FIGO Stage IA Research Articles

Laparoscopy-assisted vaginal hysterectomy compared with abdominal hysterectomy in clinical stage I endometrial cancer: safety, recurrence, and long-term outcome

To determine the feasibility of laparoscopic-assisted vaginal hysterectomy (LAVH) in the treatment of clinical FIGO stage I endometrial adenocarcinoma and long-term survival outcome. Prospective cohort study without randomization of 169 consecutive patients. Laparoscopy or laparotomy was selected based on size and mobility of the uterus and Body Mass Index (BMI). Lymphadenectomy was only performed in cases at high-risk for nodal metastases. Sixty-nine patients (41%) treated successfully by LAVH (LAVH group) while 100 (59%) by total abdominal hysterectomy (TAH) (laparotomy group). Four out of 73 patients initially approached by laparoscopy were converted to laparotomy (5.5%). Lymphadenectomy was performed in 40% of the LAVH and 57% of TAH group (P = 0.03). The median number of pelvic lymph nodes removed by LAVH and laparotomy was 15 (range 2-31) and 21 (range 2-65), respectively (P = 0.05). LAVH was associated with more surgical FIGO stage IA disease and a smaller tumor diameter. Operative time was significantly longer with laparoscopy compared with laparotomy, while blood loss and duration of hospitalization was significantly lower in the LAVH group. The recurrence rate in the LAVH group was 8.7%, compared with 16% in the laparotomy group (not significant, NS). The actuarial overall survival (OS) and disease-free survival (DFS) for the LAVH were 93% and 91% compared with 86% and 84% in the TAH, respectively (NS). In the multivariate analyses histological subtype was the only independent prognostic factor for DFS, while surgical technique was not. LAVH with lymphadenectomy in selected population in high-risk patients with clinical stage I endometrial adenocarcinoma and with favorable body mass index of less than 35 kg/m2, appears to be safe procedure.

Feasibility and outcome of laser CO2conization performed within the 18th week of gestation

The purpose of this study is to evaluate the feasibility, safety, and potential therapeutic benefit of laser CO(2) conization of the cervix for in situ and minimally invasive carcinoma diagnosed during pregnancy. Twenty-six pregnant patients with biopsy-proven carcinoma in situ/cervical intraepithelial neoplasia III but colposcopically suspicious for invasion underwent laser CO(2) conization during the 18th week of gestation in an outpatient setting under local anesthesia. No major intraoperative or postoperative complications occurred, and cervical cerclage was not required in any case. Two cases (7.7%) of occult FIGO stage IA1 minimally invasive cervical cancers with free surgical margins were diagnosed. Both patients delivered vaginally at term and were free of disease at postpartum follow-up. Median length of gestation was 39.1 weeks with a median birth weight of 3450 g. All 1-min Apgar scores were 8 or greater. Twenty patients (76.9%) delivered vaginally, while six patients underwent cesarean section for indications not related to the prior conization. After a mean postpartum follow-up of 18 months (range 3-42), 92.3% of patients continued to have both cytologic and colposcopic evaluations negative for persistent or recurrent disease. Two cases of persistent intraepithelial disease were successfully managed by reconization. In summary, our data suggest that laser CO(2) conization performed within the 18th week of gestation is safe for both the patient and the fetus, provides reliable histologic diagnosis, and can be curative. Further studies are required to confirm the favorable risk-benefit ratio of laser CO(2) conization in the management of non-reassuring cervical lesions observed in the first half of pregnancy.

1053: Distribution of Sentinel Lymph Nodes in Patients With Cervical Cancer- Implications for Target Volumes in Radiation Therapy?

1053: Distribution of Sentinel Lymph Nodes in Patients With Cervical Cancer- Implications for Target Volumes in Radiation Therapy?

