Is systematic scalene node biopsy in pretreatment evaluation of locally advanced cervical carcinoma necessary? Systematic dissection and histopathology of left scalene node biopsies in patients with locally advanced cervical carcinoma

OBJECTIVE: Cervical carcinomas mainly spread via lymphatics, stepwise from pelvic to aortic and scalenic lymph nodes. Metastatic nodes are the major prognostic factor in this disease. When scalenic nodes are involved, cervical cancer is considered to be disseminated. Since there is a major discrepancy in reported percentages of metastatic scalene nodes in the literature (0 to 50%), we proceeded to systematic pretreatment scalene node biopsy and then evaluated the validity of this procedure. METHODS: From January 1998 to May 2003, 72 patients with locally advanced cervical carcinoma and no suspicious paraaortic or scalenic nodes (respectively on magnetic resonance imaging and clinically) had a systematic surgical pretreatment lymph node evaluation (retroperitoneal laparoscopic infrarenal paraaortic lymph node dissection and left scalenic lymph node biopsy). Scalene biopsy was examined using hematoxylin/eosin stain and immunohistochemistry (KL1 antibodies). RESULTS: Among the 72 patients, 20 were stage IB2, 4 were IIA, 14 were IIB, 4 were IIIA, 27 were IIIB, 1 was IVA and 2 had a recurrent cervical carcinoma. Fourteen women had histologically confirmed paraaortic metastases (11 macroscopic, 3 microscopic). No metastatic involvement of the scalene nodes was detected. Fifteen patients developed a recurrence within 12 months (3 to 19 months). None of the patients developed scalenic recurrence. CONCLUSION: Left scalene node biopsy does not appear to be mandatory in routine pretherapeutic lymph node evaluation of patients with advanced cervical carcinoma and no clinical suspicious nodes. It may be useful to prove disseminated disease in patients with suspicious clinical nodes or hot spots on PET-scan, if fine needle biopsy is unconclusive.     

Is there a role for pelvic lymph node debulking in advanced cervical cancer?

OBJECTIVES: The objectives of this study were to characterize the prognostic features of micropapillary serous ovarian carcinoma (MPSC), examine the clinical impact of surgical staging, and define the role of cytoreductive surgery for patients with advanced disease. METHODS: Fifty-one patients with MPSC were identified from hospital and tumor registry databases. Demographic, operative, pathologic, and follow-up data were abstracted retrospectively. Survival curves were generated using the Kaplan-Meier method, and statistical comparisons were performed using the log rank test, logistic regression analysis, and the Cox proportional hazards regression model. RESULTS: The median age at diagnosis was 45 years, and follow-up extended to a median of 43.0 months. Stage I/II disease was present in 25.5% of patients and no disease-related deaths were observed in this group. Stage III disease was discovered in 29.4% of patients with tumor clinically confined to the ovaries. Stage III/IV disease (74.5% of cases) was associated with median progression-free and overall survival times of 32.8 and 114.2 months, respectively. Menopausal status and the anatomic extent of disease were significantly associated with survival outcome. However, the strongest independent predictor of survival for patients with advanced disease was the amount of residual tumor. Median overall survival for patients with optimal cytoreduction (residual disease 1 cm residual tumor (P < 0.0002). CONCLUSIONS: MPSC carries a significant risk of extraovarian spread; however, adequately sampled Stage I/II disease is associated with a favorable prognosis. Optimal cytoreduction is associated with improved survival and should be the primary therapeutic objective for patients with advanced-stage MPSC.     

Does adjuvant chemotherapy improve the prognosis of cervical carcinoma with lymph-node metastasis? A long-term follow-up

OBJECTIVE: to verify the efficacy of adjuvant therapy in the prevention of neoplastic recurrence in patients at high risk for lymph-node involvement on surgical examination. METHODS: 72 patients, suffering from squamous cell cervical carcinoma Stage IB-IIB (FIGO) who underwent radical hysterectomy with lymph-node involvement confirmed at the final histological examination, were enrolled. All the patients were treated with adjuvant chemotherapy (AC), which included cisplatin, bleomycin and vinblastine, and were followed for a minimum period of six years. The results were compared with those obtained with a historical group of 78 patients, with comparable age, stage and lymph-node involvement, on whom only radical surgery (RS) was performed. RESULTS: the average total survival rate of the two groups (RS + AC vs RS) at five years was 63.9% and 55.1%, respectively (chi2 = 1.191; p = NS). The disease-free interval was 55.6% vs 46.2% (chi2 = 1.324; p = NS). The best results were obtained in cases where the common iliac lymph-nodes were affected, with the highest survival rate of 16.9% in the RS+AC group, out of a total of 25 cases. CONCLUSIONS: adoption of adjuvant chemotherapy in patients at high risk for lymph-node positivity did not produce statistically significant results in terms of overall and disease-free survival; however, a small number of these patients, approximately 9%, could receive benefit from the treatment.     

