Radical Trachelectomy for Early Stage Cervical Cancer

Feasibility of the "cuff-sleeve" suture method in improving the uterine blood supply after radical trachelectomy: A retrospective analysis

Objective

To explore the feasibility of the "cuff-sleeve" suture method in improving the uterine blood supply after radical trachelectomy (RT).

Study design

Patients in the "cuff-sleeve" (n = 25) and traditional group (n = 10) underwent computed tomography angiography (CTA) to evaluate the residual uterine blood supply pattern after the surgery, and the preoperative group patients (n = 20) underwent CTA before the procedure.

Results

The uteri of the 20 patients in the preoperative group were all supplied by bilateral uterine arteries of average diameter, 2.25 ± 0.35 mm. The uterine artery-supplying, hybrid supplying, and ovarian artery-supplying patterns accounted for 40 %, 36 %, and 24 % in the "cuff-sleeve" group and 20 %, 50 %, and 30 %, respectively, in the traditional group. The average diameter of the uterine arteries among the uterine artery-supplying pattern in the "cuff-sleeve" group (1.98 ± 0.36 mm) was more extensive than that in the traditional group (1.73 ± 0.15 mm) (p = 0.049). As also, the ovarian artery diameter of the hybrid supplying pattern in the "cuff-sleeve" group (1.65 ± 0.25 mm) was significantly larger than that in the traditional group (1.50 ± 0.35 mm) (p = 0.010). Additionally, while the pregnancy rate in the "cuff-sleeve" group (50.0 %) was higher than that in the traditional group (25.0 %), this difference was not statistically significant.

Conclusions

The "cuff-sleeve" suture method was associated with increased diameter of the uterine and ovarian vessels and may be a feasible method to improve the uterine blood supply and pregnancy rate after radical trachelectomy. It still warrants further evaluation for both fertility and oncologic outcomes.

Comparison of the diagnostic value of [68 Ga]Ga-FAPI-04 PET/MR and [18F]FDG PET/CT in patients with T stage ≤ 2a2 uterine cervical cancer: a prospective study

PURPOSE

To compare the diagnostic value of [68 Ga]Ga-FAPI-04 PET/MR and [18F]FDG PET/CT in patients with T stage ≤ 2a2 uterine cervical cancer patients.

METHODS

Patients pathologically diagnosed with cervical cancer and with a T stage ≤ T2a2 were prospectively enrolled. All patients underwent whole-body [68 Ga]Ga-FAPI-04 PET/MR and [18F]FDG PET/CT within 2 weeks, and surgical treatment was performed within 10 days after PET.

RESULTS

Twenty-five patients were enrolled. Twenty patients underwent radical hysterectomy, among which all of them underwent pelvic lymphadenectomy, and 10 patients underwent para-aortic lymphadenectomy. Three patients received merely laparoscopic lymphadenectomy without hysterectomy. Two patients with both [18F]FDG and [68 Ga]Ga-FAPI-04 lymph node high metabolism were staged as FIGO IIIC1r, and concurrent chemoradiation therapy (CCRT) was performed. [18F]FDG and [68 Ga]Ga-FAPI-04 had equivalent detection ability on primary tumors, with a positive detection rate of 96.0%. The accuracy of T staging using [18F]FDG and [68 Ga]Ga-FAPI-04 was relatively 50% and 55.0%. Elevated and underrated staging was due to misdiagnosis of either vaginal infiltration or tumor size. In terms of lymph node metastasis detection, the specificity of [68 Ga]Ga-FAPI-04 was 100% (95% CI, 84.6% ~ 100.0%), which was significantly higher than [18F]FDG (59.1% (95% CI, 36.4% ~ 79.3%)) (p = 0.004).

CONCLUSION

[68 Ga]Ga-FAPI-04 PET/MR and [18F]FDG PET/CT demonstrated an equivalent detection ability on cervical cancer primary tumors. However, [68 Ga]Ga-FAPI-04 PET/MR's diagnostic value in lymph node metastasis was significantly higher than [18F]FDG PET/CT. [68 Ga]Ga-FAPI-04 PET/MR has the potential for more accurate treatment planning, thus clarifying fertility preservation indications for early-stage young patients.

