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Zeng S, Xiao S, Xu Y, Yang P, Hu C, Jin X, Liu L. Efficacy and safety analysis of non-radical surgery for early-stage cervical cancer (IA2 ~ IB1): a systematic review and meta-analysis. Front Med (Lausanne) 2024; 11:1337752. [PMID: 38745744 PMCID: PMC11091289 DOI: 10.3389/fmed.2024.1337752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 04/09/2024] [Indexed: 05/16/2024] Open
Abstract
Objective Radical hysterectomy has long been considered as the standard surgical treatment for early-stage cervical cancer (IA2 to IB1 stages), according to the 2009 International Federation of Obstetrics and Gynecology. This study aims to conduct an in-depth evaluation of the effectiveness and safety of non-radical surgery as an alternative treatment for patients with early-stage cervical cancer. Methods A systematic search of online databases including PubMed, Embase, and the Cochrane Library was conducted to identify relevant literature on surgical treatment options for early-stage cervical cancer. Keywords such as "cervical cancer," "conservative surgery," "early-stage," "less radical surgery," and "simple hysterectomy" were used. Meta-analysis was performed using Stata 15.0 software, which included randomized controlled trials (RCTs) and cohort studies. Results This meta-analysis included 8 eligible articles covering 9 studies, with 3,950 patients in the simple hysterectomy (SH) surgery group and 6,271 patients in the radical hysterectomy (RH) surgery group. The results indicate that there was no significant difference between the two groups in terms of the Overall Survival (OS) (HR = 1.04, 95% CI: 0.86-1.27, p = 0.671; Heterogeneity: I2 = 33.8%, p = 0.170), Disease Free Survival (DFS) (HR = 1.39, 95% CI: 0.59-3.29, p = 0.456; Heterogeneity: I2 = 0.0%, p = 0.374), Cervical Cancer Specific Survival (CCSS) (HR = 1.11, 95% CI: 0.80-1.54, p = 0.519; Heterogeneity: I2 = 11.9%, p = 0.287) and recurrence rate (RR = 1.16, 95% CI: 0.69-1.97, p = 0.583; Heterogeneity: I = 0.0%, p = 0.488). However, the mortality rate (RR = 1.35, 95% CI: 1.10-1.67, p = 0.006; Heterogeneity: I2 = 35.4%, p = 0.158) and the rate of postoperative adjuvant therapy (RR = 1.59, 95% CI: 1.16-2.19, p = 0.004; Heterogeneity: I2 = 92.7%, p < 0.10) were higher in the SH group compared to those in the RH group. On the other hand, the incidence of surgical complications was lower in the SH group (RR = 0.36, 95% CI: 0.21-0.59, p = 0.004; Heterogeneity: I2 = 0.0%, p = 0.857) than that in the RH group. Subgroup analysis revealed that patients in the IB1 stage SH group had a significantly higher mortality rate compared to those in the RH group (RR = 1.59, 95% CI: 1.23-2.07, p < 0.001; Heterogeneity: I2 = 0.0%, p = 0.332). However, there was no significant difference in mortality rates between the two groups for patients at stage IA2 (RR = 0.84, 95% CI: 0.54-1.30, p = 0.428; Heterogeneity: I2 = 26.8%, p = 0.243). In the subgroups positive for Lymphovascular Space Invasion (LVSI), patients in the SH group had a significantly higher mortality rate than those in the RH group (RR = 1.34, 95% CI: 1.09-1.65, p = 0.005; Heterogeneity: I2 = 41.6%, p = 0.128). However, in the LVSI-negative subgroups, there was no significant difference in mortality rates between the two groups (RR = 0.33, 95% CI: 0.01-8.04, p = 0.499). Conclusion For patients with early-stage cervical cancer patients at IA2 without LVSI involvement, comparisons between the two groups in terms of OS, DFS, CCSS, recurrence rate, and mortality rates revealed no statistically significant differences, indicating that the choice of surgical approach does not affect long-term survival outcomes for this specific patient group. For patients at IB1 and IA2 stages with LVSI involvement, while there were no significant differences between the two groups in OS, DFS, CSS, and recurrence rate, a significant increase in mortality rates was observed in the SH group. This indicates a potential elevated risk of mortality associated with SH in this subset of patients. Notably, the incidence of surgical complications was significantly lower in the SH group compared to the RH group, highlighting the safety profile of SH in this context. Significantly, among patients in the SH group, an increase in the rate of postoperative adjuvant treatment is associated with a higher occurrence of treatment-related complications. To facilitate more precise patient selection for conservative surgical management, future prospective studies of superior quality are imperative to gain deeper insights into this matter. Systematic review registration PROSPERO (CRD42023451609: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023451609).
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Affiliation(s)
- Siyuan Zeng
- Department of Obstetrics and Gynecology, Dalian Municipal Central Hospital, Dalian, China
- Dalian Municipal Central Hospital, China Medical University, Shenyang, China
| | - Simin Xiao
- Radiology Department, XinDu Hospital of Traditional Chinese Medicine, Chengdu, China
| | - Yang Xu
- Department of Obstetrics and Gynecology, Dalian Municipal Central Hospital, Dalian, China
- Dalian Municipal Central Hospital, China Medical University, Shenyang, China
| | - Ping Yang
- Department of Radiation Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Chenming Hu
- Department of Obstetrics and Gynecology, Dalian Municipal Central Hospital, Dalian, China
| | - Xianyu Jin
- Dalian Municipal Central Hospital, China Medical University, Shenyang, China
| | - Lifeng Liu
- Department of Obstetrics and Gynecology, Dalian Municipal Central Hospital, Dalian, China
- Dalian Municipal Central Hospital, China Medical University, Shenyang, China
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Plante M, Kwon JS, Ferguson S, Samouëlian V, Ferron G, Maulard A, de Kroon C, Van Driel W, Tidy J, Williamson K, Mahner S, Kommoss S, Goffin F, Tamussino K, Eyjólfsdóttir B, Kim JW, Gleeson N, Brotto L, Tu D, Shepherd LE. Simple versus Radical Hysterectomy in Women with Low-Risk Cervical Cancer. N Engl J Med 2024; 390:819-829. [PMID: 38416430 DOI: 10.1056/nejmoa2308900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
BACKGROUND Retrospective data suggest that the incidence of parametrial infiltration is low in patients with early-stage low-risk cervical cancer, which raises questions regarding the need for radical hysterectomy in these patients. However, data from large, randomized trials comparing outcomes of radical and simple hysterectomy are lacking. METHODS We conducted a multicenter, randomized, noninferiority trial comparing radical hysterectomy with simple hysterectomy including lymph-node assessment in patients with low-risk cervical cancer (lesions of ≤2 cm with limited stromal invasion). The primary outcome was cancer recurrence in the pelvic area (pelvic recurrence) at 3 years. The prespecified noninferiority margin for the between-group difference in pelvic recurrence at 3 years was 4 percentage points. RESULTS Among 700 patients who underwent randomization (350 in each group), the majority had tumors that were stage IB1 according to the 2009 International Federation of Gynecology and Obstetrics (FIGO) criteria (91.7%), that had squamous-cell histologic features (61.7%), and that were grade 1 or 2 (59.3%). With a median follow-up time of 4.5 years, the incidence of pelvic recurrence at 3 years was 2.17% in the radical hysterectomy group and 2.52% in the simple hysterectomy group (an absolute difference of 0.35 percentage points; 90% confidence interval, -1.62 to 2.32). Results were similar in a per-protocol analysis. The incidence of urinary incontinence was lower in the simple hysterectomy group than in the radical hysterectomy group within 4 weeks after surgery (2.4% vs. 5.5%; P = 0.048) and beyond 4 weeks (4.7% vs. 11.0%; P = 0.003). The incidence of urinary retention in the simple hysterectomy group was also lower than that in the radical hysterectomy group within 4 weeks after surgery (0.6% vs. 11.0%; P<0.001) and beyond 4 weeks (0.6% vs. 9.9%; P<0.001). CONCLUSIONS In patients with low-risk cervical cancer, simple hysterectomy was not inferior to radical hysterectomy with respect to the 3-year incidence of pelvic recurrence and was associated with a lower risk of urinary incontinence or retention. (Funded by the Canadian Cancer Society and others; ClinicalTrials.gov number, NCT01658930.).
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Affiliation(s)
- Marie Plante
- From Centre Hospitalier Universitaire de Québec, Quebec (M.P.), the University of British Columbia, Vancouver (J.S.K., L.B.), Princess Margaret Hospital, Toronto (S.F.), Centre Hospitalier de l'Université de Montréal, Montreal (V.S.), and the Canadian Cancer Trials Group, Queen's University, Kingston, ON (D.T., L.E.S.) - all in Canada; Institut Claudius Regaud, IUCT-Oncopole, Toulouse (G.F.), and Gustave Roussy Cancer Center, Villejuif (A.M.) - both in France; Leiden University Medical Center, Leiden (C.K.), and the Netherlands Cancer Institute, Amsterdam (W.V.D.) - both in the Netherlands; Royal Hallamshire Hospital, Sheffield (J.T.), and Nottingham University Hospitals, Nottingham (K.W.) - both in the United Kingdom; LMU University Hospital, Munich (S.M.), and University of Tübingen Hospital, Tübingen (S.K.) - both in Germany; Centre Hospitalier Universitaire de Liege, Liege, Belgium (F.G.); Medical University of Graz, Graz, Austria (K.T.); Oslo University Hospital, Oslo (B.E.); Seoul National University College of Medicine, Seoul, South Korea (J.-W.K.); and St. James' Hospital, Dublin (N.G.)
| | - Janice S Kwon
- From Centre Hospitalier Universitaire de Québec, Quebec (M.P.), the University of British Columbia, Vancouver (J.S.K., L.B.), Princess Margaret Hospital, Toronto (S.F.), Centre Hospitalier de l'Université de Montréal, Montreal (V.S.), and the Canadian Cancer Trials Group, Queen's University, Kingston, ON (D.T., L.E.S.) - all in Canada; Institut Claudius Regaud, IUCT-Oncopole, Toulouse (G.F.), and Gustave Roussy Cancer Center, Villejuif (A.M.) - both in France; Leiden University Medical Center, Leiden (C.K.), and the Netherlands Cancer Institute, Amsterdam (W.V.D.) - both in the Netherlands; Royal Hallamshire Hospital, Sheffield (J.T.), and Nottingham University Hospitals, Nottingham (K.W.) - both in the United Kingdom; LMU University Hospital, Munich (S.M.), and University of Tübingen Hospital, Tübingen (S.K.) - both in Germany; Centre Hospitalier Universitaire de Liege, Liege, Belgium (F.G.); Medical University of Graz, Graz, Austria (K.T.); Oslo University Hospital, Oslo (B.E.); Seoul National University College of Medicine, Seoul, South Korea (J.-W.K.); and St. James' Hospital, Dublin (N.G.)
| | - Sarah Ferguson
- From Centre Hospitalier Universitaire de Québec, Quebec (M.P.), the University of British Columbia, Vancouver (J.S.K., L.B.), Princess Margaret Hospital, Toronto (S.F.), Centre Hospitalier de l'Université de Montréal, Montreal (V.S.), and the Canadian Cancer Trials Group, Queen's University, Kingston, ON (D.T., L.E.S.) - all in Canada; Institut Claudius Regaud, IUCT-Oncopole, Toulouse (G.F.), and Gustave Roussy Cancer Center, Villejuif (A.M.) - both in France; Leiden University Medical Center, Leiden (C.K.), and the Netherlands Cancer Institute, Amsterdam (W.V.D.) - both in the Netherlands; Royal Hallamshire Hospital, Sheffield (J.T.), and Nottingham University Hospitals, Nottingham (K.W.) - both in the United Kingdom; LMU University Hospital, Munich (S.M.), and University of Tübingen Hospital, Tübingen (S.K.) - both in Germany; Centre Hospitalier Universitaire de Liege, Liege, Belgium (F.G.); Medical University of Graz, Graz, Austria (K.T.); Oslo University Hospital, Oslo (B.E.); Seoul National University College of Medicine, Seoul, South Korea (J.-W.K.); and St. James' Hospital, Dublin (N.G.)
