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Gynecologic Oncology 85, 415 422 (2002)

doi:10.1006/gyno.2002.6633

Management of Early-Stage Cervical Carcinoma


by Modified (Type II) Radical Hysterectomy
Stylianos Michalas,* Alexandros Rodolakis,*,1 Zannis Voulgaris,* George Vlachos,*
Nicholaos Giannakoulis, and Emmanuel Diakomanolis*
*First Department of Obstetrics and Gynecology, Gynecologic Oncology Unit, and Radiation Oncology Unit, Alexandra Hospital, Athens, Greece

Received September 12, 2001; published online April 24, 2002

beginning of the 20th century, with similar cure rates but


Objective. Surgical management of cervical carcinoma by radi-
cal hysterectomy has been proven a highly effective method in
variable morbidity and mortality [15].
treating early-stage disease. The purpose of this study was to Since the work of Meigs in 1940 [6] radical hysterectomy
evaluate the efficacy and safety of modified (Type II) radical has been proven by several authors to be a highly effective and
hysterectomy for the treatment of early-stage (IIIA) cervical safe method for treating early-stage cervical carcinoma [79].
carcinoma. Piver et al. in 1974 defined the extent of the radicality of this
Methods. A retrospective analysis of data on 435 patients with procedure by establishing the criteria for five classes of hys-
cervical carcinoma who were managed by modified radical hys- terectomy (Classes IV) [10]. In the class II procedure the
terectomy was performed. In 145 cases a multimodal approach limited dissection of the ureter from the cardinal ligament and
was used due to the presence of one or more risk factors such as the division of the uterine artery above the ureter preserve the
lymph node metastasis, CLS involvement, bulky tumor, and exo- blood supply to the ureter, resulting in a decreased chance of
cervical extension of disease. Preoperative irradiation was offered
morbidity compared with the class III procedure [10]. The
to 62 patients, whereas adjuvant irradiation was offered to 101
indications for and the efficacy of modified, class II radical
patients.
Results. The mean age of the patients was 42.5 years. The hysterectomy, mainly for early invasive lesions (less than 5
majority of the patients had squamous cell cancer (81.6%). The mm) or for IB1 cervical cancers, remain basically undefined
patients were clinically staged as IA (3.2%), IB (86.7%), and IIA with the limited experience reported [8, 1115].
(10.1%). Positive pelvic lymph nodes were noted in 65 patients On the other hand, the experience obtained with multimodal
(14.9%). Operative morbidity was minimal, whereas adjuvant ra- approaches to treat cervical cancer in terms of preoperative
diation treatment had no impact on the disease but caused geni- radiotherapy [16, 17] or adjuvant postoperative pelvic radio-
tourinary morbidity in terms of ureteral stricture and postopera- therapy [18 23] allows us to reevaluate the extent of surgical
tive bladder dysfunction (P < 0.001). The overall 5-year survival clearance of the disease with optimal surgical margins [13, 14].
was 88.7%. The most significant predictors related to 5-year sur- The purpose of this study was to evaluate the efficacy,
vival were nodal metastasis (P < 0.001), adenomatous histology
morbidity, and mortality of class II (modified) radical hyster-
(P < 0.001), lesion size (P < 0.001), and CLS involvement (P =
ectomy for the treatment of early-stage (III) cervical cancer
0.004). Adjuvant radiation resulted in better local pelvic control of
the disease.
based on institutional experience. The role of radiotherapy as
Conclusions. The results of our study support the concept that an adjunct to this procedure in a preoperative or postoperative
less radical procedures could be effectively applied to early-stage mode is also analyzed as are recurrence and complication rates.
cervical carcinoma 4 cm or smaller with optimal surgical
margins. 2002 Elsevier Science (USA)
MATERIAL AND METHODS
Key Words: cervical cancer; radical hysterectomy; radiation
treatment.
During the interval between January 1983 and December
1995, 438 patients underwent modified radical hysterectomy as
INTRODUCTION the sole treatment for or as part of a multimodal approach to
cervical carcinoma. A total of 1526 women were diagnosed to
Radical surgery and radiotherapy have been equally applied have cervical cancer during that time in our unit. Of these
to the management of early-stage cervical carcinoma since the patients, 988 (64.7%) were managed by primary radiation
treatment; also, in 29 cases an initial surgical approach was
1
To whom correspondence should be addressed at 11 Ioanninon Street, abandoned intraoperatively due to positive surgical findings,
Filothei, Athens 15237, Greece. Fax: +(301) 68 23 253. mainly positive paraortic nodes. The other 509 women were
415 0090-8258/02 $35.00
2002 Elsevier Science (USA)
All rights reserved.
416 MICHALAS ET AL.