Adjuvant radiotherapy and survival outcomes in early-stage endometrial cancer: A multi-institutional analysis of 608 women

Objective. The role of post-operative radiotherapy (RT) in women with early-stage, low to intermediate risk cancer of the uterine corpus remains controversial. The primary objective of this analysis was to evaluate the survival outcomes of women with early-stage endometrial cancer treated with surgery alone or surgery followed by RT. Methods. Data from two institutions were collected from 1990 to 2003. The 608 eligible women had FIGO stage IA to IIA endometrial cancer and underwent primary surgery ± RT. Univariate and multivariate analyses of pertinent variables were performed for the end points of disease-free survival (DFS) and overall survival (OS). Results. The median age for all women was 64 years. RT was delivered to 133 women (22%). Unfavorable histologic grade ( P < 0.0001) and stage ( P < 0.0001) were significantly more prevalent in the adjuvant RT group. At a median follow-up of 5.2 years, 26 pelvic (11 vaginal) and 16 distant failures occurred along with 110 deaths (with no significant differences between women undergoing surgery alone or followed by RT). Adjuvant RT, younger age, and lower stage predicted for improved DFS and OS on multivariate analysis. Stratified analysis revealed that adjuvant RT conferred a survival benefit in women with stage IC or IIA disease. Conclusions. Adjuvant RT was associated with improved disease-free and overall survival in women with higher risk disease. Despite significantly worse disease characteristics among women in the adjuvant RT group, the analyzed end points were equivalent among the two groups. These findings suggest that adjuvant radiotherapy has a significant benefit in reducing mortality and disease progression in early-stage carcinoma of the uterine corpus.

Serum YKL-40 levels in patients with cervical cancer are elevated compared to patients with cervical intraepithelial neoplasia and healthy controls

5047 Background: YKL-40 is secreted by cancer cells, macrophages and neutrophils. The exact function of YKL-40 is unknown. It may be a growth or differentiation factor, play a role in angiogenesis or protect against apoptosis. High serum YKL-40 is associated with poor prognosis in breast-, colorectal-, ovarian-, prostate-, small cell lung cancer and malignant melanoma. The aim was to examine serum YKL-40 in patients with cervical cancer and cervical intraepithelial neoplasia (CIN). Methods: YKL-40 was determined by ELISA (Quidel, Santa Clara, CA) in pretreatment serum samples from 116 patients with cervical cancer (FIGO stage Ia (N = 5), Ib (N = 55), II (N = 27), III (N = 25) and IV (N = 4); median age 50, range 27–87 years) and 152 patients with cervical CIN (34 years, 20–80 years). The controls included 63 healthy women undergoing sterilization (36 years, 25–59 years) and a group of 134 healthy women (51 years, 18–79 years). Results: Serum YKL-40 was increased (p &lt; 0.001) in the patients with cervical cancer (median 76 μg/l, range 20–2310) compared to patients with CIN (45 μg/l, 20–288), women undergoing sterilization (37 μg/l, 20–125) and healthy women (43 μg/l, 20–172). Patients with CIN had slightly elevated serum YKL-40 levels. Serum YKL-40 increased with increasing stage (Ia: median 36 μg/l, range 26–137; Ib: 56 μg/l, 20–984; II: 92 μg/l, 28–2310; III: 163 μg/l, 40–1474; and IV: 224 μg/l, 137–391; p &lt; 0.001 Kruskal-Wallis test). All stage IV patients, 72% stage III, 52% stage II, 24% stage Ib, 40% stage Ia and 13% of patients with CIN had elevated serum YKL-40 compared to healthy controls (95th percentile). Patients with squamous cell carcinoma had higher serum YKL-40 (median 92 μg/l, range 27–2310, N = 86) compared to patients with adenosquamous (67 μg/l, 20–93, N = 9, p = 0.027) and adenocarcinoma (43 μg/l, 20–1472, N = 20, p &lt; 0.001). Conclusion: Median serum YKL-40 is elevated in patients with stage Ib - IV cervical cancer. The serum level of YKL-40 seems to be correlated to the stage. No significant financial relationships to disclose.

