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Dicu-Andreescu IG, Marincaș AM, Ungureanu VG, Ionescu SO, Prunoiu VM, Brătucu E, Simion L. Current Therapeutic Approaches in Cervical Cancer Based on the Stage of the Disease: Is There Room for Improvement? MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1229. [PMID: 37512041 PMCID: PMC10384945 DOI: 10.3390/medicina59071229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 06/19/2023] [Accepted: 06/28/2023] [Indexed: 07/30/2023]
Abstract
Cervical cancer continues to be among the most common malignancies in women, and in recent decades, important measures have been taken to reduce its incidence. The first and most important steps to achieve this goal are oriented toward prevention through screening programs and vaccination, mainly against oncogenic human papillomavirus (HPV) strains 16 and 18. The therapeutic approach is based on the diagnosis and treatment guidelines for cervical cancer, which establish for each stage (FIGO, TNM) specific conduct. These guidelines summarize quite precisely the elements of therapeutic practice, but, in some places, they leave optional variants based on which nuanced approaches could be established. Adherence to these guidelines, which include the performing of minor or major surgery, with or without chemotherapy and radiation therapy, combined with advanced imaging investigations, has been able to lead to a substantial increase in survival. The purpose of this literature review is to discuss the diagnosis and treatment options in cervical cancer depending on the histological type, FIGO staging, and patient performance index, taking into account the hospital resources available in middle-income countries (percentage of gross domestic product allocated to health services around 5.5%, in the case of Romania).
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Affiliation(s)
- Irinel-Gabriel Dicu-Andreescu
- Clinical Department No 10, General Surgery, University of Medicine and Pharmacy "Carol Davila", 050474 Bucharest, Romania
- Department of Oncological Surgery, Oncological Institute "Alexandru Trestioreanu", 022328 Bucharest, Romania
| | - Augustin-Marian Marincaș
- Clinical Department No 10, General Surgery, University of Medicine and Pharmacy "Carol Davila", 050474 Bucharest, Romania
- Department of Oncological Surgery, Oncological Institute "Alexandru Trestioreanu", 022328 Bucharest, Romania
| | - Victor-Gabriel Ungureanu
- Clinical Department No 10, General Surgery, University of Medicine and Pharmacy "Carol Davila", 050474 Bucharest, Romania
| | - Sînziana-Octavia Ionescu
- Clinical Department No 10, General Surgery, University of Medicine and Pharmacy "Carol Davila", 050474 Bucharest, Romania
- Department of Oncological Surgery, Oncological Institute "Alexandru Trestioreanu", 022328 Bucharest, Romania
| | - Virgiliu-Mihail Prunoiu
- Clinical Department No 10, General Surgery, University of Medicine and Pharmacy "Carol Davila", 050474 Bucharest, Romania
- Department of Oncological Surgery, Oncological Institute "Alexandru Trestioreanu", 022328 Bucharest, Romania
| | - Eugen Brătucu
- Clinical Department No 10, General Surgery, University of Medicine and Pharmacy "Carol Davila", 050474 Bucharest, Romania
- Department of Oncological Surgery, Oncological Institute "Alexandru Trestioreanu", 022328 Bucharest, Romania
| | - Laurențiu Simion
- Clinical Department No 10, General Surgery, University of Medicine and Pharmacy "Carol Davila", 050474 Bucharest, Romania
- Department of Oncological Surgery, Oncological Institute "Alexandru Trestioreanu", 022328 Bucharest, Romania
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Muallem MZ. A New Anatomic and Staging-Oriented Classification of Radical Hysterectomy. Cancers (Basel) 2021; 13:cancers13133326. [PMID: 34283057 PMCID: PMC8267649 DOI: 10.3390/cancers13133326] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 06/25/2021] [Accepted: 06/30/2021] [Indexed: 12/02/2022] Open
Abstract
Simple Summary The main deficits of the available classifications of radical hysterectomy are the facts that they are based only on the lateral extension of resection, do not depend on the precise anatomy of parametrium and paracolpium and do not correlate with the tumour stage, size or infiltration in the vagina. This new suggested classification depends on the 3-dimentional concept of parametrium and paracolpium and the comprehensive description of the anatomy of parametrium, paracolpium and the pelvic autonomic nerve system. Each type in this classification tailored to the tumour stage according to FIGO- classification from 2018, taking into account the tumour size, localization and infiltration in the vaginal vault, which may make it the most suitable tool for planning and tailoring the surgery of radical hysterectomy. Abstract The current understanding of radical hysterectomy more is centered on the uterus and little is being discussed about the resection of the vaginal cuff and the paracolpium as an essential part of this procedure. This is because that the current classifications of radical hysterectomy are based only on the lateral extent of resection. This way is easier to be understood but does not reflect the anatomical and surgical conception of radical hysterectomy and the three-dimensional ways of tumour spreading, neither meet the need of adjusting the radicality according to the different stages of FIGO classification, which depends—at least in the early stages—on the tumour volume and the infiltration in the vagina (but not on the directly spread in the parametrium). The new classification presented in this paper does not base anymore on the lateral extent of resection only but too on the depth of resection in the small pelvic and the extent of the resected vaginal vault without or with its three-dimensional paracolpium. This classification takes into account the tumour size, stage, localization and infiltration in the vaginal vault and may offer the optimal tool to adjust and tailor the surgery according to these important variables.
