1
|
Nica A, Benseler A, Parbhakar A, Fortin LAT, Heyns M, Lee M, Covens A, Plante M, May T. Robotic versus vaginal radical trachelectomy for reproductive-aged patients with early-stage cervical carcinoma: A multi-center cohort study. Gynecol Oncol 2024; 185:95-100. [PMID: 38377763 DOI: 10.1016/j.ygyno.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/08/2024] [Accepted: 02/12/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND A randomized non-inferiority trial showed worse survival in women with early-stage cervical cancer treated with radical hysterectomy by minimally invasive approach compared to laparotomy; the impact of surgical approach on survival following radical trachelectomy is unknown. OBJECTIVE To examine oncologic outcomes in women with early-stage cervical cancer who underwent robotic or vaginal radical trachelectomy at Canadian cancer centers with the highest volumes of radical trachelectomy procedures. STUDY DESIGN Retrospective multi-centre cohort analysis which includes patients who had surgery between 2006 and 2019. Women with International FIGO 2009 stage IA-IB cervical cancer who underwent radical trachelectomy and lymph node assessment were grouped by surgical approach (vaginal versus robotic surgery). RESULTS A total of 197 patients were included from 4 regional referral centres. 56 women underwent robotic radical trachelectomy and 141 underwent vaginal radical trachelectomy. All patients had lymph node assessment by a minimally invasive technique. Median age was 32 years, median tumor size was 12 mm, and median depth of invasion was 5 mm. Recurrence-free survival was 97% in both groups at a median follow-up of 57 months. On multivariable analysis, after adjusting for previously chosen confounders (high risk pathologic criteria, tumor size, and LVSI) there was no statistically significant difference in PFS between the 2 groups (HR 2.1, 95%CI 0.3-7.1, p = 0.5). Tumor size larger than 2 cm (HR 9.4, 95%CI 2.8-26, p = 0.003) was the only variable predictive of recurrence. CONCLUSION Survival outcomes were excellent in both cohorts of patients undergoing robotic vs. vaginal radical trachelectomy. The surgical approach was not significantly associated with risk of recurrence after adjusting for clinically important confounders.
Collapse
Affiliation(s)
- Andra Nica
- Division of Gynecologic Oncology, Department of Surgery, Juravinski Cancer Centre, Hamilton, ON, Canada; Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada
| | - Anouk Benseler
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | - Ashna Parbhakar
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | - Ly-Ann Teo Fortin
- Department of Obstetrics and Gynecology, Laval University, Quebec, QC, Canada
| | - Marguerite Heyns
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
| | - Marette Lee
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; Division of Gynecology Oncology, Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
| | - Al Covens
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | - Marie Plante
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Laval University, Quebec, QC, Canada
| | - Taymaa May
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada; Division of Gynecologic Oncology, Department of Surgical Oncology, Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada.
| |
Collapse
|
2
|
Han S, Na J, Li Y, Wang J. Surgical procedures and techniques in robot-assisted uterine artery-preserving radical trachelectomy. J Robot Surg 2024; 18:222. [PMID: 38795189 DOI: 10.1007/s11701-024-01982-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/11/2024] [Indexed: 05/27/2024]
Abstract
The aim of the study was to study robotic cervical radical trachelectomy, aimed at standardizing and optimizing surgical procedures, thereby facilitating the learning process. All surgical procedures were based on the anatomy of the embryonic compartments, which not only help prevent tumor spillage due to disruption of the embryonic compartments, but also maximize the avoidance of inadequate resection margins. Using robotics to perform radical trachelectomy, combined with the concept of membrane anatomy, not only enables a bloodless surgical process, but also streamlines and simplifies the procedure, making it more efficient and precise. Utilizing robotics for radical hysterectomy can lead to a more meticulous and refined outcome. Precise surgical techniques contribute to standardizing and optimizing surgical procedures, thereby facilitating the learning process.
Collapse
Affiliation(s)
- Shichao Han
- Obstetrics and Gynecology Department, The Second Affiliated Hospital of Dalian Medical University, 467 Zhongshan Road, Shahekou District, Dalian, Liaoning province, China.
| | - Jing Na
- Obstetrics and Gynecology Department, The Second Affiliated Hospital of Dalian Medical University, 467 Zhongshan Road, Shahekou District, Dalian, Liaoning province, China
| | - Ya Li
- Obstetrics and Gynecology Department, The Second Affiliated Hospital of Dalian Medical University, 467 Zhongshan Road, Shahekou District, Dalian, Liaoning province, China
| | - Jun Wang
- Obstetrics and Gynecology Department, The Second Affiliated Hospital of Dalian Medical University, 467 Zhongshan Road, Shahekou District, Dalian, Liaoning province, China.
| |
Collapse
|
3
|
Salman L, Covens A. Fertility Preservation in Cervical Cancer-Treatment Strategies and Indications. Curr Oncol 2024; 31:296-306. [PMID: 38248104 PMCID: PMC10814061 DOI: 10.3390/curroncol31010019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 01/23/2024] Open
Abstract
Cervical cancer is frequently diagnosed in women during their reproductive years, and fertility preservation is an essential part of their cancer treatment. In highly selected patients with early stage, low-risk cervical cancer and a tumor size ≤ 2 cm, several treatment strategies can be offered for patients wishing to preserve fertility, including radical/simple trachelectomy or conization with pelvic lymph node assessment. Trachelectomy can be performed through a vaginal, abdominal, or minimally invasive approach and has been shown to have an equivalent oncologic outcome compared to radical hysterectomy. All surgical approaches for radical trachelectomy seem to have excellent survival with comparable oncologic outcomes. Nevertheless, patients undergoing vaginal trachelectomy have better obstetric outcomes compared to the other routes. In patients with larger tumors (2-4 cm), neoadjuvant chemotherapy followed by fertility-sparing surgery is an alternative option. Several chemotherapy regimens have been used for this indication, with a pathologic complete response rate of 17-73%. For locally advanced diseases that require radical hysterectomy or primary chemoradiation, fertility preservation can be performed using oocyte, embryo, or ovarian tissue cryopreservation, as well as ovarian transposition. For these patients, future pregnancy is possible through surrogacy. In addition to fertility preservation, ovarian transposition, where the ovaries are repositioned outside of the radiation field, is performed to maintain ovarian hormonal function and prevent premature ovarian failure. In summary, fertility-preservation treatment strategies for patients with early stage cervical cancer are continuously evolving, and less radical surgeries are becoming more acceptable. Additional and ongoing evidence is helping determine the impact of conservative procedures on oncologic and obstetric outcomes in these patients.
Collapse
Affiliation(s)
- Lina Salman
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON M5G 2M9, Canada;
| | - Allan Covens
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON M5G 2M9, Canada;
- Division of Gynecologic Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
| |
Collapse
|
4
|
Lv Z, Wang YY, Wang YW, He JJ, Lan WW, Peng JY, Lin ZH, Zhu RF, Zhou J, Chen ZQ, Jiang YH, Yuan Y, Xiong J. A meta-analysis of treatment for early-stage cervical cancer: open versus minimally invasive radical trachelectomy. BMC Pregnancy Childbirth 2023; 23:727. [PMID: 37838671 PMCID: PMC10576315 DOI: 10.1186/s12884-023-06036-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 09/28/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND In previous systematic reviews, meta-analysis was lacking, resulting in the statistical difference between the data of different surgeries being impossible to judge. This meta-analysis aims to contrast the fertility results and cancer outcomes between open and minimally invasive surgery. METHOD We systematically searched databases including PubMed, Embase, Cochrane, and Scopus to collect studies that included open and minimally invasive radical trachelectomy. A random-effect model calculated the weighted average difference of each primary outcome via Review Manager V.5.4. RESULT Eight studies (1369 patients) were incorporated into our study. For fertility results, the Open group excels MIS group in pregnancies-Third trimester delivery [OR = 2.68; 95% CI (1.29, 5.59); P = 0.008]. Nevertheless, there is no statistical difference in clinical pregnancy, miscarriage, and second-trimester rate. Concerning cancer outcomes, no difference was detected in the overall survival [OR = 1.56; 95% CI (0.70, 3.45); P = 0.27] and recurrence [OR = 0.63; 95% CI (0.35, 1.12); P = 0.12]. Concerning surgery-related outcomes, the comprehensive effects revealed that the estimated blood loss of the Open group was higher than that of the MIS group[MD = 139.40; 95% CI (79.05, 199.75); P < 0.0001]. However, there was no difference between the postoperative complication rate in the two groups [OR = 1.52; 95% CI (0.89, 2.60); P = 0.12]. CONCLUSION This meta-analysis suggested that the fertility result of the Open group may be better than the MIS group, while the MIS group has better surgery-related outcomes. Owing to the poor cases of our study, a more robust conclusion requires more relevant articles in the future. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022352999.
