I. Introduction

The management of early stage cervical carcinoma is primarily surgical in the majority of patients. Invasive cervical carcinoma after simple hysterectomy, can be treated with radiotherapy or reoperation involving a pelvic and/or paraaortic lymphadenectomy, radical Parametrectomy, and upper vaginectomy (Orr et al, 1986; Hopkins et al, 1990; Chapman et al, 1992; Roman et al, 1993; Crane and Schneider, 1999).

Since radiation therapy results in loss of ovarian function and greater frequency of sexual dysfunction than operative techniques, RP seems more beneficial option. It can be performed safely in most patients, who have an early stage invasive carcinoma of the cervix with the expectation of an acceptable rate of long term disease free survival (Kinney et al, 1992). Due to inadequate screening and diagnostic work up, we have frequent cases of cervical carcinoma as incidental finding in simple hysterectomy specimen (Behtash et al, 2003).

Overall survival in cervical carcinoma treated with simple hysterectomy is less than 50% at 5 years (Jones and Jones, 1943; Daniel and Brunschwig, 1961; Barber et al, 1968). Additional therapy in these patients include radiation therapy (Cosbie, 1963; Green Jr and Morse Jr, 1969; Andras et al, 1973; Davy et al, 1977; Papavasiliou et al, 1980; Perkins et al, 1984; Behtash et al, 2003), or additional surgery (Barber et al, 1968; Green Jr and Morse Jr, 1969; Orr et al, 1986; Chapman et al, 1992; Kinney et al, 1992; Behtash et al, 2003).

Described in 1961 by Daniel and Brunschwig, RP is a surgical procedure that allows one to complete the evaluation of the tissues of concern, namely upper vagina, parametrium and the regional lymphatics.

The objective of our study is to evaluate the morbidity and efficacy of RP in patients with cervical carcinoma in their simple hysterectomy specimen.

II. Materials and methods

A retrospective chart review identified 150 patients with early stage cervical carcinomas (FIGO stage I_A-II_A) treated at Vali-e-Asr University Hospital of Tehran University of Medical Sciences, Tehran, Iran from 1997-2003.

Five of these patients were evaluated for RP secondary to the diagnosis of invasive cervical cancer in cervical specimen following simple hysterectomy. To be considered eligible for RP patients were required to have a normal pelvic exam before surgery with no evidence of residual disease in the parametrium (stage IA-IIA). RP was performed on 2 months, 4months, 4months, 18 months, and 10 years after simple hysterectomy.

Clinicopathologic information including demographics, indication for hysterectomy, tumor stage, histology, nodal status, operative complications, length of stay, recurrence and survival was collected. One patient had subtotal hysterectomy in the first procedure. Follow up data were obtained by review of the medical records or by the patient correspondence.

III. Results

Two patients had stage II_A lesions; one patient had stage I_B1; one patient I_A2 and one stage I_B2. Demographic information is listed in Tables 1 and 2.

Four patients underwent RP, upper vaginectomy, pelvic and/or paraaortic lymphadenectomy, and the fifth one had an additional cervicectomy due to previous subtotal hysterectomy. Median number of dissected pelvic lymph nodes was 12.

We had no major operative and post operative complications. Mean post operative length of stay was 5 days.

Two patients had cuff biopsy (large cell non-keratinizing SCC) in preoperative evaluation. They received 3 courses of neoadjuvant chemotherapy (NACT) before operation (RP).

Table 1.

	Mean	Range
Age	41.6	35-47
Gravidity	4.75	1-9
Para	3.7	1-6
Menarche	12.5	12-13
First intercourse	15.75	12-21

Table 2.

		Number of patients
Stage	I_A2	1
	I_B1	1
	I_B2	1
	II_A	2
Pathology	SCC	4
Pathology	Adenocarcinoma	1
Indications for simple hysterectomy	CIN	2
Indications for simple hysterectomy	Abnormal uterine bleeding	3

Chemotherapy treatment consisted of Cisplatinum 20 mg/q 10 days/ for 3 courses, Vincristine 1 mg/q 10 days/ for 3 courses.

After radical surgery, both of these patients had positive lymph nodes in pelvis, residual tumor in vaginal specimen with clear margins. They received post operative external beam radiotherapy (6800-7000 cGy). One of these patients is alive without disease after 89 months. But the other one died about 15 months after completing adjuvant radiotherapy with progressive disease.

Two patients (stage I_A2, I_B1) had no residual disease in preoperative and pathologic evaluation following RP. Although one of these two patients, in preoperative colposcopic exam, showed moderate dysplasia in cuff.

Both of these patients are alive without disease in 65 months and 23 months follow up. One patient, who underwent subtotal hysterectomy due to abnormal vaginal bleeding, had stage IB2 adenocarcinoma of cervix and received 5400 cGy external radiotherapy before RP. After 6 weeks, she underwent radical cervicectomy plus RP plus upper vaginectomy plus pelvic and paraaortic lymphadenectomy. She had no residual tumor in pathologic specimens, and is alive without disease 48 months after radical surgery.

