A new surgical technique could allow surgeons to perform a radical hysterectomy in patients with early-stage cervical cancer; with fewer complications, reduced morbidity, and a lower risk of local tumour recurrence than current surgical methods, according to an article in The Lancet Oncology .
The technique, called total mesometrial resection (TMMR), is a modified version of the traditional radical hysterectomy and involves more accurate, anatomically based resection of the cancer to prevent damage to the pelvic autonomic nervous system and to minimise surgical trauma.
For over 100 years radical hysterectomy has been the standard surgical treatment for early-stage cervical cancer. However, the procedure has a relatively high rate of tumour recurrence and many patients experience postoperative bladder and bowel dysfunction because of damage to the autonomic nerve system. In addition, postoperative radiotherapy;given as part of standard treatment can have considerable unpleasant side-effects.
Current surgical practice is to remove the pelvic tissue adjacent to the tumour along with the cervix because of the risk of it harbouring cervical cancer. However, it has been suggested that local tumour spread may be restricted to the Müllerian compartment (fallopian tubes, uterus, and proximal, middle vagina and their embryologically defined mesotissues) for relatively long phases in its natural course, and that the removal of the complete Müllerian compartment in early-stage disease could improve local tumour control while reducing surgery-associated morbidity.
To improve on traditional radical hysterectomy and to show that the early stages of tumour growth are confined to the Müllerian compartment, Michael Höckel and colleagues assessed the effectiveness of TMMR without radiotherapy, in 212 patients with early-stage cervical cancer between 1999 and 2008 at the University of Leipzig in Germany. In this study, they report the histopathological tumour stages, resection margins, local recurrence, surgical morbidity, and 5-year outcomes of these patients.
Overall, findings showed recurrence-free survival of 94% and 5-year survival of 96%, with low treatment-related disease. At a median follow-up of 41 months only 10 patients had a recurrence of their cancer.
In addition, although 63% (134 patients) had high-risk histopathologic factors such as positive lymph-nodes and large tumour size, the overall recurrence rate was only 5%. This is considerably better than the 28% overall recurrence rate seen in similar patients treated with the normal surgical technique of radical hysterectomy. Indeed, the 5-year survival in patients with positive lymph-nodes was 91%, compared with previous reports in similar patients of 68-78%. Importantly, 132 (63%) patients had no treatment-related complications, 75 (35%) had grade 1 complications, just 20 (9%) of patients experienced grade 2 complications, and no grade 3 or 4 complications were reported.
The authors say that: "Based on historical controls, TMMR without adjuvant radiation has the potential to improve survival by 15-20%." They conclude by calling for further evaluation of the technique with multi-institutional controlled trials.
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