managed by primary surgery. In 438 cases a modified (type II) bulky (>4 cm in diameter) tumors, involved or close resection
radical hysterectomy was performed, and in the others 71 a margins and advanced infiltration of the cervical stroma, and
type III radical hysterectomy was performed. Patient selection parametrial and vaginal extension of the tumor.
to perform a type III procedure was based on the large size and Radiotherapy in these cases was administered as whole-
penetration depth of the tumor. However, it is the practice of pelvis external-beam radiation at a mean dose of 5000 cGy
our unit to individualize the extent of radicality by resecting the (range, 4500 5400 cGy) either alone or followed by brachy-
neoplasm with limited but adequate margins. Thus type II therapy with an afterloading domed vaginal cylinder or vaginal
procedures were applied mainly for the management of stage colpostats at a mean dose of 1400 cGy (range, 1200 1600
IB2IIA disease either alone or combined with other treatment cGy).
modalities in a pre- or postoperative form. Chemotherapy based on cisplatin at a dose of 100 mg/m2 IV
The concept of this surgical treatment is based on the limited was postoperatively given in three cases with poor-prognosis
extent of radicality of resecting parts of the endopelvic fascia histological-type tumors (small cell carcinomas) along with
related to the target organ, meaning the sacrouterine, cardinal, external-beam pelvic irradiation. These cases were excluded
and vesicocervical ligaments and sparing the vegetative nerves from statistical analysis in the study. The morbidity was clas-
of the pelvic plexus in the lower parts of the parametria. sified into acute (intraoperative and postoperative), subacute,
The technique of this modified radical procedure consisted and chronic complications.
of the development of the pelvic lateral retroperitoneal spaces, All patients were followed up for at least 5 years (range,
mobilization of the bladder and rectum, and division of the 60 149 months; mean, 107 months). Fourteen patients had an
uterosacral ligaments and parametria at their medial portion. intermittent follow-up after a minimum of regular surveillance
The uterine artery is divided at its origin from the anterior of 28 months.
division of the internal iliac artery, whereas the ureters are y2 and Fishers exact tests were used for statistical analysis.
laterally displaced. The specimen was excised along with 12 A P value less than 0.05 was considered to indicate statistical
cm of the upper part of the vagina. A complete pelvic lymph- significance.
adenenectomy, necessitating removal of the obturator, exter-
nal, internal, and common iliac lymph nodes as well as the RESULTS
presacral lymphatic tissues, was always performed. Periaortic
lymph node dissection was not routinely performed, advocat- During the 13-year review period 438 patients underwent a
ing only in bulky (>4 cm in diameter) stage IB2. Multimodal- radical type II hysterectomy and pelvic lymphadenectomy.
ity regimens that have been used in our patients include com- From these patients, 3 receiving adjuvant chemotherapy were
binations of preoperative radiation with surgery and surgery excluded from the study and the remaining 435 were recruited
with adjuvant radiation. Thus preoperative radiation therapy for analysis. The mean age at operation was 42.5 years (range,
was offered to 62 patients (14.3%) by means of intracavitary 2372). The majority of these cases were squamous cell can-
brachytherapy (N = 36), external field irradiation (N = 2), or cers (N = 355, 81.6%) whereas in the remaining 80 cases an
a combination of whole-pelvis teletherapy with brachytherapy adenocarcinoma component was found: 65 cases of pure ade-
(N = 24). Preoperative brachytherapy with the use of intra- nocarcinomas (14.9%) and 15 cases of adenosquamous carci-
cavitary radium-226 devices (Manchester method) and recently nomas (3.4%).
with afterloading applicators (Fletcher Suit) by using radium- Clinical evaluation of the cervix revealed 71 cases (16.3%)
226 or cesium-137 was offered at a dose of 2800 cGy (four with a macroscopically normal appearance. In the remaining
courses of 700 cGy). Preoperative external field irradiation of 364 an ulcerating tumor was found in 191 (43.9%), a cauli-
the pelvis alone or added to brachytherapy was applied using flower-like exophytic tumor was found in 130 cases (29.9%),
cobalt-60 or high-energy electron accelerators at a dose of and 43 cases (9.9%) were found to have a barrel-shaped cervix.
2100 cGy (seven fractions of 300 cGy). Indications for preop- The distribution of staging was as follows: IA, 14 (3.2%)
erative irradiation were bulky (>4 cm in diameter) stage IB2 patients (IA1, 5; IA2, 9); IB, 377 (86.7%) patients (IB1, 322;
and IIA cervical cancers. Preoperative radiation was applied to IB2, 55); and IIA, 44 (10.1%) patients.
some of our cases to improve the operability of the tumor. Thus Neoadjuvant radiation treatment was offered to 62 (14.2%)
in bulky (>4 cm) cervical cancers external field irradiation was patients, in terms of intracavitary brachytherapy for 36 (8.3%),
offered for shrinkage of the initial tumor mass, whereas in external irradiation for 2 (0.4%), and combined external field
cases of vaginal fornice involvement (stage IIA) brachytherapy irradiation and brachytherapy for 24 (5.5%), basically for
was offered to restore the cervicovaginal anatomy and improve bulky (>4 cm in diameter) tumors or stage II disease (Table 1).
the operability of the tumor. In all these cases there was no All patients underwent a radical type II hysterectomy with
obvious clinical parametrial involvement (stage IIB disease). pelvic lymphadenectomy as previously described. In 376
Adjuvant irradiation following surgery has been given to (86.4%) patients a bilateral salpingo-oophorectomy was also
patients in the presence of one or more risk factors such as performed whereas in the remaining 59 (13.6%) one or both
lymph node metastases, lymphatic vascular space involvement, adnexae were preserved.
MODIFIED RADICAL HYSTERECTOMY 417

