Comment on “De-escalation in Definitive Surgical Management for Cervical Cancer”

Vollständiger Abstract

Worum geht es in dieser Arbeit?

Traditionally, early-stage cervical cancer has been treated with radical hysterectomy and lymphadenectomy.Recently, this approach has changed due to advances in understanding the disease, surgical approaches and the adoption of the idea that radical procedures are not necessary for all patients. The concept of surgical de-escalation in cervical cancer is increasing in traction. Examples of de-escalation include sentinel lymph node mapping, simple hysterectomy, fertility-sparing surgery, intraoperative assessment to tailor surgical extent, and neoadjuvant treatment. These reflect the growing shift toward individualized care in cervical cancer. This review summarizes the evidence for de-escalation in surgical management for cervical cancer. Radical hysterectomy was introduced in 1895, and in 1911 a landmark study was published showing its significantly improved rates of mortality and cure. In 2018, the first study comparing minimally invasive to open radical hysterectomy (the LACC trial) showed inferior disease-free and overall survival in patients who underwent minimally invasive surgery compared with open surgery, prompting guidelines recommending open radical hysterectomy as the standard of care. There are 2 ongoing trials comparing robotic radical hysterectomy to open radical hysterectomy, but results are not yet published. Surgical complications linked to radical hysterectomy mainly stem from the removal of the parametrium, which is performed to remove metastatic spread beyond the cervix; most patients, particularly those with low-risk disease, do not have parametrial involvement and do not need this resectioin . In this subset of individuals, simple hysterectomy has been explored as a less invasive alternative to open radical hysterectomy, and research has supported this by showing no significant difference in overall survival at 5 years. Several studies of both prospective and retrospective design have shown similar results. Recent guidelines also reflect these findings and recommend simple hysterectomy for patients with low-risk early-stage cervical cancer. Previously, comprehensive pelvic lymphadenectomy was the standard for assessment of pelvic nodal status, though the rate of positive nodes in early-stage disease is low. Multiple studies have assessed the accuracy of sentinel lymph node assessment for cervical cancer and have found that the sensitivity and negative predictive values were efficacious. Oncologic outcomes of this procedure have been favorable, though this applies to a select subset of low-risk patients. Current recommendations also suggest that sentinel lymph node biopsy can replace pelvic lymphadenectomy. When lymph node involvement is found during surgery, studies show that combined morbidity of surgical and medical management is high. One study showed no significant differences between completed and abandoned hysterectomy for recurrence and overall survival, as well as the absence of a survival benefit from completing the surgery. These findings were replicated in subsequent studies, but current guidelines vary widely based on location. Administration of preoperative brachytherapy has been proposed to reduce the need for adjuvant postoperative radiotherapy; systematic reviews and retrospective analyses have shown that this method resulted in a higher rate of no residual disease and lower rates of the need for adjuvant radiotherapy. As treatments evolve, select patients may benefit from less invasive procedures, but care should be taken in surgical planning and practicing individualized care. (Summarized from Viveros-Carreño D, Agustí N, Mora-Soto N, et al De-escalation in definitive surgical management for cervical cancer. Int J Gynecol Cancer . Volume 36, Issue 3 102711 March 2026)