Overall, the 5 year survival for our patients with completed RP is 80% with a median follow up of 48 months. With a median follow up of 48 months (17-89) four patients are still alive without disease (23, 48, 65, and 89 months). One patient died due to progressive disease at 17 months after surgery.

IV. Discussion

Incidental finding of cervical carcinoma is rather frequent following simple hysterectomy for apparently benign diseases. In our series, the most common primary diagnosis was CIN and abnormal uterine bleeding. Based on our previous study, inadequate preoperative (pre-hysterectomy) evaluation for patients with abnormal Pap-smear and vaginal bleeding, were the main reasons of inappropriate management (Behtash et al, 2003). Unfortunately, in our series (Behtash et al, 2003), even patients with biopsy proven SCC of cervix underwent simple hysterectomy, although even adequate preoperative evaluation could not find occult cervical carcinoma. Simple hysterectomy is considered to be adequate surgery only for patients with microinvasion (stage IA1) (Jones and Jones, 1943; Daniel and Brunschwig, 1961; Barber et al, 1968).

Additional treatment for more invasive carcinoma finding after simple hysterectomy is radiation therapy with or without chemotherapy or RP with lymphadenectomy.

In appropriate candidates, it seems radical reoperation, especially in a young patient, allows ovarian preservation and functional vagina (Orr et al, 1986; Chapman et al, 1992; Kinney et al, 1992).

Selection of an eligible patient for RP is critical. Leath III, et al, (2004) showed patients with no clinical evidence of residual at the vaginal apex and parametrium have an excellent overall survival. They had a rather high operative morbidity (30%) including 2 incidental cystectomy and massive transfusion in 4 patients. In other series, there are rate of morbidity following RP (Orr et al, 1986; Chapman et al, 1992; Kinney et al, 1992). We had no massive transfusion, no major surgical or postoperative morbidity in these five patients.

In a study Leath III et al, (2004), the length of hospital stay was 3.6 days, which is much shorter than our series, although different insurance problems in two countries may influence this point.

Postoperative adjuvant radiotherapy may increase morbidity dramatically, which has been reported in radical hysterectomy (Martimbeau et al, 1978; Barter et al, 1989; Fiorica et al, 1990).

We planned NACT before radical surgery in two patients with disease in central culf, to minimize the likelihood of postoperative radiotherapy. Due to positive pelvic node and residual tumor in vaginal specimen (with clear margin), they received adjuvant radiotherapy. As Orr et al, (1986) noted the decision for planning radiation can only be made after surgery. Four largest series that evaluated RP in the management of cervical cancer included 18-27 patients (RP (Orr et al, 1986; Chapman et al, 1992; Kinney et al, 1992; Leath III et al, 2004). Seventeen patients out of 23 in Orr series (Orr et al, 1986) had negative RP specimen and all were with no evidence of recurrence with a modest 36 month follow up. With a median follow up of 72 months, Chapman et al (1992) reported 89% five year survival. Their study also confirmed that extended survival can be obtained in patients with a negative RP specimen. Furthermore, the absence of long term morbidities, such as urinary fistula, was encouraging.

Kinney et al, (1992) reported 82% survival with a median follow up of 8.4 years. In their series, all the recurrences occurred within 4 years.

The incidence of positive nodes in these four large series was 10% (9/93), while the incidence of positive vaginal margin or positive parametrium is 7% (7/93). Eighty percent of patients were able to have a completed RP without evidence of residual disease.

Cosbie, (1963) reported 116 patients with cervical cancer over 3 decades that received radiotherapy following simple hysterectomy. In spite of 16 patients with microinvasive disease, their 5 year survival rate was only 71%.

Green and Morse, (1969) evaluated outcome of 84 patients that received either surgery or radiation following extrafacial or subtotal hysterectomy in cervical cancer. Five year overall survival in radiation group was 30% while 67% in radical operation patients. Importantly, the authors demonstrated that a delay in further therapy of greater than 4 months was associated with an overall 5 year survival of 18% as compared to 42% when patients were treated within 4 months (Andras et al, 1973; Davy et al, 1977).

Survival data from the University of Virginia utilizing radiation therapy were 93% at 5 years (Crane and Schneider, 1999).

However, 12/18 patients suffered either grade 1 or 2 acute toxicities and 2 had long term complications consisting of chronic diarrhea and small bowel obstruction that necessitated surgical exploration. Survival statistics in these series may be influenced by inclusion of patients with higher risk factors such as large diameter tumors, tumors at the cervical margin or involving the parametrium and/or vagina and nodal metastasis.

Although radiotherapy is quite effective for patients’ early invasive carcinoma of cervix after simple hysterectomy, its serious potential morbidity and costs should be considered.

In our country, long waiting list for radiotherapy, frequent cases of inappropriately managed, common incidence of cervical carcinoma are additional reasons that make RP as an acceptable and safe alternative for carefully selected patients. To our knowledge this is the first report of radical parametrectomy in our country.

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Research Article

Received: 24 December 2004; Revised: 31 January 2005

Accepted: 8 February 2005; electronically published: March 2005

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