8Conservative management of cervical cancer: Current status and obstetrical implications
Section snippets
A growing concern about the benefit of radical surgery in early-stage disease
The standard treatment for early-stage cervical cancer has traditionally been radical hysterectomy to minimize residual tumor and prevent relapse of disease [1]. Despite excellent oncologic outcomes, radical hysterectomy is associated with several complications, primarily owing to the removal of the parametria [2]. These include bladder and rectal dysfunction, sexual dysfunction, and fistula formation [3], [4], [5], [6], [7]. While morbidity induced by parametrectomy can significantly alter the
Cervical conization
Cervical conization is defined as the excision of a cone-shaped or cylindrical wedge of the uterine cervix involving the transformation zone. It has been widely accepted for the treatment of patients with International Federation of Gynecology and Obstetrics (FIGO) stage IA1 disease [42]. In patients with lymphovascular space invasion (LVSI), pelvic lymph node dissection or sentinel lymph node mapping is recommended in addition to conization. This consensus was reached following an analysis of
Neoadjuvant chemotherapy and conservative management of cervical cancer
The role of neoadjuvant chemotherapy (NACT) in the treatment of early-stage cervical cancer is being explored. Indications for NACT are to reduce tumor size to later facilitate surgical resection and to minimize prognostic factors associated with a poor response, thereby eliminating the need for postoperative adjuvant radiotherapy [59]. In patients with stages IB1 and IIA disease with tumor size of 2–4 cm, NACT has been shown to reduce nodal metastases, parametrial infiltration, and tumor size,
Future directions
There remain several unanswered questions regarding the safety of conservative management in early-stage cervical cancer.
Ongoing trials
To provide stronger evidence on the efficacy of conservative management for early-stage cervical cancer, larger prospective trials are currently ongoing. These include an international trial (ConCerv) led by our team at the University of Texas MD Anderson Cancer Center ∗[22], [75]. Started in 2009, ConCerv is a multi-institutional trial evaluating the safety of conservative surgery in women with early-stage cervical cancer with favorable prognostic features. Patients desiring fertility in the
Summary
Conservative surgery is being investigated as an alternative to radical surgery in the management of early-stage cervical cancer. Because of the effective implementation of cervical cancer screening and early detection programs in high-resource settings, a growing number of women are diagnosed with small-volume disease. Given the increased survival and the low risk of parametrial spread observed in this population, less radical surgery will likely gain wider attention in the coming years. While
Conflicts of interest
KMS is the PI of the ConCerv trial.
JFD has no conflict of interest to disclose.
Acknowledgments
This work was supported in part by a Cancer Prevention Fellowship for JFD supported by the Cancer Prevention and Research Institute of Texas grant award, RP170259, Shine Chang, PhD, Principal Investigator, and by the MD Anderson Cancer Center Support Grant, CA016672, funded by the National Cancer Institute (CA016672).
References (77)
- et al.
Anorectal dysfunction after surgical treatment for cervical cancer
J Am Coll Surg
(2002) - et al.
'State of the art' of radical hysterectomy; current practice in European oncology centres
Eur J Cancer
(2004) - et al.
Identification of a low-risk subset of patients with stage IB invasive squamous cancer of the cervix possibly suited to less radical surgical treatment
Gynecol Oncol
(1995) - et al.
How important is removal of the parametrium at surgery for carcinoma of the cervix?
Gynecol Oncol
(2002) - et al.
The incidence of parametrial tumor involvement in select patients with early cervix cancer is too low to justify parametrectomy
Gynecol Oncol
(2007) - et al.
Early cervical cancer and parametrial involvement: is it significant?
Gynecol Oncol
(2006) - et al.
A prospective study of sentinel lymph node status and parametrial involvement in patients with small tumour volume cervical cancer
Gynecol Oncol
(2008) - et al.
Clinical tumor diameter and prognosis of patients with FIGO stage IB1 cervical cancer (JCOG0806-A)
Gynecol Oncol
(2015) - et al.
Conservative surgery in early-stage cervical cancer: what percentage of patients may be eligible for conization and lymphadenectomy?
Gynecol Oncol
(2010) - et al.
Feasibility of less radical surgery for superficially invasive carcinoma of the cervix
Gynecol Oncol
(2010)
Can parametrectomy be avoided in early cervical cancer? An algorithm for the identification of patients at low risk for parametrial involvement
Eur J Surg Oncol
Conservative management of early stage cervical cancer: is there a role for less radical surgery?
Gynecol Oncol
Gynecologic cancer treatment and the impact of cancer-related infertility
Gynecol Oncol
Oncological safety of laparoscopic-assisted vaginal radical trachelectomy (LARVT or Dargent's operation): a comparative study with laparoscopic-assisted vaginal radical hysterectomy (LARVH)
Gynecol Oncol
The vaginal radical trachelectomy: an update of a series of 125 cases and 106 pregnancies
Gynecol Oncol
Total laparoscopic radical trachelectomy in the treatment of early squamous cell cervical cancer: a retrospective study with 8-year follow-up
Gynecol Oncol
Vaginal radical trachelectomy: an oncologically safe fertility-preserving surgery. An updated series of 72 cases and review of the literature
Gynecol Oncol
Management of low-risk early-stage cervical cancer: should conization, simple trachelectomy, or simple hysterectomy replace radical surgery as the new standard of care?
