Gynecologic Oncology 92 (2004) 215 – 219

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The role of radical parametrectomy in the treatment of occult cervical

$
carcinoma after extrafascial hysterectomy
Charles A. Leath III,* J. Michael Straughn Jr., Snehal M. Bhoola, Edward E. Partridge,
Larry C. Kilgore, and Ronald D. Alvarez
Department of Obstetrics and Gynecology, Division of Gynecology Oncology, University of Alabama at Birmingham,
Birmingham, AL 35249-7333, USA
Received 21 May 2003

Abstract

Objectives. To assess the morbidity and efficacy of radical parametrectomy (RP) performed following extrafascial hysterectomy in
patients with occult cervical carcinoma.
Methods. An IRB approved retrospective chart review identified 23 patients that underwent RP with pelvic and/or para-aortic
lymphadenectomy and upper vaginectomy. Data were collected on demographics, tumor stage, grade, histology, indication for hysterectomy,
surgical findings, complications, recurrence, and survival.
Results. Of the 23 patients, 2 patients had a stage IA2 lesion while 21 patients had a stage IB1 lesion. There were 5 patients with a grade 1
tumor, 10 with grade 2, 4 with grade 3, and 4 with unknown grade. Median age was 41 years (range 27 – 59). The most common indication
(48%) for extrafascial hysterectomy was CIS of the cervix. Four patients (17%) had metastasis to pelvic nodes or evidence of tumor at the
margin at the time of RP. Three of these 4 patients with a positive specimen received adjuvant radiation and all are alive (mean follow-up 66
months). One patient declined radiation and is alive at 42 months. There were 7 (30%) operative complications: Most notably 4 patients
received blood transfusions. Two of 19 patients (11%) with no residual tumor in RP specimen recurred and 1 patient was salvaged with
radiation (follow-up 103 months). With a median follow-up of 61 months (range 9 – 103), overall 5-year survival is 96%.
Conclusions. RP is an acceptable option for patients diagnosed with an occult cervical carcinoma at the time of extrafascial hysterectomy.
Careful selection of RP for patients unlikely to have residual tumor will obviate the need for radiation in most instances.
D 2003 Elsevier Inc. All rights reserved.

Keywords: Radical parametrectomy; Occult cervical cancer; Surgical technique

Introduction therapy. Comparable survival is obtained regardless of the

The management of early stage cervical carcinoma is
primarily surgical in the majority of patients. Patients with
FIGO stage IA1 disease can be managed with an extra-
fascial hysterectomy or conization if future fertility is
desired [1,2]. More advanced early stage lesions, FIGO
stage IA2 – IIA, mandate either radical surgery with the
evaluation of regional lymphatic nodal tissue or radiation
$
Presented at the 34th Annual Meeting of the Society of Gynecologic
Oncologists, New Orleans, LA, January 31 – February 4, 2003.
* Corresponding author. Division of Gynecologic Oncology, University
of Alabama at Birmingham, 619 19th Street South, OHB538, Birmingham,
AL 35249-7333. Fax: +1-205-975-6174.
E-mail address: Trey_Leath@yahoo.com (C.A. Leath).
therapeutic modality utilized [3 –5]. A dilemma occurs if
an occult cervical carcinoma with greater than 3 mm depth
of invasion or with greater than 7 mm width is discovered
at the time of pathological evaluation following an extra-
fascial hysterectomy.
As the overall survival in the setting of cervical
carcinoma treated with an extrafascial hysterectomy is less
than 50% at 5 years [6 –8], additional therapy is warranted
for these patients. Options for treatment include radiation
therapy [9 –14] or additional surgery [7,8,10,15– 17]. One
surgical option available is radical parametrectomy (RP)
combined with lymphadenectomy, which is both diagnostic
and therapeutic.
Described in 1961 by Daniel and Brunschwig, a RP is a
surgical procedure that allows one to complete the evalu-

0090-8258/$ - see front matter D 2003 Elsevier Inc. All rights reserved.
doi:10.1016/j.ygyno.2003.10.018
216 C.A. Leath III et al. / Gynecologic Oncology 92 (2004) 215–219

