Principles of chemotherapy and radiotherapy

The current management of all gynaecological malignancy requires complex multidisciplinary investigation and discussion, leading to multi-modality treatment. The delivery of systemic therapy or radiotherapy can have different aims depending on the type of cancer, clinical context and patient wishes. This review explores the systemic treatment options and radiotherapy that form part of the standard management of this group of tumours and looks at current research that may help shape the treatment of the future.     

Pharmacodynamics of combined estrogen–progestin oral contraceptives: 4. Effects on uterine and cervical epithelia

ABSTRACT

Introduction: Steroid hormones are responsible for specific changes in the endometrium during the menstrual cycle, when they are sequentially secreted and, because of this, in the early days sequential combined oral contraceptive regimens were utilized. The same basic concept has been utilized with multi-phasic regimens, in order to produce endometrial pictures mimicking the normal cycle.

Areas covered: The Endometrial effects of progestins and estrogens; combined monophasic high- (50 μg), medium- (30 μg), low- (20 μg), ultralow- (15 μg) estrogen content; sequential regimens; multiphasic combinations; treatment schedules.

Cervical effects of combined high-dose and sequential combinations, including evidence for an increase in malignant lesions.

Expert opinion: Overall, combined oral contraceptives (COCs) inhibit normal proliferative changes and the endometrium becomes thin, narrow, with widely spaced glands and pre-decidual changes in the stroma. During the first few cycles the progestin induces a coexistence of proliferative and secretory features; with time, the picture changes because the progestin induces a down-regulation of estrogen receptors, resulting in tortuous glands similar to those in the secretory phase, but characterized by a quiescent, atrophic glandular epithelium.

In the cervical epithelium, under the influence of high-dose COCs, endocervical glands became hypersecretory and in some instances, distinctive type of atypical polypoid endocervical hyperplasia is found.     

Gastric-type mucinous carcinoma of the cervix and its precursors – historical overview

The emerging concept of gastric-type mucinous carcinoma (GAS) of the uterine cervix has been accepted worldwide because of its aggressive clinical behaviour and the absence of high-risk human papillomavirus (HPV). GAS is included as a variant of mucinous carcinoma in the 2014 World Health Organization classification, and its recognition has provoked a discussion on endocervical adenocarcinoma as a single entity such that endocervical adenocarcinoma is now divided into HPV-associated and HPV-independent groups. This article reviews historical and conceptual aspects of GAS and its precursors, starting with minimal deviation adenocarcinoma (MDA), through the ensuing confusion, up to the recent paradigm shift in cervical adenocarcinoma subclassification. The gastric immunophenotype of MDA was demonstrated by a Japanese group in 1998 using the HIK1083 antibody, which recognises gastric pyloric gland mucin, and this elucidated the pathogenesis of this particular tumour. However, this information resulted in overdiagnosis of lobular endocervical glandular hyperplasia (LEGH), first described in 1999 and which represents pyloric gland metaplasia (PGM), as malignant. In the early 2000s the relationship between MDA and LEGH/PGM became a matter of controversy. In 2007 HIK1083 immunohistochemistry extended the morphological spectrum of endocervical adenocarcinoma showing gastric differentiation beyond MDA, which resulted in the proposal of GAS as a distinct entity including MDA as its very well-differentiated subtype. GAS is now considered to be an aggressive and chemoresistant neoplasm that is not related to high-risk HPV. The LEGH/PGM–GAS sequence is currently regarded as an HPV-independent pathway of carcinogenesis. Understanding the underlying molecular events in this process is key to the development of biomarkers for early detection and molecular targeted therapy.     