| | - Vanessa Samouëlian
- From Centre Hospitalier Universitaire de Québec, Quebec (M.P.), the University of British Columbia, Vancouver (J.S.K., L.B.), Princess Margaret Hospital, Toronto (S.F.), Centre Hospitalier de l'Université de Montréal, Montreal (V.S.), and the Canadian Cancer Trials Group, Queen's University, Kingston, ON (D.T., L.E.S.) - all in Canada; Institut Claudius Regaud, IUCT-Oncopole, Toulouse (G.F.), and Gustave Roussy Cancer Center, Villejuif (A.M.) - both in France; Leiden University Medical Center, Leiden (C.K.), and the Netherlands Cancer Institute, Amsterdam (W.V.D.) - both in the Netherlands; Royal Hallamshire Hospital, Sheffield (J.T.), and Nottingham University Hospitals, Nottingham (K.W.) - both in the United Kingdom; LMU University Hospital, Munich (S.M.), and University of Tübingen Hospital, Tübingen (S.K.) - both in Germany; Centre Hospitalier Universitaire de Liege, Liege, Belgium (F.G.); Medical University of Graz, Graz, Austria (K.T.); Oslo University Hospital, Oslo (B.E.); Seoul National University College of Medicine, Seoul, South Korea (J.-W.K.); and St. James' Hospital, Dublin (N.G.)
| | - Gwenael Ferron
- From Centre Hospitalier Universitaire de Québec, Quebec (M.P.), the University of British Columbia, Vancouver (J.S.K., L.B.), Princess Margaret Hospital, Toronto (S.F.), Centre Hospitalier de l'Université de Montréal, Montreal (V.S.), and the Canadian Cancer Trials Group, Queen's University, Kingston, ON (D.T., L.E.S.) - all in Canada; Institut Claudius Regaud, IUCT-Oncopole, Toulouse (G.F.), and Gustave Roussy Cancer Center, Villejuif (A.M.) - both in France; Leiden University Medical Center, Leiden (C.K.), and the Netherlands Cancer Institute, Amsterdam (W.V.D.) - both in the Netherlands; Royal Hallamshire Hospital, Sheffield (J.T.), and Nottingham University Hospitals, Nottingham (K.W.) - both in the United Kingdom; LMU University Hospital, Munich (S.M.), and University of Tübingen Hospital, Tübingen (S.K.) - both in Germany; Centre Hospitalier Universitaire de Liege, Liege, Belgium (F.G.); Medical University of Graz, Graz, Austria (K.T.); Oslo University Hospital, Oslo (B.E.); Seoul National University College of Medicine, Seoul, South Korea (J.-W.K.); and St. James' Hospital, Dublin (N.G.)
| | - Amandine Maulard
- From Centre Hospitalier Universitaire de Québec, Quebec (M.P.), the University of British Columbia, Vancouver (J.S.K., L.B.), Princess Margaret Hospital, Toronto (S.F.), Centre Hospitalier de l'Université de Montréal, Montreal (V.S.), and the Canadian Cancer Trials Group, Queen's University, Kingston, ON (D.T., L.E.S.) - all in Canada; Institut Claudius Regaud, IUCT-Oncopole, Toulouse (G.F.), and Gustave Roussy Cancer Center, Villejuif (A.M.) - both in France; Leiden University Medical Center, Leiden (C.K.), and the Netherlands Cancer Institute, Amsterdam (W.V.D.) - both in the Netherlands; Royal Hallamshire Hospital, Sheffield (J.T.), and Nottingham University Hospitals, Nottingham (K.W.) - both in the United Kingdom; LMU University Hospital, Munich (S.M.), and University of Tübingen Hospital, Tübingen (S.K.) - both in Germany; Centre Hospitalier Universitaire de Liege, Liege, Belgium (F.G.); Medical University of Graz, Graz, Austria (K.T.); Oslo University Hospital, Oslo (B.E.); Seoul National University College of Medicine, Seoul, South Korea (J.-W.K.); and St. James' Hospital, Dublin (N.G.)
| | - Cor de Kroon
- From Centre Hospitalier Universitaire de Québec, Quebec (M.P.), the University of British Columbia, Vancouver (J.S.K., L.B.), Princess Margaret Hospital, Toronto (S.F.), Centre Hospitalier de l'Université de Montréal, Montreal (V.S.), and the Canadian Cancer Trials Group, Queen's University, Kingston, ON (D.T., L.E.S.) - all in Canada; Institut Claudius Regaud, IUCT-Oncopole, Toulouse (G.F.), and Gustave Roussy Cancer Center, Villejuif (A.M.) - both in France; Leiden University Medical Center, Leiden (C.K.), and the Netherlands Cancer Institute, Amsterdam (W.V.D.) - both in the Netherlands; Royal Hallamshire Hospital, Sheffield (J.T.), and Nottingham University Hospitals, Nottingham (K.W.) - both in the United Kingdom; LMU University Hospital, Munich (S.M.), and University of Tübingen Hospital, Tübingen (S.K.) - both in Germany; Centre Hospitalier Universitaire de Liege, Liege, Belgium (F.G.); Medical University of Graz, Graz, Austria (K.T.); Oslo University Hospital, Oslo (B.E.); Seoul National University College of Medicine, Seoul, South Korea (J.-W.K.); and St. James' Hospital, Dublin (N.G.)
| | - Willemien Van Driel
- From Centre Hospitalier Universitaire de Québec, Quebec (M.P.), the University of British Columbia, Vancouver (J.S.K., L.B.), Princess Margaret Hospital, Toronto (S.F.), Centre Hospitalier de l'Université de Montréal, Montreal (V.S.), and the Canadian Cancer Trials Group, Queen's University, Kingston, ON (D.T., L.E.S.) - all in Canada; Institut Claudius Regaud, IUCT-Oncopole, Toulouse (G.F.), and Gustave Roussy Cancer Center, Villejuif (A.M.) - both in France; Leiden University Medical Center, Leiden (C.K.), and the Netherlands Cancer Institute, Amsterdam (W.V.D.) - both in the Netherlands; Royal Hallamshire Hospital, Sheffield (J.T.), and Nottingham University Hospitals, Nottingham (K.W.) - both in the United Kingdom; LMU University Hospital, Munich (S.M.), and University of Tübingen Hospital, Tübingen (S.K.) - both in Germany; Centre Hospitalier Universitaire de Liege, Liege, Belgium (F.G.); Medical University of Graz, Graz, Austria (K.T.); Oslo University Hospital, Oslo (B.E.); Seoul National University College of Medicine, Seoul, South Korea (J.-W.K.); and St. James' Hospital, Dublin (N.G.)
| | - John Tidy
- From Centre Hospitalier Universitaire de Québec, Quebec (M.P.), the University of British Columbia, Vancouver (J.S.K., L.B.), Princess Margaret Hospital, Toronto (S.F.), Centre Hospitalier de l'Université de Montréal, Montreal (V.S.), and the Canadian Cancer Trials Group, Queen's University, Kingston, ON (D.T., L.E.S.) - all in Canada; Institut Claudius Regaud, IUCT-Oncopole, Toulouse (G.F.), and Gustave Roussy Cancer Center, Villejuif (A.M.) - both in France; Leiden University Medical Center, Leiden (C.K.), and the Netherlands Cancer Institute, Amsterdam (W.V.D.) - both in the Netherlands; Royal Hallamshire Hospital, Sheffield (J.T.), and Nottingham University Hospitals, Nottingham (K.W.) - both in the United Kingdom; LMU University Hospital, Munich (S.M.), and University of Tübingen Hospital, Tübingen (S.K.) - both in Germany; Centre Hospitalier Universitaire de Liege, Liege, Belgium (F.G.); Medical University of Graz, Graz, Austria (K.T.); Oslo University Hospital, Oslo (B.E.); Seoul National University College of Medicine, Seoul, South Korea (J.-W.K.); and St. James' Hospital, Dublin (N.G.)
| | - Karin Williamson
- From Centre Hospitalier Universitaire de Québec, Quebec (M.P.), the University of British Columbia, Vancouver (J.S.K., L.B.), Princess Margaret Hospital, Toronto (S.F.), Centre Hospitalier de l'Université de Montréal, Montreal (V.S.), and the Canadian Cancer Trials Group, Queen's University, Kingston, ON (D.T., L.E.S.) - all in Canada; Institut Claudius Regaud, IUCT-Oncopole, Toulouse (G.F.), and Gustave Roussy Cancer Center, Villejuif (A.M.) - both in France; Leiden University Medical Center, Leiden (C.K.), and the Netherlands Cancer Institute, Amsterdam (W.V.D.) - both in the Netherlands; Royal Hallamshire Hospital, Sheffield (J.T.), and Nottingham University Hospitals, Nottingham (K.W.) - both in the United Kingdom; LMU University Hospital, Munich (S.M.), and University of Tübingen Hospital, Tübingen (S.K.) - both in Germany; Centre Hospitalier Universitaire de Liege, Liege, Belgium (F.G.); Medical University of Graz, Graz, Austria (K.T.); Oslo University Hospital, Oslo (B.E.); Seoul National University College of Medicine, Seoul, South Korea (J.-W.K.); and St. James' Hospital, Dublin (N.G.)
| | - Sven Mahner
- From Centre Hospitalier Universitaire de Québec, Quebec (M.P.), the University of British Columbia, Vancouver (J.S.K., L.B.), Princess Margaret Hospital, Toronto (S.F.), Centre Hospitalier de l'Université de Montréal, Montreal (V.S.), and the Canadian Cancer Trials Group, Queen's University, Kingston, ON (D.T., L.E.S.) - all in Canada; Institut Claudius Regaud, IUCT-Oncopole, Toulouse (G.F.), and Gustave Roussy Cancer Center, Villejuif (A.M.) - both in France; Leiden University Medical Center, Leiden (C.K.), and the Netherlands Cancer Institute, Amsterdam (W.V.D.) - both in the Netherlands; Royal Hallamshire Hospital, Sheffield (J.T.), and Nottingham University Hospitals, Nottingham (K.W.) - both in the United Kingdom; LMU University Hospital, Munich (S.M.), and University of Tübingen Hospital, Tübingen (S.K.) - both in Germany; Centre Hospitalier Universitaire de Liege, Liege, Belgium (F.G.); Medical University of Graz, Graz, Austria (K.T.); Oslo University Hospital, Oslo (B.E.); Seoul National University College of Medicine, Seoul, South Korea (J.-W.K.); and St. James' Hospital, Dublin (N.G.)
| | - Stefan Kommoss
- From Centre Hospitalier Universitaire de Québec, Quebec (M.P.), the University of British Columbia, Vancouver (J.S.K., L.B.), Princess Margaret Hospital, Toronto (S.F.), Centre Hospitalier de l'Université de Montréal, Montreal (V.S.), and the Canadian Cancer Trials Group, Queen's University, Kingston, ON (D.T., L.E.S.) - all in Canada; Institut Claudius Regaud, IUCT-Oncopole, Toulouse (G.F.), and Gustave Roussy Cancer Center, Villejuif (A.M.) - both in France; Leiden University Medical Center, Leiden (C.K.), and the Netherlands Cancer Institute, Amsterdam (W.V.D.) - both in the Netherlands; Royal Hallamshire Hospital, Sheffield (J.T.), and Nottingham University Hospitals, Nottingham (K.W.) - both in the United Kingdom; LMU University Hospital, Munich (S.M.), and University of Tübingen Hospital, Tübingen (S.K.) - both in Germany; Centre Hospitalier Universitaire de Liege, Liege, Belgium (F.G.); Medical University of Graz, Graz, Austria (K.T.); Oslo University Hospital, Oslo (B.E.); Seoul National University College of Medicine, Seoul, South Korea (J.-W.K.); and St. James' Hospital, Dublin (N.G.)
