Lymph-Vascular Space Invasion on the Risk of Nodal Metastases in Women with Cervical Cancer
ABSTRACT & COMMENTARY
Synopsis: Quantification of the amount of lymph- vascular space invasion in women with early stage squamous cancer of the cervix is useful in predicting the risk of pelvic nodal metastases.
Source: Roman LD, et al. Gynecol Oncol 1998;68: 220-225.
Roman and colleagues retrospectively reviewed 105 women with stages IA2, IB, and IIA squamous carcinoma of the cervix who underwent radical hysterectomy and pelvic lymphadenectomy between 1991 and 1997 to determine if the quantity of lymph-vascular space invasion influences the risk of pelvic nodal metastases. The histopathology slides were prospectively reviewed; if lymph-vascular space invasion (LVSI) were present, the amount was quantified in four ways: percentage of cervical histopathological sections containing LVSI, percentage of sections with tumor containing LVSI, total number of foci of LVSI, and maximal number of foci of LVSI in 10 high-powered fields. These measures of LVSI were then correlated with the risk of nodal metastases. Seventy-three (70%) women had tumors with LVSI. Of these, 23 had pelvic nodal metastases. All women with nodal metastases had tumors with LVSI. Using logistic regression, independent predictors of nodal metastases were depth of cervical stromal invasion and tumor size. In women whose tumors contained LVSI, logistic regression identified tumor size and LVSI in more than 45% of cervical histopathologic sections as significant predictors of nodal metastases. Roman et al conclude that the quantity of LVSI, as defined by the percentage of all cervical histopathologic sections containing LVSI, correlates significantly with the risk of nodal metastases in women with early-stage squamous carcinoma of the cervix.
COMMENT BY DAVID M. GERSHENSON, MD
Several studies have suggested that lymph-vascular space invasion is an independent risk factor in cervical cancer. Most notably, in a study of the Gynecologic Oncology Group, Delgado and associates (Gynecol Oncol 1990;38:352-357) identified three independent factors predictive of disease-free survival in stage IB cervical cancer: depth of stromal invasion, tumor size, and LVSI. Of course, in addition to the implications for outcome, such risk factors are used in clinical trials testing the potential benefit of adjuvant therapy. Although it remains controversial, postoperative pelvic irradiation is frequently recommended for women with positive lymph nodes at radical hysterectomy. Other factors that may provoke consideration for such adjuvant treatment, even in patients with negative pelvic lymph nodes, include deep cervical invasion, positive surgical margins, positive paracervical involvement, and LVSI. There is, however, no consensus about the precise indications for or benefits of irradiation for any of these features. This study takes the issue of lymph-vascular space involvement yet one step further by attempting to quantify it. The authors have taken several approaches, and they do demonstrate a correlation between the amount of LVSI and positive lymph nodes. The next obvious step would be to expand this study in terms of number of patients and follow-up time to examine the relationship of quantity of LVSI to disease-free survival and survival. As we accumulate more information about histopathologic risk factors associated with cervical cancer, we will be able to step back even further to better select patients for the optimal primary treatment-radical hysterectomy and pelvic lymphadenectomy or pelvic irradiation.
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