Management Of Early-stage Cervical Cancer Research Articles

The impact of race, ethnicity, and socioeconomic status on fertility-sparing management of early-stage cervical cancer

The impact of race, ethnicity, and socioeconomic status on fertility-sparing management of early-stage cervical cancer

Trends in the management of early-stage cervical cancer: An analysis of the National Cancer Database

Trends in the management of early-stage cervical cancer: An analysis of the National Cancer Database

Strategic Approaches in Management of Early-Stage Cervical Cancer: A Comprehensive Editorial

Strategic Approaches in Management of Early-Stage Cervical Cancer: A Comprehensive Editorial

Efficacy and Diagnostic Reliability of Intraoperative Frozen Section in the Surgical Management of Early-Stage Cervical Cancer

Objectives: The aim of this study of this study was to evaluate preoperative radiology and histopathology findings in cervical cancer lymphadenopathy detection, allowing targeted frozen section examination (FSE). Design: A retrospective analysis was conducted of 203 early-stage cervical cancer patients between 2010 and 2019 in a tertiary centre. Participants/Materials, Setting, and Methods: All patients had histologically confirmed cervical cancer and underwent magnetic resonance imaging (MRI) prior to intraoperative FSE. The primary objectives of the study were to determine the diagnostic accuracy of intraoperative FSE in the identification of lymph node metastases (LNM) in early-stage cervical cancer by correlation with final results obtained using standard histopathology techniques and to examine different preoperative, intraoperative, demographic, radiological, and histopathological factors that could identify those at greatest risk of nodal disease and hence predict those most likely to benefit from FSE, enabling more selective and targeted use. Results: Nineteen patients were found to have LNM (9.36%) at FSE. Patients were at increased risk of LNM by 6-fold with positive LVSI, 3-fold with MRI lymphadenopathy, and 3.5-fold with MRI-visible disease. The presence of lymphadenopathy on MRI and positive LVSI in combination increased the risk of LNM by 19-fold. Limitations: We acknowledge that FSE is expensive and time intensive, exposing patients to increased surgery duration and associated risk. We also recognize that it may not be feasible for all patients. Finally, the analysis is limited by retrospective nature of the study. Conclusions: By application of the preoperative risk stratification algorithm, we may suggest that FSE can be a useful tool in high-risk patients.

Postoperative urinary retention by void trial methodology following radical hysterectomy for cervical cancer

ObjectivesRadical hysterectomy is the standard of care for management of early-stage cervical cancer and is associated with postoperative urinary retention. No clear consensus exists regarding optimal voiding trial methodology for mitigating postoperative urinary retention. Our objective was to evaluate the association between type of postoperative voiding trial and risk of urinary retention after radical hysterectomy for cervical cancer. MethodsWe conducted a retrospective analysis of patients undergoing radical hysterectomy for apparent early-stage cervical cancer (FIGO 2018 Stage IA2-IB2) between January 2014 and February 2023. We compared incidence of urinary retention and perioperative outcomes based on method of postoperative voiding trial (timed, autofill, or backfill). Multivariate logistic regression was used to determine association of type of void trial with absence of urinary retention within 30 days postoperatively. ResultsOf the 115 patients identified, 48 (41.8%) patients completed a timed void trial, 40 (34.7%) an autofill void trial, and 27 (23.5%) a backfill void trial. 44.3% of patients developed postoperative urinary retention with no differences based on void trial (p = 0.17). Urinary retention was more likely to resolve by 7 (p = 0.012) and 30 days (p = 0.01) for patients undergoing backfill voiding trials, compared to other trials. In multivariate models, backfill void trial was associated with absence of 30-day urinary retention, compared to other trials (aOR 15.1; 95% C.I. 1.5–154.9). ConclusionsRates of urinary retention following radical hysterectomy do not differ based on postoperative void trial methodology. A backfill void trial following radical hysterectomy may lead to increased rates of resolution of postoperative urinary retention.

