Extent of radical hysterectomy: evolving emphasis

The Landmark Series: Minimally Invasive Surgery for Cervical Cancer

Cervical cancer incidence and mortality have declined in developed countries during the past few decades as a result of screening programs and vaccination. However, it remains a significant cause of cancer-related mortality in young women. Early-stage cervical cancer, defined as disease limited to the cervix, has traditionally been treated with abdominal radical hysterectomy via laparotomy. Although most early-stage cervical cancers can be cured with open radical hysterectomy, the morbidity associated with open radical hysterectomy is significant compared with simple extrafascial hysterectomy. Since the early 1990s, minimally invasive surgery has been explored for the treatment of this disease, with the goal of minimizing the morbidity associated with open surgery, as reported for endometrial cancer surgery. This report reviews the landmark studies describing and evaluating minimally invasive surgery in the treatment of patients with early-stage cervical cancer.

Urinary biomarkers for the diagnosis of cervical cancer by quantitative label-free mass spectrometry analysis

Due to the invasive procedure associated with Pap smears for diagnosing cervical cancer and the conservative culture of developing countries, identifying less invasive biomarkers is of great interest. Quantitative label-free mass spectrometry was performed to identify potential biomarkers in the urine samples of patients with cervical cancer. This technique was used to study the differential expression of urinary proteomes between normal individuals and cancer patients. The alterations in the levels of urinary proteomes in normal and cancer patients were analyzed by Progenesis label-free software and the results revealed that 60 proteins were upregulated while 73 proteins were downregulated in patients with cervical cancer. This method could enrich high molecular weight proteins from 100 kDa. The protein-protein interactions were obtained by Search Tool for the Retrieval of Interacting Genes/Proteins analysis and predicted the biological pathways involving various functions including cell-cell adhesion, blood coagulation, metabolic processes, stress response and the regulation of morphogenesis. Two notable upregulated urinary proteins were leucine-rich α-2-glycoprotein (LRG1) and isoform-1 of multimerin-1 (MMRN1), while the 3 notable downregulated proteins were S100 calcium-binding protein A8 (S100A8), serpin B3 (SERPINB3) and cluster of differentiation-44 antigen (CD44). The validation of these 5 proteins was performed by western blot analysis and the biomarker sensitivity of these proteins was analyzed individually and in combination with receiver operator characteristic curve (ROC) analysis. Quantitative mass spectrometry analysis may allow for the identification of urinary proteins of high molecular weight. The proteins MMRN1 and LRG1 were presented, for the first time, to be highly expressed urinary proteins in cervical cancer. ROC analysis revealed that LRG1 and SERPINB3 could be individually used, and these 5 proteins could also be combined, to detect the occurrence of cervical cancer.

Identification of a low risk population for parametrial invasion in patients with early-stage cervical cancer

Background

Recent studies have challenged radical procedures for less extensive surgery in selected patients with early-stage cervical cancer at low risk of parametrial invasion. Our objective was to identify a subgroup of patients at low risk of parametrial invasion among women having undergone surgical treatment.

Methods

Data of 1447 patients with cervical cancer treated between 1996 and 2016 were extracted from maintained databases of 10 French University hospitals. Patients with early-stage (IA2–IIA) disease treated by radical surgery including hysterectomy and trachelectomy, were selected for further analysis. The Kaplan–Meier method was used to estimate the survival distribution. A Cox proportional hazards model including all the parameters statistically significant in univariate analysis, was used to account for the influence of multiple variables.

Results

Out of the 263 patients included for analysis, on final pathology analysis 28 (10.6%) had parametrial invasion and 235 (89.4%) did not. Factors significantly associated with parametrial invasion on multivariate analysis were: age > 65 years, tumor > 30 mm in diameter measured by MRI, lymphovascular space invasion (LVSI) on pathologic analysis. Among the 235 patients with negative pelvic lymph nodes, parametrial disease was seen in only 7.6% compared with 30.8% of those with positive pelvic nodes (p < 0.001). In a subgroup of patients presenting tumors < 30 mm, negative pelvic status and no LVSI, the risk of parametrial invasion fell to 0.6% (1/173 patients).

