Oncologic outcome of fertility-sparing radical trachelectomy versus radical hysterectomy for stage IB1 cervical carcinoma

ObjectiveTo compare the oncologic outcomes of women who underwent a fertility-sparing radical trachelectomy (RT) to those who underwent a radical hysterectomy (RH) for stage IB1 cervical carcinoma.MethodsWe performed a case–control study of all patients with stage IB1 cervical carcinoma who underwent a vaginal or abdominal RT between 11/01 and 6/07. The control group consisted of patients with stage IB1 disease who underwent an RH between 11/91 and 6/07 and who would be considered candidates for fertility-sparing surgery. Information was extracted from a prospectively acquired database. Recurrence-free and disease-specific survival (RFS and DSS) were estimated using Kaplan–Meier estimates and compared with the log-rank test where indicated. Multivariate analysis was performed using the Cox regression method.ResultsForty stage IB1 patients underwent an RT and 110 patients underwent an RH. There were no statistical differences between the two groups for the following prognostic variables: histology, median number of lymph nodes removed, node positive rate, lymph-vascular space involvement (LVSI), or deep stromal invasion (DSI). The median follow-up for the entire group was 44 months. The 5-year RFS rate was 96% (for the RT group compared to 86% for the RH group (P = NS). On multivariate analysis in this group of stage IB1 lesions, tumor size < 2 cm was not an independent predictor of outcome, but both LVSI and DSI retained independent predictive value (P = 0.033 and 0.005, respectively).ConclusionFor selected patients with stage IB1 cervical cancer, fertility-sparing radical trachelectomy appears to have a similar oncologic outcome to radical hysterectomy. LVSI and DSI appear to be more valuable predictors of outcome than tumor diameter in this subgroup of patients.     

PIK3CA mutational status and overall survival in patients with cervical cancer treated with radical chemoradiotherapy

ObjectiveMutational activation of PIK3CA is associated with poor prognosis in patients with solid tumors, and may predict favorable response to PI3K/AKT/mTOR pathway inhibitors. However, PIK3CA mutational status has not previously been evaluated in patients with cervical carcinoma treated with radical chemoradiotherapy (CRT). The aims of this study were (1) to evaluate the frequency of PIK3CA mutations in patients with cervical cancer treated with radical CRT and (2) to examine the effect of tumor PIK3CA mutational status in pre-treatment biopsies on overall survival (OS) and progression-free survival (PFS).MethodsPatients with cervical cancer, treated at a single institution with radical CRT, from 1999 to 2008, were eligible for this retrospective study. Pre-treatment tumor biopsies (n = 157) were retrieved. Genomic DNA was extracted from tumor blocks, and exons 9 and 20 of the PIK3CA gene were sequenced for mutations.ResultsEighty-two tumors were sequenced for both exon 9 and exon 20. 19/82 (23%) tumors were PIK3CA mutation positive; of these 84% were squamous cell carcinomas. 79% of mutations were in exon 9. PIK3CA mutation status was strongly associated with overall survival (OS) in FIGO stage IB/II patients, unadjusted HR 6.0 (95% CI 2.1–17.5), p = 0.0002, but not stage III/IVA patients, unadjusted HR 1.0 (95% CI 0.32–3.1), p = 0.98.ConclusionsIn cervical cancer patients treated with CRT, tumor PIK3CA mutation status was associated with overall survival in FIGO stage IB/II cervix cancers. Further evaluation with a larger dataset will be required to validate these findings to inform potential clinical trials designs involving PI3K/AKT/mTOR pathway inhibitors.     

