Novel Surgical Strategies in the Treatment of Gynecological Malignancies
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The main advancement in the surgical treatment of early cervical cancer has been a de-escalation in the radical surgical approach of early stage disease. Similarly, sentinel lymph node detection with cervical tracer injection can be performed alone in microscopic tumors (stage IA) while additional lymphadenectomy is still performed in macroscopic tumors (IB1 and IIA). Parametrial resection has been progressively reduced in tumors less than 2 cm, and simple procedures, conservative (trachelectomy) or not (simple hysterectomy), are currently being evaluated in several phase III trials. Since the preliminary results of the LACC (locally advanced cervical cancer) trial, the value of minimally invasive surgery as the standard approach for the treatment of early stage cervical cancer has been questioned and patients should be aware when discussing the approach for radical hysterectomy. While awaiting the results of ongoing clinical trials comparing radiological and surgical staging in locally advanced cervical cancer patients, surgical staging with paraaortic lymphadenectomy remains the standard of care before definitive chemoradiotherapy in patients with negative aortic PET/TDM. Patients undergoing salvage surgeries for isolated pelvic recurrences of cervical cancer benefit from advanced reconstructive techniques as DIEP flaps and continent reconstructive urinary techniques. In selected patients, a minimally invasive approach can be considered. Surgery is the mainstay of the treatment of endometrial cancer. The major evolution in surgical strategy has occurred in lymph node staging. The standard surgical staging includes pelvic and paraaortic lymph node dissection to the level of the left renal vein. Sentinel lymph node dissection has been validated as a less morbid alternative of systematic lymphadenectomy, indicated in patients with low and intermediate risk of lymph node involvement. In advanced ovarian cancer, complete cytoreduction is the main objective of surgery. To achieve this goal, upper abdominal complex procedures have been developed. Best survival rates are obtained with primary debulking surgery. Exploratory laparoscopy may be performed before cytoreduction to evaluate resectability and thus avoid unnecessary laparotomy. Although systematic pelvic and paraaortic lymphadenectomy is being questioned in patients with advanced ovarian cancer and clinically negative lymph nodes undergoing complete primary debulking surgery, this procedure is still recommended. While waiting publication of the GOG 252 trial, IP chemotherapy after complete CRS is under debate. HIPEC after interval debulking surgery in patients undergoing complete cytoreduction is an intriguing new option. Patients within the first recurrence of ovarian cancer, with score AGO-positive, benefit from a second complete cytoreductive surgery followed by chemotherapy. Ovarian cancer survival rates are higher in specialized high-volume centers, and thus cases should be centralized and quality indicators used.
KeywordsOvarian cancer Cervical cancer Endometrial cancer Surgical approach Minimally invasive surgery Novel strategies
Carlos Martínez-Gómez acknowledges the scholarship support from Fundación Martín Escudero (Madrid).
Compliance with Ethical Standards
Conflict of Interest
Martina Aida Angeles declares that she has no conflict of interest.
Carlos Martínez-Gómez declares that he has no conflict of interest.
Federico Migliorelli declares that he has no conflict of interest.
Marie Voglimacci declares that she has no conflict of interest.
Justine Figurelli declares that she has no conflict of interest.
Stephanie Motton has received research funding from Intuitive Surgical, Inc. and has also received compensation from Intuitive Surgical, Inc. for service as a consultant.
Yann Tanguy Le Gac declares that he has no conflict of interest.
Gwénaël Ferron declares that she has no conflict of interest.