Table 1 collected. Follow-up data were obtained by review of the

Demographic information for 25 RP candidates
medical record or by patient correspondence.
Mean Range
Age 40.8 (27 – 59)
Weight 165.8 (124 – 242) Results
Number Percentage
Of the 25 patients evaluated for RP, 2 patients had a stage
Race
IA2 lesion while 23 patients had a stage IB 1 lesion.
White 21 84
Black 3 12 Demographic information is listed in Table 1. The most
Asian 1 4 common indications for extrafascial hysterectomy were CIS
(48%) and AUB (44%). Of note, 9 patients (36%) had
Stage multiple pre-operative diagnoses at the time of their original
IA2 2 8
surgery (Table 2). The presence or absence of lymph
IB1 23 92
vascular space involvement was documented in the pathol-
Histology ogy report of 22 patients and was present in 8 (36%). The
Squamous 20 80 mean depth of invasion was 6.5 mm (range 2– 13).
Adenocarcinoma 4 16 Of the 25 patients evaluated for RP, 23 underwent RP,
Small cell 1 4
upper vaginectomy, and pelvic and/or para-aortic lympha-
Grade denectomy. Two patients had their procedure aborted sec-
1 5 20 ondary to the presence of extra pelvic disease; namely,
2 11 44 extensive carcinomatosis in one patient, and grossly positive
3 5 20 pelvic nodes in the other. These 2 patients were excluded
Unknown 4 8
from survival analysis. In the 23 patients who underwent
RP, the median number of pelvic nodes removed was 13
(range 1– 23). There were 7 (30%) operative complications
ation of the tissues of concern, namely, the upper vagina, including 2 incidental cystotomies, 1 post-operative ileus,
parametrium, and regional lymphatics, in the setting of and 4 blood transfusions (Table 3). A total of 8 units of
cervical carcinoma [7]. The procedure consists of an upper packed red blood cells were transfused to 4 patients. The
vaginectomy, resection of the parametrium, and removal of mean estimated blood loss for patients having a completed
the pelvic and/or para-aortic lymph nodes. The objective of RP was 900 ml (range 250– 2000). Mean post-operative
our study was to evaluate the morbidity and efficacy of RP length of stay was 3.6 days (range 3– 6).
in the setting of occult cervical carcinoma following an Overall, 19 of the 23 patients who underwent RP had no
extrafascial hysterectomy. residual disease noted in their RP specimen and no evidence
of nodal metastasis. These patients received no adjuvant
therapy. Two of the 19 patients (11%) with a negative RP
Materials and methods specimen recurred. One patient recurred distantly with liver
metastasis. She was treated with chemotherapy but was
After institutional review board approval was obtained, a dead of disease at 9 months. Initial review of her pathology
retrospective chart review identified 338 patients with early was consistent with a poorly differentiated squamous cell
stage cervical carcinoma (FIGO stage IA1 – IIA) treated at carcinoma; however, following her early recurrence, her
the University of Alabama at Birmingham from 1994 to pathology was re-evaluated and thought to be consistent
2000. Twenty-five of these patients were evaluated for a RP with a small cell carcinoma. The second patient had
secondary to the diagnosis of cervical carcinoma made
following an extrafascial hysterectomy. Table 2
To be considered eligible for RP, patients were required Pre-operative diagnoses from operative reports at the time of extrafascial
to have a normal pelvic exam before surgery with no hysterectomy for 25 RP candidates
evidence of residual disease at the vaginal cuff or in the Diagnosis Number Percentage
parametrium. Furthermore, pathology from the extrafascial CIS 12 48
hysterectomy was reviewed to exclude patients with micro- AUB 11 44
invasive lesions (IA1) or evidence of cancer involving the Pelvic prolapse 4 16
hysterectomy margin. RP was performed on average 10 Pelvic pain 3 12
Myomas 3 12
weeks after extrafascial hysterectomy (range 6– 15). Clin- Dysmenorrhea 2 8
icopathologic information including demographics, indica- Adnexal mass 1 4
tion for hysterectomy, tumor stage, histology, grade, Endometriosis 1 4
lymphvascular space involvement, nodal status, operative CIN II 1 4
complications, length of stay, recurrence, and survival was Nine patients had multiple pre-operative diagnoses listed.
 C.A. Leath III et al. / Gynecologic Oncology 92 (2004) 215–219
Table 3
Operative complications for 23 patients undergoing RP
Operative complication Number Percentage
None 16 70
Blood transfusion 4 17
Incidental cystotomy 2 9
Post-operative ileus 1 4
No patients are known to have suffered any long-term morbidities including
bladder dysfunction or urinary fistula following their surgery.
recurrence in the vagina and was salvaged with 5040 cGy
of whole pelvic radiation and 3000 cGy of brachytherapy
utilizing Syed needles. Although she remains without
evidence of disease at 103 months of follow-up, she did
require placement of a right ureteral stent following com-
pletion of radiation therapy.
