Preoperative MRI criteria for trials on less radical surgery in Stage IB1 cervical cancer

doi:10.1016/j.ygyno.2014.02.042

Gynecologic Oncology

Volume 134, Issue 1, July 2014, Pages 47-51

https://doi.org/10.1016/j.ygyno.2014.02.042 Get rights and content

Highlights

•
There was no parametrial involvement in patients categorized as low risk based on our MRI parameters (0/127).
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Low risk is defined as tumor size ≤ 25 mm and no evidence of parametrial involvement in MRI.
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Patients in the low risk category may be candidates for trials on less radical surgery.

Abstract

Objective

The aim of this study is to identify a patient group with a low-risk of parametrial involvement (PMI) in Stage IB1 cervical cancer using preoperative magnetic resonance imaging (MRI) parameters.

Methods

In total, 190 Stage IB1 cervical cancer patients with clinically visible lesions who had undergone Type C2 radical hysterectomy and preoperative MRI were included in this study. Clinical records, pathology reports, and preoperative MRI findings were reviewed retrospectively.

Results

Of the 190 patients, 19 (10%) had pathologic PMI. The largest tumor diameter identified by MRI ranged from zero (no definite mass on the cervix) to 60 mm, with a median of 21 mm. Patients were identified as being either low-risk (tumor size ≤ 25 mm and no evidence of PMI, n = 127) or high-risk (tumor size > 25 mm and/or findings indicating PMI, n = 63) based on MRI parameters. The rate of pathologic PMI in low- and high-risk patients was 0.0% and 30.2%, respectively (P < 0.001). Five-year progression-free survival in low-risk patients was 95.9%, which is significantly better than the rate of 85.6% for patients in the high-risk group (P = 0.039).

Conclusions

Preoperative MRI parameters can help identify patients with a low-risk of PMI and, therefore, possible candidates for trials on less radical surgery.

Introduction

Radical hysterectomy and pelvic lymphadenectomy are standard surgical treatments for the International Federation of Gynecology and Obstetrics (FIGO) Stage IB1 cervical cancer. Despite the excellent rate of five-year overall survival [1], [2], this surgical approach is also accompanied by high incidence of long-term morbidity, such as lower urinary tract dysfunction, sexual dysfunction, and colorectal motility disorders, which are attributable to parametrectomy [3], [4], [5], [6], [7], [8]. As researchers have previously reported low rates of parametrial involvement (PMI) in patients with early-stage cervical cancer, there has been an effort to identify a low-risk group of cervical cancer patients who may be candidates for less radical surgery while oncologic outcomes are maintained [9], [10], [11], [12].

Previous studies have shown that the rate of PMI was less than 1% in patients with low-risk characteristics, such as limited depth of invasion, absence of lymphovascular space invasion (LVSI), and negative pelvic lymph nodes [9], [11], [13]. All of these criteria were constructed on the basis of surgicopathologic parameters obtained from final pathologic reports. Although tumor size ≤ 2.0 cm is the most consistently reported criteria and the only factor that can be determined preoperatively, accurate determination of the tumor diameter from preoperative inspection and/or bimanual physical examination is difficult [14], [15]. As the current FIGO staging system recommends clinical staging for cervical cancer, tumor diameter is generally determined by pelvic examination. However, preoperative magnetic resonance imaging (MRI) can provide a more accurate and reproducible estimate of tumor size, especially for endophytic tumors, when identifying suitable candidates for less radical surgery [16], [17]. Moreover, preoperative MRI allows for noninvasive evaluation of the parametrium, nodal metastasis, and vaginal involvement.

There has been increasing demand for clinicians to help patients make informed decisions and to provide accurate information regarding the risks and benefits of parametrectomy before surgery. The aim of this study is to identify a patient group with a low-risk of PMI in Stage IB1 cervical cancer using preoperative MRI parameters.

Section snippets

Methods

After receiving approval from the Institutional Review Board, medical records, pathologic reports, and MRI findings were reviewed retrospectively for all patients treated surgically for Stage IB1 cervical cancer between 2003 and 2011 at Seoul National University Hospital. The use of MRI in diagnosis and follow-up has been widespread at this institution since 2003. Patients eligible for inclusion were those: (1) with clinical Stage IB1 cervical cancer and macroscopically visible lesions, (2) who

Results

The characteristics of the 190 patients are presented in Table 1. The median age was 49 years and the rate of pathologic PMI was 10% (19/190). Squamous cell carcinoma was most prevalent (73.2%), followed by adenocarcinoma (21.6%) and adenosquamous carcinoma (4.2%). The entire study population underwent preoperative evaluation using MRI. The largest tumor diameter measured by MRI in Stage IB1 cervical cancer ranged from zero (no demonstrable lesion on the cervix) to 60 mm, with a median diameter

Discussion

In this study, we demonstrate that there was no evidence of PMI in patients categorized as low-risk based on our MRI parameters. Our findings suggest that patients with Stage IB1 cervical cancer who have tumor diameter ≤ 25 mm and no evidence of PMI in MRI results have minimal risk of PMI and an excellent prognosis. Although further studies are required to validate our results, preoperative MRI findings can be used to categorize patients into low- and high-risk groups for PMI; those in the

Conflict of interest

We declare no conflicts of interest.