Sexual function after radical hysterectomy for early-stage cervical cancer

IntroductionFor early-stage cervical cancer, treatment with radical surgery appears effective with excellent survival. However, the treatment is associated with significant morbidities. Sexual dysfunction is the leading cause of symptom-induced distress after the treatments for early-stage cervical cancer. There has been no study that evaluates the effect of surgical treatments for cervical cancer on sexual function in the Eastern/Asian patients.AimTo examine the effect of radical hysterectomy on postoperative sexual function in women with early-stage cervical cancer.Main Outcome MeasuresThe visual analog score on seven aspects of sexual function: overall satisfaction with sexual intercourse, sexual desire, vaginal lubrication, vaginal elasticity, orgasmic satisfaction, patient-perceived partner satisfaction, and associated anxiety.MethodsThirty patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB cervical cancer undergoing radical hysterectomy and pelvic lymphadenectomy at the Chiang Mai University Hospital were recruited. All of the patients were interviewed by questionnaire on sexual function at preoperative hospital admission and then at 3 and 6 months after surgery. Relevant clinical and pathologic data were also prospectively collected.ResultsThe mean age of the patients was 45.3 ± 6 years (range 28–59). Seven (23%) of the patients were postmenopausal. Almost all (97%) had FIGO stage IB1 disease. Fourteen (46.7%) patients had bilateral salpingo-oophorectomy, and one (3.3%) patient had unilateral salpingo-oophorectomy. Squamous-cell carcinoma and adenocarcinoma were diagnosed in 83% and 17%, respectively. At 3 and 6 months after operation, 63% and 93% of the patients had sexual intercourse, respectively. Considering the overall sexual satisfaction, the patient-rated visual analog score appeared comparable at preoperative and 6-month postoperative assessment (4.2 ± 2.5 vs. 3.6 ± 2.2, P > 0.05).ConclusionRadical hysterectomy using the current technique has a minimal short-term impact on sexual function. A comparative study with long-term follow-up would provide clearer information on permanent effect of radical hysterectomy on sexual function. Jongpipan J, and Charoenkwan K. Sexual function after radical hysterectomy for early-stage cervical cancer.     

A prospective study of nerve-sparing radical hysterectomy for uterine cervical carcinoma in Taiwan

ObjectiveSurgical therapy for cervical carcinoma carries a significant risk of functional impairment to the bladder. This study evaluates the feasibility and complications of nerve-sparing radical hysterectomy (NRH) in Taiwan.MethodsBetween March 2010 and March 2011, consecutive patients diagnosed with early stage cervical cancer (FIGO stage Ia2 to Ib1) and tumor size < 3 cm were recruited prospectively to undergo NRH or conventional radical hysterectomy (RH). Patients with histories of urinary stress incontinence or bladder dysfunction disease were excluded. A modified Tokyo nerve-sparing radical hysterectomy was performed.ResultsA total of 30 patients were enrolled. Among these, 18 patients underwent NRH with successful bilaterally nerve-sparing procedures in 15 cases (83%), unilaterally nerve-sparing procedures in 2 cases (11%), and a failure in 1 case (6%). The indwelling catheter was removed on postoperative day 6. The mean ± SD duration from operation to spontaneous voiding was 6.8 ± 1.5 days for women who underwent NRH; the corresponding duration for women who underwent RH or failed NRH was 20.6 ± 3 days. None of the patients who underwent NRH required intermittent catheterization. All 12 patients who underwent RH needed self-catheterization after discharge. There was a significant reduction in the incidence of postoperative self-catheterization (p < 0.01) and bladder dysfunction (p < 0.006). Average satisfaction score analyzed by the Likert-scale questionnaire was 4.5 for the NRH group and 1.9 for RH group (p < 0.0001).ConclusionsWe concluded that the new technique of NRH can reduce postoperative bladder dysfunctions.     

Can laparoscopic radical hysterectomy be a standard surgical modality in stage IA2–IIA cervical cancer?

ObjectivesTo determine if laparoscopic radical hysterectomy (LRH) can be substituted for radical abdominal hysterectomy for women with International Federation of Gynecology and Obstetrics (FIGO) stage IA2–IIA cervical cancer.MethodsWe retrospectively reviewed the medical records of cervical cancer patients who underwent LRH with laparoscopic pelvic lymphadenectomy (LPL) and/or laparoscopic para-aortic lymphadenectomy (LPAL) from March 2003 to December 2011.ResultsOf 118 enrolled patients, six were in FIGO stage IA2, 66 were in IB1, 41 were in IB2, one was in IIA1, and four were in IIA2. The median operating time, perioperative hemoglobin change, the number of harvested pelvic and para-aortic lymph nodes were 270 min (range, 120–495), 1.7 g/dL (range, 0.1–5), 26 (range, 9–55), and 7 (range, 1–39), respectively. There was no unplanned conversion to laparotomy. Intra- and postoperative complications occurred in 16 (13.5%) and 8 (6.7%) patients, respectively. In a median follow-up of 31 months (range, 1–89), 5-year recurrence-free and overall survival rates were 90% and 89%, respectively. Univariate analysis showed that cervical stromal invasion (P = 0.023) and lymph node metastasis (P = 0.018) affected survival rate. Cox-proportional hazards regression analysis showed that lymph node metastasis was the only independent factor for poor prognosis (hazard ratio = 7.0, P = 0.022).ConclusionsLRH with LPL and/or LPAL in women with stage IA2–IIA cervical cancer is safe and feasible in terms of survival and morbidity. Our data suggest the need for larger prospective trials which could support this approach as a new standard of care for stage IA2–IIA cervical cancer.     

