Less radical surgery for early-stage cervical cancer: Can conization specimens help identify patients at low risk for parametrial involvement?

Objective

Radical hysterectomy for cervical cancer is associated with increased morbidity over an extrafascial hysterectomy. The goal of this study was to determine incidence of and risk factors for parametrial involvement (PI) based on conization specimen (CS) and to potentially identify candidates for less radical surgery.

Management of heavy menstrual bleeding: is hysterectomy the radical mastectomy of gynecology?

Both hysterectomy for heavy menstrual bleeding and radical mastectomy for breast cancer are steeped in the history of surgery and have recently been challenged as being too radical for the disorder at hand. Radical mastectomy has largely been replaced with local removal of the tumor with subsequent radiation and/or chemotherapy. Alternatives to hysterectomy include a number of medical interventions, most notably intrauterine progestin-releasing systems, and endometrial ablation, a procedure that has a relatively high success rate and one that is now feasible for many women in an office or procedure room setting. However, although radical mastectomy rates have dropped precipitously, hysterectomy rates, at least in the United States remain relatively stable. Determining the proportion of hysterectomies that are done for heavy menstrual bleeding is difficult, largely because of coding issues, so it is difficult to measure the impact of new medical and minimally invasive surgical procedures. Nevertheless, it seems clear that many women are not exposed to the plethora of options to hysterectomy, a fact that may reflect a number of issues that may include training, skill, and financial incentives or disincentives. Clearly, options to hysterectomy are not a panacea, but if women are empowered to select from all of the options available, the rate of hysterectomy for bleeding should decrease while maintaining, or even enhancing the patient's satisfaction with care.     

Can laparoscopic radical hysterectomy be a standard surgical modality in stage IA2–IIA cervical cancer?

ObjectivesTo determine if laparoscopic radical hysterectomy (LRH) can be substituted for radical abdominal hysterectomy for women with International Federation of Gynecology and Obstetrics (FIGO) stage IA2–IIA cervical cancer.MethodsWe retrospectively reviewed the medical records of cervical cancer patients who underwent LRH with laparoscopic pelvic lymphadenectomy (LPL) and/or laparoscopic para-aortic lymphadenectomy (LPAL) from March 2003 to December 2011.ResultsOf 118 enrolled patients, six were in FIGO stage IA2, 66 were in IB1, 41 were in IB2, one was in IIA1, and four were in IIA2. The median operating time, perioperative hemoglobin change, the number of harvested pelvic and para-aortic lymph nodes were 270 min (range, 120–495), 1.7 g/dL (range, 0.1–5), 26 (range, 9–55), and 7 (range, 1–39), respectively. There was no unplanned conversion to laparotomy. Intra- and postoperative complications occurred in 16 (13.5%) and 8 (6.7%) patients, respectively. In a median follow-up of 31 months (range, 1–89), 5-year recurrence-free and overall survival rates were 90% and 89%, respectively. Univariate analysis showed that cervical stromal invasion (P = 0.023) and lymph node metastasis (P = 0.018) affected survival rate. Cox-proportional hazards regression analysis showed that lymph node metastasis was the only independent factor for poor prognosis (hazard ratio = 7.0, P = 0.022).ConclusionsLRH with LPL and/or LPAL in women with stage IA2–IIA cervical cancer is safe and feasible in terms of survival and morbidity. Our data suggest the need for larger prospective trials which could support this approach as a new standard of care for stage IA2–IIA cervical cancer.     

Early adenocarcinoma of the cervix: is radical vaginal trachelectomy safe?

Objective

Radical vaginal trachelectomy (RVT) is a revolutionary option for fertility preservation in young women with early cervical tumors. Several series have demonstrated outcomes comparable to radical hysterectomy (RH), but none has addressed the influence of histology. We evaluated the safety of RVT in adenocarcinomas.

Methods

Data on surgically treated adenocarcinoma (AC) and squamous cell carcinoma (SCC) cases was taken from a centralized Toronto Cervical Cancer Database. Prognostically important tumor features, lymph node status, and the use of adjuvant therapies were compared. Adenocarcinoma cases treated with RVT were compared to AC cases treated with RH, and to SCC cases that had RVT. Recurrence-free survival was calculated from the date of surgery. Medians, proportions, and survival curves were compared with the Mann Whitney test, the Chi-square test, and the Log Rank test, respectively.

Results

74 patients with AC and 66 patients with SCC undergoing RVT, and 187 cases of AC undergoing RH were analyzed.Patients undergoing RVT were younger than patients having RH (31 vs. 40, p < 0.001). Tumor characteristics were similar, but depth of invasion and the frequency of high grade lesions were higher in the RH group (5 mm vs. 3 mm, p < 0.001; and 36% vs. 22%, p = 0.04). Adjuvant treatment was given more frequently after RH (12% vs. 3%, p < 0.05). There was no significant difference in recurrence-free survival between RH and RVT for AC, or between AC and SCC patients treated by RVT.