Predicting Lymph Node Metastasis From Primary Cervical Squamous Cell Carcinoma Based on Deep Learning in Histopathologic Images

We developed a deep learning framework to accurately predict the lymph node status of patients with cervical cancer based on hematoxylin and eosin-stained pathological sections of the primary tumor. In total, 1524 hematoxylin and eosin-stained whole slide images (WSIs) of primary cervical tumors from 564 patients were used in this retrospective, proof-of-concept study. Primary tumor sections (1161 WSIs) were obtained from 405 patients who underwent radical cervical cancer surgery at the Fudan University Shanghai Cancer Center (FUSCC) between 2008 and 2014; 165 and 240 patients were negative and positive for lymph node metastasis, respectively (including 166 with positive pelvic lymph nodes alone and 74 with positive pelvic and para-aortic lymph nodes). We constructed and trained a multi-instance deep convolutional neural network based on a multiscale attention mechanism, in which an internal independent test set (100 patients, 228 WSIs) from the FUSCC cohort and an external independent test set (159 patients, 363 WSIs) from the Cervical Squamous Cell Carcinoma and Endocervical Adenocarcinoma cohort of the Cancer Genome Atlas program database were used to evaluate the predictive performance of the network. In predicting the occurrence of lymph node metastasis, our network achieved areas under the receiver operating characteristic curve of 0.87 in the cross-validation set, 0.84 in the internal independent test set of the FUSCC cohort, and 0.75 in the external test set of the Cervical Squamous Cell Carcinoma and Endocervical Adenocarcinoma cohort of the Cancer Genome Atlas program. For patients with positive pelvic lymph node metastases, we retrained the network to predict whether they also had para-aortic lymph node metastases. Our network achieved areas under the receiver operating characteristic curve of 0.91 in the cross-validation set and 0.88 in the test set of the FUSCC cohort. Deep learning analysis based on pathological images of primary foci is very likely to provide new ideas for preoperatively assessing cervical cancer lymph node status; its true value must be validated with cervical biopsy specimens and large multicenter datasets.

Comparative single-center study between modified laparoscopic radical hysterectomy and open radical hysterectomy for early-stage cervical cancer

BACKGROUND

Since the release of the LACC trial results in 2018, the safety of laparoscopic radical hysterectomy (LRH) for cervical cancer has received huge attention and heated discussion. We developed modified laparoscopic radical hysterectomy (MLRH) incorporating a series of measures to prevent tumor spillage, which has been performed in our center since 2015.

OBJECTIVE

Present study retrospectively analyzed relevant indicators of MLRH and evaluated disease-free survival (DFS) primarily in the treatment of early cervical cancer compared with open surgery.

METHODS

Patients with 2014 International Federation of Gynecology and Obstetrics clinical stages 1B1 and 2A1 cervical cancer who underwent radical hysterectomy in the gynecological department of our hospital from October 2015 to June 2018 were enrolled retrospectively in this study. Patients were divided into two groups based on the surgical procedure: open radical hysterectomy (ORH) group (n = 336) and MLRH group (n = 302). Clinical characteristics, surgical indices, and survival prognosis were analyzed, including 2.5-year overall survival (OS) rate, 2.5-year DFS rate, recurrence rate, and recurrence pattern.

RESULTS

Compared to the ORH group, the MLRH group exhibited a longer operative time, longer normal bladder function recovery time, less intraoperative blood loss volume, and more harvested pelvic lymph nodes (P < 0.05). No significant differences were observed in postoperative complications, the 2.5-year OS, 2.5-year DFS, and recurrence rate between the two groups (P > 0.05); however, the recurrence pattern was significantly different (P < 0.05). The MLRH group mainly exhibited local single metastasis (7/11), whereas the ORH group mainly exhibited distant multiple metastases (14/16). Stratified analysis revealed that overall survival rate was higher in the MLRH group than in the ORH group in patients with stage 1B1 and middle invasion (P < 0.05).

CONCLUSION

MLRH does not show a survival disadvantage in the treatment of early-stage cervical cancer when compared with open surgery. In addition, MLRH shows a survival advantage in patients with stage 1B1 and middle 1/3 invasion. Considering this is a retrospective study, further prospective study is necessary for more sufficient data support.