Collapse
Affiliation(s)
- Zi Lv
- Department of Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
- Department of Obstetrics, Guangzhou Women and Children's Medical Center Affiliated to Guangzhou Medical University, Guangzhou, China
| | - Yu-Ying Wang
- School of Pediatrics, Guangzhou Medical University, Guangzhou, China
| | - Yu-Wen Wang
- School of Pediatrics, Guangzhou Medical University, Guangzhou, China
| | - Jun-Jie He
- School of Pediatrics, Guangzhou Medical University, Guangzhou, China
| | - Wen-Wei Lan
- School of Pediatrics, Guangzhou Medical University, Guangzhou, China
| | - Jia-Ying Peng
- School of Pediatrics, Guangzhou Medical University, Guangzhou, China
| | - Zi-Han Lin
- School of Pediatrics, Guangzhou Medical University, Guangzhou, China
| | - Ruo-Fei Zhu
- Department of Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
- Department of Gynecology, Guangzhou Women and Children's Medical Center Affiliated to Guangzhou Medical University, Guangzhou, China
| | - Jie Zhou
- Department of Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
- Department of Gynecology, Guangzhou Women and Children's Medical Center Affiliated to Guangzhou Medical University, Guangzhou, China
| | - Zi-Qi Chen
- School of Pediatrics, Guangzhou Medical University, Guangzhou, China
| | - Ying-Hui Jiang
- School of Pediatrics, Guangzhou Medical University, Guangzhou, China
| | - Yi Yuan
- Department of Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
- Department of Obstetrics, Guangzhou Women and Children's Medical Center Affiliated to Guangzhou Medical University, Guangzhou, China.
- School of Pediatrics, Guangzhou Medical University, Guangzhou, China.
| | - Jian Xiong
- Department of Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
- Department of Gynecology, Guangzhou Women and Children's Medical Center Affiliated to Guangzhou Medical University, Guangzhou, China.
| |
Collapse
|
5
|
Han L, Chen Y, Zheng A, Tan X, Chen H. Minimally invasive versus abdominal radical trachelectomy for early-stage cervical cancer: a systematic review and meta-analysis. Am J Cancer Res 2023; 13:4466-4477. [PMID: 37818069 PMCID: PMC10560958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 08/06/2023] [Indexed: 10/12/2023] Open
Abstract
The safety of minimally invasive surgery (MIS) for cervical cancer has been questioned. This systematic review and meta-analysis aimed to compare the clinical outcomes of patients with cervical cancer who underwent MIS and abdominal trachelectomy. We searched for and subsequently analyzed studies published in PubMed, Embase, Cochrane Central Register of Controlled Trials, International Clinical Trials Registry Platform, and Clinical Trials.gov from their inception until April 10, 2023. Six studies with 1,079 participants were included, constituting 512 and 567 patients in the MIS and abdominal surgery groups, respectively. No significant difference was observed in the overall survival (hazard ratio [HR], 0.51; 95% confidence interval [CI], 0.16-1.65; I2=0.0%; P=0.881), recurrence rate (RR, 1.26; 95% CI, 0.68-2.33; I2=0.0%; P=0.815), and death rate (RR, 0.54; 95% CI, 0.23-1.31; I2=0.0%; P=0.680) between the MIS and abdominal surgery groups. No significant difference was found in urinary tract complication (RR, 0.78; 95% CI, 0.28-2.17; I2=0.0%; P=0.603), cerclage erosion (RR, 0.90; 95% CI, 0.34-2.43; I2=0.0%; P=0.650), or cervical stenosis (RR, 0.69; 95% CI, 0.22-2.18; I2=0.0%; P=0.885) between both groups. However, significant differences in blood loss and length of hospital stay were observed between both groups. Among 49 females who attempted to get pregnant, 31.3% (5/16) and 51.5% (17/33) in the MIS and abdominal surgery groups, respectively, succeeded in conceiving. We established that laparoscopic and abdominal radical trachelectomy had similar efficacies for treating patients with early cervical cancer, with no significant differences in survival, tumor recurrence, and mortality rates. Additionally, they showed no significant differences in pregnancy-related outcomes. However, owing to the limited number of studies, more high-quality cohort studies are required to confirm these findings.
Collapse
Affiliation(s)
- Ling Han
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan UniversityNo. 20, 3rd Section, South Renmin Road, Chengdu 610041, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of EducationChengdu 610041, Sichuan, China
| | - Yali Chen
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan UniversityNo. 20, 3rd Section, South Renmin Road, Chengdu 610041, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of EducationChengdu 610041, Sichuan, China
| | - Ai Zheng
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan UniversityNo. 20, 3rd Section, South Renmin Road, Chengdu 610041, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of EducationChengdu 610041, Sichuan, China
| | - Xin Tan
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan UniversityNo. 20, 3rd Section, South Renmin Road, Chengdu 610041, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of EducationChengdu 610041, Sichuan, China
| | - Hengxi Chen
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan UniversityNo. 20, 3rd Section, South Renmin Road, Chengdu 610041, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of EducationChengdu 610041, Sichuan, China
| |
Collapse
|
6
|
Furey KB, Anderson ZS, Kuznicki ML, Klar M, Roman LD, Wright JD, Matsuo K. Increasing trends of cervical conization with lymph node evaluation for fertility-sparing surgery in early cervical cancer. Gynecol Oncol 2023; 173:122-129. [PMID: 37137189 DOI: 10.1016/j.ygyno.2023.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/22/2023] [Accepted: 04/25/2023] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To examine uptake, characteristics, and survival outcome of less-radical fertility-sparing surgery with cervical conization and lymph node evaluation (Cone-LN) in reproductive age patients with early cervical cancer. METHODS This retrospective cohort study examined the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. The study population included 407 patients aged <50 years with stage IA-IB2 (≤4 cm) cervical cancer who received fertility-sparing surgery from 2004 to 2019. The exposure was fertility-sparing surgery type: Cone-LN (n = 196) or trachelectomy with lymph node evaluation (Trach-LN, n = 211). The main co-outcomes were (i) temporal trends of surgery type, assessed with Cochran-Armitage test, and (ii) clinical and tumor characteristics, assessed with multivariable binary logistic regression model. The secondary outcome was overall survival, assessed with inverse probability of treatment weighting propensity score. RESULTS The number of patients receiving Cone-LN increased from 43.5% in 2004-2007 to 58.4% in 2016-2019 (P-trend = 0.005). Patients receiving conization and sentinel lymph node (SLN) biopsy alone increased from 0% to 14.4% (P-trend < 0.001). In a multivariable analysis, patients in the Cone-LN group were more likely to undergo SLN biopsy (aOR 6.04) compared to those in the Trach-LN group whereas those with adenocarcinoma (aOR 0.49) and T1b tumors (aOR for ≤2 cm 0.21, and aOR for 2.1-4.0 cm 0.10) were less likely to receive Cone-LN. In a propensity score-weighted model, the Cone-LN and Trach-LN groups had comparable overall survival (7-year rates, 98.9% vs 97.8%). Similar associations were observed for patients with squamous, adenocarcinoma / adenosquamous, T1a classification, and T1b(≤2 cm) classification. CONCLUSION The current population-based analysis suggests that the performance of cervical conization with lymph node evaluation, particularly with SLN biopsy, is gradually increasing for early cervical cancer patients desiring future fertility.
