ReviewConservative management of early stage cervical cancer: Is there a role for less radical surgery?
Research Highlights
► Retrospective studies have shown that < 1% of patients with early stage cervical cancer with favorable pathologic characteristics have parametrial involvement. ►Approximately 60% of patients undergoing radical trachelectomy have no residual disease in the final pathologic specimen. ►Conservative surgery (lymphadenectomy with simple hysterectomy or cervical conization) may therefore be an option for this group of patients. ►A prospective, multi-center, international trial is currently being performed to evaluate the outcomes of performing conservative surgery in women with early stage cervical cancer with favorable pathologic characteristics.
Section snippets
Background
Cervical cancer is the most common cause of death from gynecologic cancer worldwide. For women with early stage disease undergoing surgical management, the standard treatment consists of a radical hysterectomy and pelvic lymph node dissection [1]. Although radical hysterectomy results in excellent local tumor control, it is also associated with significant morbidity [2], [3], [4], [5], [6], [7]. Much of this morbidity is due to the removal of the parametrium, which contains autonomic nerve
Radical trachelectomy
Radical trachelectomy offers a conservative approach for women with early stage disease who wish to retain fertility. Multiple studies have reported that radical trachelectomy is feasible, safe and has equivalent disease-free and overall survival rates when compared to radical hysterectomy [8], [9], [10], [11]. However, like radical hysterectomy, radical trachelectomy involves the removal of the parametrium and associated complications. In addition, fertility cannot always be preserved in women
Parametrial involvement in early cervical cancer
The utility of parametrial resection in women with early stage cervical cancer is controversial. Several studies have shown that < 1% of patients with early cervical cancer with favorable pathologic characteristics have parametrial involvement (Table 1) [13], [14], [15], [16], [17], [18], [19]. In addition, it has been shown that in approximately 60% of patients undergoing radical trachelectomy, the final pathologic specimen contains no residual disease [9].
An early study by Kinney et al. [13]
Conservative surgery
Given the low rate of parametrial involvement in cervical cancer patients with favorable pathologic characteristics undergoing radical hysterectomy or radical trachelectomy, a more conservative surgical approach has been suggested for these patients. Recent studies by Rob et al. [20], [21] reported on the feasibility and safety of performing less radical, fertility-sparing surgery in women with stage IA1 to IB1 cervical carcinoma. All patients underwent laparoscopic sentinel lymph node
Neoadjuvant chemotherapy and conservative surgery
The use of neoadjuvant chemotherapy followed by conservative surgery in women with early cervical cancer desiring future fertility has recently been described [21], [24], [25]. Plante and colleagues [25] reported on three patients with bulky stage IB1 disease treated with three cycles of neoadjuvant chemotherapy with cisplatin, paclitaxel and ifosfamide followed by radical vaginal trachelectomy and pelvic lymph node dissection. A complete pathologic response was noted in all three patients with
Prospective study
Given the low rates of parametrial involvement reported in multiple retrospective studies, M.D. Anderson Cancer Center is currently conducting a prospective, international, multi-institutional cohort study evaluating the safety and feasibility of performing conservative surgery in women with early stage cervical cancer with favorable pathologic characteristics. The inclusion criteria include stage IA2 or IB1 disease; tumor size ≤ 2 cm; and squamous cell carcinoma or adenocarcinoma histology.
Summary
Retrospective studies have shown that less than 1% of patients with early stage cervical cancer with favorable pathologic characteristics have parametrial involvement on radical hysterectomy specimens. In addition, approximately 60% of radical trachelectomy specimens contain no residual disease. Therefore, a prospective, international, multi-center trial is currently being performed to determine the safety and feasibility of performing pelvic lymphadenectomy with conservative surgery (simple
Conflict of interest statement
The authors report no conflict of interest.
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2021, European Journal of Obstetrics and Gynecology and Reproductive BiologyFrom FIGO-2009 to FIGO-2018 in women with early-stage cervical cancer; Does the revised staging reflect risk groups?
2021, Gynecologic OncologyCitation Excerpt :The recommendations include a cone biopsy, cervical amputation, or simple hysterectomy in women with tumor size ≤20 mm, type A-B radical hysterectomy or trachelectomy in tumors >7–20 mm with LVSI, and SLN mapping in all women with tumors >7–20 mm [5]. This is a cautious adaptation to FIGO-2018 while awaiting international results from studies applying conservative surgical management in women with low risk of metastases such as no lymphovascular space invasion (LVSI), depth of invasion ≤10 mm and tumor size ≤20 mm (SHAPE, GOG-278, and ConCerv) [6–8]. The overall purpose of this paper is to evaluate if the stage migration related to the implementation of FIGO-2018 in early-stage cervical cancer correctly reflects risk groups as indicated by the presence of lymph node metastases.
Neoadjuvant chemotherapy followed by fertility sparing surgery in cervical cancers size 2–4 cm; emerging data and future perspectives
2021, Gynecologic OncologyCitation Excerpt :Unfortunately, the current selection criteria for fertility preservation in young women with cervical cancer is highly restrictive. Fertility can be preserved in a select group of patients with small tumors and favorable pathological characteristics [23]. The radical trachelectomy procedure is recognized as an alternative to the standard radical hysterectomy for young women with lesions <2 cm that desire fertility preservation [4].
Conservative (non-radical) surgery for stage IB1 cervical cancer
2021, Best Practice and Research: Clinical Obstetrics and GynaecologyCitation Excerpt :Pregnancy outcomes following abdominal radical trachelectomy show an even greater rate of 1st and 2nd trimester miscarriages and pre-term deliveries [36]. It should also be noted that 60% of radical trachelectomy specimens have no residual disease in their surgical specimen [13]. Obstetric outcomes relating to simple trachelectomy would be expected to be equivalent to radical trachelectomy on the basis that fertility ad pregnancy outcomes are related to removal of the cervix rather than the surrounding tissues.