Cervical Involvement In Endometrial Carcinoma Research Articles

Diagnostic Value of Pelvic MRI for Assessment of the Depth of Myometrial Invasion and Cervical Involvement in Endometrial Cancer: Comparison of New Versus Old FIGO Staging

BackgroundEndometrial carcinoma is a highly prevalent gynecologic malignancy. The International Federation of Gynecology and Obstetrics (FIGO) staging system underwent significant revision on 2009. Key changes in the FIGO staging system include simplification of stage I endometrial cancer and removal of cervical mucosal invasion as a separate stage. MRI is a noninvasive diagnostic method for preoperative staging of endometrial cancer.ObjectivesThe main purpose of this study was to investigate the diagnostic efficacy of pelvic MRI in determining the depth of myometrial invasion and cervical involvement in endometrial carcinoma. The other aim was to compare the accuracy of pelvic MRI using the old and new FIGO staging systems in endometrial carcinoma.Patients and MethodsBetween November 2010 and January 2012, 54 patients underwent primary surgical staging in our department due to endometrial adenocarcinoma. Pre-operative pelvic MRI was performed and MRI staging was done according to old and new FIGO staging, separately. The sensitivity, specificity, positive and negative predictive values as well as the accuracy of MRI for deep myometrial invasion and cervical infiltration were calculated. MRI accuracy was also compared for old and new FIGO staging. Pathological staging was the standard of reference.ResultsThe mean age was 53.31 (SD = 11.52) and the most common histological subtype was the endometrioid type of endometrial adenocarcinoma (90.8%). In the evaluation of deep tumoral invasion of the myometrium (> 50%), sensitivity, specificity, diagnostic accuracy and positive and negative predictive values of MRI were 82.35%, 94.59%, 90.74%, 87.5% and 92.1%, respectively. For cervical stromal involvement, these values were 54.54%, 100%, 90.74%, 100% and 89.58%, respectively. In case of cervical mucosal involvement (in old FIGO staging), the positive predictive value was only 50% and the accuracy decreased to 74.07%. Agreement between MRI and the final histology using the old and new FIGO classification was appropriate with Kappa = 0.62 and 0.72, respectively (P < 0.001).ConclusionUsing 2009 FIGO classification increases the accuracy of pelvic MR imaging for preoperative staging of patients with early stages of endometrial cancer.

Significant Variation in the Assessment of Cervical Involvement in Endometrial Carcinoma: An Interobserver Variation Study

Significant Variation in the Assessment of Cervical Involvement in Endometrial Carcinoma: An Interobserver Variation Study

Significant Variation in the Assessment of Cervical Involvement in Endometrial Carcinoma

The histologic assessment of cervical involvement in endometrial carcinoma may be problematic for a number of reasons, but an accurate evaluation of this is important for correct staging, dictating the need for adjuvant therapy, and prognostication. In this study, we assessed interobserver variation in the evaluation of cervical involvement in hysterectomy specimens of endometrial carcinoma among 6 specialist gynecologic pathologists. Seventy-six cases of endometrial carcinoma enriched for cases exhibiting some perceived issue in the assessment of cervical involvement were used. In all the cases, a single slide of the primary tumor in the uterine corpus and a single slide of the cervix were circulated among the 6 participants who filled in a proforma. On the basis of the responses, the tumors were staged according to the 1988 International Federation of Gynecology and Obstetrics (FIGO) staging system (I, IIA, IIB) and the 2009 FIGO staging system (I, II). Using the 1988 FIGO staging system, the unweighted and weighted κ values between individual observers ranged from 0.3115 to 0.6139 (average 0.4675) and from 0.3492 to 0.6533 (average 0.5065), respectively. The κ values between observers for the 2009 FIGO staging system ranged from 0.3481 to 0.6862 (average 0.4908). Although enriched for problematic cases, our study shows that there is at most a fair-to-good agreement among specialist gynecologic pathologists in the assessment of cervical involvement in endometrial carcinoma. Problematic factors include determination of the junction between the lower uterine segment and upper endocervix, the distinction between "floaters" and true cervical glandular involvement, the distinction between cervical glandular involvement and stromal involvement, and the distinction between cervical glandular involvement and reactive non-neoplastic lesions of the endocervical glands. There is a need for specialist pathology groups dealing with gynecologic cancers to develop and disseminate recommendations regarding the assessment of cervical involvement in endometrial carcinoma.