TRIAL REGISTRATION

Present research is a retrospective study. The study had retrospectively registered on Chinese Clinical Trial Registry ( http://www.chictr.org.cn/ ), and the registered number is ChiCTR1900026306.

The best postoperative adjuvant therapy for patients with early stage cervical adenosquamous carcinoma

Background

Cervical adenosquamous carcinoma (ASC) was previously thought to be a subtype of cervical adenocarcinoma, but recent studies have found that the clinical features of the two diseases are different. Moreover, the pathological characteristics, survival, prognosis, and optimal ASC therapy remain unknown. This study aims to retrospectively analyze the postoperative survival of patients with early-stage ASC and to evaluate their condition after treatment with postoperative concurrent chemoradiotherapy (CCRT) and prophylactic irradiation of the para-aortic lymphatic drainage area.

Methods

This study enrolled 131 patients with pathologically confirmed ASC screened from 3502 patients with confirmed stage I–II cervical cancer diagnosis who had completed surgical treatments in our hospital. Among the 131 enrolled patients, 75 patients received CCRT, 33 patients received chemotherapy (CT), and 23 patients did not receive adjuvant treatment (named surgery alone (S alone). Of the 75 patients CCRT, 43 patients received prophylactic irradiation of the para-aortic lymphatic drainage area. The efficacy of the postoperative treatments of patients among groups (CCRT, CT, and S alone) was compared.

Results

The median follow-up time, age, and overall survival (OS) were 76 months, 43 years, and 74 months, respectively. The 3- and 5-year survival rates were 82% and 71.4%, respectively. The median disease-free survival (DFS) was 64 months. Cox regression analysis showed that postoperative adjuvant treatment modalities and positive lymph node metastases were associated with OS and DFS. Patients who received CCRT treatment had higher OS and DFS than those with CT and S alone. Prophylactic irradiation of the para-aortic lymphatic drainage area did not improve the OS and DFS of patients with CCRT treatment. However, further subgroup analysis suggested that it might improve survival rates in patients who had positive pelvic lymph nodes as confirmed by postoperative pathology.

Conclusion

Postoperative CCRT improved the survival rates in patients with early-stage ASC. The value of prophylactic irradiation of the para-aortic lymphatic drainage area remains debatable, but it may benefit patients with pelvic lymph node involvement.

Classifying early stages of cervical cancer with MRI-based radiomics

This study aims to establish a MRI-based classifier to distinguish early stages of cervical cancer with improved diagnostic performance to assist clinical diagnosis and treatment. 57 patients with pathological diagnosis of cervical cancer from January 2018 to May 2019 were enrolled in this study. MRI examinations, including T1-weighted image(T1WI), T2-weighted image(T2W), diffusion weighted imaging (DWI) and dynamic contrast enhanced (DCE), were performed before surgery. MR images from patients of stage Ib or IIa cervical cancer with tumor segmented were used as input. Feature extraction process extracted first-order statistics and texture and applied filters. The dimensionality of the radiomic features was reduced using the least absolute shrinkage and selection operator (LASSO). Models were trained by three machine-learning (k-nearest neighbor (KNN), support vector machine (SVM), and logistic regression (LR)) and diagnostic performance in differentiating stage Ib and stage IIa cases was evaluated. A total of 27 features were extracted to establish models, including 2 features from T1WI, 5 features from T2WI, 5 features from DWI (b = 50), 4 features from DWI (b = 800), 5 features from DCE, and 6 features from ADC. For each machine learning (ML) classifier, six sequences of training set and testing set are modeled and analyzed. Among all the models, the training set and testing set of T2WI model built by SVM classifier were the best (Area under the curve (AUC) 0.915) / (AUC 0.907). Radiomic analysis of ML-based texture features and first-order statistics features can be used to stage the early cervical cancer pre-operatively.

Fertility-Sparing and Less Radical Surgery for Cervical Cancer

PURPOSE OF REVIEW

Patients with early-stage cervical cancer who desire future fertility may be candidates for less radical surgery. We review the literature supporting this approach in early-stage disease.

