Management Of Early-stage Cervical Cancer Research Articles

Novel setup techniques for radiation treatment of severely obese patients with cervical cancer

The prevalence of overweight (body mass index [BMI] N 25 kg/m2) and obesity (BMI N30 kg/m2) in the United States currently exceeds two-thirds of the adult population. Obesity and severe obesity (BMI N 40 kg/m2) may impact the management of early-stage cervical cancer, where surgical resection is often the preferred treatment.1 Due to medical comorbidities and surgical risks, these patients are often not considered surgical candidates, and definitive radiation or chemoradiation may be the only curative option. Although most patients with inoperable cervical cancer are physically able to undergo a computed tomographic (CT) simulation and subsequent radiation treatment, patients with severe obesity and large abdominopelvic girth may present obstacles in simulation, treatment planning and dosimetry, and treatment delivery. Potential clinical problems include weight in excess of simulator or treatment table limits, girth in excess of CT bore or field of view,2 poor image quality secondary to tissue attenuation, creating an accurate body contour, achieving an acceptable dose distribution and heterogeneity index given the confines of beam arrangement and body thickness, gantry clearance issues, issues with patient setup and verification, and reliability of external fiducials. In this study, we report

A comparative study of laparoscopic radical hysterectomy with radical abdominal hysterectomy for early-stage cervical cancer: a long-term follow-up study

Objective To determine whether laparoscopic radical hysterectomy (LRH) is a feasible alternative to radical abdominal hysterectomy (RAH) for early-stage cervical cancer. Study design A retrospective, matched case–control study of 24 consecutive cases with International Federation of Gynecology and Obstetrics stage I–II cervical cancer who underwent LRH by a single surgeon between January 1994 and December 2001. Cases were matched with controls (ratio 1:2) who underwent RAH by surgeon, age, stage and histology. Patient characteristics, clinical course, intra-operative complications and disease-free survival were compared between the two groups. Median counts were analyzed using the Mann–Whitney U-test. Differences between means were compared using Student's t-test. Dichotomous groupings were analyzed using Chi-squared test and Fisher's exact test as appropriate. Survival data were estimated using Kaplan–Meier estimates and compared with the log-rank test. Results The mean estimated blood loss in the RAH group was significantly greater than that in the LRH group (836.0 ml and 414.3 ml, respectively; p < 0.001). Five patients (20.8%) from the LRH group and 23 patients (47.9%) from the RAH group received blood transfusion ( p < 0.03). The mean length of hospital stay was significantly shorter in the LRH group compared with the RAH group (10.7 days and 18.8 days, respectively; p < 0.01). No statistically significant difference existed between the two groups with respect to operative time, pelvic lymph node count, frequency of lymph node involvement, extent of parametrial or vaginal resection margins, adjuvant treatment and intra-operative complications. Median follow-up was 78 months for the LRH group and 75 months for the RAH group. There was no significant difference in the 5-year disease-free survival rate between the groups (90.5% and 93.3% for LRH and RAH, respectively; p = 0.918). Conclusions LRH is a useful alternative to RAH for the management of early-stage cervical cancer. The benefits of LRH include reduced blood loss, fewer transfusions and shorter hospital stay, with comparable oncologic outcome.

Ovarian fibrosarcoma with metastasis after 12 years

trachelectomy: a valuable fertility-preserving option in the management of early-stage cervical cancer. A series of 50 pregnancies and review of the literature. Gynecol Oncol 2005; 98 (1): 3–10. 20 Farthing A. Future fertility after conservation surgery for cervical cancer. Br J Hosp Med 2006; 67 (5): 250–252. 21 Jolley JA, Battista L, Wing DA. Management of pregnancy after radical trachelectomy: case reports and systematic review of the literature. Am J Perinatol 2007; 24 (9): 531–539. 22 Shepherd JH. Challenging dogma: radical conservation surgery for early stage cervical cancer in order to retain fertility. Ann R Coll Surg Engl 2009; 91 (3): 181–187.

Total Laparoscopic Radical Hysterectomy Versus Abdominal Radical Hysterectomy with Lymphadenectomy in Patients with Early Cervical Cancer: Our Experience

