Tailoring Pelvic Lymphadenectomy for Patients with Stage IA2, IB1, and IIA1 Uterine Cervical Cancer
Identifieur interne : 004037 ( Pmc/Corpus ); précédent : 004036; suivant : 004038Tailoring Pelvic Lymphadenectomy for Patients with Stage IA2, IB1, and IIA1 Uterine Cervical Cancer
Auteurs : Juan Zhou ; Jing Ran ; Zhen-Yu He ; Song Quan ; Qiong-Hua Chen ; San-Gang Wu ; Jia-Yuan SunSource :
- Journal of Cancer [ 1837-9664 ] ; 2015.
Abstract
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DOI: 10.7150/jca.10968
PubMed: 25767608
PubMed Central: 4349878
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Tailoring Pelvic Lymphadenectomy for Patients with Stage IA2, IB1, and IIA1 Uterine Cervical Cancer</title><author><name sortKey="Zhou, Juan" sort="Zhou, Juan" uniqKey="Zhou J" first="Juan" last="Zhou">Juan Zhou</name><affiliation><nlm:aff id="A1">1. Xiamen Cancer Center, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Xiamen University, Xiamen, People's Republic of China</nlm:aff></affiliation></author><author><name sortKey="Ran, Jing" sort="Ran, Jing" uniqKey="Ran J" first="Jing" last="Ran">Jing Ran</name><affiliation><nlm:aff id="A2">2. Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China</nlm:aff></affiliation></author><author><name sortKey="He, Zhen Yu" sort="He, Zhen Yu" uniqKey="He Z" first="Zhen-Yu" last="He">Zhen-Yu He</name><affiliation><nlm:aff id="A3">3. Sun Yat-sen University Cancer Center, Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, People's Republic of China</nlm:aff></affiliation></author><author><name sortKey="Quan, Song" sort="Quan, Song" uniqKey="Quan S" first="Song" last="Quan">Song Quan</name><affiliation><nlm:aff id="A2">2. Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China</nlm:aff></affiliation></author><author><name sortKey="Chen, Qiong Hua" sort="Chen, Qiong Hua" uniqKey="Chen Q" first="Qiong-Hua" last="Chen">Qiong-Hua Chen</name><affiliation><nlm:aff id="A1">1. Xiamen Cancer Center, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Xiamen University, Xiamen, People's Republic of China</nlm:aff></affiliation></author><author><name sortKey="Wu, San Gang" sort="Wu, San Gang" uniqKey="Wu S" first="San-Gang" last="Wu">San-Gang Wu</name><affiliation><nlm:aff id="A4">4. Xiamen Cancer Center, Department of Radiation Oncology, the First Affiliated Hospital of Xiamen University, Xiamen, People's Republic of China</nlm:aff></affiliation></author><author><name sortKey="Sun, Jia Yuan" sort="Sun, Jia Yuan" uniqKey="Sun J" first="Jia-Yuan" last="Sun">Jia-Yuan Sun</name><affiliation><nlm:aff id="A3">3. Sun Yat-sen University Cancer Center, Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, People's Republic of China</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">25767608</idno><idno type="pmc">4349878</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4349878</idno><idno type="RBID">PMC:4349878</idno><idno type="doi">10.7150/jca.10968</idno><date when="2015">2015</date><idno type="wicri:Area/Pmc/Corpus">004037</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">004037</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Tailoring Pelvic Lymphadenectomy for Patients with Stage IA2, IB1, and IIA1 Uterine Cervical Cancer</title><author><name sortKey="Zhou, Juan" sort="Zhou, Juan" uniqKey="Zhou J" first="Juan" last="Zhou">Juan Zhou</name><affiliation><nlm:aff id="A1">1. Xiamen Cancer Center, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Xiamen University, Xiamen, People's Republic of China</nlm:aff></affiliation></author><author><name sortKey="Ran, Jing" sort="Ran, Jing" uniqKey="Ran J" first="Jing" last="Ran">Jing Ran</name><affiliation><nlm:aff id="A2">2. Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China</nlm:aff></affiliation></author><author><name sortKey="He, Zhen Yu" sort="He, Zhen Yu" uniqKey="He Z" first="Zhen-Yu" last="He">Zhen-Yu He</name><affiliation><nlm:aff id="A3">3. Sun Yat-sen University Cancer Center, Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, People's Republic of China</nlm:aff></affiliation></author><author><name sortKey="Quan, Song" sort="Quan, Song" uniqKey="Quan S" first="Song" last="Quan">Song Quan</name><affiliation><nlm:aff id="A2">2. Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China</nlm:aff></affiliation></author><author><name sortKey="Chen, Qiong Hua" sort="Chen, Qiong Hua" uniqKey="Chen Q" first="Qiong-Hua" last="Chen">Qiong-Hua Chen</name><affiliation><nlm:aff id="A1">1. Xiamen Cancer Center, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Xiamen University, Xiamen, People's Republic of China</nlm:aff></affiliation></author><author><name sortKey="Wu, San Gang" sort="Wu, San Gang" uniqKey="Wu S" first="San-Gang" last="Wu">San-Gang Wu</name><affiliation><nlm:aff id="A4">4. Xiamen Cancer Center, Department of Radiation Oncology, the First Affiliated Hospital of Xiamen University, Xiamen, People's Republic of China</nlm:aff></affiliation></author><author><name sortKey="Sun, Jia Yuan" sort="Sun, Jia Yuan" uniqKey="Sun J" first="Jia-Yuan" last="Sun">Jia-Yuan Sun</name><affiliation><nlm:aff id="A3">3. Sun Yat-sen University Cancer Center, Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, People's Republic of China</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Cancer</title><idno type="eISSN">1837-9664</idno><imprint><date when="2015">2015</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p><bold>Purpose:</bold> The purpose of this study was to assess the risk factors for pelvic lymph node metastasis (PLNM) in patients with early-stage uterine cervical cancer.