- Email: [email protected]
The poorer survival of patients with cervical adenocarcinoma and adenosquamous cell carcinoma compared to those with squamous cell carcinoma might be improved by a different treatment
Letters to the Editor
We do not consider radical trachelectomy an acceptable option for these patients. In fact, it is associated not only with a risk of fetal loss in 1 out of 3 patients treated and with a high risk of prematurity, but also with significant effects on the outcome of subsequent pregnancies. In patients with a tumor diameter between 2 and 4 cm we are unsure how the knowledge of nodal status would modify the approach to patients who have already decided to delay definitive treatment with the aim to have a healthy baby. In this group of patients we would recommend NACT anyway, regardless of nodal status, for both the control of local and metastatic disease, if present. In our experience, when a mother is determined to preserve her pregnancy, the awareness of the nodal status will not change her decision. The theoretical higher oncological risk of delaying definitive treatment and the potential yet questionable benefit of pregnancy termination cannot be quantified or demonstrated. The major concern of Professor Morice and colleagues is about stage Ib2 cervical cancer patients, as they judge the relapse rate too high and the clinical outcome "clearly inferior" to nonpregnant patients. Given that it is hard to generalize results obtained in such a small population and to compare them with a meta-analysis of more than two thousand non-pregnant patients, this might be true. The other side of the coin is that if one considers not only the relapse rate but also the survival among the cases published, the death rate (5/13) is not different from that reported in many trials on NACT [7,8]. We want also to underline that all the patients presented in our series had a tumor diameter>6 cm, which is usually associated with a rate of nodal spread of disease of at least 50% and a high recurrence and death rate. This is the reason why we think it is not totally appropriate to conclude that the rate of local and regional recurrences indicates that NACT was not able to obtain a stabilization of the disease until fetal viability. In fact all patients with Ib2 cervical cancer included in our study achieved at least a stable disease (in details, 2 with partial response and 3 with stable disease). We agree that our results might have been impaired by our choice to administer a monochemotherapy with cisplatin, which is without doubt suboptimal. We had two relevant adverse reactions during pregnancy with paclitaxel, and we decided to give up using it, perhaps prematurely. With the increasing evidences emerging from the literature about the safety of paclitaxel during pregnancy, we may consider to use it again in the future; even then, the doublet should be considered a suboptimal treatment, as the most effective regimen, in our opinion, includes also Ifosfamide. It is difficult to draw some conclusions or definitive guidelines on the treatment of cervical cancer during pregnancy. The sole certainty we experimented is the firm intention of patients to preserve their pregnancy. This firm purpose dictated our clinical management: the primary aim of ensuring patients a healthy baby, while taking into account the potential risk for the mother of delaying radical treatment. Conflict of interest statement All the authors disclose any possible conflict of interest.
References [1] Fruscio R, Villa A, Chiari S, Vergani P, Ceppi L, Dell'orto F, et al. Delivery delay with neoadjuvant chemotherapy for cervical cancer patients during pregnancy: a series of nine cases and literature review. Gynecol Oncol 2012 Aug;126(2):192–7. [2] Amant F, Van Calsteren K, Halaska MJ, Gziri MM, Hui W, Lagae L, et al. Long-term cognitive and cardiac outcomes after prenatal exposure to chemotherapy in children aged 18 months or older: an observational study. Lancet Oncol Mar 2012;13(3):256–64. [3] Holtan SG, Creedon DJ, Haluska P, Markovic SN. Cancer and pregnancy: parallels in growth, invasion, and immune modulation and implications for cancer therapeutic agents. Mayo Clin Proc Nov 2009;84(11):985–1000. [4] Maneo A, Sideri M, Scambia G, Boveri S, Dell'anna T, Villa M, et al. Simple conization and lymphadenectomy for the conservative treatment of stage IB1 cervical cancer. An Italian experience. Gynecol Oncol Dec 2011;123(3):557–60. [5] Cibula D, Abu-Rustum NR. Pelvic lymphadenectomy in cervical cancer—surgical anatomy and proposal for a new classification system. Gynecol Oncol Jan 2010;116(1):33–7. [6] Favero G, Chiantera V, Oleszczuk A, Gallotta V, Hertel H, Herrmann J, et al. Invasive cervical cancer during pregnancy: laparoscopic nodal evaluation before oncologic treatment delay. Gynecol Oncol Aug 1, 2010;118(2):123–7.
