MF Mitchell, et al (Univ of Texas Health Science Ctr, Houston; Univ of Texas M.D. Anderson Cancer Ctr, Houston; Memorial Clinial Associates,Houston; et al)
A Randomized Clinical Trial of Cryotherapy, Laser Vaporization, and Loop Electrosurgical Excision for Treatment of Squamous Intraepithelial Lesions of the Cervix.
Obstet Gynecol 92: 737-744, 1998.
390 women at least 18 years of age who had biopsy-proven squamous intraepithelial lesions, negative pregnancy tests, negative findings on endocervical curettage, satisfactory colposcopy examinations, and congruent Pap smear and biopsy results were studied The women were randomly assigned to receive cryotherapy (139 patients) laser vaporization or loop excision based on their squamous intraepithelial lesion grade, endocervical gland involvement, and lesion size. Evaluations occurred at 1,4, 8, 12, 16, 20 and 24 months after treatment.
Results – The women were followed for a mean of 16 months. Regarding complications, persistence (disease present less than 6 months after treatment), no differences were found.
This is an interesting randomized trial of cervical intraepithelial neoplasia. The authors performed a useful stratification for squamous intraepithelial lesion grade, endocervical gland involvement, and lesion size. Persistence was more likely among those with large lesions, which is to be expected, whereas the risk of recurrence was high for patients over the age of 30 years and those with documented human papillomavirus infection, as well as those with a history of prior therapy for cervical intraepithelial neoplasia. These latter categories appear to warrant even closer follow-up, as noted by the authors. Although no increase in complications, except for bleedings, was noted among the 130 patients who underwent loop electrosurgical excision procedure, the editor continue to be concerned about this procedure in nulla gravid women, particularly when larger specimens are taken, which she believe increases the risk of cervical stenosis and infertility.
Conclusion : All 3 modalities showed a high success rate. The 3 treatments had no significant differences. The higher-risk patients should receive additional attention and research.
LD Roman, JC Felix, et al (Univ of Southern California, Los Angeles)
Risk of Residual Invasive Disease in Women with Microinvasive Squamous Cancer in a Conization Specimen
Obstet Gynecol 90:759-764, 1997.
Cervical conization, not punch biopsy, is used to diagnose microinvasive cervical carcinoma.
Methods – There were 87 women who had a conization that contained microinvasive squamous carcinoma, followed by another conization or hysterectomy.
Results : The significant predictors of residual invasion are status of the internal margin (residual invasion present in 22% of women with an involved margin vs 3% with a negative margin) and the combined status of the internal margin and post-conization endocervical curettage (residual invasion 4% if both negative, 13% if one positive, and 33% if both positive). No significance was associated with the depth of invasion or number of invasive foci in the conization specimen.
It was Concluded that candidates for a follow-up or simple hysterectomy are women with microinvasive squamous carcinoma in a conization specimen in which both the internal conization margin and postconization endocervical curettage are negative.
Editorial comment :The authors studied 87 women whose cone specimens contained microinvasive squamous carcinoma and evaluated the risk of residual disease as a function of the status of the internal cone margin, as well as the post-conization endocervical curettage.
The message is that with microinvasive carcinoma in the specimen and either a positive internal margin or postcone endocervical curettage, invasive disease is likely to be found in the remaining specimen.
AJ Mundt, PP Connell, et al (Univ of Chicago)
Race and Clinical Outcome in Patients with Carcinoma of the Uterine Cervix Treated With Radiation Therapy.
Gynecol Oncol 71: 151-158, 1998.
The study included ninety-four white patients and 316 black patients undergoing radiation therapy for cervical cancer.
It was found that the 8-year cause-specific survival was 60% in white patients and 47%.9% in black patients. Survival differed significantly between races in the group with stage IIB to IVA disease (60% and 34% respectively).
Conclusions – Many factors adversely affect the efficacy of radiation therapy in black patients with cervical cancer. Race per se was not an independent risk factor for survival in these patients; instead, other factors, such as low hemoglobin levels and low socioeconomic status, were associated with poorer outcomes.
MA Varia, BN Bundy, et al (Univ of North Carolina, Chapel Hill; Roswell Park Cancer Inst, Buffalo, NY; Wayne State Univ, Detroit; et al)
Cervical Carcinoma Metastatic to Para-aortic Nodes: External Field Radiation therapy with Concomitant 5-Fluorouracil and Cisplatin Chemotherapy: A Gynecologic Onoclogy Group Study.
Int J Radiat Oncol Biol Phys 42:1015-1023, 1998.
Method – Concomitant IV cisplatin and 96-hour 5-FU infusion during the first and fifth weeks of pelvic and PAN radiation therapy was administered to 95 patients followed by intracavitary radiation therapy and external beam parametrial boost.
It was found that combination radiation and chemotherapy for cervical carcinoma metastatic to para-aortic nodes was effective for about one third of patients and was relatively well tolerated. It is important that PAN metastases in these high-risk patients be detected and treated.