</p><p><bold>Methods:</bold> A total of 192 patients with early-stage uterine cervical cancer (FIGO stage IA2, IB1, and IIA1) receiving radical hysterectomy with pelvic lymphadenectomy were included in the statistical analysis.</p><p><bold>Results:</bold> Thirty-six patients (18.8%) developed PLNM, and the incidences of PLNM in patients with stage IA2, stage IB2, and stage IIA1 were 0% (0/6), 13.9% (20/144), and 38.1% (16/42), respectively. The most common location of PLNM was the obturator lymph node. Univariate analysis showed that stage IIA1 (p < 0.001), tumor size greater than 3 cm (p = 0.019), deep-full thickness stromal invasion (p < 0.001), and lymphovascular invasion (p = 0.001) were associated with PLNM. Multivariate analysis showed that deep or full-thickness stromal invasion and lymphovascular invasion were significantly and independently associated with PLNM (p < 0.05 for both). The incidence of PLNM was 34.9% and 28.7% in patients with deep-full thickness stromal invasion and lymphovascular invasion, respectively, but that was only 5.7% and 9.2% in patients with superficial-middle stromal invasion and absence of lymphovascular invasion, respectively.</p><p><bold>Conclusion:</bold> Patients with superficial-middle stromal invasion and without lymphovascular invasion may be avoided pelvic lymphadenectomy in stage IA2, IB1, IIA1 uterine cervical cancer.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Chen, W" uniqKey="Chen W">W Chen</name></author><author><name sortKey="Zheng, R" uniqKey="Zheng R">R Zheng</name></author><author><name sortKey="Zhang, S" uniqKey="Zhang S">S Zhang</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Arbyn, M" uniqKey="Arbyn M">M Arbyn</name></author><author><name sortKey="Antoine, J" uniqKey="Antoine J">J Antoine</name></author><author><name 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Cancer</journal-id><journal-id journal-id-type="iso-abbrev">J Cancer</journal-id><journal-id journal-id-type="publisher-id">jca</journal-id><journal-title-group><journal-title>Journal of Cancer</journal-title></journal-title-group><issn pub-type="epub">1837-9664</issn><publisher><publisher-name>Ivyspring International Publisher</publisher-name><publisher-loc>Sydney</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">25767608</article-id><article-id pub-id-type="pmc">4349878</article-id><article-id pub-id-type="doi">10.7150/jca.10968</article-id><article-id pub-id-type="publisher-id">jcav06p0377</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Paper</subject></subj-group></article-categories><title-group><article-title>Tailoring Pelvic Lymphadenectomy for Patients with Stage IA2, IB1, and IIA1 Uterine Cervical Cancer</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Zhou</surname><given-names>Juan</given-names></name><xref ref-type="aff" rid="A1">1</xref><xref ref-type="author-notes" rid="FNA_star">*</xref></contrib><contrib contrib-type="author"><name><surname>Ran</surname><given-names>Jing</given-names></name><xref ref-type="aff" rid="A2">2</xref><xref ref-type="author-notes" rid="FNA_star">*</xref></contrib><contrib contrib-type="author"><name><surname>He</surname><given-names>Zhen-Yu</given-names></name><xref ref-type="aff" rid="A3">3</xref><xref ref-type="author-notes" rid="FNA_star">*</xref></contrib><contrib contrib-type="author"><name><surname>Quan</surname><given-names>Song</given-names></name><xref ref-type="aff" rid="A2">2</xref></contrib><contrib contrib-type="author"><name><surname>Chen</surname><given-names>Qiong-Hua</given-names></name><xref ref-type="aff" rid="A1">1</xref></contrib><contrib contrib-type="author"><name><surname>Wu</surname><given-names>San-Gang</given-names></name><xref ref-type="aff" rid="A4">4</xref><xref ref-type="corresp" rid="FNA_envelop">✉</xref></contrib><contrib contrib-type="author"><name><surname>Sun</surname><given-names>Jia-Yuan</given-names></name><xref ref-type="aff" rid="A3">3</xref><xref ref-type="corresp" rid="FNA_envelop">✉</xref></contrib></contrib-group><aff id="A1">1. Xiamen Cancer Center, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Xiamen University, Xiamen, People's Republic of China</aff><aff id="A2">2. Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China</aff><aff id="A3">3. Sun Yat-sen University Cancer Center, Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, People's Republic of China</aff><aff id="A4">4. Xiamen Cancer Center, Department of Radiation Oncology, the First Affiliated Hospital of Xiamen University, Xiamen, People's Republic of China</aff><author-notes><corresp id="FNA_envelop">✉ Corresponding authors: San-Gang Wu, Xiamen Cancer Center, Department of Radiation Oncology, the First Affiliated Hospital of Xiamen University, Xiamen, People's Republic of China. Tel. +86 592 2139531, Fax. +86 592 2139562, E-mail. <email>unowu12345@hotmail.com</email> or Jia-Yuan Sun, Sun Yat-sen University Cancer Center, Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, People's Republic of China. Tel. +86 20 87343543 Fax. +86 20 87343392 E-mail. <email>sunjy@sysucc.org.cn</email></corresp><fn fn-type="equal" id="FNA_star"><p>* Juan Zhou, Jing Ran and Zhen-Yu He contributed equally to this work.</p></fn><fn fn-type="conflict"><p>Competing Interests: The authors have declared that no competing interest exists.</p></fn></author-notes><pub-date pub-type="collection"><year>2015</year></pub-date><pub-date pub-type="epub"><day>25</day><month>2</month><year>2015</year></pub-date><volume>6</volume><issue>4</issue><fpage>377</fpage><lpage>381</lpage><history><date date-type="received"><day>2</day><month>11</month><year>2014</year></date><date date-type="accepted"><day>21</day><month>12</month><year>2014</year></date></history><permissions><copyright-statement>© 2015 Ivyspring International Publisher. Reproduction is permitted for personal, noncommercial use, provided that the article is in whole, unmodified, and properly cited. See http://ivyspring.com/terms for terms and conditions.</copyright-statement><copyright-year>2015</copyright-year></permissions><abstract><p><bold>Purpose:</bold> The purpose of this study was to assess the risk factors for pelvic lymph node metastasis (PLNM) in patients with early-stage uterine cervical cancer.</p><p><bold>Methods:</bold> A total of 192 patients with early-stage uterine cervical cancer (FIGO stage IA2, IB1, and IIA1) receiving radical hysterectomy with pelvic lymphadenectomy were included in the statistical analysis.</p><p><bold>Results:</bold> Thirty-six patients (18.8%) developed PLNM, and the incidences of PLNM in patients with stage IA2, stage IB2, and stage IIA1 were 0% (0/6), 13.9% (20/144), and 38.1% (16/42), respectively. The most common location of PLNM was the obturator lymph node. Univariate analysis showed that stage IIA1 (p < 0.001), tumor size greater than 3 cm (p = 0.019), deep-full thickness stromal invasion (p < 0.001), and lymphovascular invasion (p = 0.001) were associated with PLNM. Multivariate analysis showed that deep or full-thickness stromal invasion and lymphovascular invasion were significantly and independently associated with PLNM (p < 0.05 for both). The incidence of PLNM was 34.9% and 28.7% in patients with deep-full thickness stromal invasion and lymphovascular invasion, respectively, but that was only 5.7% and 9.2% in patients with superficial-middle stromal invasion and absence of lymphovascular invasion, respectively.</p><p><bold>Conclusion:</bold> Patients with superficial-middle stromal invasion and without lymphovascular invasion may be avoided pelvic lymphadenectomy in stage IA2, IB1, IIA1 uterine cervical cancer.</p></abstract><kwd-group><kwd>Uterine cervical cancer</kwd><kwd>pelvic lymphadenectomy</kwd><kwd>lymph node metastasis</kwd><kwd>stromal invasion</kwd><kwd>lymphovascular invasion</kwd></kwd-group></article-meta></front><body><sec sec-type="intro"><title>Introduction</title><p>Cervical cancer is a common gynecologic malignancy in women from China and other developing countries <xref rid="B1" ref-type="bibr">1</xref>, <xref rid="B2" ref-type="bibr">2</xref>. Radical hysterectomy including pelvic lymph node dissection (PLND) is the criterion standard of treatment for patients with International Federation of Gynecology and Obstetrics (FIGO) stage IA2-IIA1 cervical cancer <xref rid="B3" ref-type="bibr">3</xref>, and clinicians increasingly emphasize assessment the status of pelvic lymph nodes <xref rid="B4" ref-type="bibr">4</xref>. The results of PLND can help to guide the adjuvant therapy of patients. However, there are serious post-operative complications assciated with lymphadenectomy, such as lymphedema in the lower extremities and pelvic lymph cysts with concomitant infection and these can develop into chronic conditions <xref rid="B5" ref-type="bibr">5</xref>-<xref rid="B7" ref-type="bibr">7</xref>.</p><p>There is controversy regarding the effect of PLND on the prognosis of patients with early-stage cervical cancer <xref rid="B4" ref-type="bibr">4</xref>, <xref rid="B8" ref-type="bibr">8</xref>-<xref rid="B10" ref-type="bibr">10</xref>. The number of removed lymph nodes with PLND had no effect on the prognosis of patients with early-stage cervical cancer with negative pelvic lymph nodes <xref rid="B8" ref-type="bibr">8</xref>. Thus, we speculate that PLND may be avoided in early cervical cancer patients with low risk of pelvic lymph node metastasis (PLNM), and may help to improve the quality-of-life of patients.