Special Issue: “Management of Early Stage Cervical Cancer”

Cervical carcinoma is a common gynecological malignancy that remains a challenge for oncologic gynecologists around the world [...].

Considering the potential benefit in terms of the relapse and survival of patients undergoing conization, together with the diagnostic information that may enhance our ability to make the appropriate recommendation, the SUCCOR study showed that cervical conization, especially in small tumors (up to 2 cm, as conization has no role in large tumors), may be used for tailoring the surgery and the choice of surgical approach in cervical cancer patients [6]. Regarding the potential protective effect of conization, despite the publication of the LACC trial [7], the reasons for minimally invasive surgery having worse oncological outcomes have not been well established. In this context, the analyses of the SUCCOR group may suggest the hypothesis that in minimally invasive surgery the tumor experiences less exposure and manipulation due to prior diagnostic conization [8,9].
Fusegi et al. presented the results of their no-look no-touch technique (consisting of four steps to prevent tumor spillage), showing similar DFS rates when compared with the laparotomic approach, even when the tumor diameter exceeds 2 cm [10].
The most popular classifications of radical hysterectomy are based on the lateral extent of the resection (Piver or Querleu-Morrow). In his report, Muallem presented a new classification based on a three-dimensional way of tumor spreading, including the removal of the vaginal cuff and the paracolpium as an essential part of the surgical procedure [11]. Furthermore, this new classification is based on the concept that when there is a risk of parametrial/paracolpium involvement according to the local extent of the disease, these tissues should be completely removed to allow their evaluation, since their invasion is reported to be mainly discontinuous, in a way similar to lymphovascular space infiltration or lymph node metastasis [12].
Since almost 40% of all cervical diagnoses are made in women aged 20-39 years [13], the interest in strategies for fertility preservation is becoming more widespread. However, fertility-sparing management in cervical cancer patients when the tumor diameter exceeds 2 cm is considered to be an experimental approach [14,15]. Buda and colleagues revised the literature about the use of neoadjuvant chemotherapy followed by fertility-sparing surgery in women with stage IB2 cervical cancer. Although in a total of 114 patients they reported an optimal pathological response rate of 60.9% and a pregnancy rate of 85.7%, 61.1% of patients experienced miscarriages or pre-term labor, underlying the fact that there is not enough evidence in the literature to draw firm conclusions [16]. As in locally advanced tumors, the pathologic residual tumor after neoadjuvant therapy seems to be the most important prognostic factor [17][18][19].
On the other hand, the incidence of disease at a fertility age poses the problem of pregnancy-associated cervical cancer, which has increased in Japan in recent years. For this reason, Enomoto and colleagues published a multicenter survey to try to understand this topic, drawing attention to a period of poor adherence to the human papillomavirus (HPV) vaccination. They reported different treatment strategies (conization, trachelectomy and neoadjuvant treatment) with no differences in terms of oncological outcomes, as well as a surprising tendency for a longer duration of pregnancy in patients who underwent trachelectomy and a significantly higher incidence of fetuses that were small for their gestational age in the neoadjuvant group [20].
Last but not least, the research was continued in the study of the pathogenesis of cervical cancer. The most important cause of cervical carcinogenesis is represented by HPV, especially HPV16 and HPV18, accounting for approximately 50% and 20%, respectively, of the detected cases in cervical cancer [21]. From 2000, different studies showed that HOXD9 regulates the early promoter of HPV16. Hayashi et al. confirmed its role even in the regulation of HPV18, implementing the results in the research of a target therapy especially for the worse prognoses HPV-related histotypes [22].
In conclusion, this Special Issue presents updated research on topics that are useful for gynecologic oncologists in the management of early-stage cervical cancer.

Conflicts of Interest:
The authors declare no conflict of interest.