The aim of this study was to retrospectively compare, in a series of 127 consecutive women, the safety, morbidity, and recurrence rate of total laparoscopic radical hysterectomy (TLRH) with lymphadenectomy and abdominal radical hysterectomy with lymphadenectomy (ARH) for early cervical carcinoma. A total of 127 consecutive patients with International Federation of Gynecology and Obstetrics stage Ia1 (lymphvascular space involvement), Ia2, and Ib1 early cervical cancer, 65 of whom underwent TLRH and 62 of whom underwent ARH with pelvic lymph node dissection, comprised the study population. The para-aortic lymphadenectomy with the superior border of the dissection being the inferior mesenteric artery was performed in all cases with positive pelvic lymph nodes discovered at frozen section evaluation. The median blood loss in the ARH group (145 ml; range, 60-225 ml) was significantly greater than TLRH group (55 ml; range, 30-80 ml) (P < .01). The median length of hospital stay was significantly greater in the ARH group (7 days; range, 5-9 days) than TLRH group (4 days; range, 3-7 days) (P < .01). The median operating time was 196 min in the TLRH group (range, 182-240 min) compared with 152 min in the ARH group (range, 161-240 min) (P < .01). No statistically significant difference was found between the two groups when the recurrence rate was compared. Total laparoscopic radical hysterectomy is a safe and effective therapeutic procedure for management of early-stage cervical cancer with a far lower morbidity than reported for the open approach and is characterized by far less blood loss and shorter postoperative hospitalization time, although multicenter randomized clinical trials with longer follow-up are necessary to evaluate the overall oncologic outcomes of this procedure.

Peritoneal carcinomatosis after laparoscopic radical hysterectomy for early-stage cervical adenocarcinoma

Background. The risk of wound metastasis after laparoscopic management of early-stage cervical cancer is well known, but there are few data on peritoneal carcinomatosis of cervical adenocarcinoma. Case. We report the first case of peritoneal carcinomatosis occurring in a woman with FIGO stage Ib1 cervical adenocarcinoma who underwent laparoscopic type III radical hysterectomy and bilateral pelvic lymphadenectomy (sentinel node procedure) followed by vaginal brachytherapy. A peritoneal recurrence was diagnosed 16 months after surgery and was treated with chemotherapy and laparotomy. Conclusion. Laparoscopy for cervical adenocarcinoma may carry a risk of peritoneal dissemination.

Vaginal Radical Trachelectomy: A Valuable Fertility-Preserving Option in the Management of Early-Stage Cervical Cancer, a Series of 50 Pregnancies and Review of the Literature

The authors conducted a retrospective review of their patients with cervical cancer who been treated with vaginal radical trachelectomy (VRT) to preserve fertility. Of a total 82 patients, 31 were identified who became pregnant after this procedure and are the subjects of this report. Obstetric data was gathered through chart review and telephone calls to patients and/or their referring physicians. Because most patients received their obstetric care from a local obstetrician or high-risk specialist, the management of pregnancies was not uniform, although all patients were delivered by cesarean section. Patients were a median 32 years of age (range, 21-42 years). Three fourths (n = 53, 74%) were nulliparous, 19% (n = 14) had one child, and 7% (n = 5) had 2 or more children. After VRT, 31 women (43%) had a successful pregnancy. Among the remaining 38 patients, 33 did not attempt conception, 2 died of disease, 2 underwent hysterectomy, and one received adjuvant radiation therapy. In all, 7 women experienced infertility problems. Four became pregnant and 3 were unable to conceive. Thirty-one women had a total of 50 pregnancies. Six patients had 2 pregnancies, 2 had 3 pregnancies, and 3 had 4 pregnancies. In the 50 pregnancies, there were 10 miscarriages (8 in the first trimester and 2 in the second trimester), 2 pregnancy terminations, and 2 who were pregnant at the time of this report. Eight of the remaining 36 pregnancies ended prematurely, 3 before 32 weeks of gestation and 5 between the 34th and 36th weeks. Twenty-eight pregnancies reached 37 weeks or more (78%). All deliveries over 37 weeks were by elective cesarean section. Sixteen percent of the pregnancies resulted in a delivery before 37 weeks. Two patients accounted for the 5 earliest deliveries, including 2 in the second trimester at 20 and 25 weeks and 3 in the third trimester at 28, 31, and 34 weeks. The 2 babies delivered at 25 and 28 weeks survived and had no evidence of long-term problems at 7 and 10 years. The 31-week baby was born after premature membrane rupture and died of sepsis within 36 hours. The remaining 34 women had successful pregnancies, which reached at least 34 weeks gestation. The only other infant death was a full-term baby born with trisomy-18 and severe cardiac malformations. There were 2 women with spontaneous erosion of the cerclage suture. Both occurred in the first 15 patients when the cerclage was placed more deeply within the cervical stroma.

Vaginal radical trachelectomy: A valuable fertility-preserving option in the management of early-stage cervical cancer. A series of 50 pregnancies and review of the literature

