For a woman with FIGO stage IA2–IB1 cervical cancer, tumor ≤2 cm, clinically negative nodes, and no desire for fertility preservation, is simple total hysterectomy with sentinel‑node biopsy an appropriate alternative to radical hysterectomy according to the SHAPE trial?

Simple Hysterectomy with Sentinel Node Biopsy for Low-Risk Early Cervical Cancer

For women with FIGO stage IA2–IB1 cervical cancer with tumors ≤2 cm and clinically negative nodes who do not desire fertility preservation, simple total hysterectomy with sentinel node biopsy is an appropriate and preferred alternative to radical hysterectomy based on the SHAPE trial results. 1, 2

Evidence from the SHAPE Trial

The SHAPE trial definitively established that simple hysterectomy is non-inferior to radical hysterectomy for carefully selected low-risk patients:

• No recurrences occurred in either surgical arm among patients meeting very low-risk criteria (Conservative SHAPE group, n=107) during median follow-up of 4.5 years 2
• Even in the broader Liberal SHAPE group (n=575), simple hysterectomy showed similar 3-year outcomes: pelvic recurrence-free survival (96.9% vs 97.4%), overall recurrence-free survival (95.4% vs 97.4%), and overall survival (98.9% vs 99.3%) compared to radical hysterectomy 2
• Simple hysterectomy was not associated with increased recurrence or mortality rates in multivariate analyses 2

Significant Quality of Life Advantages

Simple hysterectomy provides substantial functional benefits without compromising oncologic outcomes:

• Sexual dysfunction was significantly reduced with simple hysterectomy, meeting dysfunction cutoff only up to 6 months versus longer with radical hysterectomy (P=0.02) 3
• Desire, arousal, pain, and lubrication scores were significantly better with simple hysterectomy up to 12 months (P≤0.018) 3
• Sexual-vaginal functioning remained better up to 24 months and sexual activity remained higher up to 36 months with simple hysterectomy (P≤0.024) 3
• Body image was significantly better at 3,24, and 36 months with simple hysterectomy (P≤0.01) 3
• Global health status was significantly higher at 36 months for simple hysterectomy (P=0.025) 3

Reduced Surgical Morbidity

Simple hysterectomy demonstrates clear perioperative advantages:

• Significantly lower risk of urinary retention and incontinence compared to radical hysterectomy in both very low-risk and broader risk groups 2
• Shorter operating time, less intraoperative blood loss, fewer intraoperative complications, fewer postoperative complications, and shorter hospital stay 4
• Lower rates of lymphedema (24%), lymphocysts (22%), and urinary complications (18.5%) compared to radical procedures 5

Critical Selection Criteria

This approach is appropriate ONLY when ALL of the following criteria are met:

• Tumor size ≤2 cm (this is the validated cutoff from SHAPE and supporting studies) 1, 2, 5, 4
• FIGO stage IA2–IB1 disease 2, 5
• Clinically negative lymph nodes (confirmed by sentinel node biopsy or pelvic lymphadenectomy) 2
• No desire for fertility preservation (as this question specifies) 6
• Ideally, absence of lymphovascular space invasion, though SHAPE included some LVSI-positive cases 2, 5

Sentinel Node Assessment is Essential

Pelvic lymph node assessment via sentinel node biopsy must be performed as part of the simple hysterectomy procedure:

• Approximately 71.8% of women in simple hysterectomy studies underwent lymph node assessment 5
• Sentinel node detection should be performed bilaterally using blue dye, technetium radiocolloid, or fluorescent indocyanine green injected directly into the cervix 6
• This technique should only be performed in centers with adequate expertise and training 6
• If sentinel nodes are positive, the patient should receive adjuvant chemoradiation rather than proceeding with more extensive surgery 6

Important Caveats and Pitfalls

Do not perform simple hysterectomy if:

• Tumor size exceeds 2 cm—these patients require radical hysterectomy or primary chemoradiation 6
• Lymph nodes are found positive intraoperatively—abandon hysterectomy and proceed with chemoradiation to avoid combined modality toxicity 6
• There is parametrial involvement, positive margins, or deep stromal invasion identified on imaging 6

Recognize that older guidelines (2017-2019) were written before SHAPE trial results:

• ESMO 2017 guidelines noted that radical hysterectomy "most likely constitutes overtreatment" for small tumors and referenced SHAPE as ongoing 6
• NCCN 2019 guidelines recommended radical hysterectomy as standard but acknowledged this was being studied 6
• The 2023-2026 SHAPE trial results now supersede these older recommendations for the specific low-risk population 1, 2, 3

Adjuvant Treatment Considerations

Post-surgical management depends on final pathology:

• Observation is appropriate if lymph nodes are negative and no high-risk pathologic features are present 6, 7
• Adjuvant pelvic radiation (with or without cisplatin) is indicated if intermediate-risk factors are found: deep stromal invasion, LVSI, or large tumor size 6, 7
• Adjuvant chemoradiation is mandatory if high-risk features are identified: positive lymph nodes, positive margins, or parametrial involvement 6, 7

Global Impact

These findings establish a new standard of care that is particularly important for resource-limited settings where radical surgery expertise may be limited and where cervical cancer mortality is highest 1