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Plaikner A, Siegler K, Hertel H, Jacob A, Petzel A, Schubert M, Blohmer JU, Böhmer G, Marnitz S, Ragosch V, Domröse C, Oppelt P, Jülicher A, Schneider A, Willems A, Favero G, Köhler C. Fertility sparing therapy in women with lymph node negative cervical cancer >2cm - oncologic and fertility outcomes of neoadjuvant chemotherapy followed by radical vaginal trachelectomy. Int J Gynecol Cancer 2023; 33:1542-1547. [PMID: 37696645 DOI: 10.1136/ijgc-2023-004669] [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] [Indexed: 09/13/2023] Open
Abstract
OBJECTIVE Simple or radical trachelectomy are accepted fertility sparing therapies for patients diagnosed with cervical cancer ≤2 cm. In patients with larger tumors a fertility sparing concept is considered experimental. The aim of our study is to present oncological and fertility outcomes of laparoscopic pelvic lymphadenectomy followed by neoadjuvant chemotherapy and subsequent radical vaginal trachelectomy. These procedures were performed in two centers in patients diagnosed with cervical cancer of diameter >2 cm. METHOD We retrospectively analyzed the demographic, histological, fertility and follow-up data of all patients with cervical cancer assessed as stage IB2, IB3 or IIA1 under the International Federation of Gynecology and Obstetrics (FIGO) 2018 system. These patients had undergone pelvic lymphadenectomy, followed by neoadjuvant chemotherapy and radical vaginal trachelectomy between February 2006 and June 2020 at Charité University Berlin and Asklepios Hospital, Hamburg. RESULTS A total of 31 patients (mean age 29.5 years, range; 26-40) underwent neoadjuvant chemotherapy followed by radical vaginal trachelectomy in case of proven tumor-free lymph nodes. Twenty-six (84%) of these patients were nulliparous. Across all 31 patients, the initial tumor stages were FIGO 2018 stage IB2 (n=27), IB3 (n=3) and IIA1 (n=1).Lymphadenectomy was completed in all but one patient (sentinel) with a median of 33 (range; 11-47) pelvic lymph nodes. The neoadjuvant chemotherapy regimen was two cycles of paclitaxel, ifosfamide and cisplatin in 17 patients; three cycles of paclitaxel, ifosfamide and cisplatin in eight patients; two cycles of paclitaxel and cisplatin in four patients; two cylces cisplatin monoagent in one patient; and two cycles of paclitaxel and cisplatin followed by two cycles of paclitaxel, ifosfamide and cisplatin in one patient. Residual tumor was histologically confirmed in 17 specimens (55%). The median residual tumor size following neoadjuvant chemotherapy was 12 mm (range; 1-60). Fertility could be preserved in 27 patients (87%); two patients underwent adjuvant chemoradiation after radical vaginal trachelectomy due to high-risk histological features; two other patients underwent radical hysterectomy with adjuvant chemoradiation therapy following neoadjuvant chemotherapy. Of 18 (67%) patients seeking motherhood, 13 became pregnant (72%). There were 12 live births in 10 women, with a median fetal weight of 2490 grams (range; 1640-3560) and five miscarriages. After a median follow-up of 94.5 months (range; 6-183) three recurrences (11.1%) were detected, one patient (3.7%) died of the disease. CONCLUSION Neoadjuvant chemotherapy followed by radical vaginal trachelectomy may be offered to patients seeking motherhood with cervical cancer >2 cm and histopathologically tumor-free lymph nodes, the rate of healthy baby pregnancy on discharge was 10/18 women (55%). This fertility-preserving strategy is associated with higher recurrence and death compared with what was published in the literature for women undergoing radical vaginal trachelectomy for tumors up to 2 cm.
