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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