Factors associated with parametrial involvement in stage IB1 cervical cancer and identification of patients suitable for less radical surgery

doi:10.1016/j.ygyno.2011.05.038

Gynecologic Oncology

Volume 122, Issue 3, September 2011, Pages 491-494

https://doi.org/10.1016/j.ygyno.2011.05.038 Get rights and content

Abstract

Objective

The purpose of the present study was to determine possible factors associated with parametrial spread in patients with stage IB1 cervical cancer and define parameters associated with a low risk for parametrial spread, in order to identify candidates for less radical surgery.

Patients and methods

We retrospectively reviewed 200 patients with stage IB1 cervical cancer who had undergone radical hysterectomy (class III) and pelvic lymphadenectomy.

Results

Overall, 20 (10.0%) of the 200 patients revealed parametrial spread, of which 11 (55%) had only direct microscopic extension of the disease, 3 (15%) had only disease spread to parametrial lymph nodes, 1 (5%) had both direct microscopic extension and disease spread to parametrial lymph nodes, and 5 (25%) had only tumor emboli within the lymph vascular channels in the parametrial tissue. Elderly age, depth of invasion, tumor size, lymph vascular space invasion (LVSI), positive pelvic nodes, and ovarian metastasis were significantly associated with parametrial involvement. The multivariate analysis model included factors that could be determined by a cone biopsy and showed LVSI, deep stromal invasion, and elderly age to be the independent predictors of parametrial involvement. Ninety-one patients had a depth of invasion of ≤ 10 mm and no LVSI, of which only 1 (1.1%) had parametrial involvement. When patients aged ≤ 50 years were further stratified into those with a depth of invasion of ≤ 10 mm and no LVSI, parametrial involvement was found to be 0.0% (0/68).

Conclusion

Patients with a tumor depth of invasion of ≤ 10 mm, no LVSI, and aged ≤ 50 years, could be considered for less radical surgery such as modified radical hysterectomy or simple hysterectomy with pelvic lymphadenectomy.

Research highlights

► We review stage IB1 cervical cancer patients who had undergone radical hysterectomy. ► We determine possible factors associated with parametrial spread. ► LVSI, stromal invasion, and age are the predictors of parametrial involvement. ► Some patients could be considered for less radical surgery.

Introduction

Patients with stage IA2–IB1 cervical cancer are commonly treated with radical hysterectomy and pelvic lymphadenectomy worldwide. The most frequent site of local spread of cervical cancer is the parametrium; parametrial spread occurs through direct microscopic extension or by lymphatic channels. Therefore, the removal of the parametrial tissue has been considered to be of paramount importance in the treatment of cervical cancer. However, parametrectomy is the main cause of postoperative complications including bladder dysfunction, sexual dissatisfaction, and anorectal mobility disorders, attributable to partial denervation of the autonomic nerve supply to the pelvic organs during the parametrial resection [1], [2]. Recent studies have questioned the efficacy and safety of radical hysterectomy due to the high rate of long-term postoperative complications [3], [4]. Although a nerve-sparing surgery may minimize these complications, no prospective randomized controlled trial to evaluate this surgery has been conducted thus far.

We previously reported that less radical surgery may be sufficient in cases of stage IA2 cervical cancer where lymph vascular space invasion (LVSI) is absent [5]. van Meurs et al. have reported in their literature review that the risk of parametrial involvement is very low in patients with stage IA2 cervical cancer and suggested that it was justifiable to assume that patients with a stage IA2 and no LVSI did not require parametrectomy [6]. In Japan, radical hysterectomy was performed in only 19% of the patients with stage IA2 cervical cancer in 2009. A majority of the other patients underwent less radical surgery, including modified radical hysterectomy, simple hysterectomy, or cervical conization. Stage IB1 cervical cancers are defined by a broad range of tumor characteristics such as tumor size, depth of invasion, LVSI, lymph node metastasis, and parametrial invasion. Recently, Kim et al. demonstrated that stage IB1 patients with a depth of invasion of ≤ 5 mm are at a very low risk for parametrial involvement and thus may be treated by less radical surgery based on the results of a cone biopsy [7].

