ReviewSurgery for early stage cervical cancer: How radical should it be?
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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Trachelectomy: How is it actually done? A review from FRANCOGYN group Titre: Trachélectomie: comment faire en pratique ? Revue de la littérature par le groupe FRANCOGYN
2022, Journal of Gynecology Obstetrics and Human ReproductionCitation Excerpt :Trachelectomy appears to be an appropriate and effective therapeutic option for the management of early cervical cancer in patients wishing to preserve fertility. Numerous studies have shown that there is no significant difference between trachelectomy and hysterectomy in terms of risk of recurrence or overall survival [6–10]. Described by Dargent in 1987, enlarged vaginal trachelectomy consists of resection of the cervix, the upper third of the vagina, and the proximal part of the parameters and preservation of the upper part of the endocervix, the uterine body, and the appendages [7,11].
Retrospective analysis of the incidence and predictive factors of parametrial involvement in FIGO IB1 cervical cancer
2021, Journal of Gynecology Obstetrics and Human ReproductionPost-Conization FIGO stage IA1 squamous cell cervical carcinoma; is hysterectomy necessary?
2021, European Journal of Obstetrics and Gynecology and Reproductive BiologyCitation Excerpt :Since these patients have a minimal risk of LVSI or parametrial involvement, not associated to a risk of recurrence or reduced disease-free survival, a post-conization management based on follow-up would be suitable [28,29]. Stage IA1 CC with negative resection margins has been associated to minimal risk of lymph node metastasis (<1%) [30,31] and nearly 100% rate of 5-year survival [24] when treated with nonradical methods such as conization alone [27]. Thus, current trends are towards adopting a management approach as conservative as possible, even when childbearing is not being planned.
Nodal metastasis in gynecologic malignancies: Update on imaging and management
2020, Clinical ImagingCitation Excerpt :Surgical debulking can be considered for large nodes. For patient with positive paraaortic nodes during surgery, screening CT chest or PET-CT are recommended [63,68]. Recognizing the precise location of nodal metastasis is essential for selecting appropriate treatment and predicting the success of optimal surgical resection in ovarian cancer patients.
Conservative management of cervical cancer: Current status and obstetrical implications
2019, Best Practice and Research: Clinical Obstetrics and GynaecologyCitation Excerpt :This consensus was reached following an analysis of the US Surveillance, Epidemiology, and End Results (SEER) database of women age ≤40 years with stage IA1 cervical cancer where no difference was found in the 5-year survival rate between those who underwent conization alone versus hysterectomy (98% versus 99%) [43]. Although radical trachelectomy is recommended in women of reproductive age with stage IA2 and stage IB1 disease who desire fertility in the future, data from retrospective studies suggest that conization with lymph node dissection could be safe in these patients, providing accurate tumor measurement is available, and the margins are negative on the conization specimen [44,45]. Table 2 summarizes the oncologic outcomes of patients with cervical cancer treated conservatively reported in the literature [42,46–57].