Uterine mesenchymal tumors: development and preliminary results of a magnetic resonance imaging (MRI) diagnostic algorithm.

PURPOSE: The aim of our study is to propose a diagnostic algorithm to guide MRI findings interpretation and malignancy risk stratification of uterine mesenchymal masses with a multiparametric step-by-step approach. METHODS: A non-interventional retrospective multicenter study was performed: Preoperative MRI of 54 uterine masses was retrospectively evaluated. Firstly, the performance of MRI with monoparametric and multiparametric approach was assessed. Reference standard for final diagnosis was surgical pathologic result (n = 53 patients) or at least 1-year MR imaging follow-up (n = 1 patient). Subsequently, a diagnostic algorithm was developed for MR interpretation, resulting in a Likert score from 1 to 5 predicting risk of malignancy of the uterine lesion. The accuracy and reproducibility of the MRI scoring system were then tested: 26 preoperative pelvic MRI were double-blind evaluated by a senior (SR) and junior radiologist (JR). Diagnostic performances and the agreement between the two readers with and without the application of the proposed algorithm were compared, using histological results as standard reference. RESULTS: Multiparametric approach showed the best diagnostic performance in terms of accuracy (94.44%,) and specificity (97.56%). DWI was confirmed as the most sensible parameter with a relative high specificity: low ADC values (mean 0.66) significantly correlated to uterine sarcomas diagnosis (p < 0.01). Proposed algorithm allowed to improve both JR and SR performance (algorithm-aided accuracy 88.46% and 96%, respectively) and determined a significant increase in inter-observer agreement, helping even the less-experienced radiologist in this difficult differential diagnosis. CONCLUSIONS: Uterine leiomyomas and sarcomas often show an overlap of clinical and imaging features. The application of a diagnostic algorithm can help radiologists to standardize their approach to a complex myometrial mass and to easily identify suspicious MRI features favoring malignancy.

Neoadjuvant Chemotherapy Followed by Radical Surgery versus Concurrent Chemo-Radiotherapy in the Treatment of Locally Advanced Cervical Cancer: A Multicenter Retrospective Analysis.

OBJECTIVES: This study aims to evaluate oncological outcomes in women affected by locally advanced cervical cancer (LACC) treated by neoadjuvant chemotherapy before radical surgery (NACT + RS) or concurrent chemo-radiotherapy (CCRT). METHODS: This was a multicenter retrospective analysis of data related to women with LACC (FIGO stage IB2-IVA), who were treated by NACT + RS or CCRT between November 2006 and January 2018. The first endpoints were the evaluation of disease-free survival (DFS) and overall survival (OS); univariate and multivariate analyses were performed for identifying the prognostic factors independently associated with these oncological outcomes. RESULTS: Overall, 106 women were included in the analysis; 55 of them (51.9%) underwent NACT + RS and 51 (48.1%) CCRT, respectively. Patients in the NACT + RS group had a significant better five-year DFS and five-year OS than those in the CCRT group (77.4% vs. 33.4%, p < .001 and 93.8% vs. 56.5%, p = .003). In the multivariate analyses, treatment choice (NACT + RS or CCRT) was the only independent prognostic factor for predicting both DFS (HR = 3.954; 95 CI = 1.898-8.236; p < 0.001) and OS (HR = 5.330; 95 CI = 1.563-18.178; p = 0.008). CONCLUSIONS: This retrospective study demonstrated an improved survival outcome for patients undergoing NACT + RS compared with those undergoing CCRT. Our findings seem to support the use of NACT before RS as an effective alternative option to CCRT standard therapy.

Early invasive cervical cancer during pregnancy: different therapeutic options to preserve fertility.

INTRODUCTION: Cervical cancer is the second most common cancer diagnosed during pregnancy. Conservative management is possible, and different options should be discussed with patients. The main decision parameters are stage of disease, lymph node status, trimester of pregnancy and wishes of the patient. We reviewed our experience on cases of early-stage cervical cancer discovered during pregnancy and treated with different options of fertility-sparing management. MATERIALS AND METHODS: Between 1990 and 2010, 5 patients with early-stage cervical cancer diagnosed during pregnancy were referred to our department for fertility-sparing treatment. The mean age at diagnosis was 28.6 years (range, 26-30 years). The stages of the tumors according to the International Federation of Gynecology and Obstetrics were IA2 in 2 women and IB1 in 3 women. The histological type was squamous carcinoma in 3 cases and adenocarcinoma in 2 cases. All patients willing to preserve their fertility were treated with vaginal radical trachelectomy (VRT) and pelvic lymph nodes dissection (PLN-D). RESULTS: Three procedures were performed in the first trimester: 1 patient was treated with medical abortion and then VRT and PLN-D, 2 patients were submitted to VRT and PLN-D during the first trimester, and 1 patient's case was complicated by spontaneous abortion. One patient was observed during the second trimester (20 weeks of gestation) and treated with VRT and PLN-D during pregnancy. Because this patient had pelvic lymph nodes positive for cancer, a cesarean delivery (CD) with radical hysterectomy and para-aortic lymph nodes dissection was performed followed by chemoradiotherapy. The last patient was evaluated during the third trimester of her pregnancy. Treatment included CD followed by VRT and PLN-D, which was delayed, to allow fetal maturity. CONCLUSIONS: Diagnosis of cervical cancer can occur during pregnancy. Different options of fertility-sparing treatment can be discussed on the basis of several factors: tumor stage, gestational age, and the patient's desire regarding fertility and pregnancy sparing.

