ConCerv: a prospective trial of conservative surgery for low-risk early-stage cervical cancer (original) (raw)
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Surgical Treatment for Early Cervical Cancer in the HPV Era: State of the Art
Healthcare
Cervical cancer (CC) is the fourth most common cancer among women worldwide. The aim of this study is to focus on the state of the art of CC prevention, early diagnosis, and treatment and, within the latter, the role of surgery in the various stages of the disease with a focus on the impact of the LACC study (Laparoscopic Approach to Cervical Cancer trial) on the scientific debate and clinical practice. We have discussed the controversial application of minimally invasive surgery (MIS) for tumors < 2 cm and the possibility of fertility-sparing surgery on young women desirous of pregnancy. This analysis provides support for surgeons in the choice of better management, including patients with a desire for offspring and the need for sentinel node biopsy (SNB) rather than pelvic lymphadenectomy for tumors < 4 cm, and without suspicious lymph nodes’ involvement on imaging. Vaccines and early diagnosis of pre-cancerous lesions are the most effective public health tool to tackle cerv...
Minimization of curative surgery for treatment of early cervical cancer: a review
Japanese journal of clinical oncology, 2015
Surgery is effective and useful for curative treatment of patients with early invasive cervical cancer, yet minimization of surgical procedures provides many additional advantages for patients. Because the mean age of patients diagnosed with cervical precancer and invasive cancer has been decreasing, the need for minimization of surgery to reduce disruption of fertility is increasing. Trachelectomy is an innovative procedure for young patients with invasive cancer. Minimally invasive procedures are increasingly implemented in the treatment of patients with early cervical cancer, such as laparoscopic/robotic surgery and sentinel lymph node navigation. The use of modified radical hysterectomy may not only be curative but also minimally invasive for Stage IA2-IB1 patients with a tumor size <2 cm in diameter. Here, we have summarized and discussed the minimally invasive procedures for the treatment of patients with early cervical cancer.
Cancers
Background: The aim of this study was to analyze the impact of tumor size > 2 cm on oncological outcomes of fertility-sparing surgery (FSS) in early cervical cancer in a Spanish cohort. Methods: A multicenter, retrospective cohort study of early cervical cancer (stage IA1 with lymphovascular space invasion -IB1 (FIGO 2009)) patients with gestational desire who underwent FSS at 12 tertiary departments of gynecology oncology between 01/2005 and 01/2019 throughout Spain. Results: A total of 111 patients were included, 82 (73.9%) with tumors < 2 cm and 29 (26.1%) with tumors 2–4 cm. Patients’ characteristics were balanced except from lymphovascular space invasion. All were intraoperative lymph node-negative. Median follow-up was 55.7 and 30.7 months, respectively. Eleven recurrences were diagnosed (9.9%), five (6.0%) and six (21.4%) (p < 0.05). The 3-year progression-free survival (PFS) was 95.7% (95%CI 87.3–98.6) and 76.9% (95% CI 55.2–89.0) (p = 0.011). Only tumor size (<2...
Fertility-Sparing Surgery in Early-Stage Cervical Cancer Patients
International Journal of Gynecological Cancer, 2015
The aim of this study was to evaluate the safety, feasibility, and effectiveness of conservative management of early-stage cervical cancer (eCC) in young women willing to preserve their childbearing potential. Methods: Data of 22 consecutive young women (aged G40 years) undergoing conservative management of eCC were prospectively collected. Conservative management consists of cervical conization plus laparoscopic pelvic lymphadenectomy. Results: Median age was 32.5 years (range, 27Y40 years). Twenty-one women (95%) were nulliparous. Histology included adenocarcinoma, squamous cell carcinoma, and adenosquamous carcinoma in 11 (50%), 10 (45%), and 1 (5%) patients, respectively. Six (27%) and 16 patients (73%) were affected by stage IA2 and IB1, respectively. The mean number of pelvic lymph node removed was 26 (SD, 8.6). After primary treatment, 3 patients required radical surgery due to the presence of metastatic nodes detected at the time of diagnostic lymphadenectomy. In addition, 1 patient (5%), after the successful execution of conservative treatment, asked for hysterectomy. After a mean follow-up of 48.8 (SD, 32.8) months, no recurrence was diagnosed among patients undergoing ultraconservative treatment, whereas 2 out of 3 patients with positive pelvic nodes who had radical hysterectomy developed recurrent disease. Considering the whole cohort, 5-year disease-free and overall survival rates were 85.9% and 93.7%, respectively. Looking at reproductive outcomes, 15 of 18 patients (4 patients had hysterectomy) attempted to conceive, and 8 (53%) women had spontaneous pregnancies Conclusions: Conservative management for eCC seems to be associated with long-term oncologic effectiveness, preserving reproductive function. Further large prospective studies are warranted to improve patients' care.