Evaluation of the accuracy of intra-operative gross examination for the surgical management of endometrial cancer

Objective The aim of this study was to explore the clinical value of intra-operative gross examination for the surgical management of endometrial carcinoma. Study design A retrospective study was conducted in 424 women who underwent surgical treatment for endometrial carcinoma between January 2002 and December 2006. The results of myometrial invasion and cervical infiltration as assessed by intra-operative gross examination were compared with the final microscopic histopathological results in 401 patients. The accuracy, sensitivity, and specificity were calculated. Chi-squared or Fisher’s exact tests were used for the comparison of categorical variables. Results Intra-operative gross examination correctly identified the depth of microscopic myometrial invasion in 90.3% of patients. The sensitivity in detecting myometrial invasion was 80.6% and the specificity was 92.4%. With regard to cervical involvement, gross examination had an overall accuracy of 84.3%. The sensitivity in detecting cervical involvement was 32.6% and the specificity was 99.0%. Usually, cervical involvement cannot be correctly identified by intra-operative gross examination in patients with diffuse foci. Conclusion The data suggest that intra-operative gross examination is a simple and good method of predicting myometrial invasion, but it may not be the ideal way to assess cervical involvement in endometrial carcinoma.

Assessment of cervical involvement in endometrial carcinoma by hysteroscopy and directed biopsy

The objective of this study was to assess the diagnostic validity of hysteroscopy and directed biopsy for assessing cervical involvement in endometrial carcinoma. We conducted a study of 240 hysteroscopies and 44 cervical biopsies performed on 240 patients with endometrial carcinoma between 2000 and 2005. Hysteroscopy results suggested cervical involvement in 55 cases, of which only 31 were confirmed (a subtotal hysterectomy was performed in two cases, and the resection margins were examined for tumor invasion). In the 31 patients with confirmed cervical involvement, 19 of the hysteroscopy-directed biopsies were positive, 3 were negative, and 3 provided insufficient material. Six patients did not undergo biopsy. In the 24 patients with hysteroscopy false positive, 10 directed biopsies were positive and 9 were negative. Five patients did not undergo biopsy. Hysteroscopy suggested an absence of cervical involvement in 185 patients. Diagnosis was confirmed in 177 cases, and there were eight false negatives. In our case, office hysteroscopy proved to be a valid means of ruling out cervical involvement in endometrial carcinoma. However, it was not a valid means of detecting tumor involvement, even when combined with directed biopsy.

Prediction of cervical involvement in endometrial cancer by hysteroscopy

This study evaluated the ability of hysteroscopy to preoperatively predict cervical involvement in endometrial cancer. The records of 110 surgically staged consecutive endometrial cancer patients treated at our institution from 1997 to 2003 were retrospectively analyzed. Data on demographics, preoperative staging procedures, surgical pathology reports, and adjuvant treatments were retrieved. Fourteen (12.7%) patients had cervical involvement (stage II) according to the surgical pathology report, of whom nine (8.1%) had stage IIA and five (4.6%) had stage IIB. Clinical evaluation by speculoscopy and palpation had failed to reveal any indication of cervical involvement. Preoperative diagnostic hysteroscopy procedures were included. None of the hysteroscopy procedures revealed any suspicious lesion in the cervical canal. Hysteroscopy and clinical examination fail to adequately predict cervical involvement in endometrial carcinoma. Fractional D&C appears to be the best method until a more effective alternative becomes available.

Histologic study of patterns of cervical involvement in FIGO stage II endometrial carcinoma.

The pathology of cervical involvement in endometrial carcinoma has not been fully defined previously. We reviewed the histopathology of 66 hysterectomies of women with stage II endometrial carcinoma. Cervical spread was categorized as macroscopic or microscopic; stage IIA or IIB; direct spread, surface or lymphvascular metastasis; and size, number, and location. The cervical tumor was macroscopically identified in 15 (23%) women and microscopically identified in 51 (77%). Twenty-one patients (32%) were stage IIA and 45 (68%) stage IIB. The method of spread was direct spread in 28 patients, surface metastases in 27, lymphovascular in 3, both direct spread and surface metastases in 7 and both direct spread and lymphovascular in 1. The cervical tumor had a mean horizontal dimension of 3 mm and a median of 2 mm. There were multiple sites of cervical tumor in 31 (47%) patients and single in 35 (53%). The sites of spread, including cases with multiple sites, were the endocervix in 60 women (90%), transformation zone in 24 (37%), and ectocervix in 3 (5%). Most patients had minimal microscopic cervical tumor. Small examples of direct spread may be an artifact of definition depending on the histology of the isthmian-endocervical junction and many surface metastases appear to follow dilatation and curettage. In 7 of 66, 11%, however, the cervical tumor was greater than 5 mm depth of invasion and/or the result of lymphvascular metastasis. Survival studies are required to compare minimal stage II endometrial carcinoma patients and those with larger and/or lymphvascular derived cervical tumor. Patients with minimal stage II and stage I patients should also be compared.

