Who should be offered non-radical surgery for early-stage cervical cancer?

worldwide [1]. The standard treatment for early-stage cervical cancer such as the International Federation of Gynecology and Obstetrics (FIGO) stage IB is radical hysterectomy combined with bilateral pelvic lymph node assessment [2]. Radical trachelectomy is a safe alternative for young women who wish to preserve fertility [3]. The 5-year survival rate is excellent, ranging from 73.4% to 97.5% [4-6]. However, those radical procedures have significant morbidity, mainly as a result of the removal of the parametria. The parametrectomy is the most challenging part of the procedure and major complications have been reported such as blood loss, bladder and rectal dysfunction, sexual dysfunction, and fistula formation [7-12]. In recent years, the value of radical hysterectomy or trachelectomy in early-stage cervical cancer has been questioned. Parametrial involvement in early-stage cervical cancer with favorable prognostic factors can be as low as 1% [13-15]. Several reports have suggested that less radical surgery such as cervical conization, simple trachelectomy or simple hysterectomy with pelvic lymph node assessment is probably sufficient in well-selected early-stage cervical cancer to achieve excellent oncologic outcomes [16-19]. Reade et al. [13] recently summarized those reports and identified 476 women with early-stage cervical cancer managed with non-radical surgery. The reported recurrence rate was 1.5% and the rate of cancer-related death was 0.5%. Although level I evidence is still missing, this report suggests that non-radical surgery is probably a safe option in low-risk early-stage cervical cancer patients. Various retrospective studies have tried to identify which patients are at low-risk of parametrial involvement. Small tumor size, limited depth of invasion, negative lymph node status, and absence of lymphovascular space invasion (LVSI) are some of the prognostic factors associated with low-risk of parametrial involvement, however no consensus has yet been reached [14,20,21]. The caveat with those low-risk criteria is that pathologic assessment of the surgical specimens is required to confirm depth invasion, lymph node status, and the presence of LVSI. To date, non-radical surgery has been offered to patients with small (<2 cm) cervical cancer with no evidence of radiological lymph node involvement. It remains unclear in which patients we may safely avoid a parametrectomy. We congratulate Dr. Yamazaki and colleagues [22] who have tried to answer this question in their retrospective cohort study titled “Pretreatment risk factors for parametrial involvement in FIGO stage IB1 cervical cancer.” More specifically, they tried to identify preoperative factors that could help guide whether radical or non-radical surgery is required. They included 115 patients who underwent radical hysterectomy or trachelectomy for the management of FIGO stage IB1 cervical cancer. All patients included had a magnetic resonance imaging (MRI) done to confirm maximum tumor diameter, tumor volume, and size of pelvic lymph node. Serum concentrations of squamous cell carcinoma (SCC) antigen with a cut-off value of 1.5 ng/mL and serum cancer antigen 125 level with a cut-off value of 35 U/mL were obtained. Factors included on univariate analysis were histologic variant (SCC vs. non-SCC), maximum tumor diameter (<25 mm vs. ≥25 mm), pelvic lymph node enlargement (no vs. yes), volume index (<5,000 mm vs. ≥5,000 mm), and tumor markers (negative vs. positive). In their cohort, the reported rate of parametrial involvement and pelvic lymph node metastases was higher than one Who should be offered non-radical surgery for earlystage cervical cancer?