Neoadjuvant chemotherapy and vaginal radical trachelectomy for fertility-sparing treatment in women affected by cervical cancer (FIGO stage IB-IIA1).

OBJECTIVES: The aim of the present report is to support the feasibility and the safety of a new fertility-sparing treatment in young women affected by bulky cervical cancer. METHODS: Between February 2007 and October 2010, seven patients presenting large IB-IIA1 tumors (30-45 mm) were scheduled for conservative treatment. All patients underwent neoadjuvant chemotherapy (NACT) followed by laparoscopic pelvic lymphadenectomy and vaginal radical trachelectomy (VRT). RESULTS: One patient presented hematological toxicity during NACT (grade 3). All patients showed complete disappearance of tumor (n=4/7) or partial response (a 50% or more decrease in total tumor size, n=3/7) to neoadjuvant treatment, and they were all treated with pelvic lymphadenectomy and VRT. Additional treatment (interstitial brachytherapy) was offered to only one woman because of a persistent parametrial tumoral lesion. After a mean follow up of 22 months (range 5-49), no relapse was observed. To date, only one woman in our study attempted to conceive and she is currently pregnant. CONCLUSIONS: Neoadjuvant chemotherapy for fertility sparing treatment is an innovative approach which is potentially quite interesting for many young women affected by bulky cervical cancer. These women, i.e. those with tumors larger than 2 cm (2-5 cm), are traditionally not offered fertility sparing treatment, thus the preliminary data we report here might have a promising impact. Nevertheless, for these patients it may be suitable to use the more radical, and time-tested, conservative surgical approach to allow for a complete and conservative excision of the residual tumor after neoadjuvant treatment. Studies with a larger number of patients and adequate follow-up are required to validate this conservative approach and to define clearly the good indications for this treatment.

Pre- and post-operative work-up in patients affected by early cervical cancer and eligible for fertility-sparing treatment: role of MRI with saline hydrocolpos.

Nowadays young women affected by early invasive uterine cervical cancer (stage IA2-IB1) may be offered a fertility-sparing treatment: the radical trachelectomy with pelvic lymph node dissection. This procedure consists in surgical removal of cervix uteri, proximal parametrial tissue, and vaginal cuff. The morphology and the functions of corpus uteri are preserved. Women candidates for trachelectomy must be closely selected. Gynecologist oncologist needs an imaging modality that can accurately value the tumoral diameter and which can demonstrate proximal extension of tumor to ensure surgical clear resection margins (especially the cranial one). Magnetic resonance imaging (MRI) is a very useful examination in pre-operative study of women affected by early cervical cancer. The aim of this study is to evaluate the role of MRI with hydrocolpos about pre- and post-operative work-up in women eligible for fertility-sparing treatment.

Oncological safety of laparoscopic-assisted vaginal radical trachelectomy (LARVT or Dargent's operation): a comparative study with laparoscopic-assisted vaginal radical hysterectomy (LARVH).

OBJECTIVE: The aim of our study was to compare the results of radical trachelectomy (LARVT or Dargent's operation) to radical vaginal hysterectomy (LARVH) in terms of intraoperative and postoperative morbidity and mainly in terms of risk of tumor recurrence. Each technique is associated with laparoscopic pelvic lymph node dissection. Our objective was to know if performing radical trachelectomy in order to preserve the fertility of a young patient with an early cervical cancer is associated or not with an increased risk of operative morbidity or tumor recurrence. METHODS: Patient affected by early invasive cervical cancer who has been submitted to LARVT (n=118) in our Institute between December 1986 and December 2003 has been compared to patients treated by LARVH (n=139) in the same period. All patient's information, surgical and pathological data and oncological results have been prospectively collected. The associations between the discrete variables were assessed using chi(2) test with Yate's correction when appropriate. Fisher's exact test was used when it was necessary. Continuous variables were compared by Student's t test. p values less than 0.05 were considered statistically significant. Statistical analysis used the Kaplan-Meier method to calculate disease-free and overall survival. RESULTS: Between December 1986 and December 2003, 118 and 139 patients have undergone LARVT and LARVH, respectively, for FIGO stage I-IIA carcinoma of the cervix. The two populations (LARVT and LARVH) are comparable in terms of the main prognostic factors of cervical cancer. The rate of intraoperative complications has been similar in the two groups (2.5% for LAVRT and 5.8% for LAVRH, p=NS). Also the rate of postoperative complications has been similar in the two groups (21.2% for LAVRT and 19.4% for LAVRH, p=NS). When considering the risk of recurrence, the results in the two groups are also identical: 7 cases (5.2%) in patients treated with LAVRT and 9 cases (8.5%) in patients treated with LAVRH (p=NS). CONCLUSION: Our data demonstrate that early cervical cancer (less than 2 cm diameter) can be treated successfully with LARVT with similar efficacy and recurrence rates to LARVH. In our experience radical trachelectomy is a safe treatment for young women affected by early cervical cancer who want to conserve their fertility.