TABLE 1 All patients were observed for a minimum of 5 years. The


Preoperative Radiation Treatment by Stage of Disease mean duration of follow-up was 107 months (range, 60 149
months). The entire group of 435 patients was analyzed for
Preoperative RT
clinicopathologic factors related to 5-year survival and disease-
External RT +
free survival.
Stage Brachytherapy External RT brachytherapy The overall 5-year survival was 88.7% (386/435). The dis-
ease-specific 5-year survival rates by stage were as follows:
IB2 2 16 Stage IA, 100%; stage IB1, 95.1%; stage IB2, 50.9%; stage
IIA 36 8
IIA, 86.3% (Table 3).
There were 62 patients diagnosed to have recurrent disease,
resulting in an overall 5-year remission rate of 85.7% (373/
Surgicopathologic tumor assessment showed 21 cases to be 435). The median time to recurrence was 14 months. The
tumors with less than 5 mm of invasion and 382 cases to be most significant predictors related to 5-year survival were
tumors with more than 5 mm of invasion. There were 32 cases nodal metastasis (P < 0.001), tumor histology (P < 0.001),
with no invasive disease found on the surgical specimen (18 lesion size (P < 0.001), and CLS involvement (P = 0.004)
with intraepithelial neoplasia, 4.1%, and 14 with no disease, (Table 4).
3.2%). All these cases were patients operated after a preceding Patients with negative lymph nodes had a 7.6% recurrence
cervical conization or neoadjuvant radiation treatment. rate and a 94.8% disease-specific 5-year survival rate versus a
The mean tumor size was 2.7 cm. The tumor was 2 cm or 52.3% recurrence rate and a 53.8% disease-specific 5-year
smaller (mean, 0.6 cm) in 123 patients, more than 2 cm and up survival for patients with positive lymph nodes (P < 0.001
to 4 cm (mean, 3.1 cm) in 233 patients, and more than 4 cm and P < 0.001 respectively).
(mean, 4.8) in 73 patients. Tumor grade was a nonsignificant predictor of disease sur-
Tumor grade was as follows: grade 1, 53 patients (12.1%); vival (P = 0.35). Patients with lymphvascular invasion had a
grade 2, 153 patients (35.2%); grade 3, 229 patients (52.6%). 86.6% 5-year survival compared with 97.6% of those without
Lymphvascular invasion was present in 350 patients (80.5%). (P = 0.004). Recurrence rate was significantly higher for
With respect to marginal status of the specimen, 429 patients patients with lymphvascular invasion (16.6%) than for those
(98.7%) had negative surgical margins. There were 6 patients without (4.7%) (P = 0.005).
(1.3%) with disease-involved margins (2 with parametrial dis- One of the most significant predictors of disease recurrence,
ease, 2 with vaginal invasive disease, and 2 with vaginal which adversely affects 5-year survival, was a tumor more than
intraepithelial neoplasia (VAIN)). 4 cm in diameter. Thus patients with cervical lesions more than
