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Chakrabarti M, Nordin A, Khodabocus J. Debulking hysterectomy followed by chemoradiotherapy versus chemoradiotherapy for FIGO stage (2019) IB3/II cervical cancer. Cochrane Database Syst Rev 2022; 9:CD012246. [PMID: 36111784 PMCID: PMC9479467 DOI: 10.1002/14651858.cd012246.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND With an estimated 570,000 new cases reported globally in 2018, and increasing numbers of new cases in countries without established human papillomavirus (HPV) vaccination programmes, cervical cancer is the third most common cancer in women worldwide. The majority of global disease burden (around 85%) is in low-and middle-income countries (LMICs), with estimates of cervical cancer being the second most common cancer in women in such regions. As it commonly affects younger women, cervical cancer has the greatest impact on years of life lost (YLL) and adverse socioeconomic outcomes compared to all other cancers in women. Management of cervical cancer depends on tumour stage. Radical hysterectomy with lymphadenectomy is the standard primary treatment modality for International Federation of Gynecology and Obstetrics (FIGO) stage (2019) 1B1 to 1B3 disease. However, for larger primary tumours, radical hysterectomy is less commonly recommended. This is mainly due to a high incidence of unfavourable histopathological parameters, which require adjuvant concurrent chemoradiotherapy (CCRT) (chemotherapy given with radiotherapy treatment). CCRT is the standard of care and is widely used as first-line treatment for cervical cancer considered to be not curable with surgery alone (i.e.those with locally advanced disease). However, a sizable cohort of women managed with primary CCRT will have residual disease within the cervix following treatment. Debulking' hysterectomy to remove (debulk) the primary tumour in locally advanced disease, prior to CCRT, may be an alternative management strategy, avoiding the potential need for surgery for residual cervical disease following CCRT, which may be more extensive, or have increased morbidity due to CCRT. However, this strategy may subject more women to unnecessary surgery and its inherent risks. OBJECTIVES To assess the efficacy and harms of debulking hysterectomy (simple or radical) followed by chemoradiotherapy (CCRT) versus CCRT alone for FIGO (2019) stage IB3/II cervical cancer. SEARCH METHODS We systematically searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 4), MEDLINE via Ovid (1946 to 12 April 2021) and Embase via Ovid (1980 to 12 April 2021). We also searched other registers of clinical trials, abstracts of scientific meetings and reference lists up to 12 April 2021. SELECTION CRITERIA We searched for randomised controlled trials (RCTs), quasi-RCTs or non-randomised studies (NRSs) comparing debulking hysterectomy followed by CCRT versus CCRT alone for locally advanced FIGO (2019) stage IB3/II cervical malignancy. DATA COLLECTION AND ANALYSIS We applied Cochrane methodology, with two review authors independently assessing whether potentially relevant studies met the inclusion criteria. We planned to apply standard Cochrane methodological procedures to analyse data and risk of bias. MAIN RESULTS We did not find any evidence for or against debulking hysterectomy followed by CCRT versus CCRT alone for FIGO (2019) stage IB3/II cervical cancer. We did not identify any studies assessing the validity of debulking hysterectomy for these women. AUTHORS' CONCLUSIONS: There was no evidence for or against debulking hysterectomy followed by CCRT versus CCRT alone for FIGO (2019) stage IB3/II cervical cancer.
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Affiliation(s)
| | - Andy Nordin
- East Kent Gynaecological Oncology Centre, Queen Elizabeth The Queen Mother Hospital, Kent, UK
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Lefebvre G, Allaire C, Jeffrey J, Vilos G. Archivée: No 109 - Hystérectomie. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:e581-e595. [DOI: 10.1016/j.jogc.2018.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Lefebvre G, Allaire C, Jeffrey J, Vilos G. No. 109-Hysterectomy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:e567-e579. [PMID: 29921436 DOI: 10.1016/j.jogc.2018.04.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify the indications for hysterectomy, preoperative assessment, and available alternatives required prior to hysterectomy. Patient self-reported outcomes of hysterectomy have revealed high levels of patient satisfaction. These may be maximized by careful preoperative assessment and discussion of other treatment choices. In most cases hysterectomy is performed to relieve symptoms and improve quality of life. The patient's preference regarding treatment alternatives must be considered carefully. OPTIONS The areas of clinical practice considered in formulating this guideline are preoperative assessment including alternative treatments, choice of method for hysterectomy, and evaluation of risks and benefits. The risk-to-benefit ratio must be examined individually by the woman and her health practitioners. OUTCOMES Optimizing the decision-making process of women and their caregivers in proceeding with a hysterectomy having considered the disease process, and available alternative treatments and options, and having reviewed the risks and anticipated benefits. EVIDENCE Using Medline, PubMed, and the Cochrane Database, English language articles were reviewed from 1996 to 2001 as well as the review published in the 1996 SOGC guidelines. The level of evidence has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination. BENEFITS, HARMS, AND COSTS Hysterectomy is the treatment of choice for certain gynaecologic conditions. The predicted advantages must be carefully weighed against the possible risks of the surgery and other treatment alternatives. In the properly selected patient, the result from the surgery should be an improvement in the quality of life. The cost of the surgery to the health care system and to the patient must be interpreted in the context of the cost of untreated conditions. The approach selected for the hysterectomy will impact on the cost of the surgery. RECOMMENDATIONS Benign Disease Preinvasive Disease Invasive Disease Acute Conditions Other Indications Surgical Approach VALIDATION: Medline searches were performed in preparing this guideline with input from experts in their field across Canada. The guideline was reviewed and accepted by SOGC Council and Executive. SPONSOR The Society of Obstetricians and Gynaecologists of Canada.
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Nantasupha C, Charoenkwan K. Predicting factors for resumption of spontaneous voiding following nerve-sparing radical hysterectomy. J Gynecol Oncol 2018; 29:e59. [PMID: 29770629 PMCID: PMC5981110 DOI: 10.3802/jgo.2018.29.e59] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/06/2018] [Accepted: 03/28/2018] [Indexed: 11/30/2022] Open
Abstract
Objective To determine factors affecting voiding recovery on the day of Foley catheter removal (postoperative day 7, POD7) after nerve-sparing radical hysterectomy (NSRH) for early-stage cervical cancer. Methods Early-stage cervical cancer patients, who underwent type C1 radical hysterectomy between January 2006 and June 2016 were included. Clinical and pathological data were reviewed. Association between inability to attain adequate voiding function on POD7 and potential predicting factors were evaluated in univariate and multivariate analysis. Results Of 755 patients, 383 (50.7%) resumed adequate voiding function on POD7 while 372 (49.3%) did not. Tumor size was larger in patients whose voiding function was inadequate (2.5 vs. 2.0 cm, p=0.001). Lengths of resected parametria and adjacent vagina were more extensive in patients with inadequate voiding function (p<0.001). In univariate analysis, factors significantly associated with inability to attain adequate voiding function included tumor size >4 cm (p<0.001), primary surgeon (p<0.001), postoperative urinary tract infection (p<0.01), grossly visible tumor (p<0.01), and not having prior conization (p<0.01). In multivariate analysis, tumor size >4 cm, postoperative urinary tract infection, and primary surgeon were significantly associated with inability to attain adequate voiding function on POD7. Conclusion Extent of disease represented by tumor size, urinary tract infection as well as individual surgeon's technique independently predict resumption of adequate voiding function on POD7 following NSRH.