Preoperative brachytherapy of early-stage cervical cancer: A multicenter study by the SFRO brachytherapy group

ObjectiveTo report the results of a multicenter cohort of preoperative brachytherapy (PBT) for treatment of early-stage cervical cancer (ESCC). MethodsA retrospective analysis was conducted among five French comprehensive cancer centers on behalf of the SFRO Brachytherapy Group to examine the outcome of patients with ESCC who received PBT between 2001 and 2019 because of adverse prognostic factors (tumor size >2 cm, presence of lymphovascular invasion, adenocarcinoma).Brachytherapy was followed 4–8 weeks later by surgery. Local relapse free, distant metastasis-free survival, disease-free, and overall survival and adverse effects were examined. Uni- and multivariate analyses were conducted looking for oncological prognostic factors. ResultsA total of 451 patients were identified, with a mean tumor size of 24.7 mm. Adenocarcinoma accounted for 43.5% of cases, and lympho-vascular space invasion (LVSI) was present in 15.7%. A complete histological response was observed in 69.6%. With a mean follow-up of 75.4 months, DFS, LRFS, and OS rates at five years were 88% [95% CI (84–91), 98% [95% CI (96–99), and 92% [95% CI (87–95)], respectively. At the last follow-up, 8.2% of patients had died, including 31 (6.8%) from cervical cancer. Severe side effects range from 1.1% to 2%. At multivariate analysis, adenocarcinoma histological type, tumor size ≥2 cm, and the presence of residual tumors were prognosticators for DFS and DMFS. ConclusionPBT shows excellent oncological outcomes in this cohort of patients with adverse histoprognostic factors. Favorable survival rates and low complications rates were observed, supporting this strategy in the management of ESCC.

Ten-year outcomes following laparoscopic and open abdominal radical hysterectomy for “low-risk” early-stage cervical cancer: A propensity-score based analysis

ObjectiveAccumulating evidence suggested the detrimental effects of adopting minimally invasive surgery in the management of early-stage cervical cancer. However, long-term evidence on the role of minimally invasive radical hysterectomy in “low-risk” patients exists. MethodsThis is multi-institutional retrospective study comparing minimally invasive and open radical hysterectomy in low-risk early-stage cervical cancer patients. A propensity-score matching algorithm (1:2) was used to allocate patients into the study groups. Kaplan-Meir model was used to estimate 10-year progression-free and overall survival. ResultsCharts of 224 “low-risk” patients were retrieved. Overall, 50 patients undergoing radical hysterectomy were matched with 100 patients undergoing open radical hysterectomy. Minimally invasive radical hysterectomy was associated with a longer median operative time (224 (range, 100–310) vs. 184 (range, 150–240) minutes; p < 0.001), lower estimated blood loss (10 (10-100) vs. 200 (100−1000) ml, p < 0.001), and shorter length of hospital stay (3.8 (3-6) vs. 5.1 (4-12); p < 0.001). Surgical approach did not influence the risk of having intra-operative (4% vs. 1%; p = 0.257) and 90-day severe (grade 3+) postoperative complication rates (4% vs. 8%; p = 0.497). Ten-year disease-free survival was similar between groups (94% vs. 95%; p = 0.812; HR:1.195; 95%CI:0.275, 5.18). Ten-year overall survival was similar between groups (98% vs. 96%; p = 0.995; HR:0.994; 95%CI:0.182, 5.424). ConclusionsOur study appears to support emerging evidence suggesting that, for low-risk patients, laparoscopic radical hysterectomy does not result in worse 10-year outcomes compared to the open approach. However, further research is needed and open abdominal radical hysterectomy remains the standard treatment for cervical cancer patients.

Surgical margin status in relation to surgical approach in the management of early-stage cervical Cancer: A Canadian cervical Cancer collaborative (4C) study

ObjectiveSurgical margin status in women undergoing surgery for early-stage cervical cancer is an important prognostic factor. We sought to determine whether close (<3 mm) and positive surgical margins are associated with surgical approach and survival. MethodsThis is a national retrospective cohort study of cervical cancer patients treated with radical hysterectomy. Patients with stage IA1/LVSI-Ib2(FIGO 2018) with lesions up to 4 cm at 11 Canadian institutions from 2007 to 2019 were included. Surgical approach included robotic/laparoscopic (LRH), abdominal (ARH) or combined laparoscopic-assisted vaginal/vaginal (LVRH) radical hysterectomy. Recurrence free survival(RFS) and overall survival (OS) were estimated using Kaplan-Meier analysis. Chi-square and log-rank tests were used to compare groups. Results956 patients met inclusion criteria. Surgical margins were as follows: negative (87.0%), positive (0.4%) or close <3 mm (6.8%), missing (5.8%). Most patients had squamous histology (46.9%); 34.6% had adenocarcinomas and 11.3% adenosquamous. Most were stage IB (75.1%) and 24.9% were IA. Mode of surgery included: LRH(51.8%), ARH (39.2%), LVRH (8.9%).Predictive factors for close/positive margins included stage, tumour diameter, vaginal involvement and parametrial extension. Surgical approach was not associated with margin status (p = 0.27). Close/positive margins were associated with a higher risk of death on univariate analysis (HR = non calculable for positive and HR = 1.83 for close margins, p = 0.017), but not significant for OS when adjusted for stage, histology, surgical approach and adjuvant treatment. There were 7 recurrences in patients with close margins (10.3%, p = 0.25). 71.5% with positive/close margins received adjuvant treatment. In addition, MIS was associated with a higher risk of death (OR = 2.39, p = 0.029). ConclusionSurgical approach was not associated to close or positive margins. Close surgical margins were associated with a higher risk of death. MIS was associated with worse survival, suggesting that margin status may not be the driver of worse survival in these cases.