RECENT FINDINGS

Retrospective data have shown that in carefully selected patients, the risk of parametrial involvement is less than 1%. This has led to interest in moving away from radical surgery towards more conservative approaches. Data from the newly published ConCerv trial, a prospective study evaluating the feasibility of conservative surgery in women with early-stage, low-risk cervical carcinoma, suggest that conservative surgery is feasible and safe in this patient population. Furthermore, neoadjuvant chemotherapy is being assessed as an option to extend fertility-sparing treatment to a larger group of women. Less radical surgery may be appropriate for carefully selected women with early-stage, low-risk cervical cancer, including those desiring future fertility.

Prospective assessment of urinary and bowel symptoms, and sexual function between laparoscopic assisted vaginal radical trachelectomy and radical hysterectomy

OBJECTIVE

Radical trachelectomy is a valid alternative to radical hysterectomy in women with a desire to retain their fertility. Data regarding the oncological outcomes of radical trachelectomy are comparable with those of radical hysterectomy but information regarding urinary and sexual function is limited. The aim of this study was to prospectively evaluate and compare quality of life, urinary and bowel symptoms, and sexual dysfunction between patients who underwent laparoscopic assisted vaginal radical trachelectomy versus radical hysterectomy for early-stage cervical cancer.

METHODS

Patients who underwent laparoscopic assisted vaginal radical trachelectomy or radical hysterectomy along with sentinel or systemic pelvic lymphadenectomy were included between May 2015 and January 2017. Patients were asked to complete a validated questionnaire (German pelvic symptom questionnaire) on bladder, bowel, prolapse, and sexual function, and total pelvic score, at least 48 hours before surgery and 6 months after surgery.

RESULTS

A total of 51 patients were included. Of these, 26 patients (50.9%) underwent laparoscopic assisted vaginal radical trachelectomy and 25 (49.1%) underwent radical hysterectomy. No patient was converted to laparotomy. The majority of patients (76%) were diagnosed with International Federation of Gynecology and Obstetrics (FIGO 2018) stage 1B1 disease, with squamous cell carcinoma (54%) and grade II tumors (52%). Four patients (7.8 %) experienced perioperative complications (two grade II and two grade III complications according to the Clavien-Dindo classification). In the preoperative evaluation, the median scores for the four items of the questionnaire (bladder, bowel, prolapse, and sexual items) and total pelvic score were comparable between the two groups. The mean scores for radical hysterectomy and radical trachelectomy at the beginning of the study for bladder, bowel, prolapse, and sexual function were 0.93 versus 0.71, 0.71 versus 1.01, 0.12 versus 0.1, and 1.06 versus 1.0, respectively. On preoperative testing, the median scores for all four items of the questionnaire (p_bladder=0.821, p_bowel=0.126, p_prolapse=0.449, p_sexual=0.965) and the total pelvic score (p=0.756) were comparable between the two groups. The radical hysterectomy group had worse total pelvic scores at the 6 month postoperative survey compared with baseline (p=0.03). There was no difference in bladder (p=0.07) or bowel symptoms (p=0.07) in the radical hysterectomy group comparing baseline with the 6 month assessment. Women undergoing radical hysterectomy experienced more urinary morbidity than women undergoing vaginal trachelectomy at 6 weeks (p=0.025). However, the mean bladder and pelvic scores in the 6 month control were comparable between patients who had and those who had not experienced urinary morbidity (p_bladder=0.127, p_{total pelvic score}=0.480).

CONCLUSION

Patients undergoing laparoscopic assisted vaginal radical trachelectomy had similar pelvic scores in both the preoperative and postoperative periods. However, patients undergoing radical hysterectomy showed worse total pelvic scores on the postoperative assessment compared with the baseline evaluation. Urinary dysfunction in the early postoperative phase was more common in the radical hysterectomy group than in trachelectomy group.

Minimally invasive versus open radical trachelectomy for early-stage cervical cancer: protocol for a multicenter randomized controlled trial in China

Background

There are limited data comparing the oncologic and fertility outcomes of patients with early-stage cervical cancer (CC) treated by minimally invasive radical trachelectomy (MIRT) or abdominal radical trachelectomy (ART). The purpose of this multicenter study is to compare the oncologic and fertility outcomes of patients treated by MIRT or ART in a randomized controlled manner in China.