Acknowledgment

The authors thank Dong-Su Jang for his excellent support with medical illustration.

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Retrospective analysis of the incidence and predictive factors of parametrial involvement in FIGO IB1 cervical cancer
2021, Journal of Gynecology Obstetrics and Human Reproduction
Radical surgery is the standard primary treatment for patients with stage IB1 (FIGO 2009 staging) cervical cancer due to latent parametrial involvement. Recent studies suggested that less radical surgery was applicable for patients with no or low risk of parametrial involvement. In this study, we aimed to determine the incidence and possible predictive factors of parametrial involvement in patients with stage IB1 cervical cancer so as to evaluate whether less radical surgery was suitable for selected patients.
Clinical data of patients who underwent type C radical hysterectomy with pelvic lymphadenectomy and diagnosed as stage IB1 cervical cancer at Union Hospital, Wuhan, China from October 2014 to December 2017 were collected and analysed retrospectively. The incidence of parametrial involvement was calculated and the risk factors for parametrial involvement were evaluated by univariate and multivariate logistic regression.
Among 282 eligible patients, 33 (11.7%) had parametrial involvement. Postmenopause, lymphovascular space invasion (LVSI), lymph node metastasis (LNM), deep stromal invasion (outer 1/3) and tumor size larger than 2 cm were statistically associated with parametrial involvement. Multivariate analysis showed that LNM (OR = 11.431; 95%CI: 3.455 - 37.821), deep stromal invasion (OR = 6.080; 95%CI: 1.814 - 20.382) and LVSI (OR = 7.147; 95%CI: 1.863–27.411) remained as independent risk factors for parametrial involvement in patients with stage IB1 cervical cancer.
The incidence of parametrial involvement in stage IB1 cervical cancer is non-negligible. Only LNM, LVSI and deep stromal invasion were independent predictors, which were not easy to evaluate accurately before surgery. Less radical surgery requires modified pre-treatment evaluation methods and prospective data support.
Predictors for pathological parametrial invasion in clinical stage IIB cervical cancer
2019, European Journal of Surgical Oncology
To examine predictors of pathological parametrial invasion in clinical stage IIB cervical cancer, and to examine prognostic factors in pathological stage IIB disease.
This study is an ancillary analysis of a nation-wide retrospective cohort examining 6,003 clinical stage IB-IIB cervical cancers. Women with clinical stage IIB disease who underwent primary radical hysterectomy with lymphadenectomy were examined (n = 714). Multivariate analysis was performed to identify independent clinico-pathological factors for pathological parametrial invasion and to identify independent prognostic factors in pathological stage IIB disease.
Parametrial invasion was identified on the surgical specimen in 400 cases (56.0%, 95% confidence interval 52.4–59.7). On multivariate analysis, deep stromal invasion (DSI, adjusted-OR 3.922), multiple pelvic nodal metastases (adjusted-OR 3.266), lympho-vascular space invasion (adjusted-OR 2.333), and uterine corpus invasion (adjusted-OR 1.656) remained independent tumor factors for pathological parametrial invasion. In classification-tree models, tumors with DSI and multiple pelvic nodal metastases had the highest incidence of pathological parametrial invasion (75.0–87.7%); contrary, tumors without DSI had the lowest incidence (21.9%). Among patients with pathological stage IIB disease, the absolute difference in 5-year disease-free survival rates was 57.2%, ranging between 80.9% in those with squamous histology with none/single pelvic nodal metastasis and 23.7% in those with non-squamous histology with multiple pelvic nodal metastases.
In clinical stage IIB cervical cancer, accuracy for pathological parametrial invasion is low-modest. With absence of DSI, only one in five clinical stage IIB diseases has pathological stage IIB disease. Survival of pathological stage IIB varies widely and is largely dependent on nodal factors.
Comparison of survival outcomes between minimally invasive surgery and conventional open surgery for radical hysterectomy as primary treatment in patients with stage IB1–IIA2 cervical cancer
2019, Gynecologic Oncology
To compare survival outcomes of minimally invasive surgery (MIS) and conventional open surgery for radical hysterectomy (RH) among patients with early-stage cervical cancer (CC).
We retrospectively identified stage IB1-IIA2 CC patients who underwent either laparoscopic or open Type C RH between 2000 and 2018. Patients' clinicopathologic characteristics and survival outcomes were compared according to the surgical approach. For a more robust statistical analysis, we narrowed the study population down to the patients with stage IB1 who underwent pre-operative MRI.