Positive pelvic lymph nodes were noted in 65 patients 4 cm in diameter had a decreased survival (54.8%) compared
(14.9%). The mean number of resected pelvic lymph nodes
was 29 (range, 9 45). Eighteen patients with positive lymph
nodes received preoperative radiation treatment in terms of TABLE 2
brachytherapy. All these patients were postoperatively treated Type and Frequency of Complications
with external beam irradiation.
Ninety-six patients (22%) found to have one or more high- Surgery Surgery + RT
risk factors mentioned before received postoperative radiother- (N = 290) (N = 145) P value
apy. External field irradiation ranging from 4500 to 5400 cGy Acute (intrapostoperative)
(mean, 5000 cGy) was used in all these patients. The mean Pulmonary embolism 2 (0.7%) 0.32
time for initiation of radiation was 40 days (range, 20 65 Deep vein thrombosis 1 (0.3%) 2 (1.4%) 0.22
days). Sixty patients (13.8%) received brachytherapy to the Vesicovaginal fistula 1 (0.3%) 2 (1.4%) 0.22
upper vagina in addition to whole-pelvis radiotherapy at a Ureteral damage repaired 1 (0.3%) 2 (1.4%) 0.22
Ureterovaginal fistula 1 (0.3%) 0.48
mean dose of 1400 cGy. The morbidity developed in our Blood loss (average) 0.5 lt 0.7 lt
patients was classified as acute (meaning intraoperative and Febrile morbidity 14 (4.8%) 17 (11.7%) 0.008
short-term postoperative), subacute, and chronic complications Intestinal obstruction 1 (0.3%) 3 (2.1%) 0.076
(Table 2). Iliac vessel damage repaired 1 (0.3%) 1 (0.7%) 0.62
Radiation therapy in either a preoperative or postoperative Subacute
Lymphocyst formation 12 (4.1%) 5 (3.4%) 0.73
mode had no impact on complication rates but for genitouri- Postoperative bladder dysfunction 7 (2.4%) 18 (12.4%) <0.001
nary morbidity (Table 2). Thus ureteral stricture and postop- Chronic
erative bladder dysfunction were significantly higher among Bladder hypotonia (long-term) 2 (0.7%) 2 (1.3%) 0.48
patients treated with radical hysterectomy and radiation ther- Ureteral stricture (stent) 2 (0.7%) 14 (9.6%) <0.001
apy than in patients treated with radical hysterectomy alone Small bowel obstruction 1 (0.3%) 1 (7%) 0.62
1 (0.3%) 3 (2.1%) 0.076
Chronic leg lymphedema
(P < 0.001).
418 MICHALAS ET AL.

TABLE 3
Association between Stage and Disease Survivala

Treatment Stage 5-Year survival 5-Year remission Recurrence

Surgery alone IA (N = 14) 14/14 (100%) 14/14 (100%)


IB1 (N = 322) 306/322 (95.1%) 300/322 (93.2%) 22/322 (6.8%)
IB2 (N = 18) 8/18 (44.4%) 6/18 (33.3%) 12/18 (66.7%)
Preoperative RT + surgery IB2 (N = 37) 20/37 (54%) 18/37 (48.6%) 19/37 (51.4%)
IIA (N = 44) 38/44 (86.3%) 35/44 (79.5%) 9/44 (20.5%)
Total 386/435 (88.7%) 373/435 (85.7%) 62/435 (14.3%)

a
Follow-up: 60 149 months (mean: 107 months).