Collapse
Affiliation(s)
- Katelyn B Furey
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Zachary S Anderson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Michelle L Kuznicki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, OH, USA
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, University of Freiburg Faculty of Medicine, Freiburg, Germany
| | - Lynda D Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
| |
Collapse
|
7
|
Laparoscopic Radical Trachelectomy after Neoadjuvant Chemotherapy for Fertility Preservation in Early-Stage Bulky Cervical Cancer: A Case Report and Literature Review. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121827. [PMID: 36557028 PMCID: PMC9788146 DOI: 10.3390/medicina58121827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 12/01/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022]
Abstract
Management of early-stage cervical cancer (CC) in young women often faces challenges to preserve fertility, as well as to achieve an adequate oncological outcome. Although existing evidence supports a fertility-sparing treatment in the case of tumors <2 cm in diameter, the approach is less clear in bulky early-stage CC. In addition, the outcomes of radical trachelectomy performed by minimally invasive techniques are also highly debatable. Highlighting the high incidences of young women with early-stage CC, the lack of sufficient data raises considerable hindrances towards the proper counseling of this vulnerable patient group. In this report, a case of a young woman with bulky early-stage CC with a strong desire to preserve fertility is presented. A satisfactory oncological outcome was achieved after neoadjuvant chemotherapy followed by laparoscopic radical trachelectomy. Ongoing prospective trials are expected to provide stronger evidence on this topic.
Collapse
|
8
|
Wang X, Hua K, Chen Y. Vaginal-assisted gasless laparoendoscopic single-site radical trachelectomy with abdominal wall suspension. Int J Gynecol Cancer 2022; 32:ijgc-2022-003688. [PMID: 36028234 DOI: 10.1136/ijgc-2022-003688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Xiaojuan Wang
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, People's Republic of China
| | - Keqin Hua
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, People's Republic of China
| | - Yisong Chen
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, People's Republic of China
| |
Collapse
|
9
|
Trachelectomy: How is it actually done? A review from FRANCOGYN group Titre: Trachélectomie: comment faire en pratique ? Revue de la littérature par le groupe FRANCOGYN. J Gynecol Obstet Hum Reprod 2022; 51:102407. [PMID: 35661829 DOI: 10.1016/j.jogoh.2022.102407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/02/2022] [Accepted: 05/12/2022] [Indexed: 11/22/2022]
Abstract
Because of the peak incidence of cervical cancer between the ages of 35 and 44 and the increasing age of first pregnancy, the issue of fertility preservation in cases of early-stage cervical cancer in women in this reproductive age category arises. Early-stage cervical cancer patients have a good prognosis and are surgically treated in cases of mildly aggressive human papillomavirus-related histological type (squamous cell carcinoma, adenocarcinoma), FIGO stage IA to IB1 (i.e., <2 cm), with shallow stromal invasion (<10 mm) and without the presence of lymph-vascular space invasion or lymph node or regional involvement. Under these conditions, conservative treatment by trachelectomy, which has recurrence-free and overall survival rates equivalent to that of hysterectomy, may be considered. After a complete pre-therapeutic assessment, including pelvic lymphadenectomy, to eliminate all contraindications to conservative treatment, a simple or enlarged trachelectomy can be chosen. According to some authors, the route of entry (vaginal, simple or robot-assisted laparoscopy, laparotomy) has no significant effect on survival or fertility, although the literature on the subject is limited. Trachelectomy offers good results in terms of fertility, with an estimated pregnancy rate of between 23% and 55% and a live birth rate of 70%. The significant reduction of the cervix associated with the procedure increases the risk of prematurity. However, this can be prevented by the use of a permanent cerclage. Close follow-up of these patients is essential for a minimum period of 5 years in order to detect any recurrence or postoperative complications.
Collapse
|
10
|
Xu M, Huo C, Huang C, Liu Y, Ling X, Xu G, Lin Z, Lu H. Round ligament suspension and vaginal purse-string suture: Newly optimized techniques to prevent tumor spillage in laparoscopic radical trachelectomy for cervical cancer. J Obstet Gynaecol Res 2022; 48:1867-1875. [PMID: 35537684 DOI: 10.1111/jog.15278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 04/09/2022] [Accepted: 04/24/2022] [Indexed: 11/29/2022]
Abstract
AIM The purpose of this study was to investigate the surgical techniques and clinical feasibility of nonuterine manipulator and enclosed colpotomy to avoid cancer cell spillages in laparoscopic radical trachelectomy (LRT) for patients with early-stage cervical cancer. METHODS We performed the newly optimized surgical techniques of round ligament suspension and vaginal purse-string suture in LRT in 12 patients with early-stage cervical cancer from May 2019 to October 2020. Surgical information and postoperative results were recorded. RESULTS All 12 patients successfully underwent LRT with round ligament suspension and vaginal purse-string suture, and no conversion to laparotomy was required. The median operation time was 268.5 min (range 200-320 min), including 5 min of round ligament suspension, and the median blood loss was 20 mL (range 5-50 mL). The median number of pelvic lymph nodes removed was 27 (range 19-35), and median amounts of paracervical tissue was 24 mm (range 21-26 mm) and vaginal tissue was 18 mm (range 16-26 mm). No intraoperative complication or serious postoperative complications were reported. CONCLUSION Round ligament suspension and vaginal purse-string suture techniques are feasible and effective in LRT. They can replace uterine manipulator and unprotected colpotomy with satisfactory perioperative outcomes.
Collapse
Affiliation(s)
- Miaochun Xu
- Department of gynecological oncology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Chuying Huo
- Department of gynecological oncology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Chunxian Huang
- Department of gynecological oncology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Yunyun Liu
- Department of gynecological oncology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Xiaoting Ling
- Department of gynecological oncology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Guocai Xu
- Department of gynecological oncology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Zhongqiu Lin
- Department of gynecological oncology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Huaiwu Lu
- Department of gynecological oncology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| |
Collapse
|
11
|
Silvestris E, Paradiso AV, Minoia C, Daniele A, Cormio G, Tinelli R, D’Oronzo S, Cafforio P, Loizzi V, Dellino M. Fertility preservation techniques in cervical carcinoma. Medicine (Baltimore) 2022; 101:e29163. [PMID: 35512072 PMCID: PMC9276378 DOI: 10.1097/md.0000000000029163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 03/08/2022] [Indexed: 01/04/2023] Open
Abstract
The usefulness of this review is to highlight how a fertility preservation (FP) approach is currently feasible for patients diagnosed with uterine cervical cancer. To this regard, a fertility sparing surgery has just overcome its traditional limits, gained acceptance within the major gynecologic oncology societies thanks to the ability to identify the "ideal" candidates to this conservative treatment. On the other hand, the use of other FPs for oocyte and ovarian cortex cryopreservation is still extremely debated. In fact, the existing risk of tumor spreading during oocyte retrieval necessary for oocyte cryostorage for patients' candidates for neo-adjuvant therapy, as well as the potential hazard of cancer cell dissemination after ovarian tissue replacement in cases of non-squamous type cervical carcinomas should not be underestimated. Therefore, in consideration of the encountered limitations and the need to ensure adequate reproductive health for young uterine cervical cancer survivors, translational research regarding the FP has progressively collected innovative insights into the employment of stemness technology. In this context, the property of ovarian stem cells obtained from the ovarian cortex to generate functional oocytes in women could represent a promising therapeutic alternative to the current procedures for a novel and safer FP approach in cancer survivors.