</p><p>In the present study, we retrospectively reviewed the records of patients with stages IA2, IB1, and IIA1 cervical cancer who received radical hysterectomy and PLND. We examined the effect of postoperative clinicopathologic factors on the risk for PLNM to identify patients with low risk for whom PLND may be avoided.</p></sec><sec sec-type="materials|methods"><title>Materials and methods</title><sec><title>Patients</title><p>We performed a retrospective analysis of data from cervical cancer patients treated at the First Affiliated Hospital of Xiamen University between January 2010 and July 2014. Criteria for inclusion in the analysis were: <italic>(i)</italic> stage IA2, IB1, or IIA1 cervical cancer according to the FIGO staging system, and received radical hysterectomy and pelvic lymphadenectomy; <italic>(ii)</italic> negative surgical margins; <italic>(iii)</italic> no preoperative radiotherapy or chemotherapy. The study was performed in accordance with the Declaration of Helsinki and was approved by the ethics committee of the First Affiliated Hospital of Xiamen University. All patients provided written consent for storage of their information in the hospital database and for use of this information in our research.</p></sec><sec><title>Clinicopathological factors</title><p>We determined the association of the following clinicopathologic factors with pelvic lymph node metastasis: age, menopausal status, FIGO stage, histological subtype, histological grade, pathologic tumor size, depth of stromal invasion, and lymphovascular invasion.</p></sec><sec><title>Surgical procedures</title><p>The primary surgery consisted of initial pelvic lymphadenectomy followed by radical hysterectomy. A systematic pelvic lymphadenectomy consisted of removal of external, internal, inter-iliac, obturator, common iliac, and inguinal lymph nodes, at both sides. The cranial, caudal, ventral, dorsal, lateral and medial boundaries of the pelvic lymphadenectomy were 3 cm above the bifurcation of the internal and external iliac arteries, the level of deep iliac circumflex vein, the level of peritoneum, the level of the obturator nerve, the inside of the psoas major muscle and the lateral border of ureter, respectively, as described previously <xref rid="B11" ref-type="bibr">11</xref>. Para-aortic lymphadenectomy was performed only in case of gross metastasis to the common iliac nodes or para-aortic nodes was suspected.</p></sec><sec><title>Examination of tumor and lymph nodes</title><p>All resected specimens were assessed by two gynecologic pathologists with a great deal of experience in gynecologic cancer. These pathologists reviewed microscopy slides to evaluate pathologic tumor size, histological subtype, histological grade, depth of cervical stromal invasion, lymphovascular invasion, and lymph node involvement, which were routinely and independently labeled by the surgeons. One section from each lymph node was analyzed by hematoxylin and eosin (H&E) staining. The examined lymph nodes included those that were embedded in the <italic>en bloc</italic> specimen and not labeled by surgeons, but were identified by the pathologists. The lymph node number was counted by low-power field microscopy. The number of involved lymph nodes and number of removed lymph nodes were determined.</p></sec><sec><title>Statistical analysis</title><p>All data were analyzed using the SPSS statistical software package (version 16.0; IBM Corporation, Armonk, NY, USA). The relationship between clinical and pathological factors and PLNM was examined by univariate analysis using the χ<sup>2</sup> and Fisher's exact probability tests. The independent effects of clinical and pathological factors on pelvic lymph node metastasis were then determined by multiple logistic regression analysis, in which factors that were statistically significant in univariate analysis were entered into multiple logistic regression analysis. A p-value < 0.05 was considered significant in all analyses.</p></sec></sec><sec sec-type="results"><title>Results</title><sec><title>Clinicopathologic characteristics of patients</title><p>There were 856 patients treated for cervical cancer between January 2010 and July 2014, of who 192 met criteria for inclusion in the present study. Table <xref ref-type="table" rid="T1">1</xref> summarizes the clinicopatholgic characteristics of the 192 patients who had early-stage uterine cervical cancer with a median age of 49 years (range, 30-74 years). A total of 119 patients (62.0%) received laparotomy and 73 patients (38.0%) underwent laparoscopic surgery. One hundred and eighteen patients (61.5%) were premenopausal and 74 patients (38.5%) were postmenopausal. Staging indicated that 6 patients (3.1%) had stage IA2 cancer, 144 patients (75.0%) had stage IB1 cancer, and 42 patients (21.9%) had stage IIA1 cancer. Analysis of histological type indicated that 82.2% patients (158/192) had squamous cell carcinoma, and 97.9% patients (188/192) had moderately to poorly differentiated cancer. Eighty-six patients (44.8%) had deep-full thickness stromal invasion, and 94 patients (49.0%) with lymphovascular invasion.