Impact of Surgical Staging in Women with Locally Advanced Cervical Cancer

doi:10.1006/gyno.1999.5472

Gynecologic Oncology

Volume 74, Issue 3, September 1999, Pages 436-442

https://doi.org/10.1006/gyno.1999.5472 Get rights and content

Abstract

Objective. The aim of this study was to evaluate the impact of surgical staging in the treatment and outcome of women with locally advanced cervical cancer.

Methods. Ninety-eight women with locally advanced cervical cancer treated between 1993 and 1997 were retrospectively reviewed. Survival probabilities were calculated by the Kaplan–Meier product limit method and compared with the log-rank test.

Results. Of the 98 women treated over the 5-year period, 86 were surgically staged: 61 by a retroperitoneal approach, 18 by laparoscopy, and 7 by laparotomy. Median blood loss was 120 cc and median length of hospitalization was 3 days. Preoperative CT scans (n = 55), when compared with surgical findings, missed macroscopic nodal disease in 20% and microscopic disease in 15% and overcalled disease in 10% of cases. Lymph node metastases were found in 45/86 patients (52%): 12 microscopic and 33 macroscopic. The highest level of nodes found to be involved was pelvic in 23, common iliac nodes in 3, para-aortic nodes in 14, and scalene nodes in 5 cases. Of the 86 patients, 49 received pelvic radiation, 27 received extended field radiation, and 10 were identified for palliative treatment only (5 scalene node metastasis, 5 extensive intraperitoneal disease). For node-negative patients, 5-year survival was 74%; for microscopic nodal involvement it was 58%; and for macroscopic involvement it was 39% (P = 0.007). Five-year survival for women with para-aortic node involvement was 52%. Number of nodes involved was a significant prognostic variable (P = 0.008). Patients who received chemotherapy had a 5-year survival of 68% compared to 35% for those who did not (P = 0.06). Factors which did not affect survival included age, histology, type of surgery, stage, and type of radiation (pelvic vs extended).

Conclusion. Surgical staging of women with locally advanced cervical cancer can be performed with acceptable morbidity and it provided more accurate information than CT scans and resulted in a modification of the standard pelvic radiation field for 43% of our patients. The information obtained from surgical staging allows better individualization of therapy, which may improve overall clinical outcome.

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Minimally invasive surgery (MIS) is practiced by more than 90% of gynecologic oncologists. Knowledge of anatomy, the disease process, and surgical technique is key during these complicated surgical procedures. Several studies have shown that 10 to 20 cases are needed to gain proficiency with a certain procedure. MIS reduces blood loss, transfusions, length of hospital stay, and wound complications without compromising adequacy of the procedure or staging even in (extremely) morbidly obese patients. Survival outcomes for endometrial and ovarian cancer are similar after MIS and laparotomy, while survival outcomes with MIS have been shown to be worse for cervical cancer. Several safe methods exist to extract an enlarged uterus after MIS. Morcellation is not recommended when there is suspicion or proven preinvasive or invasive disease. Laparoscopy can be used in ovarian cancer to assess the extent of disease and chance of complete debulking surgery. MIS in advanced or recurrent ovarian cancer and its utilization in interval debulking is still under investigation, and prospective trials to confirm safety and feasibility are ongoing.
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Concomitant chemoradiotherapy is the standard treatment for locally advanced cervical cancer. Pelvic irradiation is commonly recommended for patients with negative para-aortic lymph nodes(PALNs). However, owing to the development of imaging-guided brachytherapy, distant failure has become the main failure pattern. The PALNs are a vital site of distant metastasis, and the para-aortic region may contain occult microscopic metastases that are barely detected owing to imaging technology restriction. The prognostic of patients who experienced PALN failure is dismal. Typically, there are four ways to decrease PALN failure. First, surgical staging can be performed to assess the occurrence of metastasis in the para-aortic region; however, the application of surgical staging is decreasing owing to controversial survival benefits and accompanying complications of surgery. Second, regular imaging surveillance and timely salvage of early recurrences could reduce PALN failure. Third, better systemic adjuvant therapy could be recommended since it has enormous potential to reduce distant metastases and improve overall survival. Fourth, performing prophylactic extended-field irradiation (EFI), including pelvic and para-aortic region irradiation, can sterilize occult microscopic metastases in the para-aortic region and improve survival. Prior investigations have revealed that prophylactic EFI could reduce PALN failure as well as distant metastasis and present the benefit of survival. Yet, owing to the serious morbidity induced by enlarged irradiation field in the era of conventional irradiation techniques, further research on EFI is stagnated. Nowadays, with the development of new technologies, intensity modulated radiation therapy can deliver a higher dose to tumors with acceptable toxicity. Prophylactic EFI regained attention. However, the inclusion criteria of prophylactic EFI in existing studies reveal great discrepancies. Thus, it is urgent to precisely identify indications for better survival and lower complications in patients with cervical cancer. In this review, we identify indications and summary guidelines for prophylactic EFI, which may provide a foundation for further trials and clinical applications.
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We assessed the effect of elective extended field radiation (EFRT) and nodal dose escalation on locoregional control and survival in patients with node-positive cervical cancer treated with definitive chemoradiation at 2 academic institutions.
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^☆: Presented at the 30th Annual Meeting of the Society of Gynecologic Oncologists, San Francisco, CA, March 20–24, 1999.

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Regular ArticleImpact of Surgical Staging in Women with Locally Advanced Cervical Cancer☆

Abstract

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Regular Article
Impact of Surgical Staging in Women with Locally Advanced Cervical Cancer☆