with 94.8% of patients with tumors 2 4 cm and 96.9% of On the other hand distant metastatic disease was diagnosed
patients with tumors less than 2 cm in diameter (P < 0.001). in 12 of 22 patients (54.6%) after combined therapy compared
The disease-specific 5-year survival rate was 93.8% for with 5 of 40 (12.5%) patients who had distant metastases after
squamous cell carcinomas, 69.2% for pure adenocarcinomas, surgery alone (P < 0.001) (Table 8).
and 53.3% for adenosquamous carcinomas (P < 0.001). When
these patients were stratified by tumor size there was a definite DISCUSSION
tendency toward reduced 5-year survival for large
tumors with adenomatous histology (P < 0.001) (Table 5). Radical hysterectomy has been demonstrated to be the cus-
In Table 6 recurrence rates and 5-year survival are summa- tomary method of treatment of early-stage carcinoma of the
rized in relation to adjunctive treatment. For, stage IB2 pa- cervix with an acceptable morbidity [9, 11, 24 27]. However,
tients, survival after surgical treatment (44.4%) was not sig- several operations that extend the range of the hysterectomy
nificantly different from the survival of patients treated are useful for the treatment of patients with carcinoma of the
with preoperative radiotherapy and surgery (54%) (P = 0.5) cervix. Thus the need for extended hysterectomy and the range
(Table 7). of resection required vary depending on the amount of spread
There were 45 cases (72.6%) in which the first site of of the primary tumors and on whether prior irradiation was
recurrence was local pelvic failure and 17 cases (27.4%) in chosen for a multimodal approach to the disease [10].
which it was distant metastases. Local pelvic failure were The proper use of the extended hysterectomy in cervical
significantly higher (35/40, 87.5%) among patients treated by cancer patients is not yet clearly defined. Since 1974, the Piver
surgery alone than among patients treated by surgery and and Rutledge classification of extended hysterectomies into
radiation therapy (10/22, 45.4%) (P < 0.001) (Table 8). five classes has pointed out the need for the surgeon to indi-
vidualize and tailor the procedure to the actual extent of the
TABLE 4 disease [10, 28]. The purpose of class II extended hysterectomy
Association between Patient Characteristics and 5-Year Survival (called a modified radical hysterectomy) is to remove the
paracervical and paravaginal tissues in a less radical excision
Variable N 5-Year survival P value than in class III hysterectomy, but adequately to provide in-
surance against central and vaginal recurrence.
Nodal status
Negative 370 351 (94.9%) <0.001
Modified radical hysterectomy has been reported as a pro-
Positive 65 35 (53.9%) cedure with an accepted efficacy for early invasive squamous
Tumor grade cervical cancers associated with low morbidity and mortality
1 53 50 (94.3%) 0.35 [1113].
2 153 136 (88.9%)
On the other hand pelvic lymphadenectomy applied in the
3 229 200 (87.3%)
CLS involvement standard manner, with a minimal removal of 20 pelvic nodes,
Yes 350 303 (86.6%) 0.004 should be considered as adequate, irrespective of the tumor
No 85 83 (97.7%) size or depth of invasion [29].
Tumor size In our study the same procedure was applied in all patients
02 cm 129 125 (96.9%) <0.001 irrespective of tumor size, depth of invasion, or clinical stage
24 cm 233 221 (94.8%)
>4 cm 73 40 (54.8%)
of disease, along with systematic pelvic lymphadenectomy.
Histology Radical hysterectomy with pelvic lymphadenectomy is in-
Squamous carcinoma 355 333 (93.8%) <0.001 tended to provide curative surgical excision for early-stage
Adenocarcinoma 65 45 (69.2%) cervical carcinoma. The overall survival of patients treated
Adenosquamous carcinoma 15 8 (53.3%) with surgery alone is reported to range from 85 to 92% [9, 23,
MODIFIED RADICAL HYSTERECTOMY 419

TABLE 5
5-Year Survival and Stratification of Patients for Tumor Size and Histology

Squamous carcinoma Adenocarcinoma Adenosquamous carcinoma


Tumor size (N = 355) (N = 65) (N = 15) P value

02 cm (N = 129) 114/115 (99.1%) 10/12 (83.3%) 1/2 (50%) <0.001


24 cm (N = 233) 186/189 (98.4%) 30/36 (83.3%) 5/8 (62.5%) <0.001
>4 cm (N = 73) 33/51 (64.7%) 5/17 (29.4%) 2/5 (40%) =0.032