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Affiliation(s)
- Chalaithorn Nantasupha
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kittipat Charoenkwan
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand. ,
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Willows K, Lennox G, Covens A. Fertility-sparing management in cervical cancer: balancing oncologic outcomes with reproductive success. GYNECOLOGIC ONCOLOGY RESEARCH AND PRACTICE 2016; 3:9. [PMID: 27795832 PMCID: PMC5073939 DOI: 10.1186/s40661-016-0030-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 09/27/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cervical cancer is the fourth most common cancer among women worldwide, many of who are still within their reproductive lifespan. Advances in screening and treatment have increased the 5-year survival for early stage disease to over 90 % in developed countries. The focus is now shifting to reducing morbidity and improving fertility outcomes for cervical cancer patients. Radical trachelectomy with lymph node assessment became the standard of care for selected women with lesions <2 cm who desire fertility preservation. However, several questions still remain regarding the degree of surgical radicality required for tumors <2 cm, and fertility-sparing options for women with early-stage disesase ≥2 cm, and those with more advanced disease. Here, we compile a narrative review of the evidence for oncologic and pregnancy outcomes following radical trachelectomy, non-radical fertility-sparing surgery, and the use of neoadjuvant chemotherapy prior to surgery for larger lesions. We also review the literature for assisted reproductive technologies in women with more advanced disease. FINDINGS Available literature suggests that the crude recurrence and mortality rates after radical trachelectomy are <5 and <2 %, respectively (approx. 11 and 4 % for tumors ≥ 2 cm). Among 1238 patients who underwent fertility-sparing surgery for early cervical cancer there were 469 pregnancies with a 67 % live birth rate. Among 134 cases with lesions ≥ 2 cm, there were ten conceptions with a live birth rate of 70 %. Outcomes after non-radical surgery (simple trachelectomy or cervical conization) are similar, although only applicable among a highly selected patient population. For patients ineligible for fertility-preserving surgery or who require adjuvant radiation therapy, current options include ovarian transposition and cryopreservation of oocytes or embryos but other techniques are under investigation. CONCLUSION Today, many cervical cancer survivors have successful pregnancies. For those with early-stage disease, minimally invasive and fertility sparing techniques have resulted in improved obstetrical outcomes without compromising oncologic safety. Results from three ongoing trials on non-radical surgery for low-risk tumors <2 cm will further inform the need for radical surgery in such patients. For those in whom natural childbearing is unachievable, advances in assisted reproductive technologies provide reproductive options. Despite our advances, the effects of cervical cancer survivorship on quality of life are not fully elucidated.
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Affiliation(s)
- Karla Willows
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Toronto, M700-610 University Avenue, Toronto, M5G 2 M9 ON Canada
| | - Genevieve Lennox
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Toronto, M700-610 University Avenue, Toronto, M5G 2 M9 ON Canada
| | - Allan Covens
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Toronto, M700-610 University Avenue, Toronto, M5G 2 M9 ON Canada
- Division of Gynecologic Oncology, T2051 Odette Cancer Centre, University of Toronto, 2075 Bayview Avenue, Toronto, M4N 3 M5 ON Canada
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Chakrabarti M, Nordin A. Debulking hysterectomy followed by chemoradiotherapy versus chemoradiotherapy for FIGO stage IB2/II cervical cancer. Hippokratia 2016. [DOI: 10.1002/14651858.cd012246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Manas Chakrabarti
- Apollo Gleneagles Cancer Hospital; Consultant Gynaecological Oncologist; 58 Canal Circular Road Kolkata Kolkata India 700054
| | - Andy Nordin
- Queen Elizabeth The Queen Mother Hospital; East Kent Gynaecological Oncology Centre; St Peters Road Margate Kent UK CT9 4AN
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Role of the two-point pull-up technique for treating the uterine arteries during radical hysterectomy and trachelectomy. Eur J Obstet Gynecol Reprod Biol 2013; 170:544-9. [DOI: 10.1016/j.ejogrb.2013.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Revised: 06/11/2013] [Accepted: 08/01/2013] [Indexed: 11/21/2022]
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Cetina L, González-Enciso A, Cantú D, Coronel J, Pérez-Montiel D, Hinojosa J, Serrano A, Rivera L, Poitevin A, Mota A, Trejo E, Montalvo G, Muñoz D, Robles-Flores J, de la Garza J, Chanona J, Jiménez-Lima R, Wegman T, Dueñas-González A. Brachytherapy versus radical hysterectomy after external beam chemoradiation with gemcitabine plus cisplatin: a randomized, phase III study in IB2–IIB cervical cancer patients. Ann Oncol 2013; 24:2043-2047. [DOI: 10.1093/annonc/mdt142] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Survival outcomes for women undergoing type III robotic radical hysterectomy for cervical cancer: A 3-year experience. Gynecol Oncol 2010; 117:260-5. [DOI: 10.1016/j.ygyno.2010.01.012] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 01/05/2010] [Accepted: 01/07/2010] [Indexed: 11/24/2022]
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Samuels LA, Rattray C, Bambury I, Fletcher H, Mitchell S. Outcome of radical hysterectomies performed by general gynecologists in Jamaica. Int J Gynaecol Obstet 2009; 107:111-3. [PMID: 19664771 DOI: 10.1016/j.ijgo.2009.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Revised: 06/15/2009] [Accepted: 07/03/2009] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To review the modified (type II) radical hysterectomy procedures performed by 4 general gynecologists at the University Hospital of the West Indies, and to compare the outcomes with those of other published studies. METHODS The case notes of the 58 women who underwent radical hysterectomies between January 1997 and December 2006 were reviewed. Accuracy of staging, duration of the operation, operative blood loss, types and rates of complications, recurrence rates, and 5-year survival rates were assessed. RESULTS Accuracy of clinical staging, duration of the procedure, blood loss, and operative and postoperative complications were comparable to previously published data. The 5-year survival rate of 77.6% was also comparable to results seen in some other publications. CONCLUSION General gynecologists with significant experience in general gynecologic surgery who underwent adequate, but abbreviated, training became competent in performing a radical hysterectomy, with outcomes comparable to those seen in high-resource countries.
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Affiliation(s)
- Leslie A Samuels
- Department of Obstetrics and Gynecology, University Hospital of the West Indies, Kingston, Jamaica.
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Malzoni M, Tinelli R, Cosentino F, Fusco A, Malzoni C. Total laparoscopic radical hysterectomy versus abdominal radical hysterectomy with lymphadenectomy in patients with early cervical cancer: our experience. Ann Surg Oncol 2009; 16:1316-23. [PMID: 19224286 DOI: 10.1245/s10434-009-0342-7] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2008] [Revised: 12/14/2008] [Accepted: 12/14/2008] [Indexed: 11/18/2022]
Abstract
BACKGROUND The aim of this study was to retrospectively compare, in a series of 127 consecutive women, the safety, morbidity, and recurrence rate of total laparoscopic radical hysterectomy (TLRH) with lymphadenectomy and abdominal radical hysterectomy with lymphadenectomy (ARH) for early cervical carcinoma. METHODS A total of 127 consecutive patients with International Federation of Gynecology and Obstetrics stage Ia1 (lymphvascular space involvement), Ia2, and Ib1 early cervical cancer, 65 of whom underwent TLRH and 62 of whom underwent ARH with pelvic lymph node dissection, comprised the study population. The para-aortic lymphadenectomy with the superior border of the dissection being the inferior mesenteric artery was performed in all cases with positive pelvic lymph nodes discovered at frozen section evaluation. RESULTS The median blood loss in the ARH group (145 ml; range, 60-225 ml) was significantly greater than TLRH group (55 ml; range, 30-80 ml) (P < .01). The median length of hospital stay was significantly greater in the ARH group (7 days; range, 5-9 days) than TLRH group (4 days; range, 3-7 days) (P < .01). The median operating time was 196 min in the TLRH group (range, 182-240 min) compared with 152 min in the ARH group (range, 161-240 min) (P < .01). No statistically significant difference was found between the two groups when the recurrence rate was compared. CONCLUSIONS Total laparoscopic radical hysterectomy is a safe and effective therapeutic procedure for management of early-stage cervical cancer with a far lower morbidity than reported for the open approach and is characterized by far less blood loss and shorter postoperative hospitalization time, although multicenter randomized clinical trials with longer follow-up are necessary to evaluate the overall oncologic outcomes of this procedure.
