Surgical and radiographic staging in patients with cervical cancer

The role of pre-treatment paraaortic surgical staging for cervical cancer in the EMBRACE criteria

Background

The State-of-the-Art Treatment for Locally Advanced Cervical Cancer (LACC) is Definite Radio-Chemotherapy based on the Image-guided intensity modulated External beam radiochemotherapy and MRI-based adaptive BRAchytherapy (EMBRACE) trial, according to the FIGO staging. This staging is based on clinical examination and imaging studies; however, there are limitations of imaging techniques which may result in adverse events or death due to insufficient or overtreatment. The aim of the study was to evaluate the feasibility and outcomes of surgical staging in LACC prior to radiotherapy (RT) to personalise target volumes for radiotherapy.

Methods

From 2008 to 2018, 138 patients with FIGO 2018 stages IB3-IIIC2 cervical cancer underwent a pretherapeutic laparoscopic staging procedure. The pathological diagnosis was compared with the results of preoperative CT scan. Patients were treated with chemoradiotherapy tailored according to the staging results.

Results

The mean patient age was 43 years, the mean body mass index was 27 kg/m²; most lesions were squamous cervical cancer (92%). Staging CT scan had a 77% concordance with the histological findings. Sensitivity was 29%, specificity 85%, positive predictive value 21% and negative predictive value 89%. Surgical staging led to change of stage in 24% of cases. Para -aortic dissection led to change the initially planned radiotherapy fields in 47% of the cases. Major complications included involuntary section of the inferior mesenteric artery (IMA) without clinical repercussion, an infected retroperitoneal haematoma and a symptomatic lymphocele requiring laparoscopic drainage.

Conclusion

Laparoscopic staging before primary chemoradiation in patients with LACC was feasible, safe and reproducible, allowing reduction of the radiotherapy treatment volumes of patients.

Laparoscopic Extrafascial Hysterectomy (Completion Surgery) After Primary Chemoradiation in Patients With Locally Advanced Cervical Cancer: Technical Aspects and Operative Outcomes

Objective

This study aimed to evaluate the feasibility and safety of laparoscopic extrafascial hysterectomy and bilateral salpingo-oophorectomy after primary chemoradiation (CRT) in patients with locally advanced cervical cancer (LACC) without evidence of nodal metastasis.

Background

Currently, the standard of care for patients with advanced cervical cancer is concurrent CRT. There is an unequivocal correlation between presence of residual disease and risk of local relapse. Nevertheless, the importance of hysterectomy in adjuvant setting remains controversial.

Methods

Prospective study with patients affected by bulky LACC (International Federation of Gynecology and Obstetrics stage IB2 up to IIB) treated initially with radical CRT who underwent laparoscopic surgery 12 weeks after therapy conclusion. Inclusion criteria were absence of signs for extrapelvic or nodal involvement on initial imaging staging, as well as complete clinical and radiologic response.

Results

From January 2011 to March 2013, 33 patients were endoscopically operated. The mean age was 44 years (range, 21–77 years). Histologic finding revealed squamous cell carcinoma in 19 (60%) cases and adenocarcinoma in 14 (40%) cases. International Federation of Gynecology and Obstetrics stages distribution were as follow: 1B2, n = 3 (9%); IIA, n = 4 (11%); and IIB, n = 26 (80%). The mean pretherapeutic tumor size was 5.2 cm (range, 4–10.2 cm). Estimated blood loss was 80 mL (range, 40–150 mL), and mean operative time was approximately 104 minutes (range, 75–130 minutes). No casualty or conversion to laparotomy occurred. Hospital stay was in average 1.7 days (range, 1–4 days). Significant complication occurred in 12% of the cases; 2 vaginal vault dehiscence, 1 pelvic infection, and 1 ureterovaginal fistula. Nine (27%) patients had pathologic residual disease, and in 78% of these cases, histologic finding was adenocarcinoma (P = −0.048). All patients had free margins. After median follow-up of 16 months, all women have no signs of local recurrence.

Conclusions

Laparoscopic extrafascial hysterectomy (completion surgery) after primary CRT in patients with apparent node-negative LACC is a feasible and safe strategy to improve tumor local control mainly in cases of adenocarcinoma.

Detection of Sentinel Lymph Nodes in Gynecologic Tumours by Planar Scintigraphy and SPECT/CT

Objective: Assess the role of planar lymphoscintigraphy and fusion imaging of SPECT/CT in sentinel lymph node (SLN) detection in patients with gynecologic tumours.

Material and Methods: Planar scintigraphy and hybrid modality SPECT/CT were performed in 64 consecutive women with gynecologic tumours (mean age 53.6 with range 30-77 years): 36 pts with cervical cancer (Group A), 21 pts with endometrial cancer (Group B), 7 pts with vulvar carcinoma (Group C). Planar and SPECT/CT images were interpreted separately by two nuclear medicine physicians. Efficacy of these two techniques to image SLN were compared.