Topographic distribution of sentinel lymph nodes in patients with cervical cancer

Background Since the introduction of the sentinel concept in cervical cancer in 1999, various studies have been demonstrated the feasibility, detection rate and sensitivity and rate of false-negative sentinel lymph nodes (SLN). There are only limited data regarding the mapping of the removed SLN. A correlation between the localization of SLN and the tumor stage, histology or marker substance has never been investigated. Methods Between 2/2000 and 6/2005, the SLN distribution of 151 patients with histologically confirmed cervical cancer (FIGO stages IA n = 21, IB n = 95, IIA n = 14, IIB n = 18, IIIB n = 2, IVA n = 1), who participated in the ongoing “Uterus 3” sentinel study of the German Association of Gynecologic Oncologists (AGO), was retrospectively analyzed with respect to the histology, tumor stage and detection substance. The tumors comprised mostly of squamous cell carcinomas (75.5%) with a smaller fraction of adenocarcinomas (24.5%). Results Altogether, 406 SLN, an average of 2.7 (1–7) SLN per patient, were removed. More than one SLN was detected in 111 patients (73.5%). SLN were found unilaterally in 70 patients (46.4%) und bilaterally in 81 patients (53.6%). SLN sites were paraaortic in 4%, common iliac in 5%, external iliac in 5%, internal iliac in 8%, interiliac in 71% and parametric in 7%. Irrespective of the detection drug applied, most SLN were interiliac (blue 70%, TC 67%, TC and blue 71%). Combined application of technetium and blue dye revealed significantly more SLN in the paraaotic region ( P = 0.006). Adenocarcinomas and squamous carcinomas did not differ in the distribution of SLN ( P = 0.205). The majority of SLN are interiliac in all tumor stages (FIGO IA 76%, IB 68%, IIA 61%, IIB 83%, III and IV 88%). Conclusions Removal of SLN in the external iliac, interiliac and obturator area enables evaluation of more than 80% of all SLN. The pattern of SLN is independent from histology and tumor stage. Combined use of technetium and blue dye detects sentinels more frequently in the paraaortic region than a single marker.

Hypothetical Genes Are Frequent Targets of HPV DNA Integration in Cervical Carcinomas

Objective: Integration of HPV DNA into the host genome is a frequent event in cervical carcinogenesis. Viral integration sites seem to be randomly distributed among all chromosomes with a clear preference for genomic fragile sites. To date about 200 HPV DNA integration sites have been mapped. However, this number is still too small to fully comprehend the different mechanisms by which HPV DNA integration contributes to carcinogenesis. Methods: 55 cervical carcinoma samples of FIGO stage IA to IIIB positive for either HPV16 (n=34) or HPV18 (n=21) were analysed. Viral-cellular fusion transcripts were detected using the APOT assay (amplification of papillomavirus oncogene transcripts) introduced by Klaes and colleagues (Klaes et al., 1999). All putative viral-cellular fusion transcripts were analysed by sequencing. The genomic localisation of the integration sites were determined by database query of all available public databases. Results: The detection rate of viral-cellular fusion transcripts from HPV16 positive tumours was significantly lower (p=0.012, two-sided t-test) than that of HPV18 positive tumours (53% versus 81%, respectively). A BLASTN comparison of the fusion transcripts with the NCBI Database showed homology in 16 out of 35 cases, with 10 fusion transcripts containing known genes and 6 transcripts containing parts of Expressed Sequence Tags (EST). 16 integration sites were mapped within hypothetical genes listed in the UCSC Genome Browser Database. Conclusion: One striking finding of this study is the high proportion of viral integration sites within in silico predicted genes (46%). In contrast, only 29% of integration sites were located within known genes. This not only suggests that virus integration occurs within transcriptionally active chromosomal sites, but also that the APOT assay may be a useful tool for the detection of hypothetical genes which have not been analysed in the context of carcinogenesis thus far.