Addition of chemotherapy to definitive radiotherapy for IB1 and IIA1 cervical cancer: Analysis of the National Cancer Data Base

Purpose

The standard treatment for stage IB1 and IIA1 cervical carcinoma is surgery. For non-operative cases, the National Comprehensive Cancer Network recommends definitive radiotherapy (RT) with or without chemotherapy. This study sought to determine whether the addition of chemotherapy to RT improved overall survival (OS) for patients with stage IB1 and IIA1 cervical cancer.

A retrospective assessment of outcomes of chemotherapy-based versus radiation-only adjuvant treatment for completely resected stage I-IV uterine carcinosarcoma

PurposeTo determine the progression-free survival (PFS) and overall survival (OS) in a cohort of patients who received either platinum-based chemotherapy with or without radiation therapy (pelvic or WAI), or RT alone.MethodsMemorial Sloan-Kettering Cancer Center (MSKCC) electronic medical records from 8/1/1995 to 10/3/2007 were reviewed for patient age, diagnosis date, type of primary surgery, residual disease at the completion of primary surgery, FIGO stage, treatment details, dates of progression and death, and site(s) of first recurrence. PFS and OS by stage (I/II v III/IV) and by treatment type (chemotherapy with or without RT v RT alone) were determined using landmark analyses 8 weeks after surgery. Patients who received chemotherapy with or without RT (pelvic or abdominal) or RT alone (pelvic or abdominal) were included in the analysis. Both groups were allowed to have received intravaginal radiation therapy (IVRT).ResultsForty-nine patients met study criteria. Thirty-eight/49 patients received chemotherapy: 23/38 (60.5%) received paclitaxel-carboplatin; 7/38 (18.4%) received ifosfamide-platinum; 8/38 (21.0%) received other chemotherapy. FIGO stage was: I = 15 (31%); II = 5 (10%); III = 21 (43%); IV = 8 (16%). Three-year PFS for the entire cohort was 24%. Three-year OS for the entire cohort was 60%. Three-year median PFS time for the entire cohort was 15 months (95% CI: 11–25 months). Three-year median OS time for the entire cohort was 67 months (95% CI: 23–89 months). Three-year PFS for stages I–II was 43% v 14% for stages III–IV (HR = 1.98 [0.9–4.33]); P = 0.082. Three-year OS for stages I–II was 68% v 55% for stages III–IV (HR = 1.26 [0.47–3.41]); P = 0.648. Three-year PFS for chemotherapy with or without RT was 35% v 9% for RT alone (HR = 1.74 [0.79–3.85]); P = 0.164. Three-year OS for chemotherapy with or without RT was 66% v 34% for RT alone (HR = 2.02 [0.77–5.33]); P = 0.146.ConclusionsOur study corroborates GOG 150 results, and shows that paclitaxel-carboplatin appears to be an efficacious adjuvant chemotherapy regimen for completely resected uterine carcinosarcoma. The role of adjuvant RT in addition to chemotherapy warrants further investigation.     

Adjuvant radiation for early stage endometrial cancer with lymphovascular invasion

ObjectiveTo determine the impact of the decrease in use of postoperative pelvic external beam radiation (EBRT) in favor of intravaginal RT (IVRT) alone in patients with early stage endometrial cancer who had lymphovascular invasion (LVI).MethodsBetween 11/1988 and 5/2005, 126 patients treated with simple hysterectomy and postoperative RT had a final pathologic diagnosis of stage IB–IIB adenocarcinoma of endometrioid histology with documented LVI. The patients were divided into two groups based on the era of treatment, (early era: 1988–1996, vs. late era: 1997–2005), in order to best capture the shift away from the routine use of EBRT in favor of surgical staging and IVRT.ResultsOf the 126 patients, 35% (n = 44) were treated in the early era and 65% (n = 82) in the late era. The two groups were balanced in regards to age, race, depth of myometrial invasion, histologic grade, and cervical involvement. Significantly more patients had surgical staging and received IVRT alone in the late than early era (p = 0.0001, 0.004, respectively). The rate of pelvic control was 93% for the early era compared to 97% for latter era (p = 0.3). There was no significant impact of the treatment era on vaginal control, disease-free survival, or overall survival.ConclusionsThese data suggest that the mere presence of LVI need not trigger the use of pelvic EBRT. Instead, the decision on whether to omit EBRT in patients with LVI should be made in the context of a patient's competing risk factors and comorbid conditions.     