The use of endocervical curetage in the preoperative assessment of cervical involvement in endometrial carcinoma: A comparison between fractional curetage and office endocervical curetage

International Journal of Gynecology & ObstetricsVolume 70, Issue S1 p. A71-A71 Uterine cancer The use of endocervical curetage in the preoperative assessment of cervical involvement in endometrial carcinoma: A comparison between fractional curetage and office endocervical curetage J. Toral, J. ToralSearch for more papers by this author J. Toral, J. ToralSearch for more papers by this author First published: 09 December 2003 https://doi.org/10.1016/S0020-7292(00)82715-0AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume70, IssueS12000Pages A71-A71 RelatedInformation

A comparative study of pre-operative procedures to assess cervical invasion by endometrial carcinoma.

To compare the accuracy of different diagnostic procedures currently used to assess cervical involvement in endometrial carcinoma. Retrospective observational study. Department of Obstetrics and Gynecology, Shinshu University Hospital, Matsumoto, Japan. Sixty-four patients with endometrial carcinoma were evaluated pre-operatively for cervical involvement by six different diagnostic procedures: cervical cytology, endocervical curettage, transvaginal ultrasonography, hysteroscopy, magnetic resonance imaging, and serum levels of CA125. The number of positive and negative diagnoses of cervical invasion by each of these procedures were correlated with the actual invasion determined by histological examination. Cervical invasion was confirmed in 12 (18.8%). Endocervical curettage showed high sensitivity (91%), the highest negative predictive value (96%), and the lowest negative likelihood ratio (0.14). Hysteroscopy showed high positive likelihood ratio (8.2) and low negative likelihood ratio (0.20). Magnetic resonance imaging showed the highest positive predictive value (75%) and the highest positive likelihood ratio (12.5). Magnetic resonance imaging was excellent for predicting stromal invasion, whereas hysteroscopy was superior for assessing mucosal involvement to magnetic resonance imaging. Endocervical curettage is a good test for excluding cervical involvement by endometrial carcinoma. Hysteroscopy is a good test in making both positive and negative diagnoses for cervical involvement. Magnetic resonance imaging is an excellent test for detecting cervical involvement, especially when the stroma is invaded.

Accuracy of preoperative histology and macroscopic assessment of cervical involvement in endometrial carcinoma

Objective: To compare the diagnostic accuracy between the preoperatively and macroscopically established determination of cervical involvement in endometrial carcinoma. Study design: During the period 1987 to 1991, 154 patients with endometrial cancer were evaluated in a retrospective blind manner with the objective of assessing the diagnostic accuracy of the preoperative (prehysterectomy curettage) and the macroscopic (sectioned surgical specimen) determination of the involvement of the cervix. The results were compared with the histological findings of the hysterectomy specimen (gold standard). Results: Preoperative pre-hysterectomy currettage established a sensitivity of 38% and a specificity of 91% whereas the macroscopic findings (gross appearance) confirmed a sensitivity of 50% and a specificity of 95%. A prevalence of 17% for cervical involvement was found. In patients with cervical involvement diagnosed on pre-hysterectomy curettage, a positive predictive value of 45% aud negative predictive value of 88% were established. A positive predictive value of 68% and a negative predictive value of 90% resulted from the judgement of the cervical gross appearance. Conclusions: We conclude that the cervical involvement of endometrial carcinoma diagnosed on pre-hysterectomy tissue is less predictive than the judgement of the intraoperative gross appearance of the cervix.

Recurrence patterns and complications in endometrial adenocarcinoma with cervical involvement

Cervical involvement in endometrial carcinoma is a diverse entity, and the optimal management of these patients is not well understood. Recurrence patterns and complications in 202 patients with histologically confirmed endometrial carcinoma with cervical involvement were retrospectively studied. The 5-year actuarial survival rate for all patients was 65%. Recurrences were documented in 80 (40%) of the patients, and the overall long-term survival rate in this group was 4%. Patients treated with radical hysterectomy (n = 33) had a 6% isolated pelvic recurrence rate and the lowest serious complication rate among the five treatment groups despite having the highest frequency of risk factors for recurrence among any of the groups studied. Patients treated with extrafascial hysterectomy alone (n = 37) had a 14% pelvic recurrence rate and very few complications. When radiotherapy preceded extrafascial hysterectomy (n = 37), the frequency of pelvic recurrences was 30%, and 19% experienced serious gastrointestinal or genitourinary tract complications. When radiotherapy followed extrafascial hysterectomy (n = 68), the pelvic recurrence rate was 24%, and 13% experienced serious complications. Overall, 24% of patients (49 of 202) had isolated pelvic recurrences, whereas 10% (21 of 202) had isolated distant recurrences and 5% (10 of 202) were simultaneously diagnosed with both pelvic and distant recurrences. This large data base suggests that older conventional forms of therapy, particularly those using preoperative radiotherapy, subject the patient to significant morbidity over a 5- to 10-year period and, in terms of local control, are not necessarily superior to therapeutic modalities using primary surgical evaluation, such as radical hysterectomy. Consideration of primary surgery should be given in the appropriate situation, and radical hysterectomy should be considered when gross cervical involvement is encountered and intraoperative exploration does not show obvious extrauterine disease.