Results: Planar scintigraphy did not image SLN in 7 patients (10.9%), SPECT/CT was negative in 4 patients (6.3%). In 35 (54.7%) patients the number of SLNs captured on SPECT/CT was higher than on planar imaging. Differences in detection of SLN between planar and SPECT/CT imaging in the group of all 64 patients are statistically significant (p<0.05). Three foci of uptake (1.7% from totally visible 177 foci on planar images) in 2 patients interpreted on planar images as hot LNs were found to be false positive non-nodal sites of uptake when further assessed on SPECT/CT. SPECT/CT showed the exact anatomical location of all visualised sentinel nodes.

Conclusion: In some patients with gynecologic cancers SPECT/CT improves detection of sentinel lymph nodes. It can image nodes not visible on planar scintigrams, exclude false positive uptake and exactly localise pelvic and paraaortal SLNs. It improves anatomic localization of SLNs.

Conflict of interest:None declared.

Robot assisted laparoscopic transperitoneal para-aortic lymphadenectomy in the management of advanced cervical carcinoma

OBJECTIVES

Adequate staging of advanced cervical cancer is essential in order to optimally treat the patient. FIGO clinical staging, imaging techniques such as CT scan, MRI and PET sometimes underestimate the extension of tumors. The presence of para-aortic lymph node metastases in advanced cervical cancer identifies patients with poor prognosis who need to be treated aggressively. Laparoscopic para-aortic lymph node dissection is now proposed as a diagnostic tool in many guidelines. We evaluated the feasibility and safety of a robot assisted laparoscopic transperitoneal approach to para-aortic lymph node dissection.

STUDY DESIGN

Eight patients with advanced cervical carcinoma who were eligible for primary pelvic radiotherapy combined with concurrent cisplatin chemotherapy or pelvic exenteration underwent a pre-treatment robot assisted transperitoneal laparoscopic para-aortic lymphadenectomy.

RESULTS

We isolated from 1 to 38 para-aortic nodes per patient and had one para-aortic node positive patient who was treated with extended doses of pelvic radiotherapy. We did not encounter any major complications and post-operative morbidity was low.

CONCLUSIONS

Robot assisted transperitoneal laparoscopic para-aortic lymphadenectomy is feasible and provides the surgeon with greater precision than classical laparoscopy. Larger prospective multicentric trials are needed to validate the generalised usefulness of this technique.

New developments in the surgical therapy of cervical carcinoma

For almost a century abdominal radical hysterectomy has been the standard surgical treatment of early-stage macroscopic carcinoma of the uterine cervix. The excessive parametrial resection of the original procedures of Wertheim, Okabayashi, and Meigs has later been "tailored" to tumor extent. Systematic pelvic and eventually periaortic lymph node dissection is performed to identify and treat regional disease. Adjuvant (chemo)radiation therapy is liberally added to improve locoregional tumor control when histopathological risk factors are present. The therapeutic index of the current surgical treatment, particularly if combined with radiation, appears to be inferior to that of primary chemoradiation as an oncologically equivalent therapeutic alternative. Several avenues of new conceptual and technical developments have been used since the 1990s with the goal of improving the therapeutic index. These are: surgical staging, including sentinel node biopsy and nodal debulking; minimal access and recently robotic radical hysterectomy; fertility-preserving surgery; nerve-sparing radical hysterectomy; total mesometrial resection based on developmentally defined surgical anatomy; and supraradical hysterectomy. The superiority of these new developments over the standard treatment remains to be demonstrated by controlled prospective trials. Multimodality therapy including surgery for locally advanced disease represents another area of clinical research. Both neoadjuvant chemotherapy followed by radical surgery, with or without adjuvant radiation, and completion surgery after (chemo)radiation are feasible and have to be compared to primary chemoradiation as the new nonsurgical treatment standard. Surgical treatment of postirradiation persisting or recurrent cervical carcinoma has been traditionally limited to pelvic exenteration for central disease. Applying the principle of developmentally derived anatomical compartments increases R0 resectability. The laterally extended endopelvic resection allows even the extirpation of a subset of visceral pelvic side wall tumors with clear margins. Many questions regarding the indication for these "ultraradical" operations, the surgery of irradiated tissues, and the optimal reconstructive procedures are still open and demand multi-institutional controlled trials to be answered.

Laparoscopic para-aortic lymphadenectomy and positron emission tomography scan as staging procedures in patients with cervical carcinoma stage IB2IIIB

The objective of this study was to determine the role of laparoscopic lower para-aortic lymphadenectomy and positron emission tomography (PET) scan in the staging of cervical carcinoma. Ninety consecutive patients with FIGO stage IB2-IIIB were scheduled for laparoscopic para-aortic lymphadenectomy.