Four patients had residual disease documented at the time
of pathologic review following RP. One patient had residual
disease in the vagina. Of note, her pelvic nodes were
negative. She received 5040 cGy of whole pelvic radiation
therapy in addition to 600 cGy of vaginal brachytherapy
delivered in one application and remains NED at 57 months.
The remaining three patients had evidence of metastasis to
the pelvic nodes. One patient declined radiation and is alive
without evidence of disease at 42 months. Two patients
received adjuvant whole pelvic radiation therapy between
4400 and 5000 cGy. One patient also received vaginal
brachytherapy and both patients are alive at 74 and 66
months, respectively. All four patients with microscopic
disease documented in their RP specimen are alive with a
median follow-up of 62 months (range 42 –74). Overall, the
5-year survival for patients with a completed RP is 96%
with a median follow-up of 61 months (range 9 –103).
Discussion
It is not uncommon for occult cervical carcinoma to be
discovered following hysterectomy for apparently benign
indications. In our series, the most common pre-operative
diagnoses were CIS and AUB. This would suggest that
patients with these diagnoses warrant careful evaluation to
exclude cervical malignancy. This evaluation should include
cervical cancer screening, colposcopy and biopsy, and loop
or conization as deemed appropriate.
Unfortunately, even patients with an appropriate pre-
operative evaluation may be found to have an occult
cervical carcinoma. Extrafascial hysterectomy is not suffi-
cient for those patients with more than microinvasive
cervical carcinoma (Stage IA1) due to high recurrence rates
and mediocre survival rates [6 – 8]. Options for those
patients found to have more invasive cervical carcinoma
on pathologic evaluation of an extrafascial hysterectomy
specimen include radiation therapy with or without chemo-
therapy or RP with lymphadenectomy. In appropriate can-
didates, we favor the option of radical re-operation in this
217
group of primarily young women, which allows for ovarian
preservation and may decrease sexual dysfunction and other
morbidity associated with radiation therapy.
The determination of patient eligibility for a RP is
critical. Our study would suggest that RP should be con-
sidered for the following patients: (1) patients who have
squamous cell carcinoma, adenocarcinoma, or adenosqua-
mous carcinomas; (2) patients who have disease consistent
with Stage IA2 or IB1; (3) patients who have no evidence of
deep invasion or tumor at the margin, and (4) patients who
have no clinical evidence of residual disease at the vaginal
apex or in the parametrium. These patients are likely to have
no residual disease in the RP specimen or evidence of nodal
metastasis, require no additional therapy, and have an
excellent overall survival. The choice of therapy to be
utilized in this group of patients should be one that offers
not only an excellent likelihood of survival, but is also
acceptable in terms of morbidity. Operative morbidity
occurred in 7 of 23 patients (30%) in our series. Operative
complications included 2 incidental cystotomies, 1 ileus,
and 4 blood transfusions. A total of 8 units of packed red
blood cells were transfused to 4 patients. We are aware of no
long-term complications secondary to surgery, including
urinary fistula or voiding dysfunction.
The morbidity findings in our series are very similar to
those from the other published series on RP [15 – 17]. The
most noticeable differences were the rate of blood trans-
fusions and length of hospital stay. Eighty-nine percent of the
patients reported on by Kinney et al. [16] received a blood
transfusion, although only two patients received more than 2
units of blood products. This is in stark contrast to the
transfusion rate of 16% in our series. Also, when compared
to earlier series [15 –17], our post-operative length of hos-
pital stay is much shorter, although changes in insurance and
medical practice since 1989 likely influence these numbers.
Other than known perioperative morbidities, the primary
risk associated with RP is the increase in morbidity that a
woman may experience if she receives post-operative radi-
ation for positive nodes or margins. This morbidity is likely
to be similar to that reported by multiple investigators for
radiation following a radical hysterectomy [18 –20]. Our
selection criteria in general were successful in carefully
identifying patients not likely to require adjuvant radiation
and thus the morbidity associated with adjuvant radiation
was avoided in the majority of our patients without com-
promising overall survival. However, as noted by Orr et al.
[15], the conclusion to withhold radiation can only be
reached after the surgery is performed.
How do the results of this study compare to that in the
published literature? The three largest series that evaluate
the utility and efficacy of patients managed by RP reported
in the literature contain between 18 and 27 patients [15 – 17].
