Treatment of Gynecologic Cancers: From Halsted to the 21st Century

Halsted first proposed the concept of "radical surgery" for cancer in 1882, theorizing that cancer, along with all of its supporting tissues and regional lymph nodes, needs to be removed en bloc for the best chance of cure. Radical mastectomy with en bloc removal of the axillary nodes and pectoral muscles became the standard treatment for breast cancer. En bloc radical vulvectomy with complete superficial and deep inguniofemoral lymph node dissection became the standard of care for vulvar cancer. Subsequently, unilateral or bilateral pelvic node dissection extended the scope of the regional node dissection for vulvar cancer patients with metastases to groin nodes. Unquestionably, this surgically comprehensive technique improved cancer control rates for patients with locally extensive vulvar cancer, compared to results from piecemeal approaches that characterized surgical therapy in prior eras.

Both acutely and chronically, these operations are significantly morbid. Radical extirpative vulvectomy in continuity with bilateral inguinofemoral lymphadenectomy resulted in at least a 50% risk of postoperative wound breakdown. Deformity and loss of function including leg lymphedema, dyspareunia, anorgasmia, and occasional loss of urinary or fecal continence became the common sequelae of maximally intensive surgical therapy for cancer of the vulva.

Evolving Techniques

Over the past 2 decades, operations for both breast and vulvar cancer have progressively receded from Halsted's original principles, both with the intent to improve wound healing as well as to conserve form, function, and cosmesis. The first surgical innovation in vulvar cancer was to perform the vulvectomy and groin node dissections using three incisions rather than en bloc, diminishing the wound breakdown rate by leaving the skin bridges between the vulva and the groin in situ, thereby reducing tension on the operative closure. As lymphatic dissemination in vulvar cancer is generally embolic rather than permeative, recurrence in conserved skin bridges was found to be extraordinarily rare (and the operation consequently safe) absent extensive metastatic spread to groin nodes.

A subsequent surgical innovation was to remove the primary cancer with a 2-cm gross margin, and not the entire vulva. This allowed conservation of functionally important structures of the vulva, particularly in patients with well-lateralized primary lesions. From the standpoint of quality of life with preservation of form and function, these deviations from Halstedian orthodoxy have been invaluable. Careful outcomes analyses have documented no decrement in cancer control consequent to these conservative innovations.

Complete groin lymphadenectomy can have significant quality-of-life consequences, including significant lower-extremity lymphedema with recurring episodes of cellulitis that can become disabling. However, despite adopting a more conservative stance regarding surgery of the vulva, many gynecologic surgeons have been reluctant to endorse a less radical approach to the groin node dissection. While the technique of sentinel node dissection has become standard practice in breast cancer, its adoption has been slow for vulvar cancer.

The majority of cancer recurrences in breast cancer patients involve systemic (hematogenous) spread. In contrast, the overwhelming majority of patients who relapse after attempted curative surgery for vulvar cancer initially recur locally or in regional nodes. Even when regional nodes harbor metastatic foci, hematogenous dissemination without antecedent or coincident regional failure is uncommon. As the most frequent consequence of groin relapse is death from cancer, hesitation to embrace less radical surgical therapy of the groins is understandable

Sentinel Node Dissection

The current report by Frumovitz and Levenback provides ample data that for patients with cancer of the vulva, sentinel node dissection in the hands of an experienced provider is a fully adequate alternative to more extensive groin dissection. Such surgery should be more widely available in the United States for management of this cancer. As the authors note, there is a steep learning curve, and the gynecologic oncologist will need to invest time and effort in the training necessary to perform this surgery appropriately. As a community, gynecologic oncologists can learn from the experience of surgical colleagues treating melanoma and breast cancer patients who have successfully integrated sentinel node techniques in their practice to preserve the quality of their patients' lives without compromising cancer control.

Unfortunately, the role of sentinel node dissection in vaginal cancer and endometrial cancer is less clear. More work needs to be done in this area to determine if it is feasible to reliably identify sentinel nodes for these cancers, or whether the lymphatic drainage from each individual cancer is too difficult to accurately predict. In cervical cancer, for which more data are available, it seems more promising that a technique can be developed that will ultimately guide treatment in a manner that will conserve quality of life.

Conclusions

The dual but inherently divergent goals of cancer therapy are to maximize the probability of cancer control while minimizing the acute morbidity of treatment and the potential life-altering normal tissue sequelae in patients cured of their cancers. In the 21st century, we know we can cure many gynecologic cancers when they are diagnosed early. Our patients benefit from the addition of sophisticated chemotherapy and radiotherapy techniques unavailable to Halsted, his contemporaries, and their patients.

Prudent implementation of techniques to conserve quality of life after cancer cure should be encouraged, particularly when early diagnosis confers a very favorable prognosis and the cancer threat to life may be less compelling than the treatment threat to lower limbs. Continued investigation of alternative surgical approaches to cancer care, logically based on increasingly sophisticated understanding of cancer and host biology, will result in more individualized cancer care rewarded by better outcomes than care dictated by inflexible adherence to dogma of the past.

-Linda R. Duska, MD
-Anthony H. Russell, MD

Disclosures:

Financial Disclosure: The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.