</p></sec><sec><title>Lymph node dissection</title><p>The patterns of lymph node metastasis are summarized in Table <xref ref-type="table" rid="T2">2</xref>. The median number of dissected lymph nodes was 38 (range, 10-71). Thirty-six patients (18.8%) had pelvic lymph node metastasis with 48 positive lymph nodes. The incidences of patients with PLNM in stage IA2, stage IB1, and stage IIA1 were 0% (0/6), 13.9% (20/144), and 38.1% (16/42), respectively. The obturator lymph node was the most common location of lymph node metastasis (n = 28, 58.4%), followed by the external iliac lymph node (n = 6, 12.5%), internal iliac lymph node (n = 6, 12.5%), common iliac lymph node (n = 4, 8.3%), and parametrial lymph node (n = 4, 8.3%). There was no evidence of inguinal and para-aortic lymph node metastasis.</p></sec><sec><title>Univariate analysis of risk factors with PLNM</title><p>Table <xref ref-type="table" rid="T1">1</xref> shows the results of univariate analysis of the correlation between clinicopathologic factors and PLNM. Patients with stage IIA1 cancer (p < 0.001), tumor size greater than 3 cm (p = 0.019), deep to full thickness stromal invasion (p < 0.001), and lymphovascular invasion (p = 0.001) were significantly associated with PLNM. Age, menopausal status, histological subtype, and histological grade were not associated with PLNM (p > 0.05).</p></sec><sec><title>Multivariate analysis of risk factors with PLNM</title><p>Table <xref ref-type="table" rid="T3">3</xref> shows multivariate analysis of the clinicopathological factors associated with the PLNM in which factors that were statistically significant in univariate analysis. The results showed that deep-full thickness stromal invasion and lymphovascular invasion were significantly and independently associated with PLNM (p < 0.05 for both). FIGO stage and tumor size were not significantly associated with PLNM (p > 0.05 for both).</p><p>The incidence of PLNM was 34.9% and 28.7% in patients with deep-full thickness stromal invasion and lymphovascular invasion, respectively, but that was only 5.7% and 9.2% in patients with superficial-middle stromal invasion and absence of lymphovascular invasion, respectively.</p></sec></sec><sec sec-type="discussion"><title>Discussion</title><p>In the present study, we retrospectively examined the clinical and pathological characteristics of 192 patients with stage IA2, IB1, and IIA1 cervical cancer who received radical hysterectomy and PLND, and assessed the relationship of PLNM with these factors. The results showed that deep-full thickness stromal invasion and lymphovascular invasion were significantly and independently associated with PLNM.</p><p>Previous studies reported that the incidence of PLNM in cervical cancer was 0-7% for patients with stage IA2 cancer, 7-40% for patients with stage IB1 cancer, and 21.8-38.6% for patients with stage IIA1 cancer <xref rid="B12" ref-type="bibr">12</xref>-<xref rid="B15" ref-type="bibr">15</xref>. These previous results are similar to the present study. Thus, about 60% of patients without PLNM with early-stage cervical cancer, and that PLND may be safely avoided in such patients. A survey by the Japanese Gynecologic Oncology Group found that PLND was recommended in 86.7% of stage IA2 patients when fertility preservation was unnecessary, and in 66.3% of stage IA2 patients when fertility preservation was necessary; for patients with stage IB1 and IIA1 cancer, these percentages were 98.7% and 96.3%, respectively <xref rid="B16" ref-type="bibr">16</xref>. Thus, it is important to identify factors associated with the risk of PLNM to reduce unnecessary pelvic lymphadenectomy.</p><p>Currently, the risk factors for PLNM are uncertain, but may include advanced FIGO stage, large tumor size, deep stromal invasion, involvement of the parametrium, and lymphovascular invasion <xref rid="B17" ref-type="bibr">17</xref>. In the present study, patients were diagnosed with stage IA2, IB1, or IIA1 cervical cancer and received surgery, but did not receive neoadjuvant chemotherapy. Our multivariable logistic regression analysis showed that deep-full thickness stromal invasion and lymphovascular invasion significantly and independently increased the risk for PLNM, but FIGO stage, tumor size, histological subtype, and histological grade had no predictive value. Togami et al. <xref rid="B12" ref-type="bibr">12</xref> investigated patients with stage IA2-IIB cervical cancer and found that parametrial involvement and primary tumor size greater than 2 cm increased the risk of PLNM. However, they focused on preoperative clinical factors (including stage IIB cancer and parametrial involvement), but did not analyze the involvement of lymphovascular invasion and the extent of stromal invasion. Li et al. <xref rid="B11" ref-type="bibr">11</xref> also studied patients with cervical cancer and found that stage IIA and advanced histological grade increased the risk for PLNM; however, they also did not assess other factors, such as lymphovascular invasion and the extent of stromal invasion, and they did not use multivariate analysis.