alexa Smaller but Better? The Effort to Shrink Surgical Scale for Selected Early Stage Cervical Cancer | OMICS International
ISSN: 2161-0932
Gynecology & Obstetrics

Like us on:

Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Smaller but Better? The Effort to Shrink Surgical Scale for Selected Early Stage Cervical Cancer

Jen-Ruei Chen1,2* and Masoud Azodi3

1Division of Gynecologic Oncology, Department of OB/GYN, Mackay Memorial Hospital, Taipei, Taiwan, ROC

2Mackay Medicine, Nursing and Management College, Taipei, Taiwan, ROC

3Department of Obstetrics, Gynecology, and Reproductive Medicine, Gynecologic Oncology Section, Yale University School of Medicine, New Hvaen, CT, USA

*Corresponding Author:
Jen-Ruei Chen
Division of Gynecologic Oncology
Department of OB/GYN, Mackay Memorial Hospital
No.92, Sec. 2, Chung-sang N Rd, Chung-sang Dist
Taipei, 10449, Taiwan, ROC
Tel: +886-2-25433535
Fax: +886-2-25236376
E-mail: [email protected]

Received date: October 01, 2012; Accepted date: October 03, 2012; Published date: October 05, 2012

Citation: Chen JR, Azodi M (2012) Smaller but Better? The Effort to Shrink Surgical Scale for Selected Early Stage Cervical Cancer. Gynecol Obstet 2:e108. doi: 10.4172/2161-0932.1000e108

Copyright: © 2012 Chen JR, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Gynecology & Obstetrics

Cervical Cancer (CC) is the third most common gynecologic malignancy in United States. In 2012, new discovery and death cases are estimated to be 12,170 and 4,220 [1]. The probability of developing invasive CC in population statistics from 2006 to 2008 is 0.68% (1 in 147) life-long , and 0.15% (1 in 680) from birth to 39 years old [2]. CC is caused by the long term, repeated infection of high-risk group Human Papillomatous Virus in the transitional zone of uterine cervix. Because the sexual exposure starts younger now, approximate 60% CC is diagnosed younger than 50 years of age [1]. Early Stage Cervical Cancer (ESCC) is defined as the cancer only restricted in the uterine cervix. According to recent official stage system of Federation of International Gynecology and Obstetrics (FIGO), 2009, ESCC includes from stage IA1 to IB2. Fortunately, based on recent effective screening system and easily notable self-warning symptoms, near 42-49% CC cases are found to be ESCC [1]. Epithelial histology, including squamous cell carcinoma, adenocarcinoma and adenosquamous cell carcinoma, is covered over 95% of CC and its tumor behavior looks better than other rare histology [3].

Surgical excision plays a major role in treating ESCC. The surgical scale depends on the disease stage, risk factors, surgeons’ experience and patients’ desire. If the childbearing is no longer considered, uterus with cervix is recommended to be removed. Simple extrafascial hysterectomy is accepted for FIGO stage IA1 CC without Lymphatic Vascular Space Invasion (LVSI). From FIGO stage IA1 with LVSI to IB2, the standard recommendation is radical hysterectomy and complete Bilateral Pelvic Lymph Nodes Dissection (BPLND) [4], in order to remove uterus, para-cervical tissue, partial upper vagina and lymphatic tissue. If childbearing is still strongly desired, to preserve uterine corpus in ESCC is reasonable because the invasion of upper uterine part is rare in such cases. Today, the choice and indication of fertility-preserving surgery in ESCC been increasing, not only because of the increase of ESCC in reproductive age female, but also the childbearing age is delayed in our society. Decreasing the co-morbidity and keeping the quality of life in surgery for ESCC are the important focus. The trend and evidence of fertility sparing surgery of ESCC will be discussed according to its disease stage.

FIGO Stage IA1 ESCC without LVSI

According to the guideline of National Comprehensive Cancer Network (NCCN) [4], the standard acceptable fertility sparing procedure is just cervical cone excision to obtain negative surgical margin. This kind of ESCC is treated the same as high grade pre-cancer, intra-epithelial neoplastic lesion.