Laparoscopic staging in locally advanced cervical carcinoma: A new possible philosophy?

OBJECTIVES: The aim of this study was to evaluate the feasibility and efficacy of designing the therapeutic management of each patient, morbidity, and mortality using laparoscopic staging in locally advanced cervical carcinoma and to establish the standard procedure for a "complete" staging. METHODS: From July 10, 1995, to June 30, 1998, 98 pts were included. Clinical staging was performed according to FIGO's criteria (22 Ib2; 38 IIb; 25 IIIb; and 6 IV). The Quetelet index was calculated for each patient. Forty-nine pts were submitted to a previous CT scan. Surgical steps for a complete staging were: (1) peritoneal washings for cytology; (2) whole abdominal cavity exploration, with a biopsy of all suspicious lesions; (3) exploration of the vesicocervical and rectovaginal septums with a biopsy of suspicious areas; (4) bilateral pelvic lymphadenectomy and, when macroscopically positive, paraaortic lymphadenectomy. RESULTS: Eighty-four of 91 pts were evaluable. The average duration for the procedure was 108 min, and blood loss was less than 200 cc. Hospitalization time ranged from 24 to 48 h. The average number of resected pelvic nodes was 18.5 (9-31). Positive nodes were found in 38 cases; 19 pts had unresectable positive nodes. Paraaortic dissection was performed in 26 cases and 11 cases were positive. When tumor was <5 cm, 8/32 (25%) lymphadenectomies were positive; when it was >5 cm, 30/52 (58%) were positive. Thirty-eight of 49 pelvic CT scans were reported to be normal (18/38 had positive nodes) and 11/49 suspicious (6/11 had positive nodes). Tumor invasion of the vesicocervical space or of the anterior parametrium was found in 23/84 patients. The rectovaginal septum was positive in 10 cases. Four of 84 patients (4.7%) presented with intraperitoneal spread. Only one trauma to the vena cava occurred at the time of the Verres needle insertion and two postoperative lymphoceles were observed. All patients began curative treatment within 3 to 7 days. CONCLUSIONS: This method is feasible, complications are infrequent, and subsequent treatment is not delayed.     

Which clinical/pathologic factors matter in the era of chemoradiation as treatment for locally advanced cervical carcinoma? Analysis of two Gynecologic Oncology Group (GOG) trials

PURPOSE: To explore clinical/pathologic factors associated with prognosis of patients with locally advanced cervical carcinoma treated with weekly cisplatin and pelvic radiation. METHODS: We retrospectively reviewed data from 335 women who received weekly cisplatin and radiation while participating in similar arms of two GOG studies (protocols 120 and 165). Progression-free survival (PFS) and overall survival (OS) were evaluated for associations between clinical/pathologic factors and prognosis. Prognosis and selected toxicities were also compared between studies. RESULTS: Four-year PFS and OS for stage II patients were 64.2% and 68.1%, respectively for those treated on GOG 120 and 65.8% and 73.9% for those treated on GOG 165, compared to 51.4% and 55.4% for stage III/IV patients respectively treated on GOG 120 and 37.7% and 42.7% respectively for those treated on GOG 165. In multivariate analysis, stage, tumor grade, race and age were independently predictive of PFS and OS (for all, p<0.05). Prolonged (delayed for any cause) radiation was associated with poorer PFS (hazard ratio [HR], 1.98; 95% confidence interval [CI], 1.16-3.38; p=0.012) and OS (HR, 1.88; 95% CI, 1.08-3.26; p=0.024) in GOG 165 but not GOG 120. CONCLUSIONS: FIGO stage, tumor grade, race and age are prognostic in patients with locally advanced cervical carcinoma treated with concurrent cisplatin and radiation. This exploratory analysis has generated a hypothesis that clinical staging (as per GOG 165) is less sensitive in detecting aortic nodal metastases compared to surgical staging (as per GOG 120) and may be associated with poorer prognosis particularly when radiation is prolonged. Prospective clinical studies are needed to test this hypothesis.     