EXCLUSION CRITERIA

obvious metastatic para-aortic nodes on computed tomography (CT)/PET or PET-CT. The procedure was stopped when a node was positive on frozen section. In ten patients, no para-aortic lymphadenectomy was performed as scheduled. Forty-seven patients were operated retroperitoneally, 22 transperitoneally, and 21 cases were converted from retroperitoneally to transperitoneally. Median number of removed nodes was 6 (1-24). In 10 of 80 patients, para-aortic metastases were diagnosed. Despite a nonsuspect PET result, 5 of 44 patients had positive para-aortic nodes. Two-year survival was 76% and 16% without and with para-aortic metastases, respectively (P = 0.0001). Laparoscopic para-aortic lymphadenectomy showed metastases in 13% of the patients. In the subgroup with negative PET scan, 11% had metastases. The procedure had a low morbidity and identified a group with an extremely poor prognosis.

New surgical approaches for the management of cervical carcinoma

Cervical carcinoma remains an important health problem in both developed and developing countries even though population-based screening programs are widely available. The classical surgical management of early-stage cervical carcinoma, known as radical hysterectomy (RH), was first described by Wertheim more than one hundred years ago and was then modified and re-popularized by Meigs in 1950s. The surgical principles of this operation have undergone only minor modifications and remain the basis for the surgical approach utilized by gynecologic oncologists today. However, some recent studies have questioned the role of RH due to a high rate of postoperative complications involving the pelvic autonomic nerve system and poor oncological outcomes despite postoperative adjuvant chemoradiation. During the last 2 decades, new surgical operations (radical vaginal trachelectomy, nerve-sparing hysterectomy, total mesometrial resection, laterally extended endopelvic resection, laparoscopic assisted radical vaginal hysterectomy, laparoscopic lumbo-aortic lymph node dissection, and laparoscopic pelvic exenteration) have been proposed for the management of both early- and late-stage cervical carcinoma. In this manuscript, some technical details and oncological outcomes of these new surgical approaches are summarized.

Lymph node involvement in locally advanced cervical cancer patients administered preoperative chemoradiation versus chemotherapy

BACKGROUND

A retrospective study was planned in 127 locally advanced cervical cancer (LACC) to investigate: (1) the rate and pattern of metastatic lymph node involvement in patients administered preoperative chemoradiation (CT/RT) versus neoadjuvant chemotherapy (NACT), and (2) the profile of clinico-pathological parameters predictive of metastatic lymph node involvement in these two clinical settings. Finally, we investigated whether the pathologically assessed status of lower pelvic nodes (LPN) was able to predict the pathologically assessed status of upper pelvic nodes (UPN) and parametrium in cases administered CT/RT.

METHODS

Patients were selected including LACC patients who were administered concomitant CT/RT (n = 87) or NACT (n = 40), before radical surgery.

RESULTS

Metastatic pelvic lymph node involvement was significantly lower in cases administered CT/RT (11.5%) compared to cases administered NACT (30.0%) (P value = 0.009). In the CT/RT group, only MRI-assessed pelvic node status (both at staging and post-treatment evaluation) was associated with pathologic pelvic node status. In patients administered CT/RT, the status of LPN appeared associated with the status of UPN.

CONCLUSIONS

(1) Preoperative CT/RT treatment is associated with a lower rate of pelvic node disease in LACC patients compared to NACT; (2) there is no association between the preoperative extent of residual cervical disease after CT/RT and pathologically assessed pelvic node status; (3) the pathological status of LPN is predictive of the pathological status of UPN and parametrium.

A laparoscopy-based score to predict surgical outcome in patients with advanced ovarian carcinoma: a pilot study

BACKGROUND

Our objective was to set up a more objective quantitative laparoscopy-based model in predicting the chances of optimal cytoreductive surgery in advanced ovarian cancer patients.

METHODS

Sixty-four advanced ovarian cancer patients were submitted to both laparoscopy and standard longitudinal laparotomy sequentially, to define the chances of optimal debulking surgery (residual disease < or = 1 cm). Three patients could not be evaluated by laparoscopy because of the presence of multiple and tenacious adherences. Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were calculated for each laparoscopic parameter. On the basis of the statistical probability of each factor to predict surgical outcome, seven laparoscopic features were selected for inclusion in the final model. Each parameter was assigned a numerical score based on the strength of statistical association, and a total predictive index value was tabulated for each patient. Receiver operating characteristic curve analysis was used to assess the ability of the model to predict surgical outcome.