Impact of therapeutic strategy on disease‐free and overall survival of early‐stage cervical cancer: Surgery alone versus preoperative radiation

There is no international consensus for management of early-stage cervical cancer (ESCC). This study aimed to retrospectively investigate disease-free survival (DFS) and overall survival (OS) in patients with ESCC according to the therapeutic strategy used, surgery alone versus preoperative radiation following by surgery. Data were retrospectively collected from 1998 to 2015 using the Gynecological Cancer Registry of the Côte d'Or. The inclusion criteria were FIGO 2018 ≤ IB2; squamous cell carcinoma, adenocarcinoma or adenosquamous type. Survival curves were compared using the log-rank test. One hundred twenty-six patients were included. Median survival was 90 months. There was no significant difference in DFS (HR = 0.91, 95%CI [0.32-2.53], p = 0.858) or in OS between surgery alone versus preoperative radiation following by surgery (HR = 0.97, 95%CI [0.31-2.99], p = 0.961). In the subgroup of patients with stage ≥IB1, there was no significant difference in DFS (HR = 3.26, p = 0.2) or in OS (HR = 3.87, p = 0.2). Our study did not identify any difference in survival according to the treatment strategy. Preoperative radiation following by surgery can be an alternative to surgery alone for ESCC.

Reproductive and Obstetric Outcomes after Fertility-Sparing Treatments for Cervical Cancer: Current Approach and Future Directions

Cervical cancer is one of the leading causes of cancer-related death in women of reproductive age. The established fertility-sparing approaches for the management of early-stage cervical cancer for women who plan pregnancy are associated with a decline in fecundity and an increased risk of pregnancy complications. This article aims to offer an overview of fertility-sparing approaches and the management of potential subfertility and pregnancy complications after these treatments. An extensive search for the available data about infertility and cervical cancer, fertility-sparing techniques in patients with cervical cancer, fertility treatment, obstetrical complications, and pregnancy outcomes in cervical cancer patients was completed. Fertility-preserving procedures such as loop electrosurgical excision procedure (LEEP), cold-knife conization, and trachelectomy in women diagnosed with cervical cancer can be considered as safe and effective treatments that preserve reproductive potential. Current fertility-preserving procedures, based on the balance of the oncological characteristics of patients as well as their desire for reproduction, allow one to obtain acceptable reproductive and obstetric outcomes in women treated for cervical cancer. Nevertheless, careful monitoring of pregnancies obtained after fertility-preserving procedures is recommended, since this cohort of patients should be considered at higher risk compared with a healthy population.

New Insights on the Minimal-Invasive Therapy of Cervical Cancer

Objective: The ideal management of early-stage cervical cancer has become the subject of a global controversy following the publication of a prospective study in 2018 that reported a worse oncologic outcome when comparing the minimally invasive approach to the laparotomy approach. The discussion involves both prospective and retrospective data and general and theoretical considerations. We wanted to look at the data available today and review the different opinions, offering an impartial assessment of the ongoing controversy. Methods: The available literature was reviewed, focusing on articles arguing for and against minimally invasive surgery in cervical cancer. We tried to avoid any fundamental bias, as is often evident in the available reviews on the subject. Literature both before and after the 2018 publication was taken into consideration. Results: As is usual in discussions of concepts, the literature that is now available provides arguments for both sides of this challenging issue, depending on one’s standpoint. Science-related writing is not immune to trends. There is a curious shift in opinion seen before and after 2018. One must question whether there was a prejudice in favor of minimally invasive surgery prior to the publication of the NEJM articles and a bias against it afterward. Conclusion: Whether further minimally invasive surgery for cervical cancer is invariable is tied to the more pressing question of how this surgery will have to be centralized in the future. Unless these questions are linked, no satisfactory solution can be found.