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[7] Buda A, Fossati R, Colombo N, Fei F, Floriani I, Gueli Alletti D, et al. Randomized trial of neoadjuvant chemotherapy comparing paclitaxel, ifosfamide, and cisplatin with ifosfamide and cisplatin followed by radical surgery in patients with locally advanced squamous cell cervical carcinoma: the SNAP01 (Studio Neo-Adjuvante Portio) Italian Collaborative Study. J Clin Oncol Jun 20, 2005;23(18):4137–45. [8] Lissoni AA, Colombo N, Pellegrino A, Parma G, Zola P, Katsaros D, et al. A phase II, randomized trial of neo-adjuvant chemotherapy comparing a three-drug combination of paclitaxel, ifosfamide, and cisplatin (TIP) versus paclitaxel and cisplatin (TP) followed by radical surgery in patients with locally advanced squamous cell cervical carcinoma: the Snap-02 Italian Collaborative Study. Ann Oncol Apr 2009;20(4):660–5.
Robert Fruscio⁎ Costantino Mangioni Rodolfo Milani Clinic of Obstetrics and Gynecology, University of Milan—Bicocca, San Gerardo Hospital, Monza, Italy ⁎Corresponding author at: Clinic of Obstetrics and Gynecology, University of Milan—Bicocca, San Gerardo Hospital, Via Pergolesi, 32 Monza, 20052, Italy. Tel.: +39 039 2339434; fax: +39 039 2339435. E-mail address: [email protected] (R. Fruscio). 22 June 2012 doi:10.1016/j.ygyno.2012.06.037
The poorer survival of patients with cervical adenocarcinoma and adenosquamous cell carcinoma compared to those with squamous cell carcinoma might be improved by a different treatment
To the Editor: Galic et al. recently reported a population-based retrospective study on 24,562 patients with cervical carcinoma, and found that the multivariable odds ratio for death was 1.39 (95% CI, 1.23–1.56) for women with adenocarcinoma (AC) and 1.55 (95% CI, 1.32–1.82) for women with adenosquamous carcinoma (ASC) compared to those with squamous cell carcinoma (SCC) [1]. The editorial from the same issue discussed whether we should change the treatment paradigm for the glandular carcinoma of cervix [2]. The incidence of cervical cancer declines alone with popular Pap smear in many countries, but the patient number of cervical AC and ASC remains unchanged that results into their increased percentage [3]. Outcome of AS/ASC in comparison with that of SCC was similar in some reports [4–6] and worse in others [7–10]. Hong et al. reported 928 patients with stage I to IVa cervical cancer treated with primary irradiation, and found that primary tumors of AC/ASC (N =53) showed a slower and a poorer response (p= 0.008) than those of SCC (N= 875) [9]. Patients with AC/ASC also had lower 5-year disease-specific survival rate than those with SCC (50% vs 66%, p=0.016). Huang also reported lower 5year relapse-free survival rate for 148 patients with AC/ASC [10]. Lai's series of 891 patients with stage Ib to II cervical cancer undergoing radical hysterectomy showed that AC/ASC (N=134) has lower 5-year recurrence-free survival (72.2% vs 81.2%, p=0.0109) and OS (74.1% vs 82.8%, p=0.0136) than SCC (N =757) [8]. Further analyses revealed that stage II, parametrial invasion and deep stromal invasion were associated with lymph node metastasis. When disease recurred, successful salvage rate for squamous cell carcinoma was 11.8% and 0% for AC/ASC. Those results implied a lower survival rate for AC/ASC that might be reversed by aggressive treatment for local tumor. From April 2002 to March 2008, 83 consecutive patients with stages I and II AC (N= 59) or ASC (N=24) were treated with radical hysterectomy in our hospital. Patients eligible for radical hysterectomy also included those with positive lymph node on preoperative computed tomography or magnetic resonance imaging, full thickness cervical stromal invasion, and inner 2/3