| | - Frederic Goffin
- From Centre Hospitalier Universitaire de Québec, Quebec (M.P.), the University of British Columbia, Vancouver (J.S.K., L.B.), Princess Margaret Hospital, Toronto (S.F.), Centre Hospitalier de l'Université de Montréal, Montreal (V.S.), and the Canadian Cancer Trials Group, Queen's University, Kingston, ON (D.T., L.E.S.) - all in Canada; Institut Claudius Regaud, IUCT-Oncopole, Toulouse (G.F.), and Gustave Roussy Cancer Center, Villejuif (A.M.) - both in France; Leiden University Medical Center, Leiden (C.K.), and the Netherlands Cancer Institute, Amsterdam (W.V.D.) - both in the Netherlands; Royal Hallamshire Hospital, Sheffield (J.T.), and Nottingham University Hospitals, Nottingham (K.W.) - both in the United Kingdom; LMU University Hospital, Munich (S.M.), and University of Tübingen Hospital, Tübingen (S.K.) - both in Germany; Centre Hospitalier Universitaire de Liege, Liege, Belgium (F.G.); Medical University of Graz, Graz, Austria (K.T.); Oslo University Hospital, Oslo (B.E.); Seoul National University College of Medicine, Seoul, South Korea (J.-W.K.); and St. James' Hospital, Dublin (N.G.)
| | - Karl Tamussino
- From Centre Hospitalier Universitaire de Québec, Quebec (M.P.), the University of British Columbia, Vancouver (J.S.K., L.B.), Princess Margaret Hospital, Toronto (S.F.), Centre Hospitalier de l'Université de Montréal, Montreal (V.S.), and the Canadian Cancer Trials Group, Queen's University, Kingston, ON (D.T., L.E.S.) - all in Canada; Institut Claudius Regaud, IUCT-Oncopole, Toulouse (G.F.), and Gustave Roussy Cancer Center, Villejuif (A.M.) - both in France; Leiden University Medical Center, Leiden (C.K.), and the Netherlands Cancer Institute, Amsterdam (W.V.D.) - both in the Netherlands; Royal Hallamshire Hospital, Sheffield (J.T.), and Nottingham University Hospitals, Nottingham (K.W.) - both in the United Kingdom; LMU University Hospital, Munich (S.M.), and University of Tübingen Hospital, Tübingen (S.K.) - both in Germany; Centre Hospitalier Universitaire de Liege, Liege, Belgium (F.G.); Medical University of Graz, Graz, Austria (K.T.); Oslo University Hospital, Oslo (B.E.); Seoul National University College of Medicine, Seoul, South Korea (J.-W.K.); and St. James' Hospital, Dublin (N.G.)
| | - Brynhildur Eyjólfsdóttir
- From Centre Hospitalier Universitaire de Québec, Quebec (M.P.), the University of British Columbia, Vancouver (J.S.K., L.B.), Princess Margaret Hospital, Toronto (S.F.), Centre Hospitalier de l'Université de Montréal, Montreal (V.S.), and the Canadian Cancer Trials Group, Queen's University, Kingston, ON (D.T., L.E.S.) - all in Canada; Institut Claudius Regaud, IUCT-Oncopole, Toulouse (G.F.), and Gustave Roussy Cancer Center, Villejuif (A.M.) - both in France; Leiden University Medical Center, Leiden (C.K.), and the Netherlands Cancer Institute, Amsterdam (W.V.D.) - both in the Netherlands; Royal Hallamshire Hospital, Sheffield (J.T.), and Nottingham University Hospitals, Nottingham (K.W.) - both in the United Kingdom; LMU University Hospital, Munich (S.M.), and University of Tübingen Hospital, Tübingen (S.K.) - both in Germany; Centre Hospitalier Universitaire de Liege, Liege, Belgium (F.G.); Medical University of Graz, Graz, Austria (K.T.); Oslo University Hospital, Oslo (B.E.); Seoul National University College of Medicine, Seoul, South Korea (J.-W.K.); and St. James' Hospital, Dublin (N.G.)
| | - Jae-Weon Kim
- From Centre Hospitalier Universitaire de Québec, Quebec (M.P.), the University of British Columbia, Vancouver (J.S.K., L.B.), Princess Margaret Hospital, Toronto (S.F.), Centre Hospitalier de l'Université de Montréal, Montreal (V.S.), and the Canadian Cancer Trials Group, Queen's University, Kingston, ON (D.T., L.E.S.) - all in Canada; Institut Claudius Regaud, IUCT-Oncopole, Toulouse (G.F.), and Gustave Roussy Cancer Center, Villejuif (A.M.) - both in France; Leiden University Medical Center, Leiden (C.K.), and the Netherlands Cancer Institute, Amsterdam (W.V.D.) - both in the Netherlands; Royal Hallamshire Hospital, Sheffield (J.T.), and Nottingham University Hospitals, Nottingham (K.W.) - both in the United Kingdom; LMU University Hospital, Munich (S.M.), and University of Tübingen Hospital, Tübingen (S.K.) - both in Germany; Centre Hospitalier Universitaire de Liege, Liege, Belgium (F.G.); Medical University of Graz, Graz, Austria (K.T.); Oslo University Hospital, Oslo (B.E.); Seoul National University College of Medicine, Seoul, South Korea (J.-W.K.); and St. James' Hospital, Dublin (N.G.)
| | - Noreen Gleeson
- From Centre Hospitalier Universitaire de Québec, Quebec (M.P.), the University of British Columbia, Vancouver (J.S.K., L.B.), Princess Margaret Hospital, Toronto (S.F.), Centre Hospitalier de l'Université de Montréal, Montreal (V.S.), and the Canadian Cancer Trials Group, Queen's University, Kingston, ON (D.T., L.E.S.) - all in Canada; Institut Claudius Regaud, IUCT-Oncopole, Toulouse (G.F.), and Gustave Roussy Cancer Center, Villejuif (A.M.) - both in France; Leiden University Medical Center, Leiden (C.K.), and the Netherlands Cancer Institute, Amsterdam (W.V.D.) - both in the Netherlands; Royal Hallamshire Hospital, Sheffield (J.T.), and Nottingham University Hospitals, Nottingham (K.W.) - both in the United Kingdom; LMU University Hospital, Munich (S.M.), and University of Tübingen Hospital, Tübingen (S.K.) - both in Germany; Centre Hospitalier Universitaire de Liege, Liege, Belgium (F.G.); Medical University of Graz, Graz, Austria (K.T.); Oslo University Hospital, Oslo (B.E.); Seoul National University College of Medicine, Seoul, South Korea (J.-W.K.); and St. James' Hospital, Dublin (N.G.)
| | - Lori Brotto
- From Centre Hospitalier Universitaire de Québec, Quebec (M.P.), the University of British Columbia, Vancouver (J.S.K., L.B.), Princess Margaret Hospital, Toronto (S.F.), Centre Hospitalier de l'Université de Montréal, Montreal (V.S.), and the Canadian Cancer Trials Group, Queen's University, Kingston, ON (D.T., L.E.S.) - all in Canada; Institut Claudius Regaud, IUCT-Oncopole, Toulouse (G.F.), and Gustave Roussy Cancer Center, Villejuif (A.M.) - both in France; Leiden University Medical Center, Leiden (C.K.), and the Netherlands Cancer Institute, Amsterdam (W.V.D.) - both in the Netherlands; Royal Hallamshire Hospital, Sheffield (J.T.), and Nottingham University Hospitals, Nottingham (K.W.) - both in the United Kingdom; LMU University Hospital, Munich (S.M.), and University of Tübingen Hospital, Tübingen (S.K.) - both in Germany; Centre Hospitalier Universitaire de Liege, Liege, Belgium (F.G.); Medical University of Graz, Graz, Austria (K.T.); Oslo University Hospital, Oslo (B.E.); Seoul National University College of Medicine, Seoul, South Korea (J.-W.K.); and St. James' Hospital, Dublin (N.G.)
| | - Dongsheng Tu
- From Centre Hospitalier Universitaire de Québec, Quebec (M.P.), the University of British Columbia, Vancouver (J.S.K., L.B.), Princess Margaret Hospital, Toronto (S.F.), Centre Hospitalier de l'Université de Montréal, Montreal (V.S.), and the Canadian Cancer Trials Group, Queen's University, Kingston, ON (D.T., L.E.S.) - all in Canada; Institut Claudius Regaud, IUCT-Oncopole, Toulouse (G.F.), and Gustave Roussy Cancer Center, Villejuif (A.M.) - both in France; Leiden University Medical Center, Leiden (C.K.), and the Netherlands Cancer Institute, Amsterdam (W.V.D.) - both in the Netherlands; Royal Hallamshire Hospital, Sheffield (J.T.), and Nottingham University Hospitals, Nottingham (K.W.) - both in the United Kingdom; LMU University Hospital, Munich (S.M.), and University of Tübingen Hospital, Tübingen (S.K.) - both in Germany; Centre Hospitalier Universitaire de Liege, Liege, Belgium (F.G.); Medical University of Graz, Graz, Austria (K.T.); Oslo University Hospital, Oslo (B.E.); Seoul National University College of Medicine, Seoul, South Korea (J.-W.K.); and St. James' Hospital, Dublin (N.G.)
| | - Lois E Shepherd
- From Centre Hospitalier Universitaire de Québec, Quebec (M.P.), the University of British Columbia, Vancouver (J.S.K., L.B.), Princess Margaret Hospital, Toronto (S.F.), Centre Hospitalier de l'Université de Montréal, Montreal (V.S.), and the Canadian Cancer Trials Group, Queen's University, Kingston, ON (D.T., L.E.S.) - all in Canada; Institut Claudius Regaud, IUCT-Oncopole, Toulouse (G.F.), and Gustave Roussy Cancer Center, Villejuif (A.M.) - both in France; Leiden University Medical Center, Leiden (C.K.), and the Netherlands Cancer Institute, Amsterdam (W.V.D.) - both in the Netherlands; Royal Hallamshire Hospital, Sheffield (J.T.), and Nottingham University Hospitals, Nottingham (K.W.) - both in the United Kingdom; LMU University Hospital, Munich (S.M.), and University of Tübingen Hospital, Tübingen (S.K.) - both in Germany; Centre Hospitalier Universitaire de Liege, Liege, Belgium (F.G.); Medical University of Graz, Graz, Austria (K.T.); Oslo University Hospital, Oslo (B.E.); Seoul National University College of Medicine, Seoul, South Korea (J.-W.K.); and St. James' Hospital, Dublin (N.G.)
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3
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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.
