Letters to the Editor
To the Editor
It is well known that the classical surgical management of early-stage cervical carcinoma includes extirpation of the uterus and cervix, along with radical resection of the parametrial tissues and upper vagina, as well as complete bilateral pelvic lymphadenectomy. This surgical approach, known as radical hysterectomy (RH), was first described and systematically performed by Wertheim in 1898 and was then modified by Okabayashi in 1921 and repopularized by Meigs in the 1950s.1 Although hysterectomy was first performed in the early 1800s and RH was described in 1910, hysterectomy classifications were first suggested in the 1970s.2 In the 1990s and 2000s, fertility-sparing surgery, nerve-sparing surgery, and sentinel lymph node concepts and more radical types of exenteration, including laterally extended endopelvic resection and laterally extended parametrectomy, were proposed for early- and late-stage cervical carcinomas, which have since been incorporated into the surgical management of cervical carcinomas;3 however, classification of RH was not updated until 2005. Furthermore, although new suggested classification systems have more clearly described the steps of RH, none has included all the aforementioned concepts nor provides more objective rules and quality assurance criteria for use in daily clinical practice. Furthermore, major drawbacks of all these RH classification systems is the “autonomy of the surgeon” with respect to quantification and determination of the degree of radicality of the performed surgical operations.
It is well known that that there are 3 basic steps to RH:
- development of the surgical spaces;
- resection of the parametrium and vagina; and
- resection of lymph nodes.
Recently, Cibula et al4 described in great detail the steps involved in RH and improved on Querleu and Morrow classification.5 In that classification, class A to D was used (and its subgroups if necessary) instead of Piver classification class 1 to 5.5 Although Cibula et al clearly described all the surgical steps and anatomical landmarks in their classification, there remains a lack of definitive information concerning the length of resected parametrium, length of resected vagina, and number of pelvic/aortic lymph nodes in the available RH classifications. Furthermore, although the proposed new classification of RH by Cibula et al standardizes and improves some of the surgical steps of the procedure, we think it does not facilitate objective postsurgical assessment of RH. Furthermore, we think their classification is problematic in the same was as the Piver classification, as it does not provide clear and objective descriptions of the different classes of RH.
Major problems with all proposed classifications of RH are the attending surgeon’s autonomy and the lack of objectively defined surgical steps and quantification criteria forresected specimens. Surgeon autonomy may overestimate or underestimate the radicality the surgery. Chi et al6 compared intraoperative surgeon assessment of residual disease and early postoperative computed tomography in patients with advanced ovarian carcinoma who underwent optimal primary cytoreduction. In that study, there was only a 52% correlation between surgeon assessments and postoperative computed tomographic scan findings of residual disease in patients who underwent complete cytoreduction. The study’s findings show that surgeons sometimes mistakenly underestimate or overestimate intraoperative findings and the radicality of the surgery performed. As with the quantity of residual disease in ovarian carcinoma, lack of objectively defined criteria for classifying RH may result in surgeons overestimating the performed RH; therefore, it is important to optimize and ensure the quality of surgical care in patients with cervical cancer.
Nonetheless, to the best of our knowledge, there is no objective evaluation system for RH-resected specimens. Today, there is intense debate concerning the adequacy of resected surgical specimens in the surgical treatment of rectal cancer, prostate cancer, and bladder cancer. It has been shown that specimen adequacy is a very important criterion for local recurrences, overall and disease-free survival, and postoperative complications in randomized studies.7 Although it is well known that close surgical margins or margin involvement in vaginal or parametrial sites is a poor prognostic factor in patients who underwent RH, the adequacy of surgery and specimens have not been properly investigated in the gynecologic oncology literature, in particular, in relation to patients with cervical cancer. Quality assessment and assurance are important issues in rectal cancer surgery, and the first randomized trials of such were published more than 10 years ago. Indirect parameters, such as complications, recurrence, and survival rates, are used to evaluate the completeness of surgical procedures; however, these parameters are of limited value for the real evaluation of an individual surgeon. In the treatment of rectal cancer, there is general agreement and well-defined criteria concerning the quality and/or completeness of resection specimens based on pathological examination.