260
Letters to the Editor
parametrial involvement that we had assigned for radiotherapy previously. Patients with parametrial invasion, deep stromal invasion, lymph node metastasis, or positive vaginal section margin were put on adjuvant concurrent chemoradiation. The 5-year overall survival was 85.5% that was superior to our historical control, 74.1% [11]. From the improved survival attributed to aggressive surgery and adjuvant chemoradiation, we suggest a change of treatment policy for cervical AC/ASC. Conflict of interest statement The author declares that there are no conflicts of interest
References [1] Galic V, Herzog TJ, Lewin SN, Neugut AI, Burke WM, Lu YS, et al. Prognostic significance of adenocarcinoma histology in women with cervical cancer. Gynecol Oncol 2012;125(2):287–91. [2] Rose PG. Are the differences in treatment outcome for adenocarcinoma of the cervix different enough to change the treatment paradigm? Gynecol Oncol 2012;125(2): 285–6. [3] Chen YY, You SL, Chen CA, Shih LY, Koong SL, Chao KY, et al. Taiwan Cervical Cancer Screening Task Force. Effectiveness of national cervical cancer screening programme in Taiwan: 12-year experiences. Br J Cancer 2009;101(1):174–7. [4] Shingleton HM, Bell MC, Fremgen A, et al. Is there really a difference in survival of women with squamous cell carcinoma, adenocarcinoma, and adenosquamous cell carcinoma of the cervix? Cancer 1995;76(10 Suppl.):1948–55. [5] Alfsen GC, Kristensen GB, Skovlund E, et al. Histologic subtype has minor importance for overall survival in patients with adenocarcinoma of the uterine cervix: a population-based study of prognostic factors in 505 patients with nonsquamous cell carcinomas of the cervix. Cancer 2001;92:2471–83. [6] Lee KB, Lee JM, Park CY, Lee KB, Cho HY, Ha SY. What is the difference between squamous cell carcinoma and adenocarcinoma of the cervix? A matched case– control study. Int J Gynecol Cancer 2006;16(4):1569–73. [7] Eifel PJ, Burke TW, Morris M, et al. Adenocarcinoma as an independent risk factor for disease recurrence in patients with stage IB cervical carcinoma. Gynecol Oncol 1995;59:38–44. [8] Lai CH, Hsueh S, Hong JH, et al. Are adenocarcinomas and adenosquamous carcinomas different from squamous carcinomas in stage IB and II cervical cancer patients undergoing primary radical surgery? Int J Gynecol Cancer 1999;9:28–36. [9] Hong JH, Tsai CS, Wang CC, et al. Comparison of clinical behaviors and responses to radiation between squamous cell carcinomas and adenocarcinomas/adenosquamous carcinomas of the cervix. Chang Gung Med J 2000;23:396–404. [10] Huang YT, Wang CC, Tsai CS, Lai CH, Chang TC, Chou HH, et al. Long-term outcome and prognostic factors for adenocarcinoma/adenosquamous carcinoma of cervix after definitive radiotherapy. Int J Radiat Oncol Biol Phys 2011;80(2):429–36. [11] Chou HH, Chang HP, Lai CH, Ng KK, Hsueh S, Wu TI, et al. (18)F-FDG PET in stage IB/IIB cervical adenocarcinoma/adenosquamous carcinoma. Eur J Nucl Med Mol Imaging 2010;37(4):728–35.