The Value of Ultrasound in Preoperative Assessment of the Myometrial and Cervical Invasion in Endometrial Carcinoma

This study was undertaken to determine the accuracy of ultrasonography in depicting the depth of myometrial invasion and cervical involvement in women with adenocarcinoma of the endometrium. During the past 2 years, pelvic ultrasound using abdominal and vaginal probes was carried out as part of routine preoperative work-up in 69 consecutive patients with carcinoma of the endometrium. Fifty-eight patients were primarily operated on; the remaining 11 had preoperative intracavitary irradiation followed by surgery at the referral hospital. All patients underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and staging laparotomy. A Hitachi EUB 450 ultrasound machine with a high-resolution 6.5-MHz transvaginal transducer was used to assess the intrauterine extension of the tumor. Myometrial extension was measured from the endometrial-myometrial interface to the deepest edge of the tumor extension into the myometrium and was categorized as 0%, <50%, or >50% myometrial invasion. Cervical involvement was determined based on irregular echogenicity of the tumor in the cervix of the uterus. Sixty-three of 69 patients had no cervical involvement on ultrasound, whereas the cervix was negative in 60 subjects on pathological examination; i.e., there were 3 false-negative and no false-positive results. The correlation was highly significant (P < 0.001). Of these, the endocervix was involved in 5 cases (stage IIa) and there were 4 patients with stage IIb disease. All 3 false-negative cases were stage IIa, with microscopical involvement in 2 patients. In the third case histology demonstrated disease extending low to the inner cervical os and was considered involvement of the cervix. The inner half of myometrium was involved in 28 patients and the outer half in 31, and there was no myometrial invasion in 10 cases. The corresponding values for ultrasound were 29, 31, and 9, respectively; i.e., there was only 1 false-positive and no false-negative results. The correlation is highly significant (P < 0.001). Sonography revealed irregular interface between the endometrium and myometrium, giving the appearance of measurable myometrial involvement in the only woman with a false-positive result. Our results indicate that transvaginal sonography correctly predicts endometrial and cervical involvement in endometrial carcinoma. In evaluating these factors, ultrasound using transvaginal probes is probably more accurate than intraoperative gross evaluation or frozen section analysis. Preoperative knowledge of these variables allows the gynecologists an appropriate consultation in terms of extended surgery and to select those patients who might benefit from referral to gynecologic oncology centers.

Nature of cervical involvement in endometrial carcinoma.

In patients with endometrial carcinoma the prognostic significance of clinical and histopathologic variants of cervical involvement is unknown. Fifty-eight patients with endometrial carcinoma and cervical involvement diagnosed by gross examination or endocervical curettage are reviewed. Three clinicopathologic groups were identified: gross cervical involvement (10 patients), occult stromal invasion (25), and no evidence of stromal invasion (23). There were no differences in clinical, pathologic, surgical, or therapeutic characteristics. There was no significant difference in actuarial 5-year survival rates between patients with gross cervical involvement (70%) and occult disease (65%). There was also no significant difference in survival rates among patients with occult cervical stromal invasion (67%). The presence of cervical involvement in endometrial carcinoma is an important prognostic factor. However, the extent of cervical involvement does not appear to be of significant prognostic value.

Problems in the preoperative diagnosis of cervical involvement in endometrial carcinoma

In adenocarcinoma of the endometrium it is very important to differentiate stage I from stage II, since each of these stages involves different metastasizing paths necessitating different surgical approaches. Fractionated abrasion yields considerably imprecise information on the extension of the tumour. Whereas a negative cervical fraction is diagnostically very safe, the identification of a tumour via this fraction requires further testing, since contamination by a carcinoma of the endometrium limited to the corpus is more likely than a carcinoma which has penetrated into the cervix. It is recommended to perform additional diagnostic measures, in particular hysteroscopy with target-specific biopsy or abrasion.