Elsevier

Gynecologic Oncology

Volume 107, Issue 2, November 2007, Pages 310-315
Gynecologic Oncology

Tumor size is of prognostic value in surgically treated FIGO stage II cervical cancer

https://doi.org/10.1016/j.ygyno.2007.06.026Get rights and content

Abstract

Objectives

Tumor size is a well recognized prognostic factor in early stage cervical carcinoma (CX). However, limited knowledge exists about the value of tumor size in surgically treated CX with extrauterine extension.

Methods

245 cases of local advanced CX (FIGO stage IIA and IIB) who received upfront surgery were evaluated regarding tumor size, regarding the prediction of pelvic lymph node involvement and recurrence free and overall survival during a median follow-up time of 54 months (95% CI 45.4–62.6 months). Tumors larger than 4 cm were defined as bulky stage disease.

Results

Bulky disease was seen in 46.1% (113/245). 60.2% of these patients showed pelvic lymph node involvement, compared to 42.4% (56/132) in non-bulky tumors (p = 0.006; odds ratio: 2.2 [95% CI: 1.3–3.6]). Patients with bulky tumors showed an increase of recurrent disease (40.2% vs. 28.0%; p = 0.045). The relative risk for recurrent disease was 1.97 (95% CI: 1.3–3.0). The 5-year overall survival rate was significantly lower (67.7% [95% CI: 58.2–74.8] vs. 49.5% [95% CI: 36.8–59.1]; p = 0.0015). In multivariate analysis, tumor stage, pelvic lymph node involvement and maximal tumor size were independent prognostic factors.

Conclusions

The results suggest that tumor size, defining bulky disease as tumors larger than 4 cm, is of prognostic impact also in FIGO stage II cervical carcinomas. A revised FIGO/TNM classification system similar to the subgrouping of stage IB CX is recommended for stage II using a cut-off value of 4 cm as discriminator: stage IIA1 and stage IIB1 for tumors with ≤ 4 cm and IIA2 and IIB2 for tumors > 4 cm (i.e. bulky disease).

Introduction

The approach to the treatment of cervical carcinoma (CX) depends primarily on the stage of the disease, the age of the patient and comorbidity. Pretreatment evaluation of prognostic factors is essential for treatment planning. Tumor diameter has been proposed as an important prognostic factor in patients with CX by many authors since several years [1], [2], [3], [4]. As a consequence, a new FIGO-staging system for CX confined to the cervix was introduced in 1995 [5], defining two subgroups based on tumor diameter (FIGO IB1: maximum tumor size ≤ 4 cm; FIGO IB2: tumors > 4 cm). The prognostic impact of this substaging was confirmed during the following years [4], [6], [7], [8]. In this context, earlier studies have suggested that there might be a difference in determining the tumor size by using tumor length (i.e. vertical extension) and the tumor width [9], [10]. The results of these studies suggested that the tumor width might be of more impact in predicting pelvic lymph node involvement and disease free as well as overall survival. The following studies, cited above, have not considered this subtle measurement for determination of the tumor size in CX.

In tumors with extrauterine extension (FIGO stage II), tumor size is also of prognostic impact and valuable for treatment decision, but the knowledge is limited [8], [11], [12], [13]. The present study was designed to analyze the prognostic impact of tumor size in surgically treated CX with extrauterine extension with detailed recognition of tumor length and tumor width.

Section snippets

Materials and methods

Data from patients with CX, staged FIGO IIA and IIB were obtained from the files of our so-called Wertheim-Archive [14]. This archive contains all morphologic data from CX which were treated by primary radical hysterectomy between 03/1979 and 12/1996 with tumor stage > pT1b1.

Patients who received neoadjuvant therapy, those with incomplete local tumor resection (R1 or R2 resection) and tumors of other histologic types as squamous cell and adenocarcinomas were excluded from the study. All women

Results

245 patients were included in the study. Their characteristics are given in Table 1. The median follow-up time was 54 months (95% confidence interval 45.4 to 62.6 months).

113 of the patients (46.1%) represented tumors larger than 4 cm in the largest tumor extension (i.e. bulky disease).

60.2% (68/113) of the patients with bulky disease showed pelvic lymph node involvement compared to 42.4% (56/132) in patients with non-bulky tumors (p = 0.006). The odds ratio of 2.2 (95% CI: 1.3–3.6) indicates a

Discussion

There is important evidence that the tumor size is of prognostic impact in non-gynecological malignancies at different sites, e.g. in esophageal and renal cell carcinoma [23], [24] as well as for carcinoma of the cervix uteri [1], [2], [4], [6], [25].

Because of the fact that the majority of CX will be diagnosed in early stage disease in the Western countries, studies regarding tumor size have been focused on FIGO stage I disease [3], [4], [7]. All these studies have reported that bulky tumors

References (39)

  • A.W. Fyles et al.

    Prognostic factors in patients with cervix cancer treated by radiation therapy: results of a multiple regression analysis

    Radiother Oncol

    (1995)
  • G.C. Lowrey et al.

    Stage IB or IIA–B carcinoma of the intact uterine cervix treated with irradiation: a multivariate analysis

    Int J Radiat Oncol Biol Phys

    (1992)
  • H.H. Lin et al.

    Risk factors for recurrence in patients with stage IB, IIA and IIB cervical carcinoma after radical hysterectomy and postoperative pelvic irradiation

    Obstet Gynecol

    (1996)
  • P. Morice et al.

    Interest of para-aortic lymphadenectomy in patients with stage IB and II cervical carcinoma

    Gynecol Oncol

    (1999)
  • W.K. Kinney et al.

    Identification of a low-risk subset of patients with stage IB invasive squamous cell cancer of the cervix possibly suited to less radical surgical treatment

    Gynecol Oncol

    (1995)
  • L.L. Subak et al.

    Cervical carcinoma: computed tomography and magnetic resonance imaging for preoperative staging

    Obstet Gynecol

    (1995)
  • H.D. Homesley et al.

    Relationship of lesion size to survival in patients with stage IB squamous cell carcinoma of the cervix uteri treated by radiation therapy

    Surg Gynecol Obstet

    (1980)
  • H.J. Huang et al.

    Prognostic value of age and histologic type in neoadjuvant chemotherapy plus radical surgery for bulky (>/= 4 cm) stage IB and IIA cervical carcinoma

    Int J Gynecol Cancer

    (2003)
  • M. Modarress et al.

    Comparative study of chemoradiation and neoadjuvant chemotherapy effects before radical hysterectomy in stage IB–IIB bulky cervical cancer and with tumor diameter greater than 4 cm

    Int J Gynecol Cancer

    (2005)
  • Cited by (101)

    View all citing articles on Scopus
    View full text