271: Comparative Study of Laparoscopic Radical Hysterectomy and Abdominal Radical Hysterectomy in Patients with Early Cervical Cancer

To evaluate the outcomes of patients treated by laparoscopic radical hysterectomy and to compare surgical parameters and recurrence rates to those of patients treated by conventional abdominal radical hysterectomy. Retrospective study. From October 1997 to December 2004. Inclusion criteria for the laparoscopic group were patients with FIGO stage IA to IB. As a control, we selected 142 cases for the RH group. These groups had the same FIGO stage and the same age. We performed 185 cases of LRH (laparoscopic radical hysterectomy) with +PLN (pelvic lymphadenectomy) ± paraaortic lymph node sampling. The mean surgery duration, the number of lymph nodes and the rate of perioperative and postoperative complications were similar in both the laparoscopic and the conventional laparotomy group. The mean length of hospital stay was significantly shorter in patients treated by laparoscopic surgery (LRH vs. RH; 13 vs. 21 days). The positive rates of pelvic lymph nodes metastasis in both groups were similar at 6.4%. Six (3.2%) of 185 LRH patients and four (2.8%) of 142 RH patients had recurrences. The three year progression-free survival rates were 94.2% in the LRH group and 96.4% in the RH group (p=0.174). Overall, there were 27 (27/185, 14.6%) major perioperative complications including bladder, ureter, vessels and bowel injuries in laparoscopic group. 15 (30%) of those complications occurred during the first 50 cases, compared to 12 (8.9%) of the later cases (p>0.001). Laparoscopic surgery for treatment of early cervical cancer is a safe and effective alternative to conventional abdominal radical hysterectomy.

Lymph node mapping and sentinel node detection in patients with cervical carcinoma: A 2-year experience

Objective. To describe our experience with the sentinel lymph node biopsy in cervical cancer patients, using a laparotomic approach and blue dye technique. Methods. Between January 2003 and January 2005, patients with histologically proven FIGO stage IA 2 to IIA carcinoma of the uterine cervix were submitted to SLN procedure if they were scheduled to have radical abdominal hysterectomy and pelvic lymphadenectomy. The SLN mapping was done after intracervical methylene blue (4 ml) injection. Final pathologic evaluation of SLNs included serial step sections and wide spectrum cytokeratin immunohistochemical analysis. Results. Fifty patients were accrued to this prospective observational double-center study. A total of 86 SLNs (mean 1.9) were identified in the 45 patients with fruitful quest for SLN detection. The SLN detection rate per patient was 90%, and for the side of dissection, 72%. Bilateral SLNs were detected in 60% of cases. SLNs were identified in the external iliac and obturator areas in 55% and 38%, respectively; 5 isolated SLNs were discovered in the common iliac region. Ten patients (20%) had lymph node metastases; one of these had false-negative SLN. The false-negative rate and the negative predictive value, calculated by patient and by side of dissection, were 10% and 97.2%, and 8.3% and 98.4%, respectively. Conclusions. SLN detection with blue dye is a feasible procedure, particularly useful as a surgical staging procedure in young patients with small tumors. The true morbidity-sparing role of this technique in cervical cancer treatment is yet to be found.

Usefulness of sentinel lymph node detection in early stages of cervical cancer

Sentinel lymph node (SLN) mapping in combination with surgical biopsy is an emerging technique for use in the early stages of cervical cancer. The purpose of this study was to evaluate the technique in a series of 40 consecutive women with early stage cervical cancer. Forty patients with early stage cervical cancer [FIGO stage IA2 (2), IB1 (34), IB2 (1) or IIA (3)] were referred for radical hysterectomy with pelvic lymphadenectomy. Patients were submitted to preoperative lymphoscintigraphy (four 99mTc-nanocolloid injections around the tumour) and intraoperative SLN detection. Hand-held or laparoscopic gamma probes were used to locate SLNs during surgery. The mean number of SLNs was 2.5 per patient (interiliac 49%, external iliac 19%). Of the total of 99 SLNs, six, in four women, showed metastases (all 68 non-SLNs removed were negative). In the other 36 patients, all the removed lymph nodes (sentinel and non-sentinel) were negative (0% false negative rate). During the follow-up (median 25 months), only two patients presented distant metastases: one died 6 months after surgery (two of three SLNs positive, both hot and blue), while the second patient is alive 4 years after surgery (lung metastasis, no isotope drainage, negative blue SLN). The survival rate was 95% and disease-free survival, 97%. SLN surgical biopsy based on lymphoscintigraphy and blue dye is a feasible and useful technique to avoid lymph node dissection in the early stages of cervical cancer. It has a high negative predictive value, can be incorporated into clinical routine (laparoscopy or open surgery) and is close to achieving validation in this setting.