Objective. To report the obstetrical results following vaginal radical trachelectomy (VRT), a fertility-preserving surgery in the treatment of early-stage cervical cancer. Methods. Retrospective review of our first 72 patients treated by a laparoscopic pelvic lymphadenectomy followed by a VRT from October 1991 to October 2003 with regards to their reproductive function. Results. Patients' median age was 32 years old (21–42) and 53 (74%) were nulligravida. A total of 50 pregnancies occurred in 31 women. The majority (66%) had only one pregnancy, 19% had 2 pregnancies and 16% had 3 pregnancies or more. The rate of first trimester miscarriage was 16%, the rate of second trimester miscarriage was (4%) and 2 women (4%) elected to have pregnancy termination. A total of 36 pregnancies (72%) reached the third trimester. Of those, 3 (8%) ended prematurely at <32 weeks gestation, 5 (14%) delivered between 32 and 36 weeks and 28 (78%) delivered at term (>37 weeks). One newborn died of neonatal sepsis from E. coli infection and one died from cardiac malformation (trisomy-18). Seven patients (10%) had infertility problems: 3 from ovulatory causes of which 2 successfully conceived with IVF, one from endometriosis and low sperm count and 3 from probable cervical cause of which one conceived with IUI. One patient had a twin pregnancy following IVF and elected to have embryo reduction and subsequently delivered at 37 weeks. Conclusion. Based on our experience, the obstetrical results following VRT for early-stage cervical cancer are very encouraging. The majority of women can anticipate to conceive spontaneously and deliver near term.

Clinical significance of lympho vascular space involvement and lymph node micrometastases in early-stage cervical cancer: A retrospective case-control surgico-pathological study

Objective Several studies have shown that lympho vascular space involvement (LVSI) and lymph node micrometastases (LNmM) may be risk factors for recurrence in early-stage cervical cancer with no apparent lymph node metastases. We performed a retrospective case-control study to reassess whether the presence of lymph node micrometastases and LVSI is predictive of subsequent recurrence following surgical resection of early-stage cervical cancer. Methods In a series of 292 patients diagnosed with early cervical cancer and treated by the same surgical procedure (laparoscopic-vaginal radical hysterectomy) during the same time period, two paired series were selected. The first series consisted of 26 cases who recurred in a median time of 36.8 months and the second series were 26 cases matched for age, histological sub-type, surgico-pathological stage and maximal tumor diameter, who did not recur after a median follow-up of 122 months. Sections taken from the hysterectomy specimens were reassessed for LVSI. All the lymph node blocks which have initially been considered as uninvolved were submitted to serial sectioning. Immunohistochemical staining using anti-cytokeratins AE1 and AE3 was used for identifying LNmM. Results LVSI was twice more frequent and LNmM ten-fold more frequent in the group of patients who recurred: 20/26 (77%) versus 9/26 (35%) and 11/26 (42%) versus 1/26 (4%) respectively. The relative risk of recurrence is 2.64 (1.67–5.49, P < 0.01) in the presence of LVSI and 2.44 (1.58–3.78, P < 0.01) in the presence of LNmM. All the patients with LNmM were LVSI positive. At bivariate analysis, the true LNmM (deposits more than 200 um in size) was the only independent risk factor. Conclusions LNmM is an important risk factor of tumor recurrence in patients with early cervical cancer with no apparent lymph node metastases. LNmM seems to occur only in LVSI positive tumors. These data may lead to improve management of early-stage cervical cancer to reduce the risk of recurrence in those cases.

Chemotherapy for advanced or recurrent carcinoma of the cervix.

The management of early-stage cervical cancer involves primarily surgery and/or chemoradiotherapy. When the disease spreads beyond the cervix but remains confined to the pelvis and draining lymph node basins, the mainstay of management is chemoradiotherapy. The use of primary systemic chemotherapy is related to the management of disease that has recurred or spread beyond the pelvic radiation fields. Although the optimal chemotherapy regimen remains to be determined, current protocols and the associated research to support their use are discussed in this review. Additionally, the rationale for use of chemoradiotherapy in locally advanced disease is presented.

Accuracy of Frozen Section for Lymph Node Metastasis in Patients Undergoing Radical Hysterectomy for Carcinoma of the Cervix

The efficacy of frozen section in detecting metastases in pelvic and or periaortic lymph nodes during radical hysterectomy is unknown. The finding of positive nodes may result in termination of the operative procedure. In this study, we attempted to determine the accuracy of frozen sections in this situation. Intraoperative pathology consultation records were examined for 127 patients undergoing surgical exploration for radical hysterectomy between 1977 and 1992. Microscopic slides of lymph nodes were reviewed for accuracy. Metastasis diameters were measured and blocks cut five close microtome levels deeper. In 19 cases (15%) positive nodes were documented on permanent section, with metastases ranging in size from less than 1 to 19 mm. Thirteen cases of node metastasis were diagnosed at frozen section. All were suspicious to the pathologist on palpation and gross inspection after bisection. Six cases were missed by sampling error on frozen section; in 4, metastases were smaller than 1 mm; in 1, between 2 and 3 mm; and in 1, 19 mm. The sensitivity was 68%, the false-negative rate was 32%, and the specificity was 100%. No cases were false positive at frozen section. The frequency of nodal metastasis and detection rate by frozen section did not differ significantly between carcinoma types. No micrometastases (<2 mm) were detected by frozen section. All micrometastases were no longer present within five microtome levels. Frozen section diagnosis of pelvic node metastasis is a highly specific procedure which should alter intraoperative management of early-stage cervical cancer.