Kuan-Gen Huang

Randomized trial of surgical staging (extraperitoneal or laparoscopic) versus clinical staging in locally advanced cervical cancer

OBJECTIVE To define the role of pretreatment surgical staging for locally advanced cervical carcinoma. METHODS A two-step randomized trial was conducted to compare clinical staging (arm A) versus surgical staging (arm B) and to compare the laparoscopic (LAP) with the extraperitoneal (EXP) approach in previously untreated locally advanced cervical carcinoma. After the first randomization, those in arm B were randomly allocated to either LAP or EXP. An interim analysis was planned to evaluate the feasibility of LAP versus EXP, which led to the current report. RESULTS A total of 61 patients were eligible (arm A, 29; arm B, 32). The operation time, blood loss, and lymph node yield of LAP and EXP were not significantly different. Serious acute and late toxicity was not different between arm A and arm B, or LAP versus EXP. Para-aortic node metastasis was documented in 25% (95% confidence interval, 10% to 40%) of patients on arm B. An interim analysis was performed in January 2000. Patients on arm B had significantly worse progression-free survival than those on arm A. Hazard ratios of relapse/persistent or death were 3.13 (P = 0.005) and 1.76 (P = 0.150), respectively. Patient accrual was terminated according to the early stopping rules. With further follow-up till December 2001, the difference in progression-free survival remained significant (P = 0.003), and the difference in overall survival became significant (P = 0.024) as the data matured. CONCLUSION The benefit of pretreatment surgical staging for cervical carcinoma remained unproven. The detrimental effects of surgical staging observed in this study must be considered in the design of clinical guidelines or future trials.

Value of Dual-Phase 2-Fluoro-2-Deoxy-d-Glucose Positron Emission Tomography in Cervical Cancer

PURPOSE The role of positron emission tomography (PET) with fluorine-18-labeled fluoro-2-deoxy-d-glucose (FDG) in cervical cancer has not yet been well defined. We conducted a prospective study to investigate its efficacy in comparison with magnetic resonance imaging and/or computed tomography (MRI-CT). MATERIALS AND METHODS Patients with untreated locally advanced (35%) or recurrent (65%) cervical cancer were enrolled onto this study. In the first part of this study, 41 patients had a conventional FDG-PET (40 minutes after injection), and in the second part, 94 patients received dual-phase PET (at both 40 minutes and 3 hours after injection). The overall results of PET scans were compared with MRI-CT, and the two protocols of PET were also compared with each other. Lesion status was determined by pathology results or clinical follow-up. The receiver operating characteristic curve method with area under the curve (AUC) calculation was used to evaluate the discriminative power. RESULTS Overall (N = 135), FDG-PET was significantly superior to MRI-CT in identifying metastatic lesions (AUC, 0.971 v 0.879; P =.039), although the diagnostic accuracy was similar for local tumors. Dual-phase PET was also significantly better than the 40-minute PET (n = 94). The latter accurately recognized 70% of metastatic lesions and the former detected 90% (AUC, 0.943 v 0.951; P =.007). Dual-phase FDG-PET changed treatment of 29 patients (31%; upstaging 27% and downstaging 4%). CONCLUSION This study shows that dual-phase FDG-PET is superior to conventional FDG-PET or MRI-CT in the evaluation of metastatic lesions in locally advanced or recurrent cervical cancer.

Randomized Trial of Neoadjuvant Cisplatin, Vincristine, Bleomycin, and Radical Hysterectomy Versus Radiation Therapy for Bulky Stage IB and IIA Cervical Cancer

PURPOSE To compare the efficacy of neoadjuvant chemotherapy (NAC) followed by radical hysterectomy with that of radiotherapy (R/T) for bulky early-stage cervical cancer. PATIENTS AND METHODS Women with previously untreated bulky (primary tumor >/= 4 cm) stage IB or IIA non-small-cell carcinoma of the uterine cervix were randomly assigned to receive either cisplatin 50 mg/m(2) and vincristine 1 mg/m(2) for 1 day and bleomycin 25 mg/m(2) for 3 days for three cycles followed by radical hysterectomy (NAC arm) or receive primary pelvic radiotherapy only (R/T arm). The ratio of patient allocation was 6:4 for the NAC and R/T arms. Women with enlarged para-aortic lymph nodes on image study were ineligible unless results of cytologic or histologic studies were negative. RESULTS Of the 124 eligible patients, 68 in the NAC arm and 52 in the R/T arm could be evaluated. The median duration of follow-up was 39 months. Thirty-one percent of patients in the NAC arm and 27% in the R/T arm had relapse or persistent diseases after treatment, and 21% in each group died of disease. Estimated cumulative survival rates at 2 years were 81% for the NAC arm and 84% for the R/T arm; the 5-year rates were 70% and 61%, respectively. There were no significant differences in disease-free survival and overall survival. CONCLUSION NAC followed by radical hysterectomy and primary R/T showed similar efficacy for bulky stage IB or IIA cervical cancer. Further study to identify patient subgroups better suited for either treatment modality and to evaluate the concurrent use of cisplatin and radiation without routine hysterectomy is necessary.