Isolated para-aortic nodal metastasis or recurrence absent after radical hysterectomy for stage IA-IIA cervical carcinoma (401)

Objectives: Accumulating evidence suggests that due to the low risk of initially metastatic para-aortic lymph nodes (PaLNs), patients undergoing surgical management of early-stage cervical cancer could potentially be spared the operative and long-term morbidity of PaLN dissection. We sought to explore the upfront and downstream implications of this management philosophy in women undergoing radical hysterectomy for stage IA - IIA cervical cancer. Methods: A review of institutional data identified women undergoing curative-intent radical hysterectomy with concurrent lymphad- enectomy of any kind for FIGO stage IA - IIA cervical carcinoma from 2004 to 2021. Demographics and clinical-pathologic data were collected. Recurrence rates and locations were analyzed. Patients with no follow-up were excluded. Chi-square and Fisher’s exact test were used for statistical analysis. Results: Three hundred patients were identified, of whom 265 were included in the analysis. The Median follow-up was 56 months. Regarding tumor stages, 31 patients had stage IA, 195 stage IB1, 34 stage IB2, and five had stage IIA. Seventy-one percent of patients underwent pelvic lymphadenectomy only (PLND), with 29% undergoing both pelvic and para-aortic lymphadenectomy (PPaLND). Demographic distribution was similar between groups. LVSI was present in 37% of PLND compared to 32% of PPaLND groups (p = NS). High-risk features (GOG 109 criteria: positive nodes, parametria, or margins) were present in 13% and 15% of patients of each group, respectively (p = NS). Para-aortic nodal metastasis was not detected in any patient with early-stage cervical cancer. Disease recurrence was diagnosed in 13.8% of PLND compared to 10.3% of PPaLND patients (p =NS), of which 65% included distant or multisite recurrences. Among recurrences, median PFS was 15.5 months (IQR 8.2 - 29.7), and OS was 34 months (IQR 21.5 - 54.4). There were no isolated first disease recurrences involving the para-aortic nodal chain. Less than 3% of patients (n = 1) with multi-site recurrence had involvement of the PaLN chain, which was in the setting of receiving no adjuvant treatment with high-risk disease (positive pelvic LNs) on initial surgery. Most common distant and multi-site recurrences occurred in the liver, lungs, and brain. Conclusions: Isolated para-aortic nodal recurrence was absent in patients after surgical management of early-stage cervical cancer, irrespective of histologic type. PaLN involvement in multi-site recurrence was also very uncommon, less than 3%. These findings could potentially be utilized to further refine individualized treatment planning in the upfront setting to spare unnecessary surgical morbidity. Objectives: Accumulating evidence suggests that due to the low risk of initially metastatic para-aortic lymph nodes (PaLNs), patients undergoing surgical management of early-stage cervical cancer could potentially be spared the operative and long-term morbidity of PaLN dissection. We sought to explore the upfront and downstream implications of this management philosophy in women undergoing radical hysterectomy for stage IA - IIA cervical cancer. Methods: A review of institutional data identified women undergoing curative-intent radical hysterectomy with concurrent lymphad- enectomy of any kind for FIGO stage IA - IIA cervical carcinoma from 2004 to 2021. Demographics and clinical-pathologic data were collected. Recurrence rates and locations were analyzed. Patients with no follow-up were excluded. Chi-square and Fisher’s exact test were used for statistical analysis. Results: Three hundred patients were identified, of whom 265 were included in the analysis. The Median follow-up was 56 months. Regarding tumor stages, 31 patients had stage IA, 195 stage IB1, 34 stage IB2, and five had stage IIA. Seventy-one percent of patients underwent pelvic lymphadenectomy only (PLND), with 29% undergoing both pelvic and para-aortic lymphadenectomy (PPaLND). Demographic distribution was similar between groups. LVSI was present in 37% of PLND compared to 32% of PPaLND groups (p = NS). High-risk features (GOG 109 criteria: positive nodes, parametria, or margins) were present in 13% and 15% of patients of each group, respectively (p = NS). Para-aortic nodal metastasis was not detected in any patient with early-stage cervical cancer. Disease recurrence was diagnosed in 13.8% of PLND compared to 10.3% of PPaLND patients (p =NS), of which 65% included distant or multisite recurrences. Among recurrences, median PFS was 15.5 months (IQR 8.2 - 29.7), and OS was 34 months (IQR 21.5 - 54.4). There were no isolated first disease recurrences involving the para-aortic nodal chain. Less than 3% of patients (n = 1) with multi-site recurrence had involvement of the PaLN chain, which was in the setting of receiving no adjuvant treatment with high-risk disease (positive pelvic LNs) on initial surgery. Most common distant and multi-site recurrences occurred in the liver, lungs, and brain. Conclusions: Isolated para-aortic nodal recurrence was absent in patients after surgical management of early-stage cervical cancer, irrespective of histologic type. PaLN involvement in multi-site recurrence was also very uncommon, less than 3%. These findings could potentially be utilized to further refine individualized treatment planning in the upfront setting to spare unnecessary surgical morbidity.