Hung-Hsueh Chou E-mail address: [email protected] 14 June 2012 doi:10.1016/j.ygyno.2012.06.024
Re: Prognostic significance of adenocarcinoma histology in women with cervical cancer To the Editor: We appreciate the interest of Dr. Chou in our work. In a series of over 24,000 women with invasive cervical cancer we noted that survival for women with adenocarcinomas was inferior to that of patients with squamous cell carcinomas. These results were noted for both early and advanced-stage disease. Specifically, in multivariate analyses women with stage IB1–IIA adenocarcinomas were 39% more likely to die from their tumors than those with squamous tumors while patients with stage IIB–IVA adenocarcinomas were 21% more likely to die from their cancers than similarly staged women with squamous neoplasms. Given the decreased survival associated with adenocarcinoma histology we agree with Dr. Chou
that strategies that tailor treatment to histology would be of great interest and certainly warrant further study. Vijaya Galic Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA Jason D. Wright Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA Herbert Irving Comprehensive Cancer Center, USA Corresponding author at: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, 8th Floor, New York, NY 10032, USA. Fax: +1 212 305 3412. E-mail address: [email protected]. 23 June 2012
doi:10.1016/j.ygyno.2012.06.036
Preoperative identification of a suspicious adnexal mass To the Editor: We have read the meta-analysis of Dodge et al. on the preoperative identification of suspicious adnexal masses with interest [1]. Whilst we agree with the authors that the ideal approach to characterizing ovarian masses has not been determined, we feel their review has some serious omissions which undermine its ability to guide clinicians. Unfortunately both the frequently cited review by Geomini and the AHRQ report from 2006 have also become outdated and do not reflect the current scientific evidence relating to the preoperative characterization of adnexal masses [2,3]. The electronic literature search used in the study by Dodge et al. ended in March 2009, without providing an explanation for the selection of this cut-off. As a result the review is by definition already three years out of date. Furthermore, their complete electronic search cannot be found in an appendix, and the reviewers only used one search engine (Medline) to retrieve new studies within the existing literature. The inclusion criteria for this review are not clearly stated and the authors do not present us with a flow chart containing all potential retrieved citations. In view of this it is difficult to understand the rationale of including two systematic reviews on the accuracy of intra-operative frozen section analysis, as this contradicts with their previously stated objective to determine the optimal strategy for preoperative identification of suspicious adnexal masses. Furthermore, having included these reviews, they were not mentioned in the analysis or discussion section of the paper. We have concerns about the authors' conclusion in relation to 3-D ultrasound. Using a bivariate random effect model to retrieve pooled estimates does account for heterogeneity beyond change due to clinical or methodological differences between studies, and acknowledges the differences in precision by which effect estimates have been measured [4,5]. However, the validity of this pooled estimate for the diagnostic accuracy of 3-D ultrasound, when the definition of malignancy used in each one of the six studies is different, is debatable (Table 1). Their conclusions are based on a total of 614 patients, examined by at least 11 examiners, covered by only six studies which all combine different clinical, laboratory, or ultrasound variables to define ovarian malignancy. Two studies out of the six have been published by a research group linked to allegations of plagiarism and scientific fraud [6].
We do not consider radical trachelectomy an acceptable option for these patients. In fact, it is associated not only with a risk of fetal loss in 1 out of 3 patients treated and with a high risk of prematurity, but also with significant effects on the outcome of subsequent pregnancies. In patients with a tumor diameter between 2 and 4 cm we are unsure how the knowledge of nodal status would modify the approach to patients who have already decided to delay definitive treatment with the aim to have a healthy baby. In this group of patients we would recommend NACT anyway, regardless of nodal status, for both the control of local and metastatic disease, if present. In our experience, when a mother is determined to preserve her pregnancy, the awareness of the nodal status will not change her decision. The theoretical higher oncological risk of delaying definitive treatment and the potential yet questionable benefit of pregnancy termination cannot be quantified or demonstrated. The major concern of Professor Morice and colleagues is about stage Ib2 cervical cancer patients, as they judge the relapse rate too high and the clinical outcome "clearly inferior" to nonpregnant patients. Given that it is hard to generalize results obtained in such a small population and to compare them with a meta-analysis of more than two thousand non-pregnant patients, this might be true. The other side of the coin is that if one considers not only the relapse rate but also the survival among the cases published, the death rate (5/13) is not different from that reported in many trials on NACT [7,8]. We want also to underline that all the patients presented in our series had a tumor diameter>6 cm, which is usually associated with a rate of nodal spread of disease of at least 50% and a high recurrence and death rate. This is the reason why we think it is not totally appropriate to conclude that the rate of local and regional recurrences indicates that NACT was not able to obtain a stabilization of the disease until fetal viability. In fact all patients with Ib2 cervical cancer included in our study achieved at least a stable disease (in details, 2 with partial response and 3 with stable disease). We agree that our results might have been impaired by our choice to administer a monochemotherapy with cisplatin, which is without doubt suboptimal. We had two relevant adverse reactions during pregnancy with paclitaxel, and we decided to give up using it, perhaps prematurely. With the increasing evidences emerging from the literature about the safety of paclitaxel during pregnancy, we may consider to use it again in the future; even then, the doublet should be considered a suboptimal treatment, as the most effective regimen, in our opinion, includes also Ifosfamide. It is difficult to draw some conclusions or definitive guidelines on the treatment of cervical cancer during pregnancy. The sole certainty we experimented is the firm intention of patients to preserve their pregnancy. This firm purpose dictated our clinical management: the primary aim of ensuring patients a healthy baby, while taking into account the potential risk for the mother of delaying radical treatment. Conflict of interest statement All the authors disclose any possible conflict of interest.
