy in patients with early stage cervical cancer
2014, Gynecologic Oncology
Citation Excerpt :
The indications for chemotherapy in combination with surgery, radiotherapy or both modalities in high-risk early stage patients became evident in 1999, and it was later confirmed in different studies and a meta-analysis [5,18–20]. In our clinic, surgery is the first-choice treatment in patients with early cervical cancer, unless a patient is medically unfit for surgery or in elderly patients (> 70 years) [21,22]. PORT is routinely performed in case of lymph node metastasis, parametrial invasion, positive surgical margins or intraoperative spill [23].
The aim of this study is to investigate the impact of treatment policy changes in cervical cancer patients treated with adjuvant (chemo) radiotherapy.
Between 1970 and 2007, 292 patients received adjuvant radiotherapy after a radical hysterectomy with pelvic lymphadenectomy for early stage cervical carcinoma. All patients received pelvic radiotherapy (40 Gy–46 Gy in 1.8 Gy–2 Gy/fraction). Vaginal vault brachytherapy boost (10–14 Gy) was increasingly used for patients with high-risk factors, and since 1993 systematically applied in patients with at least 2 of the 3 risk factors: adenocarcinoma, nodal involvement and parametrial invasion. Cisplatin-based chemotherapy was introduced in this group of patients from 2000.
The 5-year cumulative risk of local recurrence (CRLR) was 13% (95%CI 9%–17%), resulting in an overall 5-year survival (OS) of 78% (95%CI 83%–73%). Since 1970, the OR for the 5-year locoregional recurrence risk (LRR) decreased from 2.5 to 1.15 (linear-OR = − 0.02/year). The OR for the 5-year mortality risk reduced from 2.2 in 1970 to 1.0 in 2007 (linear-OR = − 0.03/year). The largest risk reductions were observed before 1990 with a minor rise after 2002. The risk of severe late toxicity reduced from 1.8% to 1.5% (linear-OR = − 0.03/year). The addition of concomitant adjuvant chemotherapy since 2000 may have benefited a subgroup of patients with squamous cell carcinoma, but not the patients with adenocarcinoma, and after introduction of chemotherapy the risk of severe late toxicity tripled from 2% to 7%.
Since 1970, tumour recurrence risk and mortality have decreased, as radiation dose increased. The potential benefit of concomitant adjuvant chemotherapy could not be demonstrated in this nonrandomized study.
Early invasive cervical cancer: MRI and CT predictors of lymphatic metastases in the ACRIN 6651/GOG 183 intergroup study
2009, Gynecologic Oncology
To compare MRI, CT, clinical exam and histopathological analysis for predicting lymph node involvement in women with cervical carcinoma, verified by lymphadenectomy.
A 25-center ACRIN/GOG study enrolled 208 patients with biopsy-proven invasive cervical cancer for MRI and CT prior to attempted curative radical hysterectomy. Each imaging study was interpreted prospectively by one onsite radiologist, and retrospectively by 4 independent offsite radiologists, all blinded to surgical, histopathological and other imaging findings. Likelihood of parametrial and uterine body involvement was rated on a 5-point scale. Tumor size measurements were attempted in 3 axes. Association with histologic lymph node involvement, scored as absent, pelvic only and common iliac or paraaortic, was evaluated using Cochran–Mantel Haenszel statistics, univariate and multivariate logistic regression, generalized estimating equations, accuracy statistics and ROC analysis.
Lymphatic metastases were found in 34% of women; 13% had common iliac nodal metastases, and 9% had paraortic nodal metastases. Based on the retrospective multi-observer re-reads, the average AUC for predicting histologic lymph node involvement based on tumor size was higher for MRI versus CT, although formal statistic comparisons could not be conducted. Multivariate analysis showed improved model fit incorporating predictors from MRI, but not from CT, over and above the initial clinical and biopsy predictors, although the increase in discriminatory ability was not statistically significant.
MRI findings may help predict the presence of histologic lymph node involvement in women with early invasive cervical carcinoma, thus providing important prognostic information.
Prognostic significance of TPA versus SCC-Ag, CEA and neopterin in carcinoma of the uterine cervix
2008, Cancer Letters
Citation Excerpt :
Only a small number of patients (1%) underwent chemoradiotherapy, which can be explained by the period in which samples were collected. The question, whether the histologic type affects prognosis, remains controversial. [19,20], [18,21]. Our study found histology to be an independent prognostic factor for overall survival with an increased relative risk of 2.3 for adeno- and adenosquamous carcinoma as compared to carcinomas with a squamous cell type (Table 3).
Introduction: Prognostic significance of squamous cell carcinoma antigen (SCC-Ag), tissue polypeptide antigen (TPA), carcinoembryonic antigen (CEA) and neopterin in cervical cancer patients was compared.
Materials and methods: Pretreatment concentrations were determined in 138 women.
Results: Median age was 52 years, 85% squamous cell carcinomas, 15% adeno- or adenosquamous carcinomas were seen. In 36% Fédération Internationale de Gynécologie et d’Obstétrique (FIGO) stage I, 24% stage II, 32% stage III and 8% stage IV was diagnosed. TPA was elevated in 22%, SCC in 68%, CEA in 42% and neopterin in 29%. These patients showed significantly worse overall survival in univariate analysis (p < 0.001). TPA remained as independent prognostic factor in multivariate analysis.