These series utilized similar inclusion and exclusion criteria
before proceeding to RP. A comparison of pathological
findings from the current study and the three previous
studies is provided (Table 4). Early published data on RP
218 C.A. Leath III et al. / Gynecologic Oncology 92 (2004) 215–219
Table 4
A summary and comparison of the incidence of a positive RP from surgical
series on the basis of positive pelvic nodes or positive parametrectomy
specimen in published series
Author Year Number Positive Positive Aborted Negative
nodes margin margins and
negative nodes
Orr et al. 1986 23 3 3 0 17
Kinney 1992 27 2 2 0 23
et al.*
Chapman 1992 18 1 1 1 15
et al.
Current 2003 25 3 1 2 19
series
Totals 93 9 (10%) 7 (7%) 3 (3%) 74 (80%)
* One patient from this series had both a positive para-aortic node and a
positive vaginal specimen and is listed as a positive margin for the purpose
of this table.
by Orr et al. [15] established the feasibility, efficacy, and
acceptable morbidity of the procedure. Seventeen of their 23
patients had a negative RP specimen and all were without
evidence of recurrence with a modest 36-month follow-up.
Technical difficulty of the procedure, as determined by an
evaluation of operative parameters such as blood loss and
operative time, did not differ when compared to radical
hysterectomies.
Subsequent evaluation by Chapman et al. [17] noted an
89% 5-year survival with a median follow-up of 72 months.
Their series confirmed that extended survival can be
obtained in patients with a negative RP specimen. Further-
more, the absence of long-term morbidities, such as urinary
fistula, was encouraging. Long-term survival was also noted
by Kinney et al. [16], which reported an 82% survival with a
median follow-up of 8.4 years. However, they reported
more long-term morbidity, primarily genitourinary in origin.
This increase in post-operative long-term morbidity may be
a function of longer follow-up as compared to the prior
surgical case series. An adequate length of follow-up is
necessary to ensure that favorable survival is durable based
on the observation by Kinney et al. [16] that all recurrences
in their series occurred within 4 years. Overall, the incidence
of positive nodes in these three series and the current series
is 10% (9/93), while the incidence of a 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.
Radiation therapy has been utilized as an alternative to
RP as post-extrafascial hysterectomy therapy [9 – 14,21].
Cosbie [9] reported on 116 patients over three decades that
were evaluated for additional treatment following an extra-
fascial hysterectomy. Fifty-nine of these patients had no
detectable residual carcinoma and received post-operative
radiation therapy. However, the authors noted that 16
patients had microscopic cervical involvement. It is unclear
how many of these 16 patients would receive adjuvant
therapy today. In spite of this large number of patients with
microinvasive disease and no clinical residual disease, their
5-year overall survival was only 71%.
Green and Morse [10] evaluated the outcome of 84
patients that received either surgery or radiation following
an extrafascial or subtotal hysterectomy in the setting of
cervical carcinoma. Thirty of these patients received radia-
tion therapy with a dismal 5-year overall survival of 30%.
This was inferior to the 67% survival at 5 years noted for
patients managed with radical re-operation consisting of the
completion of a Meig’s radical hysterectomy or total pelvic
exenteration. 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 evaluated and treated
within 4 months. This observation has been confirmed in
subsequent series [11,12].
Contemporary survival data from the University of
Virginia utilizing radiation therapy were 93% at 5 years
[21]. However, 12/18 patients suffered either grade 1 or 2
acute toxicities and 2 had long-term complications consist-
ing of one case of chronic diarrhea and one small bowel
obstruction that necessitated surgical exploration. Admitted-
ly, 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 radiation therapy is quite effective for patients
with occult carcinoma of the cervix found at the time of
extrafascial hysterectomy, one must seriously consider the
potential morbidity and costs related to the radiation thera-
py. Importantly, this series documents that fact that 19 of 23
patients were able to avoid the complications of radiation
therapy. The management of the patient with occult cervical
carcinoma noted after extrafascial hysterectomy must be
carefully considered. Acceptable surgical morbidity com-
bined with an excellent survival rate make RP not only an
acceptable, safe alternative for carefully selected patients
with this diagnosis, but our preferred treatment modality.
Acknowledgments
We acknowledge Carrie A. Black and W. Jerod Greer for
their assistance in locating and collecting pertinent medical
records.
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