Collapse
Affiliation(s)
- Erica Silvestris
- Gynecologic Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II” Bari, Italy
| | - Angelo Virgilio Paradiso
- Institutional BioBank, Experimental Oncology and Biobank Management Unit, IRCCS Istituto Tumori “Giovanni Paolo II,” Bari, Italy
| | - Carla Minoia
- Unit of Hematology and Cell Therapy, Laboratory of Hematological Diagnostics and Cell Characterization, Bari, Italy
| | - Antonella Daniele
- Experimental Oncology, Center for Study of Heredo-Familial Tumors, IRCCS Istituto Tumori ”Giovanni Paolo II“ Bari, 70124 Bari, Italy
| | - Gennaro Cormio
- Department of Biomedical Sciences and Human Oncology, Unit of Obstetrics and Gynecology, University of Bari Aldo Moro, Bari, Italy
| | - Raffaele Tinelli
- Department of Obstetrics and Gynecology, ”Valle d’Itria" Hospital, Martina Franca, Italy
| | - Stella D’Oronzo
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine and Clinical Oncology, University of Bari Aldo Moro, Bari, Italy
| | - Paola Cafforio
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine and Clinical Oncology, University of Bari Aldo Moro, Bari, Italy
| | - Vera Loizzi
- Department of Biomedical Sciences and Human Oncology, Unit of Obstetrics and Gynecology, University of Bari Aldo Moro, Bari, Italy
| | - Miriam Dellino
- Department of Obstetrics and Gynecology, “San Paolo” Hospital, Bari, Italy
- Department of Biomedical Sciences and Human Oncology, Unit of Obstetrics and Gynecology, University of Bari Aldo Moro, Bari, Italy
| |
Collapse
|
12
|
Salvo G, Ramirez PT, Leitao MM, Cibula D, Wu X, Falconer H, Persson J, Perrotta M, Mosgaard BJ, Kucukmetin A, Berlev I, Rendon G, Liu K, Vieira M, Capilna ME, Fotopoulou C, Baiocchi G, Kaidarova D, Ribeiro R, Pedra-Nobre S, Kocian R, Li X, Li J, Pálsdóttir K, Noll F, Rundle S, Ulrikh E, Hu Z, Gheorghe M, Saso S, Bolatbekova R, Tsunoda A, Pitcher B, Wu J, Urbauer D, Pareja R. Open vs minimally invasive radical trachelectomy in early-stage cervical cancer: International Radical Trachelectomy Assessment Study. Am J Obstet Gynecol 2022; 226:97.e1-97.e16. [PMID: 34461074 PMCID: PMC9518841 DOI: 10.1016/j.ajog.2021.08.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/11/2021] [Accepted: 08/14/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Minimally invasive radical trachelectomy has emerged as an alternative to open radical hysterectomy for patients with early-stage cervical cancer desiring future fertility. Recent data suggest worse oncologic outcomes after minimally invasive radical hysterectomy than after open radical hysterectomy in stage I cervical cancer. OBJECTIVE We aimed to compare 4.5-year disease-free survival after open vs minimally invasive radical trachelectomy. STUDY DESIGN This was a collaborative, international retrospective study (International Radical Trachelectomy Assessment Study) of patients treated during 2005-2017 at 18 centers in 12 countries. Eligible patients had squamous carcinoma, adenocarcinoma, or adenosquamous carcinoma; had a preoperative tumor size of ≤2 cm; and underwent open or minimally invasive (robotic or laparoscopic) radical trachelectomy with nodal assessment (pelvic lymphadenectomy and/or sentinel lymph node biopsy). The exclusion criteria included neoadjuvant chemotherapy or preoperative pelvic radiotherapy, previous lymphadenectomy or pelvic retroperitoneal surgery, pregnancy, stage IA1 disease with lymphovascular space invasion, aborted trachelectomy (conversion to radical hysterectomy), or vaginal approach. Surgical approach, indication, and adjuvant therapy regimen were at the discretion of the treating institution. A total of 715 patients were entered into the study database. However, 69 patients were excluded, leaving 646 in the analysis. Endpoints were the 4.5-year disease-free survival rate (primary), 4.5-year overall survival rate (secondary), and recurrence rate (secondary). Kaplan-Meier methods were used to estimate disease-free survival and overall survival. A post hoc weighted analysis was performed, comparing the recurrence rates between surgical approaches, with open surgery being considered as standard and minimally invasive surgery as experimental. RESULTS Of 646 patients, 358 underwent open surgery, and 288 underwent minimally invasive surgery. The median (range) patient age was 32 (20-42) years for open surgery vs 31 (18-45) years for minimally invasive surgery (P=.11). Median (range) pathologic tumor size was 15 (0-31) mm for open surgery and 12 (0.8-40) mm for minimally invasive surgery (P=.33). The rates of pelvic nodal involvement were 5.3% (19 of 358 patients) for open surgery and 4.9% (14 of 288 patients) for minimally invasive surgery (P=.81). Median (range) follow-up time was 5.5 (0.20-16.70) years for open surgery and 3.1 years (0.02-11.10) years for minimally invasive surgery (P<.001). At 4.5 years, 17 of 358 patients (4.7%) with open surgery and 18 of 288 patients (6.2%) with minimally invasive surgery had recurrence (P=.40). The 4.5-year disease-free survival rates were 94.3% (95% confidence interval, 91.6-97.0) for open surgery and 91.5% (95% confidence interval, 87.6-95.6) for minimally invasive surgery (log-rank P=.37). Post hoc propensity score analysis of recurrence risk showed no difference between surgical approaches (P=.42). At 4.5 years, there were 6 disease-related deaths (open surgery, 3; minimally invasive surgery, 3) (log-rank P=.49). The 4.5-year overall survival rates were 99.2% (95% confidence interval, 97.6-99.7) for open surgery and 99.0% (95% confidence interval, 79.0-99.8) for minimally invasive surgery. CONCLUSION The 4.5-year disease-free survival rates did not differ between open radical trachelectomy and minimally invasive radical trachelectomy. However, recurrence rates in each group were low. Ongoing prospective studies of conservative management of early-stage cervical cancer may help guide future management.
Collapse
Affiliation(s)
- Gloria Salvo
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mario M Leitao
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David Cibula
- Gynecologic Oncology Center, Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Xiaohua Wu
- Department of Gynecologic Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Henrik Falconer
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Jan Persson
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences, Faculty of Medicine, Lund University Lund, Sweden
| | - Myriam Perrotta
- Servicio de Ginecología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Berit J Mosgaard
- Department of Gynecology, University Hospital Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Ali Kucukmetin
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead, United Kingdom
| | - Igor Berlev
- Department of Gynecologic Oncology, N.N. Petrov National Medical Research Center of Oncology, Saint Petersburg, Russia
| | - Gabriel Rendon
- Department of Gynecologic Oncology, Instituto de Cancerología Las Américas Auna, Medellín, Colombia
| | - Kaijiang Liu
- Department of Gynecologic Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Marcelo Vieira
- Department of Gynecologic Oncology, Hospital Israelita Albert Einstein, São Paulo, Brazil; Department of Gynecologic Oncology, Barretos Cancer Hospital, Barretos, Brazil
| | - Mihai E Capilna
- First Obstetrics and Gynecology Clinic, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu Mureş, Romania
| | - Christina Fotopoulou
- Department of Surgery and Cancer, Imperial College London and West London Gynaecological Cancer Centre, Imperial College NHS Trust, London, United Kingdom
| | - Glauco Baiocchi
- Department of Gynecologic Oncology, AC Camargo Cancer Center, São Paulo, Brazil
| | - Dilyara Kaidarova
- Department of Gynecologic Oncology, Kazakh Institute of Oncology and Radiology, Almaty, Kazakhstan
| | - Reitan Ribeiro
- Department of Gynecologic Oncology, Hospital Erasto Gaertner, Curitiba, Brazil
| | | | - Roman Kocian
- Gynecologic Oncology Center, Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Xiaoqi Li
- Department of Gynecologic Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Jin Li
- Department of Gynecologic Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Kolbrún Pálsdóttir
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Florencia Noll
- Servicio de Ginecología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Stuart Rundle
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead, United Kingdom
| | - Elena Ulrikh
- Almazov National Medical Research Centre, North-Western State Medical University named after I. I. Mechnikov, Saint Petersburg, Russia
| | - Zhijun Hu
- Department of Gynecologic Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Mihai Gheorghe
- First Obstetrics and Gynecology Clinic, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu Mureş, Romania
| | - Srdjan Saso
- Department of Surgery and Cancer, Imperial College London and West London Gynaecological Cancer Centre, Imperial College NHS Trust, London, United Kingdom
| | - Raikhan Bolatbekova
- Department of Gynecologic Oncology, Kazakh Institute of Oncology and Radiology, Almaty, Kazakhstan
| | - Audrey Tsunoda
- Department of Gynecologic Oncology, Hospital Israelita Albert Einstein, São Paulo, Brazil; Department of Gynecologic Oncology, Hospital Erasto Gaertner, Curitiba, Brazil; Department of Gynecologic Oncology, Pilar Hospital, Curitiba, Brazil
| | - Brandelyn Pitcher
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jimin Wu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Diana Urbauer
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rene Pareja
- Department of Gynecologic Oncology, Astorga Clínica de Oncología, Medellín, Colombia; Instituto Nacional de Cancerología, Bogotá, Colombia
| |
Collapse
|
13
|
Segarra-Vidal B, Persson J, Falconer H. Radical trachelectomy. Int J Gynecol Cancer 2021; 31:1068-1074. [PMID: 33707207 DOI: 10.1136/ijgc-2020-001782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 11/04/2022] Open
Abstract
Radical trachelectomy is the 'cornerstone' of fertility-sparing surgery in patients with early-stage cervical cancer wishing to preserve fertility. Growing evidence has demonstrated the oncologic safety and subsequent favorable pregnancy outcomes in well-selected cases. In the absence of prospective trials, the decision on the appropriate surgical approach (vaginal, open, or minimally invasive surgery) should be based on local resources and surgeons' preferences. Radical trachelectomy has the potential to preserve fertility in a large proportion of women with early-stage cervical cancer. However, prematurity and premature rupture of membranes are common obstetric complications after radical trachelectomy for cervical cancer. A multidisciplinary approach is crucial to optimize the balance between oncologic and obstetric outcomes. The purpose of this review is to provide an updated overview of the technical, oncologic, and obstetric aspects of radical trachelectomy.