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Affiliation(s)
- Mario Malzoni
- Advanced Gynecological Endoscopy Center, Malzoni Medical Center, Avellino, Italy
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Beiner M, Hauspy J, Rosen B, Murphy J, Laframboise S, Nofech-Mozes S, Ismiil N, Rasty G, Khalifa M, Covens A. Radical vaginal trachelectomy vs. radical hysterectomy for small early stage cervical cancer: A matched case–control study. Gynecol Oncol 2008; 110:168-71. [DOI: 10.1016/j.ygyno.2008.04.027] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2008] [Revised: 04/22/2008] [Accepted: 04/23/2008] [Indexed: 10/22/2022]
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Comparison of Total Laparoscopic and Abdominal Radical Hysterectomy for Patients With Early-Stage Cervical Cancer. Obstet Gynecol 2007; 110:1174; author reply 1174-5. [DOI: 10.1097/01.aog.0000288513.69175.93] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Malzoni M, Tinelli R, Cosentino F, Perone C, Vicario V. Feasibility, morbidity, and safety of total laparoscopic radical hysterectomy with lymphadenectomy: Our experience. J Minim Invasive Gynecol 2007; 14:584-90. [PMID: 17848319 DOI: 10.1016/j.jmig.2007.04.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2006] [Revised: 03/22/2007] [Accepted: 04/02/2007] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE The purpose of this study was to retrospectively evaluate, in a series of 65 patients, the feasibility, morbidity, and safety of total laparoscopic radical hysterectomy with lymphadenectomy for early cervical carcinoma. DESIGN Retrospective, nonrandomized study (Canadian Task Force classification II-2). SETTING Advanced Gynecological Endoscopy Center, Malzoni Medical Center, Avellino, Italy. PATIENTS Sixty-five nonconsecutive patients with International Federation of Gynecology and Obstetrics (FIGO) stage Ia1 with lymphvascular space involvement, Ia2, and Ib1 early cervical cancer. INTERVENTION Fourteen patients underwent a laparoscopic class II procedure, and 51 patients underwent a class III procedure according to the Piver classification. All the patients underwent total laparoscopic radical hysterectomy with pelvic lymphadenectomy during the study period, and none of the surgeries required conversion to laparotomy. Paraaortic lymphadenectomy is not routinely performed unless suspicious pelvic lymph nodes are confirmed to have metastatic disease on frozen section evaluation. MEASUREMENTS AND MAIN RESULTS Fifty-six patients had squamous cell carcinoma; 7 patients had adenocarcinomas, and 2 had adenosquamous carcinoma. The mean age was 40.5 years (95% CI 27.7-69.1) and the SD was +/- 7.5. The median weight was 56.2 kg (range 44-75 kg). The median operative time was 196 minutes (range 182-240 minutes), and the surgical margins were free of disease in all cases. The median blood loss was 55 mL (range 30-80 mL). No patient required an intraoperative blood transfusion. The median length of hospital stay was 4 days (range 3-7 days). CONCLUSION Laparoscopic treatment of cervical cancer offers patients the potential benefits of decreased discomfort with decreased convalescence time, but it should be reserved for oncologic surgeons trained in extensive laparoscopic procedures.
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Affiliation(s)
- Mario Malzoni
- Advanced Gynecological Endoscopy Center, Malzoni Medical Center, Avellino, Italy
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Raspagliesi F, Ditto A, Fontanelli R, Zanaboni F, Solima E, Spatti G, Hanozet F, Vecchione F, Rossi G, Kusamura S. Type II versus Type III Nerve-sparing Radical hysterectomy: Comparison of lower urinary tract dysfunctions. Gynecol Oncol 2006; 102:256-62. [PMID: 16445968 DOI: 10.1016/j.ygyno.2005.12.014] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2005] [Revised: 11/17/2005] [Accepted: 12/12/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES According to our previous experience, Type III Nerve-sparing Radical hysterectomy (NSRH) for cervical cancer presented an acceptable urologic morbidity, without compromising radicality. The aim of this study was to compare Type NSRH with other types of RH in terms of incidence of early bladder dysfunctions and perioperative complications. METHODS One hundred and ten patients with cervical cancer were submitted to Type II RH (group 1), Type III NSRH (group 2) and Type III RH (group 3). We assessed the postoperative early bladder function and complications. The follow-up period was 3 months. RESULTS Group 1 had a significantly shorter duration of the surgery, minor mean blood loss and shorter mean length of postoperative stay when compared to groups 2 and 3. No intraoperative complications were reported in either of the groups. The groups did not differ significantly in terms of GIII/IV morbidity (group 1 = 10%, group 2 = 10% and group 3 = 15%, chi(2), P value: 0.65). Not even they differed in terms of urologic GI-IV morbidity (group 1 = 13%, group 2 = 15% and group 3 = 10%, chi(2), P value = 0.88). Groups 1 and 2 presented a prompt recover of bladder function, significantly different from that of group 3. There was a significant difference between the groups regarding the number of patients discharged with self-catheterism (group 1 = 0; group 2 and group 3 = 11; chi(2), P value << 0.05). CONCLUSIONS The Type III NSRH seems to be comparable to Type II RH and superior to Type III RH in terms of early bladder dysfunctions.
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Affiliation(s)
- Francesco Raspagliesi
- Department of Gynecologic Oncology, Istituto Nazionale Tumori, via Venezian 1, 20133 Milan, Italy
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Abstract
Although the survival outcome for treated, early-stage, node-negative cervical cancer is excellent, the operation of radical hysterectomy conveys major morbidity, particularly with respect to bladder and bowel function. There may be some degree of spontaneous recovery, but a significant proportion of postoperative women will have to live with the disabling effects of surgery for decades, and few seek help for their distress. As such, quality of life issues have become highly relevant in the management of this disease, and attention has turned to reducing morbidity, especially to the pelvic viscera. This review presents an overview of the surgical mechanisms presumed to be responsible for pelvic floor denervation and describes subsequent bladder and bowel dysfunction, together with future possibilities for minimizing morbidity, including less radical, more individual surgery, and nerve-sparing techniques.
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Affiliation(s)
- K S Jackson
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, United Kingdom.