Alejandra Martinez declares that she has no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
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- 1.Cibula D, Pötter R, Planchamp F, Avall-Lundqvist E, Fischerova D, Haie Meder C, et al. The European Society of Gynecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology Guidelines for the Management of Patients With Cervical Cancer. Int J Gynecol Cancer. 2018;28:641–55.CrossRefGoogle Scholar
- 3.Frumovitz M, Plante M, Lee PS, Sandadi S, Lilja JF, Escobar PF, et al. The FILM Trial: a randomized phase III multicenter study assessing near infrared fluorescence in the identification of sentinel lymph nodes (SLN). Gynecol Oncol. Elsevier Inc. 2018;149:7.Google Scholar
- 5.Bats AS, Mathevet P, Buenerd A, Orliaguet I, Mery E, Zerdoud S, et al. The sentinel node technique detects unexpected drainage pathways and allows nodal ultrastaging in early cervical cancer: insights from the multicenter prospective SENTICOL study. Ann Surg Oncol. 2013;20:413–22.CrossRefGoogle Scholar
- 6.•• Mathevet P, Lecuru F, Magaud L, Bouttitie F. Sentinel lymph node biopsy for early cervical cancer: results of a randomized prospective, multicenter study (Senticol 2) comparing adding pelvic lymph node dissection vs sentinel node biopsy only. Gynecol Oncol. Elsevier Inc. 2017;145:2–3. Randomized trial comparing SNLD vs pelvic lymphadenectomy in early cervical cancer.Google Scholar
- 8.•• Querleu D, Cibula D, Abu-Rustum NR. Update on the Querleu–Morrow Classification of radical hysterectomy. Ann Surg Oncol. Springer International Publishing. 2017;24:3406–12. World referent classification for radical hysterectomy.Google Scholar
- 10.Pareja R, Rendón GJ, Vasquez M, Echeverri L, Sanz-Lomana CM, Ramirez PT. Immediate radical trachelectomy versus neoadjuvant chemotherapy followed by conservative surgery for patients with stage IB1 cervical cancer with tumors 2 cm or larger: a literature review and analysis of oncological and obstetrical outcomes. Gynecol Oncol. Elsevier Inc. 2015;137:574–80.Google Scholar
- 11.•• Bentivegna E, Gouy S, Maulard A, Chargari C, Leary A, Morice P, et al. Oncological outcomes after fertility-sparing surgery for cervical cancer: a systematic review. Lancet Oncol. 2016;17:e240–53. Elsevier Ltd. Deep and meticulous review for conservative management of cervical cancer.Google Scholar
- 12.Pareja FR, Ramirez PT, Borrero FM, Angel CG. Abdominal radical trachelectomy for invasive cervical cancer: a case series and literature review. Gynecol Oncol. Elsevier BV. 2008;111:555–60.Google Scholar
- 14.Ramirez PT, Schmeler KM, Malpica A, Soliman PT. Safety and feasibility of robotic radical trachelectomy in patients with early-stage cervical cancer. Gynecol Oncol. Elsevier Inc. 2010;116:512–5. https://doi.org/10.1016/j.ygyno.2009.10.063.
- 16.•• Zhou WY, Deng L, Cheng XH, Zhang Y, Qing LZ. Laparoscopy versus laparotomy for the management of early stage cervical cancer. BMC Cancer. 2015;15:928. https://doi.org/10.1186/s12885-015-1818-4 Largest review of retrospective studies comparing minimally invasive surgery versus laparotomy for early cervical cancer.
- 17.Shazly SAM, Murad MH, Dowdy SC, Gostout BS, Famuyide AO. Robotic radical hysterectomy in early stage cervical cancer: a systematic review and meta-analysis. Gynecol Oncol. Elsevier Inc. 2015;138:457–71. https://doi.org/10.1016/j.ygyno.2015.06.009.
- 18.•• Ramirez PT, Frumovitz M, Pareja R, Lopez A, Vieira M, Ribeiro R. Phase III randomized trial of laparoscopic or robotic versus abdominal radical hysterectomy in patients with early- stage cervical cancer: LACC Trial. 49th Annu Meet Soc Gynecol Oncol March. 2018;2–5. Preliminary results of LACC trial showing worse oncological outcomes in minimally invasive surgery versus laparotomy for early cervical cancer.Google Scholar
- 19.• Leblanc E, Katdare N, Narducci F, Bresson L, Gouy S, Morice P, et al. Should systematic infrarenal para-aortic dissection be the rule in the pretherapeutic staging of primary or recurrent locally advanced cervix cancer patients with a negative preoperative para-aortic PET imaging? Int J Gynecol Cancer. 2016;26:169–75 Retrospective study that shows inframesenteric lymph node dissection as a valid option for staging in locally advanced cervical cancer.CrossRefGoogle Scholar
- 20.Gouy S, Morice P, Narducci F, Uzan C, Gilmore J, Kolesnikov-Gauthier H, et al. N0odal-staging surgery for locally advanced cervical cancer in the era of PET. Lancet Oncol. Elsevier Ltd. 2012;13:e212–20. https://doi.org/10.1016/S1470-2045(12)70011-6.
