Elsevier

Gynecologic Oncology

Volume 131, Issue 1, October 2013, Pages 222-230
Gynecologic Oncology

Review
Surgery for early stage cervical cancer: How radical should it be?

https://doi.org/10.1016/j.ygyno.2013.07.078Get rights and content

Highlights

  • Radical surgery for cervical cancer confers a significant risk of intra-operative and post-operative morbidity

  • Treatment of early cervical cancer is evolving: non-radical surgery may be safe in some situations, including early adenocarcinoma

  • Ongoing large, prospective trials will help define the best candidates for non radical surgery

Abstract

Objective

Less radical or non radical surgery for early-stage cervical cancer has been proposed to reduce morbidity while maintaining oncologic outcomes. Given that a standardized approach to conservative surgery is not yet available, we have summarized the literature on less radical surgery to better inform clinical practice.

Methods

MEDLINE R and MEDLINE in-process and non-indexed citations were searched from inception to April 14, 2013 to identify all English-language articles evaluating less-radical or non radical surgery for invasive cervical carcinoma. Articles including patients with squamous cell carcinoma, adenocarcinoma and adenosquamous carcinoma were included and a narrative review of the literature is presented.

Results

Radical surgery is associated with significant adverse effects in terms of urinary function, sexual function, and body image. Radical trachelectomy is an accepted fertility-sparing option, but still leads to morbidity from parametrectomy. The importance of the parametrectomy in patients with small early-stage tumors has been questioned recently, and many studies have found simple hysterectomy and simple trachelectomy can be safe in appropriately selected patients. Cone biopsy may be a fertility-sparing option in those patients with a very low risk of parametrial involvement. Neoadjuvant chemotherapy is also being investigated as a method to reduce the need for radical surgery. Sentinel lymph node biopsy is discussed as a method to reduce the morbidity while increasing the sensitivity of pelvic lymph node assessment in women with early cervical cancers. Finally, the treatment of early adenocarcinoma is addressed.

Conclusions

It appears many women with early-stage cervical cancer can be treated less radically than has been done in the past. Large prospective trials are underway to further define candidates for less-radical surgery.

Introduction

Cervical cancer is the third most common malignancy in women worldwide [1]. While radical hysterectomy is an effective treatment in women with early stage cervical cancer (Stages IA1–IIA), with 5-year overall survival rates of 73.4%–97.5% [2], [3], [4], this procedure is not without morbidity. The risk of blood loss and transfusion, nerve or vascular injury, bladder and bowel dysfunction, fistula formation, lymphedema, and sexual dysfunction are significant [2], [5], [6], [7], [8], [9].

In certain cases of early stage cervical carcinoma, the risk of parametrial involvement and lymph node metastases is accepted to be low. In the treatment of microinvasive squamous cell carcinoma, for instance, cone biopsy or simple hysterectomy has become an acceptable alternative [10], [11]. While traditionally patients have received radical surgery for all but the smallest squamous cervical lesions [12], there is a movement towards less radical surgery in patients with 1A and small 1B cervical carcinoma.

Bergmark et al. [5] asked women whether they would be willing to make a ‘trade off’ of decreased morbidity at the cost of a slightly decreased survival. Ninety percent of women were not willing to make such a compromise. The question to be answered, therefore, appears to be whether a decrease in morbidity is possible in some patients without a compromise in oncologic outcome. While the GOG is currently evaluating physical function and quality of life in patients following non-radical surgery for early stage cervical cancer patients (IA1 with lymph-vascular space invasion (LVSI), IA2–IB1 ≤ 2 cm) this review is intended to evaluate the evidence in support of non-radical surgery in carefully selected patients.

Section snippets

Methods

MEDLINE R and MEDLINE in-process and non-indexed citations were searched from inception to April 14, 2013 to identify all English-language publications of less radical or non-radical surgery for invasive cervical carcinoma. No exclusions based on histology were embedded in the search strategy, however this review only addresses treatment of squamous cell carcinoma, adenocarcinoma and adenosquamous carcinoma. The search strategy incorporated appropriate controlled vocabulary and keyword searches

Morbidity of radical surgery for cervical cancer

The first series of radical hysterectomy in the treatment of cervical cancer was reported by Ernst Wertheim in 1912 [13]. This was followed by the series of Meigs [14]. The radical hysterectomy today is commonly categorized by amount of parametria resected (or class), with class III (radical) hysterectomy, typically employed in cases of IB or IIA disease and class II (modified radical) hysterectomy offered primarily to patients with stage IA2 disease.

Compared to the class I or non-radical

Conclusions

The treatment of cervical cancer is evolving. Less radical or non-radical surgery appears to be appropriate for many women with early stage disease and small tumors. In addition, the use of sentinel lymph node biopsy has the potential to improve the sensitivity of pelvic lymph node assessment while reducing morbidity for those without nodal metastatic spread. However, we must ensure oncologic outcomes remain excellent for women with early stage disease, as patients are not willing to accept a

Conflict of interest statement

The authors declare they have no conflicts of interest.

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