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Micha JP, Goldstein BH, Rettenmaier MA, Brown JV, John CR, Markman M. Surgery alone or surgery with a combination radiation or chemoradiation for management of patients with bulky-stage IB2 cervical carcinoma. Int J Gynecol Cancer 2006; 16:1147-51. [PMID: 16803498 DOI: 10.1111/j.1525-1438.2006.00457.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The management of stage IB2 cervical carcinoma remains controversial. This retrospective review evaluates 47 IB2 cervical carcinoma patients treated with surgery alone (S), surgery plus postoperative radiotherapy (SR), or surgery plus postoperative chemoradiation (SRC). Median progression-free interval (PFI) was 70.3 months for the SR group (n= 21), 73.3 months for the SRC group (n= 15), and 33.5 months for the S group (n= 11). The survival rate was 76% for the SR group, 87% for the SRC group, and 55% for the S group. Overall 5-year survival rate for the three groups was 75%. Median follow-up for the patient population was 61.3 months. The number of the patient and the nonrandomized nature of this study preclude any definitive conclusions, but interestingly, the SRC and SR groups exhibited a substantially better PFI and overall survival compared to the S group. Selection bias does not appear to be a factor since patients in SR or SRC group were at greater risk for recurrence (eg, higher incidence of deep stromal invasion, parametrial involvement) than patients in the S group; yet, they still experienced superior PFI and overall survival. Further studies comparing postoperative irradiation and chemoradiation with these patients in a randomized phase 3 trial may be warranted.
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Affiliation(s)
- J P Micha
- Gynecologic Oncology Associates, Hoag Cancer Center, 531 Hospital Road, Newport Beach, CA 92663, USA.
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Discussion. Am J Obstet Gynecol 2006. [DOI: 10.1016/j.ajog.2005.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nevin J, Luesley D. Re: "Laparoscopically assisted radical vaginal hysterectomy vs. radical abdominal hysterectomy for cervical cancer: a match controlled study". Gynecol Oncol 2005; 98:521-2; author reply 522-3. [PMID: 15913745 DOI: 10.1016/j.ygyno.2005.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2005] [Revised: 02/23/2005] [Accepted: 03/08/2005] [Indexed: 10/25/2022]
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Meltomaa SS, Hietanen SH, Taalikka MO, Haarala MA, Kiilholma PJA, Mäkinen JI. Hysterectomy for gynaecological cancer: a follow-up study of subjective and objective outcome. Aust N Z J Obstet Gynaecol 2004; 44:214-21. [PMID: 15191445 DOI: 10.1111/j.1479-828x.2004.00213.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS To evaluate morbidity and subjective outcome associated with hysterectomy either with or without pelvic or pelvic and para-aortic lymphadenectomy for gynaecological cancer. METHODS Ninety-nine patients who underwent hysterectomy with lymphadenectomy (n = 38) or simple hysterectomy (n = 61) for ovarian, endometrial and cervical cancer in Turku University Hospital, Turku, Finland, were followed-up prospectively to determine the incidence of complications during a 1-year period after operation. Subjective outcomes were assessed using two questionnaires, 6 weeks and 1 year after operation. Hospital records of the patients were reviewed up to 6 years after operation. RESULTS During their hospital stay 58% of patients in the hysterectomy with lymphadenectomy group and 56% in the simple hysterectomy group experienced some type of complication. Serious complications occurred in four patients (10.5%) in the former group and in two patients (3.3%) in the latter group. In the study population overall, the incidence of subjective complaints increased from 18% of respondents 6 weeks after operation to 55% 1 year after operation. Most patients (95 and 92%, respectively) remained satisfied with the operation at both times of evaluation. CONCLUSIONS More than half of the patients experienced morbidity related to surgical treatment for gynaecological cancer. The incidence of complications and subjective complaints were unaffected by the type of operation.
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Affiliation(s)
- Seija S Meltomaa
- Department of Obstetrics and Gynecology, University of Turku, Turku, Finland.
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Ohara K, Tsunoda H, Satoh T, Oki A, Sugahara S, Yoshikawa H. Use of the small pelvic field instead of the classic whole pelvic field in postoperative radiotherapy for cervical cancer: Reduction of adverse events. Int J Radiat Oncol Biol Phys 2004; 60:258-64. [PMID: 15337564 DOI: 10.1016/j.ijrobp.2004.02.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2003] [Revised: 02/06/2004] [Accepted: 02/09/2004] [Indexed: 11/28/2022]
Abstract
PURPOSE We examined whether use of small pelvic (SP) field encompassing only the pericervical regions and upper stream lymphatic will reduce the adverse events that occur with classic whole pelvic (WP) field, in postoperative radiotherapy (RT) for cervical cancer. METHODS AND MATERIAL This retrospective study included 72 patients treated with SP field (SP group) used specifically for node-negative status and 46 patients treated with WP field (WP group) used conventionally for node-positive status. Total dose was 50.0 or 50.4 Gy at 2.0 or 1.8 Gy per fraction. Acute adverse events (nausea, diarrhea, cystitis, and leukopenia) and late adverse events (lymphedema, cystitis, ileus, and diarrhea) were graded according to the Common Toxicity Criteria and compared between groups. RESULTS Diarrhea (Grades 2-3) and leukopenia (Grades 1-3) occurred significantly more often in WP group (32.4% and 80.5%, respectively) than in SP group (9.2% and 52.2%, respectively). Among the late events, lymphedema occurred most often overall (5-year rate: SP, 47.0%; WP, 49.1%). Only ileus occurred at a significantly higher rate in The WP group than in SP group (5-year rate: 16.2% vs. 3.2%). CONCLUSIONS Use of the SP field tailored for node-negative status was suggested to reduce adverse events involving the intestine and hemopoietic system.
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Affiliation(s)
- Kiyoshi Ohara
- Department of Radiation Oncology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba City 305-8575, Japan.
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Abstract
OBJECTIVE As with other oncologic operations, the indications for and the technique of radical hysterectomy for cervical cancer has changed considerably since its initial conception in the late 19th century. This paper reviews the evolution of concepts concerning the extent of radical hysterectomy for cervical cancer. METHODS A Medline literature search was performed through looking for articles published in the English language that related to radical hysterectomy for cervical cancer. Specific subjects that were searched included technique, morbidity, and histopathologic assessment of the parametria. RESULTS Initial emphasis on local control and potential long-term survival gradually shifted to reduction of mortality and serious morbidity. Early refinements directed attention to the regional lymph nodes, definition of prognostic factors, and determination of the population of patients best suited for the operation. During the mid to late 20th century, a better understanding of regional and local prognostic factors helped clarify the role of adjuvant treatment following radical hysterectomy. By the mid 20th century, the mortality and serious morbidity rates had fallen substantially, and attention turned to reduction of other types of morbidity, especially urinary bladder voiding dysfunction. Reduction of much of the serious morbidity (urinary fistulas) and voiding dysfunction has been related to modifications of the extent of radical hysterectomy. Specific nerve-sparing techniques now have been described. However, maintaining full radicality continues to be emphasized at some centers. CONCLUSION The current primary operative approaches to stage 1B cervical cancer include full radical hysterectomy, modified radical hysterectomy followed by adjuvant therapy in selected patients, radical hysterectomy with nerve-sparing, and individualization of surgical management. Studies are needed which further elucidate the significance of parametrial micrometastases, further define and refine broadly feasible nerve-sparing techniques, and more accurately preoperatively identify low and high risk cervical tumors. Optimally, these studies will remove adjuvant treatment as a confounding variable.
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Affiliation(s)
- Mitchel S Hoffman
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL 33606, USA.