The objective of this study was to estimate the incidence of parametrial involvement using radical hysterectomy specimens from patients with stage IB1 cervical cancer and to identify factors associated with parametrial spread. In addition, we aimed to define parameters correlated with a low risk of parametrial spread in order to identify candidates suitable for less radical surgery.

Section snippets

Patients and methods

The study population consisted of 200 patients who presented with stage IB1 cervical cancer according to the 1995 Federation of Gynecology and Obstetrics (FIGO) staging system and who were treated between 1985 and 2009 with radical hysterectomy (type III) and systematic pelvic lymphadenectomy at the Okayama University Hospital, Japan. Pelvic lymph node dissection consisted of removal of all fatty lymph node-bearing tissue anterior, lateral, and posterior to the common, external, and internal

Results

Patient characteristics are listed in Table 1. Overall, 20 (10.0%) of the 200 patients had parametrial spread. Of these, bilateral parametrial involvement was seen in 10%, whereas 60% had left-sided spread, and 30% had metastasis to the right parametrium. Of this 20 patients, 11 (55%) had only direct microscopic extension of disease, 3 (15%) had only disease spread to parametrial lymph nodes, 1 (5%) had both the above mentioned parameters, and 5 (25%) had only tumor emboli within the lymph

Discussion

Overall, we found parametrial involvement in 10.0% of the patients with stage IB1 cervical cancer who underwent radical hysterectomy (type III) and pelvic lymphadenectomy. These findings are similar to those of previous studies, which have reported parametrial involvement in 8.4–10.7% of similar patients [7], [8], [9]. Therefore, about 90% of the patients with stage IB1 cervical cancer are possibly overtreated with radical surgery, particularly those with a previous cervical conization and

Conflict of interest statement

The authors declare that there are no conflicts of interest.