Minimally invasive surgery for cervical cancer: consequences for treatment after LACC Study
Journal of Gynecologic Oncology
For many years, the mainstay of treatment for early cervical cancer has been radical hysterectomy. The original procedures performed by Ernst Wertheim, Friedrich Schauta, and Vincent Meigs had high mortality rates. Some were performed prior to the introduction of anaesthesia and patients might have had no recourse to chemotherapy and radiotherapy if adjuvant treatment was required. Furthermore, in the early days, there were no antibiotics if infection ensued. Over the next half a century, improvements in medicine made surgery more acceptable but the operative techniques for radical hysterectomy remained largely unchanged. Over the last 2 decades, efforts have been concentrated on reducing the morbidity of surgery. This has been achieved by selecting out women for upfront chemo-radiotherapy using new imaging techniques, providing less radical surgery for earlier stage disease, performing fertility sparing surgery for selected patients, using sentinel lymph node (LN) dissections, and utilising minimally invasive surgical techniques such as standard laparoscopy or robotics. In addition, a new understanding of malignant progression in embryologically based permissive tissue compartments [1] may change the surgical approach in other groups [2-4]. The combination of the above has changed practice unrecognisably in a relatively short time period. Furthermore, the utilization of radical hysterectomy is now less frequent. For example, a recent survey in the UK demonstrated that only about 300 such procedures were being performed annually [5]. Minimal access approaches to radical hysterectomy for cervical cancer have become increasingly popular in the last decade and have been adopted broadly across Europe and the Americas. Systematic reviews of observational studies have shown that a minimal access approach with either standard laparoscopy or robotics was associated with a shorter hospital stay, less complications, less blood loss, and lower transfusion rates [6-8]. This is in the background of recurrence rates being reported as similar in both minimally invasive and open arms [9-13]. Recently, emerging data from two groups have suggested that there might be a higher recurrence rate and lower overall survival for a minimal access approach to radical hysterectomy for cervical cancer compared to open [14-16]. This has caused surprise, reflection, and concern as to how to counsel patients when choosing a route for radical hysterectomy. More importantly, it is vital to examine what we know about both these studies to see how they might influence outcomes now and what further studies are needed in the future.
Early Cervical Cancer: Current Dilemmas of Staging and Surgery
Current Oncology Reports, 2017
Purpose of Review Advances in cervical cancer screening and treatment have resulted in high cure rates in developed countries for early-stage disease. Current research focuses on minimizing morbidity and maximizing quality of life. Recent Findings Imaging has been disappointing in identifying small volume metastases. Sentinel lymph node biopsy represents a significant advantage with high sensitivity, low false negative rates, reduced morbidity, and equivalent survival in recent studies compared to pelvic lymphadenectomy. Non-radical surgical options are currently being investigated for early cervical cancer in a number of large prospective studies in patients at low risk for metastases. Summary Evidence suggests that sentinel lymph node biopsy and non-radical surgery are safe approaches for the staging and management of early cervical cancer in appropriately selected patients with the potential to significantly reduce treatment-related morbidity.
Recent Advances in the Surgical Management of Cervical Cancer
Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine, 2000
Recent advances in the surgical management of early cervical cancer, including abdominal, laparoscopic, vaginal, and robotic approaches to radical hysterectomy as well as fertility-sparing radical trachelectomy, are reviewed. The nerve-sparing abdominal radical hysterectomy technique allows for a significant reduction in postoperative bladder morbidity. Radical vaginal hysterectomy with laparoscopic lymph node dissection is a well-recognized technique that offers excellent cure rates without abdominal entry as well as reduced postoperative febrile and gastrointestinal morbidity. Total laparoscopic radical hysterectomy is a minimally invasive alternative to the traditional abdominal radical hysterectomy approach and yields a comparable safety profile with a significant reduction in blood loss and hospital stay. Robotic surgery is becoming more widely accepted in the management of gynecologic cancers, including radical hysterectomy for early cervical cancer. Young women desiring to bear children in the future may be candidates for fertility preservation options, and the radical trachelectomy operation has been described and performed with abdominal, vaginal, laparoscopic, and robotic techniques. There are a number of surgical options for the treatment of women with early cervical cancer. The feasibility and safety of some of these techniques have been well established, whereas for others, the oncological outcome data are only preliminary. The decision to use newer techniques should be directed by patient variables as well as the surgeon's training and competence with laparoscopy, robotics, or vaginal surgery. Mt Sinai J Med 76:567-576, 2009. 2009 Mount Sinai School of Medicine