This collaborative Gynecologic Oncology Group study shows that treatment of para-aortic node metastases can be effective. All those treated had biopsy evidence of tumor in their para-aortic nodes. They received external field radiation with chemotherapy (platinum + 5-FU). Chemoradiation does offer therapeutic advantages over radiation alone. Although there was a high proportion of severe complications of grade 3 or 4, there were meaningful 3-year progression-free intervals of 34%, which is quite good for patients with biopsy-proven disease.
N Sakuragi, C Satoh, et al (Hokkaido Univ, Sapporo, Japan)Incidence and Distribution Pattern of Pelvic and Para-aortic Lymph Node Metastasis in Patients With Stages IB, IIA, and IIB Cervical Carcinoma Treated with Radical Hysterectomy.
Cancer 85:1547-1554, 1999.
This is an interesting operative-anatomic study of the distribution of lymph node metastases in cases of cervical carcinoma. Of 208 patients studied, 53 had lymph node metastases. The message appears to be that lack of metastases to the obturator node usually meant that the para-aortic nodes were free. The information appears to confirm the stepwise progression of metastatic cervical disease from pelvic to para-aortic nodes. These are the remarks of A.L.Herbst, M.D., editor of the Year Book.
A Sedlis, BN Bundy, et al (State Univ of New York, Brooklyn; Roswell Park Cancer Inst, Buffalo, NY; Bowman Gray School of Medicine, Winston-Salem, NC; et al)A Randomized Trial of Pelvic Radiation Therapy Versus No Further Therapy in Selected Patients with State IB Carcinoma of the Cervix After Radical Hysterectomy and Pelvic Lymphadenectomy: A Gynecologic Oncology Group Study.
Gynecol Oncol 73: 177-183, 1999.
Conclusions – The results of this prospective, multicenter, randomized clinical trial indicate that adjunct radiotherapy is beneficial for patients with stage I cervical cancer with risk factors such as large tumor diameter, deep stromal invasion, and tumor in the capillary lymphatic spaces. Adjunct radiotherapy reduced cancer recurrence in these patients, with acceptable morbidity.
HM Keys, BN Bundy, et al (Albany Med College, NY; Roswell Park Cancer Inst, Buffalo, NY; Indiana Univ, Indianapolis; et al) Cisplatin, Radiation, and Adjuvant Hysterectomy Compared with Radiation and Adjuvant Hysterectomy for Bulky Stage IB Cervical Carcinoma.
N Engl J Med 340:1154-1161, 1999
Pelvic Radiation with Concurrent Chemotherapy Compared with Pelvic and Para-aortic Radiation for High-Risk Cervical Cancer.
M Morris, PJ Eifel, et al (Univ of Texas MD Anderson Cancer Ctr, Houston; Radiation Therapy Oncology Group, Philadelphia; Washington Univ, St.Louis; et al)
N Engl J Med 340:1137-1143, 1999.
Of 403 participants, 193 were available for evaluation in each group. It was found that among women with locally advanced cervical cancer, survival was significantly improved with the addition of chemotherapy with fluorouracil and cisplatin to intracavitary radiotherapy.
Editorial comment -This is one in a series of articles in the ‘New England Journal of Medicine’ from the Gynecologic Oncology Group after achievement of superior results in cervical carcinoma with chemoradiation (platinum plus 5 FU) compared with radiotherapy alone. This improvement does come at a price, which in the acute phase resulted in markedly more hematologic effects, but the long-term complications (over 60 days) are fairly comparable. Two cycles of chemoradiation were given 3 weeks apart along with another cycle at the second implant. The results are impressive for locally advanced disease, which shows significantly better survival among those who receive chemoradiation. Today most of us use weekly infusions of cisplatin, which appears to have similar results. This comment is by A.L. Herbst, MD.
K Bergmark, E Avall-Lundqvist, et al (Karolinska Inst, Stockholm, Huddinge Hosp, Stockholm)Vaginal Changes and Sexuality in Women with a History of Cervical Cancer.
N Engl J Med 340:1383-1389, 1999.
The study group consisted of 256 women with a history of early-stage cervical cancer, who had been treated in 1991 and 1992 at the 7 gynecology departments in Sweden. The control group consisted of 350 randomly selected women from the Swedish Population Register, matched for age and place of residence.
This Swedish study has shown what has generally been suspected for many years. Women who have been treated for cervical cancer have an increased frequency of lack of vaginal lubrication and accompanying sexual difficulties. The cancer group also reported a problem with a short and inelastic vagina, all of which led to more dyspareunia. In spite of these problems, the frequency of orgasm appeared to be comparable between the cancer and control groups. These patients were aged 51 to 52 at the time of the survey, and those who had only surgical treatment of cervical cancer seemed to have problems, including lack of vaginal lubrication, comparable to those of the rest of the cancer group. These findings are important to the physician who cares for patients who have been treated for cervical carcinoma and should be kept in mind when these patients are counseled.
PT Valente, et al (Univ of Texas Health Sciences Ctr, San Antonio)Cytologic Changes in Cervical Smears Associated with Prolonged Use of Depot-Medroxyprogesterone Acetate.
Cancer 84:328-334, 1998.
Methods : Smears from 29 women (average age, 26 years) who had been using depot-medroxyprogesterone acetate for 5 to 72 months were evaluated and compared with those of 25 matched controls.