Conclusion

Our analysis suggests that there is a subgroup of patients at very low risk of parametrial invasion, potentially eligible for less radical procedures.

Electronic supplementary material

The online version of this article (10.1186/s12967-018-1531-6) contains supplementary material, which is available to authorized users.

Risk of Parametrial Spread in Small Stage I Cervical Carcinoma: Pathology Review of 223 Cases With a Tumor Diameter of 20 mm or Less

BACKGROUND

Considering the morbidity of radical hysterectomy, the advent of fertility-sparing approaches, and the low risk of parametrial involvement in patients with early stage I cervical tumors, the benefit from parametrial resection is debatable. Objectives of this study were to determine factors predicting parametrial tumor spread and to define a group of patients who might be safely spared parametrial resection.

METHODS

Pathology review was done on patients with stages IA2 and small IB1, treated by radical hysterectomy and pelvic lymph node dissection. Analysis was performed to determine factors associated with parametrial spread and to define risks of obeying parametrial resection.

RESULTS

A total of 223 patients with tumors less than 20 mm in diameter were identified. Parametrial metastases were documented in 8 patients (3.6%); nodes, 1.3%; lymphovascular space invasion (LVSI), 1.8%; contiguous spread, 0.9%. Of 211 (94.6%) patients with negative pelvic nodes, none had parametrial nodal involvement, 0.9% had LVSI, and 0.4% had contiguous spread. Factors associated with parametrial disease were deep cervical invasion, LVSI, tumor volume, and pelvic lymph node metastases (P < 0.01 for each). In patients without tumor LVSI and the depth of invasion was within the inner third, the rate of parametrial spread was 0.45%.

CONCLUSIONS

Our data show a risk of parametrial spread of 0.45% for tumors less than 20 mm in diameter, no LVSI, and a depth of invasion within the inner third. Patients wanting fertility preservation might be prepared to take this risk of recurrence. Morbidity after nerve-sparing radical hysterectomy is tolerably low, and for patients in whom fertility preservation is not an issue, this should be considered the standard of care.

A comparison of laparoscopic and abdominal radical parametrectomy for cervical or vaginal apex carcinoma and stage II endometrial cancer after hysterectomy

The authors conclude that laparoscopic radical parametrectomy is superior to abdominal parametrectomy in terms of shorter operative time, less blood loss, and shorter hospital stay.

Background and Objective:

Radical parametrectomy (RP), performed either abdominally (ARP) or laparoscopically (LRP), is a viable alternative to radiotherapy in treating invasive cervical cancer, vaginal apex cancer, and endometrial cancer that is more advanced than initially suspected after hysterectomy. We carried out a comparative study on intra- and postoperative parameters between the two performed by similarly experienced surgeons.

Methods:

Forty consecutive patients indicative for RP were reviewed: 22 and 18 underwent ARP and LRP, respectively. Information was collected on demographics, indications for initial and this surgery, tumor characteristics, intra- and postoperative parameters, and complications. The lengths of resected parametrial and vaginal tissues were measured.

Results:

Compared with ARP, LRP resulted in shorter operative time (200 vs 239 min), less blood loss (627.8 vs 929.5 mL), shorter hospital stay (16.8 vs 19.9 days), and removal of more pelvic lymph nodes (27.4 ± 5.9 vs 23.1 ± 7.1). Although it was not attempted in ARP to remove lymph nodes in the deep obturator space, it was attempted in LRP and one positive node was found. In the ARP cohort there was one case of injury to the small intestine during surgery, whereas in LRP there was one instance of lower urologic fistula after surgery.

Conclusion:

LRP is superior to ARP in terms of shorter operative time, less blood loss, and shorter hospital stay while still maintaining the completeness of the procedure. It can be safely performed in the hands of experienced surgeons for cervical or vaginal apex carcinoma and stage II endometrial cancer after hysterectomy.

