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Factors Associated with Parametrial Involvement

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Factors Associated with Parametrial Involvement Original Article Obstet Gynecol Sci 2018;61(1):88-94 https://doi.org/10.5468/ogs.2018.61.1.88 pISSN 2287-8572 · eISSN 2287-8580 Factors associated with parametrial involvement in patients with stage IB1 cervical cancer: who is suitable for less radical surgery? Seung-Ho Lee1, Kyoung-Joo Cho1, Mi-Hyang Ko1, Hyun-Yee Cho2, Kwang-Beom Lee1, Soyi Lim1 1Departments of Obstetrics and Gynecology, 2Pathology, Gil Medical Center, Gachon University of Medicine and Science, Incheon, Korea Objective To detect the possible clinicopathologic factors associated with parametrial involvement in patients with stage IB1 cervical cancer and to identify a cohort of patients who may benefit from less radical surgery. Methods We retrospectively reviewed 120 patients who underwent radical hysterectomy and pelvic lymphadenectomy as treatment for stage IB1 cervical cancer. Results Overall, 18 (15.0%) patients had parametrial tumor involvement. Tumor size larger than 2 cm, invasion depth greater than 1 cm, presence of lymphovascular space involvement (LVSI), corpus involvement, and positive lymph nodes were statistically associated with parametrial involvement. Multivariate analysis for other factors showed invasion depth >1 cm (P=0.029), and corpus involvement (P=0.022) were significantly associated with parametrial involvement. A subgroup with tumor size smaller than 2 cm showed no parametrial involvement, regardless of invasion depth or presence of LVSI. Conclusion Tumor size smaller than 2 cm showed no parametrial involvement, regardless of invasion depth or presence of LVSI. Invasion depth >1 cm and corpus involvement were significantly associated with parametrial involvement in multivariate analysis. These finding may suggest that tumor size may a strong predictor of parametrial involvement in International Federation of Gynecology and Obstetrics stage IB1 cervical cancer, which can be used to select a subgroup population for less radical surgery. Keywords: Uterine cervical neoplasms; Hysterectomy Introduction Women with stage IB1 cervical cancer are typically treated Received: 2017.04.10. Revised: 2017.06.22. Accepted: 2017.07.06. by radical hysterectomy and bilateral lymph node dissection. Corresponding author: Soyi Lim Radical hysterectomy includes removal of the parametrial Department of Obstetrics and Gynecology, Gil Medical Center, tissue, as well as a third to half of the upper vagina. The Gachon University of Medicine and Science, 21 Namdong-daero removal of parametrial tissue is important in the treatment 774-beon-gil, Namdong-gu, Incheon 21565, Korea E-mail: [email protected] of cervical cancer because this area is the most frequently http://orcid.org/0000-0001-8886-3107 affected site of cancer spread. The tumor can spread to the parametrium through either direct microscopic extension Articles published in Obstet Gynecol Sci are open-access, distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons. or by tumor embolization from the primary lesion to lymph org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, nodes in the parametrial tissue. The incidence of pathological and reproduction in any medium, provided the original work is properly cited. parametrial involvement has been reported to be between 6% Copyright © 2018 Korean Society of Obstetrics and Gynecology 88 www.ogscience.org Seung-Ho Lee, et al. Parametrial invasion in early cervical cancer and 31% [1-3]. Important prognostic factors in cervical cancer The histological diagnosis was made using either punch include tumor size, parametrial disease spread, lymphovas- biopsy or cone excision. Tumor diameter was obtained from cular space involvement (LVSI), and lymph node metastasis. the pathological measurements at conization or using the However, parametrectomy is the main cause of postoperative hysterectomy specimen. Radical hysterectomy included com- complications which may include bladder dysfunction, sexual plete resection of cervical fascia (anterior parametrium), and dysfunction, and anorectal mobility disorders attributable uterosacral and rectovaginal ligaments (lateral and posterior to partial denervation of the autonomic nerve supply to the parametrium). The pelvic lymphadenectomy consisted of sys- pelvic organs which may occur during parametrial resection. tematic dissection of the common iliac, internal and external Although, in the randomized controlled trial about nerve- iliac vessels, and the obturator nodes both above and below sparing surgery to minimize these complications, nerve- the obturator nerves. Para-aortic lymph node dissection was sparing radical surgery was effective in preserving bladder performed from the level of the