Results : Smears of 6 women were abnormal. Two cases, diagnosed with high-grade squamous intraepithelial lesions, were confirmed by biopsy; 1 was diagnosed with a low-grade squamous intraepithelial lesion and lost to follow-up; and 1 was diagnosed with atypical squamous cells of undetermined significance. The last patient had a negative Papanicolaou smear at follow-up.
Conclusions: Chronic users of depot-medroxyprogeserone acetate have Papanicolaou smears that demonstrate an atrophic postpartum pattern with atypia and enlarge cervical cells that complicate cytologic diagnosis.
P Holowaty, AB Miller, et al (Univ of Toronto), Natural History of Dysplasia of the Uterine Cervix.
J Natl Cancer Inst 91: 252-258, 1999
Although it is known that most cases of cervical dysplasia do not progress to invasive cancer, there is little information on the natural progression and regression of cervical dysplasia. The Pap smear history of a cohort of Toronto women was related to the risk of subsequent cervical cancer.
Methods – Screening histories were collected by the Ontario Cancer Registry between 1962 and 1980 and analyzed along with the outcomes and Pap smear histories of 17,217 women given a diagnosis of dysplasia between 1970 and 1980.
They concluded the risks of progression increased with the degree of dysplasia. Most patients with mild dysplasia regressed to a normal Pap smear within 2 years.
N Ylitalo, P Sorensen, et al (Karolinska Institute, Stockholm; Statens Serum Institut, Copenhagen; Uppsala Univ, Sweden; et al)Smoking and Oral Contraceptives as Risk Factors for Cervical Carcinoma in Situ.
Int J Cancer 81:357-365, 1999.
Background – Human papillomavirus (HPV) is probably requisite but is not sufficient to cause cervical carcinoma. However, it is not clear which factors in addition to HPV contribute to the development of cervical carcinoma and its precursor lesions.
It was found that after adjustment for covariates in a multivariate analysis, current smokers had a 2-fold greater risk than those who had never smoked. This association appears to be limited to women younger than 45 years of age. Current OC use was associated with a 4-fold increase in overall risk, with a monotonic increase as duration of use increased. Number of sexual partners was significantly, positively correlated with risk among HPV negative women but not among HPV positive women.
Conclusions – Smoking is associated with cervical carcinoma in-situ (CIS), possibly in an age-dependent fashion. In addition, OC use is correlated with risk of cervical CIS.
NP Yost, JT Santoso, et al (Univ of Texas Southwestern Med Ctr, Dallas; Univ of Texas Med Branchm Galveston)Postpartum Regression Rates of Antepartum Cervical Intraepithelial Neoplasia II and III Lesions.
Obstet Gynecol 93:359-362, 1999.
Abnormal Pap smears are obtained in 5% of pregnancies. Whether caesarian delivery reduces cervical cancer is controversial. The biopsy-proven, antepartum cervical intraepithelial neoplasia (CIN) II and III lesions and their regression and progression rates postpartum were studied, and the issue of the effect of caesarian section was resolved.
Methods- 279 pregnant women evaluated at Parkland Memorial Health Hospital and they were followed-up. The effect of vaginal deliveries and caesarian section were reevaluated.
Conclusion – Conservative management of pregnant women with CIN II and CIN III during pregnancy is warranted.
Editorial comment: This is a small, but useful, study showing the course of CIN II and III diagnosed antenatally to the postpartum period, it shows that most of the lesions regress regardless of the route of delivery. As the authors correctly note, these lesions should be followed conservatively during pregnancy and evaluated post partum by means of cytology, colposcopy, and directed biopsy.
AY EL-Bastawissi, TM Becker, (Swedish Med Ctr, Seattle; Oregon Health Sciences Univ, Portland)Effect of Cervical Carcinoma In Situ and its Management on Pregnancy Outcome.
Obstet Gynecol 93:207-212, 1999.
Cryosurgery, laser ablation, and cold-knife or laser conization are current treatments, with the loop electrosurgical excision the most-recent procedure of choice.
Of 1847 women diagnosed with cancer in situ during an 8-year period. 312 were diagnosed during pregnancy. They were retrospectively reviewed and compared with a group of 9200 women without cancer in situ who gave birth during the same year.
Results : A small increased risk of preterm delivery and no increased risk of a low birth weight infant was found with women with cancer in situ who were not treated with conization when compared with women without cancer in situ. There was a greater likelihood of delivering premature infants among women with cancer in situ who had conization when compared with women without cancer in situ.
OB Ioffe, SE Brooks, et al (Univ of Maryland, Baltimore)Artifact in Cervical LLETZ Specimens: Correlation with Follow-up
Int J Gynecol Pathol 18: 115-121, 1999.
Background : Large-loop excision of transformation zone (LLETZ) is being performed increasingly in the diagnosis and treatment of cervical dysplasia.
Cold-knife conizaiton (CKCs) were performed on 24 specimens, and LLETZ was performed on 76.
Pathology department concluded that margin status better predicts abnormal follow-up findings in cold-knife conization than in large-loop excision of transformation zone specimens. Specimen fragmentation is an additional factor that compounds the inevitable artifact.