Radical parametrectomy after ‘cut-through’ hysterectomy in low-risk early-stage cervical cancer: Time to consider this procedure obsolete
Introduction
The standard recommendation for patients with early-stage (IA2-1B1) cervical cancer who are not interested in fertility preservation remains radical hysterectomy and; more recently, sentinel lymph node mapping when available, in substitution for bilateral pelvic lymphadenectomy [1,2]. Unfortunately, up to 15% of patients with early cervical cancer will undergo suboptimal treatment in the form of simple hysterectomy [3]. Previously published literature suggests that if no additional treatment is given, between 42% and 60%, of all patients who undergo a simple hysterectomy in the setting of invasive disease will die from it [4,5]; and if surgical margins in the hysterectomy specimen are involved, the overall 5-year survival rate drops to 16% [6]. However, it is important to note that in the published literature, most manuscripts do not stratify by low- vs. high-risk features.
According to NCCN guidelines, treatment options for patients with invasive cervical cancer who undergo simple hysterectomy include adjuvant radiation therapy or further surgery in the form of radical parametrectomy [7]. However, ideally one would want to avoid the adverse effects of radiation therapy such as loss of ovarian function resulting in menopausal symptoms, as well as radiation cystitis, proctitis, fistula formation, vaginal stricture, or the possibility of developing secondary tumors induced by the radiation therapy [8,9]. In order to avoid unnecessary radiation therapy, radical parametrectomy has been the standard recommendation for patients with invasive cervical cancer found after simple hysterectomy (‘cut-through’ hysterectomy).
Radical parametrectomy was first described by Daniel and Brunschwig in 1961 [10]. The aim of this procedure is to remove the upper vagina, parametrium, and regional lymph nodes. Radical parametrectomy is a technically challenging procedure and may be associated with a high risk of perioperative complications (18.5–30%) [11,12]. These include, but not limited to, cystotomy, ileus, blood transfusions, urinary fistulae, and/or bladder dysfunction.
A number of studies have identified ‘low-risk’ criteria that allow patients with early cervical cancer to be adequately treated with either simple conization or simple hysterectomy even in the setting of invasive disease [[13], [14], [15], [16], [17], [18], [19], [20]]. These criteria include: squamous, adenosquamous, or adenocarcinoma, no lymph-vascular invasion (LVSI), tumor size < 2 cm, and tumor stromal invasion < 10 mm. The aim of our study was to define criteria based on simple ‘cut-through’ hysterectomy specimen that would identify those patients with early cervical cancer who could potentially avoid a radical parametrectomy.
Section snippets
Methods
Our study was approved by the Institutional Review Board of the MD Anderson Cancer Center and the Instituto de Cancerología Las Américas in Medellin, Colombia. A search of the departmental databases was performed to identify patients who underwent radical parametrectomy and bilateral pelvic lymphadenectomy, with a diagnosis of invasive cervical cancer after simple hysterectomy (‘cut-through’) for benign gynecologic conditions or preinvasive cervical lesions. The information was collected from
Results
A total of 37 patients were obtained in the initial search (20 patients from Instituto de Cancerología - Las Américas and 17 from MD Anderson Cancer Center). Seven patients were excluded from the analysis (2 patients with stage IA1 cervix cancer and LVSI, 4 patients without information about tumor size, and 1 patient with a 3 cm cervical tumor at initial surgery). The study group is composed of 30 patients with tumors < 2 cm in the initial surgery specimen. The median age was 40.4 years (range;
Discussion
Our study showed that radical parametrectomy and its associated morbidity may be avoided in well-selected patients, with early low-risk cervical cancer. We found that none of the patients had residual tumor, lateral cervical involvement, vaginal involvement, or lymph node metastases. Including our series, there have been a total of 270 patients published in the literature (limiting search to manuscripts with >10 patients) thus far that underwent a radical parametrectomy and pelvic lymph node
Conflict of interest
The authors report no conflict of interest.
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