Korreliert die Therapie des Zervixkarzinoms mit den S2-Leitlinienempfehlungen? - Eine Untersuchung der Organkommission Uterusmalignome der Arbeitsgemeinschaft Gynäkologische Onkologie e. V.

Einleitung: Die Behandlung des Zervixkarzinoms hat sich in den letzten Dekaden deutlich gewandelt. Neben Modifikationen der operativen Therapie hat auch die Radiotherapie gleiche Heilungsraten wie die radikale Tumorchirurgie zeigen können, standardisierte Richtlinien zur Behandlung des Zervixkarzinoms gibt es jedoch nicht. In der vorliegenden Untersuchung wurden mittels einer Umfrage die verschiedenen Behandlungsansätze in deutschen Kliniken untersucht und diese mit der Leitlinienempfehlung der S2-Leitlinie der Deutschen Krebsgesellschaft (DKG) verglichen. Material und Methode: Es wurde ein 13 Fragen umfassender Fragebogen zur Therapie des Zervixkarzinoms erarbeitet, der im Jahr 2003 an 430 gynäkologische Abteilungen versandt wurde. Die Fragen zum therapeutischen Vorgehen beim Zervixkarzinom waren entsprechend der FIGO-Klassifikation stadienabhängig unterteilt. 172 Kliniken, darunter 24 Universitätskliniken, 64 Kliniken mit mehr als 50 Betten, und 84 Kliniken mit weniger als 50 Betten, sandten einen auswertbaren Antwortbogen zurück. Ergebnisse: Die Therapie des Zervixkarzinoms unterschied sich in den verschiedenen FIGO-Stadien teilweise deutlich, insbesondere in den höheren Stadien wurden sehr unterschiedliche Therapieschemata angewandt. Im Stadium IA1 therapierten 92 % der antwortenden Kliniken leitlinienkonform, im Stadium IA2 waren dies nur 48,5 %. In den höheren Tumorstadien FIGO IB2 und IIB war eine Übereinstimmung mit den Empfehlungen der S2-Leitlinie in 51,1 %, respektive in 33,6 % der antwortenden Kliniken festzustellen. Zusammenfassung: Die Ergebnisse der Untersuchung zeigen, dass es erhebliche Unterschiede in der Therapie von Zervixkarzinomen gibt. Insbesondere in höheren Tumorstadien kommen verschiedenste Therapiekombinationen zur Anwendung. Während in den Frühstadien eine hohe Übereinstimmung mit der S2-Leitlinie, im Stadium FIGO IA jedoch mit Tendenz zur Übertherapie bestand, wurde in den höheren Stadien oft zu wenig radikal vorgegangen. Die vorliegenden Ergebnisse unterstreichen die Notwendigkeit von Leitlinien, die sich an evidenzbasierenden Daten zur Therapie des Zervixkarzinoms orientieren.

Widespread lymph node metastases in a young woman with FIGO stage IA1 squamous cervical cancer

Background Lymphatic and hematologic metastases are rare in microinvasive cervical cancers (FIGO stage IA1), supporting a role for conservative treatment. Cervical conization followed by prolonged surveillance is an accepted treatment in patients with low-risk features and negative surgical margins. This option is particularly appealing for younger or nulliparous patients, in whom fertility may be highly desired. Case We report a case of a 22-year-old, HIV-negative female with stage IA1 squamous cell cervical carcinoma who was found to have bilateral lymph node metastases in both pelvic and para-aortic distributions after electing to undergo hysterectomy. Conclusion Clinicians treating patients with microinvasive cervical cancer conservatively must be aware of the possibility of lymph node involvement and should consider radiological imaging to look for metastatic disease.

Korreliert die Therapie des Zervixkarzinoms mit den S2-Leitlinienempfehlungen? - Eine Untersuchung der Organkommission Uterusmalignome der Arbeitsgemeinschaft Gynäkologische Onkologie e. V.

