Conservative approaches in early stages of cervical cancer

The role of cytological follow-up after radical vaginal trachelectomy for early-stage cervical cancer

OBJECTIVES

To identify whether recurrences were picked up by cytology alone after radical vaginal trachelectomy and to determine the false-positive rate of abnormal cytology.

METHODS

Retrospective collection of patients from the cancer registry since radical vaginal trachelectomy was first performed in Bristol in 1999. All cytology results were collated and re-reviewed by a senior consultant cellular pathologist at the cytopathology centre in Southmead Hospital, Bristol. Cytology results and pathology and survival data are discussed, and any downgrading or upgrading of reports is reviewed.

RESULTS

Eighteen women were identified and 80 isthmic cytology samples were reviewed. Only one recurrence has occurred. Lower uterine segment sampling was apparent in 25 samples and other endometrial cells in 21 samples: thus 58% showed endometrial cell sampling. Odd metaplastic cells from the newly formed transformation zone were found in 25 samples (31%). Fifteen (19%) showed significant inflammation, two with actinomyces. After cytology review, seven of 80 reports were changed: two between negative and inadequate, two borderline changes in endocervical cells and one mild dyskaryosis were downgraded to negative, and two cases reported as ?glandular neoplasia were changed to squamous cell carcinoma and negative, respectively.

CONCLUSIONS

Cytology reporting may be challenging after trachelectomy. Cytology in our series did not add to the diagnosis of recurrence in the one case in which it occurred. We propose a pragmatic follow-up regime, and discuss the importance of the centralization of cytology reporting in these patients.

Fertility-preserving surgery in patients with early stage cervical carcinoma

Fertility preservation is an important issue for patients in reproductive age with early stage cervical cancer. In view of recent developments, our purpose was to review and discuss available surgical alternatives. A literature search was conducted using PUBMED, including papers between 1980 and December 2011. In patients with stage IA1 cervical cancer, conization is a valid alternative. Patients with stage IA2-IB1 disease can be conservatively treated by radical trachelectomy. This is as well-established conservative approach and appears to be safe and effective in allowing a high chance of conception. Prematurity is the most serious issue in pregnancies following trachelectomy. Less invasive options such as simple trachelectomy or conization seem to be feasible for stages IA2-IB1, but more and better evidence is needed. Neoadjuvant therapy might allow conservative surgery to be performed also in patients with more extensive lesions. Ovarian transposition is important when adjuvant radiation is needed. In conclusion, available literature shows that there are interesting fertility-sparing treatment alternatives to the “golden standard” for the management of early cervical cancer in young women.

Early-stage cervical cancer: agreement between ultrasound and histopathological findings with regard to tumor size and extent of local disease

OBJECTIVES

To determine the agreement between ultrasound and histological examination of the cervix in patients with early stage cervical cancer with regard to tumor size and local extent of the disease.

METHODS

Eighteen patients with histologically proven cervical cancer Stage IB1-IIA according to traditional clinical staging (FIGO 1988) who were scheduled for radical surgery underwent a standardized transvaginal ultrasound examination. The maximum tumor length, anteroposterior tumor diameter, tumor width, tumor area, depth of cervical stroma invasion, and the minimal thickness of tumor-free cervical stroma on sagittal and transverse planes through the cervix were measured, and the local extent of the disease within the parametria and vagina were evaluated. The surgical specimens were examined using a specifically devised method of histopathological examination. The results of the ultrasound and histopathological examinations were compared.

RESULTS

Limits of agreement were wide and the intraclass correlation coefficient (ICC) was low (0.51-0.58) for three of the four measurements taken to represent the minimal depth of tumor-free cervical stroma, i.e. the results of the measurements taken posteriorly and laterally. However, the limits of agreement were narrower and the ICC values were higher (0.74-0.92) for the depth of cervical stroma invasion and for the tumor size measurements. Histological examination revealed parametrial cancer infiltration in four patients, which was detected during ultrasound examination, with no false-positive results.

CONCLUSIONS

Transvaginal sonography is acceptably accurate for evaluation of tumor size and depth of cervical stroma invasion in clinical practice.