Conclusions

RVT is a safe alternative for early stage cervical adenocarcinoma in appropriately selected patients wishing to preserve fertility.     

Conservative management of early stage cervical cancer: is there a role for less radical surgery?

Objectives

The utility of parametrial resection in women with early stage cervical cancer is controversial. In patients with favorable pathologic characteristics such as tumor size < 2 cm and the absence of lymphovascular space invasion, the rate of parametrial involvement is very low. More conservative surgical approaches have therefore been suggested. The objective of this report is to review the existing literature in this area and to describe an ongoing prospective study evaluating the safety and efficacy of conservative surgery in women with early stage cervical cancer.

Methods

We performed a search of PubMed for English language articles published between 1970 and 2010 using the MeSH terms “cervical cancer”, “conservative surgery”, and “cone biopsy”.

Results

Several retrospective studies have shown that < 1% of patients with early stage cervical cancer with favorable pathologic characteristics have parametrial involvement. In addition, approximately 60% of patients undergoing radical trachelectomy have no residual disease in the final pathologic specimen. Recent studies have reported on the feasibility and safety of performing less radical surgery consisting of pelvic lymphadenectomy with cone biopsy, simple trachelectomy or simple hysterectomy in women with stage IA1 to IB1 cervical carcinoma. In addition, a prospective, multi-center, international trial is currently being performed to evaluate the outcomes of performing pelvic lymphadenectomy with conservative surgery (simple hysterectomy or cervical conization) in patients with favorable pathologic characteristics. Neoadjuvant chemotherapy followed by conservative surgery is also being explored as an option for patients with larger tumors and other pathologic characteristics that do not meet the criteria to perform conservative surgery alone.

Conclusions

The rate of parametrial involvement in women with early stage cervical cancer with favorable pathologic characteristics is low. Should the results of ongoing studies be favorable, conservative surgery could become the standard of care for certain women with early stage cervical cancer.     

Small volume stage 1B1 cervical cancer: Is radical surgery still necessary?

Objective

Current surgical treatment of FIGO stage 1B1 cervical cancer is radical surgery. However, several reports have shown that for small tumours a more conservative approach can be as effective in terms of survival, whilst at the same time reducing the morbidity associated with removing the parametrium. The objective of our study was to report survival and obstetric outcomes following conservative management of small-volume stage 1B1 disease.

Methods

All patients with FIGO stage 1B1 cancer and estimated tumour volume of less than 500 mm³ in a loop biopsy specimen were included in the study, irrespective of other histological characteristics. A second loop biopsy was performed to rule out residual disease in 79% of patients.

Results

Sixty two women were identified with a median age of 35 years (range 27-67). Median tumour length was 9.75 mm (7.2-20) and median depth of invasion was 1.55 mm (0.3-5). Thirty five women (56.4%) were treated with loop biopsy, whilst 27 (45.6%) had simple hysterectomy. Fifty seven women (92%) had pelvic lymphadenectomy and one positive node was recorded. After a median follow up of 56 months (16-132) no recurrence was noted. Seven full term pregnancies have been achieved. There were no preterm deliveries or mid-term miscarriages.

Conclusion

Cervical loop biopsy or simple hysterectomy combined with negative pelvic lymphadenectomy for small-volume stage 1B1 cervical cancer offers excellent prognosis in terms of survival. Postoperative morbidity is reduced and obstetric outcomes may be improved. Should these results be verified by further prospective studies, radical surgery for these women may be avoided.     

Is concurrent chemotherapy and radiotherapy the new standard of care for locally advanced cervical cancer?

Abstract. Lehman M, Thomas G. Is concurrent chemotherapy and radiotherapy the new standard of care for locally advanced cervix cancer?
The results of five multi-institutional randomized controlled trials demonstrating a survival advantage for the concurrent administration of chemotherapy and radiotherapy in the management of cervix cancer represented the first major advance in the management of this malignancy in many years and prompted many practitioners to alter their pattern of practice. More recently, the results of the National Cancer Institute of Canada (NCIC) trial demonstrating no survival benefit when combined modality therapy is compared with optimally delivered radiotherapy, has led many to question the strength of the evidence supporting the adoption of combined modality therapy as the standard therapy for cervix cancer and in particular the magnitude of the benefit derived from the addition of chemotherapy to an optimally delivered radiotherapy regimen. This review paper will critically examine the evidence presented in the literature indicating a benefit for the use of combined modality therapy, discuss possible reasons why the conclusions of negative trials such as the NCIC study differ from those of the other studies and highlight those aspects of the use of combined modality therapy that require further evaluation.     

First-trimester screening for aneuploidy: research or standard of care?