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Affiliation(s)
- Andrea Plaikner
- 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
| | - Hermann Hertel
- Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Anna Jacob
- Department of Gynecology, Asklepios Clinic Wandsbek, Hamburg, Germany
| | - Anja Petzel
- Institute for Dysplasia and Cytology, MVZ Kreuzberg, Berlin, Germany
| | - Melanie Schubert
- Department of Obstetrics and Gynecology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Jens-Uwe Blohmer
- Charité University Medicine, Department of Gynecology, Charité, Campus Mitte, Berlin, Germany
| | - Gerd Böhmer
- Institute for Dysplasia and Cytology, IZD Hannover, Hannover, Germany
| | - Simone Marnitz
- Department of Radiooncology, Radiation Oncology Vosspalais, Private Clinic, Berlin, Germany, Berlin, Berlin, Germany
| | - Volker Ragosch
- Department of Obstetrics, Asklepios Clinic Altona, Hamburg, Germany
| | - Christian Domröse
- Department of Obstetrics and Gynecology, Medical Faculty of the University of Cologne, Köln, Nordrhein-Westfalen, Germany
| | - Peter Oppelt
- Department for Gynecology, Obstetrics and Gynecological Endocrinology, Johannes Kepler University Linz, Linz, Austria
| | - Anne Jülicher
- Institute for Dysplasia and Cytology, MVZ Fürstenbergkarree, Berlin, Germany
| | - Achim Schneider
- Institute for Dysplasia and Cytology, MVZ Fürstenbergkarree, Berlin, Germany
| | - Anne Willems
- Institute for Dysplasia and Cytology, MVZ Köpenick, Germany
| | - Giovanni Favero
- Department of Gynecology and Obstetrics, Asklepios Hospital Lich, Lich, Germany
| | - Christhardt Köhler
- Department of Special Operative and Oncologic Gynecology, Asklepios Klinik Altona, Hamburg, Hamburg, Germany
- Institute for Dysplasia and Cytology, MVZ Fürstenbergkarree, Berlin, Germany
- Department of Gynecology, German Red Cross Clinic Berlin Westend, Berlin, Germany
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Dicu-Andreescu IG, Marincaș AM, Ungureanu VG, Ionescu SO, Prunoiu VM, Brătucu E, Simion L. Current Therapeutic Approaches in Cervical Cancer Based on the Stage of the Disease: Is There Room for Improvement? MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1229. [PMID: 37512041 PMCID: PMC10384945 DOI: 10.3390/medicina59071229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 06/19/2023] [Accepted: 06/28/2023] [Indexed: 07/30/2023]
Abstract
Cervical cancer continues to be among the most common malignancies in women, and in recent decades, important measures have been taken to reduce its incidence. The first and most important steps to achieve this goal are oriented toward prevention through screening programs and vaccination, mainly against oncogenic human papillomavirus (HPV) strains 16 and 18. The therapeutic approach is based on the diagnosis and treatment guidelines for cervical cancer, which establish for each stage (FIGO, TNM) specific conduct. These guidelines summarize quite precisely the elements of therapeutic practice, but, in some places, they leave optional variants based on which nuanced approaches could be established. Adherence to these guidelines, which include the performing of minor or major surgery, with or without chemotherapy and radiation therapy, combined with advanced imaging investigations, has been able to lead to a substantial increase in survival. The purpose of this literature review is to discuss the diagnosis and treatment options in cervical cancer depending on the histological type, FIGO staging, and patient performance index, taking into account the hospital resources available in middle-income countries (percentage of gross domestic product allocated to health services around 5.5%, in the case of Romania).
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Affiliation(s)
- Irinel-Gabriel Dicu-Andreescu
- Clinical Department No 10, General Surgery, University of Medicine and Pharmacy "Carol Davila", 050474 Bucharest, Romania
- Department of Oncological Surgery, Oncological Institute "Alexandru Trestioreanu", 022328 Bucharest, Romania
| | - Augustin-Marian Marincaș
- Clinical Department No 10, General Surgery, University of Medicine and Pharmacy "Carol Davila", 050474 Bucharest, Romania
- Department of Oncological Surgery, Oncological Institute "Alexandru Trestioreanu", 022328 Bucharest, Romania
| | - Victor-Gabriel Ungureanu
- Clinical Department No 10, General Surgery, University of Medicine and Pharmacy "Carol Davila", 050474 Bucharest, Romania
| | - Sînziana-Octavia Ionescu
- Clinical Department No 10, General Surgery, University of Medicine and Pharmacy "Carol Davila", 050474 Bucharest, Romania
- Department of Oncological Surgery, Oncological Institute "Alexandru Trestioreanu", 022328 Bucharest, Romania
| | - Virgiliu-Mihail Prunoiu
- Clinical Department No 10, General Surgery, University of Medicine and Pharmacy "Carol Davila", 050474 Bucharest, Romania
- Department of Oncological Surgery, Oncological Institute "Alexandru Trestioreanu", 022328 Bucharest, Romania
| | - Eugen Brătucu
- Clinical Department No 10, General Surgery, University of Medicine and Pharmacy "Carol Davila", 050474 Bucharest, Romania
- Department of Oncological Surgery, Oncological Institute "Alexandru Trestioreanu", 022328 Bucharest, Romania
| | - Laurențiu Simion
- Clinical Department No 10, General Surgery, University of Medicine and Pharmacy "Carol Davila", 050474 Bucharest, Romania
- Department of Oncological Surgery, Oncological Institute "Alexandru Trestioreanu", 022328 Bucharest, Romania
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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.