In total, 435 and 158 patients were assigned to open surgery and MIS groups, respectively. MIS group had significantly less parametrial invasion (6.3% vs. 15.4%; P = 0.004). Despite similar proportions of patients received adjuvant treatment, concurrent chemoradiation therapy was performed less frequently in MIS group. After a median follow up of 114.8 months, the groups showed similar overall survival; however, MIS group displayed poorer progression-free survival (PFS; 5-year rate, 78.5% vs. 89.7%; P < 0.001). Multivariate analyses identified MIS as an independent poor prognostic factor for PFS (adjusted HR, 2.883; 95% CI, 1.711–4.859; P < 0.001). Consistent results were observed among 349 patients with stage IB1: MIS was associated with higher recurrence rates (adjusted HR, 2.276; 95% CI, 1.039–4.986; P = 0.040). However, MIS did not influence PFS of stage IB1 patients with cervical mass size ≤2 cm on pre-operative MRI (adjusted HR, 1.146; 95% CI, 0.278–4.724; P = 0.850).
Overall, MIS RH was associated with higher recurrence rates than open RH in patients with early-stage CC. However, MIS was not a poor prognostic factor among those with stage IB1 and cervical mass size ≤2 cm on pre-operative MRI.
Pretreatment neutrophil-lymphocyte and platelet-lymphocyte ratio predict clinical outcome and prognosis for cervical Cancer
2018, Clinica Chimica Acta
Citation Excerpt :
And in advanced cervical cancer patients it could help in identifying the appropriate range of radiation. Previous studies had confirmed that tumor size, tumor-invasion depth, LVSI, and pelvic LNM are pathological risk factors for parametrial involvement in cervical cancer [16–18]. Our results suggested that NLR and PLR act as preoperatively predictive markers for parametrial involvement in cervical cancer patients.
Variations in systemic inflammatory response biomarker levels have been associated with adverse clinical outcome in various malignancies. In this study, we aimed to evaluate the predictive and prognostic role of the pretreatment neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in cervical cancer. We retrospectively investigated 616 patients who underwent initial radical hysterectomy with pelvic lymphadenectomy for cervical cancer between July 2012 and December 2014 in China. Their clinical and histopathological markers and complete blood counts were obtained and analyzed. Then we chose the group of 339 of the total 616 patients who were not combined preoperative radiotherapy or chemotherapy for the survival analysis. Prognostic factors were assessed by univariate and multivariate analyses. The ROC curve revealed NLR and PLR had significant ability to predict parametrial involvement, and the cutoff values for NLR and PLR were 2.5 and 138.8 respectively. Clinicopathologic analysis showed that NLR was linked to age, parametrial involvement, tumor-invasion depth and histologic grade, and PLR was related to age, parametrial involvement, tumor-invasion depth and FIGO stage. Univariate analysis identified high PLR as a significant poor predictor for progression-free survival (PFS) and overall survival (OS), and NLR exhibited no predict power on OS or PFS. Multivariable analysis showed that PLR was an independent predictor of PFS, but not OS. NLR and PLR were associated with the clinical characteristics of cervical cancer. Additionally, PLR had independence prognostic value for PFS in patients with cervical cancer receiving radical hysterectomy with pelvic lymphadenectomy.
Preoperative nomogram for prediction of microscopic parametrial infiltration in patients with FIGO stage IB cervical cancer treated with radical hysterectomy
2016, Gynecologic Oncology
Citation Excerpt :
Recently, MRI-based tumor diameter ≥ 25 mm, volume index ≥ 5000 mm3, and serum SCC-Ag > 1.5 ng/mL or cancer antigen 125 (CA-125) > 35 U/mL were suggested as pretreatment risk factors for PMI in FIGO stage IB2 cervical cancer [35]. However, approximately 5% to 10% of all FIGO stage IB1 cervical cancer patients, particularly those with tumors equal to or > 2 cm in diameter, showed microscopic PMI [4,7–9]. Therefore, it seems reasonable that patients with a low risk of PMI should be treated with less radical surgery such as type C1 (nerve-sparing) RH, not simple hysterectomies, since metastatic parametrial disease is randomly located in the lateral and medial parametria [36–38].
This study aimed to establish a nomogram to predict microscopic parametrial infiltration (PMI) by combining preoperative clinicopathologic factors in FIGO stage IB cervical cancer patients treated by radical hysterectomy (RH).