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Affiliation(s)
- Mustafa Zelal Muallem
- Department of Gynecology with Center for Oncological Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Virchow Campus Clinic, Charité Medical University, 13353 Berlin, Germany
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Abstract
Objective To describe the laterally extended parametrectomy (LEP) surgical technique, emphasizing the main challenges of the procedure. Methods LEP was designed as a more radical surgical procedure aiming to remove the entire parametrial tissue from the pelvic side wall. Its initial indications were for lymph node positive Stage Ib (current FIGO 2018 Stage IIIc) and Stage IIb cervical cancer. Currently, with most guidelines recommending definitive radiochemotherapy for these cases, initial LEP indications have become debatable. LEP is now mainly indicated for removing tumors involving the soft structures of the pelvic side wall during a pelvic exenteration, aiming to obtain lateral free margins. This expands the lateral borders of the dissection to not only the medial surface of internal iliac vessels, but also to the true limits of the pelvic side wall. Results During LEP, the parietal and visceral branches of the hypogastric vessels are divided at the entry and exit level of the pelvis. Consequently, the entire internal iliac system is excised, and no connective or lymphatic tissue remain on the pelvic side wall. The main technical challenges of LEP are caused by the difficulty in ligating large caliber vessels (internal iliac artery and vein) and the variable anatomic distribution of pelvic side wall veins. Conclusion LEP is a feasible technique for removing pelvic side wall recurrences, aiming to obtain surgical free margins.
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Muallem MZ, Jöns T, Seidel N, Sehouli J, Diab Y, Querleu D. A Concise Paradigm on Radical Hysterectomy: The Comprehensive Anatomy of Parametrium, Paracolpium and the Pelvic Autonomic Nerve System and Its Surgical Implication. Cancers (Basel) 2020; 12:cancers12071839. [PMID: 32650542 PMCID: PMC7408662 DOI: 10.3390/cancers12071839] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/02/2020] [Accepted: 07/04/2020] [Indexed: 11/18/2022] Open
Abstract
The current understanding of radical hysterectomy is more centered on the uterus and little is discussed regarding the resection of the vaginal cuff and the paracolpium as an essential part of this procedure. The anatomic dissections of two fresh and 17 formalin-fixed female pelvis cadavers were utilized to understand and decipher the anatomy of the pelvic autonomic nerve system (PANS) and its connections to the surrounding anatomical structures, especially the paracolpium. The study mandates the recognition of the three-dimensional (3D) anatomic template of the parametrium and paracolpium and provides herewith an enhanced scope during a nerve-sparing radical hysterectomy procedure by precise description of the paracolpium and its close anatomical relationships to the components of the PANS. This enables the medical fraternity to distinguish between direct infiltration of the paracolpium, where the nerve sparing technique is no longer possible, and the affected lymph node in the paracolpium, where nerve sparing is still an option. This study gives rise to a tailored surgical option that allows for abandoning the resection of the paracolpium by FIGO stage IB1, where less than 2 cm vaginal vault resection is demanded.