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Abstract
PURPOSE OF REVIEW This article discusses recent developments towards less radical surgical treatment for early-stage cervical cancer. RECENT FINDINGS Surgery is the standard treatment for early-stage cervical cancer. In the last decades, new treatment strategies have been developed aiming to reduce morbidity, without hampering oncological safety. We provide an update of the latest knowledge on safety and morbidity following less radical surgical procedures in early-stage cervical cancer. In cervical cancer with a tumour size of 2 cm or less, radical surgery (simple hysterectomy or fertility-sparing conisation) may be a well tolerated option. For patients with larger lesions (>2 cm) and wishing to preserve fertility, administration of neoadjuvant chemotherapy followed by less extensive surgery appears to be a feasible and well tolerated alternative to abdominal trachelectomy. With regard to lymph node assessment, increasing evidence shows the feasibility of the sentinel lymph node procedure instead of full pelvic lymphadenectomy. Prospective trials reporting on oncological safety are awaited.It is important to exercise caution when new surgical strategies are introduced. Despite promising retrospective data, prospective randomized studies may present unexpected results, for instance, minimally invasive radical hysterectomy showed inferior results compared to laparotomy. SUMMARY There is a shift towards less radical treatment for early-stage cervical cancer. This review explores whether and when less is really more.
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Huang Y, Li R, Yang Y. Role of Pyroptosis in Gynecological Oncology and Its Therapeutic Regulation. Biomolecules 2022; 12:biom12070924. [PMID: 35883480 PMCID: PMC9313147 DOI: 10.3390/biom12070924] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 02/04/2023] Open
Abstract
With the continuous advances in molecular biotechnology, many new cell death methods have been discovered. Pyroptosis is a programmed cell death process that differs from apoptosis and autophagy in cell morphology and function. Compared with apoptosis and autophagy, pyroptosis is primarily mediated by intracellular inflammasome and gasdermin D of the gasdermin protein family and involves the release of numerous inflammatory factors. Pyroptosis has been found to be involved in the occurrence and development of infectious diseases and other diseases involving the nervous system and the cardiovascular system. Recent studies have also reported the occurrence of pyroptosis in tumor cells. Accordingly, exploring its effect on tumors has become one of the research hotspots. Herein, recent research progress on pyroptosis is reviewed, especially its role in the development of gynecological tumors. As the pathogenesis of gynecological tumor is better understood, new targets have been introduced for the prevention and clinical treatment of gynecological tumors.
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Affiliation(s)
- Yi Huang
- The First Clinical Medical College, Lanzhou University, Lanzhou 730000, China; (Y.H.); (R.L.)
| | - Ruiyun Li
- The First Clinical Medical College, Lanzhou University, Lanzhou 730000, China; (Y.H.); (R.L.)
| | - Yuan Yang
- The Reproductive Medicine Center, The 1st Hospital of Lanzhou University, Lanzhou 730000, China
- Correspondence:
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Ind T. Overview of fertility sparing treatments for cervical cancer. Best Pract Res Clin Obstet Gynaecol 2021; 75:2-9. [PMID: 34053867 DOI: 10.1016/j.bpobgyn.2021.04.004] [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: 03/31/2021] [Accepted: 04/30/2021] [Indexed: 11/16/2022]
Abstract
Until the late 1980s, the mainstay of treatment for cervical cancer has been either hysterectomy or radiotherapy. From the mid to late 1990s, surgical treatments have been focussed more on sparing fertility by preserving the corpus of the womb with trachelectomy or even conserving part of the cervical stroma with a cone biopsy. In carefully selected cases, less radical treatment that preserves the uterus has been considered safe. However, these approaches can be associated with specific operative and obstetric complications such as stitch ulceration, cervical stenosis, late miscarriage, and premature labour. Most guidelines agree that the management of such patients should be centralised in a unit with specialist gynaecological oncology, radiology, and histopathology services supported by specialist cancer nurses.
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Affiliation(s)
- Thomas Ind
- Royal Marsden Hospital, London, SW3 6JA, UK; St George's University of London, Cranmer Terrace, Tooting, London SW17 0RE, UK.
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