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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
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Bizzarri N, Querleu D, Dostálek L, van Lonkhuijzen LRCW, Giannarelli D, Lopez A, Salehi S, Ayhan A, Kim SH, Ortiz DI, Klat J, Landoni F, Pareja R, Manchanda R, Kosťun J, Ramirez PT, Meydanli MM, Odetto D, Laky R, Zapardiel I, Weinberger V, Dos Reis R, Pedone Anchora L, Amaro K, Akilli H, Abu-Rustum NR, Salcedo-Hernández RA, Javůrková V, Mom CH, Scambia G, Falconer H, Cibula D. Survival associated with extent of radical hysterectomy in early-stage cervical cancer: a subanalysis of the Surveillance in Cervical CANcer (SCCAN) collaborative study. Am J Obstet Gynecol 2023; 229:428.e1-428.e12. [PMID: 37336255 DOI: 10.1016/j.ajog.2023.06.030] [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: 12/22/2022] [Revised: 06/11/2023] [Accepted: 06/14/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND International guidelines recommend tailoring the radicality of hysterectomy according to the known preoperative tumor characteristics in patients with early-stage cervical cancer. OBJECTIVE This study aimed to assess whether increased radicality had an effect on 5-year disease-free survival in patients with early-stage cervical cancer undergoing radical hysterectomy. The secondary aims were 5-year overall survival and pattern of recurrence. STUDY DESIGN This was an international, multicenter, retrospective study from the Surveillance in Cervical CANcer (SCCAN) collaborative cohort. Patients with the International Federation of Gynecology and Obstetrics 2009 stage IB1 and IIA1 who underwent open type B/C1/C2 radical hysterectomy according to Querleu-Morrow classification between January 2007 and December 2016, who did not undergo neoadjuvant chemotherapy and who had negative lymph nodes and free surgical margins at final histology, were included. Descriptive statistics and survival analyses were performed. Patients were stratified according to pathologic tumor diameter. Propensity score match analysis was performed to balance baseline characteristics in patients undergoing nerve-sparing and non-nerve-sparing radical hysterectomy. RESULTS A total of 1257 patients were included. Of note, 883 patients (70.2%) underwent nerve-sparing radical hysterectomy, and 374 patients (29.8%) underwent non-nerve-sparing radical hysterectomy. Baseline differences between the study groups were found for tumor stage and diameter (higher use of non-nerve-sparing radical hysterectomy for tumors >2 cm or with vaginal involvement; P<.0001). The use of adjuvant therapy in patients undergoing nerve-sparing and non-nerve-sparing radical hysterectomy was 27.3% vs 28.6%, respectively (P=.63). Five-year disease-free survival in patients undergoing nerve-sparing vs non-nerve-sparing radical hysterectomy was 90.1% (95% confidence interval, 87.9-92.2) vs 93.8% (95% confidence interval, 91.1-96.5), respectively (P=.047). Non-nerve-sparing radical hysterectomy was independently associated with better disease-free survival at multivariable analysis performed on the entire cohort (hazard ratio, 0.50; 95% confidence interval, 0.31-0.81; P=.004). Furthermore, 5-year overall survival in patients undergoing nerve-sparing vs non-nerve-sparing radical hysterectomy was 95.7% (95% confidence interval, 94.1-97.2) vs non-nerve-sparing 96.5% (95% confidence interval, 94.3-98.7), respectively (P=.78). In patients with a tumor diameter ≤20 mm, 5-year disease-free survival was 94.7% in nerve-sparing radical hysterectomy vs 96.2% in non-nerve-sparing radical hysterectomy (P=.22). In patients with tumors between 21 and 40 mm, 5-year disease-free survival was 90.3% in non-nerve-sparing radical hysterectomy vs 83.1% in nerve-sparing radical hysterectomy (P=.016) (no significant difference in the rate of adjuvant treatment in this subgroup, P=.47). This was confirmed after propensity match score analysis (balancing the 2 study groups). The pattern of recurrence in the propensity-matched population did not demonstrate any difference (P=.70). CONCLUSION For tumors ≤20 mm, no survival difference was found with more radical hysterectomy. For tumors between 21 and 40 mm, a more radical hysterectomy was associated with improved 5-year disease-free survival. No difference in the pattern of recurrence according to the extent of radicality was observed. Non-nerve-sparing radical hysterectomy was associated with better 5-year disease-free survival than nerve-sparing radical hysterectomy after propensity score match analysis.
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Affiliation(s)
- Nicolò Bizzarri
- Unità Operativa Complessa Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.
| | - Denis Querleu
- Unità Operativa Complessa Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Lukáš Dostálek
- First Faculty of Medicine, Department of Obstetrics and Gynecology, Gynecologic Oncology Center, Charles University and General University Hospital (Central and Eastern European Gynecologic Oncology Group), Prague, Czech Republic
| | - Luc R C W van Lonkhuijzen
- Center for Gynaecologic Oncology Amsterdam, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Diana Giannarelli
- Biostatistics Unit, Scientific Directorate, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Aldo Lopez
- Department of Gynecological Surgery, National Institute of Neoplastic Diseases, Lima, Peru
| | - Sahar Salehi
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Ali Ayhan
- Division of Gynecologic Oncology, Department of Gynecology and Obstetrics, Baskent University School of Medicine, Ankara, Turkey
| | - Sarah H Kim
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - David Isla Ortiz
- Gynecology Oncology Center, National Institute of Cancerology Mexico, Mexico City, Mexico
| | - Jaroslav Klat
- Faculty of Medicine, Department of Obstetrics and Gynecology, University Hospital and University of Ostrava, Ostrava, Czech Republic
| | - Fabio Landoni
- IRCCS Fondazione San Gerardo - Università Milano Bicocca, Monza, Italy
| | - Rene Pareja
- Department of Gynecologic Oncology, Instituto Nacional de Cancerología, Bogotá, Colombia
| | - Ranjit Manchanda
- Wolfson Institute of Population Health, Barts Cancer Centre, Queen Mary University of London, and Barts Health NHS Trust, London, United Kingdom; Department of Gynaecological Oncology, Barts Health NHS Trust, London, United Kingdom; Faculty of Public Health and Policy, Department of Health Services Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jan Kosťun
- Department of Gynaecology and Obstetrics, University Hospital Pilsen, Charles University, Prague, Czech Republic
| | | | - Mehmet M Meydanli
- Department of Gynecologic Oncology, Zekai Tahir Burak Women's Health and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Diego Odetto
- Department of Gynecologic Oncology, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - Rene Laky
- Department of Gynecology, Medical University of Graz, Graz, Austria
| | - Ignacio Zapardiel
- Gynecologic Oncology Unit, La Paz University Hospital - IdiPAZ, Madrid, Spain
| | - Vit Weinberger
- Faculty of Medicine, University Hospital Brno, Masaryk University, Brno, Czechia
| | - Ricardo Dos Reis
- Department of Gynecologic Oncology, Barretos Cancer Hospital, Barretos, Sao Paulo, Brazil
| | - Luigi Pedone Anchora
- Unità Operativa Complessa Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Karina Amaro
- Oncology Unit, Cayetano Heredia Hospital, Lima, Peru
| | - Huseyin Akilli
- Division of Gynecologic Oncology, Department of Gynecology and Obstetrics, Baskent University School of Medicine, Ankara, Turkey
| | | | | | - Veronika Javůrková
- Faculty of Medicine, Department of Obstetrics and Gynecology, University Hospital and University of Ostrava, Ostrava, Czech Republic
| | - Constantijne H Mom
- Center for Gynaecologic Oncology Amsterdam, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Giovanni Scambia
- Unità Operativa Complessa Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Henrik Falconer
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - David Cibula
- First Faculty of Medicine, Department of Obstetrics and Gynecology, Gynecologic Oncology Center, Charles University and General University Hospital (Central and Eastern European Gynecologic Oncology Group), Prague, Czech Republic
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Bianchi T, Grassi T, Bazzurini L, Di Martino G, Negri S, Fruscio R, Trezzi G, Landoni F. Radical Hysterectomy in Early-Stage Cervical Cancer: Abandoning the One-Fits-All Concept. J Pers Med 2023; 13:1292. [PMID: 37763060 PMCID: PMC10532817 DOI: 10.3390/jpm13091292] [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: 07/14/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 09/29/2023] Open
Abstract
Two pillars in modern oncology are treatment personalization and the reduction in treatment-related morbidity. For decades, the one-fits-all concept of radical hysterectomy has been the cornerstone of early-stage cervical cancer surgical treatment. However, no agreement exists about the prevalent method of parametrial invasion, and the literature is conflicting regarding the extent of parametrectomy needed to achieve adequate surgical radicality. Therefore, authors started investigating if less radical surgery was feasible and oncologically safe in these patients. Two historical randomized controlled trials (RCTs) compared classical radical hysterectomy (RH) to modified RH and simple hysterectomy. Less radical surgery showed a drastic reduction in morbidity without jeopardizing oncological outcomes. However, given the high frequency of adjuvant radiotherapy, the real impact of reduced radicality could not be estimated. Subsequently, several retrospective studies investigated the chance of tailoring parametrectomy according to the tumor's characteristics. Parametrial involvement was shown to be negligible in early-stage low-risk cervical cancer. An observational prospective study and a phase II exploratory RCT have recently confirmed the feasibility and safety of simple hysterectomy in this subgroup of patients. The preliminary results of a large prospective RCT comparing simple vs. radical surgery for early-stage low-risk cervical cancer show strong probability of giving a final answer on this topic.
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Affiliation(s)
- Tommaso Bianchi
- Department of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy; (T.B.); (S.N.); (R.F.); (F.L.)
- Clinic of Obstetrics and Gynecology, IRCCS Fondazione San Gerardo dei Tintori, 20900 Monza, Italy; (L.B.); (G.D.M.); (G.T.)
| | - Tommaso Grassi
- Clinic of Obstetrics and Gynecology, IRCCS Fondazione San Gerardo dei Tintori, 20900 Monza, Italy; (L.B.); (G.D.M.); (G.T.)
| | - Luca Bazzurini
- Clinic of Obstetrics and Gynecology, IRCCS Fondazione San Gerardo dei Tintori, 20900 Monza, Italy; (L.B.); (G.D.M.); (G.T.)
| | - Giampaolo Di Martino
- Clinic of Obstetrics and Gynecology, IRCCS Fondazione San Gerardo dei Tintori, 20900 Monza, Italy; (L.B.); (G.D.M.); (G.T.)
| | - Serena Negri
- Department of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy; (T.B.); (S.N.); (R.F.); (F.L.)
- Clinic of Obstetrics and Gynecology, IRCCS Fondazione San Gerardo dei Tintori, 20900 Monza, Italy; (L.B.); (G.D.M.); (G.T.)
| | - Robert Fruscio
- Department of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy; (T.B.); (S.N.); (R.F.); (F.L.)
- Clinic of Obstetrics and Gynecology, IRCCS Fondazione San Gerardo dei Tintori, 20900 Monza, Italy; (L.B.); (G.D.M.); (G.T.)
| | - Gaetano Trezzi
- Clinic of Obstetrics and Gynecology, IRCCS Fondazione San Gerardo dei Tintori, 20900 Monza, Italy; (L.B.); (G.D.M.); (G.T.)
| | - Fabio Landoni
- Department of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy; (T.B.); (S.N.); (R.F.); (F.L.)
- Clinic of Obstetrics and Gynecology, IRCCS Fondazione San Gerardo dei Tintori, 20900 Monza, Italy; (L.B.); (G.D.M.); (G.T.)
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Wolswinkel JT, Eikelder MLGT, Verhoef CG, Zusterzeel PLM. High- or Intermediate-Risk Histologic Features in Patients with Clinical Early-Stage Cervical Cancer Planned for Fertility-Sparing Surgery: A Systematic Review. Cancers (Basel) 2023; 15:3920. [PMID: 37568735 PMCID: PMC10417237 DOI: 10.3390/cancers15153920] [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: 07/03/2023] [Revised: 07/28/2023] [Accepted: 07/30/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Fertility-sparing surgery (FSS) is a viable option for young women with early-stage cervical cancer (ECC); however, certain risk factors may necessitate additional treatments and impact fertility. This review examines the prevalence of these risk factors and available treatment options. METHODS A systematic search was conducted of studies including patients with ECC (IA1 with LVSI, IA2, IB1 (FIGO 2009)) who underwent FSS. RESULTS Sixty-four articles, comprising a total of 4118 women planned for FSS, were included. High- or intermediate-risk histologic features were found in 638 (15.5%) women: 5.1% had positive lymph node(s), 4.1% had positive resection margins, 0.3% had parametrial involvement, 1.0% had unspecified high-risk features, and 5.1% had intermediate-risk histology (primarily based on the Sedlis criteria). Adjuvant treatment impaired fertility in all women with adjuvant hysterectomy and/or (chemo)radiation (58.7%). Adjuvant chemotherapy was given to 1351 (32.8%) patients, which may reduce fertility. CONCLUSIONS Fertility preservation could be achieved in most women; but high- or intermediate-risk factors necessitate more extensive surgery or radiotherapy leading to infertility. Adjuvant chemotherapy could be an alternative treatment option considering its effectiveness, safety and higher change in fertility preservation. The low incidence of parametrial involvement justifies waiving parametrectomy in tumors < 2 cm.