We retrospectively analyzed clinicopathologic data of 298 patients with FIGO stage IB cervical cancer treated by RH between February 2000 and March 2015. The nomogram was developed based on multivariate logistic regression analysis of preoperative clinicopathologic data. The accuracy and discriminative ability of the nomogram were evaluated by a concordance index and calibration curve. The low-risk group was predefined as having a predicted probability of PMI < 10%.
Multivariate analysis identified diameter-based tumor volume and disruption of the cervical stromal ring on magnetic resonance imaging, serum squamous cell carcinoma antigen level, and menopausal status as independent prognostic factors associated with PMI. The concordance index of the nomogram was 0.940 (95% CI, 0.908–0.967), and calibration plots revealed good agreement between the observed probabilities and nomogram-predicted probabilities (Hosmer Lemeshow test, p = 0.574). The nomogram classified 200 out of 298 patients (67.1%) as low risk. In the low-risk group, the predicted probability of PMI was 3.5% and the actual PMI rate was 2.5% (5 out of 200).
We developed a preoperative nomogram predicting microscopic PMI in surgically treated FIGO stage IB cervical cancer patients. The probabilities derived from this nomogram may have the potential to provide valuable guidance for physicians regarding the primary management of FIGO stage IB cervical cancer patients.
How often parametrial involvement leads to post-operative adjuvant treatment in locally advanced cervical cancer after neoadjuvant chemotherapy and type C radical hysterectomy?
2015, European Journal of Surgical Oncology
Citation Excerpt :
Our study group and other observed that type B radical hysterectomy upholds the long-term oncologic effectiveness of type C1 radical hysterectomy, minimizing post-operative surgical morbidity and the occurrence of pelvic dysfunction.8,17 Similarly, other investigations supported the choice to perform less radical surgery.22–26 Lee et al. suggested that in absence of radiological evidence of parametrial involvement (assessed by magnetic resonance imaging (MRI)) and small tumor diameter, the rate of parametrial involvement is extremely low.22
Parametrial involvement (PMI) is one of the most important factors influencing prognosis in locally advanced stage cervical cancer (LACC) patients. We aimed to evaluate PMI rate among LACC patients undergoing neoadjuvant chemotherapy (NACT), thus evaluating the utility of parametrectomy in tailor adjuvant treatments.
Retrospective evaluation of consecutive 275 patients affected by LACC (IB2-IIB), undergoing NACT followed by type C/class III radical hysterectomy. Basic descriptive statistics, univariate and multivariate analyses were applied in order to identify factors predicting PMI. Survival outcomes were assessed using Kaplan–Meier and Cox models.
PMI was detected in 37 (13%) patients: it was associated with vaginal involvement, lymph node positivity and both in 10 (4%), 5 (2%) and 12 (4%) patients, respectively; while PMI alone was observed in only 10 (4%) patients. Among this latter group, adjuvant treatment was delivered in 3 (1%) patients on the basis of pure PMI; while the remaining patients had other characteristics driving adjuvant treatment. Considering factors predicting PMI we observed that only suboptimal pathological responses (OR: 1.11; 95% CI: 1.01, 1.22) and vaginal involvement (OR: 1.29 (95%) CI: 1.17, 1.44) were independently associated with PMI. PMI did not correlate with survival (HR: 2.0; 95% CI: 0.82, 4.89); while clinical response to NACT (HR: 3.35; 95% CI: 1.59, 7.04), vaginal involvement (HR: 2.38; 95% CI: 1.12, 5.02) and lymph nodes positivity (HR: 3.47; 95% CI: 1.62, 7.41), independently correlated with worse survival outcomes.
Our data suggest that PMI had a limited role on the choice to administer adjuvant treatment, thus supporting the potential embrace of less radical surgery in LACC patients undergoing NACT. Further prospective studies are warranted.

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View full text

Preoperative MRI criteria for trials on less radical surgery in Stage IB1 cervical cancer

Highlights

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conflict of interest

Acknowledgment

J Am Coll Surg

Eur J Surg Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Eur J Cancer

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Survival of Korean adult cancer patients by stage at diagnosis, 2006–2010: National Cancer Registry study

Cancer Res Treat

Cancer statistics, 2012

CA Cancer J Clin

Vaginal changes and sexuality in women with a history of cervical cancer

N Engl J Med

Lymphedema and bladder-emptying difficulties after radical hysterectomy for early cervical cancer and among population controls

Int J Gynecol Cancer