Einleitung: Die Behandlung des Zervixkarzinoms hat sich in den letzten Dekaden deutlich gewandelt. Neben Modifikationen der operativen Therapie hat auch die Radiotherapie gleiche Heilungsraten wie die radikale Tumorchirurgie zeigen können, standardisierte Richtlinien zur Behandlung des Zervixkarzinoms gibt es jedoch nicht. In der vorliegenden Untersuchung wurden mittels einer Umfrage die verschiedenen Behandlungsansätze in deutschen Kliniken untersucht und diese mit der Leitlinienempfehlung der S2-Leitlinie der Deutschen Krebsgesellschaft (DKG) verglichen.

A Nationwide Study of Granulosa Cell Tumors in Pre- and Postpuberal Girls: Missed Diagnosis of Endocrine Manifestations Worsens Prognosis

There are very few data on the natural history of ovarian granulosa cell tumors (OGCT) in children. The aim of this study was to determine whether early recognition and diagnosis of the initial endocrine signs could improve the outcome of these tumors. In a nationwide study from 1990 to 2004, we analyzed the clinical, biological and pathologic data from 40 pre- and postpubertal girls presenting an OGCT. 1. Among the prepubertal girls (n = 29), 17 OGCTs were diagnosed on the basis of precocious pseudopuberty. None of the 17 girls had a peritoneal spread of the tumor (100% FIGO stage Ia). Diagnosis based on a tumoral or acute abdomen (12 cases) was associated with frequent intraperitoneal ruptures of the tumor (50%) and a risk of relapse (2 cases). Of the eight girls who had had a misdiagnosed precocious pseudopuberty, five had a pre- or perioperative tumoral rupture. 2. Among the postpubertal girls (n = 11), endocrine manifestations such as secondary amenorrhea or virilization had been underevaluated in three of them and the diagnosis was established from a tumoral abdomen. This clinical presentation was associated with frequent ruptures of the mass in the peritoneum (80%) and a higher risk of recurrence (30%). 3. A delayed diagnosis of OGCT despite previous endocrine signs (11 cases; 8 pre- and 3 postpubertal) was associated with a high risk of pre- or peri-operative peritoneal tumor spreading (70% FIGO stage Ic or IIc, p <0.05). The mean delay for diagnosis ranged from 3 to 11 months. This study highlights the critical role of early diagnosis of OGCT in pre- and postpubertal girls, particularly at the first seemingly banal signs of endocrine disorder. Peritoneal spread of the tumor may thereby be prevented, which improves the prognosis.

Correlation p53 expression and human papilloma virus deoxyribonucleic acid with clinical outcome in early uterine cervical carcinoma

Background: In the present study we assessed whether expression of p53 protein or HPV DNA correlates with recurrence as well as several known prognostic factors in uterine cervical carcinoma. Methods: Forty-nine patients with FIGO stage IA–IIB who underwent hysterectomy between 1998 and 2002 were retrospectively studied. All 49 cancer tissue samples were used for immunohistochemical study. Twenty-five of 49 cases were also examined by PCR–RFLP for detection and typing of HPV DNA. Results: Twenty of 49 (40.8%) specimens demonstrated nuclear staining for p53. A significant association between p53 overexpression and age, hormonal status , FIGO stage, or recurrence was observed ( p = 0.02, 0.01, 0.03, 0.01). However, no significant association was found between p53 overexpression and lymph node metastases, parametrium involvement, or risk of death ( p = 0.18, 0.06, 0.14). Nineteen of 25 (76%) were HPV DNA-positive and 6 (24%) were negative. Discussion: There was no relation between HPV DNA positivity and age, FIGO stage, lymph node metastases, parametrium involvement, recurrence, or risk of death. Conclusion: p53 overexpression is associated with age, hormonal status, FIGO stage, and recurrence in uterine cervical carcinoma.

Tailoring the parametrectomy in stages IA2–IB1 cervical carcinoma: is it feasible and safe?