Clinical evaluation of neoadjuvant chemotherapy followed by radical surgery in the management of stage IB2-IIB cervical cancer

ObjectiveTo evaluate clinical efficacy, toxicity, and survival outcomes of neoadjuvant chemotherapy (NACT) followed by radical surgery (RS) among patients with cervical cancer stage IB2–IIB.MethodsIn a retrospective clinical study at West China Second Hospital, Chengdu, data were analyzed from 414 patients who underwent NACT followed by radical surgery (NACT–RS) or RS alone between January 2008 and November 2009.ResultsThe clinical response for NACT was 90%. Lymph node metastasis (25% versus 48%, P < 0.05) and deep cervical stromal invasion more than 0.5, (68% versus 91%, P < 0.05) were significantly lower among responders than among non-responders, respectively, in the NACT–RS group. The 2-year progression-free survival and 2-year overall survival were 93.0% and 95.5% in the NACT–RS group, and 94.5% and 97.1% in the RS group (P > 0.05). Parametric infiltration (hazard ratio [HR], 7.668; P < 0.05) and lymph node metastasis (HR, 7.714; P < 0.05) were independent risk factors for all study patients.ConclusionCompared with RS, NACT–RS did not show a significant advantage for patients with locally advanced cervical cancer. However, the data provide the rationale for assessing NACT–RS in a multicenter randomized clinical trial setting. NACT may be considered as an alternative treatment when radiotherapy is not available.     

A multi-institutional cohort study of adjuvant therapy in stage I-II uterine carcinosarcoma

ObjectiveTo evaluate the impact of adjuvant post-operative therapy in women with early stage uterine carcinosarcoma.MethodsAfter IRB approval was obtained at all sites, a multi-center retrospective study of women with FIGO stage I–II uterine carcinosarcoma diagnosed from 1997 to 2007 was conducted. Post-operative treatment included observation (OBS), radiation (RT), chemotherapy (CT) alone or with RT (CT + RT). Data analyzed included demographic and pathologic factors, adjuvant therapy outcomes, and time-to-event information. The Kaplan–Meier method was used to estimate time-to-event functions. Cox regression modeling was used to examine the impact of selected covariates on progression free survival (PFS), and overall survival (OS).Results111 women were identified: 94 (85%) had stage I and 17 (15%) had stage II uterine carcinosarcoma. Forty-four women (40%) did not receive adjuvant therapy (OBS), 29 (26%) women had adjuvant CT, 23 (20%) women underwent RT and 15 (14%) women underwent RT + CT. Seventy-three patients were alive without disease and 38 had progressed or died at the close of data collection. In multivariate analysis, CT (p = 0.003), LVSI (p < 0.0001) and a pre-existing cancer (p = 0.004) were most predictive of PFS. LVSI was predictive of shortened OS (p = 0.01).ConclusionsIn women with FIGO stage I–II uterine carcinosarcoma, adjuvant chemotherapy is associated with improved PFS compared to radiation or observation alone. Ongoing clinical trials will clarify the role of chemotherapy in women with this disease.     

Risk factors for poor prognosis in microinvasive adenocarcinoma of the uterine cervix (IA1 and IA2): a pooled analysis

ObjectiveTo identify adverse risk factors for FIGO IA1 and IA2 cervical adenocarcinoma.MethodsPubMed was used to identify all microinvasive adenocarcinoma cases. Case specific data pooled for 35 “high risk” microinvasive adenocarcinoma (MIAC), defined as cases with lymph node or lymphovascular space involvement, positive surgical margins, or recurrence was compared with 478 “low risk” cases abstracted from the SEER database (1988–1997). Statistical methods included non-paired t and Fisher's Exact tests.ResultsSurvival for 1A1 and 1A2 MIAC is 99% and 98%, respectively. Significantly more 1A2 patients underwent aggressive radical surgery and received postoperative treatment. Parametrial involvement was rare (1/373 cases). Significantly more “high-risk” cases were of endometrioid histology (6/34 vs. 14/478, p = 0.001), whereas adenocarcinoma (p = 0.046) and mucinous (p = 0.021) tumors were observed in the “low-risk” group. Among the “high-risk” cases with at least 5 years follow-up, 1.4% has recurred or died.ConclusionsEndometrioid histology may be associated with late recurrence and worse survival in stage 1A1 and 1A2 MIAC.     