The status of surgical margins in relation to the type of surgical approach in the management of early-stage cervical cancer: Canadian Cervical Cancer Collaborative (4C) study (533)

<b>Objectives:</b> Surgical margin status in women undergoing surgery for early-stage cervical cancer is considered an important prognostic factor. We sought to determine if positive or close surgical margin status (<3mm) is related to the type of surgical approach and associated with worse outcomes. <b>Methods:</b> A national retrospective cohort study of cervical cancer treated with a radical hysterectomy was conducted. Patients with stage IA1 (LVSI positive) to IIIC2 (FIGO 2018) with lesions up to 4cm at ten Canadian institutions from 2007-2019 were included. Surgical approaches for the radical hysterectomy included robotic/laparo- scopic (RLRH), abdominal (ARH), or laparoscopic-assisted vaginal/ vaginal hysterectomy (LVVRH). Recurrence-free survival (RFS) and overall survival (OS) were estimated using Kaplan-Meier analysis. Chi-square and log-rank tests were used to compare between cohorts. <b>Results:</b> A total of 960 patients met the inclusion criteria. The majority of patients had squamous histology (470, 49%), while 343 (35.7%) had adenocarcinomas and 113 (11.8%) had adenosquamous. Most were stage IB (681, 70.0%) and 183 (19%) were IA. Mode of surgery included: 495 (51.6%) RLRH, 88 (9.2%) LVVRH and 376 (39.2%) ARH. Surgical margins were negative in 819 (85.3%), positive in 15 (1.6%) or close in 103 (10.7%) patients. Factors predictive of close/positive margins included stage, tumor diameter, vaginal involvement, and parametrial extension; the surgical approach was not a predictor of margin status (p=0.38). Close/positive margins were associated with a higher risk of death on univariate analysis (HR: 2.53; 95% CI: 0.78-8.22) for positive margins and 1.83 (95% CI: 1.04-3.24) for close margins, p=0.05), but margin status was not significant for OS or PFS when adjusting for stage, histology, surgical approach, and adjuvant treatment. Overall, 71% of patients with positive margins and 60% of patients with close margins received adjuvant treatment. One patient (6.7%) with positive margins recurred distantly, despite having received adjuvant chemoradiation; 16 patients (15.3%) with close margins recurred (p=0.023), with 73% having received either adjuvant radiation or chemoradiation. The surgical approach was not statistically associated with either OS (p=0.067) or PFS (p=0.06). <b>Conclusions:</b> Positive or close surgical margins were not found to be associated with the use of the minimally invasive surgical (MIS) approach. MIS approach did not appear to negatively impact outcomes. Positive or close surgical margins were not associated with worse outcomes, possibly due to adjuvant treatment.

The MEMORY Study: MulticentEr study of Minimally invasive surgery versus Open Radical hYsterectomy in the management of early-stage cervical cancer: Survival outcomes