- 21.Gouy S, Morice P, Narducci F, Uzan C, Martinez A, Rey A, et al. Prospective multicenter study evaluating the survival of patients with locally advanced cervical cancer undergoing laparoscopic para-aortic lymphadenectomy before chemoradiotherapy in the era of positron emission tomography imaging. J Clin Oncol. 2013;31:3026–33.CrossRefGoogle Scholar
- 24.• Pomel C, Martinez A, Bourgin C, Beguinot M, Benoit C, Naik R, et al. Survival effect of laparoscopic para-aortic staging in locally advanced cervical cancer: a retrospective cohort analysis. BJOG An Int J Obstet Gynaecol. 2017;124:1089–94 Retrospective study that questions the benefit of paraaortic surgical staging in locally advanced cervical cancer.CrossRefGoogle Scholar
- 25.Höckel M. Long-term experience with (laterally) extended endopelvic resection (LEER) in relapsed pelvic malignancies. Curr Oncol Rep. 2015;17.Google Scholar
- 26.Ferron G, Gangloff D, Querleu D, Frigenza M, Torrent JJ, Picaud L, et al. Vaginal reconstruction with pedicled vertical deep inferior epigastric perforator flap (diep) after pelvic exenteration. A consecutive case series. Gynecol Oncol. Elsevier B.V. 2015;138:603–8.Google Scholar
- 32.Chiva LM, Lapuente F, Núñez C, Ramírez PT. Ileal orthotopic neobladder after pelvic exenteration for cervical cancer. Gynecol Oncol. Elsevier Inc. 2009;113:47–51. https://doi.org/10.1016/j.ygyno.2008.12.020.
- 33.Querleu D, Darai E, Lecuru F, Rafii A, Chereau E, Collinet P, et al. Prise en charge primaire des cancers de l’endomètre: recommandations SFOG-CNGOF. Gynecol Obstet Fertil Senol. Elsevier Masson SAS. 2017;45:715–25. https://doi.org/10.1016/j.gofs.2017.10.008.
- 37.Colombo N, Creutzberg C, Amant F, Bosse T, González-Martín A, Ledermann J, et al. ESMO–ESGO–ESTRO consensus conference on endometrial cancer: diagnosis, treatment and follow-up. Radiother Oncol. Elsevier BV. 2015;117:559–81.Google Scholar
- 38.Palomba S, Falbo A, Mocciaro R, Russo T, Zullo F. Laparoscopic treatment for endometrial cancer: a meta-analysis of randomized controlled trials (RCTs). Gynecol Oncol. Elsevier Inc. 2009;112:415–21.Google Scholar
- 39.Uccella S, Bonzini M, Palomba S, Fanfani F, Malzoni M, Ceccaroni M, et al. Laparoscopic vs. open treatment of endometrial cancer in the elderly and very elderly: an age-stratified multicenter study on 1606 women. Gynecol Oncol. Elsevier B.V. 2016;141:211–7.Google Scholar
- 41.Mäenpää MM, Nieminen K, Tomás EI, Laurila M, Luukkaala TH, Mäenpää JU. Robotic-assisted vs traditional laparoscopic surgery for endometrial cancer: a randomized controlled trial. Am J Obstet Gynecol. Elsevier Inc. 2016;215:588.e1–7.Google Scholar
- 42.•• Frost JA, Webster KE, Bryant A, Morrison J. Lymphadenectomy for the management of endometrial cancer. In: Morrison J, editor. Cochrane Database Syst Rev. Chichester: John Wiley & Sons, Ltd.; 2015. p. 30. Largest meta-analysis about the role of lymph node dissection in endometrial cancer.Google Scholar
- 44.Holloway RW, Abu-Rustum NR, Backes FJ, Boggess JF, Gotlieb WH, Jeffrey Lowery W, et al. Sentinel lymph node mapping and staging in endometrial cancer: a Society of Gynecologic Oncology literature review with consensus recommendations. Gynecol Oncol. Elsevier Inc. 2017.Google Scholar
- 45.Kang S, Yoo HJ, Hwang JH, Lim M-C, Seo S-S, Park S-Y. Sentinel lymph node biopsy in endometrial cancer: meta-analysis of 26 studies. Gynecol Oncol. Elsevier Inc. 2011;123:522–7.Google Scholar
- 47.•• Holloway RW, Abu-Rustum NR, Backes FJ, Boggess JF, Gotlieb WH, Jeffrey Lowery W, et al. Sentinel lymph node mapping and staging in endometrial cancer: a Society of Gynecologic Oncology literature review with consensus recommendations. Gynecol Oncol. Elsevier Inc. 2017;146:405–15. Review about different techniques in order to detect SNLD in endometrial cancer.Google Scholar
- 48.How J, Gotlieb WH, Press JZ, Abitbol J, Pelmus M, Ferenczy A, et al. Comparing indocyanine green, technetium, and blue dye for sentinel lymph node mapping in endometrial cancer. Gynecol Oncol. Elsevier Inc. 2015;137:436–42. https://doi.org/10.1016/j.ygyno.2015.04.004.
