Tailoring radicality in early cervical cancer: how far can we go?

Abstract

Today, the patient who is diagnosed with early cervical cancer is offered a variety of treatments apart from standard therapy. Patients can be treated with a less radical hysterectomy (RH) regarding parametrectomy, a trachelectomy either vaginal or abdominal, and this can be performed through a minimal invasive or open procedure. All this in combination with nerve sparing and/or sentinel node technique. Level 1 evidence for the oncological safety of all these modifications is only available from 3 randomized controlled trials (RCTs). Two RCTs on more or less radical parametrectomy both showed that oncological safety was not compromised by doing less radical surgery. Because of the heterogeneity of the patient population and the high frequency of adjuvant radiotherapy, the true impact of surgical radicality cannot be assessed. Regarding the issue of oncological safety of fertility sparing treatments, case-control and retrospective case series suggest that trachelectomy is safe as long as the tumor diameter does not exceed 2 cm. Recently, both a RCT and 2 case-control studies showed a survival benefit for open surgery compared to minimally invasive surgery, whereas many previous case-control and retrospective case series on this subject did not show impaired oncological safety. In a case-control study the survival benefit for open surgery was restricted to the group of patients with a tumor diameter more than 2 cm. Although modifications of the traditional open RH seem safe for tumors with a diameter less than 2 cm, ongoing prospective RCTs and observational studies should give the final answer.

A New Anatomic and Staging-Oriented Classification of Radical Hysterectomy

“…The current practice on radical hysterectomy suffers under a variety of tailored surgical procedures apart from standard radical hysterectomy without clear evidence for the oncological safety of all these modifications. Even when we have two randomized control studies on more or less radical parametrectomy, which showed that oncological safety was not compromised by doing less radical surgery, because of the heterogeneity of the patient population and the high frequency of adjuvant radiotherapy, the true impact of surgical radicality cannot be assessed [19]. The outcomes of LACC-Trial [20] give rise to more awareness about the importance of the prevention of tumour cell contamination and avoiding the intracorporal colpotomy before closing the vaginal vault beneath the cervical tumour [21][22][23][24].…”

Radical Hysterectomy After Neoadjuvant Chemotherapy for Locally Bulky-Size Cervical Cancer: A Retrospective Comparative Analysis between the Robotic and Abdominal Approaches

“…In both studies, no significant difference was observed in the recurrence pattern, DFS, and OS during the 3-year follow-up between NACT-R-RH and NACT-A-RH [50,51]. A recent review of many previous case-control and retrospective case series also demonstrated the safety of NACT-R-RH considering the oncological outcomes [52].…”

“…The goal of NACT includes downstaging the tumor to improve the radical curability and safety of surgery and inhibit micro-metastasis and distant metastasis [29,30,31,32,33,34,35,36], as well as allow surgeons to perform less radical surgery without compromising oncological safety [52,53]. An early Cochrane review showed a significant decrease in adverse pathological findings after NACT (odds ratio [OR] 0.54, 95% CI 0.40–0.73, p < 0.0001 for LN status; OR 0.58, 95% CI 0.41–0.82, p = 0.002 for parametrial infiltration), contributing to an improvement in both OS and PFS.…”

Cervical Cancer Surgery

“…It is worthy to note that many studies have shown that tumor size, surgical volume, surgery approach (the use of Uterine manipulator, colpotomy, circulating CO 2 , squeezing the cervix), the standardization of surgery, whether cervical cancer surgery was performed by qualified doctors, etc., affected the outcomes of surgery and OS as well as DFS. [ 3 12 39 40 41 42 43 44 45 46 47 48 49 50 51 52 ] For example, Magrina et al . first compared the perioperative results of patients undergoing radical hysterectomy by robotics, laparoscopy, and laparotomy and found that there was no significant difference in the mean number of removed lymph nodes among the three surgery approaches.…”