30 36]. However, because of the high incidence of recurrence for stage IB2 was observed for patients treated by surgery
in patients with poor prognostic factors, adjuvant radiation alone (44.4%) as well as for patients treated by a multimodal
therapy to the pelvic area has been advocated [2123, 32, 37, approach (54%) (P = 0.50). The high rates of treatment
38]. Although a survival advantage has not been convincingly failures among patients with large (>4 cm) tumors could
proven in patients who received postoperative radiation, better indicate a higher risk of lateral parametrial involvement, ne-
local control of the disease has been reported in some series cessitating probably a more radical surgical approach than type
[21, 22]. We treated our patients based on this approach, i.e., II radical hysterectomy. Adjuvant therapy in terms of pelvic
surgery alone for low-risk patients and multimodal combined irradiation offers no survival benefit for our patients with large
surgery and radiation treatment for high-risk patients. The cervical lesions (54.8%) and these results are quite similar to
survival rates in our study ranged from 84.3 to 95.4% depend- the survival of patients with larger tumors treated with primary
ing on the disease stage. The results are comparable to those radiation therapy [42, 44]. Adjuvant radiation therapy among
of other series employing more radical procedures [21, 23, our patients offers better local control of the disease, resulting
37, 39]. in a decreased local recurrence rate (45.4%) compared with
The disease-specific survival at 5 years for the patients in 87.5% for those patients treated with surgery alone (P <
this study was proven very good for stage IA (100%) and IB1 0.001). On the other hand patients who received combination
(95.1%) as well as for early stage II disease (86.3%). Thus, for therapy had a higher incidence of distant metastases (54.6%)
tumors smaller than 4 cm modified radical hysterectomy was than those treated with surgery alone (12.5%) (P < 0.001).
proven adequate to control the disease. Other reports also have These results confirm other reports and do support the concept
indicated comparable 5-year survival rates with similar recur- that adjuvant radiation therapy may reduce the incidence of
rence rates (6 8%) in patients with tumors smaller than 2 cm pelvic recurrences in high-risk patients [19, 22, 23, 45].
and early stromal invasion treated with radical hysterectomy Pelvic lymphadenectomy was routinely performed in all our
[13, 40]. patients irrespective of the size of the tumor and depth of
The low rates of central pelvic recurrence among our pa- invasion. The rate of pelvic node metastases was 14.9%. Anal-
tients with tumors smaller than 4 cm could be an indication that ogous incidence of nodal metastases was reported in other
these tumors have a low risk of lateral parametrial nodal studies resulting in a dismal prognosis [35, 41, 42]. Lymph
involvement and distant metastasis. Thus the appropriateness node metastatic disease was proven in our study to be a
of the central resection provided by a modified hysterectomy significant predictor of disease recurrence, resulting in a 52.3%
could be considered adequate for these tumors [12, 13]. recurrence rate for node-positive patients compared with 7.6%
Large cervical lesions, usually those greater than 4 cm in for node-negative patients (P < 0.001). The disease-specific
diameter, are usually associated with increased recurrence rate survival rate at 5 years was also significantly affected for the
and decreased survival [41 44]. In our study as well as others, patients with node-positive histology (53.8%) compared with
larger lesions are associated with an increased recurrence rate those with node-negative histology (94.8%) (P < 0.001).
(56.4%) and a poor survival rate (50.9%). This poor survival

TABLE 7
TABLE 6 Association between Treatment and Disease Survival
Association between Treatment and Disease Survival for Stage IB2 Patients

5-Year Treatment
N Recurrence survival
Surgery alone Preoperative RT + surgery
Surgery alone 290 40 (13.8%) 258 (88.9%) (N = 18) (N = 37) P value
Neoadjuvant RT + surgery 44 4 (9.1%) 42 (95.4%)
Neoadjuvant RT + surgery + adjuvant RT 18 2 (11.1%) 16 (88.9%) Recurrences 12 (66.7%) 19 (51.4%) 0.28
Surgery + adjuvant RT 83 16 (19.2%) 70 (84.3%) 5-Year survival 8 (44.4%) 20 (54%) 0.50
420 MICHALAS ET AL.