Conclusions: Elevation of TPA was associated with worse overall survival.
The incidence of parametrial tumor involvement in select patients with early cervix cancer is too low to justify parametrectomy
2007, Gynecologic Oncology
Citation Excerpt :
However, it is unclear what proportion of the parametrium should be removed and in a significant amount of patients, radical trachelectomy may be over treatment. The incidence of parametrial involvement (PI) in pelvic node negative patients is low [8–11,13]. Hence, in selected patients it might suffice to perform a conization with pelvic lymphadenectomy.
To determine the incidence of parametrial involvement in a select group of patients with early cervical cancer.
We retrospectively reviewed the records of patients with cervical cancer and a maximum tumor diameter of 2 cm, infiltration depth < 10 mm and negative pelvic lymph nodes who underwent a radical hysterectomy in two university hospitals. In addition, the literature was reviewed.
103 patients were identified in our databases that met the abovementioned criteria. In two of these patients (1.94%), parametrial involvement was found. Both patients had LVSI. Literature review revealed 696 patients described in three studies that satisfied the selection criteria. Three (0.43%) of these patients had parametrial involvement. In patients with early stage cervical carcinoma, tumor size < 2 cm, infiltration depth < 10 mm, negative pelvic lymph nodes and absent LVSI the risk of parametrial involvement is 0.63%.
Because of a very low risk on parametrial involvement, patients who fulfil strict selection criteria could be candidates for conization and pelvic lymphadenectomy instead of more extensive surgery. Morbidity and pregnancy complications may decrease while it is unlikely that survival will be compromised.
Lymphovascular and perineural invasion in the parametria: A prognostic factor for early-stage cervical cancer
2003, Obstetrics and Gynecology
Citation Excerpt :
Lymphovascular space invasion might lead to tumor emboli infiltrating the parametria and pelvic and paraaortic nodes.12 Although many studies have examined the role of parametrial involvement as a prognostic factor in treating early-stage cervical cancer, there are no reports specifically characterizing the role of lymphovascular space invasion or perineural invasion within the parametria.13–16 Presence of lymphovascular space invasion within the cervix is an independent prognostic variable in the treatment of patients with early-stage cervical cancer, as shown in a prospective study performed by the Gynecologic Oncology Group.17
To estimate the impact of parametrial lymphovascular and perineural involvement on nodal metastasis and failure pattern of women with early-stage, surgically treated cervical cancer.
Clinical records and pathologic slides of 93 patients with early-stage cervical cancer (2 IA₂, 52 IB₁, 31 IB₂, and 8 IIA) treated with radical hysterectomy and pelvic lymphadenectomy with or without paraaortic lymphadenectomy were reviewed. The study group comprised 80 patients with squamous cell carcinoma and 13 patients with adenocarcinoma of the cervix. Median follow-up time was 33 months. The association among the various histopathologic predictors of outcome was determined with χ² analysis. The influence of the predictors on outcome was examined with log rank survival methods and the Cox regression model.
The presence of parametrial lymphovascular space invasion is a predictor of disease in the pelvic (P < .001) and paraaortic (P < .05) lymphatics independently. Large tumor size (greater than 4 cm), parametrial perineural invasion, cervical lymphovascular space invasion, and tumor depth (greater than two thirds) were found to be simultaneous predictors of recurrence on multivariate analysis (P < .05). Using these four binary predictor variables, we have computed a model-based relative risk. Based on this model, the presence of perineural invasion in the parametria more than doubles the risk of recurrence in the cohort of patients with large (greater than 4 cm) tumors (P < .05). In a subset analysis of patients with negative nodal disease, parametrial perineural invasion and tumor size were independent predictors of poor outcome (P < .05).
Presence of parametrial lymphovascular space invasion correlates significantly with the risk of nodal metastasis in women with early-stage cervical cancer. Parametrial perineural invasion is an independent poor prognostic factor. Histopathologic findings within the parametria are a valuable independent predictor of recurrence and thus may influence the selection of patients for adjuvant treatment.

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The significance of microscopic involvement of the parametrium and/or pelvic lymph nodes in cervical cancer stages IB and IIA

Abstract

Amer. J. Obstet. Gynecol.

Amer. J. Obstet. Gynecol.

Gynecol. Oncol.

Surgical treatment of carcinoma of the cervix

Obstet. Gynecol.

Prognostic significance of cervical lesion size and pelvic node metastases in cervical carcinoma

Obstet. Gynecol.

Optimal surgical treatment and its role in cervical carcinoma