RESULTS

After debulking surgery, 41 (67.2%) of 61 patients were left with optimal residual disease. The presence of omental cake, peritoneal carcinosis, diaphragmatic carcinosis, mesenteric retraction, bowel and/or stomach infiltration, and liver metastases satisfied the basic inclusion criteria and were assigned a final predictive index value of 2. In the final model, a predictive index score > or = 8 identified patients undergoing suboptimal surgery with a specificity of 100%. The positive predictive value was 100%, and the negative predictive value was 70%.

CONCLUSIONS

The reliability of laparoscopy in assessing the chance of optimal cytoreduction can be improved by using a simple scoring system.

[Laparoscopic pelvic exenteration for cervical cancer relapse: preliminary study]

OBJECTIVES

To determine the feasibility and short and midterm results of laparoscopic pelvic exenteration for cervical cancer relapse. Materials and methods. Five patients with centro-pelvic recurrence within 3 to 13 months after combined chemo-radiation therapy (associated to surgery for two cases) for cervical cancer tumors were included in a pilot study.

RESULTS

The procedures consisted in a complete pelvic exenteration with colo-anal anastomosis and ileal-loop conduit for 2 patients, a posterior pelvic exenteration including uterus, vagina and rectum with colo-anal anastomosis for 1 patient, an anterior pelvic exenteration including bladder and vagina with an ileal-loop conduit for 1 patient and a anterior pelvic exenteration with a laparoscopic hand assisted Miami Pouch for 1 patient. The 5 procedures were successful with no conversion to laparotomy. Time of procedure ranged between 4 h 30 and 9 hours. Average blood loss was 370 cc. Three patients developed metastatic recurrences and died. The two patients with anterior exenteration are alive and free of disease 11 and 15 months after the procedure.

CONCLUSION

Laparoscopic pelvic exenteration procedures are feasible. A larger series is necessary to determine the advantages of this technique compared to laparotomy.

From 'points' to 'profiles' in intracavitary brachytherapy of cervical cancer

PURPOSE OF REVIEW

This article reviews some recent developments that have occurred with the widespread use of imaging modalities during intracavitary brachytherapy in cervical cancer.

RECENT FINDINGS

The practice of dose prescription with intracavitary brachytherapy continues to be largely based on the traditional hypothetical point - point A. Recent studies have indicated that significant uncertainties could result with such point dose prescriptions. Gradually a shift is perceived towards the incorporation of target and normal structure outlines for dose prescription and treatment planning during intracavitary brachytherapy.

SUMMARY

Dose prescriptions during brachytherapy could be framed with certainty if various imaging modalities are integrated during the intracavitary procedure. With the availability of computerized tomography/magnetic resonance imaging-compatible applicators, dose prescriptions and distributions could be based on either anatomical images of the diseased and normal organs obtained from computerized tomography or magnetic resonance imaging studies or on anatometabolic images after co-registration of the anatomical and functional images obtained from computerized tomography/magnetic resonance imaging and positron emission tomography. A shift from traditional two-dimensional 'points' to three-dimensional 'profiles' for targets and normal tissue doses could be expected in the near future with the use of image-guided intracavitary brachytherapy in cervical cancer.

Usefulness of sentinel lymph node detection in early stages of cervical cancer

PURPOSE

Sentinel lymph node (SLN) mapping in combination with surgical biopsy is an emerging technique for use in the early stages of cervical cancer. The purpose of this study was to evaluate the technique in a series of 40 consecutive women with early stage cervical cancer.

METHODS

Forty patients with early stage cervical cancer [FIGO stage IA2 (2), IB1 (34), IB2 (1) or IIA (3)] were referred for radical hysterectomy with pelvic lymphadenectomy. Patients were submitted to preoperative lymphoscintigraphy (four 99mTc-nanocolloid injections around the tumour) and intraoperative SLN detection. Hand-held or laparoscopic gamma probes were used to locate SLNs during surgery.

RESULTS

The mean number of SLNs was 2.5 per patient (interiliac 49%, external iliac 19%). Of the total of 99 SLNs, six, in four women, showed metastases (all 68 non-SLNs removed were negative). In the other 36 patients, all the removed lymph nodes (sentinel and non-sentinel) were negative (0% false negative rate). During the follow-up (median 25 months), only two patients presented distant metastases: one died 6 months after surgery (two of three SLNs positive, both hot and blue), while the second patient is alive 4 years after surgery (lung metastasis, no isotope drainage, negative blue SLN). The survival rate was 95% and disease-free survival, 97%.

CONCLUSION

SLN surgical biopsy based on lymphoscintigraphy and blue dye is a feasible and useful technique to avoid lymph node dissection in the early stages of cervical cancer. It has a high negative predictive value, can be incorporated into clinical routine (laparoscopy or open surgery) and is close to achieving validation in this setting.