Parametrial resection for invasive cervical cancer

Removal of the parametrium represents the greatest technical challenge and is the main source of treatment related morbidity during radical surgery for carcinoma of the cervix. The move away from radical en bloc strategies, seen in breast and vulvar cancer surgery, has not taken place in cervical cancer; rather an increase of radicality has been advocated. One important reason is uncertainty about the pattern of lymphatic drainage in the parametrium, in particular the existence or absence of parametrial lymph nodes. According to classic anatomic studies and more recent lymphangiographic studies, the parametrium is viewed as a lymph collecting trunk interposed between the organ of drainage (the cervix) and the regional nodes located on the pelvic wall. In contrast to this view, studies in cervical cancer patients using the giant section technique have reported nodes that may be involved early in spread of cervical cancer and which are distributed randomly throughout the parametrium. Based on this observation a strategy of uncompromised radicality regarding parametrial resection has evolved in preference to an individualized strategy with the degree of radicality tailored according to the need for safe margins around the central tumor. This review presents an overview of current knowledge about the parametrium and a discussion about decision making regarding parametrial resection in cervical cancer.