aortic bifurcation to the infe- function without sacrificing oncologic safety [4], more data is rior mesenteric artery. The para-aortic nodes were dissected necessary for this issue. if suspicious pelvic nodes were detected. Pathologic data was Some authors suggested that less radical surgery should collected by review of the pathology report. All hysterectomy be applied in patient populations with favorable prognostic specimens were collected and processed in a routine manner. factors and low risk of parametrial involvement. Kim et al. [5] The parametrium was usually defined as the connective tissue reported that stage IB1 patients with superficial invasion (<5 of the pelvic floor extending laterally from the fibrous sub- mm) have very low risk of parametrial involvement and thus, serous coat between the layers of the broad ligament in the less radical surgery may be performed. Kodama et al. [6] also supracervical part of the uterus. The parametrial tissue from demonstrated that stage IB1 patients with depth of invasion all excised specimens was processed and examined to evalu- (DOI) less than 10 mm, no LVSI, and less than 50 years of age ate possible microscopic tumor spread. Abstracted pathologic should be considered as potential recipients of modified radi- data included: histologic subtype, depth of tumor invasion, cal hysterectomy, or simple hysterectomy with pelvic lymph- LVSI, parametrial tumor involvement, vaginal or uterine corpus adenectomy. involvement, lymph node status, and status of the margins In the present study, we evaluated the clinicopathologic of resection. DOI and tumor size after conization were not factors associated with pathologic parametrial involvement in added to those of hysterectomy specimens. patients with stage IB1 cervical cancer. In addition, we identi- The associations between these pathologic factors and fied those patients at low risk for parametrial involvement parametrial tumor involvement were evaluated using either χ2 who may benefit from less radical surgery. or Fisher exact tests. Multivariate analysis was performed us- ing stepwise logistic regression analysis. A P-value under 0.05 was taken to indicate statistical significance, and all tests were Materials and methods 2-sided. The statistical analysis was performed using SPSS ver- sion 12.0 (SPSS Inc., Chicago, IL, USA). A retrospective study was performed using a database of pa- tients who underwent type III radical hysterectomy between January 2002 and December 2007 with the approval of the Results Institutional Review Board. We found that 120 consecutive patients diagnosed with International Federation of Gynecol- The study population consisted of 120 women with FIGO ogy and Obstetrics (FIGO) stage IB1 were treated with type III stage IB1 who underwent radical hysterectomy, and pelvic radical hysterectomy and pelvic lymph node dissection, either and/or para-aortic lymph node dissection. Patient characteris- with or without para-aortic lymph node dissection. Patients tics are shown in Table 1. Overall, 18 (15.0%) cases were ob- who received primary radiotherapy and chemotherapy were served to include parametrial tumor involvement. The median excluded from our study. Patients with microinvasive carcino- follow-up period was thirty-seven months (range, 1–81). ma and patients treated by type I simple hysterectomy or type Patients with tumors larger than 2 cm had a 22.5% risk II modified radical hysterectomy, were also excluded. of parametrial involvement, compared with 0% for patients www.ogscience.org 89 Vol. 61, No. 1, 2018 Table 1. Clinical characteristics of patients tors associated with parametrial involvement, because a Characteristics Patients (n=120) subgroup with tumor size smaller than 2 cm showed no Age (yr) 46 (22–77) parametrial involvement regardless of invasion depth or pres- DOI (mm) 9 (2–28) ence of LVSI. Therefore, multivariate analysis was performed Tumor size (mm) 19 (4–75) for other clinicopathologic factors most associated with Histologic subtype parametrial involvement except tumor size. After controlling Squamous cell carcinoma 100 (83.3) for confounding factors, multivariate analysis for other fac- Adenocarcinoma 15 (12.5) tors showed invasion depth more than 1 cm (odds ratio [OR], Adenosquamous 5 (4.2) 11.5; P=0.029), and uterine involvement (OR, 10.1; P=0.022), No. of lymph nodes removed 34 (12–96) were significantly associated with parametrial involvement LVSI 50 (41.7) (Table 3). Parametrial involvement 18 (15.0) We identified a cohort of women with low risk for parame- trial involvement using preoperatively accessible risk factors Lymph node metastasis 17 (14.2) including tumor size, DOI, and LVSI (Table 4). There was no Positive resection margin 4 (3.3) parametrial spread for any of the 40 patients with tumor size Uterine
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