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Obermair A, Ginbey P, McCartney AJ. Feasibility and Safety of Total Laparoscopic Radical Hysterectomy. ACTA ACUST UNITED AC 2003; 10:345-9. [PMID: 14567809 DOI: 10.1016/s1074-3804(05)60259-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVE To evaluate feasibility and morbidity of a total laparoscopic radical hysterectomy (TLRH). DESIGN Retrospective chart review (Canadian Task Force classification II-3). SETTING Gynecologic cancer center. PATIENTS Fifty-five women with cervical (39), endometrial (8), vaginal (2), or recurrent colon cancer (1), or severe pelvic endometriosis (5) followed for 3 years. INTERVENTION TLRH in 55 women, converted to laparotomy in 3 (5.5%). MEASUREMENTS AND MAIN RESULTS Feasibility, safety, patterns of recurrence, and survival were assessed. Estimated blood loss was 200 ml (range 50-2000 ml), median total operating time was 210 minutes, and median hospital stay was 5 days. Intraoperative complications were three vascular injuries and one obturator nerve palsy, all of which occurred in the first half of the series. Early postoperative morbidity included deep vein thrombosis, pulmonary embolism, bladder infection and dysfunction, and vaginal fistula. These events occurred less frequently in the second half of the series. Late postoperative morbidity consisted of lymphedema, pelvic abscess and lymphocyst formation, pelvic cellulitis, hyperesthesia of the leg, and small bowel obstruction. The only fatality was a patient who developed a pulmonary embolus on postoperative day 3. Median follow-up was 36.5 months. Of 39 women with cervical cancer, 34 were alive and disease free at their last visit. No case of port site metastasis occurred during follow-up. CONCLUSION TLRH carries acceptably low morbidity that can be reduced with experience with the technique.
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Affiliation(s)
- Andreas Obermair
- King Edward Memorial Hospital for Women, Royal Women's Hospital, Herston, Australia
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Spirtos NM, Eisenkop SM, Schlaerth JB, Ballon SC. Laparoscopic radical hysterectomy (type III) with aortic and pelvic lymphadenectomy in patients with stage I cervical cancer: surgical morbidity and intermediate follow-up. Am J Obstet Gynecol 2002; 187:340-8. [PMID: 12193922 DOI: 10.1067/mob.2002.123035] [Citation(s) in RCA: 188] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the risk of recurrence and to quantify morbidity and mortality rates in patients with cervical cancer who consented to undergo laparoscopic radical hysterectomy (type III) and retroperitoneal lymphadenectomy. STUDY DESIGN Seventy-eight consecutive patients with stage IA(2) and IB cervical cancer with at least 3 years of follow-up consented to undergo this surgical procedure with argon beam coagulation and endoscopic staplers. All patients had a Quetelet index of <35. The average age was 41.5 years (range, 26-62 years). Sixty-eight patients had squamous cell carcinomas; 8 patients had adenocarcinomas, and 2 patients had adenosquamous carcinomas of the cervix. RESULTS All but 5 surgical procedures were completed laparoscopically. The average operative time was 205 minutes (range, 150-430 minutes). The average blood loss was 225 mL (range, 50-700 mL). One patient (1.3%) had transfusion. Operative cystotomies occurred for 3 patients: 2 cystotomies were repaired laparoscopically, and 1 cystotomy required laparotomy. One patient underwent laparotomy because of equipment failure, and another patient underwent laparotomy to pass a ureteral stent. Two other patients underwent laparotomy to control bleeding sites. The average lymph node count was 34 (range, 19-68). Nine patients (11.5%) had positive lymph nodes. All surgical margins were macroscopically negative, but 3 patients had microscopically positive and/or close surgical margins. One patient had a ureterovaginal fistula after the operation that required reoperation. Follow-up has been provided every 3 months. There have been 4 documented recurrences (5.1%), with a minimum of 3 years of follow-up. CONCLUSION Laparoscopic radical hysterectomy (type III) can be successfully completed in patients with early-stage cervical cancer with acceptable morbidity. Intermediate-term follow-up validates the adequacy of this procedure.
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Michalas S, Rodolakis A, Voulgaris Z, Vlachos G, Giannakoulis N, Diakomanolis E. Management of early-stage cervical carcinoma by modified (Type II) radical hysterectomy. Gynecol Oncol 2002; 85:415-22. [PMID: 12051867 DOI: 10.1006/gyno.2002.6633] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE . Surgical management of cervical carcinoma by radical hysterectomy has been proven a highly effective method in treating early-stage disease. The purpose of this study was to evaluate the efficacy and safety of modified (Type II) radical hysterectomy for the treatment of early-stage (I-IIA) cervical carcinoma. METHODS A retrospective analysis of data on 435 patients with cervical carcinoma who were managed by modified radical hysterectomy was performed. In 145 cases a multimodal approach was used due to the presence of one or more risk factors such as lymph node metastasis, CLS involvement, bulky tumor, and exocervical extension of disease. Preoperative irradiation was offered to 62 patients, whereas adjuvant irradiation was offered to 101 patients. RESULTS The mean age of the patients was 42.5 years. The majority of the patients had squamous cell cancer (81.6%). The patients were clinically staged as IA (3.2%), IB (86.7%), and IIA (10.1%). Positive pelvic lymph nodes were noted in 65 patients (14.9%). Operative morbidity was minimal, whereas adjuvant radiation treatment had no impact on the disease but caused genitourinary morbidity in terms of ureteral stricture and postoperative bladder dysfunction (P < 0.001). The overall 5-year survival was 88.7%. The most significant predictors related to 5-year survival were nodal metastasis (P < 0.001), adenomatous histology (P < 0.001), lesion size (P < 0.001), and CLS involvement (P = 0.004). Adjuvant radiation resulted in better local pelvic control of the disease. CONCLUSION The results of our study support the concept that less radical procedures could be effectively applied to early-stage cervical carcinoma 4 cm or smaller with optimal surgical margins.
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Affiliation(s)
- Stylianos Michalas
- First Department of Obstetrics and Gynecology, Alexandra Hospital, Athens, Greece
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Hystérectomie. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2002. [DOI: 10.1016/s1701-2163(16)30273-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Covens A, Rosen B, Murphy J, Laframboise S, DePetrillo AD, Lickrish G, Colgan T, Chapman W, Shaw P. How important is removal of the parametrium at surgery for carcinoma of the cervix? Gynecol Oncol 2002; 84:145-9. [PMID: 11748991 DOI: 10.1006/gyno.2001.6493] [Citation(s) in RCA: 221] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The aims of this study were (1) to determine the incidence and factors predictive for pathologic parametrial involvement in clinical stage IA1/2 and IB1 cervical cancer after radical surgery and (2) to identify a population at low risk for pathologic parametrial involvement. METHODS All patient information was collected prospectively and extracted from a cervical cancer radical surgery database. Selection criteria for surgery were generally based upon tumor size, with the cutoff for surgery between 3 and 4 cm. Parametrial involvement (PI) was defined as either positive parametrial lymph nodes (PMLN) or malignant cells in the parametrial tissue (PT) (including lymphovascular channels) by either contiguous or discontiguous spread. Statistical analysis included the chi2 test, the Wilcoxon rank test, and the Mantel-Haentzel test. RESULTS Between July 1984 and January 2000, 842 patients underwent radical surgery for clinical stage IA1/2 and IB1 cervical cancer at our center. Forty-nine patients (6%) had positive pelvic lymph nodes. Thirty-three patients (4%) had pathologic PI, 8 in the PMLN and 25 in the PT (none had both). PI was associated with older age (42 vs 40 years, P < 0.04), larger tumor size (2.2 vs 1.8 cm, P < 0.04), higher incidence of capillary-lymphatic space invasion (85% vs 45%, P = 0.0004), tumor grades 2 and 3 (95% vs 65%, P = 0.001), greater depth of invasion (18.0 vs 5.0 mm, P < 0.001), and pelvic lymph node metastases (44% vs 5%, P < 0.0001). The incidence of PI in patients with tumor size < or =2 cm, negative pelvic lymph nodes, and depth of invasion < or =10 mm was 0.6%. CONCLUSION Pathologic parametrial involvement in clinical stage IA1/2 and /IB1 cervical cancer is uncommon. Acknowledging that almost all patients with pelvic lymph node metastases and a high proportion of patients with tumor invasion >10 mm will receive adjuvant radiation regardless of the radicality of surgery, a population at low risk for pathologic parametrial involvement can be identified. These patients are worthy of consideration for studies of less radical surgery performed in conjunction with pelvic lymphadenectomy.
