Christian Dagher

Oncologic outcomes based on lymphovascular space invasion in node-negative FIGO 2009 stage I endometrioid endometrial adenocarcinoma: a multicenter retrospective cohort study

The 2023 International Federation of Gynecology and Obstetrics (FIGO) staging system includes lymphovascular invasion quantification as a staging criterion for endometrioid endometrial carcinomas; no lymphovascular invasion and focal invasion (≤4 vessels involved) are grouped as one category, and substantial invasion as another. To assess the association between lymphovascular invasion and oncologic outcomes. We retrospectively identified patients with FIGO 2009 stage I endometrioid endometrial cancer treated surgically with total hysterectomy and lymph node assessment at two tertiary care centers between January 1, 2012, and December 31, 2019. Lymphovascular space invasion was categorized as focal (<5 vessels involved), substantial (≥5 vessels involved), and no lymphovascular invasion using WHO criteria. Of 1555 patients included, 65 (4.2%) had substantial, 119 (7.7%) had focal, and 1371 (88.2%) had no lymphovascular invasion. Median age was 64 years (range 24-92). Thirty-five patients (53.8%) with substantial, 44 (37%) with focal, and 115 (8.4%) with no lymphovascular invasion had stage IB disease (p<0.001); 21 (32.3%) with substantial, 24 (20.2%) with focal, and 91 (6.6%) with no lymphovascular invasion had grade 3 disease (p<0.001). Thirty-six patients (55.4%) with substantial, 80 (67.2%) with focal, and 207 (15.1%) with no lymphovascular invasion received adjuvant treatment (p<0.001). Median follow-up was 61.5 months (range 0.8-133.9). Five-year progression-free survival rates were 68.7% (substantial), 70.5% (focal), and 90.7% (no invasion) (p<0.001). On multivariate analysis, any lymphovascular invasion was associated with increased risk of progression/death (adjusted HR (aHR)=1.84 (95% CI 1.73 to 1.96) for focal; 2.17 (95% CI 1.96 to 2.39) for substantial). Compared with focal, substantial lymphovascular invasion was associated with an aHR for disease progression of 1.18 (95% CI 1.00 to 1.39). Focal and substantial lymphovascular invasion were associated with increased risk of disease progression and do not appear to be prognostically distinct. Focal versus no lymphovascular invasion have different prognostic outcomes and should not be combined into one category.

Pre-operative imaging in clinical International Federation of Gynecology and Obstetrics stage IB2 or less cervical carcinoma

To assess clinical utility of pre-operative imaging in cervical cancer beyond pelvic magnetic resonance imaging (MRI) in patients with pre-operative International Federation of Gynecology and Obstetrics (FIGO) stage IB2 or less. We retrospectively identified patients who underwent evaluation or received consultation for newly diagnosed cervical squamous cell carcinoma, adenocarcinoma, or adeno-squamous carcinoma at our institution from January 2006 until February 2024. Patients with stage ≤IB2 disease on examination and a pre-operative pelvic MRI demonstrating a tumor ≤4 cm were included. Cases with evidence of gross pelvic nodal involvement or unequivocal parametrial/vaginal extension on MRI were excluded. All patients then underwent surgical treatment. Patients were included if they also underwent chest, abdominal, and pelvic computed tomography with/without positron emission tomography. Additional imaging was performed prior to consultation at our institution or at the treating physician's discretion. We sought to assess the findings of additional imaging in identifying extra-pelvic gross nodal or extra-nodal abdominal and/or chest disease. We did not seek to identify the role of imaging in identifying microscopic disease in normal-sized lymph nodes and such cases were included. Among 183 patients, the median age at diagnosis was 36 years (range; 18-81); 100 (54.6%) had adenocarcinoma, 78 (42.6%) squamous cell carcinoma, and 5 (2.7%) adeno-squamous carcinoma. The final pathologic FIGO 2018 stages included IA1 (n = 34, 18.6%), IA2 (n = 18, 9.8%), IB1 (n = 96, 52.5%), IB2 (n = 14, 7.7%), IB3 (n = 1, 0.5%), and IIIC1 (n = 20, 10.9%). The median tumor size was 0 mm (range; 0-38) on imaging and 8 mm (range; 0-41) on final pathology. Twenty-eight patients (15.3%) had non-specific/borderline enlarged pelvic lymph nodes on MRI, 6 (21.4%) of whom had final pathologic lymph node involvement. Thirty-four patients (18.6%) had "extra-pelvic" findings on computed tomography with/without positron emission tomography; 21 (61.8%) had non-specific findings, and 13 (38.2%) underwent further diagnostic intervention but none had cervical cancer metastases. There were no cervical cancer-related findings on additional imaging beyond MRI of the pelvis. Additionally, no extra-pelvic disease was encountered intra-operatively. The false-positive rate for imaging to detect extra-pelvic intra-abdominal metastasis of cervical carcinoma was 100% (13 of 13, 95% confidence interval [CI] 75.3% to 100%), with no false negatives (0%, 95% CI 0% to 1.7%). For patients with cervical carcinoma ≤4 cm and confined to the cervix on pre-operative MRI, additional imaging appears to be of limited utility, leading to unnecessary interventions.

Assessing the clinical value of pre-operative imaging in endometrial carcinoma by symptoms and low-risk versus high-risk histology

This study aimed to assess the concordance between pre-operative imaging results and intra-operative findings in patients with endometrial carcinoma, based on pre-operative risk stratification and the clinical indication for obtaining imaging. We identified all patients who had surgery for newly diagnosed endometrial carcinoma at our institution from January 2017 to January 2021 and categorized them as low or high risk. We reviewed pre-operative images or radiologic evidence of extra-uterine disease and correlated with intra-operative findings, and we categorized the findings as true positive or false negative. We identified a total of 1970 patients for this analysis. Within the study cohort, 1247 tumors (63.3%) were low-risk histology, 719 (36.5%) were high-risk histology, and 4 patients (0.2%) had no pre-operative biopsy. Pre-operative imaging was performed for 676 low-risk (54.2%) and 700 high-risk patients (97.4%) (p <.001) and detected the presence of extra-uterine disease in 50 of 676 low-risk (7.4%) and 140 of 700 high-risk patients (20%). In the low-risk cohort, there was radiologic evidence of extra-uterine disease present for 12 of 60 patients (20%) with an abnormal exam or ultrasound, 16 of 126 patients (12.7%) with symptoms or a delayed diagnosis, and 16 of 490 asymptomatic patients (3.3%). In the high-risk cohort, there was radiologic evidence of extra-uterine disease present for 32 of 66 patients (48.5%) with symptoms or a delayed diagnosis, 21 of 46 patients (45.7%) with an abnormal exam or ultrasound, and 84 of 583 asymptomatic patients (14.4%). A total of 122 of 1376 patients (8.9%) had a change in clinical management based on pre-operative imaging findings: 32 of 676 (4.7%) low-risk and 90 of 700 high-risk patients (12.9%). Over 90% of patients with low-risk tumors had no findings suspicious for metastatic disease on pre-operative imaging, indicating limited utility in that cohort. However, pre-operative imaging yielded clinically meaningful information in patients with high-risk histology, particularly, those with symptoms, delayed diagnosis, or concerning exam findings.