Gynecol Oncol
Treatment of microinvasive adenocarcinoma of the uterine cervix: a retrospective study and review of the literature
Gynecol Oncol
Surgery for early stage cervical cancer: how radical should it be?
Gynecol Oncol
Chemo-conization in early cervical cancer
Gynecol Oncol
A less radical treatment option to the fertility-sparing radical trachelectomy in patients with stage I cervical cancer
Gynecol Oncol
Less radical surgery than radical hysterectomy in early stage cervical cancer: a pilot study
Gynecol Oncol
Excisional cone as fertility-sparing treatment in early-stage cervical cancer
Fertil Steril
Simple conization and lymphadenectomy for the conservative treatment of stage IB1 cervical cancer. An Italian experience
Gynecol Oncol
Simple extrafascial trachelectomy and pelvic bilateral lymphadenectomy in early stage cervical cancer
Gynecol Oncol
Small volume stage 1B1 cervical cancer: is radical surgery still necessary?
Gynecol Oncol
Non-radical surgery for small early-stage cervical cancer. Is it time?
Gynecol Oncol
Neoadjuvant chemotherapy followed by large cone resection as fertility-sparing therapy in stage IB cervical cancer
Gynecol Oncol
Less radical surgery for early-stage cervical cancer: to what extent do we justify it?-Our belief
Taiwan J Obstet Gynecol
Neoadjuvant chemotherapy and vaginal radical trachelectomy for fertility-sparing treatment in women affected by cervical cancer (FIGO stage IB-IIA1)
Gynecol Oncol
Neoadjuvant chemotherapy and conservative surgery for stage IB1 cervical cancer
Gynecol Oncol
Efficacy of neoadjuvant chemotherapy in patients with FIGO stage IB1 to IIA cervical cancer: an international collaborative meta-analysis
Eur J Surg Oncol
Immediate radical trachelectomy versus neoadjuvant chemotherapy followed by conservative surgery for patients with stage IB1 cervical cancer with tumors 2cm or larger: a literature review and analysis of oncological and obstetrical outcomes
Gynecol Oncol
Laparoscopic lymph node dissection should be performed before fertility preserving treatment of patients with cervical cancer
Gynecol Oncol
Advancing fertility-sparing treatments in cervical cancer: where is the limit?
Gynecol Oncol
Is parametrectomy always necessary in early-stage cervical cancer?
Gynecol Oncol
A model for prediction of parametrial involvement and feasibility of less radical resection of parametrium in patients with FIGO stage IB1 cervical cancer
Gynecol Oncol
Cited by (22)
Gynecologic cancers and non-coding RNAs: Epigenetic regulators with emerging roles
2021, Critical Reviews in Oncology/HematologyCitation Excerpt :Moreover, the incidence rate of cervical adenocarcinoma in women 39 years or younger steadily increased from 1976 to 2012 with an annual % change equal to 5.0 in Japan (Yagi et al., 2019). For example, cervical cancer in U.S. was the most-often diagnosed disease in females aged 35–44, in comparison to females between 45 and 54 years in the 1990s (Fokom Domgue and Schmeler, 2019). Additionally, there is an overall poor prognosis for advanced cervical cancer (Cohen et al., 2019).
Therapeutic potential of p53 reactivation in cervical cancer
2021, Critical Reviews in Oncology/HematologyNeoadjuvant chemotherapy followed by conization in stage IB2–IIA1 cervical cancer larger than 2 cm: a pilot study
2021, Fertility and SterilityFertility preservation in women with cervical cancer
2020, Critical Reviews in Oncology/HematologyCitation Excerpt :It has also been suggested that tumors between 2 and 4 cm (FIGO 2018 IB2) can be treated with neoadjuvant chemotherapy followed by conization or simple/radical trachelectomy (Pareja et al., 2015; Tomao et al., 2016; Tesfai et al., 2020; Zusterzeel et al., 2020). Reported outcomes are comparable to those observed after standard treatment (recurrence rate 8.5 %) (Fokom Domgue and Schmeler, 2019). However, conservative surgical treatment for patients with IB2 tumors should be still considered experimental.
Simple conization and pelvic lymphadenectomy in early-stage cervical cancer: A retrospective analysis and review of the literature
2020, Gynecologic OncologyCitation Excerpt :Generally, they were chosen from patients who had low rates of PI. Domgue et al. [9] listed the published studies about the prognostic factors used to identify patients with low risk of parametrial spread. Among patients who had a PI <1%, almost all the patients had tumor size ≤2 cm and a histology of SCC, AC, and AS.
Long-term results of fertility-sparing treatment for early-stage cervical cancer
2019, Gynecologic OncologyCitation Excerpt :In recent years, accumulating data underlined the safety and effectiveness of various methods to preserve fertility in young women diagnosed with cervical cancer. Conization is recommended in patients affected by stage IA1 cervical cancer while radical trachelectomy should be considered in stage IA2 and IB1 [7]. However, several retrospective experiences underlined that more conservative approaches including conization are safe and effective in young women [20–23].