First-trimester screening for Down syndrome has been proposed as a significant improvement with respect to second-trimester serum screening programs, the current standard of care, because of apparently higher detection rates and an earlier gestational age at diagnosis. First-trimester nuchal translucency on ultrasonography forms the basis of this new form of screening, although studies of its efficacy have yielded widely conflicting results, with detection rates ranging from 29% to 91%. Studies of first-trimester serum screening with measurements of pregnancy-associated plasma protein A and free beta-human chorionic gonadotropin serum concentrations have been much more consistent, with Down syndrome detection rates of 55% to 63% at a 5% false-positive rate. The combination of first-trimester ultrasonographic and serum screening has the potential to yield a Down syndrome detection rate of 80% at a 5% false-positive rate, although this approach has not been adequately studied. There have been no studies performed to date to directly compare the performance of first-trimester and second-trimester methods of screening. Two major trials are underway that will address this issue, one in the United Kingdom and one in the United States. Until the results of these trials are available, the current standard of care with respect to Down syndrome screening should not be changed, and first-trimester screening should remain investigational.     

Radical abdominal versus laparoscopic hysterectomy for stage IB cervical cancer: what's the point?

OBJECTIVE: To evaluate surgical morbidity and length of stay for type III radical abdominal hysterectomy performed in the private practice setting, and to compare these results with currently available data on laparoscopic radical hysterectomy. METHODS AND MATERIALS: One hundred seventy-five consecutive type III radical abdominal hysterectomies performed by the author in a uniform fashion over a ten-year period for patients with stage IB cervical cancer were evaluated. All surgeries were performed in private community hospitals in New Jersey. RESULTS: Type III radical abdominal hysterectomy performed in the private setting using the author's protocol resulted in lower surgical morbidity, equivalent hospital stay and resumption of normal activities, and much shorter operating times than laparoscopic radical hysterectomy. CONCLUSION: Laparoscopic radical hysterectomy provides no surgical or financial advantage over radical abdominal hysterectomy when the latter is performed in the private practice setting; results from laparoscopic surgery are inferior with respect to morbidity.     

Is the pathologic tumor size associated with survival in early cervical cancer treated with radical hysterectomy and adjuvant radiotherapy?

ObjectiveIn 2018 International Federation of Gynecology and Obstetrics (FIGO) staging system of uterine cervix cancer, size criteria of primary tumor has been revised. This study aimed to evaluate the validity of this new size criteria (<2, 2–4, and ≧4 cm) in patients who underwent radical hysterectomy and adjuvant radiation therapy (RT) for early cervical cancer.Materials and methodsWe retrospectively examined 312 patients who underwent radical hysterectomy and adjuvant RT for early cervical cancer (IB-IIA) from 2001 to 2014. The effects of clinical and pathological factors on disease-free survival (DFS) and overall survival (OS) were evaluated in univariate and multivariate analyses.ResultsAfter a median follow-up of 71.5 months, the 5-year DFS and OS rates were 89.5% and 94.7%, respectively. The primary tumor size was not a significant factor for DFS (p = 0.382) or OS (p = 0.725) in all patients.ConclusionPrimary tumor size was not a significant factor for survival in patients who received hysterectomy and adjuvant RT for early cervical cancer. Adequacy of new tumor size criteria (<2, 2–4, and ≧4 cm) in new 2018 FIGO stage needs to be validated in further studies.     

Do elderly cancer patients care about cure? Attitudes to radical gynecologic oncology surgery in the elderly

OBJECTIVE: The aim of this study was to address the hypothesis of no difference between elderly and younger patients' desire for optimal surgery and disease cure. METHODS: The new ARGOSE questionnaire with established instruments was administered to 189 gynecologic cancer patients (95 aged <65, 57 aged 65-74, and 37 aged 75+ years). RESULTS: Disease diagnosis differed between the <65 years and 65+ years cohorts (P < 0.001), but treatment modalities were similar (P = 0.28). Influences of family and friends and past experiences of cancer had little influence on treatment decisions. There was no difference between cohorts in desire for surgery offering a chance of disease cure (P = 0.75), except that the elderly desire cure more if treatment is associated with disfigurement than do the young. (P = 0.029). The elderly believe more strongly than the young that the elderly value cure (P < 0.001). Issues of sexuality and femininity associated with gynecologic cancer and treatment are more important to younger patients (P < 0.001). The elderly support equality of care with relation to age more strongly than the young. However, in a situation of resource limitation, inequality favoring the young is opposed less strongly by the elderly than by the young. Social desirability bias may have influenced this finding. All cohorts reported symptom palliation to be of secondary importance to treatments offering a possibility of cure (P = 0.26). The elderly believe more strongly that doctors should make management decisions (P < 0.001). CONCLUSION: The elderly desire radical surgery and disease cure as strongly as the young. They are less likely to question their doctors' decisions and are therefore vulnerable to physicians' age bias. There is no justification for rationing care on the basis of chronological age.