Lymph Node Involvement in Early-Stage Cervical Cancer: Is Lymphangiogenesis a Risk Factor? Results from the MICROCOL Study

Abstract

Background: In patients with cervical cancer, the presence of tumoral lymph-vascular space invasion (LVSI) is the main risk factor for pelvic lymph node metastasis (PLNM). The objective of this study was to evaluate the presence of several markers of lymphangiogenesis in early-stage cervical cancer and their correlation with PLNM and tumoral recurrence. Materials and Methods: Seventy-five patients with early-stage cervical carcinoma underwent sentinel lymph node (SLN) sampling in association with complete pelvic lymph node dissection. Primary tumors were stained with the following markers: Ki67, D2-40, CD31 and VEGF-C. A 3-year follow-up was performed to evaluate the disease-free survival. Results: Overall, 14 patients (18.6%) had PLNM. Positive LVSI was seen in 29 patients (38.6%). There was a significant correlation between LVSI evidenced by H/E staining and PLNM (p < 0.001). There was no correlation between high Ki67, CD31, D2-40, and VEGF-C staining with PLNM or tumor recurrence. Conclusions: Our data support that lymphatic spread does not require the proliferation of new lymphatic endothelial cells in early-stage cervical cancer. These results emphasize the importance of pre-existing peritumoral lymphatic vessels in the metastatic process in early cervical cancer. None of the markers of lymphangiogenesis and proliferation assessed in this study were predictive of PLNM or recurrence.

Keywords: angiogenesis; cervical cancer; lymph nodal metastasis; lymph-vascular space invasion; lymphangiogenesis.

Figure A1

H/E staining and D2-40 antibody staining in emboli detection. Examples of detection of lymphatic invasion in H&E staining and D2-40 antibody staining. (A) Detection of peripheric emboli in H&E staining (A1) and D2-40 antibody staining (A2) (original magnification 200×). (B) Unclear detection of intra-tumoral emboli in H&E staining (B1), after D2-40 antibody staining the intra-tumoral emboli detection appear clear (original magnification 400×) (B2).

Figure A2

Cytoplasmic VEGF-C antibody staining. Exemples of cytoplasmic VEGF-C antibody staining in squamous cell carcinoma and adenocarcinoma of the cervix. The cytoplasmic staining intensity was scored from 0 (not staining) to 3 (most intensely stained). (A) Squamous cells carcinoma: (A1) staining score 1+ (original magnification 200×); (A2) staining score 2+ (original magnification 400×). (B) Adenocarcinoma: (B1) staining score 1+ in tumor area and staining score 0 in normal gland (original magnification 400×); (B2) staining score 2+ (original magnification 400×); (B3) staining score 3+ (original magnification 400×); (B4) staining score 3+ (original magnification 200×).

Figure A3

Cytoplasmic staining with D2-40 antibody. Examples of the pattern of podoplanin D2-40 antibody expression in squamous cell carcinoma and adenocarcinoma of the cervix. (A) Focal weakly staining in squamous carcinoma (score 1a) original magnification 400×. (B) Diffuse weakly staining in adenocarcinoma (score 1b) original magnification 400×. (C) Focal strong staining in squamous carcinoma (score 2a) original magnification 200×. (D) Diffuse strong staining in squamous carcinoma (score 2b) original magnification 200×. (E) Diffuse strong staining in adenocarcinoma (score 2b) original magnification 400×.

Figure 1

ROC curve: LVSI detected by H/S and positive lymph node.

Figure 2

DFS in patients with positive and negative LN. LN−: negative lymph node; LN+: positive lymph node.