</p><p>Our results showed that the incidence of PLNM was 34.9% and 28.7% in patients with deep-full thickness stromal invasion and lymphovascular invasion, respectively, but that was only 5.7% and 9.2% in patients with superficial-middle stromal invasion and without lymphovascular invasion, respectively. Previous study showed that 30% of patients who had lymphovascular invasion and 1/3 of the stromal invasion developed recurrence when postoperative radiotherapy was not performed <xref rid="B18" ref-type="bibr">18</xref>. Combined with present study, patients with deep-full thickness stromal invasion and lymphovascular invasion should be performed pelvic lymphadenectomy and subsequent radiotherapy/chemotherapy.</p><p>After extensive PLND in women with gynecologic cancer, about 34.5% of patients develop pelvic lymphocysts and 11.4% of patients develop lower extremity lymphedema, both of which significantly harm the quality-of-life <xref rid="B5" ref-type="bibr">5</xref>. Previous studies indicated that the axillary lymph nodes may be avoided in some breast cancer patients when the status of axillary lymph nodes is determined by sentinel lymph node biopsy (SLNB) before surgery, and this may significantly reduce the incidence of upper extremity edema <xref rid="B19" ref-type="bibr">19</xref>-<xref rid="B21" ref-type="bibr">21</xref>. In recent years, clinicians were increasingly using SLNB in the therapy of cervical cancer <xref rid="B22" ref-type="bibr">22</xref>-<xref rid="B26" ref-type="bibr">26</xref>. A systematic review reported that the sensitivity of SLNB in early cervical cancer was 92% (95% CI: 84-98%) and the detection rate was 97% (95% CI: 95-98%) when the combined technique of technetium-99 radiotracer and blue dye was used <xref rid="B27" ref-type="bibr">27</xref>. A recent prospective study of 35 cervical cancer patients (FIGO stage IA1-IIA1) showed that patients without sentinel lymph node metastasis who did not receive subsequent PLND experienced no recurrence of pelvic lymph node, and also had a lower incidence of lower extremity edema (8.7% vs. 42%, p = 0.030) <xref rid="B28" ref-type="bibr">28</xref>. However, prospective studies with large sample sizes are required to confirm whether SLNB can be used to replace PLND for patients with early-stage uterine cervical cancer.</p><p>There were several limitations in our study. First, this was a single-center retrospective study and the sample size was small, so our patients should not be considered representative of the general population. In addition, the prediction of PLNM was mainly evaluated on the basis of postoperative clinicopathologic factors, and the intra-operative clinicopathological factors were not assessed. Thus, further study is needed to evaluate the intra-operative clinicopathological factors to confirm our findings.</p></sec><sec sec-type="conclusions"><title>Conclusion</title><p>In conclusion, stage IA2, IB1, and IIA1 cervical cancer patients with deep-full thickness stromal invasion and lymphovascular invasion were risk factors with PLNM. Patients with superficial-middle stromal invasion and without lymphovascular invasion maybe avoided pelvic lymphadenectomy and thereby reduce the incidence of postoperative complications. More studies are required to confirm our findings.</p></sec></body><back><ack><p>This work was supported by grants from the National Natural Science Foundation of China (No. 81402527), the Sci-Tech Office of Guangdong Province (No. 2013B021800157) and the Education Scientific Research Project of Young Teachers in Fujian Province (No. JB13131).</p></ack><glossary><title>Abbreviations</title><def-list><def-item><term id="GL1">PLNM</term><def><p>pelvic lymph node metastasis</p></def></def-item><def-item><term id="GL2">PLND</term><def><p>pelvic lymph node dissection</p></def></def-item><def-item><term id="GL3">H&E</term><def><p>hematoxylin and eosin</p></def></def-item><def-item><term id="GL4">FIGO</term><def><p>The International Federation of Gynecology and Obstetrics.</p></def></def-item></def-list></glossary><ref-list><ref id="B1"><label>1</label><element-citation 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publication-type="journal"><name><surname>Rossi</surname><given-names>EC</given-names></name><name><surname>Ivanova</surname><given-names>A</given-names></name><name><surname>Boggess</surname><given-names>JF</given-names></name><article-title>Robotically assisted fluorescence-guided lymph node mapping with ICG for gynecologic malignancies: a feasibility study</article-title><source>Gynecol Oncol</source><year>2012</year><volume>124</volume><issue>1</issue><fpage>78</fpage><lpage>82</lpage><pub-id pub-id-type="pmid">21996262</pub-id></element-citation></ref><ref id="B27"><label>27</label><element-citation publication-type="journal"><name><surname>van de Lande</surname><given-names>J</given-names></name><name><surname>Torrenga</surname><given-names>B</given-names></name><name><surname>Raijmakers</surname><given-names>PG</given-names></name><etal></etal><article-title>Sentinel