Problematic issues in the staging of endometrial, cervical and vulval carcinomas

The International Federation of Gynecology and Obstetrics (FIGO) staging of tumours of the uterine corpus, cervix and vulva was revised in 2009. The greatest impact of the revised staging was on carcinomas of the uterine corpus. Uterine sarcomas are now staged separately. Changes to the staging system for vulvar carcinomas largely reflect the significance of lymph node status. Only minor amendments have been introduced for cervical carcinomas, which remain the only gynaecological tumours to be staged clinically. These revisions, based on recent evidence, require careful, more detailed assessment of several histological parameters at each anatomical site. The present review deals with the evidence and rationale underpinning the revisions, and includes practical guidance on tumour staging. This covers the assessment and measurement of myoinvasion and evaluation of cervical, parametrial, serosal and vaginal involvement in carcinomas of the uterine corpus; the identification and accurate measurement of stromal invasion in cervical and vulvar carcinomas; the assessment of unusual variants of carcinoma at each of these sites; and the assessment of lymph node involvement.

To what extent should we perform parametrectomy in FIGO stage IB cervical cancer?

OBJECTIVE

To demonstrate the histopathological basis of individually tailored less radical surgery concept in patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB cervical cancer.

MATERIAL AND METHODS

The study was performed in the gynaecologic oncology department of Başkent School of Medicine Hospital, Ankara, Turkey between January 1(st) 2008 and January 1(st) 2009. Cardinal and uterosacral ligaments were serially sectioned in an alternative approach, and were examined by a senior gynaecologic pathologist. Clinical and pathological features and findings in sections of uterine ligaments were recorded. Study data were analysed using the SPSS 17.0 program.

RESULTS

Thirty-two out of 38 cases had squamous cell carcinoma (SCC) (84.2 %), and six had non-squamous cell tumours (15.8%). Four cases had microscopic (10.5 %) and one case had macroscopic (2.6 %) tumour extension in cardinal ligaments. Mean tumour-free cardinal ligament length was 16.8±7.39 mm. Presence of tumour invasion in cardinal ligaments correlated significantly with pelvic lymph node metastasis (p=0.02). No isolated tumour deposits were found in any of the cases in serial sections of the cardinal or uterosacral ligaments.

CONCLUSION

This research was designed as a preliminary study. Future studies are needed to determine the optimal resection margins of the uterine ligaments in surgically treated stage IB cervical cancer. With continuing research and the development of newer surgical techniques, patients' quality of life will be optimised accordingly.

The influence of surgical volume on morbidity and mortality of radical hysterectomy for cervical cancer

OBJECTIVE

We examined the influence of physician and hospital volume on the morbidity and mortality of radical hysterectomy for cervical cancer.

STUDY DESIGN

Women who underwent radical hysterectomy for cervical cancer between 2003 and 2007 were examined. The effect of surgeon and hospital volume on morbidity and mortality was examined using multivariable generalized estimating equations.

RESULTS

A total of 1536 women who underwent radical hysterectomy were identified. Patients treated by high-volume surgeons had fewer medical complications (odds ratio, 0.55; 95% confidence interval, 0.34-0.88) and shorter lengths of stay (odds ratio, 0.49; 95% confidence interval, 0.25-0.98). After adjustment for case mix and surgeon volume, hospital volume had no independent effect on any of the variables of interest.

CONCLUSION

High-volume surgeons have fewer postoperative medical complications, shorter lengths of stay, and lower transfusion requirements. Hospital volume appears to have only a minor influence on outcomes after radical hysterectomy.

Less radical surgery than radical hysterectomy in early stage cervical cancer: a pilot study

OBJECTIVE

The purpose of this pilot study was to evaluate the feasibility and safety of a less radical surgery; laparoscopic lymphadenectomy followed by a simple vaginal hysterectomy in sentinel lymph node (SLN) negative early cervical cancer patients. Treatment-associated morbidity and oncological outcome were evaluated.

