The European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology guidelines for the management of patients with cervical cancer

BackgroundThe efficacy of adjuvant radiotherapy in patients with intermediate risk early cervical cancer after radical hysterectomy is still under debate. Most guidelines recommend adjuvant radiotherapy, whereas others consider observation a viable option.ObjectiveTo investigate if patients with intermediate risk factors for cervical cancer who underwent radical hysterectomy may benefit from adjuvant radiotherapy.MethodsConsecutive patients with tumor confined to the cervix and intermediate risk factors (according to Sedlis), treated between January 1982 and December 2014 who were observed after a type C2 radical hysterectomy formed the basis for this study. The frequency of recurrences, specifically isolated loco-regional recurrences, and the risk of death from recurrences, were analyzed. Data were analyzed using SPSS, version 23.0 for WindowsResultsA total of 161 patients were included in the analysis. Median age was 40 (range 20–76). Stages IB1 and IB2 were seen in 87 (54%) and 74 patients (46%), respectively. Squamous cell and non-squamous histology was seen in 114 (70.8%) and 47 patients (29.2%), respectively. Of the 161 patients, 25 (15.5%) had recurrent disease, of whom nine had an isolated loco-regional recurrence (5.6%). Median time to recurrence for isolated loco-regional recurrences was 28 months (range 9–151). Treatment for an isolated loco-regional recurrence was radiotherapy (n = 4) and chemoradiotherapy (n = 5). Four patients (2.5%) died from disease as a result of an isolated loco-regional recurrence. Actuarial disease- specific survival was 93.0% for the total group. No variables were found that predicted an isolated loco-regional recurrence.DiscussionThe mortality from isolated loco-regional recurrence in patients with intermediate risk factors for cervical cancer who underwent only radical hysterectomy type C2 was 2.5%. Further studies should compare outcomes between patients who undergo a type C2 radical hysterectomy without adjuvant radiotherapy with those undergoing a less radical hysterectomy but with adjuvant radiotherapy.

Section: Discussionsupporting

confidence: 84%

“…This should preferably be tested in a prospective randomized study. It is our opinion that, as long as this debate has not been settled, the ESGO guideline13 should be followed for the indication for adjuvant radiotherapy after radical surgery for patients with a stage IB cervical cancer and intermediate risk factors.…”

Section: Discussionmentioning

confidence: 99%

Analysis of isolated loco-regional recurrence rate in intermediate risk early cervical cancer after a type C2 radical hysterectomy without adjuvant radiotherapy

Velden

Mom

Lonkhuijzen

et al. 2019

“…Patients with or without intention to spare fertility can be enrolled in the study, even though the requirements for maximum tumor size are different. In fertility-sparing treatment, a 2 cm maximum tumor size is considered to be safe in accordance with current guidelines, whereas in the non-fertility-sparing group, the size can be up to 4 cm 5. Although some older papers show worse results for SLN biopsy in tumors larger than 2 cm, recent studies on large cohorts of patients have proved a comparable detection rate and sensitivity of SLN assessment in pelvic node staging in groups of tumors up to 2 cm and between 2 and 4 cm 7 13…”

Section: Discussionmentioning

confidence: 98%

“…It is considered an acceptable approach for the treatment of early stages in the National Comprehensive Cancer Network (NCCN) guidelines. In the new European Society of Gynaecological Oncology (ESGO)-European Society for Radiotherapy and Oncology (ESTRO)-European Society of Pathology (ESP) guidelines it is considered an adequate method for lymphatic staging in stage T1a and is strongly recommended as the first step of surgical treatment in all early stages in combination with systematic pelvic lymphadenectomy 5. An increasing number of recent publications recommend SLN alone or the treatment of stage T1b1 6–8.…”

Section: Introductionmentioning

confidence: 99%

A prospective multicenter trial on sentinel lymph node biopsy in patients with early-stage cervical cancer (SENTIX)