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Affiliation(s)
- A Covens
- Department of Obstetrics and Gynecology, University of Toronto, Toronto-Synnybrook Regional Cancer Centre, Ontario, M4N 3M5, Canada.
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Grisaru D, Covens A, Chapman B, Shaw P, Colgan T, Murphy J, DePetrillo D, Lickrish G, Laframboise S, Rosen B. Does histology influence prognosis in patients with early-stage cervical carcinoma? Cancer 2001; 92:2999-3004. [PMID: 11753977 DOI: 10.1002/1097-0142(20011215)92:12<2999::aid-cncr10145>3.0.co;2-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The objective of this study was to examine the influence of histology on the outcome of patients with surgically treated, Stage IA-IB carcinoma of the uterine cervix. METHODS All patient information was collected prospectively and was extracted subsequently from the University of Toronto cervical carcinoma surgery data base. Selection criteria for surgery were based on tumor size and were independent of histology. Patients with adenocarcinoma were separated into two groups: those with mucinous/endometrioid adenocarcinoma (M/E AC) and those with adenosquamous/clear cell adenocarcinoma (AS/CC AC). Statistical analysis used Wilcoxon rank tests, Mantel-Hanzel tests, chi-square tests, and Cox regression analyses. RESULTS Between July 1984 and January 2000, 880 patients with Stage IA-IB cervical carcinoma underwent radical surgery, including pelvic lymphadenectomy, as the primary treatment. Two hundred fifty-five patients had M/E AC (29%), 81 patients had AS/CC AC (9%), and 544 patients had squamous cell carcinoma (SCC; 62%). Compared with patients who had SCC, patients with M/E AC had significantly more favorable prognostic characteristics: age (median, 39 years vs. 41 years; P < 0.03), depth of invasion (3.7 mm vs. 5.5 mm; P < 0.001), vascular space involvement (24% vs. 57%; P < 0.0001), Grade 2-3 tumor (40% vs. 78%; P < 0.0001), and pelvic lymph node metastases (4% vs. 8%; P < 0.04), respectively. Characteristics among patients with AS/CC AC tended have values similar to the median values for patients with SCC (or intermediate between the values for patients with M/E AC and the values for patients with SCC): age (38 years), depth of invasion (6 mm), vascular space involvement (40%), Grades 2-3 (70%), and pelvic lymph node metastases (6%). The 2-year and 5-year recurrence free survival rate was similar between patients with M/E AC and patients with SCC (95% vs. 94% and 90% vs. 90%, respectively); however, both were significantly superior to the rates for patients with AS/CC AC (2-year recurrence free survival rate: 86%, P < 0.03; 5-year recurrence free survival rate: 81%, P % 0.03). There were no differences in the pattern of first recurrence by histology. CONCLUSIONS Patients with surgically treated Stage IA-IB cervical carcinoma with M/E AC and SCC histology have a similar prognosis. For patients with disease with AS/CC AC histology, the current results and the literature indicate that patients with uncommon histologies have an inferior recurrence free survival rate. Although the optimal therapy for these patients remains undefined, there is no obvious rationale for altering the treatment strategies from those currently employed for patients with M/E AC and SCC.
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Affiliation(s)
- D Grisaru
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
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Covens A, Rosen B, Murphy J, Laframboise S, DePetrillo AD, Lickrish G, Colgan T, Chapman W, Shaw P. Changes in the demographics and perioperative care of stage IA(2)/IB(1) cervical cancer over the past 16 years. Gynecol Oncol 2001; 81:133-7. [PMID: 11330939 DOI: 10.1006/gyno.2001.6158] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The aim of this study was to determine whether there have been any significant changes in the demographics and perioperative care of FIGO stage IA(2)/IB(1) cervical cancer over the past 16 years and, if so, to quantify them. METHODS Since July 1984, all patients with FIGO stage IA(2)/IB(1) cervical cancer undergoing radical surgery by members of our division have been entered into a prospective database. Selection for surgery has been unchanged over the past 16 years. Since March 1994 and November 1996, one surgeon has performed radical vaginal trachelectomy and laparoscopic assisted radical vaginal hysterectomy, respectively. Statistical analysis used Spearman's correlation analysis, the proportional hazards regression model of Cox, and the Mantel-Hanzel test was performed. Due to the number of statistical analyses, statistical significance was defined as P < 0.01. RESULTS Eight hundred sixty-four patients have undergone radical surgery (784 radical hysterectomy, 42 radical vaginal trachelectomy, 32 radical vaginal hysterectomy, 6 radical abdominal trachelectomy) for FIGO stage IA(2)/IB(1) carcinoma of the cervix by members of our division since 1984. There have been no changes in the median age (40 years), tumor size (2.0 cm), incidence of capillary lymphatic space involvement (47%), or positive pelvic lymph nodes (6%) over the past 16 years. The median Quetelet index (24.6), depth of tumor invasion (squamous cell carcinomas only) (6.0 mm), and proportion of patients with comorbid conditions (17%) have increased over time (P = 0.001, P = 0.003, and P < 0.001, respectively). Pathologically, there has been an increase in the proportion of adenocarcinomas (28%) and a decrease in the proportion of grade 3 tumors (28%) (P < 0.001 and P < 0.001, respectively). The median operating time (2.8 h), hospital stay (7.0 days), blood loss (600 cc), allogeneic blood transfusion (23%), postoperative infections (13%), and noninfectious complications (6%) have all decreased (P < 0.001, P < 0.001, P < 0.001, P < 0.001, P < 0.001, and P = 0.002, respectively). There has been no change in the incidence of positive surgical margins (3%), adjuvant radiation (13%), or recurrence-free survival (2 and 5 years, 94 and 90%, respectively) after a median follow-up of 45 months. CONCLUSION Despite no substantive changes in the selection criteria for surgery and the small time interval studied (16 years), almost all indices of operative and postoperative morbidity analyzed have decreased significantly. These changes have occurred without an increase in the use of adjuvant radiation or decrease in recurrence-free survival. Although little progress has been made in the cure rates associated with surgical management of FIGO stage IA(2)/IB(1) cervical cancer during this time interval, it appears that the morbidity of surgery has decreased.