ObjectiveThe Laparoscopic Approach to Cervical Cancer (LACC) trial found that minimally invasive radical hysterectomy compared to open radical hysterectomy compromised oncologic outcomes and was associated with worse progression-free survival (PFS) and overall survival (OS) in early-stage cervical carcinoma. We sought to assess oncologic outcomes at multiple centers between minimally invasive (MIS) radical hysterectomy and OPEN radical hysterectomy. MethodsThis is a multi-institutional, retrospective cohort study of patients with 2009 FIGO stage IA1 (with lymphovascular space invasion) to IB1 cervical carcinoma from 1/2007–12/2016. Patients who underwent preoperative therapy were excluded. Squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinomas were included. Appropriate statistical tests were used. ResultsWe identified 1093 cases for analysis—715 MIS (558 robotic [78%]) and 378. OPEN procedures. The OPEN cohort had more patients with tumors >2 cm, residual disease in the hysterectomy specimen, and more likely to have had adjuvant therapy. Median follow-up for the MIS and OPEN cohorts were 38.5 months (range, 0.03–149.51) and 54.98 months (range, 0.03–145.20), respectively. Three-year PFS rates were 87.9% (95% CI: 84.9–90.4%) and 89% (95% CI: 84.9–92%), respectively (P = 0.6). On multivariate analysis, the adjusted HR for recurrence/death was 0.70 (95% CI: 0.47–1.03; P = 0.07). Three-year OS rates were 95.8% (95% CI: 93.6–97.2%) and 96.6% (95% CI: 93.8–98.2%), respectively (P = 0.8). On multivariate analysis, the adjusted HR for death was 0.81 (95% CI: 0.43–1.52; P = 0.5). ConclusionThis multi-institutional analysis showed that an MIS compared to OPEN radical hysterectomy for cervical cancer did not appear to compromise oncologic outcomes, with similar PFS and OS.

Impact of therapeutic strategy on disease-free and overall survival of early-stage cervical cancer: Surgery alone versus preoperative radiotherapy.

e17517 Background: At present, there is no international consensus for management of early-stage cervical cancer. This study aimed to retrospectively investigate disease-free survival (DFS) and overall survival (OS) in patients with early cervical cancer according to the therapeutic strategy used, surgery alone versus pre-operative radiotherapy following by surgery. Methods: Data from patients with early-stage cervical cancer were retrospectively collected from January 1998 to December 2015 using the Breast &amp; Gynecological Cancer Registry of the Côte d’Or, regrouping data from 7 centers. The inclusion criteria were: FIGO 2009 stage IB1 or lower; epidermoid, adenocarcinoma or adenosquamous type. The exclusion criteria were: history of pelvic radiation; concomitant radiochemotherapy; adjuvant radiotherapy; total radiation dose less than 50 Gy, or more than 66 Gy or not documented. In the surgery group, patients had only a surgical treatment for early-stage cervical cancer. The surgical treatment was either a hysterectomy, a trachelectomy or a conization. In the radiation group; patients had radiotherapy, brachytherapy and/or radiotherapy followed by surgery. DFS and OS were determined using the Kaplan-Meier method .Survival curves were compared using the log-rank test. Results: A total of 126 patients were included. Median survival in the whole population was 90 months (47-148); 72 months for those receiving primary surgery, and 135.5 months for those receiving primary radiation therapy. There was no significant difference in DFS between the surgery and radiation groups (HR=2.82, 95%CI (0.82-9.65), p=0.08). Similarly, there was no significant difference in OS between groups (HR=1.35, 95%CI (0.6-3.05), p=0.5). In the sub-group of patients with stage IB1 (FIGO 2009), there was no significant difference in DFS (HR=3.26, 95%CI (0.4-26.76), p=0.2) or in OS (HR=3.87, 95%CI (0.49-30.35), p=0.2) between groups. Conclusions: Cervical cancer counts among the only solid tumors for which increasing mortality has been observed in recent years. Radiation therapy is still a major source of morbidity for young patients. Therefore, key issues remain outstanding for the future management of young patients with cervical cancer and include reducing the morbidity of existing therapeutic options by identifying subgroups of patients at low or intermediate risk, and facilitating fertility-sparing surgery.

Management of Early-Stage Cervical Cancer: A Literature Review.

Simple SummaryDespite being a preventable disease, cervical cancer still causes morbidity and deaths worldwide. In the early stages (FIGO IA1 with lymph-vascular space invasion-IIA1), the disease is highly curable. The primary treatment for early-stage cervical cancer is radical hysterectomy with pelvic lymphadenectomy. This surgical treatment has changed during the past decades, and we aimed to review and discuss the advances in the literature. We performed a literature review through PubMed focusing on English articles about the topic of surgical management of early-stage cervical cancer. The emergent topics considered here are the FIGO 2018 staging system update, conservative management for selected patients, sentinel lymph node mapping, fertility preservation, surgical approach, and management of tumors up to 2 cm. These topics show an evolvement to a more tailored treatment to prevent morbidity and assure oncologic safety.Cervical cancer (CC) remains a public health issue worldwide despite preventive measures. Surgical treatment in the early-stage CC has evolved during the last decades. Our aim was to review the advances in the literature and summarize the ongoing studies on this topic. To this end, we conducted a literature review through PubMed focusing on English-language articles on the surgical management of early-stage CC. The emergent topics considered here are the FIGO 2018 staging system update, conservative management with less radical procedures for selected patients, lymph node staging, fertility preservation, preferred surgical approach, management of tumors up to 2 cm, and prognosis. In terms of updating FIGO, we highlight the inclusion of lymph node status on staging and the possibility of imaging. Regarding the preferred surgical approach, we emphasize the LACC trial impact worldwide in favor of open surgery; however, we discuss the controversial application of this for tumors < 2 cm. In summary, all topics show a tendency to provide patients with tailored treatment that avoids morbidity while maintaining oncologic safety, which is already possible in high-income countries. We believe that efforts should focus on making this a reality for low-income countries as well.