新辅助化疗在宫颈癌治疗中的应用及疗效观察

目的探讨术前新辅助化疗对局部晚期宫颈癌的治疗效果。方法对55例Ib2～Ⅱb期的宫颈癌患者行新辅助化疗，并对治疗效果进行评价。以同期未行新辅助化疗的33例宫颈癌患者作为对照，比较两组患者术中出血量、宫旁浸润率、阴道切缘阳性率及淋巴结转移率的差异。对患者进行随访，分析新辅助化疗对远期预后的影响。结果新辅助化疗组总有效率为94．6％，病理完全缓解者5例（9．1％）。有效的52例患者接受了手术。新辅助化疗组淋巴结转移率为36．5％，对照组为48．5％，两组比较，无差异（P〉0．05）。但新辅助化疗组中Ⅱ期患者淋巴结转移率（35．3％）低于对照组（69．2％），两者比较，差异有显著性（P〈0．05）。两组的宫旁浸润率分别为1．9％和18．2％，经精确概率法计算，两者比较，差异有显著性（P〈0．05）。术中出血量分别为（874．0±675．6）ml和（493．9±316．7）ml，两者比较，差异有显著性（P〈0．05）。NACT组与对照组的1年无瘤生存率分别为77．78％和81．04％，5年无瘤生存率分别为75．41％和81．04％，1年总生存率分别为93．91％和96．88％，5年总生存率分别为84．37％和88．03％，两组比较，差异均无显著性（P〉0．05）。结论新辅助化疗对局部晚期宫颈癌患者近期疗效显著，但对无瘤生存时间和总生存时间无明显影响。术后化疗、淋巴结转移是影响患者无瘤生存时间的主要因素。     

Carcinostatic effect of pelvic vascular bed isolation chemotherapy in the management of cervical cancer

A patient with advanced and probably radioresistant cervical cancer underwent pelvic vascular bed isolation, and 60 mg of mitomycin C was given in a one-shot manner into the internal iliac arteries. Visual, cytological, and histological evidence of local malignancy and cytoscopic evidence of bladder invasion were all gone 2 weeks after the isolation. Macroscopic evidence of malignancy of the uterus and vagina surgically removed 3 weeks after the isolation also disappeared. However, a remnant of microscopic malignancy was found in a small area of one fragment of the cervix radially divided into eight sections.     

局部晚期宫颈癌术前新辅助化疗的益处

局部晚期宫颈癌的标准治疗方案目前仍存在争议,而新辅助化疗在局部晚期宫颈癌中的应用并没有在世界范围内达成共识,其临床治疗效果也不确定。多项临床试验表明术前新辅助化疗在局部晚期宫颈癌的治疗中发挥着重要作用,但我们必须明确该治疗方案的适应证和禁忌证,实施前充分考虑其利弊。术前新辅助化疗治疗局部晚期宫颈癌的疗效还有待进一步验证。     

局部晚期宫颈癌动脉化疗应注意的问题

动脉化疗应用于局部晚期宫颈癌主要是指放射介入性动脉灌注或栓塞化疗。目前国内外相关的研究多在临床疗效方面。该文就目前动脉化疗临床应用值得注意的问题进行了探讨。     

Neoadjuvant high-dose intraarterial infusion chemotherapy under percutaneous pelvic perfusion with extracorporeal chemofiltration in patients with stages IIIa-IVa cervical cancer

OBJECTIVE: The objective of this study was to evaluate the response rate and survival of patients with locally advanced uterine cervical cancer who were treated with intraarterial infusion chemotherapy under percutaneous pelvic perfusion with extracorporeal chemofiltration (PPPEC). METHODS: Twenty-three untreated patients with stages IIIa-IVa cervical cancer were enrolled in the study. PPPEC was administered twice at 2 weeks interval using high-dose cisplatin alone (140-250 mg/m(2)) or high-dose cisplatin plus mitomycin C (7 mg/m(2)), pepleomycin (7 mg/m(2)) and 5-fluorouracil (700 mg/m(2)). Eighteen patients in whom the tumor downstaging was confirmed underwent radical surgery following PPPEC, whereas in the remaining five patients, radiotherapy was administered. RESULTS: Two weeks after the second PPPEC, the median volumetric tumor reduction and tumor response were 76% and 87%, respectively. Histologic response was 96%, while the tumor downstaging reached 83%. The curative surgery rate achieved was 89%. Five-year progression-free survival was 47% and 5-year survival rate was 74%. CONCLUSION: High-dose intraarterial infusion chemotherapy under PPPEC effectively achieved tumor downstaging and resulted in the favorable performance of the subsequent radical surgery and improved the 5-year survival rate of patients with locally advanced uterine cervical cancer.     

局部晚期宫颈癌治疗的争议与对策

局部晚期宫颈癌治疗方式的选择,是妇科肿瘤治疗争议的热点问题。同步放化疗、直接手术、放疗后行手术治疗是局部晚期宫颈癌的3种主要治疗方法。文章就局部晚期宫颈癌的几种治疗方法进行讨论,并建议对局部晚期宫颈癌实施个体化的治疗。