LACC临床随机对照试验研究的启示

LACC研究结果提示对于早期子宫颈癌患者，接受微创手术相比于开腹手术的患者有更高的复发率和更低的生存率。基于该研究结果，目前包括安德森癌症中心在内的国内外医疗机构均已停止或减少对ⅠA2～ⅠB1期子宫颈癌患者提供微创手术。文章在回顾LACC试验结果的同时，分析了目前妇科肿瘤学界对LACC研究结论存在的疑问及微创手术的改良空间，探讨了随机对照试验的临床价值及中国现状。     

从并发症角度看子宫颈癌腹腔镜手术与开腹手术之争

        2018年Ramirez等［1］发表在《新英格兰医学杂志》上的LACC（laparoscopic approach to cervical cancer）前瞻性临床试验结果显示，子宫颈癌微创手术（84.4%为腹腔镜手术）的无病生存率及总生存率较开腹手术低。此文章颠覆了国内外妇瘤医生对于子宫颈癌中运用腹腔镜技术的肿瘤学安全性的认知［2-3］，因而2019年美国国家综合癌症网络（NCCN）指南［4］推荐，在患者行腹腔镜或其他微创手术前，需明确告知腹腔镜手术会导致较差的远期肿瘤学预后。 浏览更多请关注本刊微信公众号及当期杂志。     

Metastatic adenocarcinoma of the mandibular condyle from uterine cervix: Report of a case

Metastasis to the mandibular condyle is rare, and such lesions should be identified by both clinical and pathological examinations. We experienced a case of adenocarcinoma occurring in the right mandibular condyle. A 65-year-old female with uterine cervical cancer showed condylar dysfunction. Imaging examinations revealed a tumor with bone destruction and a rapidly progressive course, while pathological examinations suggested metastasis originating from another site. Based on the clinical and pathological findings, the patient was diagnosed with condylar metastasis derived from the uterine cervix, in addition to a recurrence of uterine cervical cancer.     

宫保散联合LEEP治疗宫颈癌前病变合并HPV感染的临床效果分析

目的:探讨分析宫保散联合高频电波刀(LEEP)对宫颈癌前病变合并人乳头瘤病毒(HPV)感染的临床效果。方法:将我院2013年2月至2015年6月收治的宫颈癌前病变合并HPV感染患者74例按照病床单双号分为试验组和对照组,每组各37例。对照组患者在常规治疗基础上给予LEEP治疗,试验组在对照组基础上给予宫保散局部涂抹治疗,比较两组疗效,分析宫保散联合LEEP治疗宫颈癌前病变合并HPV感染价值。结果:两组手术时间、术中出血量无显著差异(P0.05),而试验组住院时间和医疗费用均较对照组显著降低(P0.05);两组治疗前HPV病毒载量无显著差异(P0.05),治疗后均显著降低(P0.05),且试验组远低于对照组(P0.05);试验组HPV转阴率和总有效率(86.49%和91.89%)均明显高于对照组(51.35%和64.86%)(P0.05);两组不良反应发生率差异无统计学意义(P0.05)。结论:宫保散联合LEEP治疗宫颈癌前病变合并HPV感染效果确切,可以显著减少HPV病毒载量,提高HPV转阴率和总有效率,且安全可靠。     

VCE取材Bethesda 2001报告在宫颈癌筛查中的意义

目的：探讨VCE取材Bethesda 2001报告系统在宫颈癌筛查中的意义。方法：采用VCE取材Bethesda2001报告系统对3 056例健康体检女性进行阴道细胞学检查,并对不明确意义的不典型鳞状上皮细胞（ASC-US）以上病变者经阴道镜取材进行宫颈组织病理学诊断。结果：阴道细胞学检查(VCE取材Bethesda 2001报告系统)检出宫颈异常鳞状上皮细胞66例,阳性率2.15%。其中不明确意义的不典型鳞状上皮细胞（ASC-US）17例（25.76％）,不除外高度病变的不典型鳞状上皮细胞（ASC-H）4例,（6.06％）,低度鳞状上皮内病变（LSIL）28例（42.42％）,高度鳞状上皮内病变(HSIL)14例（21.21％）,宫颈鳞癌（SCC）3例（4.55％）。66例细胞学阳性诊断病例经宫颈活检组织病理学诊断CIN I级以上病变60例（90.91％）,其中CIN Ⅰ级35例（53.03％）,CIN Ⅱ级12例（18.18％）,CIN Ⅲ级7例（10.61％）,宫颈鳞癌6例（9.09％）。结论：VCE取材Bethesda2001报告系统取材方便、报告准确,阴道细胞学检查阳性诊断与病理诊断符合率高达90.91％,VCE取材Bethesda2001报告系统在宫颈癌筛查中具有重要意义。