References [1] Fruscio R, Villa A, Chiari S, Vergani P, Ceppi L, Dell'orto F, et al. Delivery delay with neoadjuvant chemotherapy for cervical cancer patients during pregnancy: a series of nine cases and literature review. Gynecol Oncol 2012 Aug;126(2):192–7. [2] Amant F, Van Calsteren K, Halaska MJ, Gziri MM, Hui W, Lagae L, et al. Long-term cognitive and cardiac outcomes after prenatal exposure to chemotherapy in children aged 18 months or older: an observational study. Lancet Oncol Mar 2012;13(3):256–64. [3] Holtan SG, Creedon DJ, Haluska P, Markovic SN. Cancer and pregnancy: parallels in growth, invasion, and immune modulation and implications for cancer therapeutic agents. Mayo Clin Proc Nov 2009;84(11):985–1000. [4] Maneo A, Sideri M, Scambia G, Boveri S, Dell'anna T, Villa M, et al. Simple conization and lymphadenectomy for the conservative treatment of stage IB1 cervical cancer. An Italian experience. Gynecol Oncol Dec 2011;123(3):557–60. [5] Cibula D, Abu-Rustum NR. Pelvic lymphadenectomy in cervical cancer—surgical anatomy and proposal for a new classification system. Gynecol Oncol Jan 2010;116(1):33–7. [6] Favero G, Chiantera V, Oleszczuk A, Gallotta V, Hertel H, Herrmann J, et al. Invasive cervical cancer during pregnancy: laparoscopic nodal evaluation before oncologic treatment delay. Gynecol Oncol Aug 1, 2010;118(2):123–7.
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[7] Buda A, Fossati R, Colombo N, Fei F, Floriani I, Gueli Alletti D, et al. Randomized trial of neoadjuvant chemotherapy comparing paclitaxel, ifosfamide, and cisplatin with ifosfamide and cisplatin followed by radical surgery in patients with locally advanced squamous cell cervical carcinoma: the SNAP01 (Studio Neo-Adjuvante Portio) Italian Collaborative Study. J Clin Oncol Jun 20, 2005;23(18):4137–45. [8] Lissoni AA, Colombo N, Pellegrino A, Parma G, Zola P, Katsaros D, et al. A phase II, randomized trial of neo-adjuvant chemotherapy comparing a three-drug combination of paclitaxel, ifosfamide, and cisplatin (TIP) versus paclitaxel and cisplatin (TP) followed by radical surgery in patients with locally advanced squamous cell cervical carcinoma: the Snap-02 Italian Collaborative Study. Ann Oncol Apr 2009;20(4):660–5.