The effect of maximal surgical cytoreduction on sensitivity to platinum-taxane chemotherapy and subsequent survival in patients with advanced ovarian cancer

ObjectivesLimited information exist about the frequency of micrometastases, their topographic distribution and prognostic impact in patients with cervical carcinoma (CX).MethodsLymph nodes of patients with surgically treated CX, FIGO IB to IIB, with pelvic lymph node involvement, were re-examined regarding the size of metastatic deposits, their topographic distribution within the pelvis. Lymph node status (pN0 vs. pN1mic = metastasis < 0.2 cm vs. pN1 = metastasis > 0.2 cm) was correlated to recurrence free (RFS) and overall survival (OS).Results31.4% of all patients (281/894) represented pelvic lymph node involvement. 22.2.% of the node positive ones showed micrometastases (pN1mic). Most commonly, obturator and internal nodes were affected by pN1mic, without any side differences. Patients with macrometastases (pN1) and micrometastases (pN1mic) represented significant reduced RFS-rate at 5-years (62% [95% CI: 54.2 to 69.8] for pN1 and 68.9% [95% CI: 55.5 to 82.4] for pN1mic) when compared to patients without metastatic disease (91.4% [95% CI: 89.0 to 93.8]; p < 0.001) The 5-years OS-rate was decreased in patients with metastatic disease (pN0: 86.6% [95% CI: 83.7 to 89.5], pN1mic: 63.8% [95% CI: 50.9 to 76.7], pN1: 48.2% [95% CI: 40.4 to 56.0]; p < 0.0001). These differences persisted in detailed analysis within these subgroups. In multivariate analysis, tumor stage, pelvic lymph node involvement and micrometastases were independent prognostic factors.ConclusionsA remarkable number of patients with CX show micrometastases within pelvic nodes. Micrometastatic disease represents an independent prognostic factor. So, all patients with pelvic lymph node involvement, including micrometastatic deposits, might be candidates for adjuvant treatment.     

Twenty-year review of radiotherapy for vaginal cancer: an institutional experience

ObjectiveTo evaluate clinical outcome, prognostic factors and chronic morbidity with radiotherapy for vaginal cancer treatment.Materials and methods68 patients with vaginal cancer treated by radical or adjuvant radiotherapy (RT) were selected. Five with rare subtypes of histopathology and 8 with adenocarcinoma were excluded from this study. 76.4% of the remainder had early-stage diseases (stage I: 14, II: 28, III: 9, and IV: 4). The patients in the years from which they were treated were almost evenly distributed (1st 5 years: 13, 2nd: 14, 3rd: 16, and 4th: 12). There were four treatment groups: external beam radiotherapy (EBRT) alone (n = 18), brachytherapy (BT) alone (n = 4), EBRT and BT (n = 30), and surgery plus RT (n = 3).ResultsMedian follow-up was 50.3 months ranging from 3 to 213 months. 5-year overall survival (OS) was 55.6%, disease-specific survival (DSS) was 77.3%, disease-free survival was 74.2%, and local control was 87.7%. Independent prognostic factors for DSS and OS were tumor stage, site and size (p < 0.05). Late radiation toxicity was minimal in the bladder (4.6%) and bowel (4.6%). Vaginal morbidity was observed in 35 patients (63.6%). It was lowest in the BT alone (0%), and highest in the EBRT and BT group (82.1%), especially for those received more than 70 Gy (p = 0.05, Odds ratio = 4.64, 95% confidence interval: 1.01–21.65).ConclusionThis retrospective review suggested that tumor stage, site, and size were important prognostic factors in patients with vaginal cancer. Higher radiation dose was associated with more frequent vaginal toxicity.     