Collapse
Affiliation(s)
| | - Jan Persson
- Department of Obstetrics and Gynecology, Lund University Hospital, Lund, Sweden
| | - Henrik Falconer
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
14
|
Schuurman T, Zilver S, Samuels S, Schats W, Amant F, van Trommel N, Lok C. Fertility-Sparing Surgery in Gynecologic Cancer: A Systematic Review. Cancers (Basel) 2021; 13:1008. [PMID: 33670929 PMCID: PMC7975326 DOI: 10.3390/cancers13051008] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 12/15/2022] Open
Abstract
Fertility-sparing surgery (FSS) is increasingly being offered to women with a gynecological malignancy who wish to preserve fertility. In this systematic review, we evaluate the best evidence currently available on oncological and reproductive outcome after FSS for early stage cervical cancer, epithelial ovarian cancer, and endometrial cancer. An extensive literature search was conducted using the electronic databases Medline (OVID), Embase, and Cochrane Library to identify eligible studies published up to December 2020. In total, 153 studies were included with 7544, 3944, and 1229 patients who underwent FSS for cervical, ovarian, and endometrial cancer, respectively. We assessed the different FSS techniques that are available to preserve fertility, i.e., omitting removal of the uterine body and preserving at least one ovary. Overall, recurrence rates after FSS are reassuring and therefore, these conservative procedures seem oncologically safe in the current selection of patients with low-stage and low-grade disease. However, generalized conclusions should be made with caution due to the methodology of available studies, i.e., mostly retrospective cohort studies with a heterogeneous patient population, inducing selection bias. Moreover, about half of patients do not pursue pregnancy despite FSS and the reasons for these decisions have not yet been well studied. International collaboration will facilitate the collection of solid evidence on FSS and the related decision-making process to optimize patient selection and counseling.
Collapse
Affiliation(s)
- Teska Schuurman
- Department of Gynecologic Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, 1066 CX Amsterdam, The Netherlands; (T.S.); (S.S.); (F.A.); (N.v.T.)
| | - Sanne Zilver
- Department of Gynecology, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands;
| | - Sanne Samuels
- Department of Gynecologic Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, 1066 CX Amsterdam, The Netherlands; (T.S.); (S.S.); (F.A.); (N.v.T.)
| | - Winnie Schats
- Department of Scientific Information Service, Netherlands Cancer Institute, Antoni van Leeuwenhoek, 1066 CX Amsterdam, The Netherlands;
| | - Frédéric Amant
- Department of Gynecologic Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, 1066 CX Amsterdam, The Netherlands; (T.S.); (S.S.); (F.A.); (N.v.T.)
- Department of Oncology, Catholic University of Leuven, 3000 Leuven, Belgium
| | - Nienke van Trommel
- Department of Gynecologic Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, 1066 CX Amsterdam, The Netherlands; (T.S.); (S.S.); (F.A.); (N.v.T.)
| | - Christianne Lok
- Department of Gynecologic Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, 1066 CX Amsterdam, The Netherlands; (T.S.); (S.S.); (F.A.); (N.v.T.)
| |
Collapse
|
15
|
Salvo G, Pareja R, Ramirez PT. Minimally invasive radical trachelectomy: Considerations on surgical approach. Best Pract Res Clin Obstet Gynaecol 2021; 75:113-122. [PMID: 33888410 DOI: 10.1016/j.bpobgyn.2021.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/31/2021] [Indexed: 11/26/2022]
Abstract
Current evidence supports that radical trachelectomy is a safe and feasible alternative to patients with early-stage cervical cancer who wish to preserve fertility. In addition, published retrospective literature supports that oncologic outcomes are equivalent to those of radical hysterectomy. First published as a vaginal approach, a number of other approaches have been reported including laparotomic, laparoscopic, and robotic. In 2018, the first ever prospective randomized trial (LACC) comparing open vs. minimally invasive radical hysterectomy showed worse disease-free and overall survival for the minimally invasive (both laparoscopic and robotic) approach than the open approach. This landmark publication raised concerns regarding the oncologic safety of minimally invasive radical trachelectomy. In the United States, minimally invasive became the dominant approach by 2011 for radical trachelectomy. Given that radical trachelectomy is an infrequent performed procedure, only small retrospective studies, systematic reviews, and large database studies have been published. These studies are limited by their retrospective nature, small sample size, patient selection bias, unbalanced groups, and sequential surgical approach comparisons. However, the available evidence thus far shows that oncologic outcomes for both open and minimally invasive radical trachelectomy are equivalent. Given the rarity of the procedure and the low recurrence and death rates of patients with early-stage cervical cancer undergoing radical trachelectomy, a prospective randomized trial seems unlikely. A multi-institutional international registry study (International Radical Trachelectomy Assessment - IRTA - study) has been recently completed evaluating open vs. minimally invasive radical trachelectomy. There are three ongoing prospective studies evaluating the possibility of less radical surgery in a low-risk early-stage cervical cancer population, ConCerv, SHAPE, and GOG 278. We look forward to the final results of these studies that will hopefully shed light on the optimal treatment option for patients with early-stage cervical cancer wishing to preserve fertility. This article will review the most impacting publications comparing open vs. minimally invasive radical trachelectomy and analyze the limitations of the current available literature.
