Linda R. Duska, MD

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.

Childbearing is one of the most important life goals for many women, and fertility preservation is a very important factor in the overall quality of life of cancer survivors. Cervical cancer frequently affects young women; because some women tend to delay childbearing, fertility preservation must be considered when treatment options are discussed. Over the past decade, the radical trachelectomy procedure has become a well established fertility-preserving option for young women with early-stage cancer; this procedure is associated with low morbidity, good oncologic outcome, and a high proportion of pregnancies that reach the third trimester and babies that are delivered at term. This article will review available literature on the vaginal radical trachelectomy procedure and data from other surgical approaches, such as the abdominal radical trachelectomy. In addition, the potential future application of neoadjuvant chemotherapy followed by fertility-preserving surgery in patients with locally advanced cervical cancer will be examined. Finally, ultraconservative surgical approaches (eg, conization alone with or without laparoscopic lymphadenectomy) in very early-stage disease will be discussed.