Robert Fruscio⁎ Costantino Mangioni Rodolfo Milani Clinic of Obstetrics and Gynecology, University of Milan—Bicocca, San Gerardo Hospital, Monza, Italy ⁎Corresponding author at: Clinic of Obstetrics and Gynecology, University of Milan—Bicocca, San Gerardo Hospital, Via Pergolesi, 32 Monza, 20052, Italy. Tel.: +39 039 2339434; fax: +39 039 2339435. E-mail address: [email protected] (R. Fruscio). 22 June 2012 doi:10.1016/j.ygyno.2012.06.037
The poorer survival of patients with cervical adenocarcinoma and adenosquamous cell carcinoma compared to those with squamous cell carcinoma might be improved by a different treatment
To the Editor: Galic et al. recently reported a population-based retrospective study on 24,562 patients with cervical carcinoma, and found that the multivariable odds ratio for death was 1.39 (95% CI, 1.23–1.56) for women with adenocarcinoma (AC) and 1.55 (95% CI, 1.32–1.82) for women with adenosquamous carcinoma (ASC) compared to those with squamous cell carcinoma (SCC) [1]. The editorial from the same issue discussed whether we should change the treatment paradigm for the glandular carcinoma of cervix [2]. The incidence of cervical cancer declines alone with popular Pap smear in many countries, but the patient number of cervical AC and ASC remains unchanged that results into their increased percentage [3]. Outcome of AS/ASC in comparison with that of SCC was similar in some reports [4–6] and worse in others [7–10]. Hong et al. reported 928 patients with stage I to IVa cervical cancer treated with primary irradiation, and found that primary tumors of AC/ASC (N =53) showed a slower and a poorer response (p= 0.008) than those of SCC (N= 875) [9]. Patients with AC/ASC also had lower 5-year disease-specific survival rate than those with SCC (50% vs 66%, p=0.016). Huang also reported lower 5year relapse-free survival rate for 148 patients with AC/ASC [10]. Lai's series of 891 patients with stage Ib to II cervical cancer undergoing radical hysterectomy showed that AC/ASC (N=134) has lower 5-year recurrence-free survival (72.2% vs 81.2%, p=0.0109) and OS (74.1% vs 82.8%, p=0.0136) than SCC (N =757) [8]. Further analyses revealed that stage II, parametrial invasion and deep stromal invasion were associated with lymph node metastasis. When disease recurred, successful salvage rate for squamous cell carcinoma was 11.8% and 0% for AC/ASC. Those results implied a lower survival rate for AC/ASC that might be reversed by aggressive treatment for local tumor. From April 2002 to March 2008, 83 consecutive patients with stages I and II AC (N= 59) or ASC (N=24) were treated with radical hysterectomy in our hospital. Patients eligible for radical hysterectomy also included those with positive lymph node on preoperative computed tomography or magnetic resonance imaging, full thickness cervical stromal invasion, and inner 2/3
260
Letters to the Editor
parametrial involvement that we had assigned for radiotherapy previously. Patients with parametrial invasion, deep stromal invasion, lymph node metastasis, or positive vaginal section margin were put on adjuvant concurrent chemoradiation. The 5-year overall survival was 85.5% that was superior to our historical control, 74.1% [11]. From the improved survival attributed to aggressive surgery and adjuvant chemoradiation, we suggest a change of treatment policy for cervical AC/ASC. Conflict of interest statement The author declares that there are no conflicts of interest
References [1] Galic V, Herzog TJ, Lewin SN, Neugut AI, Burke WM, Lu YS, et al. Prognostic significance of adenocarcinoma histology in women with cervical cancer. Gynecol Oncol 2012;125(2):287–91. [2] Rose PG. Are the differences in treatment outcome for adenocarcinoma of the cervix different enough to change the treatment paradigm? Gynecol Oncol 2012;125(2): 285–6. [3] Chen YY, You SL, Chen CA, Shih LY, Koong SL, Chao KY, et al. Taiwan Cervical Cancer Screening Task Force. Effectiveness of national cervical cancer screening programme in Taiwan: 12-year experiences. Br J Cancer 2009;101(1):174–7. [4] Shingleton HM, Bell MC, Fremgen A, et al. Is there really a difference in survival of women with squamous cell carcinoma, adenocarcinoma, and adenosquamous cell carcinoma of the cervix? Cancer 1995;76(10 Suppl.):1948–55. [5] Alfsen GC, Kristensen GB, Skovlund E, et al. Histologic subtype has minor importance for overall survival in patients with adenocarcinoma of the uterine cervix: a population-based study of prognostic factors in 505 patients with nonsquamous cell carcinomas of the cervix. Cancer 2001;92:2471–83. [6] Lee KB, Lee JM, Park CY, Lee KB, Cho HY, Ha SY. What is the difference between squamous cell carcinoma and adenocarcinoma of the cervix? A matched case– control study. Int J Gynecol Cancer 2006;16(4):1569–73. [7] Eifel PJ, Burke TW, Morris M, et al. Adenocarcinoma as an independent risk factor for disease recurrence in patients with stage IB cervical carcinoma. Gynecol Oncol 1995;59:38–44. [8] Lai CH, Hsueh S, Hong JH, et al. Are adenocarcinomas and adenosquamous carcinomas different from squamous carcinomas in stage IB and II cervical cancer patients undergoing primary radical surgery? Int J Gynecol Cancer 1999;9:28–36. [9] Hong JH, Tsai CS, Wang CC, et al. Comparison of clinical behaviors and responses to radiation between squamous cell carcinomas and adenocarcinomas/adenosquamous carcinomas of the cervix. Chang Gung Med J 2000;23:396–404. [10] Huang YT, Wang CC, Tsai CS, Lai CH, Chang TC, Chou HH, et al. Long-term outcome and prognostic factors for adenocarcinoma/adenosquamous carcinoma of cervix after definitive radiotherapy. Int J Radiat Oncol Biol Phys 2011;80(2):429–36. [11] Chou HH, Chang HP, Lai CH, Ng KK, Hsueh S, Wu TI, et al. (18)F-FDG PET in stage IB/IIB cervical adenocarcinoma/adenosquamous carcinoma. Eur J Nucl Med Mol Imaging 2010;37(4):728–35.