Laparoscopic Radical Trachelectomy for Stage Ib1 Cervical Cancer

Radical trachelectomy by vaginal approach is an alternative for young women with early-stage cervical cancer. We modified this procedure to treat two patients with stage Ib1 cervical cancer. With 100% laparoscopic pelvic lymphadenectomy and 80% laparoscopic approach, the technique is laparoscopic radical trachelectomy (LRT). Under direct enhanced vision of the laparoscope, it is easy to identify and preserve ascending branches of the uterine arteries and to divide ligaments surrounding the cervix and vagina. Vaginal procedures require only colpotomy, amputation of cervix, dividing caudal paracolpium, and corpus-vagina anastomosis. Short-term follow-up results of our first patients are satisfactory. Thus, LRT could be a useful alternative for women with early cervical cancer who want to preserve fertility.

Recurrent cervical carcinoma after primary radical surgery

OBJECTIVE This study was undertaken to investigate prognostic factors in patients with recurrent cervical carcinoma who had undergone a primary radical hysterectomy and pelvic lymphadenectomy. STUDY DESIGN A retrospective analysis of 177 patients with recurrent cervical carcinoma after radical hysterectomy and pelvic lymphadenectomy for stage IB to II disease at a single institution was performed to evaluate clinicopathologic parameters, time to recurrence, pattern of failure, use of salvage therapy, and survival after recurrence. RESULTS The 5-year survival rate from diagnosis of recurrence in this series was 10.1%. Survival after recurrence was significantly decreased in patients with pelvic lymph node metastasis at primary surgery and adenocarcinoma-adenosquamous carcinoma histologic type. Patients with extravaginal recurrences receiving chemoradiation for recurrent cervical carcinoma had significantly better outcomes than those receiving radiation alone. Six patients who had a distant relapse at a sole site had prolonged survival after salvage therapy, which was accomplished by chemoradiation, surgery plus radiotherapy, or surgery alone. CONCLUSIONS Our results demonstrate the benefit of adding chemotherapy to radiotherapy in the treatment of recurrent cervical carcinoma. Salvage multimodality treatment should be offered to selected patients who have isolated relapse at a single distant site.

Comparison of Laparoscopic and Conventional Surgery in the Treatment of Early Cervical Cancer

STUDY OBJECTIVE To compare efficacy, results, and complications of laparoscopic-assisted radical hysterectomy (LARH) and pelvic lymphadenectomy with abdominal radical hysterectomy (ARH) and pelvic lymphadenectomy in management of early (stages 1a2, 1b) invasive cervical carcinoma. DESIGN Prospective cohort study (Canadian Task Force classification II-2). SETTING University-affiliated hospital. PATIENTS Sixty women enrolled for radical hysterectomy as most appropriate primary treatment. INTERVENTION Radical hysterectomy performed by laparoscopy or laparotomy. MEASUREMENTS AND MAIN RESULTS Thirty patients each underwent LARH and ARH. The groups did not differ in terms of age, weight, disease stage, operating time, and hospital stay. Mean blood loss was 962 +/- 543 ml for ARH and 450 +/- 284 ml for LARH. No laparoscopic procedure was converted to laparotomy. There was no significant difference in intraoperative and postoperative complications. There was no significant difference in recurrence rates. CONCLUSION LARH with pelvic lymphadenectomy does not increase recurrence rates and morbidity when performed by experienced endoscopists and oncologists.