Collapse
Affiliation(s)
- Gloria Salvo
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Rene Pareja
- Instituto Nacional de Cancerología, Bogotá and Clínica Astorga, Medellín, Colombia
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
16
|
Olascoaga-Torres M, Reyes-Báez F, Escobar-Rodríguez P. Opciones quirúrgicas ginecológicas de preservación de fertilidad en cáncer. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2021. [DOI: 10.1016/j.gine.2020.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
17
|
Nica A, Kim SR, Gien LT, Covens A, Bernardini MQ, Bouchard-Fortier G, Kupets R, May T, Vicus D, Laframboise S, Hogen L, Cusimano MC, Ferguson SE. Survival after minimally invasive surgery in early cervical cancer: is the intra-uterine manipulator to blame? Int J Gynecol Cancer 2020; 30:1864-1870. [DOI: 10.1136/ijgc-2020-001816] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/18/2020] [Accepted: 09/21/2020] [Indexed: 11/03/2022] Open
Abstract
ObjectivesMinimally invasive radical hysterectomy is associated with decreased survival in patients with early cervical cancer. The objective of this study was to determine whether the use of an intra-uterine manipulator at the time of laparoscopic or robotic radical hysterectomy is associated with inferior oncologic outcomes.MethodsA retrospective cohort study was carried out of all patients with cervical cancer (squamous cell carcinoma, adenocarcinoma or adenosquamous carcinoma) International Federation of Gynecology and Obstetrics 2009 stages IA1 (with positive lymphovascular space invasion) to IIA who underwent minimally invasive radical hysterectomy at two academic centers between January 2007 and December 2017. Treatment, tumor characteristics, and survival data were retrieved from hospital records.ResultsA total of 224 patients were identified at the two centers; 115 had surgery with the use of an intra-uterine manipulator while 109 did not; 53 were robotic and 171 were laparoscopic. Median age was 44 years (range 38–54) and median body mass index was 25.8 kg/m2 (range 16.6–51.5). Patients in whom an intra-uterine manipulator was not used at the time of minimally invasive radical hysterectomy were more likely to have residual disease at hysterectomy (p<0.001), positive lymphovascular space invasion (p=0.02), positive margins (p=0.008), and positive lymph node metastasis (p=0.003). Recurrence-free survival at 5 years was 80% in the no intra-uterine manipulator group and 94% in the intra-uterine manipulator group. After controlling for the presence of residual cancer at hysterectomy, tumor size and high-risk pathologic criteria (positive margins, parametria or lymph nodes), the use of an intra-uterine manipulator was no longer significantly associated with worse recurrence-free survival (HR 0.4, 95% CI 0.2 to 1.0, p=0.05). The only factor which was consistently associated with recurrence-free survival was tumor size (HR 2.1, 95% CI 1.5 to 3.0, for every 10 mm increase, p<0.001).ConclusionAfter controlling for adverse pathological factors, the use of an intra-uterine manipulator in patients with early cervical cancer who underwent minimally invasive radical hysterectomy was not an independent factor associated with rate of recurrence.
Collapse
|
18
|
Smith ES, Moon AS, O’Hanlon R, Leitao MM, Sonoda Y, Abu-Rustum NR, Mueller JJ. Radical Trachelectomy for the Treatment of Early-Stage Cervical Cancer: A Systematic Review. Obstet Gynecol 2020; 136:533-542. [PMID: 32769648 PMCID: PMC7528402 DOI: 10.1097/aog.0000000000003952] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To assess surgical, oncologic, and pregnancy outcomes in patients undergoing radical vaginal, abdominal, or laparoscopic trachelectomy for the treatment of early-stage cervical cancer, using a methodic review of published literature. DATA SOURCES PubMed, EMBASE, and Cochrane Library sources, including ClinicalTrials.gov, were searched from 1990-2019 with terms "cervical cancer" and "(vaginal, abdominal, open, minimally invasive, or laparoscopic) radical trachelectomy." Grey literature and unpublished data were omitted. METHODS OF STUDY SELECTION After removal of duplicates from a combined EndNote library of results, 490 articles were reviewed using Covidence software. Two reviewers screened titles and abstracts, and then screened full texts. Selection criteria included articles that reported radical trachelectomy with lymph node assessment as primary therapy for cervical carcinoma, with stated follow-up intervals and recurrences. TABULATION, INTEGRATION, AND RESULTS Variables of interest were manually extracted into an electronic database. A total 47 articles that reported on 2,566 women met inclusion criteria. Most tumors were of squamous histology (68.5%), stage IB1 (74.8%), 2 cm or less (69.2%), and without lymphovascular invasion (68.8%). Of planned trachelectomies, 9% were converted intraoperatively to hysterectomy. Separated by route of trachelectomy, 58.1%, 37.2%, and 4.7% were performed using radical vaginal, abdominal, and laparoscopic approaches, respectively. With median follow-up of 48 months (range 2-202 months) across studies, median recurrence rate was 3.3% (range 0-25%); median time to recurrence was 26 months (range 8-44 months). Median 5-year recurrence-free and overall survival were 94.6% (range 88-97.3%) and 97.4% (range 95-99%), respectively. The posttrachelectomy pregnancy rate was 23.9%, with a live-birth rate of 75.1%. CONCLUSION Radical trachelectomy for fertility-preserving treatment of cervical cancer is widely reported in the literature, though publications are mainly limited to case reports and case series. Reported follow-up periods infrequently meet standard oncologic parameters but show encouraging recurrence-free and overall survival rates and pregnancy outcomes. Higher-level evidence needed for meta-analysis is lacking. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42019132443.
Collapse
Affiliation(s)
- Evan S. Smith
- Gynecology Service, Department of Surgery, Memorial Sloan
Kettering Cancer Center, New York, NY, USA
| | - Ashley S. Moon
- Department of Obstetrics and Gynecology, Danbury Hospital,
Nuvance Health, Danbury, CT, USA
| | - Robin O’Hanlon
- Medical Library, Memorial Sloan Kettering Cancer Center,
New York, NY, USA
| | - Mario M. Leitao
- Gynecology Service, Department of Surgery, Memorial Sloan
Kettering Cancer Center, New York, NY, USA
- Joan & Sanford I. Weill Medical College of Cornell
University, New York, NY, USA
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan
Kettering Cancer Center, New York, NY, USA
- Joan & Sanford I. Weill Medical College of Cornell
University, New York, NY, USA
| | - Nadeem R. Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan
Kettering Cancer Center, New York, NY, USA
- Joan & Sanford I. Weill Medical College of Cornell
University, New York, NY, USA
| | - Jennifer J. Mueller
- Gynecology Service, Department of Surgery, Memorial Sloan
Kettering Cancer Center, New York, NY, USA
- Joan & Sanford I. Weill Medical College of Cornell
University, New York, NY, USA
| |
Collapse
|
19
|
Somigliana E, Mangili G, Martinelli F, Noli S, Filippi F, Bergamini A, Bocciolone L, Buonomo B, Peccatori F. Fertility preservation in women with cervical cancer. Crit Rev Oncol Hematol 2020; 154:103092. [PMID: 32896752 DOI: 10.1016/j.critrevonc.2020.103092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 07/15/2020] [Accepted: 08/17/2020] [Indexed: 12/16/2022] Open
Abstract
Fertility preservation in women with cervical cancer is a demanding but evolving issue. Some remarkable achievements have been reached, in particular the improvement of primary and secondary prevention and the broadening of the indications for conservative surgery up to FIGO 2018 stage IB2. Natural pregnancy rate and the rate of obstetrics complications following conservative approach is satisfactory even if not optimal. On the other hand, the use of classic strategies for fertility preservation such as oocytes or ovarian cortex freezing is extremely limited, being the uterus compromised by treatment in a high proportion of cases. In fact, the availability of uterine surrogacy can play a role in the counseling and the decision-making process. The recent advent of uterus transplantation is fascinating but, at present, cannot be viewed as a realistic solution.