Methods

This is a noninferiority, randomized controlled trial performed at 28 Chinese centers; the study is designed to compare the oncologic and fertility outcomes of patients treated by MIRT (robot-assisted or laparoscopic RT) or ART. Patients will be recruited if they have been diagnosed with stage IA1 (with lymphovascular space invasion), IA2, or IB1 CC (with a maximum tumor diameter ≤ 2 cm) in the FIGO 2009 staging system and histological subtypes of squamous carcinoma, adenocarcinoma, or adenosquamous carcinoma and if they are also aged 18 to 40 years. These candidates will be randomly assigned to undergo MIRT or ART. The primary endpoint will be disease-free survival. Secondary endpoints will consist of overall and disease-free survival rates, fertility outcomes, and quality of life. A total of 414 patients are needed to accomplish the study goal, with 90.1% power at a 0.050 significance level to detect an equivalence hazard ratio of 0.75 in the ART group, considering 20% loss to follow-up.

Discussion

The results of the trial should provide robust evidence to surgeons regarding options for the surgical approach in patients with early-stage CC who have a strong willingness to preserve fertility.

Trial registration

ClinicalTrials.gov NCT03739944. Registered on November 14, 2018

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-020-04938-3.

Outcome and Subsequent Pregnancy after Fertility-Sparing Surgery of Early-Stage Cervical Cancers

We aimed to investigate the outcomes and subsequent pregnancies of early-stage cervical cancer patients who received conservative fertility-sparing surgery. Women with early-stage cervical cancer who underwent conservative or fertility-sparing surgery in a tertiary medical center were reviewed from 2004 to 2017. Each patient's clinicopathologic characteristics, adjuvant therapy, subsequent pregnancy, and outcome were recorded. There were 32 women recruited, including 12 stage IA1 patients and 20 stage IB1 patients. Twenty-two patients received conization/LEEP and the other 10 patients received radical trachelectomy. Two patients did not complete the definite treatment after fertility-sparing surgery. There were 11 women who had subsequent pregnancies and nine had at least one live birth. The live birth rate was 73.3% (11/15). We conclude that patients with early-stage cervical cancer who undergo fertility-sparing surgery can have a successful pregnancy and delivery. However, patients must receive a detailed consultation before surgery and undergo definitive treatment, if indicated, and regular postoperative surveillance.

The safety and effectiveness of preserving the ascending uterine artery in a modified fertility-sparing abdominal radical trachelectomy

OBJECTIVE

To evaluate the outcome of preserving the ascending uterine artery in a modified fertility-sparing abdominal radical trachelectomy and understand whether preserving uterine arteries during abdominal radical trachelectomy is helpful for patients.

METHODS

From September 2005 to September 2019, 31 early uterine cervical cancer patients who underwent modified fertility-sparing abdominal radical trachelectomy were enrolled in this study, and were followed up in our cancer center. Computed tomography (CT) of the abdomen and pelvis was advised as the initial investigation to evaluate the ascending uterine artery in 11 patients. The major outcomes were recurrence, mortality, CT results and obstetric outcomes.

RESULTS

During the median follow-up of 56 months, two recurrences were recorded. Among 11 patients who underwent CT, none of them showed uterine arteries occlusion. Fifteen patients attempted to conceive, and 5 pregnancies were achieved in 5 patients. Hence, the pregnancy rate among patients who attempted to conceive was 33.3 %. There was only one artificial first-trimester abortion. Three pregnancies resulted in live births, and two of them got full-term births.

CONCLUSIONS

The modified fertility-sparing abdominal radical trachelectomy in preserving uterine arteries is effective, and it is recommended that surgeon should retain the uterine artery as much as possible during operation.

Gynecological cancer among adolescents and young adults (AYA)

Adolescents and young adults (AYA) patients with cancer show specific biological, sociodemographic and behavioral features, with lower survival rates than younger group. Gynecologic malignancies that occur among AYA requires a multidisciplinary management and a tailored model of care, in order to enhance the early diagnosis, the adherence to the treatment, the enrollment in clinical trials, the rate of survival and the quality of life (QoL). In this article, we review the main gynecological tumors that may occur in AYA, with a focus on the clinical signs at the diagnosis and the modality of treatment. In addition, we proposed a model of multidisciplinary and personalized care for AYA with gynecological tumors, which can help the clinicians to manage the specific gynecologic concerns, such as ovarian failure, contraception, fertility, late psychosocial effects.