The place of surgery in cervical cancer under current treatment protocols

Health issue: cervical cancer is the most common gynecologic malignancy and the fourth most common cancer in women worldwide. In most cases, the onset of cervical cancer is the result of human papillomavirus (HPV) infection. It should be borne in mind that the evolution of the infection contributes to multiple factors that are host dependent. Compared to other gynecological cancers, cervical cancer tends to appear at a younger age, which is why the Pap test is indicated. Data sources: Fertility and Sterility, PubMed, The New England Journal of Medicine, European Journal of Obstetrics Gynecology and Reproductive Biology, the Lancet (inception to June 25, 2022), performed in an academic medical setting. Key findings: surgery plays a decisive role in the management of early-stage cervical cancer. The gold standard is the type III radical hysterectomy with bilateral pelvic lymph node dissection using the open route. Laparoscopic or robotic approach for radical hysterectomy is emerging, but more data still need to be evaluated for the use of these procedures. Fertility preserving surgery is feasible, but only when reasonably used for highly selected young patients, with no children. There are still questions about the use of less radical surgical procedures in patients with mild disease and good prognostic factors. Still, there are procedures, such as conization, trachelectomy, total hysterectomy without bilateral adnexectomy or pelvic lymph nodes, that are highly used and have good anticipated results. Purpose of review: the advances in gynecological oncology now permit the election of the best individualized treatment method for patients who have early-stage disease. This research focuses on maximizing the quality of life by minimizing morbidity for patients who are candidates for different types of surgery.

Open vs minimally invasive radical trachelectomy in early-stage cervical cancer: International Radical Trachelectomy Assessment Study

Minimally invasive radical trachelectomy has emerged as an alternative to open radical hysterectomy for patients with early-stage cervical cancer desiring future fertility. Recent data suggest worse oncologic outcomes after minimally invasive radical hysterectomy than after open radical hysterectomy in stage I cervical cancer. We aimed to compare 4.5-year disease-free survival after open vs minimally invasive radical trachelectomy. This was a collaborative, international retrospective study (International Radical Trachelectomy Assessment Study) of patients treated during 2005-2017 at 18 centers in 12 countries. Eligible patients had squamous carcinoma, adenocarcinoma, or adenosquamous carcinoma; had a preoperative tumor size of ≤2 cm; and underwent open or minimally invasive (robotic or laparoscopic) radical trachelectomy with nodal assessment (pelvic lymphadenectomy and/or sentinel lymph node biopsy). The exclusion criteria included neoadjuvant chemotherapy or preoperative pelvic radiotherapy, previous lymphadenectomy or pelvic retroperitoneal surgery, pregnancy, stage IA1 disease with lymphovascular space invasion, aborted trachelectomy (conversion to radical hysterectomy), or vaginal approach. Surgical approach, indication, and adjuvant therapy regimen were at the discretion of the treating institution. A total of 715 patients were entered into the study database. However, 69 patients were excluded, leaving 646 in the analysis. Endpoints were the 4.5-year disease-free survival rate (primary), 4.5-year overall survival rate (secondary), and recurrence rate (secondary). Kaplan-Meier methods were used to estimate disease-free survival and overall survival. A post hoc weighted analysis was performed, comparing the recurrence rates between surgical approaches, with open surgery being considered as standard and minimally invasive surgery as experimental. Of 646 patients, 358 underwent open surgery, and 288 underwent minimally invasive surgery. The median (range) patient age was 32 (20-42) years for open surgery vs 31 (18-45) years for minimally invasive surgery (P=.11). Median (range) pathologic tumor size was 15 (0-31) mm for open surgery and 12 (0.8-40) mm for minimally invasive surgery (P=.33). The rates of pelvic nodal involvement were 5.3% (19 of 358 patients) for open surgery and 4.9% (14 of 288 patients) for minimally invasive surgery (P=.81). Median (range) follow-up time was 5.5 (0.20-16.70) years for open surgery and 3.1 years (0.02-11.10) years for minimally invasive surgery (P<.001). At 4.5 years, 17 of 358 patients (4.7%) with open surgery and 18 of 288 patients (6.2%) with minimally invasive surgery had recurrence (P=.40). The 4.5-year disease-free survival rates were 94.3% (95% confidence interval, 91.6-97.0) for open surgery and 91.5% (95% confidence interval, 87.6-95.6) for minimally invasive surgery (log-rank P=.37). Post hoc propensity score analysis of recurrence risk showed no difference between surgical approaches (P=.42). At 4.5 years, there were 6 disease-related deaths (open surgery, 3; minimally invasive surgery, 3) (log-rank P=.49). The 4.5-year overall survival rates were 99.2% (95% confidence interval, 97.6-99.7) for open surgery and 99.0% (95% confidence interval, 79.0-99.8) for minimally invasive surgery. The 4.5-year disease-free survival rates did not differ between open radical trachelectomy and minimally invasive radical trachelectomy. However, recurrence rates in each group were low. Ongoing prospective studies of conservative management of early-stage cervical cancer may help guide future management.