- 49.Rossi EC, Kowalski LD, Scalici J, Cantrell L, Schuler K, Hanna RK, et al. A comparison of sentinel lymph node biopsy to lymphadenectomy for endometrial cancer staging (FIRES trial): a multicentre, prospective, cohort study. Lancet Oncol. Elsevier Ltd. 2017;18:384–92.Google Scholar
- 53.Zhou M, Wang X, Jiang L, Chen X, Bao X, Chen X. The diagnostic value of one step nucleic acid amplification (OSNA) in differentiating lymph node metastasis of tumors: a systematic review and meta-analysis. Int J Surg IJS Publishing Group Ltd. 2018;56:49–56.Google Scholar
- 54.López-Ruiz ME, Diestro MD, Yébenes L, Berjón A. Díaz de la Noval B, Mendiola M, et al. One-step nucleic acid amplification (OSNA) for the detection of sentinel lymph node metastasis in endometrial cancer. Gynecol Oncol. Elsevier Inc. 2016;143:54–9.Google Scholar
- 57.Murali R, Soslow RA, Weigelt B. Classification of endometrial carcinoma: more than two types. Lancet Oncol. Elsevier Ltd. 2014;15:e268–78.Google Scholar
- 58.Du Bois A, Reuss A, Pujade-Lauraine E, Harter P, Ray-Coquard I, Pfisterer J. Role of surgical outcome as prognostic factor in advanced epithelial ovarian cancer: a combined exploratory analysis of 3 prospectively randomized phase 3 multicenter trials: by the Arbeitsgemeinschaft Gynaekologische Onkologie Studiengruppe Ovarialkarzin. Cancer. 2009;115:1234–44.CrossRefGoogle Scholar
- 59.Heitz F, Harter P, Alesina PF, Walz MK, Lorenz D, Groeben H, et al. Pattern of and reason for postoperative residual disease in patients with advanced ovarian cancer following upfront radical debulking surgery. Gynecol Oncol. Elsevier Inc. 2016;141:264–70.Google Scholar
- 62.Chi DS, Eisenhauer EL, Zivanovic O, Sonoda Y, Abu-Rustum NR, Levine DA, et al. Improved progression-free and overall survival in advanced ovarian cancer as a result of a change in surgical paradigm. Gynecol Oncol. Elsevier Inc. 2009;114:26–31.Google Scholar
- 63.Martinez A, Pomel C, Mery E, Querleu D, Gladieff L, Ferron G. Celiac lymph node resection and porta hepatis disease resection in advanced or recurrent epithelial ovarian, fallopian tube, and primary peritoneal cancer. Gynecol Oncol. Elsevier Inc. 2011;121:258–63. https://doi.org/10.1016/j.ygyno.2010.12.328.
- 64.Prader S, Harter P, Grimm C, Traut A, Waltering KU, Alesina PF, et al. Surgical management of cardiophrenic lymph nodes in patients with advanced ovarian cancer. Gynecol Oncol. Elsevier B.V. 2016;141:271–5. https://doi.org/10.1016/j.ygyno.2016.03.012.