Risk assessment model for overall survival in patients with locally advanced cervical cancer treated with definitive concurrent chemoradiotherapy

ObjectiveTo develop a nomogram for predicting the probability of 5 year survival after definitive concurrent chemoradiotherapy (CCRT) in locally advanced cervical cancer (LACC).MethodsBetween 1998 and 2008, 209 patients with LACC were treated with definitive CCRT. Multivariate analysis using Cox proportional hazards regression model was performed. A nomogram based on this Cox model was developed and internally validated by bootstrapping. Its performance was assessed by using the concordance index and a calibration curve.ResultsThe median age was 55 years (range, 26–78). Of the patients, 9, 16, 129, 3, 42 and 10 had FIGO stage IB2, IIA, IIB, IIIA, IIIB, and IVA disease, respectively. Histology revealed that 190, 13, 4, and 2 patients had squamous, adenocarcinoma, adenosquamous, and small cell cervical cancer, respectively. In 91 patients, PET/CT was performed before CCRT. The median follow-up period was 51 months (range, 6–151) and there were 50 (23.9%) disease-related deaths. Multivariate regression analysis revealed that histology, tumor size, and paraaortic lymph node metastasis (defined by MRI), but not PET/CT before CCRT, were independent predictors of overall survival. A nomogram for predicting the 5 year survival incorporating these three significant variables was constructed. The concordance index was 0.69. The predictive ability of the nomogram proved to be superior to that of the FIGO staging system (p < 0.05).ConclusionsThe nomogram was a better predictive model for overall survival than the FIGO staging system. If externally validated, it could be used to counsel patients with LACC who must choose additional treatment modalities after definitive CCRT.     

Comparison of pulsed actinomycin D versus 5-day methotrexate for the treatment of low-risk gestational trophoblastic disease

ObjectiveTo determine the effectiveness of 2 standard chemotherapy regimens for low-risk gestational trophoblastic disease according to the International Federation of Gynecology and Obstetrics (FIGO) staging system.MethodsFrom 2008 until 2010, 75 women with low-risk gestational trophoblastic disease received either pulsed actinomycin D (n = 50) or 5-day methotrexate (n = 25). The primary remission rate, the duration of treatment, the number of treatment courses, and the adverse effects were compared.ResultsThe complete remission rates were 90% for the actinomycin D group and 68% for the methotrexate group (P = 0.018). The mean number of chemotherapy courses administered to achieve complete remission (including courses of second-line therapy) was 3.1 in the methotrexate group and 5.3 in the actinomycin D group (P = 0.01). No major adverse effects were experienced in either treatment group and there were no significant differences in terms of adverse effects. Second-line chemotherapy was indicated for 11 patients.ConclusionBased on the present study, pulsed actinomycin D seems to be an appropriate first-line treatment for patients with low-risk gestational trophoblastic disease.     

Prognostic value of pre-treatment human papilloma virus DNA status in cervical cancer

Objective

Although the relationship between human papilloma virus (HPV) and cervical cancer is well established, the prognostic value of HPV status has not been determined, largely because previous studies have yielded conflicting results. This study aimed to investigate the prognostic value of pre-treatment HPV DNA for predicting tumor recurrence in cervical cancer.

Impact of para-aortic recurrence risk-guided intensity-modulated radiotherapy in locally advanced cervical cancer with positive pelvic lymph nodes

Objectives

A previous study has suggested the benefit of sub-renal vein radiotherapy (SRVRT) for pelvic lymph node (PLN)-positive cervical cancer. In order to better select patients for SRVRT, this study aimed to evaluate the value of a risk-based radiation field based on PLN location and number in PLN-positive cervical cancer.

Quality of life and emotional distress in early stage and locally advanced cervical cancer patients: a prospective, longitudinal study