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Affiliation(s)
- Janneke T. Wolswinkel
- Department of Obstetrics and Gynecology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands; (J.T.W.); (M.L.G.t.E.)
| | - Mieke L. G. ten Eikelder
- Department of Obstetrics and Gynecology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands; (J.T.W.); (M.L.G.t.E.)
| | - Cornelia G. Verhoef
- Department of Radiation Oncology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands;
| | - Petra L. M. Zusterzeel
- Department of Obstetrics and Gynecology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands; (J.T.W.); (M.L.G.t.E.)
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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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Llueca A, Ibañez MV, Torne A, Gil-Moreno A, Martin-Jimenez A, Diaz-Feijoo B, Serra A, Climent MT, Gil-Ibañez B. Fertility-Sparing Surgery versus Radical Hysterectomy in Early Cervical Cancer: A Propensity Score Matching Analysis and Noninferiority Study. J Pers Med 2022; 12:jpm12071081. [PMID: 35887578 PMCID: PMC9325092 DOI: 10.3390/jpm12071081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 06/27/2022] [Accepted: 06/28/2022] [Indexed: 12/02/2022] Open
Abstract
Objective: Fertility-sparing surgery (FSS) is the treatment of choice for patients with early cervical cancer (ECC) and fertility desire, but survival rates compared to radical hysterectomy (RH) have been scarcely reported. The aim of this study was to analyse the oncological outcomes of FSS compared to a balanced group of standard RH. Methods: A retrospective multicentre study of ECC patients who underwent FSS or RH was carried out in 12 tertiary hospitals in Spain between January 2005 and January 2019. The experimental group included patients who underwent a simple and radical trachelectomy, and the control group included patients who underwent RH. Optimal 1:1 propensity score (PS) matching analysis was performed to balance the series. Results: The study included 222 patients with ECC; 111 (50%) were treated with FSS, and 111 (50%) were treated with RH. After PS matching, a total of 38 patients in the FSS group and 38 patients in the RH group were analysed. In both groups, the overall survival (HR 2.5; CI 0.89, 7.41) and recurrence rates (28.9% in the FSS group vs. 13.2% in RH group) were similar. The rate of disease-free survival at 5 years was 68.99% in the FSS group and 88.01% in the RH group (difference of −19.02 percentage points; 95% CI −32.08 to −5.96 for noninferiority). In the univariate analysis, only tumour size reached statistical significance. Conclusion: FSS offers excellent disease-free and overall survival in women with ECC with fertility desire and is not inferior compared to RH.
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Affiliation(s)
- Antoni Llueca
- Multidisciplinary Unit of Abdominopelvic Oncology Surgery (MUAPOS), Department of Obstetrics and Gynaecology, University General Hospital of Castellon, 12004 Castellón, Spain; (A.S.); (M.T.C.)
- Department of Medicine, University Jaume I (UJI), 12004 Castelló de la Plana, Spain
- Correspondence: ; Tel.: +34-964726500
| | - Maria Victoria Ibañez
- Department of Mathematics, University Jaume I (UJI), 12004 Castelló de la Plana, Spain;
| | - Aureli Torne
- Unit of Gynaecologic Oncology (ICGON), Endocrinology, Gynaecology and Human Reproduction (IDIBAPS), Hospital Clinic of Barcelona, 08007 Barcelona, Spain; (A.T.); (B.D.-F.)
| | - Antonio Gil-Moreno
- Gynaecological Oncology Department, Hospital Universitari Vall d’Hebron, Universitat Autonoma de Barcelona, Centro de Investigación Biomedica en Red de Cancer, 08035 Barcelona, Spain;
| | | | - Berta Diaz-Feijoo
- Unit of Gynaecologic Oncology (ICGON), Endocrinology, Gynaecology and Human Reproduction (IDIBAPS), Hospital Clinic of Barcelona, 08007 Barcelona, Spain; (A.T.); (B.D.-F.)
| | - Anna Serra
- Multidisciplinary Unit of Abdominopelvic Oncology Surgery (MUAPOS), Department of Obstetrics and Gynaecology, University General Hospital of Castellon, 12004 Castellón, Spain; (A.S.); (M.T.C.)
- Department of Medicine, University Jaume I (UJI), 12004 Castelló de la Plana, Spain
| | - Maria Teresa Climent
- Multidisciplinary Unit of Abdominopelvic Oncology Surgery (MUAPOS), Department of Obstetrics and Gynaecology, University General Hospital of Castellon, 12004 Castellón, Spain; (A.S.); (M.T.C.)
- Department of Medicine, University Jaume I (UJI), 12004 Castelló de la Plana, Spain
| | - Blanca Gil-Ibañez
- Gynaecological Oncology and Endoscopy Unit, Department of Obstetrics and Gynaecology, University Hospital 12 de Octubre, Research Institute i+12, 28041 Madrid, Spain;
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Lin S, Li X, Zhang Y, Mao X, Liang X, Cheng S, Zhang L. Manifestation of Urinary Tract Injury during Cervical Cancer Surgery Based on CT Urography Secretion Phase Images. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:2572681. [PMID: 35821887 PMCID: PMC9217568 DOI: 10.1155/2022/2572681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/18/2022] [Accepted: 04/28/2022] [Indexed: 11/17/2022]
Abstract
Methods We grouped the patients who had undergone cervical cancer surgery in a hospital in this article and compared the nanodrug carrier system under CT imaging with traditional laparoscopy. The postoperative physical parameters of surgical patients are collected from cervical cancer patients of different degrees, and the parameters and prognostic health of patients after different operations are compared. Results The results of the study show that the postoperative patient's body parameters of the nanodrug delivery system under the CT imaging technology used in this article are better than those of the traditional surgery group, and the average intraoperative blood loss is about 20% less than that of the traditional surgery. Postoperative complications occur. The situation is even lower, more than 30% lower than traditional surgery. Conclusion This shows that the operation of the nanodrug delivery system based on CT imaging technology has broken through some of the limitations of the development of laparoscopic technology and has played an important role in the surgical treatment of cervical cancer.
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Affiliation(s)
- Song Lin
- Department of Surgery, Maternal and Child Health Hospital of Hubei Province, Wuhan 430070, Hubei, China
| | - Xiaoshan Li
- Department of Urology, Yangtze River Shipping General Hospital, Wuhan 430014, Hubei, China
| | - Yan Zhang
- Department of Women's Health, Maternal and Child Health Hospital of Hubei Province, Wuhan 430070, Hubei, China
| | - Xiaowen Mao
- Department of Surgery, Maternal and Child Health Hospital of Hubei Province, Wuhan 430070, Hubei, China
| | - Xingchi Liang
- Department of Surgery, Maternal and Child Health Hospital of Hubei Province, Wuhan 430070, Hubei, China
| | - Shigang Cheng
- Department of Surgery, Maternal and Child Health Hospital of Hubei Province, Wuhan 430070, Hubei, China
| | - Lingli Zhang
- Department of Gynecology, Maternal and Child Health Hospital of Hubei Province, Wuhan 430070, Hubei, China
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10
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Li B, Shou Y, Zhu H. Predictive value of hemoglobin, platelets, and D-dimer for the survival of patients with stage IA1 to IIA2 cervical cancer: a retrospective study. J Int Med Res 2021; 49:3000605211061008. [PMID: 34939884 PMCID: PMC8725234 DOI: 10.1177/03000605211061008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective Coagulation indexes may be useful survival biomarkers for cervical cancer.
This study evaluated the ability of hemoglobin, red blood cells (RBCs),
platelets, and D-dimer levels to predict post-hysterectomy survival outcomes
in patients with stage IA1 to IIA2 cervical cancer. Methods In this retrospective study, coagulation-related indexes were compared
between the anemia and non-anemia groups. Independent variables were
analyzed by the Cox proportional hazards model. Survival was assessed by the
Kaplan–Meier method with the log-rank test. Mortality predictions were
evaluated by receiver operating characteristic curves. Results Among this study’s 1088 enrolled patients, 152 had anemia. The 10-year
overall survival and recurrence-free survival rates were 90.8% and 86.5%,
respectively. Hemoglobin, RBC, and the rate of abnormal platelet counts were
significantly lower in the anemia group. Abnormal preoperative D-dimer was
an independent factor for recurrence-free survival. Receiver operating
characteristic curves showed that D-dimer had area under the curve of 0.734
(cut-off value: 0.685, sensitivity: 85.7%, and specificity: 64.0%).
Hemoglobin and platelets had areas under the curves of 0.487 and 0.462,
respectively. Conclusion Preoperative D-dimer was the most effective prognostic predictor for patients
with cervical cancer. The prognosis of patients with cervical cancer was
poorer if their D-dimer levels were >0.685 mg/L.
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Affiliation(s)
- Bilan Li
- Department of Gynecology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yueyao Shou
- Department of Gynecology, 89657The First Affiliated Hospital of Wenzhou Medical University, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Haiyan Zhu
- Department of Gynecology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China.,Department of Gynecology, 89657The First Affiliated Hospital of Wenzhou Medical University, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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11
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Tsaousidis C, Kraemer B, Kommoss S, Hartkopf A, Brucker S, Neis K, Andress J, Neis F. Large Conization-Retrospective Monocentric Results for Fertility Preservation in Young Women with Early Stage Cervical Cancer. Reprod Sci 2021; 29:791-799. [PMID: 34845668 PMCID: PMC8863693 DOI: 10.1007/s43032-021-00807-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 11/14/2021] [Indexed: 11/30/2022]
Abstract
The shorter cervical segment after classic radical trachelectomy (RT) imposes a number of pregnancy associated risk factors. In this aspect, large conization (LC) could be an oncologically safe alternative to RT in young women with early stage cervical cancer who want to spare their fertility. Our aim was to evaluate fertility-sparing surgical treatment of early stage cervical cancer after the introduction of LC. Our objectives were to assess surgical, oncological, fertility and obstetric outcomes. We retrospectively investigated oncological and fertility outcomes of patients who underwent LC in a large oncological single University centre between 2009 and 2014. Medical records were reviewed and analysed for surgical, oncological, fertility and obstetric outcomes. Postal questionnaires were collected to further evaluate and validate the fertility and obstetric outcomes. A total of 23 LCs were analysed. Seven patients had to undergo secondary radical hysterectomy after LC due to unclear resection margins. Nine of 16 women tried to conceive, of which all nine became pregnant. Seven patients underwent a prophylactic cerclage between 13 and 16 gestational weeks and seven women delivered 9 children; the majority of women conceived spontaneously. Follow-up time was a median of 3.9 years (2.6–8 years). There was no relapse of cervical cancer in the investigated timeframe. Early stage cervical cancers treated by LC are associated with excellent oncological outcomes. LC appears to be a safe option for eligible women who intend to maintain their fertility.
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Affiliation(s)
| | - Bernhard Kraemer
- Department of Women's Health, Women's University Hospital, Tuebingen University Hospital, Calwerstr. 7, 72076, Tuebingen, Germany
| | - Stefan Kommoss
- Department of Women's Health, Women's University Hospital, Tuebingen University Hospital, Calwerstr. 7, 72076, Tuebingen, Germany
| | - Andreas Hartkopf
- Department of Women's Health, Women's University Hospital, Tuebingen University Hospital, Calwerstr. 7, 72076, Tuebingen, Germany
| | - Sara Brucker
- Department of Women's Health, Women's University Hospital, Tuebingen University Hospital, Calwerstr. 7, 72076, Tuebingen, Germany
| | - Katrin Neis
- Department of Women's Health, Women's University Hospital, Tuebingen University Hospital, Calwerstr. 7, 72076, Tuebingen, Germany
| | - Juergen Andress
- Department of Women's Health, Women's University Hospital, Tuebingen University Hospital, Calwerstr. 7, 72076, Tuebingen, Germany
| | - Felix Neis
- Department of Women's Health, Women's University Hospital, Tuebingen University Hospital, Calwerstr. 7, 72076, Tuebingen, Germany.