The impact of modern preoperative high-dose-rate brachytherapy in early-stage cervical cancer

PurposeTo analyze the clinical outcomes and the safety of preoperative high-dose-rate (HDR) image-guided adaptive brachytherapy (IGABT) followed by minimally invasive surgery (MIS) in the multidisciplinary management of early-stage cervical cancer. Methods and materialsMedical records of all consecutive patients with early-stage cervical cancer treated at our institution between 2012 and 2018 with preoperative IGABT in a multidisciplinary approach were reviewed. Treatment schedule was pelvic node dissection, preoperative IGABT followed 6–8 week later by MIS hysterectomy. ResultsSeventy patients with cervical cancer FIGO stages (IB1 18.6%, IB2 75.7% and IIA1 5.7%) were treated by preoperative HDR brachytherapy. With a median follow-up of 37.4 months [95% confidence interval, 32.1-39.7 months] isolated vaginal vault recurrence was not observed, 3 pelvic relapses were reported (4.3%). None of patients received postoperative radiotherapy (EBRT) or radiochemotherapy. The estimated 3-year local and pelvis relapse free survival for the entire population were respectively 98% [95% confidence interval, 89%–100%] and 90% [80%–96%]. The estimated 3-year disease-free survival (DFS) for the entire population was 88% [77–94%]. The 3-year overall survival (OS) rate was 97% [88%–99%]. Microscopic vaginal resection margin (R1) was observed in one patient ([1].4%). Lymph-vascular space invasion (LVSI) was found found in 6 (8.6%) patients. Forty-eight late complications in 36 patients (51.4%) were observed. Five (7.1%) grade 3 vaginal wound dehiscence toxicities were observed. Urinary and gastrointestinal toxicities were grade 1–2. No grade 4–5 complications were observed. ConclusionsPreoperative image-guided adaptive brachytherapy followed by minimally invasive surgery allows high local control, reduces positive surgical margins and rates of lymph-vascular space invasion avoiding adjuvants treatments. Surgical approaches must be discussed with patients including preoperative brachytherapy as a down-staging treatment.

Surgery for cervical cancer: consensus & controversies.

Surgery plays an important role in the management of early-stage cervical cancer. Type III radical hysterectomy with bilateral pelvic lymph node dissection using open route is the standard surgical procedure. There is level I evidence against the use of laparoscopic/robotic approach for radical hysterectomy for cervical cancer. Emerging data support the use of sentinel lymph node biopsy and nerve sparing radical hysterectomy in carefully selected patients with early-stage disease. In locally advanced cervical cancer patients, the use of neoadjuvant chemotherapy (NACT) followed by radical surgery yields inferior disease-free survival compared to definitive concurrent chemoradiation therapy. Therefore, definitive concurrent chemoradiation is the standard treatment for locally advanced disease. Fertility preserving surgery is feasible in highly selected young patients. Role of less-radical surgical procedures in patients’ with low-stage disease with good prognostic factors is under evaluation.