Stages IA2, IB1, and nonbulky IIA disease

Radical hysterectomy A standard treatment for patients with small cervical carcinomas (≤ 4 cm) confined to the uterine cervix or with minimal involvement of the vagina (stage IIA) is radical hysterectomy (removal of the uterus, cervix, and parametrial tissue), pelvic lymphadenectomy, and para-aortic lymph node sampling. The overall success of this treatment is similar to that of radiation therapy, and for patients with early lesions, radical hysterectomy may provide an improved quality of life. The benefits of surgical excision include rapid treatment, less time away from normal activities, and preservation of normal ovarian and vaginal function.

A randomized trial for patients with early-stage cervical cancer reported no difference in survival between radical hysterectomy and definitive radiation therapy. Because a significant percentage of patients following radical hysterectomy required postoperative pelvic radiotherapy, the morbidity was increased in the surgery arm. Therefore, patients selected for radical hysterectomy should have small-volume disease so adjuvant pelvic radiation therapy is unnecessary.

Currently, there are no specific contraindications to radical hysterectomy. Several studies have demonstrated that patients ≥ 65 years old tolerate this procedure well, and age alone should not be considered a contraindication. Obesity also is not a contraindication to radical hysterectomy.

Alternatives to radical hysterectomy Reports have described laparoscopically assisted radical vaginal hysterectomy and laparoscopic abdominal radical hysterectomy as less invasive alternatives to traditional radical hysterectomy. Although these procedures are not performed in all centers, the results from centers that have the surgical expertise are promising. The use of fertility-preserving surgery by means of pelvic lymphadenectomy combined with radical vaginal trachelectomy (removal of the uterine cervix) has also been evaluated in selected women with early cervical cancer (see box). Successful pregnancies after this procedure have been reported. However, further data are needed to assess the safety and efficacy of fertility-preserving surgery. There is a lack of long-term follow-up data and survival rates between conservative and radical treatment. These techniques should be performed by fully trained surgeons. The role of laparoscopic sentinel lymph node dissection is an area of active investigation.

Complications Due to improved surgical techniques, as well as the use of prophylactic antibiotics and prophylaxis against deep vein thrombosis, the morbidity and mortality associated with radical hysterectomy have declined significantly over the past several decades. The currently accepted complication rate for radical hysterectomy includes approximately a 0.5%–1.0% incidence of urinary tract injury, a 0.5%–1.0% incidence of deep vein thrombosis, and an overall mortality of < 1.0%.

The increased awareness of the risks associated with blood transfusion is reflected in the fact that, in many cases, no transfusions are administered. The need for heterologous blood transfusion also can be decreased by encouraging autologous blood donation prior to radical hysterectomy or by using intraoperative hemodilution.

The average hospital stay for patients undergoing radical hysterectomy is between 4 and 7 days. Follow-up should include a vaginal Pap smear every 3 months for 2 years, twice a year for 3 years, and yearly thereafter.

Stages IB2 and bulky IIA disease

Numerous studies have demonstrated that patients with early-stage “bulky” lesions (> 4 cm) have a worse prognosis than those with nonbulky tumors. Therefore, patients who have undergone radical hysterectomy and pelvic lymphadenectomy for early-stage bulky cervical cancer have traditionally received postoperative adjuvant pelvic radiation therapy. However, a randomized trial from Italy demonstrated that radical hysterectomy plus radiotherapy does not improve overall or disease-free survival in patients with early-stage bulky tumors, as compared with radiation therapy alone, but does significantly increase morbidity.

Furthermore, a recent GOG trial (GOG 123) demonstrated the benefit of the addition of cisplatin chemotherapy to pelvic radiation therapy followed by extrafascial hysterectomy in this group of patients (Figure 1). Therefore, many experts believe that patients with stage IB2 and bulky IIA cervical cancer should be treated initially with chemoradiation therapy instead of radical hysterectomy. Others argue that treatment decisions should not be based on tumor size alone, because some studies have demonstrated that significant independent predictors of disease-free survival are lymphovascular space involvement and outer two-thirds depth of invasion. GOG attempted to compare chemoradiation therapy with radical hysterectomy followed by chemoradiation therapy for bulky stage IB2 cervical cancer, but unfortunately, the trial closed prematurely due to poor accrual.

CHEMORADIATION THERAPY FOR LOCALLY ADVANCED DISEASE

The role of curative surgery diminishes once cervical cancer has spread beyond the confines of the cervix and vaginal fornices. Intracavitary irradiation for central pelvic disease and external-beam radiation therapy for lateral parametrial and pelvic nodal disease are typically combined to encompass the known patterns of disease spread with an appropriate radiation dose while sparing the bladder and rectum from receiving full doses. The addition of intracavitary irradiation to external-beam irradiation is associated with improved pelvic control and survival over external irradiation alone, as the combination can achieve high central doses of radiation.