Collapse
Affiliation(s)
- Edgardo Somigliana
- Dept of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy; Obstet-Gynecol Dept, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Giorgia Mangili
- Obstet-Gynecol Dept, San Raffaele Scientific Institute, IRCCS Milan, Italy
| | - Fabio Martinelli
- Gynecologic Oncology Unit, Fondazione IRCCS National Cancer Institute, Milan, Italy
| | - Stefania Noli
- Dept of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy; Fertility and Procreation Unit, Division of Gynaecologic Oncology, European Institute of Oncology IRCCS, Milan, Italy
| | - Francesca Filippi
- Obstet-Gynecol Dept, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alice Bergamini
- Obstet-Gynecol Dept, San Raffaele Scientific Institute, IRCCS Milan, Italy
| | - Luca Bocciolone
- Obstet-Gynecol Dept, San Raffaele Scientific Institute, IRCCS Milan, Italy
| | - Barbara Buonomo
- Fertility and Procreation Unit, Division of Gynaecologic Oncology, European Institute of Oncology IRCCS, Milan, Italy
| | - Fedro Peccatori
- Fertility and Procreation Unit, Division of Gynaecologic Oncology, European Institute of Oncology IRCCS, Milan, Italy
| |
Collapse
|
20
|
Plaikner A, Jacob A, Siegler K, Schneider A, Ragosch V, Barinoff J, Kohler C. Modification of Dargent's radical vaginal trachelectomy to facilitate ureteral dissection: description of technique. Int J Gynecol Cancer 2020; 30:1210-1214. [PMID: 32675055 DOI: 10.1136/ijgc-2020-001478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/09/2020] [Accepted: 06/11/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Radical vaginal trachelectomy is the fertility-preserving surgery for patients with early stage cervical cancer. However, it has not gained widespread approval by gynecologic oncologists because of difficulties in the dissection of the bladder pillars and identification of the ureter during the vaginal portion of the surgery. METHOD We describe a modification of radical vaginal trachelectomy for easier dissection of the bladder pillar. Following pelvic lymphadenectomy, the vesicovaginal space is widely opened laparoscopically. After identification of the uterine arteries, one should proceed along the course of the arteries laterally and, thus, visualize the overcrossing of the artery with the ureter. The medial aspect of the supraureteric bladder pillar is transected and the ureter marked with vessel loops on both sides close to its entry into the bladder. The lateral portion of the supraureteric bladder pillar remains intact. During the vaginal part of radical vaginal trachelectomy, the ureter may be easily found by grasping the formerly placed vessel loop and dissection of the infraureteric bladder pillar may be done without risk of ureteral injury. RESULTS Between October 2018 and August 2019 our group has performed radical vaginal trachelectomy using this modified ureteral dissection in 12 patients. Median operation time was 239 min (range 127-290) and median blood loss was 25 mL (range 10-100). No intra- or post-operative urologic complication occurred. Median time to normal bladder function was 4 days (range 3-13). CONCLUSION The vaginal portion of radical vaginal trachelectomy may be simplified using this technique, especially when difficult circumstances such as endometriosis, prior operations, or unusual anatomy in nulliparous women are encountered.
Collapse
Affiliation(s)
- Andrea Plaikner
- Department of Special Operative and Oncologic Gynecology, Asklepios Klinik Altona, Hamburg, Hamburg, Germany
| | - Anna Jacob
- Department of Special Operative and Oncologic Gynecology, Asklepios Klinik Altona, Hamburg, Hamburg, Germany
| | - Kathrin Siegler
- Department of Special Operative and Oncologic Gynecology, Asklepios Klinik Altona, Hamburg, Hamburg, Germany
| | - Achim Schneider
- Center for Dysplasia and Cytology, MVZ Fürstenbergkarree Berlin, Berlin, Germany
| | - Volker Ragosch
- Department of Obstetrics and Gynecology, Asklepios-Clinic Hamburg-Altona, Asklepios Hospital Group, Hamburg, Germany
| | - Jana Barinoff
- Department of Gynecology and Obstetrics, Sankt Gertrauden Krankenhaus GmbH, Berlin, Berlin, Germany
| | - Christhardt Kohler
- Department of Special Operative and Oncologic Gynecology, Asklepios Klinik Altona, Hamburg, Hamburg, Germany.,Department of Gynecology, University of Cologne, Koln, Germany
| |
Collapse
|
21
|
Chernyshova A, Kolomiets L, Chekalkin T, Chernov V, Sinilkin I, Gunther V, Marchenko E, Baigonakova G, Kang JH. Fertility-Sparing Surgery Using Knitted TiNi Mesh Implants and Sentinel Lymph Nodes: A 10-Year Experience. J INVEST SURG 2020; 34:1110-1118. [PMID: 32281433 DOI: 10.1080/08941939.2020.1745965] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objectives: The aim of this cohort study is to improve the procedure of fertility-sparing surgery and to assess oncological and reproductive follow-up outcomes after radical trachelectomy (RT) for cervical cancer (T1a2-1bNxM0).Methods: We have suggested the method combining sentinel lymph nodes (SLNs) and cervicoisthmic cerclage using a superelastic knitted TiNi mesh (KTNM) implant to facilitate the primary biomechanical/retention function of the uterus. Sixty-eight consented patients, who underwent fertility-sparing surgery using both transabdominal and laparoscopic route from 2009 through 2019, were recruited in the study and prospectively followed for a mean of 69 months.Results: There were no intraoperative or postoperative complications. No cervical stenoses or mesh failures were noted in all cases. The 5-year overall and recurrence-free survival rates were 100% and 97%, respectively. Two patients indicated recurrence, it occurred in 3 and 36 months. There were 19 (28%) spontaneous pregnancies, 6 resulted in full-term delivery, whereas 2 and 11 ended in miscarriage and early abortion, respectively.Conclusions: This sparing-surgery technique is turned out to be feasible and efficient as allows to achieve well oncologic and fertility outcomes, mimicking the effect of the cervix. It complements existing surgical approaches and may provide further insight into how to overcome challenges even in aggravated cases or previously failed procedures.
Collapse
Affiliation(s)
- Alena Chernyshova
- Tomsk Cancer Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, Tomsk, Russia
| | - Larisa Kolomiets
- Tomsk Cancer Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, Tomsk, Russia.,Siberian State Medical University, Tomsk, Russia
| | - Timofey Chekalkin
- Tomsk State University, Tomsk, Russia.,R&D Center, Kang and Park Medical Co, Ochang, Korea
| | - Vladimir Chernov
- Tomsk Cancer Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, Tomsk, Russia
| | - Ivan Sinilkin
- Tomsk Cancer Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, Tomsk, Russia
| | | | | | | | - Ji Hoon Kang
- R&D Center, Kang and Park Medical Co, Ochang, Korea
| |
Collapse
|
22
|
Matsuo K, Matsuzaki S, Mandelbaum RS, Matsushima K, Klar M, Grubbs BH, Roman LD, Wright JD. Association between hospital surgical volume and perioperative outcomes of fertility-sparing trachelectomy for cervical cancer: A national study in the United States. Gynecol Oncol 2020; 157:173-180. [PMID: 31982179 DOI: 10.1016/j.ygyno.2020.01.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 01/04/2020] [Accepted: 01/06/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To examine the association between hospital surgical volume and perioperative outcomes for fertility-sparing trachelectomy performed for cervical cancer. METHODS This is a population-based retrospective observational study utilizing the Nationwide Inpatient Sample from 2001 to 2011. Women aged ≤45 years with cervical cancer who underwent trachelectomy were included. Annualized hospital surgical volume was defined as the average number of trachelectomies a hospital performed per year in which at least one case was performed. Perioperative outcomes were assessed based on hospital surgical volume in a weighted model, specifically comparing the top-decile centers to the lower volume centers. RESULTS There were a total of 815 trachelectomies performed at 89 centers, and 76.4% of the trachelectomy-performing centers had a minimum surgical volume of one trachelectomy per year. The top-decile group had a higher rate of lymphadenectomy performance compared to the lower volume group (96.4% versus 82.4%, odds ratio [OR] 5.65, 95% confidence interval [CI] 2.81-11.4, P < 0.001). There was a significant inverse linear association between annualized surgical volume and the number of perioperative complications (P = 0.020). The top-decile group also had a lower rate of perioperative complications (9.7% versus 21.0%, P < 0.001) and prolonged hospital stay ≥7 days (2.0% versus 6.5%, P = 0.006) compared to the lower volume group. In a multivariable analysis, the top-decile group had a 65% relative decrease in perioperative complication risk compared to the lower volume group (adjusted-OR 0.35, 95%CI 0.20-0.59, P < 0.001). CONCLUSION Fertility-sparing trachelectomy for young women with cervical cancer is a rare surgical procedure; <90 centers performed this procedure from 2001 to 2011 and most hospitals perform a small number of cases annually. Higher hospital surgical volume for trachelectomy may be associated with reduced perioperative morbidity.