FIGO Stage IA1 with LVSI, Stage IA2 and “Selected Small Tumor Volume” Stage IB1 ESCC

LVSI is an important histological factor for predicting the risks of recurrence and metastases in ESCC after reviewing of literatures. The relationship of LVSI, parametrial invasion and pelvic lymph node metastasis has been established after histopathological studies. Increase of primary tumor size is usually correlated with deeper cervical stromal invasion, which also increase the risk of parametrial spread. For preserving fertility, pelvic lymph nodes and paracervical tissue are suggested to be removed. NCCN guideline traditionally recommends modified (type II) Radical Trachelectomy (RT) with BPLND for LVSI positive stage IA1 ESCC. Class-III RT with BPLND is recommended for all ESCC cases with stage IA2 or “selected small tumor volume” stage IB1 regardless of LVSI.

Because of the heterogeneity of stage FIGO IB1, the “small tumor volume” needs to be defined clearly. Recent most acceptable criteria are: Age ≤ 45 years old, favorable epithelial histology, gross visible tumor ≤ 2 cm, tumor limited to the cervix which is confirmed by image study, no corpus or uterine cavity invasion, no evidence of pelvic lymph node metastasis and/or other distant metastases [5]. For preserving the ability of childbearing, these cases chosen for RT should desire their future fertility without known documentation of infertility [6].

RT is to remove entire exo-cervix, majority of endo-cervix, some upper vagina and parametrium via vaginal, abdominal and minimal invasive (laparoscopic or robotic) approach. Dargent et al. described their first series of vaginal approach in 1994 [7]. After couple decades, the recurrent and death rate of RT in selected ESCC is approximate 5% and 3%, which is comparative to traditional radical hysterectomy [3]. However, for the purpose of fertility sparing, this procedure still seems imperfect in clinical practice. Major possible complications are classified into 3 parts:

Surgical related complications: RT has the same surgical complication as radical hysterectomy. Damage to bladder, ureters, rectum, and autonomic nerve intra-operatively are all possible although they are rare. Urinary retention, constipation or ileus is frequent during post-operative period [8].

Menstrual or sexual related complications: Menstrual problems are most frequently encountered after surgery. Dysmenorrhea, metrorragia and amenorrhea are easily complained. Problems with cerclage sutures include excessive vaginal discharge, isthmic stenosis, and occasional deep dyspareunia [9]. Obstetrical complications: This is the most criticized part of RT. Infertility, high possibility of second trimester miscarriage (double than normal population), premature rupture of membranes and premature delivery (near 30%) are all reported, probably originated from the ascending infections because of absence of cervix [10].

Alternative Smaller Scale Surgery for FIGO Stage IA1 with LVSI, Stage IA2 and “Specific Selected Small Tumor Volume” Stage IB1 ESCC

After accumulating experience from many trials and literatures gradually, to shrink the surgical scale has been proposed in many kinds of cancers. Smaller scale decreases the surgery related complications but not the therapeutic effect. For example, surgical scale of breast and vulvar cancer is smaller than it used to be. However, more strict selective criteria is reasonable in decision making of choosing smaller scale surgery, in order not to compromise patients’ disease free period and survivorship.

RT can preserve the fertility, but it is not good enough in maintenance of fertile and obstetrical outcome clinically. Lack of real cervical stroma and para-cervical tissue probably the underlying problem. Parametrial invasion is estimated to be only 0.6% if primary tumor ≤ 20 mm, cervical stromal invasion ≤ 10 mm and absence of pelvic lymph nodes metastases in ESCC [11]. The surgical role of trachelectomy with parametrectomy for such early stage cases is questionable now. Surprising, some pioneers try to introduce large cone excision (cold knife, laser or loop) for specific small tumor volume stage IB1 candidates after pathologic negative pelvic lymph nodes confirmed by laparoscopic BPLND [12,13]. FIGO stage IA1 and IA2 can also fit these selective criteria because they are only microscopic tumors in ESCC.

Their selective criteria for specific stage IB1 cases include: gross tumor size ≤ 15-20 mm, depth of stromal invasion ≤ 10 mm [12], or tumor volume ≤ 500 mm3 (length2 × depth × 1/2) [13], with pathologic negative pelvic lymph nodes. Other requirements are the same as RT. In the preliminary retrospective data compared with RT, they showed comparative prognosis, survivorship, but markedly decreased postoperative co-morbidities with excellent obstetrical outcome [7,8]. Now, large scale, ongoing prospective trials have been carried out for confirming this inspiring result [14].