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12
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Cervical Cancer and Fertility-Sparing Treatment. J Clin Med 2021; 10:jcm10214825. [PMID: 34768345 PMCID: PMC8585101 DOI: 10.3390/jcm10214825] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/12/2021] [Accepted: 10/18/2021] [Indexed: 12/09/2022] Open
Abstract
Radical hysterectomy with pelvic node dissection is the standard treatment for early-stage cervical cancer. However, the latter can be diagnosed at a young age when patients have not yet achieved their pregnancy plans. Dargent first described the vaginal radical trachelectomy for patients with tumors <2 cm. It has since been described a population of low risk of recurrence: patients with tumors <2 cm, without deep stromal infiltration, without lymphovascular invasion (LVSI), and with negative lymph nodes. These patients can benefit from a less radical surgery such as conization or simple trachelectomy with the evaluation of the pelvic node status. Tumors larger than 2 cm have a higher risk of recurrence and their treatment is a challenge. There are currently two options for these patients: abdominal radical trachelectomy or neoadjuvant chemotherapy (NACT), followed by fertility-sparing surgery. All patients who wish to preserve their fertility must be referred to expert centers.
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13
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Yüksel D, Karataş Şahin E, Ünsal M, Çakır C, Kılıç Ç, Kimyon Cömert G, Korkmaz V, Türkmen O, Turan T. The prognostic factors in 384 patients with FIGO 2014 stage IB cervical cancer: What is the role of tumor size on prognosis? Eur J Obstet Gynecol Reprod Biol 2021; 266:126-132. [PMID: 34634671 DOI: 10.1016/j.ejogrb.2021.09.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/26/2021] [Accepted: 09/26/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To define the relationship of tumor size with surgico-pathological factors and oncological outcome in FIGO 2014 stage IB cervical cancer. METHODS This study retrospectively evaluated 384 FIGO 2014 Stage IB cervical cancer patients who underwent radical hysterectomy and lymphadenectomy. Tumor size was stratified according to 2 cm (≤ 2cm, 2-≤4 cm, >4 cm) and 4 cm (≤4 cm, >4 cm), and the relationship with poor prognostic factors, and the effects on survival were examined. The distribution of prognostic factors was compared between three subgroups: ≤2 cm vs. 2-≤4 cm; 2-≤4 cm vs. > 4 cm and ≤ 2 cm vs. > 4 cm. Survival rate was evaluated using the Kaplan-Meier method and compared with the log-rank test. Multivariate analysis was performed using Cox proportional-hazards regression. RESULTS Stratification of tumor size according to 4 cm was found to better determine pelvic lymph node determination. Parametrial involvement, uterine involvement and deep cervical stromal invasion were correlated with increasing tumor size. Lymph node involvement and uterine involvement were an independent prognostic risk factor for recurrence and cancer-specific survival. Tumor size showed no association with prognosis. CONCLUSION There is no meaningful cut-off value for tumor size determining all surgico-pathological factors. There was also seen to be no association between tumor size and recurrence or disease-related mortality.
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Affiliation(s)
- Dilek Yüksel
- Gynecologic Oncology Department, Health Sciences University Etlik Zubeyde Hanim Women's Health Teaching and Research Hospital , Ankara, Turkey.
| | - Ediz Karataş Şahin
- Gynecology and Obstetrics Department, Health Sciences University Etlik Zubeyde Hanim Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Mehmet Ünsal
- Gynecology and Obstetrics Department, Health Sciences University Etlik Zubeyde Hanim Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Caner Çakır
- Gynecologic Oncology Department, Health Sciences University Etlik Zubeyde Hanim Women's Health Teaching and Research Hospital , Ankara, Turkey
| | - Çiğdem Kılıç
- Gynecologic Oncology Department, Health Sciences University Etlik Zubeyde Hanim Women's Health Teaching and Research Hospital , Ankara, Turkey
| | - Günsu Kimyon Cömert
- Gynecologic Oncology Department, Health Sciences University Etlik Zubeyde Hanim Women's Health Teaching and Research Hospital , Ankara, Turkey
| | - Vakkas Korkmaz
- Gynecologic Oncology Department, Health Sciences University Etlik Zubeyde Hanim Women's Health Teaching and Research Hospital , Ankara, Turkey
| | - Osman Türkmen
- Gynecologic Oncology Department, Health Sciences University Etlik Zubeyde Hanim Women's Health Teaching and Research Hospital , Ankara, Turkey
| | - Taner Turan
- Gynecologic Oncology Department, Health Sciences University Etlik Zubeyde Hanim Women's Health Teaching and Research Hospital , Ankara, Turkey
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14
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Schmeler KM, Pareja R, Lopez Blanco A, Humberto Fregnani J, Lopes A, Perrotta M, Tsunoda AT, Cantú-de-León DF, Ramondetta LM, Manchana T, Crotzer DR, McNally OM, Riege M, Scambia G, Carvajal JM, Di Guilmi J, Rendon GJ, Ramalingam P, Fellman BM, Coleman RL, Frumovitz M, Ramirez PT. ConCerv: a prospective trial of conservative surgery for low-risk early-stage cervical cancer. Int J Gynecol Cancer 2021; 31:1317-1325. [PMID: 34493587 DOI: 10.1136/ijgc-2021-002921] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 08/11/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE The objective of the ConCerv Trial was to prospectively evaluate the feasibility of conservative surgery in women with early-stage, low-risk cervical cancer. METHODS From April 2010 to March 2019, a prospective, single-arm, multicenter study evaluated conservative surgery in participants from 16 sites in nine countries. Eligibility criteria included: (1) FIGO 2009 stage IA2-IB1 cervical carcinoma; (2) squamous cell (any grade) or adenocarcinoma (grade 1 or 2 only) histology; (3) tumor size <2 cm; (4) no lymphovascular space invasion; (5) depth of invasion <10 mm; (6) negative imaging for metastatic disease; and (7) negative conization margins. Cervical conization was performed to determine eligibility, with one repeat cone permitted. Eligible women desiring fertility preservation underwent a second surgery with pelvic lymph node assessment, consisting of sentinel lymph node biopsy and/or full pelvic lymph node dissection. Those not desiring fertility preservation underwent simple hysterectomy with lymph node assessment. Women who had undergone an 'inadvertent' simple hysterectomy with an unexpected post-operative diagnosis of cancer were also eligible if they met the above inclusion criteria and underwent a second surgery with pelvic lymph node dissection only. RESULTS 100 evaluable patients were enrolled. Median age at surgery was 38 years (range 23-67). Stage was IA2 (33%) and IB1 (67%). Surgery included conization followed by lymph node assessment in 44 women, conization followed by simple hysterectomy with lymph node assessment in 40 women, and inadvertent simple hysterectomy followed by lymph node dissection in 16 women. Positive lymph nodes were noted in 5 patients (5%). Residual disease in the post-conization hysterectomy specimen was noted in 1/40 patients-that is, an immediate failure rate of 2.5%. Median follow-up was 36.3 months (range 0.0-68.3). Three patients developed recurrent disease within 2 years of surgery-that is, a cumulative incidence of 3.5% (95% CI 0.9% to 9.0%). DISCUSSION Our prospective data show that select patients with early-stage, low-risk cervical carcinoma may be offered conservative surgery.
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Affiliation(s)
- Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rene Pareja
- Instituto Nacional de Cancerología, Bogotá, and Clínica de Oncología Astorga, Medellin, Colombia
| | | | | | - Andre Lopes
- Instituto Brasileiro de Controle do Cancer, Sao Paulo, Brazil
| | | | | | | | - Lois M Ramondetta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tarinee Manchana
- Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Orla M McNally
- Royal Women's Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Martin Riege
- Instituto de Ginecología de Rosario, Rosario, Argentina
| | - Giovanni Scambia
- Fondazione Policlinico Universitario A. Gemelli IRCCS and Catholic University of the Sacred Heart, Rome, Italy
| | | | | | - Gabriel J Rendon
- Instituto de Cancerologia - Las Américas - AUNA, Medellin, Colombia
| | - Preetha Ramalingam
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bryan M Fellman
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Michael Frumovitz
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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15
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Halaska MJ, Drochytek V, Shmakov RG, Amant F. Fertility sparing treatment in cervical cancer management in pregnancy. Best Pract Res Clin Obstet Gynaecol 2021; 75:101-112. [PMID: 33992541 DOI: 10.1016/j.bpobgyn.2021.03.014] [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: 02/05/2021] [Accepted: 03/29/2021] [Indexed: 12/09/2022]
Abstract
The article focuses on fertility-sparing management during pregnancy and obstetrical management after fertility-sparing surgery. Over the years, more women in developed countries tend to delay childbirth to a later age, which leads to cervical cancer more often diagnosed during pregnancy. The advances in our understanding of prognosis and treatment options in these patients have helped us to address avenues and to circumvent standard therapy and fetal demise, respecting maternal and fetal chances. Childbearing trends also lead to an increase in the number of patients considering fertility-sparing management when diagnosed with cervical cancer. Such management represents a challenge for obstetricians as prior cervical surgery is a known risk factor for various adverse events. These include decreased fertility, second trimester miscarriage, preterm labor, or preterm premature rupture of membranes. Watchful follow-up and various prophylactic measures are keys when striving for the best possible outcome.
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Affiliation(s)
- Michael J Halaska
- Dept. of Obstetrics and Gynaecology, Faculty Hospital Kralovske Vinohrady, 3rd Medical Faculty, Charles University, Prague, Czech Republic
| | - Vit Drochytek
- Dept. of Obstetrics and Gynaecology, Faculty Hospital Kralovske Vinohrady, 3rd Medical Faculty, Charles University, Prague, Czech Republic
| | - Roman G Shmakov
- National Medical Research Center for Obstetrics, Gynecology and Perinatology Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - Frédéric Amant
- Dept. Gynaecology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Dept. Oncology, KU Leuven, Belgium; Dept. Obstetrics and Gynaecology, Amsterdam University Medical Centers, the Netherlands.
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16
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Noll F, Palacios Torres AT, Pecci P, Lucchini SM, Heredia F. Neoadjuvant chemotherapy in early-stage cervical cancer (<2 cm) before conization for fertility preservation: is there any advantage over upfront conization? Int J Gynecol Cancer 2021; 31:379-386. [PMID: 33649005 DOI: 10.1136/ijgc-2020-001751] [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: 09/15/2020] [Revised: 01/18/2021] [Accepted: 01/21/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Neoadjuvant chemotherapy before fertility-sparing surgery is an accepted option for patients with cervical tumors between 2 cm and 4 cm. There is a paucity of data regarding its role in patients with tumors <2 cm. Our objective was to compare the oncological and obstetrical outcomes between patients who underwent neoadjuvant chemotherapy before cervical conization versus upfront cervical conization in patients with cervical cancer with tumors <2 cm. METHODS We conducted a systematic literature review and searched MEDLINE, EMBASE, and CINAHL (from 1995 to March 2020) using the terms: uterine cervix neoplasms, cervical cancer, fertility-sparing surgery, fertility preservation, conization, cone biopsy, and neoadjuvant chemotherapy. We included manuscripts with information on patients with tumor size <2 cm, lymph node status, follow-up, oncological and obstetrical outcome, and toxicity related to neoadjuvant chemotherapy. We excluded review articles or articles with duplicated patient information. RESULTS We identified 12 articles, including 579 patients. For final analysis, 261 patients met inclusion criteria. The most common histology was non-squamous cell carcinoma (62%). Median follow-up time was 63.5 (range 7-122) months for the neoadjuvant chemotherapy group and 48 (range 12-184) months for the upfront cervical conization group. There was no difference in either overall survival (neoadjuvant chemotherapy group 100% vs upfront cervical conization 99.7%, p=0.79) or disease-free survival (neoadjuvant chemotherapy 100% vs upfront cervical conization 98.9%, p=0.59) between the groups. Fertility preservation rate was 81.4% versus 99.1% (p<0.001) favoring upfront cervical conization. No statistically significant differences were seen in live birth rate or pregnancy loss. Also, we found that all neoadjuvant chemotherapy patients reported chemotherapy-related toxicity (30.7% grade 3 and 69.2% grade 1-2). CONCLUSIONS There was no difference in disease-free survival or overall survival between patients who underwent neoadjuvant chemotherapy followed by conization and upfront cervical conization. Patients who underwent upfront cervical conization had a higher fertility preservation rate.
