Is there a benefit of pretreatment laparoscopic transperitoneal surgical staging in patients with advanced cervical cancer?

Abstract

Objective.

At present, cervical cancer remains the only gynecologic tumor, which is staged by clinical examination according to FIGO. This is associated with a high percentage of over- and understaging of tumor extent. With the operative, especially laparoscopic staging, exact information about intraabdominal tumor spread, lymph node metastases, and involvement of adjacent organs is possible. However, the advantage of operative staging is still discussed controversially. The aim of this study is to describe the laparoscopic transperitoneal staging procedure in patients with cervical cancer and their oncologic outcome after primary chemoradiation.

Methods.

From November 1994 to October 2003, 456 consecutive patients with histologically confirmed primary cervical cancer were admitted to the Department of Gynecology of the Friedrich–Schiller-University Jena, Germany. Out of these, 84 patients with locally advanced tumor (tumor size ≥4 cm) and/or lymph node involvement and/or tumor infiltration to bladder or rectum were selected by a standardized laparoscopic staging procedure for primary chemoradiation. Data of surgery, chemoradiation, and follow-up were analyzed retrospectively for these patients.

Results.

The mean age of the patients was 54 years (26–80), and the mean body-mass-index was 24.8 (17.9–42.2). Preoperative clinical evaluation showed a stage distribution according to FIGO with stage IB1 in 15.5%, IB2 in 15.5%, IIA in 8.3%, IIB in 23.8%, IIIA in 8.3%, IIIB in 21.4%, IVA in 6%, and IVB in 1.2%. In 15 out of 84 (17.8%) patients, intraabdominal tumor spread was diagnosed by laparascopy. In 24 out of 84 (28.5%) patients, invasion of bladder and/or rectum was proven histologically after biopsy. In 60 out of 84 (71%) patients, lymph node metastases were confirmed histologically. In 2 out of 13 patients with FIGO-stage Ib1, skip metastases in infrarenal paraaortic lymph nodes were seen. Removal of more than 5 pelvic and/or more than 5 positive paraaortic lymph nodes was associated with significant improvement of overall survival. According to the histological findings following laparoscopic staging in 36 out of 84 (43%) patients, a higher tumor stage was diagnosed. If tumor involvement of lymph nodes is also included, an upstaging in 73/84 (87%) of patients has to be noted down. Downstaging was not necessary in any patient following laparoscopic evaluation.

Conclusion.

Only operative staging gives exact information about tumor extension in patients with locally advanced and/or nodal positive cervical cancer and allows individual treatment planning. This can be done successfully by a transperitoneal laparoscopic approach without serious adverse effects delaying chemoradiation. Debulking of tumor-involved lymph nodes significantly improves overall survival and should be performed prior to primary chemoradiation. Laparoscopic staging should be the basis for all treatment studies in order to group patients according to true tumor extent.

Introduction

Primary therapy of patients with cervical cancer is done surgically or by chemoradiation. Patients with early tumor stage such as IA2 to IIB are mainly treated surgically, whereas patients diagnosed with stage IB2 or higher undergo primary chemoradiation [1], [9], [10], [17], [29], [30], [40]. The clinical staging according to FIGO is based on the quality of the clinical examination and forms the basis for the decision to recommend surgery or chemoradiation. Comparison of surgery versus radiation in patients with FIGO stage IB to IIA shows no survival benefit in either arm, but increased morbidity when adjuvant radiotherapy has to be given after surgery [26].

According to the FIGO guidelines, cervical cancer continues to be the only gynecologic malignancy that is at present not surgically staged. This implicates a considerable rate of over- and understaging [40], [51]. Imaging techniques such as CT, MRI, or PET show high accuracy for evaluating tumor size, involvement of parametrium or vagina, and lymph node enlargement. However, the detection of tumor-involvement in regular sized lymph nodes, and of tumor foci in edematous tissue is difficult [2], [13], [14], [15], [18], [19], [31], [41], [44]. Thus, imaging techniques cannot fill the diagnostic gap between clinical and surgical–histological staging. On the other hand, detection of metastases in pelvic and/or paraaortic lymph nodes is the most important prognostic factor for the survival in patients with cervical cancer [3], [25], [28], [31], [35], [45], [47], [51]. Exact evaluation of tumor spread intraabdominally, in lymph nodes and/or adjacent organs can only be done by surgical and histophathologic evaluation [3], [7], [8], [12], [13], [24], [32], [38], [48]. However, operative staging by laparotomy is associated with increased bowel morbidity during subsequent radiation and delayed beginning of radiation, reasons which have led in the past to an extraperitoneal approach [6], [12], [38], [43], [49]. Following the introduction of laparoscopic pelvic and paraaortic lymphadenectomy, minimal invasive staging of patients with cervical cancer can be done without increasing morbidity [3], [4], [21], [22], [36], [38], [43], [48]. However, a recent prospective study showed a survival disadvantage for patients following surgical (open or laparoscopic) staging compared to clinical staging when primary chemoradiation was performed [24].

Sentinel concept may be useful in the future for detection and exstirpation of relevant lymph nodes, but is still under research [34]. The value of debulking of tumor-involved lymph nodes in patients with cervical cancer is also controversially discussed [11], [20], [23], [27], [37], [46]. Since multimodal therapy and improvement of the technique of brachytherapy allow successful treatment of the loco-regional disease, techniques which allow treatment of lymph node metastases become increasingly important [9], [10], [25], [27]. It was the purpose of this study to evaluate the results of primary laparoscopic transperitoneal staging including debulking of lymph nodes in patients with primary cervical cancer and to analyze the oncologic outcome following subsequent primary chemoradiation.