A randomized control trial reported that patient prognosis was predicted via use of a classification of macroscopic completeness of rectal resection specimens7; therefore, pathologists have recommended the use of some criteria to evaluate postoperative surgical specimens in rectal cancer, including macroscopic assessment of the quality of surgical excision of the mesorectum, microscopic measurement of the circumferential resection margin, and assessment of 12 or more mesorectal lymph nodes for metastasis.8 According to these criteria, surgery for rectal cancers is classified as complete, nearly complete, or incomplete.
We think that similar criteria must be applied to cervical cancer to objectively evaluate the completeness of RH specimens. As such, we arbitrarily defined criteria for the pathologic evaluation of RH specimens (Table 1) and the degree of completeness (Table 2). These criteria are based on suggestions offered by Cibula et al4 and the adequacy of lymphadenectomy. We think that this classification will facilitate better communication between pathologists and surgeons and provide objective criteria for radicality and external quality control systems for the surgical treatment of cervical cancer.
This letter was intended to draw the attention of the gynecologic oncology community to the issues of surgical completeness and to propose a set of quality indicators that can be used to audit and improve the quality of cervical cancer specimen evaluation. The proposed classification system does not systematically describe the steps of RH because these steps have been described extensively and perfectly by Cibula et al4 and Querleu and Moronow.5 This new proposed system of objective classification/standardization is intended to be used by pathologists. We think that the real classification and radicality should also be evaluated and confirmed based on quality and quantity of pathological specimens. This classification system can also be used for macroscopic and microscopic pathological evaluations.
We eagerly await the opinions of surgeons and pathologists regarding the proposed classification system. We realize that this proposed classification requires confirmation based on randomized trials and improvement based on the consensus of gynecopathologists and gynecologic oncologists.
Polat Dursun, MD, Associate Professor
Ali Ayhan, Professor
Division of Gynecologic Oncology
Department of Obstetrics and Gynecology
Baskent University School of Medicine
The authors have no conflicts of interest to declare.
1. Dursun P, Ayhan A, Kuscu E. Nerve-sparing radical hysterectomy for cervical carcinoma. Crit Rev Oncol Hematol
. 2009; 70: 195–205.
2. Dursun P, Gultekin M, Ayhan A. The history of radical hysterectomy. J Low Genit Tract Dis
. 2011; 15: 235–245.
3. Dursun P, Ayhan A, Kuscu E. New surgical approaches for the management of cervical carcinoma. Eur J Surg Oncol
. 2008; 34: 487–496.
4. Cibula D, Abu-Rustum NR, Benedetti-Panici P, et al. New classification system of radical hysterectomy: emphasis on a three-dimensional anatomic template for parametrial resection. Gynecol Oncol
. 2011; 122: 264–268.
5. Querleu D, Morrow CP. Classification of radical hysterectomy. Lancet Oncol
. 2008; 9: 297–303.
6. Chi DS, Ramirez PT, Teitcher JB, et al. Prospective study of the correlation between postoperative computed tomography scan and primary surgeon assessment in patients with advanced ovarian, tubal, and peritoneal carcinoma reported to have undergoneprimary surgical cytoreduction to residual disease 1 cm or less. J Clin Oncol
. 2007; 25: 4946–4951.
7. Nagtegaal ID, van de Velde CJ, van der Worp E, et al.; Cooperative Clinical Investigators of the Dutch Colorectal Cancer Group. Macroscopic evaluation of rectal cancer resection specimen: clinical significance of the pathologist in quality control. J Clin Oncol
. 2002; 20: 1729–1734.
© 2013 by the International Gynecologic Cancer Society and the European Society of Gynaecological Oncology.
8. Olszyna-Serementa M, Kołodziejczyk M, Sprawka A, et al. The quality of pathological reports of postoperative specimens in rectal cancer: an audit from the Mazovia region. Pol J Pathol
. 2009; 3: 130–133.