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Affiliation(s)
- Florencia Noll
- Department of Gynecologic Oncology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina .,Department of Gynecology, Section of Gynecologic Oncology, Sanatorio Allende, Cordoba, Argentina
| | - Ana Tatiana Palacios Torres
- Gynecologic Oncology, Fundacion Universitaria de Ciencias de la Salud - FUCS, Hospital de San José, Bogota, Colombia
| | - Pablo Pecci
- Gynecologic Oncology, Centro Oncologico Puerto Madryn, Chubut, Argentina.,Gynecologic Oncology, Centro de Diagnóstico Roca, Trelew, Argentina
| | - Sergio Martin Lucchini
- Department of Gynecology, Section of Gynecologic Oncology, Sanatorio Allende, Cordoba, Argentina
| | - Fernando Heredia
- Gynecologic and Obstetrics Department, Faculty of Medicine, Universidad de Concepción, Concepción, Chile.,Minimally Invasive and Robotic Gynecology Unit, Clínica Andes Salud, Concepción, Chile
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17
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Parra-Herran C, Malpica A, Oliva E, Zannoni GF, Ramirez PT, Rabban JT. Endocervical Adenocarcinoma, Gross Examination, and Processing, Including Intraoperative Evaluation: Recommendations From the International Society of Gynecological Pathologists. Int J Gynecol Pathol 2021; 40:S24-S47. [PMID: 33570862 PMCID: PMC7969178 DOI: 10.1097/pgp.0000000000000745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The International Society of Gynecological Pathologists (ISGyP) Endocervical Adenocarcinoma Project aims to provide evidence-based guidance for the pathologic evaluation, classification, and reporting of endocervical adenocarcinoma. This review presents the recommendations pertaining to gross evaluation and intraoperative consultation of specimens obtained from patients in the setting of cervical cancer. The recommendations are the product of review of published peer-reviewed evidence, international guidelines and institutional grossing manuals, as well as deliberation within this working group. The discussion presented herein details the approach to the different specimen types encountered in practice: loop electrosurgical excision procedure, cone, trachelectomy, radical hysterectomy, pelvic exenteration, and lymphadenectomy specimens. Guidelines for intraoperative evaluation of trachelectomy and sentinel lymph node specimens are also addressed. Correlation with ISGyP recommendations on cancer staging, which appear as a separate review in this issue, is also included when appropriate. While conceived in the framework of endocervical adenocarcinoma, most of the discussion and recommendations can also be applied to other cervical malignancies.
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18
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Burbano J, Heredia F, Sanabria D, Ardila EG, Viveros-Carreño D, Rodriguez J. Neoadjuvant chemotherapy prior to fertility-sparing surgery in cervical tumors larger than 2 cm: a systematic review on fertility and oncologic outcomes. Int J Gynecol Cancer 2021; 31:387-398. [PMID: 33649006 DOI: 10.1136/ijgc-2020-001765] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Management of cervical cancer tumors >2 cm has been a subject of controversy, with management often considered as either up-front radical trachelectomy or neoadjuvant chemotherapy before fertility-sparing surgery. METHODS A systematic literature review was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) checklist. This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO). We searched Medline through PubMed, EMBASE, Cochrane Central Register of Controlled Trials, SCOPUS, and OVID between January 1985 and December 2020. Eligibility criteria for selecting studies were English language, randomized controlled trials, and observational studies including information on fertility and oncologic outcomes. All titles were managed in EndNote X7. Risk of bias was evaluated using the Joanna Briggs Institute (JBI) critical appraisal checklist for observational studies. RESULTS Twenty-three studies with 205 patients who received neoadjuvant chemotherapy were included. The majority of patients (92.2%, n=189) had stage IB FIGO 2009 cervical cancer. The preferred regimen used was cisplatin in combination with paclitaxel or ifosfamide (80%, n=164). One hundred and eighty patients (87.8%) underwent fertility-sparing surgery; radical vaginal trachelectomy, abdominal trachelectomy, conization, and simple trachelectomy were performed in 62 (34.4%), 49 (27.2%), 34 (18.9%), and 26 (14.4%) women, respectively. In nine patients (5%) the type of procedure was not specified. The follow-up time reported in all studies ranged between 6 and 69 months. In 112 women who sought a pregnancy after surgery, 84.8% (n=95) achieved a gestation.The global recurrence and death rates were 12.8% and 2.8%, respectively. CONCLUSION Neoadjuvant chemotherapy followed by fertility-sparing surgery is a promising strategy that might allow fertility preservation in highly selected patients with cervical cancer with tumors >2 cm while providing acceptable oncologic outcomes. Results of prospective studies are required to validate its oncological safety. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42020203789.
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Affiliation(s)
- Javier Burbano
- Department of Gynecologic Oncology, Fundacion Clinica Valle del Lili, Cali, Colombia
| | - Fernando Heredia
- Department of Gynecology and Obstetrics, School of Medicine, Universidad de Concepción, Concepción, Chile
| | - Daniel Sanabria
- Department of Gynecologic Oncology, Clínica Los Nogales, Bogota, Colombia.,Department of Gynecologic Oncology, Instituto Nacional de Cancerología, Bogota, Colombia
| | | | - David Viveros-Carreño
- Department of Gynecologic Oncology, Instituto Nacional de Cancerología, Bogota, Colombia
| | - Juliana Rodriguez
- Department of Gynecologic Oncology, Instituto Nacional de Cancerología, Bogota, Colombia .,Department of Gynecology and Obstetrics, Section of Gynecologic Oncology, Fundación Santa Fe de Bogota, Bogota, Colombia
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19
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Kohn JR, Katebi Kashi P, Acosta-Torres S, Beavis AL, Christianson MS. Fertility-sparing Surgery for Patients with Cervical, Endometrial, and Ovarian Cancers. J Minim Invasive Gynecol 2020; 28:392-402. [PMID: 33373729 DOI: 10.1016/j.jmig.2020.12.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Nearly 10% of the 1.3 million women living with a gynecologic cancer are aged <50 years. For these women, although their cancer treatment can be lifesaving, it's also life-altering because traditional surgical procedures can cause infertility and, in many cases, induce surgical menopause. For appropriately selected patients, fertility-sparing options can reduce the reproductive impact of lifesaving cancer treatments. This review will highlight existing recommendations as well as innovative research for fertility-sparing treatment in the 3 major gynecologic cancers. TABULATION, INTEGRATION, AND RESULTS For early-stage cervical cancers, fertility-sparing surgeries include cold knife conization, simple hysterectomy with ovarian preservation, or radical trachelectomy with placement of a permanent cerclage. In locally advanced cervical cancer, ovarian transposition before radiation therapy can help preserve ovarian function. For endometrial cancers, fertility-sparing treatment includes progestin therapy with endometrial sampling every 3 to 6 months. After cancer regression, progestin therapy can be halted to allow attempts to conceive. Hysterectomy with ovarian preservation can also be considered, allowing for fertility using assisted reproductive technology and a gestational carrier. For ovarian cancers, fertility-sparing surgery includes unilateral salpingo-oophorectomy or bilateral salpingo-oophorectomy (with lymphadenectomy and staging depending on tumor histology). With higher-risk histology or higher early-stage disease, adjuvant chemotherapy is recommended-however, this carries a 3% to 10% risk of ovarian failure. Use of oocyte or embryo cryopreservation in patients with early-stage ovarian malignancy remains an area of ongoing research. CONCLUSION Overall, fertility-sparing management of gynecologic cancers is associated with acceptable rates of progression-free survival and overall survival and is less life-altering than more radical surgical approaches.
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Affiliation(s)
- Jaden R Kohn
- Kelly Gynecologic Oncology Service (Drs. Kohn, Kashi, Acosta-Torres, and Beavis).
| | - Payam Katebi Kashi
- Kelly Gynecologic Oncology Service (Drs. Kohn, Kashi, Acosta-Torres, and Beavis)
| | | | - Anna L Beavis
- Kelly Gynecologic Oncology Service (Drs. Kohn, Kashi, Acosta-Torres, and Beavis)
| | - Mindy S Christianson
- Division of Reproductive Endocrinology and Infertility (Dr. Christianson), Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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20
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Ueda K, Yanaihara N, Iida Y, Kobayashi R, Kato S, Matsuda Y, Tomita K, Yamamura N, Saito R, Hirose S, Kuroda T, Seki T, Saito M, Takano H, Yamada K, Okamoto A. Analysis of risk factors for patients with early-stage cervical cancer: A study of 374 patients. J Obstet Gynaecol Res 2020; 47:270-278. [PMID: 33078517 DOI: 10.1111/jog.14510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/05/2020] [Accepted: 09/21/2020] [Indexed: 12/24/2022]
Abstract
AIM This study aimed to identify the postoperative histological features affecting the prognosis of patients with early-stage cervical cancer who underwent open radical hysterectomy. METHODS This retrospective study enrolled 374 patients with pT1a, 1b1 and 2a1 early-stage cervical cancer who underwent open radical hysterectomy between 2001 and 2018. Survival outcomes were analyzed by Kaplan-Meier method and compared with log-rank test. Using the Cox proportional hazards regression test, we conducted a multivariate analysis for disease-free survival and overall survival. RESULTS Others histology, including other epithelial tumors and neuroendocrine tumors, had a significantly worse prognosis in both disease-free survival and overall survival than those of squamous cell carcinoma and adenocarcinoma (hazard ratio, 4.37 and 11.76; P = 0.006 and P = 0.002, respectively), along with lymph node metastasis (hazard ratio, 2.99 and 7.03; P = 0.009 and P = 0.001, respectively). CONCLUSION Others histology including adenosquamous carcinoma had a poor prognosis in early-stage cervical cancer as with high-risk factors.
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Affiliation(s)
- Kazu Ueda
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan.,Department of Gynecologic Oncology, International University of Health and Welfare Mita Hospital, Tokyo, Japan
| | - Nozomu Yanaihara
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yasushi Iida
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ritsuko Kobayashi
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Sayako Kato
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuna Matsuda
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Keisuke Tomita
- Department of Obstetrics and Gynecology, The Jikei University Kashiwa Hospital, Tokyo, Japan
| | - Nami Yamamura
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ryosuke Saito
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Sou Hirose
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Takafumi Kuroda
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Toshiyuki Seki
- Department of Obstetrics and Gynecology, The Jikei University Kashiwa Hospital, Tokyo, Japan
| | - Motoaki Saito
- Department of Obstetrics and Gynecology, The Jikei University Katsushika Medical Center, Tokyo, Japan
| | - Hirokuni Takano
- Department of Obstetrics and Gynecology, The Jikei University Kashiwa Hospital, Tokyo, Japan
| | - Kyosuke Yamada
- Department of Obstetrics and Gynecology, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Aikou Okamoto
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
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21
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Plante M, Renaud MC, Sebastianelli A, Gregoire J. Simple vaginal trachelectomy in women with early-stage low-risk cervical cancer who wish to preserve fertility: the new standard of care? Int J Gynecol Cancer 2020; 30:981-986. [PMID: 32499393 DOI: 10.1136/ijgc-2020-001432] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE There is a trend toward less radical surgery in women with small-volume disease who wish to preserve fertility. The objective of our study was to evaluate the oncologic and obstetrical outcome of simple vaginal trachelectomy and lymph node assessment in patients with low-risk early-stage cervical cancer (<2 cm). METHODS From May 2007 to January 2020, 50 patients underwent a simple vaginal trachelectomy/conization with laparoscopic sentinel lymph node mapping±complete pelvic node dissection. Patients underwent loop electrocautery excision (LEEP), cone/cervical biopsies, or simple trachelectomy. A preoperative pelvic MRI with gadolinium contrast was systematically performed in all cases. The size of the lesion was established by review of the LEEP, cone or trachelectomy specimen, MRI, and clinical examination. Data was collected prospectively in a computerized database. Descriptive statistics and the Kaplan-Meier estimate were used for analysis. RESULTS The median age was 29 years (range: 21-44) and 35 (70%) patients were nulliparous. As per FIGO 2009 classification, 11 patients had stage IA1 with lymphovascular space invasion (LVSI), 13 patients had stage IA2, and 26 patients had stage IB1. Twenty-six patients had squamous histology, 20 patients adenocarcinoma, and four patients other histologies. On final pathology, lymph nodes were negative in 46 patients (92%), three patients had isolated tumor cells, and one patient had micrometastasis. Thirty patients (60%) had either no residual disease in the trachelectomy specimen (22) or residual dysplasia only (eight). With a median follow-up of 76 months (range: 1-140), only one local recurrence occurred which was treated initially with chemoradiation. She recurred again locally and underwent a pelvic exenteration: the patient progressed again and died of disease. The 5-year progression-free survival and overall survival was 97.9% and 97.6%, respectively. There were 40 pregnancies: five (12.5%) ended in the first trimester, one (2.5%) in the second trimester, and three (7.5%) were late preterm: all the others (30 or 75%) delivered >36 weeks and one pregnancy is ongoing. CONCLUSION Simple trachelectomy/conization and lymph node assessment is an oncologically safe fertility-preserving surgery in well-selected patients with low-risk early-stage cervical cancer (<2 cm). Obstetrical outcomes are comparable to the general population.