PATIENTS AND METHODS

From December 2000 to September 2007, 60 patients (50 squamous and 10 adenocarcinoma patients) in stages 3-IA1, 11-IA2 and 46-IB1 with median age of 44.6 years (range 33-64 years) were enrolled. Patients were selected based on favorable cervical tumors (IA1 with lymph-vascular space invasion [LVSI], IA2 and IB1 with tumor size less than 20 mm and less than half of stromal invasion). All patients underwent laparoscopic SLN identification using frozen section (FS). Negative SLN patients underwent complete pelvic laparoscopic lymphadenectomy and vaginal hysterectomy. FS positive patients underwent radical hysterectomy with low paraaortic lymphadenectomy.

RESULTS

The average number of sentinel nodes per side was 1.4 with detection rate per side of 95%. The average number of removed nodes was 23.2. Five patients (8.3%) were SLN positive. There were two false negative FS results (both were micrometastases in SLN). Median follow-up was 47 months (range 12-92). There were no recurrences in 55 SLN negative patients and in 5 SLN positive patients.

CONCLUSION

Lymphatic mapping and SLN identification improved safety in less radical surgery in early stage cervical cancer. This preliminary study showed that it is both feasible and safe to reduce the radicality of parametrial resection for small tumor volume in SLN negative patients. Results also indicated that treatment-associated morbidity is low.

The vascular portion of the cardinal ligament: surgical significance during radical hysterectomy for cervical cancer

OBJECTIVE

The objective of the study was to analyze the histopathologic content of the vascular portion of the cardinal ligament in patients undergoing radical hysterectomy for cervical cancer.

STUDY DESIGN

The vascular portion of the cardinal ligament was completely removed during radical hysterectomy. The maximum cervical diameter and length of the vascular ligament were measured on the fresh specimen. After inking, the pathologist separated and embedded the entire vascular segment from each side. Microscopic examination followed.

RESULTS

Eighty-four patients were available for analysis. The mean cervical diameter was 3.9 cm (2-8), whereas the mean vascular segment length on the right and left sides were 4 cm (1-10) and 3.8 cm (1-7), respectively. Mean number of vascular segment lymph nodes were as follows: medial right = 0.7 (0-4), medial left = 0.6 (0-5), lateral right = 0.4 (0-3), and lateral left = 0.6 (0-6). Mean diameter of medial and lateral lymph nodes were 2 mm (0.25-8) and 3.3 mm (0.25-16), respectively. The length of the vascular segment correlated inversely with maximum cervical diameter. Thirty-one percent (26 of 84) had positive pelvic side wall lymph nodes. Fourteen patients had positive vascular segment lymph nodes (1 positive = 7, more than 1 positive = 7). Three of 7 patients had bilateral positive vascular segment lymph nodes; all 7 had microscopic disease in the paravaginal soft tissue, and all 7 had positive pelvic side wall lymph nodes (6 of 7 bilateral). Including the 14 patients, a total of 19 had nodal or nonnodal microscopic disease in the vascular segment. Of these, 7 had disease in the lateral half of the vascular ligament. Histologic sectioning revealed nerve twigs and/or scattered ganglia in the vascular segment but no large nerve trunks.

CONCLUSION

Among a population of women with high-risk, early-stage cervical cancer, the lateral vascular segment of the cardinal ligament contained metastatic disease in a substantial number of patients. This segment contains no major nerve trunks. When radical hysterectomy is chosen as primary treatment for such patients, the vascular segment of the cardinal ligament should be completely excised.

Female sexual dysfunction: classification, pathophysiology, and management

Female sexual dysfunction is a prevalent problem in the general community; however, it has not been studied as extensively as male sexual dysfunction. Female sexual dysfunction is a common complication after most pelvic surgeries. With the introduction of screening programs, most pelvic malignancies are detected at earlier stages and in younger patients. Sexual dysfunction is a major quality-of-life issue in these young women. Hysterectomy (simple or radical) is the most common type of pelvic surgery in women and is one of the most important causes of female sexual dysfunction. Additionally, female sexual dysfunction is an important issue after urologic (radical cystectomy) and colorectal surgeries (simple and radical proctocolectomy). Sexual dysfunction is a common problem among postmenopausal women. Modifications in the surgical technique (nerve sparing) are rapidly evolving in the field of urology and colorectal surgery, which will be soon followed by modifications in the field of gynecologic surgery. In this article we summarize the pathophysiology and classification of female sexual dysfunction, with special emphasis on the relationship between female sexual dysfunction and pelvic surgeries.