Collapse
Affiliation(s)
- Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
| | - Shinya Matsuzaki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Rachel S Mandelbaum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, University of Freiburg, Freiburg, Germany
| | - Brendan H Grubbs
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Lynda D Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| |
Collapse
|
23
|
Brandt B, Sioulas V, Basaran D, Kuhn T, LaVigne K, Gardner GJ, Sonoda Y, Chi DS, Long Roche KC, Mueller JJ, Jewell EL, Broach VA, Zivanovic O, Abu-Rustum NR, Leitao MM. Minimally invasive surgery versus laparotomy for radical hysterectomy in the management of early-stage cervical cancer: Survival outcomes. Gynecol Oncol 2020; 156:591-597. [PMID: 31918996 DOI: 10.1016/j.ygyno.2019.12.038] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/16/2019] [Accepted: 12/23/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To compare oncologic and perioperative outcomes in patients who underwent minimally invasive surgery (MIS) compared to laparotomy for newly diagnosed early-stage cervical carcinoma. METHODS We retrospectively identified patients who underwent radical hysterectomy for stage IA1 with lymphovascular invasion (LVI), IA2, or IB1 cervical carcinoma at our institution from 1/2007-12/2017. Clinicopathologic characteristics and surgical and oncologic survival outcomes were compared using appropriate statistical testing. Multivariable Cox regression analysis was used to control for potential confounders. RESULTS We identified 196 evaluable cases-117 MIS (106 robotic [90.6%]) and 79 laparotomy cases. Cohorts had similar age, BMI, substage, histologic subtype, clinical and pathologic tumor size, positive margins, and presence of LVI. The MIS group had more cases with no residual tumor in the hysterectomy (24.8% vs. 10.1%, P = 0.01). The laparotomy group had more cases with positive nodes (29.1% vs. 17.1%, P = 0.046) and more patients who received adjuvant therapy (53.2% vs. 33.3%, P = 0.006). Median follow-up was ~4 years. Five-year disease-free survival (DFS) rates were 87.0% in the MIS group and 86.6% in the laparotomy group (P = 0.92); 5-year disease-specific survival (DSS) rates were 96.5% and 93.9%, respectively (P = 0.93); and 5-year overall survival (OS) rates were 96.5% and 87.4%, respectively (P = 0.15). MIS was not associated with DFS, DSS, or OS on multivariable regression analysis. The rate of postoperative complications was significantly lower in the MIS cohort (11.1% vs. 20.3%; P = 0.04). CONCLUSIONS MIS radical hysterectomy for cervical carcinoma did not confer worse oncologic outcomes in our single-center and concurrent series of patients with early-stage cervical carcinoma.
Collapse
Affiliation(s)
- Benny Brandt
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
| | - Vasileios Sioulas
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
| | - Derman Basaran
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
| | - Theresa Kuhn
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
| | - Katherine LaVigne
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
| | - Ginger J Gardner
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY 10065, USA
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY 10065, USA
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY 10065, USA
| | - Kara C Long Roche
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY 10065, USA
| | - Jennifer J Mueller
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY 10065, USA
| | - Elizabeth L Jewell
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY 10065, USA
| | - Vance A Broach
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY 10065, USA
| | - Oliver Zivanovic
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY 10065, USA
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY 10065, USA
| | - Mario M Leitao
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY 10065, USA.
| |
Collapse
|
24
|
Machida H, Iwata T, Okugawa K, Matsuo K, Saito T, Tanaka K, Morishige K, Kobayashi H, Yoshino K, Tokunaga H, Ikeda T, Shozu M, Yaegashi N, Enomoto T, Mikami M. Fertility-sparing trachelectomy for early-stage cervical cancer: A proposal of an ideal candidate. Gynecol Oncol 2019; 156:341-348. [PMID: 31767188 DOI: 10.1016/j.ygyno.2019.11.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/13/2019] [Accepted: 11/16/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To propose an ideal patient candidate with early-stage cervical cancer for undergoing fertility-sparing trachelectomy. METHODS This nationwide, multicenter, retrospective study was conducted by the Japan Society of Obstetrics and Gynecology involving women aged <45 years with clinical stage I-II cervical cancer who had planned fertility-sparing trachelectomy and pelvic lymphadenectomy between 2009 and 2013 (n = 393). Ideal candidates were defined to have a tumor size of ≤2 cm, no lymph node metastasis, no deep stromal invasion, and no high-risk histology (n = 284, 69.6%). Less-ideal candidates were defined to have any one of these four characteristics (n = 109, 30.4%). Propensity score inverse probability of treatment weighting was used to assess survival outcomes. RESULTS Less-ideal candidates were more likely to undergo hysterectomy conversion (22.9% versus 3.2%), receive postoperative radiotherapy (11.9% versus 0.4%), or chemotherapy (32.1% versus 3.2%) compared with ideal candidates (all, P < 0.05). The weighted model revealed that among those who underwent trachelectomy (ideal candidates, n = 275 and less-ideal candidates, n = 84), less-ideal candidates had significantly decreased disease-free survival (5-year rates: 85.5% versus 95.5%; HR 3.93, 95% CI 1.99-7.74; P < 0.001) and cause-specific survival (92.5% versus 98.6%; HR 5.47, 95% CI 1.68-17.8, P = 0.001) compared with ideal candidates. Similarly, less-ideal candidates were significantly associated with decreased disease-free survival compared with ideal candidates among those who were young age, had small tumors or squamous histology, and underwent surgery alone (all, P < 0.05). CONCLUSION Less-ideal candidates had approximately four-fold higher recurrence risk and cancer mortality compared with ideal candidates. Ideal candidates for fertility-sparing trachelectomy for early-stage cervical cancer proposed in our study may be useful as the future framework for developing guidelines for fertility-sparing trachelectomy in Japan.
Collapse
Affiliation(s)
- Hiroko Machida
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Japan
| | - Takashi Iwata
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Japan
| | - Kaoru Okugawa
- Department of Obstetrics and Gynecology, Kyushu University School of Medicine, Japan
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, USA; Norris Comprehensive Cancer Center, University of Southern California, USA
| | - Tsuyoshi Saito
- Department of Obstetrics and Gynecology, Sapporo Medical University, Japan
| | - Kyoko Tanaka
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Japan
| | - Kenichiro Morishige
- Department of Obstetrics and Gynecology, Gifu University Graduate School of Medicine, Japan
| | - Hiroaki Kobayashi
- Department of Obstetrics and Gynecology, Kagoshima University, Japan
| | - Kiyoshi Yoshino
- Department of Obstetrics and Gynecology, University of Occupational and Environmental Health, Japan
| | - Hideki Tokunaga
- Department of Obstetrics and Gynecology, Tohoku University, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University, Japan
| | - Makio Shozu
- Department of Obstetrics and Gynecology, Chiba University, Japan
| | - Nobuo Yaegashi
- Department of Obstetrics and Gynecology, Tohoku University, Japan
| | - Takayuki Enomoto
- Department of Obstetrics and Gynecology, Niigata University School of Medicine, Japan
| | - Mikio Mikami
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Japan.
| |
Collapse
|
25
|
Matsuo K, Melamed A, Wright JD. Reply. Am J Obstet Gynecol 2019; 221:538. [PMID: 31394071 DOI: 10.1016/j.ajog.2019.07.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 07/30/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Alexander Melamed
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY.
| |
Collapse
|
26
|
Dietl A, Klar M, Aumann K. Minimally invasive surgery for early-stage cervical cancer: is the uterine manipulator a risk factor? Am J Obstet Gynecol 2019; 221:537-538. [PMID: 31394066 DOI: 10.1016/j.ajog.2019.07.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/30/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Anna Dietl
- Department of Obstetrics and Gynecology, University Medical Centre Erlangen, Erlangen, 91054 Erlangen.
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, University Medical Centre Freiburg, Freiburg iBr, 79106 Freiburg, Germany.
| | - Konrad Aumann
- Institute for Surgical Pathology, Medical Centre-University of Freiburg, Freiburg, Germany
| |
Collapse
|
27
|
Bixel KL, Fowler JM. Fertility-sparing surgery for early-stage cervical cancer: does surgical approach have an impact on disease outcomes? Am J Obstet Gynecol 2019; 220:417-419. [PMID: 31076039 DOI: 10.1016/j.ajog.2019.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 02/02/2023]
|