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Affiliation(s)
- Marie Plante
- Gynecologic Oncology, CHU de Quebec; LHotel-Dieu de Quebec, Quebec City, Quebec, Canada
| | - Marie-Claude Renaud
- Gynecologic Oncology, CHU de Quebec; LHotel-Dieu de Quebec, Quebec City, Quebec, Canada
| | | | - Jean Gregoire
- Gynecologic Oncology, CHU de Quebec; LHotel-Dieu de Quebec, Quebec City, Quebec, Canada
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22
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Nguyen JMV, Covens A. Simple Hysterectomy for Early-Stage Cervical Cancer: Caution, But Don't Throw the Baby Out With the Bathwater! Obstet Gynecol 2019; 134:1129-1131. [PMID: 31764720 DOI: 10.1097/aog.0000000000003589] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Julie My Van Nguyen
- Dr. Nguyen is from the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Toronto, and Dr. Covens is from the Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada;
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23
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Tewari KS, Monk BJ. Evidence-Based Treatment Paradigms for Management of Invasive Cervical Carcinoma. J Clin Oncol 2019; 37:2472-2489. [PMID: 31403858 PMCID: PMC7098831 DOI: 10.1200/jco.18.02303] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2019] [Indexed: 12/24/2022] Open
Affiliation(s)
| | - Bradley J. Monk
- University of Arizona, Phoenix, AZ
- Creighton University, Phoenix, AZ
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24
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Prodromidou A, Iavazzo C, Fotiou A, Psomiadou V, Douligeris A, Vorgias G, Kalinoglou N. Short- and long term outcomes after abdominal radical trachelectomy versus radical hysterectomy for early stage cervical cancer: a systematic review of the literature and meta-analysis. Arch Gynecol Obstet 2019; 300:25-31. [PMID: 31062151 DOI: 10.1007/s00404-019-05176-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 04/24/2019] [Indexed: 12/09/2022]
Abstract
PURPOSE Cervical cancer (CC) ranks 2nd for mortality among women of reproductive age in the United States. Abdominal radical trachelectomy (ART) is a fertility sparing approach that has been proposed in women with early stage CC who wish to preserve their fertility. The aim of the present meta-analysis was to evaluate the short- and long-term outcomes of RH vs ART for early stage CC. METHODS A total of 5 electronic databases were searched for articles published up to December 2018. Prospective and retrospective trials reporting outcomes for women who underwent ART or RH for the management of early stages CC, were considered eligible for inclusion. Statistical meta-analysis was performed using the RevMan 5.3 software. RESULTS A total of 5 studies which included 840 women who underwent ART or radical trachelectomy (RH) were included in the present meta-analysis. Among them, 324 underwent ART whereas the remaining 516 had RH. Despite the fact that ART was associated with significantly prolonged operative time compared to RH (840 patients MD 36.82 min, 95% CI 20.15-53.49, p < 0.001), neither 5-year OS nor 5-year DFS were different among the two groups (714 patients OR 1.39, 95% CI 0.53-3.62, p = 0.51 and 682 patients OR 1.08, 95% CI 0.52-2.25, p = 0.84, respectively). CONCLUSIONS ART is a more complex and time consuming technique, but equally safe compared to RH in terms of oncological outcomes for selected women with early stage CC and allows for more CC survivors of childbearing age to preserve their fertility.
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Affiliation(s)
- Anastasia Prodromidou
- Department of Gynecological Oncology, Metaxa Memorial Cancer Hospital, Piraeus, Greece.
- Department of Surgical Oncology, Metaxa Memorial Anticancer Hospital, Mpotasi 51, Piraeus, Greece.
| | - Christos Iavazzo
- Department of Gynecological Oncology, Metaxa Memorial Cancer Hospital, Piraeus, Greece
| | - Alexandros Fotiou
- Department of Gynecological Oncology, Metaxa Memorial Cancer Hospital, Piraeus, Greece
| | - Victoria Psomiadou
- Department of Gynecological Oncology, Metaxa Memorial Cancer Hospital, Piraeus, Greece
| | - Athanasios Douligeris
- Department of Gynecological Oncology, Metaxa Memorial Cancer Hospital, Piraeus, Greece
| | - Georgios Vorgias
- Department of Gynecological Oncology, Metaxa Memorial Cancer Hospital, Piraeus, Greece
| | - Nikolaos Kalinoglou
- Department of Gynecological Oncology, Metaxa Memorial Cancer Hospital, Piraeus, Greece
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25
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Matsuo K, Machida H, Mandelbaum RS, Mikami M, Enomoto T, Roman LD, Wright JD. Trachelectomy for stage IB1 cervical cancer with tumor size >2 cm: trends and characteristics in the United States. J Gynecol Oncol 2019; 29:e85. [PMID: 30207094 PMCID: PMC6189433 DOI: 10.3802/jgo.2018.29.e85] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 07/08/2018] [Accepted: 07/13/2018] [Indexed: 11/30/2022] Open
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.
| | - Hiroko Machida
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Isehara, Japan
| | - Rachel S Mandelbaum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Mikio Mikami
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Isehara, Japan
| | - Takayuki Enomoto
- Department of Obstetrics and Gynecology, Niigata University School of Medicine, Niigata, Japan
| | - 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
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26
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Plante M, van Trommel N, Lheureux S, Oza AM, Wang L, Sikorska K, Ferguson SE, Han K, Amant F. FIGO 2018 stage IB2 (2-4 cm) Cervical cancer treated with Neo-adjuvant chemotherapy followed by fertility Sparing Surgery (CONTESSA); Neo-Adjuvant Chemotherapy and Conservative Surgery in Cervical Cancer to Preserve Fertility (NEOCON-F). A PMHC, DGOG, GCIG/CCRN and multicenter study. Int J Gynecol Cancer 2019; 29:969-975. [PMID: 31101688 DOI: 10.1136/ijgc-2019-000398] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND There are limited data regarding the optimal management of pre-menopausal women with cervical lesions measuring 2-4 cm who desire to preserve fertility. PRIMARY OBJECTIVES To evaluate the feasibility of preserving fertility. STUDY HYPOTHESIS Neo-adjuvant chemotherapy will be effective in reducing the size of the tumor and will enable fertility-sparing surgery without compromising oncologic outcome. TRIAL DESIGN Pre-menopausal women diagnosed with stage International Federation of Gynecology and Obstetrics (FIGO) IB2, 2-4 cm cervical cancer who wish to preserve fertility will receive three cycles of platinum/paclitaxel chemotherapy. Patients with complete/partial response will undergo fertility-sparing surgery. Patients will be followed for 3 years to monitor outcome. Patients with suboptimal response (residual lesion ≥2 cm) will receive definitive radical hysterectomy and/or chemoradiation. MAJOR ELIGIBILITY CRITERIA Patients must have histologically confirmed invasive cervical cancer, 2-4 cm lesion, by clinical examination and magnetic resonance imaging (MRI), negative node, and pre-menopausal (≤40 years old). Following three cycles of neo-adjuvant chemotherapy, patients must achieve a complete/partial response (residual lesion <2 cm). Exclusion criteria include high-risk histology, tumor extension to uterine corpus/isthmus (as per MRI), and suboptimal response/progression following neo-adjuvant chemotherapy. PRIMARY ENDPOINTS Assess the rate of functional uterus defined as successful fertility-sparing surgery and no adjuvant therapy. SAMPLE SIZE A total of 90 evaluable patients will be needed to complete the study. ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS Expected complete accrual in 2022 with presentation of results by 2025. TRIAL REGISTRATION NUMBER Pending ethics submission.
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Affiliation(s)
- Marie Plante
- Obstetrics and Gynecology, Centre Hospitalier Universitaire de Quebec, Quebec City, Quebec, Canada
| | - Nienke van Trommel
- Gynecologic Oncology, Netherlands Cancer Institute, Amsterdam, Noord-Holland, Netherlands.,Gynecologic Oncology, Center for Gynecologic Oncology Amsterdam, Amsterdam, Netherlands
| | - Stephanie Lheureux
- Drug Development Program, Princess Margaret Consortium, Toronto, Ontario, Canada
| | - Amit M Oza
- Department of Medicine, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - Lisa Wang
- Drug Development Program, Princess Margaret Consortium, Toronto, Ontario, Canada
| | - Karolina Sikorska
- Department of Biostatistics, Netherlands Cancer Institute, Amsterdam, Noord-Holland, Netherlands
| | | | - Kathy Han
- Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - Frederic Amant
- Netherlands Cancer Institute, Amsterdam, Noord-Holland, Netherlands.,Gynecologic Oncology, Amsterdam University Medical Centers, Amsterdam, Netherlands
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27
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van der Velden J, Mom CH. Tailoring radicality in early cervical cancer: how far can we go? J Gynecol Oncol 2018; 30:e30. [PMID: 30479099 PMCID: PMC6304411 DOI: 10.3802/jgo.2019.30.e30] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 11/14/2018] [Indexed: 12/27/2022] Open
Abstract
Today, the patient who is diagnosed with early cervical cancer is offered a variety of treatments apart from standard therapy. Patients can be treated with a less radical hysterectomy (RH) regarding parametrectomy, a trachelectomy either vaginal or abdominal, and this can be performed through a minimal invasive or open procedure. All this in combination with nerve sparing and/or sentinel node technique. Level 1 evidence for the oncological safety of all these modifications is only available from 3 randomized controlled trials (RCTs). Two RCTs on more or less radical parametrectomy both showed that oncological safety was not compromised by doing less radical surgery. Because of the heterogeneity of the patient population and the high frequency of adjuvant radiotherapy, the true impact of surgical radicality cannot be assessed. Regarding the issue of oncological safety of fertility sparing treatments, case-control and retrospective case series suggest that trachelectomy is safe as long as the tumor diameter does not exceed 2 cm. Recently, both a RCT and 2 case-control studies showed a survival benefit for open surgery compared to minimally invasive surgery, whereas many previous case-control and retrospective case series on this subject did not show impaired oncological safety. In a case-control study the survival benefit for open surgery was restricted to the group of patients with a tumor diameter more than 2 cm. Although modifications of the traditional open RH seem safe for tumors with a diameter less than 2 cm, ongoing prospective RCTs and observational studies should give the final answer.
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Affiliation(s)
- Jacobus van der Velden
- Department of Gynecologic Oncology, Amsterdam University Medical Center, Amsterdam, The Netherlands.
| | - Constantijne H Mom
- Department of Gynecologic Oncology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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