A New Portal for Gynecologic Laparoscopy

We used the middle upper abdomen as a primary port insertion as an alternative portal for laparoscopy and multiport operative pelviscopy in 188 women who were at high risk for subumbilical adhesions because of previous abdominal surgeries or history of gynecologic cancer. Primary cannula insertion was in the middle upper abdomen between xyphoid process and umbilicus (Lee-Huang point). This was the single entry site for the Veress needle and primary laparoscopy port. In 184 (98.4%) of 188 women surgery was performed without complications. No procedure was converted to laparotomy due to visceral or vascular injuries. Two omentum injuries from primary port insertion were repaired with bipolar electrocoagulation; a colon injury was repaired with laparoscopic sutures. In our experience, this laparoscopic port is effective in women who have had abdominal surgery or gynecologic malignancy. (J Am Assoc Gynecol Laparosc 8(1):147-150, 2001)

Total Laparoscopic Radical Hysterectomy Using Lee-Huang Portal and McCartney Transvaginal Tube

A surgical approach to the treatment of invasive cervical carcinoma 1b1 may result in decreased mortality and morbidity as well as better functional quality of life. Laparoscopic-assisted radical vaginal hysterectomy (LARVH) is an alternative treatment for early cervical cancer, with parts of the procedures performed vaginally. We modified LARVH to total laparoscopic radical hysterectomy (TLRH) using Lee-Huang portal and McCartney transvaginal tube. The advantage of TLRH for cervical cancer is that the entire procedure is performed under direct observation. It may reduce the possibility of visceral organ injury during vaginal procedures and could minimize vaginal bleeding due to dissection. The Lee-Huang portal as primary laparoscopic port affords wide access to the abdominal cavity and proper visual angle, and increases the working distance. A plastic McCartney transvaginal tube placed inside the vagina maintains pneumoperitoneum and performs a circular incision on the vagina around the uterus with ease. Our preliminary experience with 12 patients suggests that this method of TLRH is feasible for selected patients and may be a useful alternative in treating early cervical cancer.

Long-term survival outcomes of laparoscopically assisted radical hysterectomy in treating early-stage cervical cancer

OBJECTIVE The objective of the study was to determine the long-term disease-free and overall survival outcomes of laparoscopic treatment of early-stage cervical cancer. STUDY DESIGN This was a longitudinal study of prospectively registered patients of cervical cancer undergoing laparoscopic surgery from June 1994 to December 2005. RESULTS A total of 139 patients were included, in which 60 patients were in International Federation of Gynecology and Obstetrics stage IA, 76 in IB, and 3 in IIA. Mean operation time was 231.1 +/- 6.1 minutes. Median number of pelvic lymph node retrieval was 16. Major intraoperative complications included 1 great vessel injury, 1 ureteral injury, 1 colon injury, and 6 cystotomies. In a median follow-up of 92.1 months, the mean +/- SEM cumulative disease-free and overall survival rates were 91.01% +/- 2.77% and 92.78% +/- 3.06%, respectively. CONCLUSION The laparoscopic approach has favorable long-term survival outcomes and perioperative morbidity. With the advantage of minimal invasiveness, laparoscopic treatment by experienced surgeons is an ideal alternative for early-stage cervical cancer.

Bladder Injury after LAVH: A Prospective, Randomized Comparison of Vaginal and Laparoscopic Approaches to Colpotomy During LAVH

STUDY OBJECTIVE To compare results of a vaginal approach to colpotomy (type IA) and laparoscopic-assisted abdominal colpotomy (type ID) in performing a laparoscopic-assisted vaginal hysterectomy (LAVH). DESIGN Prospective, randomized study (Canadian Task Force classification I). SETTING Tertiary teaching hospital. PATIENTS Five hundred forty-one women, 274 in group 1 (type 1D) and 267 in group 2 (type 1A). INTERVENTION LAVH with follow-up for 3 months to 5 years. MEASUREMENTS AND MAIN RESULTS There were no statistically significant differences in age, preoperative and postoperative hemoglobin values, or postoperative hospital stay between groups. Operating time and estimated blood loss were significantly reduced in group 2 (p <0.001 and <0.001, respectively). Women in group 1 had nine urinary tract injuries (3.28%), including eight cases of intraoperative bladder injury (2.91%) and one vesicovaginal fistula (0.36%), but no ureteral injury. The bladder injury rate in group 2 was 0.37%, which was significantly lower (p = 0.038). There were no significant differences in ureteral or bowel injuries, pelvic hematomas, or pelvic abscesses. CONCLUSION LAVH type IA achieved better results than type ID in preventing bladder injury.