ObjectivesThis prospective, longitudinal study investigates QoL issues and emotional distress in early stage cervical cancer (ECC) patients undergoing radical surgery (RS) and in locally advanced cervical cancer (LACC) patients triaged to chemoradiation (CT/RT) followed by RS.MethodsThe Global Health Status scale of EORTC QLQ-C30 (GHS), the EORTC QLQ-CX24 (CX24) and the Hospital Anxiety and Depression Scale (HADS) questionnaire were administered at baseline, and after 3, 6, and 12 months from surgery. For LACC patients QoL assessment was also performed after CT/RT. Statistical analysis was performed by the ANOVA for repeated measures and the Between Subject test.ResultsIn ECC and LACC patients, the GHS scores improved over time (5.5% difference in mean scores compared to baseline in ECC, and 7.0% difference in mean score compared to baseline in LACC patients). An early worsening of lymphedema scores was documented in ECC cases (14.6% difference in mean values compared to baseline, p value = 0.001), and in LACC patients (difference up to 28.3% of mean values, value = 0.0001). Menopausal symptoms persistently worsened over time reaching > 15% difference of mean values compared to baseline in both groups. Sexual activity scores markedly improved both in ECC and LACC patients (difference of mean score values compared to baseline was 16.5% in ECC, and 6.7% in LACC patients). Both ECC and LACC patients experienced an improvement of anxiety scores.ConclusionsLymphedema and menopausal symptoms were the most disabling treatment-related sequelae; the amount of QoL issues and their multifaceted aspects require the cooperation of multidisciplinary teams.     

Endocervical involvement in endometrial adenocarcinoma is not prognostically significant and the pathologic assessment of the pattern of involvement is not reproducible

ObjectivesSince 1988, cervical gland involvement and stromal invasion defined stage IIA and stage IIB endometrial carcinoma. In 2009, FIGO changed the criteria for stage II disease to include only those with cervical stromal invasion. We wished to: 1) assess the reproducibility of pathologists to distinguish patterns of cervical spread, and 2) determine the prognostic significance of cervical involvement.MethodsSlides from 46 women with cervical involvement by endometrial adenocarcinoma were scored for 5 patterns of involvement by 6 experienced pathologists to determine reproducibility. To assess prognostic significance, 206 patients with FIGO 1988 stage II adenocarcinoma formed the study population with matched FIGO stage I controls.ResultsAt least 5 of the 6 pathologists agreed that the cervix was involved in the 46 cases. The reproducibility for cervical gland involvement and endocervical stromal invasion was slight (kappas of 0.15 and 0.28). The survival with any type of cervical involvement was not significantly different from that of matched stage I controls (p = 0.18). The 5 year recurrence-free survival rates were 84% for FIGO 1988 stage I, 73% for stage IIA, and 82% for stage IIB (FIGO 2009 stage II).ConclusionsPathologists reliably recognize cervical involvement by endometrial carcinoma. However, reproducibility for the determination of pattern of cervical spread by experienced pathologists is too low to be of clinical utility. Women with spread of carcinoma to the cervix do not have a significantly lower survival than matched stage I controls. Cervical spread should not be the basis for determination of stage II disease.     

Robotic versus open radical hysterectomy: a comparative study at a single institution

ObjectiveTo compare the short-term surgical outcome of patients undergoing robotic radical hysterectomy (RRH) versus open radical hysterectomy (ORH) for the treatment of early stage cervical cancer.MethodsIRB approval was obtained for a retrospective chart review of all radical hysterectomies (RHs) for Stage I and II cervical cancer performed at Brigham and Women's Hospital between August 1, 2004 and August 1, 2007. Prior to August 1, 2006 all procedures were ORHs. After this date, all procedures were RRHs. Demographic data, operative data and short-term outcomes were compared. Statistical analysis using t-tests and Fisher's Exact test were performed with SAS software.ResultsA total of 48 RHs were identified, including 16 RRHs and 32 ORHs. The groups did not differ significantly in age, body mass index, stage, or histology. Mean operative time was significantly longer for RRH than ORH (4:50 vs 3:39 h, p = 0.0002). The mean estimated blood loss was significantly less for RRH than ORH (81.9 vs 665.6 mL, p < 0.0001). The mean number of lymph nodes resected did not differ between RRHs and ORHs (15.6 vs 17.1, p = 0.532). There were no intra-operative complications in the RRH group and one ureteral transection in the ORH group. Three RRH patients (18.8%) suffered post-operative complications which included a vaginal cuff infected hematoma, a transient ureterovaginal fistula, and a pelvic lymphocele, in comparison to seven in the ORH group (21.9%) which included 3 wound infections, two patients with pulmonary emboli, a partial small bowel obstruction with a mesenteric abscess, and a post-operative ileus (p = 0.999). Mean length of stay was significantly shorter for the RRH group (1.7 vs. 4.9 days, p < 0.0001).ConclusionRRH results in lower blood loss and shorter length of stay, compared to ORH. Intra-operative and post-operative complication rates are comparable. RRH is a promising new surgical technique that deserves further study.