- 65.Mert I, Kumar A, Sheedy SP, Weaver AL, McGree ME, Kim B, et al. Clinical significance of enlarged cardiophrenic lymph nodes in advanced ovarian cancer: implications for survival. Gynecol Oncol. Elsevier Inc. 2018;148:68–73.Google Scholar
- 68.Ataseven B, Grimm C, Harter P, Prader S, Traut A, Heitz F, et al. Prognostic value of lymph node ratio in patients with advanced epithelial ovarian cancer. Gynecol Oncol. Elsevier Inc. 2014;135:435–40.Google Scholar
- 70.Chang SJ, Hodeib M, Chang J, Bristow RE. Survival impact of complete cytoreduction to no gross residual disease for advanced-stage ovarian cancer: a meta-analysis. Gynecol Oncol. Elsevier Inc. 2013;130:493–8.Google Scholar
- 71.•• Dahm-kähler P, Palmqvist C, Staf C, Holmberg E, Johannesson L. Gynecologic oncology centralized primary care of advanced ovarian cancer improves complete cytoreduction and survival—a population-based cohort study. Gynecol Oncol. Elsevier Inc. 2016;142:211–6. Retrospective study showing the importance of cancer centralization.Google Scholar
- 72.Bristow BRE, Tomacruz RS, Armstrong DK, Trimble EL, Montz FJ. Maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era. 2002;20:1248–59.Google Scholar
- 73.Sugarbaker PH. Surgical responsibilities in the management of peritoneal carcinomatosis. 2010;713–24.Google Scholar
- 75.Petrillo M, Vizzielli G, Fanfani F, Gallotta V, Cosentino F, Chiantera V, et al. Definition of a dynamic laparoscopic model for the prediction of incomplete cytoreduction in advanced epithelial ovarian cancer: proof of a concept 272 enrolled pts. 234 eligible pts. receiving S-LPS followed by. Gynecol Oncol. Elsevier Inc. 2015;5–9.Google Scholar
- 76.Gupta R, Gan TJ. Preoperative nutrition and prehabilitation. Anesthesiol Clin. Elsevier Inc. 2016;34:143–53.Google Scholar
- 77.Spratt JS, Adcock RA, Muskovin M, Sherrill W, Mckeown J. Clinical delivery system for intraperitoneal hyperthermic chemotherapy. 1980;40:256–60.Google Scholar
- 82.Chiva LM, Gonzalez-Martin A. A critical appraisal of hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of advanced and recurrent ovarian cancer. Gynecol Oncol. Elsevier Inc. 2015;136:130–5.Google Scholar
- 84.Fotopoulou C, Sehouli J, Mahner S, Harter P, Van Nieuwenhuysen E, Gonzalez-Martin A, et al. HIPEC: HOPE or HYPE in the fight against advanced ovarian cancer? Ann Oncol. 2018;1–14.Google Scholar
- 86.Markman M, Bundy BN, Alberts DS, Fowler JM, Clark-Pearson DL, Carson LF, et al. Phase III trial of standard-dose intravenous cisplatin plus paclitaxel versus moderately high-dose carboplatin followed by intravenous paclitaxel and intraperitoneal cisplatin in small-volume stage III ovarian carcinoma: an intergroup study of the gynecologic oncology group, Southwestern Oncology Group, and Eastern Cooperative Oncology Group. J Clin Oncol. 2001;19:1001–7.CrossRefGoogle Scholar
- 90.•• Walker J, Brady M, Di Silvestro P. A phase III clinical trial of bevacizumab with IV versus IP chemotherapy in ovarian, fallopian tube, and primary peritoneal carcinoma: a GOG/NRG trial (GOG 252). 2016. Society of Gynecologic Oncology Annual Meeting on Women’s Cancer. Abstract 6. Outcomes of intraperitoneal chemotherapy in ovarian cancer.Google Scholar
- 91.Mirza MR, Pignata S, Ledermann JA. Latest clinical evidence and further development of PARP inhibitors in ovarian cancer. Ann Oncol. 2018.Google Scholar
- 93.Harter P, Sehouli J, Reuss A, Hasenburg A, Scambia G, Cibula D, et al. Prospective validation study of a predictive score for operability of recurrent ovarian cancer: the multicenter intergroup study DESKTOP II. A project of the AGO kommission OVAR, AGO study group, NOGGO, AGO-Austria, and MITO. Int J Gynecol Cancer. 2011;21:289–95.CrossRefGoogle Scholar
- 94.•• Du Bois A, Vergote I, Ferron G, Reuss A, Meier W, Greggi S, et al. Randomized controlled phase III study evaluating the impact of secondary cytoreductive surgery in recurrent ovarian cancer: AGO DESKTOP III/ENGOT ov20. J Clin Oncol. 2017;35:5501 Role of surgery in ovarian cancer recurrence.CrossRefGoogle Scholar
- 95.Bommert M, Harter P, Heitz F, du Bois A. When should surgery be used for recurrent ovarian carcinoma? Clin Oncol. Elsevier Ltd. 2018;1–5.Google Scholar
- 96.Bristow RE, Chang J, Ziogas A, Randall LM, Anton-culver H. Gynecologic oncology high-volume ovarian cancer care: survival impact and disparities in access for advanced-stage disease. Gynecol Oncol. Elsevier Inc. 2013.Google Scholar
- 97.Ling Y, Kyrgiou M, Bryant A, Everett T, Dickinson HO. Centralisation of services for gynecological cancers—a Cochrane systematic review. Gynecol Oncol. Elsevier Inc. 2012;126:286–90.Google Scholar
- 99.Harter P, Muallem ZM, Buhrmann C, Lorenz D, Kaub C, Hils R, et al. Impact of a structured quality management program on surgical outcome in primary advanced ovarian cancer. Gynecol Oncol. Elsevier Inc. 2011;121:615–9.Google Scholar