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Affiliation(s)
- A Covens
- Department of Obstetrics and Gynecology, University Health Network, and Sunnybrook and Women's College Health Science Centre, Toronto, Ontario, M4N 3M5, Canada
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Orr JW, Roland PY, Orr PJ, Bolen DD, Hutcheson SL. Subspecialty training: does it affect the outcome of women treated for a gynecologic malignancy? Curr Opin Obstet Gynecol 2001; 13:1-8. [PMID: 11176226 DOI: 10.1097/00001703-200102000-00001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A review of available direct and indirect scientific reports strongly suggests that subspecialty training increases the likelihood that the appropriate surgical procedure will be completed in women operated on for gynecologic cancer. It is likely that specialty care lessens the costs associated with diagnosis, treatment and surveillance, and frequently improves survival.
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Affiliation(s)
- J W Orr
- Gynecologic Oncology and Gynecologic Cancer Research, Lee Cancer Care, Lee Memorial Hospital, Fort Myers, Florida 33901, USA.
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Covens A, Shaw P, Murphy J, DePetrillo D, Lickrish G, Laframboise S, Rosen B. Is radical trachelectomy a safe alternative to radical hysterectomy for patients with stage IA-B carcinoma of the cervix? Cancer 1999; 86:2273-9. [PMID: 10590368 DOI: 10.1002/(sici)1097-0142(19991201)86:11<2273::aid-cncr15>3.0.co;2-c] [Citation(s) in RCA: 191] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The prognosis associated with lymph node negative, early stage carcinoma of the cervix is excellent, with 5-year survival rates greater than 90%. Radical trachelectomy in combination with pelvic lymph node dissection (RVT + LPL) has emerged as an alternative to radical hysterectomy (RH) for these patients who desire preservation of fertility. However, there are limited data to support its efficacy and safety. METHODS All patient information was collected prospectively and was subsequently extracted from the cervical cancer surgery database of the Division of Gynecologic Oncology at the University of Toronto. Patients treated by RVT + LPL for fertility preservation were compared with two groups of patients treated by RH. One control group was matched for age, tumor size, histology, depth of invasion, presence of capillary lymphatic space involvement, lymph node metastases, and use of adjuvant radiation. The other control group consisted of patients with tumor sizes </=2 cm, negative pelvic lymph nodes who had not received adjuvant radiation therapy. RESULTS Thirty of 32 patients treated by RVT + LPL between March 1994 and November 1998 were matched. The only statistically significant difference in prognostic factors between the patients who underwent RVT + LPL and unmatched controls (556 patients) was the median depth of invasion in the adenocarcinomas (2. 0 mm vs. 4.0 mm, respectively; P < 0.02). The 2-year actuarial recurrence free survival was 95%, 100%, and 97% for the patients who underwent RVT + LPL, matched controls, and unmatched controls, respectively. The actuarial conception rate at 12 months was 37%. CONCLUSIONS Acknowledging the small numbers and short follow-up, RVT + LPL appears to be similar in efficacy to RH. If longer follow-up with more patients confirms the above, this procedure will represent an acceptable alternative to RH for patients with early Stage I carcinoma of the cervix who desire preservation of fertility.
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Affiliation(s)
- A Covens
- Division of Gynecologic Oncology, Toronto-Sunnybrook Regional Cancer Center, Toronto, Ontario, Canada
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Covens A, Kirby J, Shaw P, Chapman W, Franseen E. Prognostic factors for relapse and pelvic lymph node metastases in early stage I adenocarcinoma of the cervix. Gynecol Oncol 1999; 74:423-7. [PMID: 10479503 DOI: 10.1006/gyno.1999.5466] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The aim of this study was to assess the prognostic significance of local tumor factors in predicting lymph node metastases and/or recurrence in early adenocarcinoma of the cervix. METHODS Patients were selected from the prospective computerized cervical cancer database of the division of gynecologic oncology. All patients had radical surgery and pelvic lymph node dissection. The study population consisted of all patients with stage I adenocarcinoma having tumor thickness <10 mm. Pathology was re-reviewed to assess histological subtype, depth, volume, grade, and presence of capillary lymphatic space involvement. RESULTS The study group consisted of 68 patients, with a mean age of 40 years. The median follow-up was 40 months (range 8-102 months). The median tumor depth and volume were 2.8 mm (range 0.3-8.0 mm) and 237 mm(3) (range 0.1-7996 mm(3)), respectively. Twenty-two patients had tumor volumes greater than 600 mm(3), and of these, 5 (23%) patients either had positive pelvic lymph nodes (2) or developed recurrent disease (3) (none node positive) at a median time of 49 months. In comparison, 46 patients (68%) had tumor volumes of less than 600 mm(3), none of whom had positive pelvic lymph nodes or developed recurrence (P<0.005). Only 1 of 20 patients with a depth of invasion <2 mm had a tumor volume >600 mm(3) in comparison to 21 of 48 patients with deeper invasion (P<0.002). CONCLUSION The incidence of positive pelvic lymph nodes and/or recurrence in this patient population is very low. As all patients with metastatic disease or recurrence had tumor volumes >600 mm(3), volume of disease rather than depth of invasion may be the single most important prognostic factor for the above events. However, many more patients will have to be studied to confirm this.
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Affiliation(s)
- A Covens
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, M4N 3M5, Canada
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Arango HA, Hoffman MS, Roberts WS, Decesare SL, Fiorica JV, Drake J, Murphy S, Cavanagh D. Does ligation of the hypogastric artery at the time of radical hysterectomy and lymphadenectomy decrease blood loss? Results of a prospective randomized trial. Int J Gynecol Cancer 1999; 9:137-140. [PMID: 11240755 DOI: 10.1046/j.1525-1438.1999.09906.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A prospective, randomized study of patients undergoing radical hysterectomy for gynecologic malignancies was undertaken from 10/95 to 11/96 to determine if ligation of the hypogastric arteries at the time of radical hysterectomy decreases blood loss. Patients were randomized to either ligation of the hypogastric artery (Group 1) or no ligation (Group 2) prior to a standard Piver type III radical hysterectomy. Surgeries were performed by Board certified gynecologic oncologists with gynecologic oncology fellows and/or OB/GYN residents. Patients were analyzed for demographic characteristics and intraoperative and postoperative parameters. Statistical analysis was performed with independent samples t-test, Mann-Whitney rank sum test, Chi square and Fisher exact test. Twenty-one patients were randomized to group 1 and 22 to group 2. Groups were similar with respect to demographics and preoperative parameters except for age. There were no differences among the groups with respect to intraoperative and postoperative parameters. The mean estimated blood loss for group 1 was 600 ml and 550 ml for group 2 (P = NS). Hypogastric artery ligation (HAL) at the time of radical hysterectomy for gynecologic malignancy does not reduce blood loss.