TABLE 8 complications in the urinary tract in terms of fistula formation


Association between Treatment and Recurrence Pattern (0.6%) and long-term bladder dysfunction (0.7%) are consid-
erably lower than those reported for class III procedures (4.8
Treatment Local recurrence Distant recurrence Total
and 40%, respectively) [6, 12].
Surgery alone (N = 290) 35 (87.5%) 5 (12.5%) 40 The addition of pelvic irradiation was a significant factor in
Surgery + RT (N = 145) 10 (45.4%) 12 (54.6%) 22 the development of a long-term ureteral stricture requiring a
stent catheterization (P < 0.001) and postoperative bladder
dysfunction (P < 0.001) but not in the development of
urinary tract fistula. The operative morbidity after irradiation
The therapeutic benefit of a pelvic lymphadenectomy has therapy is reportedly high [9, 10]. It has also been suggested
been reported to be applied only to patients with positive that postoperative adjuvant radiation therapy may lead to in-
nodes [13, 14, 46]. However, since pelvic lymph node me- creased gastrointestinal and urologic complications [22, 34]. In
tastasis has been proven a significant prognostic factor for our experience and that of others, major complications were
surgically treated early-stage cervical carcinoma patients, com- comparable in the two groups of patients [31, 46].
plete pelvic lymphadenectomy does appear to be reasonable Although the retrospective nature of our study does not
[23, 47, 48]. allow us to make firm statements it is obvious that we can draw
Tumor grade in our study does not appear to be a significant some useful conclusions especially due to the large sample size
predictor of treatment failure or of the 5-year survival rate and the close and long-term follow-up. The results from this
(P = 0.35). However, tumor grade is considered in some study support the concept that less radical procedures could be
series as one of the adverse risk factors that could influence effectively applied to early-stage cervical cancers 4 cm or
recurrence rate and disease survival [11, 49]. Patients with smaller. The accurate determination of lesion size preopera-
high-grade (III) tumors are considered, in our clinic, candidates tively would help individualize the operative approach [53].
for adjuvant treatment only if other adverse risk factors are also Although the benefit of adjuvant radiation therapy has not been
found, and not as a sole indication.
convincingly proven, it is common practice by most of the
Lymphvascular space involvement decreased the 5-year sur-
services to offer irradiation to patients with adverse risk factors
vival rate from 97.6 to 86.5%, the difference being statistically
irrespective of the radicality of the procedure. Further studies
significant (P = 0.004). Analogous reports have been pub-
of class II versus class III radical hysterectomy with adjuvant
lished [21, 50].
irradiation in patients with adverse risk factors would be ap-
Histologic type has been reported to be one of the most
propriate to evaluate the necessity of the radicality of the
controversial risk factors affecting survival of cervical carci-
procedure.
noma patients [51, 52]. Although primary treatment is usually
The optimal width of the margins of parauterine and para-
independent of the histologic type of cancer, adenocarcinomas
vaginal tissues around the tumor is not standardized. Although
and especially adenosquamous carcinomas have been reported
an uncompromised radical operation with complete removal of
to recur more often after surgery, especially at distant sites [51,
the parametria out to the lateral pelvic wall is considered by
52]. However, this propensity for an increasing risk of recur-
many authors [54 56], there are no convincing data to support
rence with adenomatous histology is not generally accepted. In
our study the adenomatous component was proven a significant a survival benefit for these patients compared with an individ-
adverse prognostic factor affecting 5-year survival (P < ualized modified approach. The lack of information about
0.001). The worst prognosis was noted for large (>4 cm) parametrial pathology and its role in the natural history of the
adenocarcinomas (29.4%) and large (>4 cm) adenosquamous disease is currently an obstacle to establishing a logical ap-
carcinomas (40%) (P = 0.032). proach to surgical decision making in cervical cancer [53].
Modified radical hysterectomy has been reported to be a less Since complete pelvic lymphadenectomy usually identifies all
morbid procedure than class III radical hysterectomy [10, 11]. node-positive patients and parametrial metastases are rarely
However, the scarcity of data, as well as the lack of large identified in the absence of sidewall lymph node involvement
prospective studies, does not allow firm statements to be made [54, 56], radical surgical excision of the parametria with ther-
[10 13], beyond that this type of procedure was applied in apeutic intent could be questionable. Thus in the absence of
selected patients with microscopic cervical cancers or various clear information about parametrial lymphatics, surgical efforts
neoplastic pelvic diseases [11, 12]. should be directed toward obtaining clear margins around the
In our study modified radical hysterectomy has been applied primary tumor and avoiding being dogmatic about the extent of
to cervical carcinoma patients, irrespective of the stage, tumor parametrial resection.
volume, or histologic type, as a sole or multimodal approach. It is our belief and of other authors also that an individual-
The complication rates in our patients reveal a quite low rate of ized surgical approach to early-stage cervical carcinoma should
adverse effects compared with those reported in the literature be advocated in the future, based on preoperative assessment of
after radical (class III) hysterectomy [10 12]. Thus, rates of the tumors special characteristics.
MODIFIED RADICAL HYSTERECTOMY 421

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