Lymphedema and bladder-emptying difficulties after radical hysterectomy for early cervical cancer and among population controls

The aim of the study was to acquire knowledge that can be used to refine radical hysterectomy to improve quality-of-life outcome. Data were collected in 1996-1997 by means of an anonymous postal questionnaire in a follow-up study of two cohorts (patients and population controls). We attempted to enroll all 332 patients with stage IB-IIA cervical cancer registered in 1991-1992 at the seven departments of gynecological oncology in Sweden and 489 population controls. Ninety three (37%) of the 256 women with a history of cervical cancer who answered the questionnaire (77%) were treated with surgery alone. Three-hundred fifty population controls answered the questionnaire (72%). Women treated with radical hysterectomy, as compared with controls, had an 8-fold increase in symptoms indicating lymphedema (25% reported distress due to lymphedema), a nearly 9-fold increase in difficult emptying of the bladder, and a 22-fold increase in the need to strain to initiate bladder evacuation. Ninety percent of the patients were not willing to trade off survival for freedom from symptoms. Avoiding to induce long-term lymphedema or bladder-emptying difficulties would probably improve quality of life after radical hysterectomy (to cure cervical cancer). Few women want to compromise survival to avoid long-term symptoms.

Utility of parametrectomy for early stage cervical cancer treated with radical hysterectomy

BACKGROUND

Removal of the parametrial soft tissue is recommended for patients with cervical cancer undergoing radical hysterectomy. Parametrectomy results in significant morbidity. The objective of the study was to determine factors predictive of parametrial tumor spread and to define a subset of patients at low risk for parametrial disease.

METHODS

Patients with invasive cervical cancer who underwent radical hysterectomy from 1989-2005 were examined. Analysis was performed to determine factors associated with parametrial tumor spread. Survival estimates were determined using the Kaplan-Meier method.

RESULTS

A total of 594 patients were identified. Parametrial metastases were documented in 64 (10.8%). Factors associated with parametrial disease were: histology, advanced grade, deep cervical invasion, lymphovascular space invasion (LVSI), large tumor size, advanced stage, uterine or vaginal involvement, and pelvic or para-aortic lymph node metastases (P < .0001 for each). Parametrial metastases were associated with increased risk of recurrence and decreased disease-free and overall survivals (P < .0001). A subgroup analysis was performed to identify patients at low risk for parametrial spread. In pelvic node-negative women parametrial disease was noted in 6.0% (30/498) compared with 47.9% (34 of 71) of those with positive pelvic nodes (P < .0001). If further stratified to women with negative nodes, no LVSI, and tumors < 2 cm, the incidence of parametrial disease was only 0.4%.

CONCLUSIONS

Parametrial spread is a strong predictor of recurrence and decreased survival. Parametrial invasion is rare in patients with small tumors, no LVSI, and negative pelvic nodes (no poor prognostic factors). Further study is warranted to determine the feasibility of omitting parametrectomy in these low-risk patients.

Type II versus Type III Nerve-sparing Radical hysterectomy: Comparison of lower urinary tract dysfunctions

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.

Management of cervical cancer

AIMS

The aim of the article was to review the current approach to management of cervical cancer.

METHODS

The relevant literature has served as a source for review of different options applied in the management of cervical cancer.

