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The Role of Surgery in the Treatment of Gynecologic Cancers—A Shifting Paradigm
US Oncology Review, 2005;1(1):1-3
Gynecologic cancers originate at broadly defined organ sites including vulva, vagina, cervix, endometrium, and ovary with fallopian tube. The incidence and prevalence of cancers of each of these sites varies by decade of life, history of exogenous exposure, genetic predisposition, body habitus, and geographic location. While surgery is the oldest therapeutic modality consistently applied in the treatment of gynecologic cancers, the actual operations vary considerably among different therapists and the procedures employed are quite different for the different organ sites.
Citation US Oncology Review, 2005;1(1):1-3
This article summarizes the evolution of commonly employed surgical remedies and concludes with a description of trends in current surgical approaches.
Among the earliest reports of tumor removal in the female is a reference in 1862 by Edwin Smith, an Egyptologist, who was able to date abdominal excisions of the ovary as early as 1600BC from a recovered papyrus. These observations were made from studying Egyptian mummies whose internal anatomy had been altered and whose ovaries had been removed. However, with the influence of Hippocrates (460-375BC), who advocated with- holding surgery in the treatment of cancers, surgery was largely abandoned. This emphasis was later reinforced by Galen, and it was not until the late 18th century that resection of cancers became more widely practiced. In the US, the first elective ovarian tumor removal was performed in 1809 by Efraim McDowell and this was done before Crawford Long introduced anesthesia (1842) in wide application. In 1890, Halstead described the radical mastectomy establishing a paradigm that was to dictate cancer surgical principles until the last third of the 20th century - the widest possible resection in order to remove all disease and the sites that might harbor escaped tumor cells.This concept was not applied to ovarian cancer, which when diagnosed had escaped from the ovary and spread to other parts of the abdominal cavity 75% of the time and was considered to be beyond the scope of surgical remedy.Thus, until the 1960s, therapy consisted of removing enough disease for a diagnosis or for patient comfort and then treating with radiation therapy, and eventually chemotherapy in the 1950s. In 1972 Griffiths observed that patient survival was inversely proportional to the amount of disease remaining after the first surgical encounter for patients with ovarian cancer.This was subsequently substantiated by other therapists and the new standard of care encouraged an attempt at complete surgical removal of all visible disease when ovarian cancer was diagnosed. It was observed that this maneuver rendered the patient better able to receive cytotoxic chemotherapy, which finally included more effective chemotherapeutic agents.This effort at maximum surgical cytoreduction remains the standard of care today.
At the other end of the spectrum, the introduction of sonographic surveillance and the discovery of circulating serum tumor markers encouraged screening programs for finding ovarian cancer while it is confined to the ovary.The developments of fiber- optic light transmission and miniaturized video cameras have allowed the application of minimally invasive (laparoscopic) surgery for diagnosis, staging, and treatment of early ovarian cancer. Only by a proper staging operation, in which all areas in the abdomen that might be potential sites for a metastasis are sampled, can one rule out such metastasis and prove that the cancer is confined to the ovary, reducing the requirement for aggressive adjuvant therapy in early-stage cancer.
Such surgical techniques are also applicable to patients who are thought to be cured but develop recurrent ovarian cancer. Secondary cytoreduction is generally considered highly useful prior to re-treatment with targeted non-surgical therapy.
Cancer of the endometrium was the next gynecologic cancer to be treated surgically, and the traditional treatment was extra-fascial hysterectomy and bilateral salpingo-oophorectomy. Because the vast majority of endometrial cancers are diagnosed early in their course, this remedy was highly successful most of the time. However, during the 1950s, the role of radiation therapy was established in improving cure rates for those patients who were thought to have unusually aggressive tumors. In 1985 and 1987 there The Role of Surgery in the Treatment of Gynecologic Cancers - A Shifting Paradigm 2 B USINESS BRIEFING: US ONCOLOGY REVIEW 2004 Reference Section were initial reports from collaborative staging studies in which lymph node excisions were included in the conventional surgical approach in the treatment of endometrial cancer. Based on a study of the lymph nodes removed, cytologic analysis of washings from the peritoneal cavity, measurement of the depth of penetration in the uterine wall, and the virulence of the individual tumor cells, data was accumulated allowing prediction of lymphatic spread of disease even prior to the hysterectomy itself. The staging system for endometrial cancer was redefined incorporating the lymphadenectomy, and by this more complete surgical exercise a large proportion of patients with endometrial cancer are now spared post-operative adjunctive therapy.
Recently,laparoscopic designs for these operations were introduced and, to date, in several small series there has been no diminution in survival as a result of laparoscopy compared with laparotomy. There are on-going collaborative studies designed to verify these observations, and while minimally invasive surgery is not less extensive, it is certainly less debilitating for the patient and results in earlier recovery. However, based on the data from the staging pilot studies, the application of the most extensive surgery can be limited to approximately 20% to 30% of patients with endometrial cancer.