Clinical significance of lympho vascular space involvement and lymph node micrometastases in early-stage cervical cancer: a retrospective case-control surgico-pathological study.

OBJECTIVE: Several studies have shown that lympho vascular space involvement (LVSI) and lymph node micrometastases (LNmM) may be risk factors for recurrence in early-stage cervical cancer with no apparent lymph node metastases. We performed a retrospective case-control study to reassess whether the presence of lymph node micrometastases and LVSI is predictive of subsequent recurrence following surgical resection of early-stage cervical cancer. METHODS: In a series of 292 patients diagnosed with early cervical cancer and treated by the same surgical procedure (laparoscopic-vaginal radical hysterectomy) during the same time period, two paired series were selected. The first series consisted of 26 cases who recurred in a median time of 36.8 months and the second series were 26 cases matched for age, histological sub-type, surgico-pathological stage and maximal tumor diameter, who did not recur after a median follow-up of 122 months. Sections taken from the hysterectomy specimens were reassessed for LVSI. All the lymph node blocks which have initially been considered as uninvolved were submitted to serial sectioning. Immunohistochemical staining using anti-cytokeratins AE1 and AE3 was used for identifying LNmM. RESULTS: LVSI was twice more frequent and LNmM ten-fold more frequent in the group of patients who recurred: 20/26 (77%) versus 9/26 (35%) and 11/26 (42%) versus 1/26 (4%) respectively. The relative risk of recurrence is 2.64 (1.67-5.49, P < 0.01) in the presence of LVSI and 2.44 (1.58-3.78, P < 0.01) in the presence of LNmM. All the patients with LNmM were LVSI positive. At bivariate analysis, the true LNmM (deposits more than 200 um in size) was the only independent risk factor. CONCLUSIONS: LNmM is an important risk factor of tumor recurrence in patients with early cervical cancer with no apparent lymph node metastases. LNmM seems to occur only in LVSI positive tumors. These data may lead to improve management of early-stage cervical cancer to reduce the risk of recurrence in those cases.

Laparoscopic lymphadenectomy and sentinel node biopsy in uterine cancer.

This article discusses laparoscopic lymphadenectomy and sentinel node biopsy in uterine cancer.

Sentinel lymph node biopsy is not accurate in predicting lymph node status for patients with cervical carcinoma.

BACKGROUND: The authors evaluated the accuracy of sentinel lymph node biopsy in predicting lymph node status for patients with early cervical carcinoma. In particular, the authors set out to determine the false-negative rate associated with sentinel lymph node biopsy in this setting. METHODS: Twenty-nine consecutive patients with early cervical carcinoma who were treated with pelvic laparoscopic lymphadenectomy and radical surgery underwent sentinel lymph node biopsy following lymphatic mapping with patent blue dye. All sentinel and nonsentinel lymph nodes were evaluated for micrometastases via multilevel sectioning followed by immunohistochemical staining. RESULTS: At least one sentinel lymph node was identified for each patient. On routine pathologic evaluation, 3 patients (10%) were found to have positive lymph nodes. Among the remaining 26 patients, multilevel sectioning in conjunction with immunohistochemical analysis identified 5 patients (19%) who had micrometastases in the pelvic lymph nodes. Two of these five patients had micrometastases in a sentinel lymph node; however, the more notable finding was that the other three patients had micrometastases in nonsentinel pelvic lymph nodes despite having negative findings on sentinel lymph node biopsy. Thus, the negative predictive value of sentinel lymph node biopsy in the current study was 87.5%. CONCLUSIONS: Multilevel sectioning followed by cytokeratin immunohistochemistry may identify additional patients who have lymph node micrometastases; in the current study, this technique identified cases in which micrometastases were present in nonsentinel lymph nodes even when sentinel lymph nodes were found to be negative for disease on biopsy. This high false-negative rate associated with sentinel lymph node biopsy, raises questions regarding the validity of the sentinel lymph node concept in cervical carcinoma.