RESULTS

Treatment of invasive cervical cancer is affected by the stage of the disease, which is based on clinical evaluation. Microinvasive carcinoma of the cervix has limited metastatic potential and therefore is most likely curable by non-radical treatment. There is no standard management of stage Ib-IIa cervical carcinoma. Both radical surgery and radical radiotherapy have proven to be equally effective, but differ in associated morbidity and complications. Most often, stage Ib1 cervical cancer is treated by radical hysterectomy with pelvic lymphadenectomy. Laparoscopically assisted radical vaginal hysterectomy has shown similar efficacy and recurrence rates. Radical vaginal trachelectomy with laparoscopic pelvic lymphadenectomy may be an option in small cervical cancer where preservation of fertility is desired. There is lot of conflicting published work regarding the treatment of bulky stage Ib-IIa cervical cancer. While some centers are performing primary surgery as for Ib1 disease followed by tailored postoperative radiation with or without chemotherapy, the others are in favor of primary chemo-radiation therapy. Neoadjuvant chemotherapy followed by radical surgery has emerged as a possible alternative, which may improve a survival in patients with stage Ib2 disease. Concomitant chemoradiation is becoming a new standard in treatment of advanced disease, because it has been clearly shown to improve disease-free, progression-free and overall survival. Management of recurrent disease depends on previous treatment, site and extent of recurrence, disease-free interval and patient's performance status.

CONCLUSIONS

Treatment decisions should be individualized and based on multiple factors including the stage of the disease, age, medical condition of the patient, tumor-related factors and treatment preferences, to yield the best cure with minimum complications.

Operative management of cervical cancer

Radical abdominal hysterectomy with pelvic lymph node dissection remains the treatment of choice for most patients with early-stage cervical cancer. The radicality and extent of lymph node dissection and parametrial resection should be tailored to tumour- and patient-related risk factors. Adjuvant therapy after radical surgery improves local control in high-risk patients and some intermediate-risk patients. The absolute indications for adjuvant therapy include multiple or macroscopically involved nodes, parametrial invasion and positive surgical margins. Adjuvant therapy may be given as chemoradiation or as radiotherapy alone, depending on risk assessment and expected morbidity. Primary chemoradiation is an equally effective alternative, but adjuvant surgery or finishing hysterectomy after pelvic radiation is not beneficial. Promising new developments include neo-adjuvant chemotherapy followed by surgery for bulky early-stage disease, tailoring radicality to reduce therapeutic morbidity and integrating minimal access surgical techniques into current treatment protocols.

Laparoscopic modified radical hysterectomy: a strategy for a clinical dilemma

OBJECTIVE

To investigate the role of laparoscopic modified radical (type 2) hysterectomy when cervical cancer cannot be excluded or documented preoperatively.

METHODS

Between 1996 and 2004, 50 patients with cervical intraepithelial neoplasia (CIN III) or adenocarcinoma in situ (AIS) involvement of cone endocervical margins and/or endocervical curettings, who were not candidates for observation or repeat conization, underwent laparoscopy to perform a modified radical hysterectomy.

RESULTS

Forty-nine (98.0%) modified radical hysterectomies were completed laparoscopically and one (2.0%) patient required a laparotomy. Of the overall group, 35 (70.0%) had residual pathology; 26 (52.0%) were precancerous lesions, and 9 (18.0%) had invasive disease (5 adenocarcinomas, 3 squamous lesions, and 1 adenosquamous carcinoma). Of the nine with cancer, one had stage IA1 disease, three had stage IA2 disease, and five had stage IB1 disease. Five (55.6%) invasive lesions were diagnosed intraoperatively (frozen section), and a laparoscopic pelvic and lower aortic lymph node dissection was performed. The median operative time was 96 min (range 58-185), blood loss 100 ml (50-450), and postoperative hospital stay 2.5 days (range 1-14). There were no incidences of prolonged urinary retention fistulas, or other serious complications. All patients with cancer remain disease-free (median follow-up 44.2 months, range 1-88.7 months).

CONCLUSIONS

Laparoscopic modified radical hysterectomy is a treatment option for patients for whom cervical cancer cannot be definitively excluded, and can be completed with acceptable operative time, blood loss, and hospitalization.