Objective. Several authors have proposed the use of a less aggressive surgery (i.e., modified or type 2 radical hysterectomy) for patients affected by early stages cervical carcinoma. However, little attention has been given to the evaluation of adverse prognostic factors before selecting the surgical approach. The aim of this study is to evaluate the feasibility and safety of tailoring parametrectomy on the basis of specific prognostic factors preoperatively assessed. Methods. Patients with cervical carcinoma FIGO IA2–IB1 entered the study. Eligibility criteria were: age < 75 years, no contraindications for surgery, informed consent, expected cooperation for follow-up. Tumor size was preoperatively assessed by pelvic examination under anesthesia and pelvic MRI. Patients were submitted to systematic lymphadenectomy of superficial obturator, external iliac, and interiliac nodes by laparotomy or laparoscopy. Lymph nodes were sent for frozen section. Node-negative patients were submitted to modified radical hysterectomy (type 2). Patients with nodal metastases underwent classical radical hysterectomy (types 3–4) and systematic pelvic and aortic node dissection up to the inferior mesenteric artery. Survival rates were calculated using the Kaplan–Meier product-limit method. Results. Eighty-three patients were enrolled in the study. Among these, 63 patients were node-negative at frozen section, and therefore submitted to modified radical hysterectomy (Group A); 20 patients were found having nodal metastases intra-operatively, and therefore submitted to classical radical hysterectomy (Group B). Median follow up was 30 months. Five years overall survival was 95% for Group A, and 74% for Group B. Conclusions. Pre-treatment evaluation of adverse prognostic factors in patients affected by cervical cancer FIGO stages IA2–IB1 is feasible and mandatory to determine if a less radical surgery is applicable and safe.

Total laparoscopic radical hysterectomy with intraoperative sentinel node identification in patients with early invasive cervical cancer

Objectives To describe the feasibility and results of total laparoscopic radical hysterectomy with intraoperative sentinel lymph node identification in patients with early cervical cancer. Methods Between March 2001 and October 2003, 12 patients with FIGO stage IA 2 ( n = 1) or IB 1 ( n = 11) cancer of the cervix underwent surgical treatment through the laparoscopic route. All patients underwent a laparoscopic sentinel node identification with preoperative lymphoscintigraphy (technetium-99 m colloid albumin injection around the tumor) and intraoperative lymphatic mapping with isosulfan blue dye and a laparoscopic gamma probe followed by systematic bilateral pelvic lymphadenectomy and laparoscopic type II ( n = 5) or type III ( n = 7) hysterectomy. Results A mean of 2.5 sentinel nodes per patient (range 1−4) was detected, with a mean of 2.33 nodes per patient by gamma probe and a mean of 2 per patient after blue injection (combined detection rate 100%). The most frequent localization of the nodes was the interiliac region. Histopathologic examination of sentinel nodes including cytokeratin immunohistochemical analysis did not show metastasis. Microscopic nodal metastases were not found. The mean number of resected pelvic nodes was 18.6 per patient (range 10–28). The operation was performed entirely by laparoscopy in all patients and no case of laparotomy conversion was recorded. The mean duration of operation was 271 min (range 235–300), with a mean blood loss of 445 mL (range 240–800), and a mean length of stay of 5.25 days (range 3−10). No major intraoperative complications occurred. After a median follow-up of 20 months (range 5–34), all patients are free of disease. Conclusions This study shows the feasibility of the combination of laparoscopic intraoperative sentinel node mapping and laparoscopic radical surgery in the context of minimally invasive surgery for the management of patients with early cervical cancer.

Estrogen receptor, progesterone receptor, and bcl-2 are markers with prognostic significance in CIN III.

