Validity of Laparoscopic Staging to Avoid Adjuvant Chemoradiation following Radical Surgery in Patients with Early Cervical Cancer

Abstract

Purpose: To determine the rate of unavoidable adjuvant chemoradiation (RCTX) due to histologic results after radical surgery in patients with early cervical cancer. Patients and Methods: Between May 2004 and July 2011, 448 consecutive patients diagnosed with invasive cervical cancer stage IA1 L1 to IIA underwent laparoscopic staging at the Department of Gynecology and Gynecologic Oncology at Charité Berlin. Only in patients without lymph node metastases (n = 394) on frozen section, radical operation was continued either by laparoscopic radical hysterectomy (n = 228) or by radical vaginal trachelectomy (n = 166). The decision for adjuvant RCTX was reached among the members of an interdisciplinary tumor board according to the presence of risk factors. The mean age of patients was 39 years. Squamous cell cancer was found in 62.5%, adenocarcinoma in 32.7%, adenosquamous cancer in 3.8% and others in 1% of patients. Adjuvant treatment was indicated if at least one category 1 risk factor (pN1, R1 or RX, parametrial involvement) and/or any combination of category 2 risk factors (lymphovascular space involvement (LVSI), hemovascular space involvement, grading 3, young age, deep stromal invasion, large tumor size) were present. Results: In 39 of 394 patients (9.9%), adjuvant RCTX was recommended due to category 1 risk factors (n = 25/6.4%) and category 2 risk factors (n = 14/3.5%). Tumor-involved (R0) or unclear resection margins (RX) were present in 4 (1%) and 1 (0.3%), parametrial involvement in 12 (3%) and positive lymph nodes in 11 (2.8%) patients, respectively. Hemovascular involvement was found in 14 (3.5%), LVSI in 113 (28.7%) and grading 3 in 122 (31%) patients, respectively. Conclusion: Laparoscopic staging is a reliable tool to keep the rate of tri-modal (surgery + chemotherapy + radiotherapy) treatments in patients with cervical cancer stage I and IIA after radical surgery at 10%. This percentage should be used as benchmark for the quality of interdisciplinary treatment of patients diagnosed with cervical cancer.

Evaluation of Clinical and Pathologic Risk Factors May Reduce the Rate of Multimodality Treatment of Early Cervical Cancer

“…This high rate is comparable with other reports. 6,20 The main goals in the treatment of early cervical cancer are to achieve the high cure rate with an overall 5-year survival in the range of 90%, to minimize possible short and long-term morbidities and to preserve fertility and ovarian function when it is relevant. Although in early-stage disease, the survival outcome is similar after either primary surgery or primary RT, 5,6,25-27 surgery is more commonly utilized than RT.…”

“…This undesirable 2-modality treatment was also reported by others who reported the rate of adjuvant radiation between 10% and 64%, depending on the years of the study and the criteria chosen for radiation. 6,13,[16][17][18][19][20] Historically, adjuvant pelvic RT was indicated in cases of lymph nodes metastasis, positive surgical margins, or PI. In these cases, which are considered high risk because of these prognostic factors, recurrences are more frequent and when one or more of these factors are found, the 5-year survival can drop to 40% to 70%.…”

“…These studies include the utilization of modern imaging techniques, laparoscopic staging, and different prognostic factors like the traditional pathologic criteria that we have used, sentinel lymph nodes assessment, and other newer biologic markers still being investigated. 20,46 There is no doubt that we are in the beginning of an era, where less radical treatments for early-stage disease will be the rule. Large prospective studies are currently needed and actually are already being conducted, 47 to prove each new suggested strategy.…”

“…[10][11][12][13][14][15] The reported rate of adjuvant RT following radical hysterectomy and pelvic lymphadenectomy is 10% to 64%. 6,13,[16][17][18][19][20] Thus, a significant proportion of patients undergo treatment by both modalities with potentially compounding morbidities. Only 2 randomized studies compared radical hysterectomy and surgery plus adjuvant RT, and no randomized study has compared surgery and adjuvant chemoradiation with primary surgery for patients with early-stage cervical cancer.…”

Endoscopy in Gynecologic Oncology

“…They concluded that laparoscopic staging is a feasible and safe procedure. Marnitz et al [ 5 ] published in 2012 the results of a prospective study. They demonstrated that in patients with early cervical cancer, laparoscopic staging with the use of frozen section of the lymph nodes successfully tailored the treatment.…”