FIGO Stage IB1 ESCC which Cannot Fit the Criteria of RT or Experimental Cone Excision

This kind of stage IB1 is not suitable for fertility preserving surgical procedure because of high failure rate of local control. The possibility of LVSI, microscopic parametrial invasion and pelvic lymph nodes metastases are still higher [15]. Radiation therapy seems not avoidable in this group if any of major risk factor presents. For such cases with strong desire of child-bearing, there are two possible solutions in this group: the first one is to try laparoscopic BPLND for excluding nodal disease in this group, then start Neoadjuvant Chemotherapy (NACT) before RT in node-negative group. Case series has been published [16] but the experience and evidence are not sufficient. Large scale prospective trial may be necessary in the future. The second choice is the transposition of both ovaries out of pelvic region in nodal positive group if pelvic radiation therapy is not avoidable. This procedure is effective to prevent ovarian damage [17], make them possible to process artificial reproductive procedure later.

Stage IB2 ESCC

Some experts exclude this stage from ESCC. According to recent NCCN guideline, no fertility preserving procedure is recommended. Laparoscopic BPLND follow by NACT then RT for nodal negative cases or ovarian transposition for nodal positive cases are their possible choices like bulky IB1 ESCC mentioned above [16,17].

In conclusion, many experts did their much effort to preserve the reproductive ability in ESCC. Shrinking surgical scale to preserve more and more residual cervical stroma, reducing primary tumor volume by NACT and laparoscopic BPLND for excluding nodal and parametrial metastases before conservative procedure all make childbearing possible. But some management still needs time and strong enough evidence to support the safety and acceptance in the future.

References

Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Relevant Topics

Recommended Conferences

  • 7th International Conference on Clinical and Medical Case Reports June 01-02, 2018 Osaka, Japan Theme: Focusing the breakthroughs of case reports in Clinical & Medical Research
    June 01-02, 2018 Osaka, Japan
  • 7th International Conference and Exhibition on Surgery June 21-23, 2018 Dublin, Ireland Theme: Advancements and Endeavours in the Field of Surgery
    June 21-23, 2018 Dublin, Ireland Dublin, Ireland
  • Annual Congress on Research and Innovations in Medicine July 02-03, 2018 Bangkok, Thailand Theme: Current Research and Innovations in Medicine to Improve Human Health
    July 02-03, 2018 Bangkok, Thailand
  • International Conference on Medical and Health Science August 24-25, 2018 Tokyo, JAPAN Theme: Scrutinize the Modish of Medical and Health Science
    August 24-25, 2018 Tokyo, Japan
  • World Summit on Trauma and Reconstructive Surgery Sep 10-11, 2018 Singapore Theme: Expanding new horizons in Trauma and Surgery
    Sep 10-11, 2018 Singapore City, Singapore
  • 6th American Gynecological Surgery Conference September 28-29, 2018 San Antonio | Texas | USA
    September 28-29, 2018 San Antonio, USA
  • World Congress on Fetal and Maternal Medicine October 15-17, 2018 Osaka, Japan Theme: A New Beginning on Fetal, Maternal & Neonatal Medicine
    October 15-17, 2018 Osaka, Japan
  • International Conference on Reproduction and Fertility October 18-19, 2018 Abu Dhabi, UAE
    October 18-19, 2018 Abu Dhabi, UAE

Article Usage

  • Total views: 11698
  • [From(publication date):
    December-2012 - May 26, 2018]
  • Breakdown by view type
  • HTML page views : 7933
  • PDF downloads : 3765
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2018-19
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri & Aquaculture Journals

Dr. Krish

[email protected]

1-702-714-7001Extn: 9040

Biochemistry Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

[email protected]

1-702-714-7001Extn: 9042

Chemistry Journals

Gabriel Shaw

[email protected]

1-702-714-7001Extn: 9040

Clinical Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Engineering Journals

James Franklin

[email protected]

1-702-714-7001Extn: 9042

Food & Nutrition Journals

Katie Wilson

[email protected]

1-702-714-7001Extn: 9042

General Science

Andrea Jason

[email protected]

1-702-714-7001Extn: 9043

Genetics & Molecular Biology Journals

Anna Melissa

[email protected]

1-702-714-7001Extn: 9006

Immunology & Microbiology Journals

David Gorantl

[email protected]

1-702-714-7001Extn: 9014

Materials Science Journals

Rachle Green

[email protected]

1-702-714-7001Extn: 9039

Nursing & Health Care Journals

Stephanie Skinner

[email protected]

1-702-714-7001Extn: 9039

Medical Journals

Nimmi Anna

[email protected]

1-702-714-7001Extn: 9038

Neuroscience & Psychology Journals

Nathan T

[email protected]

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

Ann Jose

[email protected]

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

[email protected]

1-702-714-7001Extn: 9042

 
© 2008- 2018 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version
Leave Your Message 24x7