lymph node detection in early stage uterine cervix carcinoma: a systematic review</article-title><source>Gynecol Oncol</source><year>2007</year><volume>106</volume><issue>3</issue><fpage>604</fpage><lpage>13</lpage><pub-id pub-id-type="pmid">17628644</pub-id></element-citation></ref><ref id="B28"><label>28</label><element-citation publication-type="journal"><name><surname>Niikura</surname><given-names>H</given-names></name><name><surname>Okamoto</surname><given-names>S</given-names></name><name><surname>Otsuki</surname><given-names>T</given-names></name><etal></etal><article-title>Prospective study of sentinel lymph node biopsy without further pelvic lymphadenectomy in patients with sentinel lymph node-negative cervical cancer</article-title><source>Int J Gynecol Cancer</source><year>2012</year><volume>22</volume><issue>7</issue><fpage>1244</fpage><lpage>50</lpage><pub-id pub-id-type="pmid">22864335</pub-id></element-citation></ref></ref-list></back><floats-group><table-wrap id="T1" position="float"><label>Table 1</label><caption><p>Clinicopathological characteristics of patients with stage IA2/IB1/IIA1 cervical cancer (n = 192), who presented with (n = 36) and without (n = 156) pelvic lymph node metastases.</p></caption><table frame="hsides" rules="groups"><thead valign="top"><tr><th rowspan="1" colspan="1">Characteristics</th><th rowspan="1" colspan="1">n</th><th rowspan="1" colspan="1">Without lymph<break></break>node metastasis n (%)</th><th rowspan="1" colspan="1">With lymph<break></break>node metastasis n (%)</th><th rowspan="1" colspan="1">p-value</th></tr></thead><tbody valign="top"><tr><td rowspan="1" colspan="1"><bold>Age, years </bold></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"><40</td><td rowspan="1" colspan="1">38</td><td rowspan="1" colspan="1">35 (22.4)</td><td rowspan="1" colspan="1">3 (8.3)</td><td rowspan="1" colspan="1">0.064</td></tr><tr><td rowspan="1" colspan="1">≥40</td><td rowspan="1" colspan="1">154</td><td rowspan="1" colspan="1">121 (77.6)</td><td rowspan="1" colspan="1">33 (91.7)</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"><bold>Menopausal status</bold></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1">Premenopausal</td><td rowspan="1" colspan="1">118</td><td rowspan="1" colspan="1">100 (64.1)</td><td rowspan="1" colspan="1">18 (50.0)</td><td rowspan="1" colspan="1">0.117</td></tr><tr><td rowspan="1" colspan="1">Postmenopausal</td><td rowspan="1" colspan="1">74</td><td rowspan="1" colspan="1">56 (35.9)</td><td rowspan="1" colspan="1">18 (50.0)</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"><bold>FIGO stage</bold></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1">IA2/IB1</td><td rowspan="1" colspan="1">150</td><td rowspan="1" colspan="1">130 (83.3)</td><td rowspan="1" colspan="1">20 (55.6)</td><td rowspan="1" colspan="1">< 0.001</td></tr><tr><td rowspan="1" colspan="1">IIA1</td><td rowspan="1" colspan="1">42</td><td rowspan="1" colspan="1">26 (16.7)</td><td rowspan="1" colspan="1">16 (44.4)</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"><bold>Histological type</bold></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1">Squamous</td><td rowspan="1" colspan="1">158</td><td rowspan="1" colspan="1">129 (82.7)</td><td rowspan="1" colspan="1">29 (80.6)</td><td rowspan="1" colspan="1">0.380</td></tr><tr><td rowspan="1" colspan="1">Adenocarcinoma</td><td rowspan="1" colspan="1">28</td><td rowspan="1" colspan="1">21 (13.5)</td><td rowspan="1" colspan="1">7 (19.4)</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1">Others</td><td rowspan="1" colspan="1">6</td><td rowspan="1" colspan="1">6 (3.8)</td><td rowspan="1" colspan="1">0 (0)</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"><bold>Histological grade</bold></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1">Well differentiated</td><td rowspan="1" colspan="1">4</td><td rowspan="1" colspan="1">4 (2.6)</td><td rowspan="1" colspan="1">0 (0)</td><td rowspan="1" colspan="1">0.236</td></tr><tr><td rowspan="1" colspan="1">Moderately differentiated</td><td rowspan="1" colspan="1">125</td><td rowspan="1" colspan="1">105 (67.3)</td><td rowspan="1" colspan="1">20 (55.6)</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1">Poorly differentiated</td><td rowspan="1" colspan="1">63</td><td rowspan="1" colspan="1">47 (30.1)</td><td rowspan="1" colspan="1">16 44.4)</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"><bold>Tumor size (cm)</bold></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1">≤2</td><td rowspan="1" colspan="1">84</td><td rowspan="1" colspan="1">73 (46.8)</td><td rowspan="1" colspan="1">11 (30.6)</td><td rowspan="1" colspan="1">0.094</td></tr><tr><td rowspan="1" colspan="1">>2</td><td rowspan="1" colspan="1">108</td><td rowspan="1" colspan="1">83 (53.2)</td><td rowspan="1" colspan="1">25 (69.4)</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"><bold>Tumor size (cm)</bold></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1">≤3</td><td rowspan="1" colspan="1">143</td><td rowspan="1" colspan="1">122 (78.2)</td><td rowspan="1" colspan="1">21 (58.3)</td><td rowspan="1" colspan="1">0.019</td></tr><tr><td rowspan="1" colspan="1">>3</td><td rowspan="1" colspan="1">49</td><td rowspan="1" colspan="1">34 (21.8)</td><td rowspan="1" colspan="1">15 (41.7)</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"><bold>Depth of stromal invasion</bold></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1">Superfical</td><td rowspan="1" colspan="1">85</td><td rowspan="1" colspan="1">80 (51.3)</td><td rowspan="1" colspan="1">5 (13.9)</td><td rowspan="1" colspan="1"><0.001</td></tr><tr><td rowspan="1" colspan="1">Middle</td><td rowspan="1" colspan="1">21</td><td rowspan="1" colspan="1">20 (12.8)</td><td rowspan="1" colspan="1">1 (2.8)</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1">Deep</td><td rowspan="1" colspan="1">47</td><td rowspan="1" colspan="1">35 (22.4)</td><td rowspan="1" colspan="1">12 (33.3)</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1">Full</td><td rowspan="1" colspan="1">39</td><td rowspan="1" colspan="1">21 (13.5)</td><td rowspan="1" colspan="1">18 (50.0)</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"><bold>Lymphovascular invasion</bold></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1">Negative</td><td rowspan="1" colspan="1">98</td><td rowspan="1" colspan="1">89 (57.1)</td><td rowspan="1" colspan="1">9 (25.0)</td><td rowspan="1" colspan="1">0.001</td></tr><tr><td rowspan="1" colspan="1">Positive</td><td rowspan="1" colspan="1">94</td><td rowspan="1" colspan="1">67 (42.9)</td><td rowspan="1" colspan="1">27 (75.0)</td><td rowspan="1" colspan="1"></td></tr></tbody></table></table-wrap><table-wrap id="T2" position="float"><label>Table 2</label><caption><p>Location of pelvic lymph node metastases in 36 patients (48 positive lymph nodes) with stage IA2/IB1/IIA1 cervical cancer.</p></caption><table frame="hsides" rules="groups"><thead valign="top"><tr><th rowspan="1" colspan="1">Pelvic Lymph Node Location</th><th rowspan="1" colspan="1">Metastasis, n (%)</th></tr></thead><tbody valign="top"><tr><td rowspan="1" colspan="1">Common iliac</td><td rowspan="1" colspan="1">4 (8.3)</td></tr><tr><td rowspan="1" colspan="1">Internal iliac</td><td rowspan="1" colspan="1">6 (12.5)</td></tr><tr><td rowspan="1" colspan="1">External iliac</td><td rowspan="1" colspan="1">6 (12.5)</td></tr><tr><td rowspan="1" colspan="1">Obturator</td><td rowspan="1" colspan="1">28 (58.4)</td></tr><tr><td rowspan="1" colspan="1">Parametrial</td><td rowspan="1" colspan="1">4 (8.3)</td></tr><tr><td rowspan="1" colspan="1">Inguinal</td><td rowspan="1" colspan="1">0 (0)</td></tr></tbody></table></table-wrap><table-wrap id="T3" position="float"><label>Table 3</label><caption><p>Multivariate analysis of the association of clinicopathological characteristics with pelvic lymph node status in patients with stage IA2/IB1/IIA1 cervical cancer.</p></caption><table frame="hsides" rules="groups"><thead valign="top"><tr><th rowspan="1" colspan="1">Characteristics</th><th rowspan="1" colspan="1">HR</th><th rowspan="1" colspan="1">95% CI</th><th rowspan="1" colspan="1">p-value</th></tr></thead><tbody valign="top"><tr><td rowspan="1" colspan="1"><bold>FIGO Stage </bold></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1">IA2-IB1</td><td rowspan="1" colspan="1">1</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1">IIA1</td><td rowspan="1" colspan="1">1.170</td><td rowspan="1" colspan="1">0.664-4.400</td><td rowspan="1" colspan="1">0.266</td></tr><tr><td rowspan="1" colspan="1"><bold>Tumor size (cm)</bold></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1">≤3</td><td rowspan="1" colspan="1">1</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1">>3</td><td rowspan="1" colspan="1">1.556</td><td rowspan="1" colspan="1">0.646-3.746</td><td rowspan="1" colspan="1">0.324</td></tr><tr><td rowspan="1" colspan="1"><bold>Depth of cervical stromal invasion</bold></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1">Superfical</td><td rowspan="1" colspan="1">1</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1">Middle</td><td rowspan="1" colspan="1">0.626</td><td rowspan="1" colspan="1">0.068-5.773</td><td rowspan="1" colspan="1">0.679</td></tr><tr><td rowspan="1" colspan="1">Deep</td><td rowspan="1" colspan="1">4.491</td><td rowspan="1" colspan="1">1.439-14.014</td><td rowspan="1" colspan="1">0.010</td></tr><tr><td rowspan="1" colspan="1">Full</td><td rowspan="1" colspan="1">10.719</td><td rowspan="1" colspan="1">3.480-33.016</td><td rowspan="1" colspan="1"><0.001</td></tr><tr><td rowspan="1" colspan="1"><bold>Lymphovascular invasion</bold></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1">Negative</td><td rowspan="1" colspan="1">1</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1">Positive</td><td rowspan="1" colspan="1">2.936</td><td rowspan="1" colspan="1">1.218-7.079</td><td rowspan="1" colspan="1">0.016</td></tr></tbody></table></table-wrap></floats-group></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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