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Affiliation(s)
- Mustafa Zelal Muallem
- Department of Gynecology with Center for Oncological Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Virchow Campus Clinic, Charité Medical University, 13353 Berlin, Germany
| | - Thomas Jöns
- Department of Anatomy, Mitte Campus Clinic, Charité Medical University, 10117 Berlin, Germany
| | - Nadja Seidel
- Department of Anatomy, Mitte Campus Clinic, Charité Medical University, 10117 Berlin, Germany
| | - Jalid Sehouli
- Department of Gynecology with Center for Oncological Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Virchow Campus Clinic, Charité Medical University, 13353 Berlin, Germany
| | - Yasser Diab
- Department of Gynecology, Portland Hospital, Portland, VIC 3305, Australia
| | - Denis Querleu
- Department of Surgery, Institut Bergonié, 33076 Bordeaux, France
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Nishikimi K, Tate S, Matsuoka A, Shozu M. Removal of the entire internal iliac vessel system is a feasible surgical procedure for locally advanced ovarian carcinoma adhered firmly to the pelvic sidewall. Int J Clin Oncol 2019; 24:941-949. [DOI: 10.1007/s10147-019-01429-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/13/2019] [Indexed: 12/18/2022]
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Chhabra S, Kutchi I. Fertility preservation in gynecological cancers. CLINICAL MEDICINE INSIGHTS. REPRODUCTIVE HEALTH 2013; 7:49-59. [PMID: 24453519 PMCID: PMC3888069 DOI: 10.4137/cmrh.s10794] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
For cancers of reproductive system in women, fertility preservation is complex. Fertility is also affected by therapies, however prevention is possible. Radiotherapy affects gonads, uterus, and subsequent pregnancy outcomes in all ages. However, degree and damage depend on dose, irradiation field, and age at the time of exposure. Ovarian transposition is considered if ovarian involvement is unlikely. Gonadotoxic effects of chemotherapy are related to agent's type, cumulative doses, age, and ovarian reserve. Some agents are highly toxic. Rendering follicular development quiescent by suppression of gonadotropins does reduce the ovarian damage. Simple or radical trachelectomy can be used in early cervical cancer. Fertility saving surgery is possible only in early stage low grade epithelial cancers of the ovary, however, in germ cell tumors even in advanced stages it may be possible to preserve fertility. There are no standard recommendations for endometrial cancer. Embryo, oocyte, and ovarian tissue cryopreservation are possible. The human embryo is very resistant to damage. In view of these possibilities, it is advocated that attention to long term health and quality of life in gonadotoxic therapy must be incorporated into plans as early as possible.
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Affiliation(s)
- Shakuntala Chhabra
- Obstetrics Gynecology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India
| | - Imran Kutchi
- Obstetrics Gynecology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India
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Verleye L, Vergote I, Reed N, Ottevanger P. Quality assurance for radical hysterectomy for cervical cancer: the view of the European Organization for Research and Treatment of Cancer—Gynecological Cancer Group (EORTC-GCG). Ann Oncol 2009; 20:1631-8. [DOI: 10.1093/annonc/mdp196] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Ungár L, Smith JR, Pálfalvi L, Del Priore G. Abdominal Radical Trachelectomy During Pregnancy to Preserve Pregnancy and Fertility. Obstet Gynecol 2006; 108:811-4. [PMID: 17018513 DOI: 10.1097/01.aog.0000216015.15415.5f] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND For 10,000-40,000 women each year, cervical cancer complicates pregnancy. Current therapy usually terminates the pregnancy and results in the loss of future fertility. Abdominal radical trachelectomy is a fertility-preserving alternative to radical hysterectomy for young women with cervical cancer. CASES We report five pregnancies complicated by cervical cancer treated by abdominal radical trachelectomy with preservation of the concurrent pregnancy and the birth of two healthy term infants. CONCLUSION Pregnancy complicated by concurrent cervical cancer can be managed with abdominal radical trachelectomy during pregnancy while preserving future fertility.
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Affiliation(s)
- László Ungár
- Department of Gynaecologic Oncology, St Stephen Hospital, Budapest, Hungary
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