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Affiliation(s)
- H. A. Arango
- The Watson Clinic, Division of Gynecologic Oncology, Lakeland, Florida; Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of South Florida College of Medicine, Tampa, Florida; Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Florida College of Medicine, Pensacola, Florida
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Mundt AJ, Waggoner S, Herbst A, Rotmensch J. Preoperative intracavitary brachytherapy in early-stage cervical carcinoma. Am J Clin Oncol 1999; 22:73-7. [PMID: 10025386 DOI: 10.1097/00000421-199902000-00018] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Local failure within the central pelvis is a common site of recurrence in patients with early stage cervical carcinoma who experience recurrence after radical hysterectomy and pelvic lymphadenectomy. To reduce the risk of local failure, the authors treated selected patients with early stage cervical carcinoma with a moderate dose (45 Gy) of preoperative intracavitary brachytherapy before radical hysterectomy and pelvic lymphadenectomy. Given the low risk of recurrence in patients with small (<2 cm) tumors, the authors included only patients with tumors 2 cm or more in size. Forty-three patients (37 with stage IB disease, six with stage IIA disease) were treated from 1986 through 1995. Forty-two completed intracavitary brachytherapy; intracavitary brachytherapy was stopped early in one patient secondary to a low-grade fever. Exploratory laparotomy and planned radical hysterectomy were performed 2 weeks later. Radical hysterectomy was aborted in patients found to have extrauterine disease. At a median follow-up of 45 months, only one local failure has been noted, which occurred in the patient unable to complete intracavitary brachytherapy as planned. The most significant factor correlated with poor outcome was nodal involvement (p < 0.0004). A trend to a better disease-free survival was seen in patients with no residual or only microscopically residual disease. No patients developed significant chronic bowel or bladder toxicity, including fistulae. The results suggest that preoperative intracavitary brachytherapy in selected patients with early stage cervical carcinoma is a promising approach and is associated with a high rate of local control without significant adverse sequelae. Further data is needed to determine whether this approach improves the long-term outcome of these patients.
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Affiliation(s)
- A J Mundt
- Department of Radiation and Cellular Oncology, University of Chicago Hospitals, Illinois 60637, USA
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Roy M, Plante M. Pregnancies after radical vaginal trachelectomy for early-stage cervical cancer. Am J Obstet Gynecol 1998; 179:1491-6. [PMID: 9855586 DOI: 10.1016/s0002-9378(98)70014-6] [Citation(s) in RCA: 142] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the role of fertility-preserving surgery in the treatment of early-stage cervical cancer. STUDY DESIGN We retrospectively reviewed our first 30 patients treated by laparoscopic pelvic lymphadenectomy, followed by radical vaginal trachelectomy, from October 1991 to April 1998. RESULTS The median age of the patients was 32 years (range 22-42 years); 15 were nulligravid and 19 nulliparous. Twenty cancers were at stage IB, 1 was at stage IA1, 7 were at stage IA2, and 2 were at stage IIA. The majority (18/30) were squamous. Two lesions were >2 cm in size, and only 4 had vascular space invasion. The median operative time was 285 minutes (range 155-455 minutes), median blood loss 200 mL (range 50-1200 mL), and median hospital stay 4 days (range 2-9 days). There were 4 intraoperative complications-2 attributed to the trachelectomy and 2 resulting from the lymphadenectomy. The current median follow-up time is 25 months (range 1-79 months). One patient had a recurrence in the left parametrium 18 months after vaginal radical trachelectomy and died of metastatic disease. The only 6 patients attempting pregnancy so far have succeeded: 4 have had healthy babies delivered by cesarean section at 39, 38, 34, and 25 weeks of gestation. Two are currently 33 and 8 weeks pregnant. CONCLUSION Radical vaginal trachelectomy appears to be a valuable procedure in well-selected patients with early-stage cervical cancer. Successful pregnancies are definitely possible after this procedure. This new surgical technique warrants further careful evaluation to determine precise indications.
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Affiliation(s)
- M Roy
- Divison of Gynecologic Oncology, Université Laval, and the Department of Gynecology, Centre Hospitalier Universitaire Québec-Pavillion L'Hôtel-Dieu de Québec, Quebec City, Quebec, Canada
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Perez CA, Grigsby PW, Camel HM, Galakatos AE, Mutch D, Lockett MA. Irradiation alone or combined with surgery in stage IB, IIA, and IIB carcinoma of uterine cervix: update of a nonrandomized comparison. Int J Radiat Oncol Biol Phys 1995; 31:703-16. [PMID: 7860381 DOI: 10.1016/0360-3016(94)00523-0] [Citation(s) in RCA: 124] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE Definitive radiation therapy alone or combined with surgery in carcinoma of the uterine cervix yields comparable tumor control and survival in Stages I and IIA when patients are adequately treated with either modality. Our 30-year institutional experience is described. METHODS AND MATERIALS This is a nonrandomized comparison of treatment results of 415 patients with Stage IB, 137 with Stage IIA, and 340 with Stage IIB carcinoma of the uterine cervix treated with irradiation alone and 197 with Stage IB, 44 with Stage IIA, and 65 with limited Stage IIB treated with pre- or postoperative irradiation and surgery. Irradiation alone consisted of a combination of external beam therapy and intracavitary insertions to deliver doses of 70 to 85 Gy to point A for patients with Stages IB and IIA disease and 80 to 90 Gy for patients with bulky or Stage IIB tumors. For patients treated with irradiation and surgery, various combinations of external beam and intracavitary therapy were used to deliver 60 to 75 Gy to point A. Surgical procedures consisted of radical hysterectomy with or without lymph node dissection in 130 patients with Stage IB, 28 patients with Stage IIA, and 10 patients with limited Stage IIB. Fifty-seven patients had total abdominal or conservative hysterectomy with or without lymph node dissection, and 3 had vaginal hysterectomy. In addition, 51 patients with Stage IIB tumors underwent pelvic lymphadenectomy after definitive irradiation. RESULTS The 5-year cause-specific survival (CSS) rates for patients with Stage IB nonbulky tumors treated with irradiation alone or irradiation combined with surgery were 90 and 85%, respectively, and the 10-year survival rate was 84% with either modality. In patients with bulky tumors (> 5 cm), the 5-year CSS rates were 61% with irradiation alone and 63% with irradiation plus surgery; at 10 years the rates were 61 and 68%, respectively (p = 0.5). For those with Stage IIA nonbulky tumors, the 5-year CSS rates were 75% with irradiation alone and 83% with combined irradiation and surgery, and 10-year CSS rates were 66 and 71%, respectively. In patients with Stage IIA bulky tumors, the 5-year CSS rates were 69% with irradiation alone and 60% with irradiation plus surgery, and at 10 years, 69 and 44%, respectively (p = 0.05). In patients with Stage IIB nonbulky tumors treated with irradiation alone or combined with surgery, the 5- and 10-year CCS rates were 72 and 65%, respectively; the corresponding survival rates with bulky tumors or bilateral parametrial involvement were 56 and 50%. Incidence of pelvic failures, alone or with distant metastasis, for Stage IB was 10% (43 out of 415) with irradiation alone and 14% (28 of 197) with irradiation plus surgery; for Stage IIA, 17% (23 out of 137) with irradiation alone and 20% (9 our of 44) with irradiation plus surgery; and for Stage IIB, 23% (88 out of 391) with irradiation alone and 29% (4 out of 14) with irradiation plus surgery. Grade 3 sequelae were comparable in both groups (irradiation alone, 5% to 11%; irradiation combined with surgery, 8% to 12%); the differences are not statistically significant. The most frequent major sequelae in 892 patients receiving irradiation only were rectovaginal fistula (13 cases, 1.5%), proctitis (10, 1.1%), small bowel obstruction (16, 1.8%), ureteral stricture (16, 1.8%), and vesicovaginal fistula (8, 0.9%). In 306 patients treated with irradiation plus surgery, the most commonly recorded major sequelae were small bowel obstruction/perforation (13 cases, 4.2%), ureteral stricture (8, 2.6%), vesicovaginal fistula (5, 1.6%), and rectovaginal fistula (4, 1.3%). CONCLUSION Irradiation alone or combined with surgery yields comparable pelvic tumor control, survival, and morbidity in patients with Stage IB, IIA, and limited IIB carcinoma of the uterine cervix.
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Affiliation(s)
- C A Perez
- Radiation Oncology Center, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO
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