A step-by-step approach to early stage cervical cancer treatment

Abstract

The treatment of choice for early stage cervical cancer to date has been a radical hysterectomy including pelvic lymph node dissection. In case of more extensive disease chemoradiation is given in an adjuvant setting. On one hand the combination of both modalities may lead to severe morbidity, and, on the other hand, routine radical hystrectomy may constitute overtreatment in e.g. small tumours withouth negative prognostic factors. With the introduction of new cenpcepts and techniques a more personalized approach needs evaluation. As almost half of patients are under the age of forty years, fertility sparing minimal invasive treatment becomes increasingly important. Combined with the use of a sentinel node patients may undergo laparoscopic lymph node evaluation before either surgical treatment or radiation therapy. This thesis aims to help tailor treatment with emphasis on minimal invasive therapy. The use of blood serum tumor markers such as SCC-Ag and CYFRA 21-1 has been investigated, and a cut-off level for SCC-Ag was defined, to identify patients with tumor-negative sentinel lymph nodes but with a poorer prognosis. A systematic review was performed on the use of sentinel lymph nodes in case of early stage cervical cancer, regarding the type of tracer (patent blue, a radioactive tracer or both) used and the resulting detection rate and sensitivity. The combined technique yielded the best results, with a detection rate of 97% and sensitivity of 92%. In a retrospective study, the use of laparoscopy to harvest lymph nodes was evaluated, with respect to surgical outcome and oncologic safety. The laparoscopic route proved to be equal to a laparotomy in terms of lymph node yield, and adverse events including number and mode of recurrences. Finally, we evaluated te use of a radical vaginal trachelectomy for small early stage cervical cancer in 67 patients since its introduction in the Netherlands in 2000 to 2008, with follow-up until 2012. Results were comparable with the literature in terms of oncologic and obstetric outcome. As a new finding we concluded that conisation proved not have sufficed as final treatment in half of the cases in this series. As a conclusion, a step-by-step flowchart was made including the use of blood serum tumor markers to select patients for full lymphadenectomy instead of a sentinel node procedure, in order to tailor treatment.