A Comparison of Stages IB1 and IB2 Cervical Cancers Treated With Radical Hysterectomy. Is Size the Real Difference?

Abstract

To compare stages IB1 and IB2 cervical cancer, the authors conducted a review of all patients with stage IB cancer of the cervix who underwent a type III radical hysterectomy with bilateral pelvic lymphadenectomy at theirinstitutions between 1990 and 2000. They identified 195 patients who had no gross extrauterine disease and sufficient data for analysis. One hundred seventy-seven (91%) subjects also underwent a bilateral paraaortic lymphadenectomy. No patient received preoperative radiation therapy. The mean age of the study subjects was 41.3 years. One hundred nine patients with tumor size 4 cm or less were identified as stage IB 1 and 86 whose tumor was larger than 4 cm were considered stage IB2. Tumor characteristics included lymphovascular space involvement in 98 women (53%), parametrial involvement in 31 (15.9%), and outer two thirds cervical stromal involvement in 110 (58.2%). Histologic cell type was squamous in 144 (73.8%) patients, adenocarcinoma in 37 (19%), adenosquamous in 10 (5.1%), and a mixture of small and clear in 4 (2.1%). Tumor grade was identified in 189 patients, of whom 9 (4.7%) were grade 1, 92 (47.1%) were grade 2, and 88 (45.1%) were grade 3. Stage IB1 and IB2 patients had a similar cell type and grade distribution, but those with stage IB2 had a significantly greater number of high-risk factors. Lymphovascular space involvement, outer two thirds cervical invasion, parametrial involvement, and nodal involvement were all more common in these women. There were no significant differences seen in rates of perioperative or postoperative complications, except that more patients with stage IB2 disease who received adjuvant radiation therapy were more likely to develop a postoperative bowel obstruction. Univariate analysis found no factors that were significant predictors of surgical complications. Positive pelvic nodes were seen in 38 (19.5%) patients, of whom 14 (12.8%) were stage IB1 and 24 (27.9%) were stage IB2. Two women with stage IB1 and 7 with stage IB2 disease had parametrial involvement. Univariate analysis of clinicopathologic factors identified lymphovascular space invasion (P = 0.001), >2/3 depth of invasion (P = 0.011), parametrial involvement (P = 0.001), disease stage (P = 0.008), and age of patient (P = 0.048) to be significant predictors of nodal involvement. After multivariate analysis, lymphovascular space involvement and parametrial involvement emerged as highly significant predictors of nodal involvement (odds ratios, 6.4; CI = 2.4-1.7 and 8, CI = 3.1-20, respectively). Median follow up in this series was 35 months. In that time, 10 patients with stage IB1 and 20 with stage IB2 tumors had disease recurrence. The overall disease-free survival was 92.5% for stage IB1 patients and 74.3% for stage IB2 patients (P = 0.009 for difference). Univariate analysis found that nodal positivity, lymphovascular space involvement, parametrial involvement, and outer two thirds stromal involvement were all significantly associated with disease-free survival, regardless of disease stage. After univariate analysis, lymphovascular involvement and outer two thirds stromal involvement were identified as independent predictors of disease-free survival. The relative risks were 7.75 (CI = 2-27; P = 0.0001) and 5.8 (CI = 2-20; P = 0.0029), respectively.