Cibula

Dušek

Jarkovský

et al. 2019

Self Cite

ObjectiveSentinel lymph node (SLN) biopsy has been increasingly used in the management of early-stage cervical cancer. It appears in guidelines as an alternative option to systematic pelvic lymphadenectomy. The evidence about safety is, however, based mostly on retrospective studies, in which SLN was combined with systematic lymphadenectomy.Materials and methodsSENTIX is a prospective multicenter trial aiming to prove that less-radical surgery with SLN is non-inferior to treatment with systematic pelvic lymphadenectomy. The primary end point is recurrence rate; the secondary end point is the prevalence of lower-leg lymphedema and symptomatic pelvic lymphocele. The reference recurrence rate was set up conservatively at 7% at 24 months after treatment. With a sample size of 300 patients treated per protocol, the trial is powered to detect a non-inferiority margin of 5% (90% power, p = 0.05) for recurrence rate, 30% reduction in the prevalence of symptomatic lymphocele or lower-leg lymphedema, with reference rates of 30% and 6% at 12 months (p = 0.025, Bonferroni correction). The patients eligible for SENTIX have stage IA1/LVSI+, IA2, IB1 (<2 cm for fertility sparing), with negative LN on pre-operative imaging. Intra-operatively, patients are excluded when there is a failure to detect SLN on both sides of the pelvis in cases of more advanced cancer (stage >IB1), or a positive intra-operative SLN assessment. The quality of SLN pathology evaluation will be assessed by central review. Three interim safety analyses are pre-planned when 30, 60, 150 patients complete 12 months' follow-up.ConclusionsThe first patient was enrolled into the study in June 2016 and, by June 2018, 340 patients had been enrolled. The first analysis of secondary outcomes should be available in 2019 and the oncological outcome of 300 patients at the end of 2021. The trial is registered as a CEEGOG trial (CEEGOG CX-01), ENGOT trial (ENGOT-Cx 2), and at the ClinicalTrials.gov database (NCT02494063).

“…Using ICG does not require advance planning involving nuclear protection and delayed surgery, as are mandatory when using 99 Tc detection. ICG allows the surgeon to visualize the lymph nodes through the peritoneum and thus avoid wide dissection.According to European guidelines,1 the indications for SLND in cervical cancer are for patients with FIGO (International Federation of Gynecology and Obstetrics) IA1–IA2 disease, lymphovascular space involvement - positive status, without systematic pelvic lymphadenectomy – and patients with FIGO IB1–IIA1 disease, prior to systematic pelvic lymphadenectomy. Guidelines1 2 for endometrial cancer management state that SLND is indicated in cases of low-risk endometrial cancer (FIGO IA, grade 1–2), without systematic lymphadenectomy in cases of non-detection, with the technique being preferable to systematic lymphadenectomy in cases of intermediate-risk endometrial cancer (FIGO IB, grade 1–2, or FIGO IA, grade 3) 2…”

mentioning

confidence: 99%

How to perform a laparoscopic pelvic sentinel lymph node dissection using near-infrared fluorescence with indocyanine green in gynecological cancers

Vesale

Azaïs

Belghiti

et al. 2019

The role of pelvic sentinel lymph node dissection (SLND) is increasing in oncological pelvic surgery, especially in the management of cervical and endometrial cancer.SLND using indocyanine green (ICG) is safe and effective, and its sensitivity is higher than with other detection methods. The advantages of ICG are its low toxicity, its confinement within the vascular compartment, its rapid excretion, and the rarity of allergic reaction. These advantages confer to this fluorescent dye a superiority over blue, which can cause anaphylactic reactions. Using ICG does not require advance planning involving nuclear protection and delayed surgery, as are mandatory when using 99Tc detection. ICG allows the surgeon to visualize the lymph nodes through the peritoneum and thus avoid wide dissection.According to European guidelines,1 the indications for SLND in cervical cancer are for patients with FIGO (International Federation of Gynecology and Obstetrics) IA1–IA2 disease, lymphovascular space involvement - positive status, without systematic pelvic lymphadenectomy – and patients with FIGO IB1–IIA1 disease, prior to systematic pelvic lymphadenectomy. Guidelines1 2 for endometrial cancer management state that SLND is indicated in cases of low-risk endometrial cancer (FIGO IA, grade 1–2), without systematic lymphadenectomy in cases of non-detection, with the technique being preferable to systematic lymphadenectomy in cases of intermediate-risk endometrial cancer (FIGO IB, grade 1–2, or FIGO IA, grade 3).2 Our objective is to review the technique of ICG injection and the real-time detection of pelvic SLNs using near-infrared imaging by means of a step-by-step explanation of the procedure using an instructional Video 1.