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Which factors predict parametrial involvement in stage IB cervical cancer? A Chinese multicentre study
2023, European Journal of Surgical Oncology
To explore the clinicopathological risk factors influencing parametrial involvement (PI) in stage IB cervical cancer patients and compare the oncological outcomes between Q-M type B radical hysterectomy (RH) group and Q-M type C RH group.
Univariate and multivariate analyses were performed to explore the clinicopathological factors related to PI. Overall survival (OS) and disease-free survival (DFS) in patients with stage IB cervical cancer who underwent Q-M type B or Q-M type C RH under different circumstances of PI were also compared before and after propensity score matching (1:1 matching).
A total of 6358 patients were enrolled in this study. Depth of stromal invasion>1/2 (HR: 3.139, 95% CI: 1.550–6.360; P = 0.001), vaginal margin (+) (HR: 4.271, 95% CI: 1.368–13.156; P = 0.011), lymphovascular space invasion (LVSI) (+) (HR: 2.238, 95% CI: 1.353–3.701; P = 0.002) and lymph node metastases (HR: 5.173, 95% CI: 3.091–8.658; P < 0.001) were associated with PI. Among the 6273 patients with negative PI, those in the Q-M type B RH group had a higher 5-year OS and DFS than those in the Q-M type C RH group before and after 1:1 matching. Among the 85 patients with positive PI, Q-M type C RH showed no survival benefits before and after 1:1 matching.
Stage IB cervical cancer patients with no lymph node metastasis, LVSI(−) and depth of stromal invasion ≤1/2 may be considered for Q-M type B radical hysterectomy.
Retrospective analysis of the incidence and predictive factors of parametrial involvement in FIGO IB1 cervical cancer
2021, Journal of Gynecology Obstetrics and Human Reproduction
Radical surgery is the standard primary treatment for patients with stage IB1 (FIGO 2009 staging) cervical cancer due to latent parametrial involvement. Recent studies suggested that less radical surgery was applicable for patients with no or low risk of parametrial involvement. In this study, we aimed to determine the incidence and possible predictive factors of parametrial involvement in patients with stage IB1 cervical cancer so as to evaluate whether less radical surgery was suitable for selected patients.
Clinical data of patients who underwent type C radical hysterectomy with pelvic lymphadenectomy and diagnosed as stage IB1 cervical cancer at Union Hospital, Wuhan, China from October 2014 to December 2017 were collected and analysed retrospectively. The incidence of parametrial involvement was calculated and the risk factors for parametrial involvement were evaluated by univariate and multivariate logistic regression.
Among 282 eligible patients, 33 (11.7%) had parametrial involvement. Postmenopause, lymphovascular space invasion (LVSI), lymph node metastasis (LNM), deep stromal invasion (outer 1/3) and tumor size larger than 2 cm were statistically associated with parametrial involvement. Multivariate analysis showed that LNM (OR = 11.431; 95%CI: 3.455 - 37.821), deep stromal invasion (OR = 6.080; 95%CI: 1.814 - 20.382) and LVSI (OR = 7.147; 95%CI: 1.863–27.411) remained as independent risk factors for parametrial involvement in patients with stage IB1 cervical cancer.
The incidence of parametrial involvement in stage IB1 cervical cancer is non-negligible. Only LNM, LVSI and deep stromal invasion were independent predictors, which were not easy to evaluate accurately before surgery. Less radical surgery requires modified pre-treatment evaluation methods and prospective data support.
Conservative (non-radical) surgery for stage IB1 cervical cancer
2021, Best Practice and Research: Clinical Obstetrics and Gynaecology
There has been lively debate in recent years following the publication of various retrospective case series and small cohort studies that suggest certain women presenting with International Federation of Gynecology and Obstetrics (FIGO) stage IB1 cervical cancer (pre-2018 revised classification) may be treated by non-radical surgery, either simple hysterectomy or cone biopsy, where fertility preservation is required. A strictly defined histological criterion is necessary for selecting such cases, incorporating tumour dimensions including estimated tumour volume, lympho-vascular space invasion and pelvic lymph node status. Meta-analyses of these studies show that the oncological outcomes are comparable to the excellent results achieved by radical hysterectomy and radical trachelectomy. In addition, the fertility and pregnancy outcomes for cases treated by conisation are superior to cases managed by radical trachelectomy. Multi-centre, ethically approved, prospective studies are currently on-going, which will provide better quality evidence in an attempt to contribute to this debate, with the intention of improving outcomes, including quality of life, in women presenting with small-volume stage IB1 cervical cancer.
Prognostic factors influencing pelvic, extra-pelvic, and intraperitoneal recurrences in lymph node-negative early-stage cervical cancer patients following radical hysterectomy
2020, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
The rate of distant metastasis in patients with adenocarcinoma was also higher than in patients with squamous cell carcinoma [34]. Previous studies have suggested that elderly women have a higher incidence of capillary lymphatic invasion and PMI [35,36]. Similarly, cancerous cells in older women tend to display more EMI.
The aim of this study was to evaluate the clinicopathologic factors influencing pelvic, extra-pelvic, and intraperitonal recurrences and survival in patients with lymph node-negative early-stage cervical cancer treated with abdominal/laparoscopic/robotic radical hysterectomy (ARH/LRH/RRH).
