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Minimally invasive surgery for early-stage cervical cancer: is the uterine manipulator a risk factor?

Published:August 05, 2019DOI:https://doi.org/10.1016/j.ajog.2019.07.042
      To the Editors:
      We read with great interest the study by Matsuo et al

      Matsuo K, Chen L, Mandelbaum RS, Melamed A, Roman LD, Wright JD. Trachelectomy for reproductive-aged women with early-stage cervical cancer: minimally-invasive surgery versus laparotomy. Am J Obstet Gynecol 2019;220:469.e1-469.e13.

      highlighting the minimally invasive surgery (MIS)/MIS trachelectomy for reproductive women with early-stage cervical cancer. Given the results of recent reported studies that demonstrated decreased survival with MIS, the authors discuss the use of uterine manipulators as well as vaginal colpotomy as potential factors affecting tumor spread following MIS.
      An uncommon variant of cervical adenocarcinoma is the villoglandular adenocarcinoma (VGA). VGA generally presents as an exophytic mass arising from the endocervical canal. It occurs mostly in young women and has an excellent prognosis. In a systematic literature review (unpublished data) from 1989 to 2018, we found 8 reported recurrences in 231 patients treated surgically for VGA of the cervix (FIGO stage Ia–Ib1). All 8 cases were histologically well differentiated pure VGA and had neither lymphovascular space invasion nor lymph node involvement. The recurrence sites were in 5 cases: episiotomy scar (n = 1), pelvic wall (n = 2), vaginal vault (n = 2). The primary treatment was open surgery. A recent case series (n = 15) reported 3 intraabdominal metastases: 2 in the ovary and 1 in the liver.
      • Ju U.C.
      • Kang W.D.
      • Kim S.M.
      Is the ovarian preservation safe in young women with stages IB–IIA villoglandular adenocarcinoma of the uterine cervix?.
      The 3 patients were treated through MIS.
      This intraabdominal metastasis of VGA is remarkable because VGA has an unusually favorable prognosis. Was there a residual tumor in the endocervical canal? In all 15 cases, VGA was diagnosed after a punch biopsy. Only with uncertain tumor was a conization conducted. Among potential reasons for the inferior oncological outcomes in patients with cervical cancer who underwent MIS than in women who underwent open surgery, the routine use of a uterine manipulator might increase the propensity for tumor spillage intraperitoneally after colpotomy under laparoscopic vision.
      • Park J.-Y.
      • Nam J.-H.
      How should gynecologic oncologists react to the unexpected results of LACC trial?.
      Another conceivable mechanism is the hematogenous tumor cell spread intraoperatively because of the continuous mechanical manipulation of the cervix, potentially leading to an influx of tumor cells into veins and lymphatic vessels. The unavoidable damage of the tumor and its vasculature during surgery leads to a shedding of tumor cells into the blood circulation. The level of circulating cancer cells is a strong predictor of tumor recurrence.
      • Thome S.
      • Simmons R.L.
      • Tsung A.
      Surgery for cancer: a trigger for metastases.
      Given the uncertainty of the oncological safety of uterine manipulators in patients with cervical cancer, their use should be limited to patients with removed tumors. A pretherapeutic large loop excision with tumor-free margins may be an indispensable prerequisite for the use of manipulators during MIS if open surgery is not an option.

      References

      1. Matsuo K, Chen L, Mandelbaum RS, Melamed A, Roman LD, Wright JD. Trachelectomy for reproductive-aged women with early-stage cervical cancer: minimally-invasive surgery versus laparotomy. Am J Obstet Gynecol 2019;220:469.e1-469.e13.

        • Ju U.C.
        • Kang W.D.
        • Kim S.M.
        Is the ovarian preservation safe in young women with stages IB–IIA villoglandular adenocarcinoma of the uterine cervix?.
        J Gynecol Oncol. 2018; 218: e54
        • Park J.-Y.
        • Nam J.-H.
        How should gynecologic oncologists react to the unexpected results of LACC trial?.
        J Gynecol Oncol. 2018; 29: e74
        • Thome S.
        • Simmons R.L.
        • Tsung A.
        Surgery for cancer: a trigger for metastases.
        Cancer Res. 2017; 77: 1548-1552

      Linked Article

      • Fertility-sparing surgery for early-stage cervical cancer: does surgical approach have an impact on disease outcomes?
        American Journal of Obstetrics & GynecologyVol. 220Issue 5
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          Historically, laparotomy was the preferred surgical approach for the management of gynecological malignancies. Laparoscopy was introduced in the early 1990s; however, gynecological oncologists were slow to incorporate standard laparoscopic techniques for radical and other complicated pelvic surgeries. This is likely due to the difficult and relatively long learning curve, limits of the technology (2-dimensional view; rigid instruments with limited articulation and rotation), poor ergonomics, longer operative times, and challenging patient factors such as obesity.
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        American Journal of Obstetrics & GynecologyVol. 221Issue 5
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          We appreciate the comments and insights by Dietl et al regarding our recent study.1 The authors expressed their concern regarding uterine manipulator use during minimally invasive radical hysterectomy for early-stage cervical cancer as a risk factor for tumor spillage and dissemination. Several previous studies may support their hypothesis. First, uterine manipulator use during minimally invasive radical hysterectomy for early-stage cervical cancer was associated with increased risk of tumor surface disruption (45% vs 13%) and artificial parametrial tumor carryover (65% vs 29%) compared with laparotomy (both, P<.05).
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