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Then and now: outcomes of surgical


treatment for early cervical cancer 1902

DAVID JEEVAN, ST5 AND KARL OLAH,
CONSULTANT OBSETRICIAN & GYNAECOLOGIST DEPARTMENT OF OBSETRICS & GYNAECOLOGY, WARWICK HOSPITAL, WARWICK, UK

.........................................................................................................................................................................

n the early twentieth century cervical


cancer had become a recognised
pathology separate from the uterine
body and different operators were
reporting their success. These operations
included Braun performing galvanic ecraseur (perhaps a forerunner of large loop
excision of the transformation zone),
Schroeders supravaginal amputation of
the cervix, Hegar devising conical excision and then Sauter (1822) describing
vaginal extirpation of the uterus and
cervix (vaginal hysterectomy).

Thomas Wilson described the international work being undertaken in the


field of cervical and uterine cancer in
1902 (Wilson BJOG 1902;1:52646).
His paper is a comprehensive description of the state of the art at this time.
From this tome it is evident that gynaecologists were a small community of clinicians and it is fascinating to read how
they would debate. One wonders how
they would now react to Twitter. Of
interest then was the time elapsed
before giving an assurance of definite
cure. They recognised the impossibility
of assigning a time beyond which recurrence would not take place but

convened on 5 years as the arbitrary


time beyond which recurrence was
rare.

became more conscious of operative


mortality and the average operable
ratio was between 25 and 33%.

There is a description of a survival study


comparing radical abdominal surgery versus radical vaginal surgery. Of 137
women undergoing abdominal surgery,
99 died immediately (72% mortality rate)
and of 276 women undergoing vaginal
surgery, 79 deaths occurred (28.6% mortality rate). But supravaginal amputation
was reported to carry an 8% mortality
rate. The general agreement was that
amputation of the cervix was to be preferred and that risks of vaginal hysterectomy were so great as to condemn its
employment in an attempt to radically
cure cancer (Figure 1).

The twenty-first century now offers


robot-assisted laparoscopy for earlystage cervical cancer (up to Stage IIB).
A Dutch study consecutively treated
100 women with this technology
between 2008 and 2013 (Hoogendam
et al. BJOG 2014;121:153845). Their
procedures consisted of pelvic lymph
node dissection combined with radical
hysterectomy, radical vaginal trachelectomy or parametectomy. Their mortality rate was 7% (median follow up
29.5 months) but overall 5-year disease-specific survival rates were 88.7%
whereas in those women that were
lymph node negative this rate was 95%.
Frequent complications were lymphoedema (26%), lower urinary tract symptoms (19%) and sexual disorders (5%).
Just five women had vaginal cuff dehiscence.

But that pessimistic conclusion did not


deter the pioneers of their day. Careful
and continued attempts improved the
technique of vaginal hysterectomy and by
1897 the mortality rate dropped to 12%
and serious risks of injury to the ureters,
bladder or rectum was reported as 5
13%.
Wilsons review reports that with time
Krukenburg, Pfannenstiel and D
odelein

The cases that are suitable for it [supravaginal amputation] are


very early ones, where, for instance, there is an ulcer confined to
one lip with little subjacent induration, or where there is a small
excresence not exceeding, say, the size of a pigeons egg.
Figure 1. An early description of Stage IB/IIA cervical cancer (Wilson T).

1524

The theme that resonates is the pursuit by early gynaecologists of vaginal


surgery to treat early-stage cervical
cancer. They recognised the value of
its development to reduce recurrence
and improve survival and long-term
complication rates.

Disclosure of interests
None declared. Completed disclosure
of interests form available to view
online as supporting information. &

2015 Royal College of Obstetricians and Gynaecologists