Hung-Hsueh Chou E-mail address: [email protected] 14 June 2012 doi:10.1016/j.ygyno.2012.06.024
Re: Prognostic significance of adenocarcinoma histology in women with cervical cancer To the Editor: We appreciate the interest of Dr. Chou in our work. In a series of over 24,000 women with invasive cervical cancer we noted that survival for women with adenocarcinomas was inferior to that of patients with squamous cell carcinomas. These results were noted for both early and advanced-stage disease. Specifically, in multivariate analyses women with stage IB1–IIA adenocarcinomas were 39% more likely to die from their tumors than those with squamous tumors while patients with stage IIB–IVA adenocarcinomas were 21% more likely to die from their cancers than similarly staged women with squamous neoplasms. Given the decreased survival associated with adenocarcinoma histology we agree with Dr. Chou
that strategies that tailor treatment to histology would be of great interest and certainly warrant further study. Vijaya Galic Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA Jason D. Wright Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA Herbert Irving Comprehensive Cancer Center, USA Corresponding author at: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, 8th Floor, New York, NY 10032, USA. Fax: +1 212 305 3412. E-mail address: [email protected]. 23 June 2012
doi:10.1016/j.ygyno.2012.06.036
Preoperative identification of a suspicious adnexal mass To the Editor: We have read the meta-analysis of Dodge et al. on the preoperative identification of suspicious adnexal masses with interest [1]. Whilst we agree with the authors that the ideal approach to characterizing ovarian masses has not been determined, we feel their review has some serious omissions which undermine its ability to guide clinicians. Unfortunately both the frequently cited review by Geomini and the AHRQ report from 2006 have also become outdated and do not reflect the current scientific evidence relating to the preoperative characterization of adnexal masses [2,3]. The electronic literature search used in the study by Dodge et al. ended in March 2009, without providing an explanation for the selection of this cut-off. As a result the review is by definition already three years out of date. Furthermore, their complete electronic search cannot be found in an appendix, and the reviewers only used one search engine (Medline) to retrieve new studies within the existing literature. The inclusion criteria for this review are not clearly stated and the authors do not present us with a flow chart containing all potential retrieved citations. In view of this it is difficult to understand the rationale of including two systematic reviews on the accuracy of intra-operative frozen section analysis, as this contradicts with their previously stated objective to determine the optimal strategy for preoperative identification of suspicious adnexal masses. Furthermore, having included these reviews, they were not mentioned in the analysis or discussion section of the paper. We have concerns about the authors' conclusion in relation to 3-D ultrasound. Using a bivariate random effect model to retrieve pooled estimates does account for heterogeneity beyond change due to clinical or methodological differences between studies, and acknowledges the differences in precision by which effect estimates have been measured [4,5]. However, the validity of this pooled estimate for the diagnostic accuracy of 3-D ultrasound, when the definition of malignancy used in each one of the six studies is different, is debatable (Table 1). Their conclusions are based on a total of 614 patients, examined by at least 11 examiners, covered by only six studies which all combine different clinical, laboratory, or ultrasound variables to define ovarian malignancy. Two studies out of the six have been published by a research group linked to allegations of plagiarism and scientific fraud [6].