There are no known biological markers or technologies to predict the natural history of an individual CIN III. The probability of progression is considered greater with the persistence of high-risk human papillomavirus (HPV) infection and age. p53 polymorphism has been associated with cervical carcinogenesis. Hormone-induced cervical cancer is mediated by estrogen receptor (ER) and progesterone receptor (PR). In cervical cancer, increased bcl-2 and Bax immunoreactivity is generally associated with a better prognosis. The purpose of this study was to evaluate the value of HPV 16 and HPV 18 typing and p53 codon polymorphism genotyping by polymerase chain reaction and ER, PR, bcl-2, and Bax expression by immunohistochemistry in predicting the CIN III clinical behavior of CIN III lesions. We studied the expression of these prognostic factors in the CIN III adjacent to squamous cell microinvasive carcinomas of the cervix (MIC) from 29 patients with FIGO stage IA1 cervical cancer and in 25 patients with CIN III and no documented focus of invasion. In the MIC group, only the CIN III was considered at least 2 mm away from the microinvasive complex. The ER, PR, bcl-2, and Bax immunoreactivity was scored as positive (>10% staining cells) and negative (<10% staining cells). No significant difference was observed between MIC and CIN III group concerning HPV infection and p53 polymorphism. The ER, PR, bcl-2, and Bax immunohistochemical expression was stronger and more frequent in the CIN III group. After multivariable analysis, coexpression of ER, PR, and bcl-2 was the only independent factor in defining low risk of progression for CIN III. Our study suggests that coexpression of ER, PR, and bcl-2 may be a useful tool in identifying the CIN III lesions with low risk of progression to cervical cancer.

Estrogen receptor, progesterone receptor, and bcl-2 are markers with prognostic significance in CIN III

There are no known biological markers or technologies to predict the natural history of an individual CIN III. The probability of progression is considered greater with the persistence of high-risk human papillomavirus (HPV) infection and age. p53 polymorphism has been associated with cervical carcinogenesis. Hormone-induced cervical cancer is mediated by estrogen receptor (ER) and progesterone receptor (PR). In cervical cancer, increased bcl-2 and Bax immunoreactivity is generally associated with a better prognosis. The purpose of this study was to evaluate the value of HPV 16 and HPV 18 typing and p53 codon polymorphism genotyping by polymerase chain reaction and ER, PR, bcl-2, and Bax expression by immunohistochemistry in predicting the CIN III clinical behavior of CIN III lesions. We studied the expression of these prognostic factors in the CIN III adjacent to squamous cell microinvasive carcinomas of the cervix (MIC) from 29 patients with FIGO stage IA1 cervical cancer and in 25 patients with CIN III and no documented focus of invasion. In the MIC group, only the CIN III was considered at least 2 mm away from the microinvasive complex. The ER, PR, bcl-2, and Bax immunoreactivity was scored as positive (&gt;10% staining cells) and negative (&lt;10% staining cells). No significant difference was observed between MIC and CIN III group concerning HPV infection and p53 polymorphism. The ER, PR, bcl-2, and Bax immunohistochemical expression was stronger and more frequent in the CIN III group. After multivariable analysis, coexpression of ER, PR, and bcl-2 was the only independent factor in defining low risk of progression for CIN III. Our study suggests that coexpression of ER, PR, and bcl-2 may be a useful tool in identifying the CIN III lesions with low risk of progression to cervical cancer.

Magnetic resonance imaging in the diagnosis of benign and malignant pelvic tumors

Magnetic resonance imaging (MRI) is an accepted imaging method for diagnosing diseases of the female pelvis. This review article describes the role of MR imaging for the diagnosis of benign and malignant pelvic tumors. Sagittal T2-weighted fast spin echo sequences can be effectively applied to diagnose leiomyomas of the uterus and provide exact pretreatment measurements of size and localization. In the diagnostic work-up of endometrial carcinoma, fat-saturated, T1-weighted gradient echo sequences make it possible to determine precisely how deep myometrial infiltration extends and what tissue should be included in preoperative treatment planning. In cervical cancer staging, MRI permits both assessment of local tumor extent and determination of tumor volume for planning and monitoring radiotherapy. The usefulness of MRI in cervical cancer staging is, however, limited since not all early-stage cancer (FIGO stage IA and small stage IB tumors) can be detected. Hence, it appears that the use of MRI as a screening method for cervical cancer cannot be recommended. MRI can distinguish between benign and malignant ovarian tumors with high sensitivity and specificity. Standard and fat-saturated T1-weighted sequences usually can diagnose teratomas with a specificity of 100 %. Axial fat-saturated, contrast enhanced T1-weighted spin echo sequences are useful in the staging of malignant ovarian tumors since they facilitate evaluation of their internal structure and will disclose peritoneal metastases. Besides staging of ovarian cancer, MRI can be applied for localization and for monitoring treatment response.