We retrospectively reviewed clinicopathologic data of 342 patients with FIGO stage IB-IIA cervical cancer (2018 FIGO staging) treated with RH and retroperitonal lymphadenectomy between February 2000 and November 2018. Several clinicopathologic factors such as surgical methods including LRH/RRH-vaginal colpotomy (VC) and LRH/RRH-intracorporeal colpotomy (IC), surgical resection margin, and parametrial/endomyometrial infiltration were selected. Univariate and multivariate Cox proportional hazard regression and logistic regression models were used to determine prognostic factors.
The median follow-up time was 54 months (range, 6–202 months). In multivariate analysis, positive endomyometrial infiltration (HR, 13.576; 95 % CI, 2.917−63.179; P = 0.001), positive parametrial resection margin (HR, 32.648; 95 % CI, 2.774−384.181; P = 0.006), and LRH/RRH-IC (HR, 4.752; 95 % CI, 1.154−19.578; P = 0.031) were significantly related to overall survival. Six (26.3 %) out of 21 patients with endomyometrial infiltration showed extra-pelvic recurrences associated with lung, liver, and brain. Three (50.0 %) out of 6 patients with positive parametrial margin showed both pelvic and extra-pelvic metastases, such as pelvis and supraclavicular/paratracheal lymph nodes. Five (62.5 %) out of the eight relapsed patients who received LRH/RRH-IC showed intraperitoneal recurrences including omentum, liver surface, colon serosa, and splenic hilum.
Three risk factors including parametrial margin, endomyometrial infiltration, and laparoscopic IC appear to be involved in pelvic, extra-pelvic, and intraperitoneal recurrences in node-negative early-stage cervical cancer patients following RH. In particular, endomyometrial infiltration may be one of the strongest independent prognostic factors for extra-pelvic recurrence. Adjuvant systemic therapy may be indicated for lymph node-negative early-stage cervical cancer patients with endomyometrial infiltration.
Which factors predict parametrial involvement in early stage cervical cancer? A Turkish multicenter study
2019, European Journal of Obstetrics and Gynecology and Reproductive Biology
To evaluate the clinical and pathological factors for predicting the parametrial involvement (PI) in early stage cervical cancer.
This study included 406 patients with type III radical hysterectomy + pelvic ± para-aortic lymphadenectomy and FIGO stage I and II cervical adenocarcinoma, squamous type, and adenosquamous type cervical cancer.
The entire cohort of patients had lymphadenectomy performed. Early stage cervical cancer patients were evaluated. FIGO 2014 stage, uterine invasion, LVSI, surgical border involvement, vaginal metastasis, stromal invasion and lymph node metastasis were found to be effective for PI on univariate analyses. However; age, tumor type and tumor size did not determine the parametrial invasion. LVSI (HR: 4.438, 95%CI: 1.771–11.121; p = 0.001), lymph node metastases (HR: 2.418, 95%CI: 1.207–4.847; p = 0.013) and vaginal involvement (HR: 4.109, 95%CI: 1.674–10.087; p = 0.02) are independent prognostic factors on multivariate analysis.
Lymph node metastases, LVSI and surgical border involvement are independent prognostic factors for PI in early stage cervical cancer patients. Therefore, less radical surgical approaches for early stage tumors with no nodal spread, negative LVSI and no surgical border involvement are applicable.
Less versus more radical surgery in stage IB1 cervical cancer: A population-based study of long-term survival
2018, Gynecologic Oncology
Standard surgical treatment for women with stage IB1 cervical cancer consists of radical hysterectomy. This study assesses survival outcomes of those treated with less radical surgery (LRS; conization, trachelectomy, simple hysterectomy) compared to more radical surgery (MRS; modified radical, radical hysterectomy).
Using the Surveillance, Epidemiology and End Results database, we identified women <45 years with FIGO stage IB1 cervical cancer diagnosed from 1/1998 to 12/2012. Only those who underwent lymph node (LN) assessment were analyzed. Disease-specific survivals (DSSs) of LRS were compared with those of MRS.
Of 2571 patients, 807 underwent LRS and 1764 underwent MRS, all with LN assessment. For LRS vs. MRS, 28% vs. 23% were diagnosed with adenocarcinoma (p = 0.024), 31% vs. 39% had G3 disease (p < 0.001), 40% vs. 45% had tumor size >2 cm (p < 0.001), and 27% vs. 29% received adjuvant radiation therapy (p = 0.005). Median follow-up was 79 months (range, 0–179). Ten-year DSS for LRS vs. MRS was 93.5% vs. 92.3% (p = 0.511). There was no difference in 10-year DSS when stratified by tumor size ≤2 cm (LRS 95.1% vs. MRS 95.6%, p = 0.80) or > 2 cm (LRS 90.1% vs. MRS 88.2%, p = 0.48). Factors independently associated with increased risk of death included adenosquamous histology (HR 2.37), G3 disease (HR 2.86), tumors >2 cm (HR 1.82), and LN positivity (HR 2.42). Compared to MRS, LRS was not associated with a higher risk of death.
In a select group of young women with stage IB1 cervical cancer, LRS compared to MRS does not appear to compromise DSS.

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Factors associated with parametrial involvement in stage IB1 cervical cancer and identification of patients suitable for less radical surgery

Abstract

Objective

Patients and methods

Results

Conclusion

Research highlights

Introduction

Section snippets

Patients and methods

Results

Discussion

Conflict of interest statement

Lancet Oncol

Gynecol Oncol

Eur J Obstet Gynecol Reprod Biol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol